April 3, 2019
by Dr. Galip Gurel; Dr. Les Rykiss
How did you come to put your focus on aesthetic dentistry?
Well actually I’m coming from a family, which my father and mother used to be dentists. I opened my eyes in a dental practice and that was my first choice to be and I must admit I love the profession and this is why I’m doing it with great happiness and confidence. Sometimes your wishes don’t match up with your expectations. I was happy that I chose a profession that I didn’t know which way to go, but then it happened to be a very colourful journey for me.
I started working in my parents’ office and, having said that, I was doing some normal, per se, dentistry. The regulars: drilling, filling, crowns, bridges; but the year I started working with them, which was very early 80’s, veneers were getting popular. Besides the veneers, I started realizing that regardless of the difficulty of the case, patients were really enjoying better looking smiles. Those days aesthetic dentistry was not an issue. We were just trying to do better looking smiles. When I saw that patients were really looking after better smiles, or even if they weren’t looking after, but when we deliver a nice-looking smile I completely realized that they were looking much happier, actually enjoying what they had in their mouths. This is how I started thinking about different ways to set up a case and esthetically design it and then keep on treatment planning it.
You discuss the intraoral mock-up quite a bit. What is the thought process that brought you to the idea of the mock-up?
When aesthetic dentistry was not the primary issue in the late 70’s or early 80’s, we really didn’t need a design. What I have seen through my parents’ office or through many, many dentists’ offices is you have a case where patients come for better looking teeth. The patient would come, the teeth would be prepped and sent to a laboratory, and regardless of what the material being used was (those days porcelain was the top material) a design would come that would try to fit into the patient’s mouth, and then if it’s way off, try shortening the teeth, changing the shape a little bit. The design that came from the laboratory would try to fit in the patient’s mouth as good as it can be. This was the basic rules or set-up when a case would be treated for the anterior incisors. Then I realized that in an architecture office, when you ask to build a house, even if they wouldn’t tell you all the details, which an engineer can understand, at least they would deliver you a 3D sketch of what would happen. Then you would have an idea of how many rooms you would have? Do you want it on a single floor or double floor? You would have a basic idea of what would happen. In dentistry nothing like this existed except for the wax rims we were using for the fabrication of a complete denture. So in fix prosthodontics that part was a big gap. What I realized in the mid 80’s was why can’t we give a 3D set-up of the whole case so that we’ll have a starting point together with the patient. My first tries were using the wax that the denture teeth would be attached to. I would take the teeth out, then from there I would grab this pink wax and position it over the patients existing teeth, at least to define the length of the teeth, the incisal edge position and the proportions of the central to lateral and canine. That was my first mock-up trial in the early 80’s.
What would you say is the goal of this intraoral mock-up?
Well, that was just to have a very basic idea of how to start the case. Then we started improving it a lot and finally we came to the point of how we do the mock-up as of today – using composites, placing it over patient’s teeth, set-up the length, give the proportions, and maybe even give the shape of the teeth. What that would give me was, first of all, I would know my limits. I would know how much I can lengthen the teeth, how much I can broaden buccal corridor or how much I can carry the teeth facially up front. Then, secondly, that was a great communication tool between myself and the patient. Regardless of how many hours I would explain it verbally to a patient, there’s a limit that they can understand. They are not dentists. They are patients and don’t have the capacity to understand unless they see it in treating their mouths. This true mock-up, created a great communication between myself and the patient so they could visualize the whole thing. Not only the teeth, or the smile design itself, but the reflections, for example, on the soft tissues. That was a great starting point for us to discuss the case with the patient. Depending on the additive or subjective nature of the mock-ups that would also show me the need for any kind of adjunctive therapy for this, for example ortho or perio, and that was the easiest way to explain it to the patient.
From the mock-up you go to the smile design. Please tell us about the three stages for that.
They’re really simple three steps. First, it’s the mock-up, as I mentioned. “How do I do the mock-up?” Just take any composite, you can use any composite even if the date has expired and it’s ready to be thrown away. Get one of those and just start placing your direct composite veneers over the teeth. This is the basic essence of the mock-up. Depending on the time you spend on it, on your experience, the number of mock-ups you did, you can create an amazing mock-up or you can create an average mock-up. In the mockup what is very essential is to set up the incisal edge position because incisal edge position is the start-up point of any aesthetic design. If we don’t set up that part properly, this will be a complete different issue.
