The ﬁfth dimension in esthetic dentistry

10 | The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021

CLINICAL RESEARCH

The fifth dimension in esthetic

dentistry

Galip Gürel, DDS, MSc

Private Practice, Istanbul, Turkey

Visiting Professor, Department of Prosthodontics, College of Dentistry, New York

University, New York, USA

Braulio Paolucci, DDS

Private Practice, Barbacena, Brazil

Georgi Iliev, DMD, PhD

Assistant Professor, Department of Prosthetic Dental Medicine, Faculty of Dental

Medicine, Medical University of Sofia, Bulgaria

Dimitar Filtchev, DMD, PhD

Associate Professor, Department of Prosthetic Dental Medicine, Faculty of Dental

Medicine, Medical University of Sofia, Bulgaria

Adriano Schayder, CDT

Certified Dental Technician, VIS Laboratory, São Paulo, Brazil

Correspondence to: Dr Galip Gürel

Dentis Dental Clinic, Tesvikiye St, Bayer Apt No:63 6th floor, Sisli/Istanbul 34765, Turkey;

Email: [email protected]

GÜREL ET AL

1111The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 |

Abstract

Every human smile is unique and special, reflecting the

different shapes, textures, and colors of the teeth as

well as their combinations. This uniqueness conveys a

direct and specific message when it comes to creating

a new smile design. Dentists need to consider the ‘uni-

ty of the whole’ concept in this task, which involves

bringing together biology, structure, function, and es-

thetics to create the fifth dimension of the smile. This

approach is quite different from the traditional one. A

smile reflects the personality and emotional state of

the patient, and the translation of this into a new smile

design occurs in various ways. This can be performed

either through analog methods or digitally; however,

the use of visual language will assist the dentist and

dental technician in the creation of a personalized

smile design. Nowadays, with the significant digital

advances that have occurred in dentistry, there are

systems on the market that help the dental team to

create a personalized new smile design for each spe-

cific patient. The Rebel system is one example of such

a system. It is actually a virtual laboratory that creates

individualized smile designs in three dimensions. The

system, with its very sophisticated artificial intelligence

(AI)-based software, immediately creates a digital wax-

up (STL file). It is therefore simple to use for dentists

and dental technicians at all skill levels because the

direct mock-up and wax-up stages are eliminated.

(Int J Esthet Dent 2021;16:10–32)

11

CLINICAL RESEARCH


treatment planning sequences. The entire

treatment plan is now based on the final

look of the procedure, ie, the final esthetic

outcome, which is decided at the very start

of the treatment.

As an example of such communication

for an interdisciplinary treatment, in smile

design cases with diastemas between an-

terior teeth, the final 3D esthetic digital de-

sign can guide the orthodontic treatment to

move teeth to the most favorable 3D posi-

tion, aiming to use these diastemas inside

the restorative needed volume for future ve-

neer restorations, thus reducing the amount

of natural tooth preparation because most

of the preparation depth would stay in the

[a]esthetic preevaluative temporaries (APTs)

themselves.

To serve this purpose, a third of the in-

cisal parts of our digital esthetic designs are

digitally cut and printed or milled. Toward

the end of the preprosthodontic orthodon-

tic treatment, orthodontists can decide if

any further movements need to be made

by placing these partial APTs over the incisal

edges of the incisors and then fine tune

their treatments accordingly (Fig 1).

Introduction

In the past few decades, dentistry, and spe-

cifically restorative dentistry, has undergone

significant changes. There has been a major

shift from analog to digital dentistry. How-

ever, the basics are crucial and remain the

same whether an analog or a digital ap-

proach is applied, and if there are missing

pieces of the esthetic smile design, the re-

sults will not be favorable.

Over the years, the esthetic expectations

of patients have grown, which has led to

the era of interdisciplinary dentistry that op-

timizes the search for ideal solutions to new

smile designs.

Interdisciplinary dentistry

The concept of interdisciplinary dentist-

ry involves the need for a complete treat-

ment plan from the start, and the entire

interdisciplinary team involved in the case

then perform their specialty tasks and func-

tions according to this previsualized treat-

ment plan.1,2 This interdisciplinary approach

has therefore changed the workflow in

Fig 1 In this patient

case of spaced

dentition, orthodon-

tic treatment was the

first requirement

(a to d).

