Aesthetic Rehabilitation According to the Visagism Concept
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Nowadays the people’s demand and level of information has driven the clinicians to a certain questioning about customization, especially about planning, according to the individual psychological characteristics, that if ignored, may lead to dissatisfaction, even though all the classical rules which tend to establish standards are being used.
In aesthetic dentistry are used concepts, techniques, and materials by which dentists could establish new smiles with minimally invasive approaches and maximum natural effect on the restorations and in the same time to restore the mastication and phonetics, for a better quality of life.
Besides the aesthetic rules established throughout time, the emotional expression of the treatment, represented by the shapes and lines constituent of a smile, should also be taken into consideration of creating a customized and personalized treatment planning.
The concept of “visagism” may help dentists to do restorations that correspond not only to the aesthetic but also to the psychological features of the created image which affects the emotions, identity, behaviour and confidence of the patient. On the other side these factors affect the way the patients react to the definite treatment. 
These concepts recently have been applied in software such as “VisagiSmile” which can help clinicians to change the smile design.
For achieving an optimal aesthetic result from a dental treatment, we
need to create a suitable smile design that should create a perception which has to fulfill the aesthetic expectations.   It is also important that the teeth proportions to be correctly diagnosed and designed before an irreversible restorative dental procedure to be done. 
To create a personalised smile design we need to use the “visagism” concept.
Excellent quality DSD (Digital Smile Design) software products exist on the market, such as DSD 2D, Smile Designer Pro, Planmeca Romexis® Smile Design . However these solutions do not apply the visagism concept which produces a smile design in relation to the facial type and personality of the patient which is perceived as more harmonious.
Visagism applied in aesthetic dentistry is associated with assessment of the facial type, which involves subjective judgment, time consuming personality test and also complex calculations of the teeth configuration. The numerical results were then visualized as a teeth design which served for the patient, for the dentist and for the dental laboratory.
VisagiSMile is a software that automates the process of creating dental visagism case. VisagiSMile is a multiplatform web application for aesthetic dentistry which does not require installation, but only a simple registration process to get started. All cases and data are stored on a server to allow dentists to work on different devices and platforms – computers, tablets and smartphones. The research on the Visagism concept is an ongoing process which constantly changes the requirements for the software
Two main photographs were needed: one full-face with maximal smile and visible dentition and the other photograph of the upper jaw with retracted lips and black contrasting tool.
The photograph in full-face with maximal smile and visible dentition uploaded in “Visagismile” software were automatically placed behind the facial frame. By marking the landmark points on the image, the software analyzed the face structure and classiFied the face as strong, dynamic, sensitive and calm representing in percentages.
Img. 1 Facial map with landmark points and type classiFication.
Img.2 Personality interview The optimal tooth shape was determined by an interview (questionnaire in the software). Based on the data from the interview, a software algorithm automatically calculates the temperament, as perceived by the patient. The temperament is a combinations of strong, dynamic, delicate and calm. Combination of tooth shapes conformed to individual characteristics of the patient respectively are: strong(rectangle), dynamic(triangle), sensitive(circle),calm(square). The patient’s preferences about the desired teeth design which was also included in the calculation of the optimal teeth configuration. The preferences include characteristics of the teeth related to their colour, texture and shape.
Img. 3 Final design with detailed text description analysis summery of face reading, interview and patient choice. According to the face reading the software calculated the main parameters of the individual smile frame: incisal projetion; tooth inclination; dominance. The integration was determined by the interview tooth shapes conformed to the personality of the patient along with the patient choice, Finished the construction of the new smile design in accordance with the psycho-dentofacial harmony of the personality.
Img.4 Final design digitally positioned on patient’s face. Created digital project easily could be visualised on patient’s face in order clinician to be able to analyse the teeth proportions, incisor edge projection and other aesthetic parameters in relation to the patient’s face.