Let’s say you made an average mock-up. The next step is making a good impression of this mock-up, sending it to the laboratory. The lab should now mimic this mockup with the help of photos, videos, or silicon indexes and create this wax-up with a refined detail that you would want the lab to do. Your mock-up is now being translated into a better looking, 3D smile design. The other thing that came to us is that this wax-up is amazing for making the provisionals and there’s nothing wrong with that. After we prepped the teeth, we would make a silicon impression of this wax-up, fill it with a flowable composite, place it into the patient’s mouth and boom, we’d have the best-looking provisionals ever. However, after doing hundreds and hundreds of cases and failing in some of them, we realized that even if this sounds very clear, what might have happened is after we prepped the teeth, after we made the impressions, we placed this provisional, which is a copy of the wax-up, into the patient’s mouth and then what if the patient says “I don’t like this smile”? Then you have a problem, because you already accommodated your staff to the case, you’ve prepped the teeth and there’s no going back. Or after you prepped your teeth, you placed the provisional into the patient’s mouth, the patient likes the smile, however you see a tooth showing through the provisional, meaning the tooth hasn’t been prepared enough. That’s also a hassle – either you compromise the final outcome of the porcelain veneers or you gave to step back to reprep the teeth, remake the impression and remake the provisional.
This is why I came up with an idea of using this provisional as an intermediate step, which I named the APT (Aesthetic Pre-evaluative Temporaries) – placing this sort of provisional or transferring the 3D wax-up into the patient’s mouth before we even start the case, before we anaesthetise the patient, before we prep any teeth. Once we place it into the patient’s mouth it’s final check for me to functionally and aesthetically discuss the case with the patient. The functional part is more on me, because at that point the patient wouldn’t realize what the difficult function is. However aesthetically they will have a lot to say. If you have done a nice mock-up, the wax-up is like translating this mock-up into a better design. When we bring it into the patient’s mouth as an APT, most of the time it really looks very nice, nothing much to change. But let’s say the patient isn’t happy with a few things, then you can easily touch-up and add a little bit of flowable and make it the desirable outcome that both you and the patient enjoy the most.
These three steps, mock-up, wax-up and application of the wax up as the APT into the patient’s mouth, creates a big difference in case acceptance and more than that to secure next steps of the whole procedure.
Why is the mock-up so important in smile design?
I will combine this mock-up with the APT because what is happening is there are two amazing goals of APT: (1) Communication with the patient. The patient will confirm the smile design. Then the next extremely important step is (2) the way we will prep the teeth. That creates the big difference. Previously I was thinking old school – I was placing this APT in the patient’s mouth. Once the patient likes it and I like it, it will be time to prep the teeth. What I would do, thinking old school to prep the teeth, is I need to see the teeth. I would take this precious APT away and, again, just by guessing and using silicon indexes, try to prep the teeth and it would never be 100 per cent. Sometimes too much of a preparation, sometimes not enough preparation. Then one day I realized “What if I leave the APT in the patient’s mouth and start doing my preparations through that?” The reason for that was that if I would be using a depth cutter, which everybody should use when doing a preparation, and then using the most solid reference to prep, which is the facial contour of the veneer (in this case the facial contour of the APT), using the depth cutter through that and reaching to the depth, which is equal to the thickness of the veneer. Finalise your depths through the depth cutter, both horizontal and vertical. Then, once you’ve created the depth you want to create with the depth cutter, take the rest of the APT out, just remove the part of the facial enamel as much as you would until you reach that depth, which would be extremely minimal preparation if you did an additive wax-up or APT and then you just focus on finalising the margins with the help of loupes or microscopes. Again, the help of the mock-up is not only for sharing this final aesthetic outcome with the patient, but it is also for extremely precise and repeatable to preparations if you want to try to be minimally invasive create the ideal ceramic thickness for the ceramist, and I can assure you this should be your goal in dentistry.
Can you please define and explain the concept of Visagism?
Well, actually, what Visagism is, is the creation of a customized personal image that expresses a person’s sense of identity. It all starts with research of Carl Jung in the late days of his career. He went around meeting people from different cultures, background, religions, all different types of people, but still realised that there are some symbols that express the same meaning, such as vertical lines representing strength; inclined lines representing dynamism; or horizontal lines representing calm and stability; or rounded lines representing suavity. So this is the way the brain perceives these lines and line angels, or curves. Visagism came out with the idea of applying this into some art work by the artist named Philip Hallowell. He started making portraits and he tried to see if he would create a rectangular face, which will be perceived as strong; or a triangular looking face, which is perceived as dynamic; or a rounded face, which would be perceived as calm. He became very, very successful in that concept, so basically what Visagism was, was trying to convert this visual language into your facial expression, or trying to extract it from a face that was given to you by God, by nature, anyways.
How did you come to realize this concept and how was it extended to dentistry and smile design?