a

c

b

d

GÜREL ET AL


Fig 1 cont Due to the final esthetic smile design, it was not necessary

for the orthodontist to close all the spaces between the teeth (see j), as

these would later be closed with the correctly proportionally designed

[a]esthetic pre-evaluative temporary (APT) (see k). The ideal digital Rebel

smile design is created during the ongoing orthodontic treatment,

regardless of the current position of the teeth and the existing facially

positioned orthodontic braces (e). The incisal third of this design is

separated in a resected manner from the whole digital design (f). These

parts can be 3D printed or milled (Telio; Ivoclar Vivadent) and positioned

over the incisal edges of the incisors as a partial APT to perfectly guide

and fine-tune the rest of the orthodontic treatment (g). Taking the 3D

positioning of the partial APT as a reference representing the final

esthetic design of the porcelain laminate veneers, this fine-tuning can

be communicated with the orthodontist, and executed. This will allow

the evaluation of the current status of the teeth in all directions such as

vertical, sagittal (buccolingual), and horizontal (mesiodistal). 1) Vertical

positioning: In a porcelain laminate veneer restoration, 1.5 to 2 mm of

incisal lengthening is the ideal. Depending on the final incisal edge

position of the smile design, through the partial APT, that space can be

vertically evaluated, and the decision can be made regarding whether

to intrude or extrude the tooth. 2) Sagittal (buccopalatal) positioning: If

one can see through the facial surface of the tooth from the partial APT,

then a decision should be made regarding whether to further position

the tooth more palatally to naturally create the space for the previously

decided thickness of the eventual porcelain veneer, in order to be

thoroughly minimally invasive during the final tooth preparation. This

decision of positioning the tooth further buccally or palatally can also

be taken by measuring the surface thickness of the partial APT. 3)

Horizontal (mesiodistal) positioning: The spacing mesial and distal of

the tooth position can easily be detected and evaluated relative to this

position of the partial APT, and the final decision of whether to move

the tooth further mesial or distal can then be made (h). 4) Tooth axis

positioning: Depending on the individual tooth shape selected and the

tooth axis of the final porcelain laminate veneers, the tooth can easily

be tilted during this last orthodontic refinement. Specific to this case,

due to the Rebel personalized smile design, a triangular tooth shape

and an inclined tooth axis were selected. This also affects the zenith

point of the tooth, whether it be slightly medial or distal (i). The case

would be finalized with porcelain laminate veneer restorations (l and m).

j

k

m

l

e

i

g

f

h

CLINICAL RESEARCH


treatment planning is complete) and shared

with the patient directly in the mouth in or-

der to communicate the dentist’s intention.

This also has an enormous impact on the

patient’s understanding of the rest of the

treatment.

Visualizing the fi nal result at the start: the mock-up

In restorative dentistry, the mock-up is a

diagnostic tool that allows for the intra-

oral try-in of a prosthetic rehabilitation.9-11

Whether it is a case of a worn dentition,

which necessitates altering the vertical di-

mension, or a straightforward case of the

need for veneers, the starting point of the

esthetic design (mock-up/wax-up/digital

design) should be the incisal edge position.

The esthetic plane of occlusion and func-

tional design will be based on this starting

point, accordingly.

There are diff erent ways to make the

mock-up. It can be directly created in the

patient’s mouth or indirectly created, either

through a wax-up or via digital methods. A

direct mock-up is the fastest way of start-

ing the communication with the patient.

This step is extremely important, since the

At the same time, function needs to be

reconsidered, and then the teeth are struc-

turally restored, taking into account biologic

compatibilities. So, in this new era of four-

dimensional dentistry, the treatment plan-

ning sequence would be: 1) defi ning the

esthetic outcome; 2) creating the new func-

tional setup; 3) restoring the case accord-

ingly, whether it be with the use of crowns,

bridges or implants; and 4) biologically inte-

grating this into the patient’s mouth.

Esthetics-based treatment planning

The treatment planning should be based

on the realistic expectations of the patient

and the dentist. The treatment is then se-

quenced and executed accordingly.3-8

The most creative part of the workfl ow

is the design phase; however, at this stage,

verbal communication is not enough. All

esthetic procedures are very subjective, and

without materializing the esthetic smile de-

sign it is not possible for the dentist to ex-

plain to the patient what will be delivered

at the end of the treatment (Fig 2). There-

fore, the fi nal design needs to be creat-

ed in three dimensions (even before the

Technical Creative Project Execution

Data Communication Design Treatment plan ning Treatment Control

History Patient wishes Mock-up Team meeting Specialties sequence Chairside

Clinical Photographs Offl ine team meeting Timing Patient

Radiographs Videos Esthetics Online team meeting Materials

Models Function Methods

Structure Decision ( conventional/digital)

Biology

Laboratory

Design

Mock-up

Esthetics

Function

Structure

Biology

Fig 2 The design is the most creative part of the workfl ow, whether it be analog or digital. A good design makes the diff erence between a

merely nice result and an amazing one.

GÜREL ET AL


Fig 3 The patient request was for an esthetic

treatment to resolve the differing sizes of her teeth and

her negative smile line (a). The new smile design and

the related treatment planning started with the

positioning of the incisal edge location of the two

maxillary central incisors (b and c). The factors that

were influential in the decision-making process for this

procedure were the relationship of the central incisors,

primarily to the upper lip line and then to the lower lip

line, as well as their proportions and the age and facial

perception of the patient. The tooth preparation and

final porcelain veneers were designed based on the

mock-up design (d).

a

b

d

c

treatment planning and smile design that

follow is based on this outcome.

The first decision to be made is based on

the location of the incisal edges of the two

maxillary central incisors. Many factors influ-

ence the decision making in this procedure

such as the relationship of the central inci-

sors primarily to the upper lip line and then

to the lower lip line; also taken into account

are their proportions, the mobility of the up-

per lip, and the age and sex of the patient.

