Protocol for facially guided digital orthodontic diagnosis and treatment planning

•A fully integrated interdisciplinary workflow to solve complex treatments is proposed.•This protocol establishes a comprehensive digital orthodontic diagnosis.•It guides the multidisciplinary team through the planning and treatment phases.•Treatment results are verified using 3D superimposition, photography, and videography.•This workflow allows the multidisciplinary team to stay on track and save time. Using a digital workflow in orthodontics and interdisciplinary dentistry undoubtedly benefits both the patient and professional. This 9-step protocol guides orthodontists through an interdisciplinary treatment planning and execution. First, it establishes an exhaustive digital diagnosis and then formulates an interdisciplinary digital treatment plan with 3-dimensional (3D) goals. Finally, objective verification of the treatment results occurs through 3D superimposition. This 9-step protocol proposes a fully integrated workflow platform by providing a digital, 3D, clear planning protocol for the interdisciplinary team. It gives them a clear vision of successfully managing the patient from start to finish. It is versatile, logical, and methodical and can be applied to any clinical situation involving orthodontics. Using a digital workflow in orthodontics and interdisciplinary dentistry undoubtedly benefits both the patient and professional. This 9-step protocol guides orthodontists through an interdisciplinary treatment planning and execution. First, it establishes an exhaustive digital diagnosis and then formulates an interdisciplinary digital treatment plan with 3-dimensional (3D) goals. Finally, objective verification of the treatment results occurs through 3D superimposition. This 9-step protocol proposes a fully integrated workflow platform by providing a digital, 3D, clear planning protocol for the interdisciplinary team. It gives them a clear vision of successfully managing the patient from start to finish. It is versatile, logical, and methodical and can be applied to any clinical situation involving orthodontics. As the digital age of dentistry continues to flourish, it has never been more important to have protocols to guide dentists through interdisciplinary treatment planning and execution using the latest technology and software. Digital workflows have reduced patient chair time and improved treatment accuracy. In orthodontics, it has revolutionized the visualization of potential treatment outcome depictions for patients willing to consider orthodontic treatments. Nowadays, after just a single visit for record taking, the diagnosis can be made, and the full treatment can be planned with virtual simulations at every step.1Farronato G Galbiati G Esposito L Mortellaro C Zanoni F Maspero C Three-dimensional virtual treatment planning: presurgical evaluation.J Craniofac Surg. 2018; 29: e433-e437Crossref PubMed Scopus (23) Google Scholar Furthermore, a digital workflow facilitates collaboration and virtual records sharing between dental specialists in an interdisciplinary environment and allows open and transparent communication with the patient.2Lv L He W Ye H Cheung K Tang L Wang S et al.Interdisciplinary 3D digital treatment simulation before complex esthetic rehabilitation of orthodontic, orthognathic and prosthetic treatment: workflow establishment and primary evaluation.BMC Oral Health. 2022; 22: 34Crossref PubMed Scopus (8) Google Scholar Establishing a comprehensive diagnosis is crucial when a patient requires extensive treatment. With digital software, treatment simulations can show the patient an approximation of the desired treatment results before the treatment begins and then at every step. A key focus of this protocol is facial harmony, especially considering that the chief complaint in >80% of patients is to improve facial and smile esthetics.3Di Blasio M Vaienti B Pedrazzi G Cassi D Magnifico M Meneghello S et al.Are the reasons why patients are referred for an orthodontic visit correct?.Int J Environ Res Public Health. 2021; 18: 5201Crossref PubMed Scopus (7) Google Scholar In this sense, simulations and visualizations of the potential treatment alternatives can be useful in improving patient adherence and overall acceptance of treatment goals. This is a key component of a continuous informed consent process and reduces the likelihood of legal claims.4Venugopal A Flores-Mir C Vaid NR Autonomy and consent in this era of unconscious priming.Am J Orthod Dentofacial Orthop. 2022; 161: e297-e302Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar From the point of view of each interdisciplinary team member, by having a protocol to guide them through the treatment, each phase of the treatment can be performed correctly, and at the end of the treatment, facial harmony between soft and hard tissues can be achieved. This versatile 9-step protocol aims to guide orthodontists in treating their patients no matter the treatment that is planned, whether orthodontic alone or with a restorative or surgical component.5Ferrando Cascales R Ferrando Cascales A Temporización en ortodoncia y odontología restauradora para casos de rehabilitación completa en dientes desgastados. [Temporarization of worn down teeth in full mouth reconstruction cases in orthodontics and restorative dentistry].Ortodoncia Española. 