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 gratitudeto MiguelTarnes,
lr4yrnfirrite RafaelTam€s.
To Cesar Hrnostroza. our friend and our guide: Pablo Mayer.Diego Genov6s,Rail Uriza, Errrilio
Althoughyou preierto stay out of tlre pictufe.it is Canales. Ariuro l\4onroy,and Mario,who took me In
inrpossibleto leaveyolrout of it: everything
hasyour likefanrilydLrringnryfirst stepsin dentistry.
To all of
footprint.Youaretl.remosti{nportant piecein eachof you.MonteLibanolaysin this book.
oLrrpro,ects.
Toour two artists,the peoplewhofilledour liveswith
ToWalterDevotoand AngeloPutignano, because this colors,Luis AlbertoVillanueva (Beto) and Daniele
bookand manythingsin our livesafe only possible Rondoni. Yourwork is not only printedIn thrs book.
because of you. it is deeplyprintedin our lives.We cannotimagine
whichroadwe wouldhavetakenwithoutknowing you.
Vincenzo. Gaetano. lVlonaldo,Daniele,
andSinrone. for
sharingStyleltalrano. To tl.ienlemoryof Luis Bellet,whoseunexpected
absence leftin us a terriblevoid.
To the dentistswe admirethe most, LorenzoVanini
and Francesco lvlangani. ToJoanChavarria and JordaCabeceran: Workingwith
youhasbeena pleasure.
To the peoplewho, with tlreireyesclosed,gaveus
theirwordsto begineachoneoi thesechapters. lt is a To our assistants in ltalyand Spain.Half of whatwe
dreamto sharethese pageswithyou.Pascal,Daniele. areis because of you.
Angelo,Walter,Lorenzo,David.And16,Jean.Louis,
Jean.Crisiophe, Francesco. Serhiy,Bernd. Ricardo. To the ones who havesufferedfrom our chaosand
GalipL. ui z . a n d L u i s . desksfull of composiies. Letr-rsdedicate this bookto
you.ln the end it wasnot sucha mess.Weloveyou!
To ManuelRuizAlfaro,our friend and the graphic
and editorialdesigner whosetalentmadethis booka ToJuanManuelCasasandlVarcos Sando,for providing
reality.Thankyou for the countless hourson Dropbox us with theil materialin the momentwe neededit
and Skype.for yourtalentand professionalism. In the the Inost.while it was the worst possiblentoment
end, we did it. it is possibleto build a wltolellooli for them.As we promisedyou,our thankfulness is as
i0,000 km arvayfronreacl)otherlwww.asterizco. conl wicleas this book.

ToAsunci6n Mendoza andEnrique Solano, forteaching To Josd Lurs Lopez.thanks for your 30 years of
us to nevergiveLrpour dreams. experience and knowledgein the world of books.
editorialdesign,and publishing. Youradvicemade
O u r g r a t i t u d e t o t h e c o n r p a n i e s3 M ( U S A ) , l ( e r r this prolectreal.
( S w i t z e r l a n d )S, m i l e L i r r e( S w i t z e r l a n d )M
, icerium
( l t a l y ) K u r a r a y( . J a p a n ) l.v o c l a r ( Li et c ht enst e i n) , To Quintessence Publishing.for the beautifuljob,
Heraeus(Germany), DMG(Gernrany), FGM(Brazil), carriecl out together
LM (Finland).for providingmany of their products
withoutaskinganythingin returnthat couldharmthe To anyonewhom we wronglyand unfairlydid not
objectiveness ol thecontentsof this book. mention.Unfortunately we do not lraveenoughspace
in thiswholebookto mentioneveryone wewish.Forgive
We want to mentionour teachersMiguelRoig,Luis u s .
Jan6.and Juan Basilioas representatives of every
memberof the UlC,who gaveus the knowledge and An apologyto oLrrfan.rilyand iriends- nothing.
the toolsto buildthis book. absolutely nothing,is worthspendingtimeawayfrom
yoLr.
To MoisesMitraniand ftlinaNudel.lrecause theywill
represent and conveymy gratefulness and affection
to everyone whowasinvolved in my 5 wonderful years
of dentaltrainingat the Technological University ol
Mexico(UNITEC). Toall of you,classntates, teachers. Sincerely,
and assistants, all my bestthoughts. Thankyou. Jordi and Anna
w Gr,to'n t*'
r **l J

eI
lia-J
ry
FgEF--l I
'qiI-='
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 Layers
.J gr l i V3n6Lr ta. Anna Sal ai

Interviewwith PascalMagne

1
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 TTITIT
W lrEacail{Tl?fJitr

Q: Whatdoes/ayersmeansto you?