Ideally, the first step is to start morph-

ing the composite onto the two maxillary

central incisors. The incisal edge position

of these two teeth is decided just after the

composite is placed on them and before it

is added to the remaining teeth. This pro-

cess should be undertaken with the patient

sitting upright in the dental chair, and with

the dentist face to face with the patient.

Once this has been done, the mock-up

can be carried out on the rest of the teeth

(Fig 3).

The [a]esthetic pre-evaluative temporary (APT)

Once the preliminary design of the direct

mock-up is approved by both the dentist

and the patient, the case can be sent to the

dental laboratory for a wax-up to be made.

Once the wax-up is returned to the dental

office, a silicone impression is made from it

that is filled with a flowable resin and placed

in the patient’s mouth before the patient is

anesthetized for tooth preparation. This is

called the (a)esthetic pre-evaluative tempo-

rary (Fig 4).10,12

CLINICAL RESEARCH


the restored teeth do not really ‘belong’ to

them.13 These patients may not be able to

identify exactly what they think is ‘wrong’

with or lacking in their smiles, and in most

cases they are not able to adequately ver-

balize their feelings or needs – everything

looks fine and is functional, but it just does

not feel ‘right’ somehow.14

The personal identity of the patient

At the end of the treatment, the patient

needs to feel happy. If the new smile design

is received in a very positive way by the pa-

tient (as opposed to a feeling of lukewarm

satisfaction with standard ‘nicely aligned

teeth’), then both the dentist and the patient

will feel very differently. What most people

really want is diversity and differentiation,

something that helps them to stand out

in a crowd. This is often easier to achieve

for smaller, independent concerns who in-

vest in tailormade solutions. The senses of

touch, smell, and taste all evoke individual

personalized feelings that everyone experi-

ences in a different way (Fig 5).

Smile design and self-identification

For many years, dentists and dental techni-

cians have used all the basic esthetic rules

to properly create new smile designs for pa-

tients. These rules are the fundamental keys

and should set the tone of any smile design.

However, at times, the final esthetic results

fail to meet the patient’s expectations due to

a disharmony between the smile design and

the patient’s sense of self-identity. High pa-

tient expectations together with the amount

of information available today has driven the

profession to reassess the customization of

new smile designs, which need to take into

account the individual psychologic char-

acteristics of each patient. If this aspect is

ignored, it may lead to the patient’s dissatis-

faction with the final outcome, despite the

incorporation of all the esthetic principles

and rules which tend to establish accept-

able standards.

Sometimes, newly created smile de-

signs may look picture perfect on close-up

photographs (eg, when taken with the lips

retracted), but in reality patients feel that

Fig 4 The detailed wax-up, which is prepared by copying the direct mock-up design, is then transferred to the

patient’s mouth as the APT (a). Upon approval of the esthetic outcome by the patient and the dentist, the tooth

preparation is done through the APT and, based on this final wax-up/APT design, the final porcelain veneers are

fabricated (b).

a b

GÜREL ET AL


contrary, it may well be – but it does not

match the patient’s personality. Similarly,

imagine delivering to a patient with a very

delicate personality a smile design with very

strong and dominant central incisors and

aggressive-looking canines. Again, it does

not necessarily mean that the design is not

a good one, but rather that it does not fit

the patient’s personality or the way that the

person wants to be perceived by others. In

the end, the patient will feel uncomfortable

with this smile.

The aim of this article is to reflect the

results of our research of the past 13 years

evaluating the new smile designs on which

our team has been working. The objective

is always to create not just a satisfied patient

response to the smile design, but one of

amazement, because the new smile reflects

The fifth dimension of the smile

Until recent years, smile design in dentistry

was based on the four dimensions of biol-

ogy, structure, function, and esthetics – the

last being largely dependent on the age and

sex of the patient. However, in reality, none

of these dimensions took into account the

personality of the patient, despite the fact

that a ‘perfect’ smile design should reflect

this. Patient identity, which includes person-

ality, is therefore the fifth dimension of the

smile.

Imagine a down-to-earth patient with a

dynamic personality who usually dresses in

jeans, trainers, and a simple white shirt being

forced to wear a dress, high-heeled shoes,

and makeup. This does not mean that the

latter style of dress is not beautiful – on the

Fig 5a to c The smile design elements that visually ‘translate’ each patient’s identity may help the dentist to

improve the psychologic features of the created image, which affect the emotions, behavior, and confidence of

the patient. The senses such as touch, smell, and taste are experienced subjectively and differently by all individuals.

a

b

c

CLINICAL RESEARCH


the patient’s personality and emotional

needs/feelings (ie, it takes into account the

fifth dimension of the smile). This makes the

present approach quite different from the

traditional one. The key to this translation

of the patient’s personality and feelings into

the new smile design is visual language.

The visual language of lines

Lines and shapes represent the most basic

elements of visual language.