At one part of my dental career, I started working with a lot of amazingly talented Brazilian technicians. Christian Coachman was one of them. Adriano Schayder was another one of them. These people, knowing the work of some Brazilian dentists and my work, they told me there are some similarities between the designs I created by intuition and a very talented dentist from Brazil, Dr. Braulio Paolucci . They were curious to understand how we do it the same way. Then Braulio, myself and Adriano started searching whether these smile designs were coming out with intuition only, or if there is something different that was affecting our perception, triggering us to come out with different smile designs for every other patient. With this thought, Braulio started explaining to me a concept he was working on. That concept was the merging of facial outcome and the personality of the patient into a smile design. In other words, he was trying to use the visual language of Carl Jung, combining it with the personality traits of Hippocrates which is also divided into strong, dynamic, calm and sensible (or delicate) and on the other side the artwork of Philip Hallowell under the concept of Visagism. So, when we combined all this stuff and then tried to work with the whole concept and apply it into dentistry, some very interesting results started coming out. With this concept we further moved on and converted this visual language into a smile design. If we want to define a smile like a strong design, well the lines should be vertical, the tooth shape should be rectangular; if it’s a dynamic smile, the tooth shape should be triangular, the tooth access should be slightly inclined and the canines, for example, should be slightly inclined towards the 1/3rd incisal tips. This of course was the preliminary start of how we came up with the idea, but then after we walked through the patients we started selecting the best cases we did–the best cases meaning the patients were also in love with [the smile] and then we loaded this information into an artificial intelligence-based software program and we started running hundreds of algorithms trying to connect these designs to the other facial or personality features of the patients. The reason why we did this was that even if we would select like five amazingly good looking smile designs which the patients felt great with the final results, we would see that none of them would be alike. In some of them we would have a triangular silhouette, in the other one it would be maybe flat. In some of them we’ll have dominant centrals, the other one it’s average dominance. In some of them you would see triangular teeth, in the other square or rectangular teeth. In some of them we would have tooth access inclined, in the other ones straight tooth access. There must be a reason why these patients were falling in love with one of these smiles and this is how the first concept of Visagismile started. We tried to have the facial reading and perception of the patient, which has been done by a psyche analysis for many, many years. Then incorporate the personality traits, whether this person has a strong personality, a dynamic personality, or a calm personality, combine this and that translates into this visual language of our smile design and we started coming up with amazing results. The concept was very simple: let’s say you’re a very calm person and I’m offering you a great trip, which would consist of skiing, hiking, jumping, all dynamic activities. You may not like it. Or vice versa. You can be a very dynamic person, a very active person and I can tell you we’re going on a holiday and you can only go fishing and read books. Both are amazing alternatives, but one would fit better with the other personality. Because of that, we started doing lots of different wax-ups for the same patients and we would ask them to choose which one they like the most and that would start the very final outcomes that we did for the new smile designs.
Can you please tell us a bit about the process you go through in a smile design using Visagismile smile or other software?
Actually, VisagiSMile software, the first software, was an amazing tool that will deliver the dentist the general outlines of the personalised smile design but it was in 2D and most of our colleagues were having a difficult time reading this 2D design and converting this into a 3D design–mock up- in the patient’s mouth directly, or translating it to the wax-ups in the laboratory. Then we came up with the REBEL (sophisticated simplicity) software that would simply convert this 2D information on a 3D digital wax-up and create the STL file of the final personalized aesthetic smile design. What that software was doing was through some mandatory full- face photos, definition of the incisal edge position and a small questionnaire; it will go through the facial tracing, it will make a personality assessment and it would also add the personal preferences of the dentist or the patient, evaluate everything differently for each patient, convert that information into mathematic language and through preprogrammed algorithms, initially the two-dimensional smile design would be converted to or transferred automatically into a 3D customized model. In my mind that was revolutionary because just by defining the incisal edge position, that can be a very simple, single mock-up (on a single maxillary central) the dentist would be able to start the whole new smile design process. You don’t need to mock-up 10 teeth, you don’t need make the most beautiful looking mock-up, just define the incisal edge position. This is the starting point of any aesthetic case. Make the five mandatory full-face photos, so that you would connect the 3D intraoral scan model with a single mock-up to the facial pictures so it will adapt everything relative to the face. With the personality questionnaire the algorithm and artificial intelligence will choose the shape of the incisal silhouette of the design: triangular, rounded or flat; it will decide on the axis: straight, vertical or inclined; it will decide on the dominance: very dominant, medium dominant or not dominant; and the
individual tooth shape rectangular, ovoid, triangular or square, or a combination of the two. With this in less than minute, going through all these algorithms, it will create you a 3D design, not only to show on the screen but it will create an STL file, so when the dentist receives the STL file via email he would very easily be able to convert it into a real 3D model, by 3D printing it. This process has made smile design come out extremely personalized and then very simple to use just by using a very simple mock-up on a single central.