2019; 57: 33-41Google Scholar It is valid for any malocclusion, regardless of age or treatment required, as a digital workflow easily integrates different treatment types.6Ebker T Korn P Heiland M Bumann A Comprehensive virtual orthognathic planning concept in surgery-first patients.Br J Oral Maxillofac Surg. 2022; 60: 1092-1096Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar It aims to address the lack of a fully integrated interdisciplinary workflow to solve complex orthodontic treatment.2Lv L He W Ye H Cheung K Tang L Wang S et al.Interdisciplinary 3D digital treatment simulation before complex esthetic rehabilitation of orthodontic, orthognathic and prosthetic treatment: workflow establishment and primary evaluation.BMC Oral Health. 2022; 22: 34Crossref PubMed Scopus (8) Google Scholar,7Mirabella D MacCa U Pancari C Giunta G Lombardo L Detailed three-dimensional orthodontic tooth repositioning to improve restorative outcome.Angle Orthod. 2022; 92: 415-425Crossref PubMed Scopus (2) Google Scholar,8Prado N Hosni S Darcey J Aminian A Malik O Smile makeover treatments.Br Dent J. 2022; 233: 391-396Crossref PubMed Scopus (2) Google Scholar This step aims to collect an exhaustive series of digital records. A full series of facial photographs are taken in the NHP, followed by a series of intraoral photographs. The orthodontist uses judgment to find this position, ensuring that the patient is relaxed and looking into the distance at a point at the same level as their eyes. Digital scans are then performed on the maxillary and mandibular arch and the occlusion of the patient. When the patient has a stable bite, the occlusal scan will be taken with the patient in maximum intercuspation. If the patient presents an unstable bite, the centric relationship can be found, recorded using a wax registration, and then scanned. Cone-beam computed tomography (CBCT) imaging can provide vast information; however, it is up to the clinician to decide if and when it is necessary. CBCT aids in the superimposition of facial photographs with digital scans, mounting the virtual articulator, segmenting the roots of the teeth, and assessing the midface and lower face. The limits of any treatment and how much tooth movement is anatomically possible can also be assessed using CBCT.9Hirschhaut M Weinstein C Flores-Mir C An Introduction to the systematic evaluation and management of complex malocclusions.Semin Orthod. 2024; (in press)Abstract Full Text Full Text PDF Scopus (0) Google Scholar Without a CBCT, superimposition of the NHP photographs with intraoral scans can still be performed, and a semiadjustable virtual articulator can still be mounted. NHP photographs and digital scans are considered mandatory for this protocol. A CBCT may be chosen on a case-by-case basis. If a CBCT is not performed, then panoramic or lateral cephalometric x-rays can be performed instead. Once all the records have been obtained, the digital scans can be superimposed onto the NHP photographs using a software package such as NemoCeph (Nemotec SL, Madrid, Spain). If a CBCT was taken, it could be superimposed onto the photographs using the same software—landmarks identified in the CBCT reconstruction aid in the superimposition process. The key in this stage is to obtain the precise orientation of the STL and DICOM files on the basis of the NHP. Correct orientation of the digital records facilitates accurate determination of desired movements. The next step of the protocol involves analyzing crowding or spacing in both arches. The presence or absence of crowding in the maxillary arch guides the first stages of the treatment. On the basis of this measurement, it may be determined that treatments such as extractions or skeletal or dental expansion are required. In some patients, the magnitude of the sagittal and vertical facial imbalances necessitates considering orthognathic surgery to reach reasonable and stable results. Next, we can observe the occlusal relationship using the virtual articulator. This includes interferences and the occlusal contacts present during protrusive and lateral movements. The virtual articulator is mounted on the basis of the CBCT reconstructions of the condyles, glenoid fossa, and cranial base and all 3 parts of the intraoral scan (maxillary arch, mandibular arch, and interocclusal). If CBCT imaging is unavailable, then a semiadjustable virtual articulator can still be mounted with the intraoral scans orientated and aligned with the NHP photographs using software such as NemoCeph (Nemotec SL). Furthermore, the curves of Wilson and Spee can be measured to determine whether flattening the curves is required and what space is required to do this. A 2D cephalometric analysis is performed to determine the patient's current situation and establish the measurements outside the normal ranges. First, the hard tissues are analyzed to determine the patient's facial pattern and skeletal imbalances. A lateral cephalometric analysis is required (ie, Ricketts, Steiner, Jarabak, and McNamara analysis). After this, an additional analysis is performed to provide information on the soft tissue structures and their projection to the true vertical line. An Arnett analysis is suggested,10Arnett GW Jelic JS Kim J Cummings DR Beress A Worley CM et al.Soft tissue cephalometric analysis: diagnosis and treatment planning of dentofacial deformity.Am J Orthod Dentofacial Orthop. 