Each type of line has a specific emo-

tional connotation.15 Horizontal lines, due

to their conformity with gravity, express

stability, passivity, and calmness, while ver-

tical lines represent the movement of the

point against gravity and express strength

and power. Inclined lines arouse a sense

of instability, a tendency to movement

and dynamism, while curved lines are as-

sociated with delicacy, sensuality, and

femininity.16

The combination of lines generates the

most basic shapes/forms, each reflect-

ing a unique expression. Thus, the vertical

rectangle expresses strength by the pre-

dominance of the vertical element on the

horizontal, the triangle evokes dynamism,

the oval gives a sense of delicacy, and the

square represents stability and immobility

due to the balance between the vertical and

horizontal elements intrinsic to this shape

(Fig 6).

Visual identity of the smile (VIS)

The word ‘visage’ is derived from the French

word for ‘face,’ and the term ‘visagism’ refers

to the study of the face in terms of its con-

stituent traits, the esthetic relation among

its elements, and its visual expression. The

Visagism concept was defined by the plastic

artist Philip Hallawell as the art of creating a

customized personal image that expresses

a person’s sense of identity.13,17

This idea is the basis of the fifth dimen-

sion of the smile. Every human smile is

unique and special and reflects the smiler’s

personality. Shape, texture, color, and the

way the teeth are combined convey direct

messages when it comes to creating new

smile designs, where the idea of the ‘unity

of the whole’ is relevant as it brings together

biology, structure, function and esthetics as

well as the fifth element – the identity. This

fifth element is the quintessential one be-

cause the others balance it like a keystone.

In our research, these effects have been

recognized and incorporated into our new

smile designs. Using the visual language

created by lines and shapes, we have tried

to deliver new smile designs to patients

that reflect their personalities, eg, a patient

with a strong personality would not appre-

ciate a calm-looking smile with non-domi-

nant central incisors, softer rounded tooth

shapes, and rounded canines; instead, a

design with more dominant central incisors,

more pronounced and sharper canines, and

vertical, rectangular tooth shapes would be

more apt.

The knowledge of visual language is

therefore applied to the main expressive

elements of a smile design (dental shapes,

incisal edge, interdental ratio dominance,

and 3D positioning of the teeth in the arch)

and determines the following four smile de-

sign types (Fig 7):

Strong: Design is composed mainly of rect-

angular dental shapes, strong dominance

of the central incisors and canines on the

lateral incisors (radial symmetry) as well as

plane incisal edge and rectilinear 3D dental

positioning on the arch in the occlusal view

(Fig 8a1 and a2).

Dynamic: Triangular or trapezoidal dental

shapes, standard dominance, inclined in-

cisal edge, and angled 3D dental positioning

on the arch (Fig 8b1 and b2).

GÜREL ET AL


Fig 6 The vertical lines and rectangular shapes express strength due to the predominance of the vertical element

on the horizontal (a), the inclined lines and triangular shapes express dynamism (b), the oval and round shapes

express delicacy (c), and the horizontal line expresses stability and immobility due to the balance between the

vertical and horizontal elements (d).

a bbbb

c ddddddd

CLINICAL RESEARCH


Delicate: Oval dental shapes, medium

dominance, curved incisal edge, and stan-

dard 3D dental positioning (Fig 8c1 and c2).

Calm or stable: Smoothly rounded square

dental shapes, weak dominance (current

symmetry), horizontal incisal edge, and 3D

rectilinear or standard dental positioning on

the arch (Fig 8d1 and d2).

The new concept

When a dentist first evaluates a new patient

with esthetic concerns, many critical factors

may be overlooked. The verbal information

exchange needs to be translated into a vi-

sual perception in order for the patient and

the dentist to exactly understand the final

end-of-treatment expectations.

Through the large number of smile de-

sign elements such as incisal edge, domi-

nance, dental axis, and tooth shapes as well

as sub-elements such as the morphologic

details of each tooth, it is possible to estab-

lish – based on the dental scientific litera-

ture – which ones should be determined by

the facial typology and which would visually

represent the unique personality of patients,

beyond their personal preferences and the

expression of their desires.18

Thus, for standard practice, a concept

for smile design customization was elabo-

rated by Paolucci et al13,19 that is reproduc-

ible and accessible to all professionals. This

concept derived from the association of

different knowledge bases, such as esthetic

and functional dental fundamentals, artistic

visual language, facial recognition, and per-

sonality typology. These denominate the vi-

sual identity of the smile (VIS). For the objec-

tive application of this concept, the Rebel

software was developed.

b

a

c

d

Fig 7 The knowledge of visual language applied to the main expressive

elements of smile design (such as dental shapes, incisal edge, interdental ratio or

dominance, and 3D positioning of the teeth in the arch) determines four basic

smile designs types with primary expression, from top to bottom: strong (a),

dynamic (b), delicate (c), calm (d).

