20 DIGITAL Dental Tribune Middle East & Africa Edition | 5/2020 The art of a personalised smile design By Dr Galip Gürel, Turkey; Drs Dimitar Filtchev & Georgi Iliev, Bul- garia; Dr Braulio Paolucci & Adriano Schayder, Brazil Introduction Aesthetics has become one of the most important out- comes of den- tal treatments. Regardless of the complexity of the case, patients are seeking better-looking smiles. For many years, we, as dentists or labo- ratory technicians, have been using all the basic aesthetic rules in order to properly create a smile design. These rules should be fundamen- tal to the design. At the end of the treatment, the patients should feel happy. If one can evoke this feeling with a smile design, both the dentist and the patient will be satisfi ed giv- ing and receiving more than stand- ard, well-aligned teeth. However, the fi nal aesthetic results may often fail to meet the patient’s expectations, owing to a disharmony between the smile design and the patient’s identity. Patients’ demands and the level of information needed have driven the profession to question it- self regarding the customisation of smile designs, which if ignored may lead to dissatisfaction with the aes- thetic outcome, even though all the aesthetic principles and rules which tend to establish standards have been taken into account. The mock-up Visualisation of the smile design will have a great impact on the patient’s understanding of the rest of the treatment. It is much more power- ful than only verbally explaining what will be done. Prior to initiating any treatment, it is necessary to visu- alise the desired outcome. It then becomes possible to formulate the steps required to achieve this result. Mock-ups facilitate signifi cant im- provement in communicating with the patient by showing him or her the potential fi nal outcome of the treatment and allowing an easy com- parison of the pre- and postoperative situations, and mock-ups allow the clinician to be able to check the func- tional aspects. Whether it is a case of worn dentition that requires alter- ing the vertical dimension or just a straightforward veneer case, the aes- thetic plane of occlusion and func- tion will be based on the length—in- cisal edge position—and position of the anterior teeth. It is very diffi cult to convey the envisioned fi nal length of the central incisors to the patient just by adding composite to the in- cisal edges of the central incisors; thus, the patient needs to see the whole smile, including the length and position of the posterior teeth. There are different ways to make the mock-up. It can be created directly in the patient’s mouth or indirectly either through a wax-up or by using digital tools. The personalised smile design Every human being is unique and special and the design of his or her smile should refl ect his or her per- sonality. Shape, texture, colour and Fig.1: When the dentist fi rst evaluates a new patient with aesthetic concerns, many critical factors may be overlooked. The verbal infor- mation exchange should be translated into a visual representation in order to aid in understanding what the fi nal expectations should be at the end of the treatment, for the patient and the dentist. The basic means of this communication starts with a 3D preview of the design in the patient’s mouth (APT: Aesthetic Pre-evaluative Temporaries) even before the rest of the treatment is planned. No matter what clinical diffi culties a dentist will face and how problems will technically be solved, if the patient does not like the fi nal aesthetic outcome, the treatment will be considered a failure. combination of teeth convey direct messages, and when it comes to cre- ating smile designs, dentists must consider the unity of the whole, which means bringing the biology, structure, function and aesthetics together with a fi fth element, per- sonality. Personality is the quintes- sential part here, because the other cacy, sensuality and the feminine gender.2 The combination of lines generates the most basic forms, transferring to them their own expressions. Thus, the vertical rectangle expresses strength by the pre- dominance of the vertical element on the horizon- dental shapes, standard dominance, inclined incisal edge and angled 3D dental positioning on the arch. – Delicate: oval dental shapes, medi- um dominance, curved incisal edge and standard 3D dental positioning. – Calm or stable: smoothly rounded 2a 2b 2c Figs.2a–c: The aim of this aesthetic treatment was to enhance the patient’s smile. However, additional to all the aesthetic smile design basics, the facial analysis and the personality of the patient should be refl ected in this design, in order to create the most natural, minimally invasive, personalised smile design. four elements are traditionally laid to balance it like a keystone. Through the large number of smile design elements, such as incisal edge, domi- nance of central incisors, tooth axis and shape, as well as sub elements such as morphological details of each tooth, it is possible to establish, based on the dental scientifi c litera- ture, which should be determined by the facial typology and which could visually represent the unique personality of each patient, beyond his or her personal preferences and expression of his or her will. Visual language Each type of line or shape has a specifi c emotional meaning.1 Lines represent the most basic elements of visual language. Horizontal lines, because they con- form to gravity, express stability, passivity and calm- ness, while vertical lines represent the movement of the point against gravity, expressing strength and power, just as inclined lines arouse the sensation of instability, tenden- cy to movement and dynamism. Curved lines are associated with deli- tal, the triangle dynamism, the oval delicacy, the square stability and im- mobility with the balance between its vertical element and horizontal one. These basic shapes can be ob- served in the facial contour as well as in the incisors’ shapes and 3D confi g- uration of the dental arrangement, thus the incisal silhouette. The visual language knowledge ap- plied to the main expressive ele- ments of smile design, such as dental shape, incisal edge, interdental ratio or dominance of central incisors, and 3D positioning of the teeth in the arch, determines four smile de- sign types with primary expression (Fig. 1): – Strong: composed mainly of rec- tangular dental shapes, strong domi- nance of the central incisors and ca- nines over the lateral incisors (radial symmetry), as well as plane incisal edge and rectilinear 3D dental posi- tioning on the arch from an occlusal view. square dental shapes, weak domi- nance (current symmetry), horizon- tal incisal edge and 3D rectilinear or standard dental positioning on the arch. Case presentation The patient had short teeth and was not happy with the narrow buccal corridors and the yellowish colour of her teeth (Figs. 2a–c). Aesthetic analysis and Rebel Sim- plicity Aesthetic design can be challenging for dentists. Rebel (Visagismile) is a recent digital previsualisation tech- nique that allows the clinician to: – effi ciently design the new smile; – improve the communication be- tween the dental team members in- volved in the treatment; – obtain better communication and achieve better patient motivation; and – visualise the fi nal aesthetic result even before the treatment is started. – Dynamic: triangular or trapezoidal ÿPage 21 Fig.3: Once the mock-up on the central incisor has been completed, it should be digitally scanned. It can be scanned with any intraoral scanner that can produce an STL fi le. Most intra-oral scanners convert the 3D scan into an STL fi le automatically. However, if the dentist does not have an intra-oral scanner in the dental practice, an analog impres- sion of the upper jaw (preferably with the direct mock-up done on the central incisors) is taken and sent to the nearest dental laboratory that owns a scanner (laboratories that work with a CAD/CAM machine will have a digital scanner). The dental technician can digitalise this impression for the dentist and upload the STL fi le to Rebel, in order to complete the order via a provided link.