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Cosmetic Simulation: Every Nail Deserves a Hammer

March 1, 2011
by Martin B. Goldstein, DMD


If you are like me and enjoy spending your time working in the front of the mouth as opposed to repairing lower second molars and the like, then you are ever watchful for anterior dentistry projects. I find this not only healthy for my back (I can usually sit upright when “rehab-ing” smiles) but also healthy for my mind as I take great pride in making my patients look better and thus making them feel better about themselves. (Needless to say, it’s also good for one’s office production if you can do it efficiently.)

Some patients know they have poor smiles but a surprising number have no idea how bad their smiles have gotten. The challenge has always been to somehow easily communicate to my patient in as gentle and quickly a fashion as possible that a dental fix up might be in order. Few would argue that a side by side, before and after is an effective tool when attempting to bring home this message. Let’s call this “instant demo” the “nail” and SNAP Instant Dental Imaging the “hammer”; a keen union in dentistry for those seeking more involvement with anterior dentistry. Yes, I know there are some who enjoy the concept of doing intra-oral composite mock-ups to a similar end. In some “I’m ready to go ahead, doctor” cases, that might be appropriate. But that approach is considerably more time consuming and in fact wastes a lot of composite! SNAP’s focus is FAST with IMPACT, punctuated with an “anyone can do it” design. Most importantly it is aimed at getting the patient’s ATTENTION and putting in motion that often inescapable feeling of “I want this….how can I get it?”

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HOW TO PARTICIPATE…

Besides owning the SNAP software, the chief ingredient in this “stew” is the digital portrait and your ability to capture a serviceable likeness of your patient. By serviceable, I simply refer to a straight on shot that clearly demonstrates the patient’s present smile. Below are some tips on how to make this happen. (You do have a digital camera don’t you? If not, go to www.photomed.net and ask Sean or Mike for help.)

SUMMARY OF PORTRAIT TECHNIQUE…

  • Distance: 6 to 8 feet from patient;
  • Camera is in auto-focus mode if camera and lens combination allow this;
  • F 5.6-6.7 or portrait mode;
  • Camera turned vertically;
  • Lens perpendicular to the nose;
  • Focus on the teeth, (lock focus by pressing shutter release half way down) then frame the face by lifting camera and having face fill most of the screen;
  • Have patient say “hiiiieeeeeee” sustained. The “eeeee” sound keeps the lips high and out of the way;
  • Take six shots and pick the best one.

Consider adding portrait accessories to your armamentarium for professional quality results: a step stool for you to go eye to eye with tall patients, a flash diffuser with a standard (non-ring) flash and a non-reflective background (Fig. 1). Photomed’s Easy Portrait Kit covers most of these additions while Portrait Professional 9.0 software allows you to touch up your images like a pro with virtually no skill required. (www.portraitprofessional.com)

The stew also calls for a chair-side PC monitor as well as a color printer which will enable your patients to take home your simulation handy work for sharing with their family and friends. The SNAP Software installation is seamless and can be networked if the need is there. Once all the ingredients are in place, anticipate a brief learning curve which is rendered ever so short by the multiple training videos included with the SNAP package. The short videos can be called up individually as you need them, so you can watch the one minute segment that you need help with at that moment, and don’t have to sift through the entire 20 minutes to find what you want.

JUST WHAT DOES SNAP DO?

As you are already aware, SNAP is a cosmetic simulation program that enables you to demonstrate all things dental to your patients. Veneers and crowns, diastema closures, gum lifts, tooth replacement and plain vanilla whitening demonstrations are at your beckon call once you’ve taken full advantage of the SNAP package.

CASE PRESENTATION…

Allow me to walk you through a typical application of SNAP. Last Summer the orthodontist with whom I often trade cases referred Bianca to me. Bianca had been in braces for quite some time but removal of her appliance was just a few months away. He anticipated that there would be a need for cosmetic bonding or veneering in order to make her smile truly attractive. See figure 2 for an example of a “serviceable” pre-op portrait and figure 3 for a sneak preview of how her dentition appeared upon removal of her orthodontic appliances. You’ll observe a host of asymmetries, considerable hypocalcification as well as an inordinate amount of wear for a seventeen year old teenager. Yes, Bianca was a bruxer!

As Bianca’s referral was unscheduled (as is often the case from across-the-hall referrals) I had about ten minutes in between scheduled patients to demonstrate to mom and Bianca what the possibilities for Bianca’s new smile might be.

After SNAP had imported my portrait of Bianca into its image editing module I chose a button on the left of the screen called “veneers and crowns.” Immediately, the program began to flash text prompts at the top of the screen, telling me what to do on the next step. I was then able to zoom in on her smile and quickly outline Bianca’s smile with the “lasso tool” which is selected automatically as shown in Figure 4. Most other buttons are “grayed out” so you cannot pick the wrong tool by accident. Multiple sliders on either side of the chosen image allow for easy zooming and visualization of the project at hand. In Figure 5, you’ll notice I had zoomed out and could then see Bianca’s original smile plus the new set of teeth that I had chosen from the set of 30 smile designs that accompany the SNAP system. SNAP will initially choose one for you but the user is free to experiment with different styles simply by clicking on one of the smile selections found to the right of the smile that is under construction.