GÜREL ET AL


Fig 8a1 to d2 Not all smile designs look good on all patients because each person displays a different variation of incisal silhouette, tooth

axis, central incisor dominance, and combination of individual tooth shapes out of many different possibilities. If the final smile design from

one patient is copied and placed into the mouth of another, it will definitely look different and may be unpleasant. To build the precise esthet-

ic design for every individual, the visual language of the patient’s facial perception and personality must be carefully analyzed so that they are

reflected in the smile design for that individual.

a1

b1

c1

d1

a2

b2

c2

d2

CLINICAL RESEARCH


Although the AI-based Rebel software

is very sophisticated, it provides great sim-

plicity to end users (dentists and dental

technicians).

Case presentation

The patient was dissatisfied with her smile

due to her short teeth and yellowish tooth

color. The aim of the esthetic treatment was

therefore to enhance her smile (Fig 9a to d)

by utilizing the Rebel software as described

above to create the most natural and per-

sonalized smile design possible, following a

minimally invasive approach.

Esthetic analysis and Rebel

As already mentioned, the Rebel system

performs a digital previsualization that al-

lows the clinician to efficiently design the

new smile, improve the communication be-

tween the dental team members involved

in the treatment, and achieve better com-

munication with the patient regarding visu-

alizing the final esthetic result, even before

the start of treatment. This also serves to

motivate the patient. By the same token,

Rebel enhances the predictability of the en-

tire treatment, which guides the actual clin-

ical treatment. This approach allows for the

sharing of the treatment plan among team

members and for creating a 3D visual per-

ception of the case in the patient’s mouth.

The digital project is therefore tested and

approved before the start of treatment and,

accordingly, allows the dentist to present

treatment solutions.

The Rebel workflow

The Rebel system probably has one of the

simplest interfaces for transferring all the

necessary information to the Rebel digital

laboratory. These are three mandatory steps

to be followed:

The Rebel software

The computational ‘mind’ of this new soft-

ware is fueled not only by the traditional

biologic, structural, functional, and esthet-

ic parameters but also by the variables re-

lated to the patient’s personality. This fifth

dimension makes a world of difference

when properly introduced into the artificial

intelligence (AI)-based algorithm on which

the Rebel software is built. The information

about the personality is gathered from two

sources: The Dellinger and Eysenck Person-

ality Test and controlled interviews with the

patient. The data derived from these sourc-

es is then simply fed into the software by

the dentist,20 where a facial reading, person-

ality assessment, and personal preference

evaluation of each patient is performed and

converted into mathematical language. Ini-

tially, the 2D smile design is created through

preprogrammed algorithms. The software

is capable of automatically transforming

this 2D smile design into a 3D customized

model. The model generation is performed

through a custom 3D library, developed

specifically for the Rebel Simplicity soft-

ware. Every model is personalized accord-

ing to the proposed tooth configuration.

The virtual laboratory

The Rebel system is actually a virtual labora-

tory that decides on the 2D design and con-

verts it immediately into three dimensions to

create a 3D digital wax-up (in STL format). The

2D design is created by relating the patient’s

facial perception and personality to the smile

design, and by applying algorithms for com-

puting the optimal combination of the incisal

silhouette, tooth axis, dominance of the cen-

tral incisors, and combination of individual

tooth shapes out of thousands of possibili-

ties. It may sound complicated; however, it

is the simplest way of getting one of the best

3D digital wax-ups possible in dentistry today.

GÜREL ET AL


This approach therefore allows any den-

tist at any level of experience and skills to

start by working with mock-ups and end

up with high-level wax-ups.

Once the mock-up is complete, it is dig-

itally scanned with an intraoral scanner to

create an STL file. Most intraoral scanners

on the market today perform this conver-

sion automatically (Fig 10b). If an intraoral

scanner is not available in the dental prac-

tice, an analog impression of the maxil-

la can be made (preferably with the direct

mock-up on the central incisors in place)

and sent to a dental laboratory with a CAD/

CAM setup, which will include an extraoral

digital scanner. The dental technician will

then digitalize the impression and upload

the STL file into the link to the Rebel system

provided by the dentist.

1. Single central incisor mock-up and digi-

tal scanning.

2. Full-face photography protocol.

3. Simple interview/questionnaire.

1. Single central incisor mock-up and intra-

oral digital scanning

A composite mock-up on one (or two) of

the central incisors is performed to identi-

fy the incisal edge position vertically and

the position of the facial surface buccolin-

gually (Fig 10a). Although this is no differ-

ent from making any direct mock-up, the

great advantage of creating it this way is

that the software, and not the dentist, will

make the choices of parameters such as

tooth shape, angulation of tooth axis, sur-

face texture, etc, according to the facial

perception and personality of the patient.

Fig 9a to d The patient is not happy with her smile due to her short teeth and the yellowish tooth color.

a d

b

c

CLINICAL RESEARCH


smile softly (if possible, so that the incisal

edges of the maxillary incisors are shown).

12 o’clock position

There are two simple ways to take this

photograph.

The first and easy choice is for the pa-

tient to remain in the same position but tilt

the face 45 degrees forward while smiling a

full smile. The photograph should be taken

in such a way that it shows the relationship

to the maxillary central incisors and the dis-

played arch position to the lower lip line.