Dr PascalMagne was born in La Chaux.de-Fonds, A: Layershas a broad range of meanings,from the

Switzerland,and eventuallymovedto Geneva,where basicdefinliionof a singlethicknessto the stratumof
he graduatedwith a degreein dentistryin 1989 and materialconstitutinga morecomplexstructure.A layer
completeda doctoralthesis in 1992. He taught and may implyits dependence on otherlayersof materials
continuedhis postgraduate in prosthodontics
education to obtain a "whole"structure.The propertiesof each
and operativedentistryat the University
of Genevauntil layersynergistically
combinewith eachotherto create
L997. uniquefeatures, properties,optics, mechanics, and
functions.
Awarded with major granis by the Swiss Science
Foundation, the SwissFoundationfor lVedical.B
iological Thebestexampleof d ivinelydesignedlayeredstructures
Grants,and the International Association for Dental is the tooth, becauseit assemblestotally different
Research,Dr Magne spent 2 years as a full.time substrates,dentin,the dentinoenamel junction,and
researchscholar in biomaterialsand biomechanics enamel,and resultsin a pedectcombination of their
at the Universityof lVlinnesota.
Back at the University respectlve propertiesthat eliminatestheir individual
of Geneva,he receivedhis PhD degree and served weaknesses. Enamelis brittle but resistswear;dentin
as senior lecturer.Since February2004, he has been the opposite.Thedentinoenamel junctionis the perfect
an associateprofessorat the Universityof Southern gluebetween theni.Thereis no doubtthat this "dental
(LosAngeles),
California wherehe wasnamedchairof trinity" (enamel-dentinoenamel junction-dentin)is
EstheticDentistry. the best exampleto illustratehow our societycould
functionin harmonybecause eachof us is unique,with
He is coauthor of the textbook BondedPorcelain our strengthsand weaknesses, and the "assembly" of
Restorationsin the Anterior Dentition: A Biomimetic humanbeingscan resultin the mostbeautiful pieceof
Approach (Quintessence 2002). Dr Magne
Publishing, art. Theartist,and onlypossibleartist,in this work is
has written numerousclinicaland researcharticles God.
on estheticsand adhesivedentistryand is frequently
invitedto lectureon thesetopics.

1B 19
 Weare madeof layers,atoms,and universes, as big The amazingpart camewhen I took the slidesand The planetwe livein is an infiniteset of The single cells that form us bear an
and as smallas that sounds.Are we a small layer analyzedthem under the microscope.I landedthe layers,starting from the nucleusand incredibleresemblanceto the planet
of a biggeruniverse,or is eachof our atomsa tiny firsttimenearthedentin,d iscovering a small unknown finishingin the invisiblemagneticfield and the atomsthat form matter
structure,
universethat putsustogether?Probably bothnotions jungle.Watchlng everycell of the cementum,every locatedin outerspace.lt is amazinghow look pretty much Iike a solar system.
canbe realor at leastcannotbe provenwrongyet. conglomeration of prismsin the enamel,and all the ice layersin the earth'spoleshavebeen lvlanypatternsseem to repeatfrom the
interactionbetweenits frontierswiththe dentinjust pilingup for thousandsof years:A single submicronworldto the massiveuniverse,
Walkingthrougha forest,I got a smallwoundin my mademe feel intriguedand broughtto the surface material,andthousands of differentlayers includingproportions, measures,relatlve
arm.Dayslater,a blackscabappeared. I caressedits bothmy ignorance and my curiosity. of it havebeencreated. weight,and shapes.
roughness with the tip of the finger.Curiositymade
me detachit, causingthe appearance of a newone Weand our organsarenottheonly onesbuilt in layers, Rememberthe first time you glanced We have expressedthese thoughts to
dayslater.After I left it alonefor a coupleof days,it which often are hiddenand not evident;thinking at a largemountainfull of lines?lt was highlightthe importanceof layers in
startedto fall into tiny pieces,revealing new,white aboutit carefully,we realizethat actuallyeverything incredible ngthe different
appreciati layers. our life, generally,professionally, and
skinbelow, smoothandsoftas velvet. Thisis the way is madeof layers,including atoms,molecules, DNA, Thanksto layers,we can understand the scientificallyspeaking.Looking into a
that the majorityof us discovered ihat we are made cells,tissues,organs,livingbeings,soil,mountains, age of our planetand that our size and single layer we learn about the whole
of layers. ice,atmosphere, planets,stars,planetarysystems, age,comparedto our solarsystemtime ensemble, and studyingthe entireentity
galaxies,and the entireuniverse. Manytimes,even line, are ridiculously
small; all we know we are able to learnmanythingsfrom its
I especiallyrememberthe first time ltook a natural the insubstantial things are understoodin layers: aboutthe humanracewouldcorrespond lndividua I strata.
tooth in my hand, placedit carefullyin a stone computer sofiware,conscience,weather,music, to a second,whilethe age of our planet
trimmeruntil it was left as flat as a paper,and then hierarchies, andcartoons, just to mentiona few. wouldoccupythe time of a century. Biologically,layersare the keystoneof
dehydrated, dyed,andfixedit betweentwo tiny pieces our existence.Losingand injuringthem is
of glasswithan organicresin. inherentto the humancondition.lt is our
naturalcondition as wellto try to maintain
them as bestwe can,because mostoften
our layersare irreplaceable, Or are our
regenerative capabilities
infinite? Theyare
not.

