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]
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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
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12 | The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021
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
13The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 |
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
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14 | The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021
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.
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15The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 |
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
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16 | The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021
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
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17The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 |
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
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18 | The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021
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).
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19The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 |
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
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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).
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21The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 |
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
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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.
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23The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 |
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
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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
25The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 |
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
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26 | The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021
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
27The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 |
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
28 | The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021
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
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GÜREL ET AL
29The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 |
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
30 | The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021
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
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31The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021 |
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
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32 | The International Journal of Esthetic Dentistry | Volume 16 | Number 1 | Spring 2021
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,
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