Alternatively, the patient is asked to lie in

a supine position on the dental chair. The

dentist then moves into the 12 o’clock po-

sition, asks the patient for a full smile, and

takes a photograph at a 45-degree angle.

Retracted, mouth closed

The patient should be asked to hold the full-

mouth retractors, again keeping the posi-

tion of the eyes parallel to the horizon, the

head upright (not tilted to the right, left, upt

or down), and the teeth closed. The occlu-

sal plane is parallel to the horizon.

Retracted, mouth open

The same protocol as for the previous pho-

tograph should be repeated, but this time

with the maxilla and mandible separated.

2. Full-face photography protocol

The software requires a full-face photogra-

phy protocol comprising five images9 in or-

der to obtain the facial recognition of the

patient and relate the 3D intraoral digital

scan to the facial features, as follows (Fig 11):

Lips at rest

This purpose of this photograph is for the

software to perform automatic facial recog-

nition. Part of the new Rebel smile design

will be based on this facial perception of

the patient. Technically, the patient’s fore-

head and ears must be visible. Long hair

must be kept away from the face. It is cru-

cial for the head to be kept upright (not tilt-

ed to the right, left, up or down). The eyes

should preferably be positioned parallel to

the horizon with the lips apart. The software

automatically checks the required full-face

photograph for its suitability and sends an

immediate message to the dentist if it does

not meet the requirements and needs to be

redone.

Smiling

The patient should remain in the same po-

sition with the eyes open and parallel to the

horizon and the head kept upright (not tilted t

to the right, left, up or down). For this image,

the patient should keep the lips apart and

Fig 10 The treatment of every esthetic case should start by defining the incisal edge position of the maxillary

central incisors. A composite mock-up on one (or both) of the central incisors identifies the incisal edge position

(vertically) and the position of the facial surface (buccolingually) (a). This simple mock-up is digitally scanned

together with the full maxillary arch (b).

a b

GÜREL ET AL


interview/questionnaire are checked by an

algorithm in the software, which automat-

ically calculates the patient’s temperament

personality. The temperament will be a

combination of strong, dynamic, delicate,

and calm. After this procedure, the dentist

and dental technician will have a complete

assessment of the patient’s facial percep-

tion and personality (Figs 13 and 14).

When the entire Rebel workflow is

completed, the software guides the den-

tist to exit, and with a mouse click, the file

is immediately sent to the Rebel digital

laboratory.

Rebel digital laboratory

The next step is the conversion of the 2D

digital project into a 3D mock-up through

the Rebel digital laboratory and the creation

3. Simple interview and questionnaire

The next step is the completion of an inter-

view and questionnaire. This is achieved in

less than a minute through the question-

naire incorporated in the software, and pro-

vides data which indicate the primary and

complementary personality traits and char-

acter of the patient (Fig 12).

The personality type of each individual is

defined by a unique combination of diverse

characteristics of the four main tempera-

ment types. Therefore, for a precise and

practical evaluation of personality, it is nec-

essary to apply a specific questionnaire. The

questionnaire is based on popular psycho-

logic tests for personal self-assessment. The

first question is an adapted test by Dellinger,

and the other three concern personality

traits based on the theory and questionnaire

by Eysenck.21,22 The data resulting from the

Fig 11 The full-face photography protocol requires five mandatory photographs to be taken: lips at rest (a), smiling (b), 12 o’clock position

(c), retracted mouth closed (d), retracted mouth open (e). Note: For all the photographs (except the 12 o’clock position), the patient should

remain in the same position with the eyes open and parallel to the horizon and the head held upright (not tilted to the right, left, up or down), t

with the ears and forehead visible (patients with long hair should tie it back).

Smiling Lips at rest 12 o’clock position Retracted mouth closed

Retracted mouth open

Five photographs

a b c d e

CLINICAL RESEARCH


Fig 13 The software dictates the perception of the face through recognition of the full-face photographs and the refl ection of the personali-

ty according to the questionnaire, which immediately demonstrates in graphics (visually) the strength of the characteristics ‘strong, dynamic,

delicate, calm’ and their relation to the patient’s face and personality. The software uses this information to create a new smile design based

on the visual language.

Fig 14 At this stage, any specifi c designs such as the expected position of the buccal corridors, perfect imperfections that need to be

emphasized, the intensity of the surface texture, etc, are chosen by clicking as the dentist is guided by the software. Any extra optional

features or comments can be added in the text box, if necessary.

Fig 12 Based on the data from the questionnaire (adapted from the Dellinger questionnaire), the software algorithm automatically calculates

the patient’s character (personality/temperament) and the way the patient wants to be perceived. The temperament illustrated here is a

combination of dominantly strong, with complementary elements of dynamic and calm.

GÜREL ET AL


shape relative to the facial perception and

personality of the patient (Fig 15a and b).