1999; 116: 239-253Abstract Full Text Full Text PDF PubMed Google Scholar or the Ayala method if surgery is planned.11Ayala J Tratamiento ortodóncico-quirúrgico: un nuevo método de planificación [Orthodontic-surgical treatment: a new planning method].Rev Española Ortod ISSN. 2005; 35: 293-314Google Scholar The key in this step of the protocol is to first determine the desired position of the maxillary central incisors from a 2D sagittal view (following Arnett's method) before transferring this position to 3-dimensional (3D) in the next step of the protocol. This forms an important part of the treatment planning as these teeth will be virtually moved first. Their vertical position regarding the upper lip is a crucial consideration. After the lateral cephalometric analysis, a VTO is performed with attention to crowding and cephalometric discrepancy. The desired projection of the maxillary central incisor and the interincisal angle can be visualized. If surgical correction is considered necessary to achieve the amount of dental movement required, an STO can be performed after a method such as Ayala's method. Now, the maxillary central incisor position in VTO/STO (2D) is transferred to SETUP (3D) using the most incisal point. At this stage, work continues from the patient's lateral view. Therefore, the critical measurement is the anteroposterior and vertical position of the central incisors. Now, the virtual movement of the maxillary teeth can begin in the sequence: central incisors to lateral incisors to canines to premolars to molars. The maxillary central incisor in the most unfavorable position will be moved first, followed by the contralateral central incisor. Simple rotations can then be planned once the maxillary teeth correct anteroposterior and vertical position has been achieved. Planning the movements of the maxillary arch in this sequence enables the orthodontist to achieve a harmonic arch shape. At the start of this step, attention shifts from the lateral view of the patient to the frontal view, whereby a frontal facial analysis is performed. This step considers 3 key factors: maxillary transverse dimension, occlusal plane transverse angulation (canting), and midlines’ symmetry. First, the midline is corrected, then canting, and finally, the transverse dimension of the maxilla. During this stage, techniques, including maxillary expansion (either tooth- or bone-anchored), temporary anchorage devices, etc, may be planned to achieve a desired transversal result for the maxilla and maxillary dentition. The arch contour should be parallel to the smile line. Now that the future position of the maxillary dentition has been chosen, the focus of the orthodontist moves to the mandibular arch. Once again, planning moves in a distal direction from tooth to tooth. The mandibular central incisors are placed in a correct overbite and overjet with maxillary antagonists. Then, the rest of the mandibular teeth are virtually moved in the sequence: central incisors to lateral incisors to canines to premolars to molars. Similar to the maxillary arch, once the correct anteroposterior positions have been planned, the virtual position of each tooth is corrected to give the desired arch shape. At the end of the protocol's stage, a functional occlusion should have been established. A Bolton analysis is performed to determine a correct relationship between both arches. If this relationship is incorrect, alterations such as interproximal reduction or composite build-ups can be planned. Now that the virtual movement of the maxillary and mandibular teeth has been completed, the position of each tooth can be analyzed and compared with the initial positions. On the basis of the results of this analysis, tooth movement complexity becomes clear to reach the overall objectives. The choice of mechanics or technique is guided by the orthodontist's expertise and the strengths and weaknesses of the available approaches. During this final step, an analysis of the final results is performed. Moreover, 2D superimpositions such as pretreatment and posttreatment lateral cephalometric analysis can provide helpful information regarding the treatment success but not exact quantitative values. To quantify the results and provide exact numerical discrepancies, a 3D superimposition using a stable anatomic reference can be performed using a pretreatment and posttreatment STL file. The superimposition of STL files is helpful in tracking the results of dental movements. The superimposition of DICOM files also has value in tracking growth and the results of surgical treatments. Finally, it must be mentioned that photography and videography are very powerful tools that allow orthodontists to verify