At this point in the simulation process SNAP enables the user to stretch or shrink the new smile images to more accurately coincide with the patient’s existing dental anatomy. Your adjustments are “remembered,” and automatically applied to the next set of teeth that you select, so that you do not have to constantly make changes to each set that you try. New smiles can also be rotated if per chance the portrait features a tilt in head posture. Most impressive is SNAP’s latest addition. That is, the ability to curve the “smile line” of the library image to match the patient’s existing smile line as seen in the portrait image. This feature is accompanied by the added ability to asymmetrically stretch entire smiles or just single teeth resulting in smile simulations that look exceptionally natural. SNAP automatically “blends” the hard edges of any “cut and paste” routines, saving time and creating an even more natural look. Finally, the added ability to alter tooth brightness and color makes for a creative environment that has few boundaries. Figure 6 demonstrates a zoomed out view of Bianca’s simulation in a side by side rendering before going to print.

In figure 7, following a quick click on the “print” button found in the top right hand of the screen, you’ll observe the simulation previewed for printing. SNAP will automatically print up to 3 lines of text at the bottom of the picture, including the patients name, the name and phone number of your practice, and a small legal disclaimer if desired. Omitting the text in the print out will cause SNAP to automatically enlarge the images which in some cases may be desirable. Figure 8 depicts what Bianca did with her simulation
and a handy refrigerator magnet. (This is EXACTLY where you want this creation to be placed!)

In figure 9 you’ll observe a zoomed in view of the simulation while figure 10 demonstrates a close up of the actual set of direct bonded veneers that Bianca received. Figure 11 is the “money shot.” A delighted Bianca is sporting a new smile that bears a striking resemblance to what was shown to her in the simulation. (Please note; this case was accomplished with free handed direct composite bonding using a dual-layered approach.)

OTHER TIRCKS…

While I’ve already alluded to the varied capabilities offered by SNAP it’s worth mentioning my second favorite tool, that is, the diastema closure tool. It’s ingenious. As can be seen in figure 12 two central incisors have been outlined with individual boxes as prompted by SNAP when this function is invoked. (You can’t mess this up!!) The user may then slide the mesial surfaces towards one another to effect space closure as seen in figure 13. The user then zooms out to demonstrate the effect of the closure thus helping to determine the overall effect before beginning treatment. Such “visual realizations” often make it apparent to the patient that involving more than two teeth might make for a more attractive result. Figure 14 demonstrates the effect after treating only 8 and 9. Ultimately this two tooth solution was elected but not without the patient being aware of the end result before proceeding.

PITFALLS…

SNAP is geared for high volume usage, such as offering a “free smile evaluation picture” to patients that may have originally come in for just a cleaning or checkup. Although many simulations can be easily done by an assistant or hygienist (good examples are whitening, close diastema, bridge & implant), all simulations (especially full mouth restorations) should definitely be run by the dentist first, in order to avoid the possibility of a patient viewing a clinically unrealistic simulation photo.

Common sense would tell us that in all instances we need to keep our promises and simulations in line with what is actually possible via the methodology that we might be recommending. This calls for diagnostic and operating experience that enables the practitioner to know if a smile can simply be treated with surface alterations or is in need of orthodontics, surgery or both to accompany those surface changes. In its best implementation, SNAP (SnapDenatal.com) simulations are directed at stimulating patients to ask those questions of the practitioner, such as…..”this is wonderful…how might I get there?” At this juncture your clinical judgment and experience may guide the patient to that end.

At this time, I will also make mention of another simulation service that I employ regularly; that is, Smile Vision Inc. of Newton, Massachusetts. Smile Vision (smilevision.net) will render excellent simulations from portrait images uploaded to them on the internet and make them available to you typically within three days. They are rendered in tooth by tooth fashion and lean towards “restorative authenticity.” That is, since Smile Vision is also the lab that I use to prepare my diagnostic wax ups and templates, their simulations must lend themselves to plausible translation into mock-ups that very much resemble the changes seen in the simulations they generate. As they are also a ceramic lab, they can be called upon to make the final case remain in step with their simulation driven mock ups (called Resin Replicas as a trademarked name).

So you may already perceive the flow that I am describing here. I find it easy, inexpensive and quick to get a patient to ask the right questions after having received their SNAP simulation. Upon case acceptance, treatment plans that mandate thoughtful tooth preparation and occlusal considerations (as is typical of advanced wear and crowding cases) will be uploaded to Smile Vision to begin the systematic process of fulfilling the promise of the simulation.

In conclusion, if it’s more anterior dentistry that you desire, the tools (the hammer!) are available to get patients excited about the prospects of a new smile and you don’t have to be a computer whiz to take advantage of these new capabilities. Every effort has been made to make SNAP as fool-proof as might be imagined. It’s also worth mentioning that the software developers are continually improving upon a product that is already good! These updates are provided free of charge, with no yearly fees, and there is no charge for telephone phone technical support. Frequent and judicious use of the cosmetic simulation process can assist you in both increasing your case load as well as assisting you in case design. If you’ve already invested in a digital camera system for your practice, the cosmetic simulation process is a natural progression that can enable you to unleash the power of the digital images that your system is capable of. Take advantage of it! OH

Dr. Martin Goldstein, a Fellow of the International Academy of Dento-Facial Esthetics, practices general dentistry in Wolcott, CT, USA. Recognized as a Dentistry Today Top 100 CE Leader for the last six years and for his expertise in the field of dental digital photography, he lectures and writes extensively concerning cosmetics and the integration of digital photography into the general practice. Dr. Goldstein is a contributing editor for Dentistry Today and has also authored numerous articles for multiple dental periodicals. Dr. Goldstein also serves as a consultant to a host of dental manufacturers. He can be reached at: martyg924@cox.net

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