Once this design is automatically placed

over the digitally scanned original maxilla of

the patient and rendered, an STL file of this

new digital wax-up is made.

of a digital wax-up. The AI-based algorithms

of the software decide on the main ele-

ments of the new smile design (incisal sil-

houette, dominance of the central incisors,

tooth axis, and arch form). It also choos-

es the ideal (most natural) individual tooth

Fig 15a and b In the Rebel digital laboratory, the software immediately creates the new Rebel smile design, first by designing it in the 2D

Visagismile format, and then by automatically transforming that into the 3D Rebel design in less than a few minutes.y At the same time, the

AI-based software decides on and chooses the main elements of the new smile design.

a

b

CLINICAL RESEARCH


their ideal shape, surface texture, etc. The

harder this silicone transfer impression, the

more precise the transfer will be (Fig 17).

This transfer should be done prior to any-

thing else, ie, the dentist should evaluate the

new design (as the APT or final mock-up) well

before starting the tooth preparation (Fig 18).

Not only does this achieve the ideal 3D smile

design, but it also creates a great opportunity

Back to chairside/3D printing

The STL file is then sent to the dentist via

email, ready to be 3D printed (Fig 16). Once

a 3D-printed model is made, the dentist can

easily transfer the design into the patient’s

mouth by making a silicone impression of

the digital wax-up, duplicating all the details

such as the line angles that give the teeth

Fig 16a to c L file is received via email from the

Rebel digital laboratory and is 3D printed.

Fig 17a and b Once the 3D-printed model is created, the dentist can easily transfer the design into the patient’s

mouth by means of a silicone impression of the digital wax-up that is created using a provisional material of choice

(eg, Luxatemp; DMG).

aaaaaaaaaaaaaaaaaaa

c

b

aaaaaa bbbbbbbbb

GÜREL ET AL


esthetic smile design (created by Rebel) as

a base.

Tooth preparation through the APT

Once the final design is approved by the

dentist and the patient, the dentist can anes-

thetize the patient and start preparing the

teeth through the APT (Fig 19a to d).

for the dentist to communicate the 3D smile

design to the patient. The final esthetic de-

sign should be approved at this point.

After this esthetic approval, in cases of

worn dentition or if any alterations need to

be carried out on the occlusal surfaces, the

final functional digital wax-up can be com-

pleted with any digital software that can

deliver these additional changes, using the

DOMINANCE TOOTH AXIS

TOOTH SHAPE INCISAL SILHOUETTE

Fig 18a and b The visualization of the APT in the mouth and its relation to the facial appearance. This design was created by the software,

with dominant central incisors (green), triangular-to-rectangular tooth shapes (orange), a triangular-to-rounded incisal silhouette (black), and a

slightly inclined tooth axis (blue), all based on the facial perception and personality of the patient. As can be seen in this illustration, the

software can create a smile design with many different combinations of the different shapes, lines, and line angles.

aaaa

bb

CLINICAL RESEARCH


Conclusion

Combining modern digital technolo-

gies with classical treatment rules can be

beneficial for achieving predictable es-

thetic results. More natural and personal-

ized smiles are created by the new smile

design approach through the combina-

tion of the basic rules of esthetics with the

reflection of the patient’s facial analysis

and personality (character/temperament)

(Fig 20). This principle presumes a harmo-

nious relationship between the smile de-

sign and the patient’s identity. However,

in the dental practice, its application has

been limited due to the lack of an ob-

jective method for assessing personality

Finalizing the case

Once the teeth are prepared, the dentist

can choose to continue the case digital-

ly by creating an intraoral digital scan, or

continue in a conventional analog manner.

The patient is dismissed with the provisional

restoration.23

In the same way, the laboratory can

produce the veneers digitally by milling, or

by using pressable ceramics or feldspathic

veneers. In this case, IPS e.max pressable

ceramics (Ivoclar Vivadent) were chosen,

with a one-third incisal cutback and felds-

pathic porcelain applied on top utilizing the

micro-layering technique, and bonded onto

the teeth.24-26

Fig 19a to d After the approval of the esthetic outcome of the APT (from the 3D digital wax-up), the dentist can start minimally invasive

tooth preparation through the APT. Note: Esthetics allowing, the more additive the nature of the facial contouring of the Rebel design, the

less invasive the dentist can be.

a b c

d

GÜREL ET AL


Fig 20a to d The final result: Monolithic IPS e.max porcelain

laminate veneers (Ivoclar Vivadent) performed with a minor

cutback technique are applied over the incisal edges. The smile

flows with the facial appearance and the personality of the

patient, who is extremely happy with the new smile design. The

patient expressed her feelings by saying that “even though a major

change has been made to my smile, nobody hardly ever

understands that I have been treated with veneers.”

a

c

b

d

CLINICAL RESEARCH


a minimum success rate of 80% is seen in

the acceptance of the final smile design

when this concept is applied.

A final note: The acceptance of a final

smile design by a patient is a very subjec-

tive matter. If the patient is not satisfied with

the final result after the application of this

concept, before any further investigation

and research is done, the dentist can always

make minor alterations to adapt the smile

design according to the patient’s wishes.

and incorporating it meaningfully into the

smile design.

The Visagismile/Rebel software can help

clinicians to provide new smile designs that

reflect the patient holistically by incorpo-

rating the personality into the smile design.