the results of their treatment. Given that this protocol is facially guided, the final result must be esthetically acceptable from the patient's perspective. Videos of the patient talking and smiling can be taken to provide valuable information on conversational esthetics, which may not be provided by traditional static imaging. Figure provides examples of six cases were the 9-step protocol was used. This protocol provides the orthodontist and interdisciplinary team with a clear vision of how to treat patients successfully. It addresses the lack of a fully integrated, interdisciplinary, 3D proposed digital workflow for orthodontists working in an interdisciplinary team. Working exclusively in a digital environment usually saves chair time, reduces necessary physical storage space, and allows easy and fast collaboration between professionals. The versatility of this protocol means that it is valid for any patient, whether orthodontic, surgical, or restorative, regardless of the required treatment. It incorporates all the elements of a traditional orthodontic analysis: record taking, teeth models, cephalometric analysis, and VTO, but introduces digitalization at each step, creating a modern take on the traditional method. The protocol's first key is to position the patient's head in its natural position, facilitating an accurate and repeatable analysis. Weber et al12Weber DW Fallis DW Packer MD Three-dimensional reproducibility of natural head position.Am J Orthod Dentofacial Orthop. 2013; 143: 738-744Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar specifically investigated the 3D reproducibility of NHP and stated that it is reproducible in the sagittal, coronal, and axial planes. CBCT imaging is a valuable tool in modern orthodontics, providing 3D information that 2D methods cannot. In this protocol, CBCT imaging allows for the segmentation of each tooth, including the roots, which allows for precise planning of tooth movements, including root torque.13Cui Z Fang Y Mei L Zhang B Yu B Liu J et al.A fully automatic AI system for tooth and alveolar bone segmentation from cone-beam CT images.Nat Commun. 2022; 13: 2096Crossref PubMed Scopus (102) Google Scholar For this protocol, a CBCT is suggested in the following situations: adults with periodontal problems, patients with temporomandibular joint disorder (TMD), patients in which a change in vertical dimension is planned, and patients with severe crowding but with the possibility to treat The superimposition performed in step has been and in different of especially in digital smile uses 3 facial reference to aid in this and facial C N The digital workflow in interdisciplinary J 2021; Google Scholar software to this by such as the R F et tomography imaging superimposition protocols to in orthognathic a systematic with comprehensive 2022; PubMed Scopus Google Scholar In step 3 of the protocol, functional such as occlusal and lack of correct are A virtual articulator can be for patients orthodontic treatment. et R of virtual and 2019; PubMed Scopus Google Scholar a between a articulator and the virtual In patients complex orthodontic treatment, such as interdisciplinary treatment by orthodontists and or with a fully anatomic articulator can be M J C Y analysis of mandibular recorded for a of 2021; Scopus Google Scholar It should be that using a virtual articulator and the the for physical storage space, facilitates the sharing of information between and is H Y Wang Y Yu H H of the of virtual articulator mounting a clinical Oral PubMed Scopus Google Scholar In treatment, Ayala on facial in analysis, in which from the planning the final situation for the soft tissues the hard J Tratamiento ortodóncico-quirúrgico: un nuevo método de planificación [Orthodontic-surgical treatment: a new planning method].Rev Española Ortod ISSN. 2005; 35: 293-314Google Scholar The position of the upper lip is determined first, which is placed in of the true vertical to in This guides the future position of the maxillary A of working in this sequence is that movements in the teeth or structures are not fully to the soft the future position of the maxillary central Arnett's method is whereby the central incisors are placed with of at rest in and in GW Jelic JS Kim J Cummings DR Beress A Worley CM et al.Soft tissue cephalometric analysis: diagnosis and treatment planning of dentofacial deformity.Am J Orthod Dentofacial Orthop. 1999; 116: 239-253Abstract Full Text Full Text PDF PubMed Google Scholar to of tissue the maxillary teeth is acceptable when the treatment the orthodontist must the mechanics and will to achieve the desired movements on the basis of the patient's diagnosis and the To this it must be determined whether the amount of planned movement is stable and If then a or surgery may be severe skeletal be and be with or growth in N M M S K of or surgical orthodontic treatment for skeletal patients on analysis of Dent 2022; PubMed Scopus (2) Google Scholar Once the tooth movements have been completed, the results must be This protocol is facially facial and harmony are key when the success of the treatment. 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