Img.5 a Initial view
Img.5 b Initial view
Img.5 c Initial view A 26 years old female patient came with the desire to enhance the aesthetics. We have already worn out enamel which need to be preserved in order to improve the durability of the treatment. There was an erosion on the central incisors and the left lateral incisor. The main challenge in this case was to go minimally invasive to the teeth structures and also to create a harmonious gingival contour.
Img. 6 VisagSmile design preview - based on the parameters like shapes, proportions and arrangement of the front teeth provided by VisagiSMile software digital proposal, diagnostic wax up was made.
Img.7 Diagnostic wax up front view
Img. 8 First additive composite mock-up was based on the diagnostic wax up. A light curing composite material was injected into a silicon key and inserted on the unprepared teeth.
Img.9 First mock up made on the non-prepared teeth served as a powerful motivational and communicational tool with the patient showing and explaining all the changes that can be made as the desired final outcome. New full face and intra oral pictures were made and all the changes were discussed with the patient by comparing the relevant before and after mock up pictures. After the mock up was done some parts of the composite covered the gingival margin, but other were in a distance. This analyse helped us to plan the next step to treat the gingival recession. After the patient acceptance the treatment and the following steps were planned - Fixation of Five ceramic veneers, the upper central and lateral incisors and the left canine.
Img.10 Tooth preparation trough the mock up - by using this technique of preparation through the mock up allowed us to keep tooth structures and enamel preservation.
Img.11 Smoothing and polishing the tooth surface was done to ensure less stress under veneer and also a more uniform film thickness of cement. This also leads to better adhesion.
Img. 12 a Recession treatment
Img. 12 b Result after the operation.The following stage in the treatment was the harmonization of the gingival contour by increasing the level of the soft tissue on the right lateral incisor. For this purpose was used the tunnel technique. By preparing a partial thickness flap with a micro-blade to the mucogingival junction and after that a full thickness flap, it was coronal repositioned. After completing the healing process a final impression was taken using polyether impression material (Impregum, 3M Espe) and sent to the dental laboratory.
Img. 13 Five ceramic veneers were fabricated by the dental technician Vincenzo Musella.
Img.14 First try-in of the ceramic veneers - The veneers were tried after removing the provisionals using try-in paste (Variolink Esthetic Try-in paste Neutral).
The final stage of the treatment was the fixation of the veneers.
Img. 15 Adhesive protocol - the veneers were sandblasted and then treated with hydrofluoric acid, neutralized in ultrasonic cleaner, rinsed off and dried. After that silanized and bonded.
Img. 16 Sandblasting the tooth surface - prepared teeth were isolated with rubber-dam for an adequate control during the fixation process. The first step in preparing teeth was to sandblast the surface to remove the smear layer for greater retention.
Img. 17 The following step was to apply etching gel - phosphoric acid and then it was carefully rinsed off and the teeth were dried.
Img. 18 Primer and adhesive (Opti Bond FL) was applied to the teeth. After multiple coat application, the solvent in the bonding agent was eliminated blowing the bonding agent without polymerize.
Img.19 The final fixation was done using light-curing cement (Variolink Aesthetic Light). The complete curing was done applying air blocking gel to the teeth. (Oxyguard Panavia)
Img.20 Final view after fixation
Img. 21 The Final result before and after the dental treatment was the creation of harmonious gingival contour and optimal aesthetic vision.
Img. 22 a
Img. 22 b A photograph was taken 6 months follow up
Img. 23 a Side view
Img. 23 b Side view
Img. 24 Occlusal view
Img. 25 The final result
ConclusionsVisagiSMile is a novel dental software which is an: - Important guideline for the dentist to do the direct mock up, (or concepts like DSD, SKYN etc.) - Important guideline for the dental technicians to re-create the design wanted by the clinicians and the patient. - Planning tool which helps clinicians to do precise, predictable and adequate smile designs - Used in CAD/CAM technologies. The generated design can be integrated to the digital planning of dental constructions. - Used as an education tool to save and share cases worldwide.
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