This has a positive effect on the identity, be-

havior, and self-esteem of the patient. The

concept can be applied very quickly, easily,

and practically by the entire dental team. Ac-

cording to the authors’ clinical experience,

References

1. Gurrea J, Bruguera A. Wax-up and mock-

up. A guide for anterior periodontal and

restorative treatments. Int J Esthet Dent

2014;9:146–162.

2. Fradeani M. Evaluation of dentolabial pa-

rameters as part of a comprehensive esthet-

ic analysis. Eur J Esthet Dent 2006;1:62–69.

3. Fradeani M, Redemagni M, Corrado

M. Porcelain laminate veneers: 6- to 12-

year clinical evaluation – a retrospective

study. Int J Periodontics Restorative Dent

2005;25:9–17.

4. Burke FJ. Survival rates for porcelain lam-

inate veneers with special reference to the

effect of preparation in dentin: a literature re-

view. J Esthet Restor Dent 2012;24:257-265.

5. Friedman MJ. A 15-year review of

porcelain veneer failure – a clinician’s

observations. Compend Contin Educ Dent

1998;19:625–630.

6. Dumfahrt H, Schäffer H. Porcelain

laminate veneers. A retrospective evaluation

after 1 to 10 years of service: Part II— Clinical

results. Int J Prosthodont 2000;13:9–18.

7. Swift EJ Jr, Friedman MJ. Critical ap-

praisal. Porcelain veneer outcomes, part I. J

Esthet Restor Dent 2006;18:54–57.

8. Calamia JR, Calamia CS. Porcelain lam-

inate veneers: reasons for 25 years of suc-

cess. Dent Clin North Am 2007;51:399–417.

9. Coachman C, Calamita M. Digital Smile

Design: A tool for treatment planning and

communication in esthetic dentistry. Quin-

tessence Dent Technol 2012;35:101–109.

10. Gürel G, Morimoto S, Calamita MA,

Coachman C, Sesma N. Clinical perfor-

mance of porcelain laminate veneers:

outcomes of the aesthetic pre-evaluative

temporary (APT) technique. Int J Periodon-

tics Restorative Dent 2012;32:625–635.

11. Mclaren EA, Cao PT. Smile analysis and

esthetic design: “In the zone”. Inside Dentist-

ry 2009;5:44–48.

12. Gürel G. The Science and Art of Porce-

lain Laminate Veneers. Berlin: Quintessenz,

2003.

13. Paolucci B. Visagismo e odontologia.

In: Hallawell P (ed). Visagismo Integrado:

Identidade, Estilo, Beleza. São Paulo: Senac,

2009:243–250.

14. Paolucci B, Calamita M, Coachman CH,

Gürel G, Schayder A, Hallawell PH. Visagism:

The art of dental composition. Quintes-

sence Dent Technol 2012:1:187–200.

15. Jung CG, von Franz M-L, Henderson

JL, Jacobi J, Jaffe A. Man and his Symbols.

Anchor Press Doubleday, 1968.

16. Arnheim R. Visual Thinking. University of

California Press, 1969.

17. Hallawell P. Visagismo: Harmonia e

Estética. São Paulo: Senac, 2003.

18. Kois JC. Diagnostically driven interdis-

ciplinary treatment planning. In: Cohen M

(ed). Interdisciplinary Treatment Planning:

Principles, Design, Implementation. Quin-

tessence, 2008:193.

19. Paolucci B, Hallawell P, Sauer C, et

al. Visagismo: a arte de personalizar o

desenho do sorriso. São Paulo: Vm Cultural,

2011:252.

20. Yankov B, Iliev G, Filtchev D, et al. Soft-

ware Application for Smile Design Automa-

tion Using the Visagism Theory. Proceed-

ings of the 17th International Conference

on Computer Systems and Technologies,

CompSysTech’16, June 23-24, Palermo,

Italy, ACM International Conference

Proceeding Series, Vol 1164, ACM Inc, NY,

USA:237–244.

21. Dellinger S. Communicating beyond

our differences: introducing the psy-

cho-geometrics® system. Tampa, FL: Jade

Inc, 1996:204.

22. Eysenck HJ, Eysenck SB. Manual of the

Eysenck Personality Questionnaire. London:

Hodder and Stoughton, 1975:47.

23. Mitrani R, Phillips K, Escudero F. Pro-

visional restoration of teeth prepared for

porcelain laminate veneers: an alternative

technique. Pract Proced Aesthetic Dent

2003;15:441–445.

24. Pashley DH, Tay FR, Breschi L, et al.

State of the art etch-and-rinse adhesives.

Dent Mater 2011;27:1–16.

25. Van Meerbeek B, Yosihara K, Yoshida Y,

Mine A, De Munck J, Van Landuyt KL. State

of the art of self-etch adhesives. Dent Mater

2011;27:17–28.

26. Spreafico RC. Composite resin reha-

bilitation of eroded dentition in a bulimic

patient: a case report. Eur J Esthet Dent

2010;5:28–48.

The ﬁfth dimension in esthetic dentistry

Documents

Transcript of The ﬁfth dimension in esthetic dentistry