You often talk about the concept of minimally invasive dentistry. Why is this important?
Yes, I am a great, great fan of minimally invasive dentistry and there’s so many reasons for that. First of all, yes of course we can bond on dentin, but if given the chance, I would 100 per cent prefer to bond on enamel, which is more controllable, much stronger and less technique sensitive. We made a research in our office and this was published at the JPRD (Quintessence publication) in 2012 and 2013 in two different articles. In this retrospective study, we went through hundreds of veneers bonded in the past 12 years and evaluated the success rates. The success rates were basically the same with all of the previous different retrospective studies, done by great names and it was about 93 per cent. However, the huge difference came out when we divided the prep styles into two, meaning that the prep’s limited to enamel versus the preps with dentin or root surface exposure, the results varied tremendously. In the ones which we were 100 per cent on enamel, the success rates went up to almost 99 per cent. On the other ones, when you extend the veneers over the root surfaces or expose a lot of dentin surfaces, the success rate went down to 68 per cent, meaning that one veneer out of three will have a problem in the next 12 years. So, this was really very, very important data for us and I would do anything to be minimally invasive, starting with an additive mock-up, additive wax-up, additive APT. Of course this has its limitations, working in an additive fashion would be my first choice, but if I don’t have that choice I would definitely want to use ortho to bring the teeth into a better position so that I will still then do an additive wax-up and that will make me go through the minimally invasive preps. This is, again, another beauty of applying the APT because that will not only allow you to see the final design but will allow you to be minimally invasive. With the APT, you will have a great option of designing or treatment planning the case starting from the final outcome, final look, then from there moving backwards and then decide on the type of treatment plan you need to do. For example, if your final design doesn’t allow you to do additive work, then you may consider ortho. Extrusion, intrusion, bringing the teeth inwards, outwards – these are all the things you have to decide. Or, depending on that design, let’s say if you have a missing tooth and you want to place an implant, this is the way you should consider positioning the implant because the incisal edge position depending on the proportions will dictate your gingival margin, how deep or buccal or lingual you should position the implants. This is why, when you combine APT with the design, with the treatment planning and with being minimally invasive, I think it has a great, great place in dentistry on starting a case knowing the final design in the beginning and deciding on everything prosthetically driven.
Where do you see the start of dentistry heading?
What I’ve seen is, of course, now we’re living in a digital era so the simplistic way of explaining this is it’s going to be a mixture of digital and analog. Of course, I cannot say, at least for today, that we can do everything 100 per cent digital – it doesn’t exist. I also agree with the arguments that human touch is much more delicate and artistic and creative than a computer design. I agree with that, but there’s so many tools now that have been developed and are being developed which will be a great help for the dentist and technician to be repeatable and be more precise when they are trying to redo the things in an order. This starts, again, in an aesthetic case, with a mock-up. Now a days we can create the design with the 3D printed models, 3D digital wax-ups, with software like Rebel, which will relate the design into your facial outcome and the personality. Even in the worst-case scenario, let’s say you tried all of these things and the patients really didn’t like it too much, you can always make very small touches to make the smile look great instead of having an empty canvas without knowing where to go, trying to paint it the whole way. Rebel is giving you a painted canvas, so if you don’t like some colours you can change it. We’re in a very exciting era in dentistry.
Finally, we are now working on our patented project, which will be a robotic device that will prep the teeth without the human effort. All we need to have is the ATP or a 3D design and a robot reading the facial contours of that design by a software, deciding on the depth you want to prep the teeth, the machine will prep the teeth. This used to look like fiction but now we have the report of durability of the project, which was a huge step and now we’re working on the prototype. I think this will be another keystone in dentistry because it will give courage to many dentists who are afraid of creating a smile design and then trying to prep the teeth, while being minimally invasive.
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About The Author
Dr. Galip Gurel graduated from University of Istanbul, Dental School in 1981. He continued his education at the University of Kentucky, Department of Prosthodontics. Received his MSc degree from Yeditepe University in, Istanbul. Dr. Gurel is the founder and honorary president of EDAD (Turkish Academy of Aesthetic Dentistry). He is also a member of the American Society for Dental Aesthetics and American Academy of Restorative Dentistry and the honorary diplomate of the American Board of Aesthetic Dentistry. He is a visiting professor at the New York University (USA), Marseille Dental. He has been practicing in his own clinic in Istanbul, specializing in Aesthetic Dentistry, since 1984.
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