20
 .a|.. ..
.1'.i3i-:.r,,I

!: Modernresearcl.r is focusecl on biomaterials,

-1' l i s s : e r e g e n e . a l ' o ns .le-ncells.anJ healing.
R n mo nf lhaca , o nlq r rf, , c
^n, -P'
\ fict on, but we hope just for a short time. At
p.eserl sore gre?l le.1no ogi" advances
\: and reseafch have prov ded ncredible,
functroral malerials i'rar l'ave l-elped solve
r -:--- some pfoblems,althoughneveras accurately
as the natLrralrnaterias. Each layer has an
'- nfinitevalLre;
an intacttooih s a waysour first
opl,on belore any denlal rralefia . despile its
'-,./' a llegedadvantages.

r.'! A journey through tooth ayers and the

It
l- 4Y ' dif'e"entapproaclresto liem will al easl g've
,! - l 'tp .,1 n v",l a fo F r n l r Fe
'1 q li.ir d SeaSeS and
mimictheir beauty.
. :----r;-:4
-.---- W e n e e d t o u r d e r s t ard color, rl'ick1ess,
/r n:.
urJ!,! t\/ 2rri noarnanl
!,i,1,,,6,-,,,1'..i :o
1.6 : zc. 5||.'P!',
-J. '6,
orientation, abnormalit es, and how time
p laysgracefuly with them.

A r tr l l e JL l n B tn l 5 - e xt W e are SUle yOU W ll

a 2 "n a l l cp s' n o 'n Inve a IOOIh.
^ n c "h

We wou d like to invit e you on an incredible

l-
i n t r r o ', n' - ? r-hrr-prs ,rt<i tO lttdefSLand
.l
t ..J,v basically two incredibleayersthatson.retimes
are lost and it is our beautifuleveryday
work
to replace.
')

l, I

q
 Chapt er l
Color
Jordi Manauta.Anna Salat. DanieleRondoni. MiquelCoronel

Interviewwith DanieleRondoni
I I ttryto appty%OLO ) tikewordsthatshapepoems,
l i ken o te sth a t cr e a tem u si c.
,,

Jsan )lLtr,'A
 mlrlll
13".1irl'qr,fF{lr;li'qrrir-,r,
' !r'r-

Q: Do you thinkcolormatchingand colorreproduction

IT
that requires
is a discipline merelyacquiredknowledge,
training,anddiligence or do youthinkit is necessary
to
havespecia I artisticskills?

Daniele
Rondoniwasbornin Savona,lialy,wherehe has A: Matchingcolor and transferringthe information
beenrunninghis owndentallaboratory
since1982. for applicationto esihetic materialsrepresentthe
a mimeticrestoration.
maincriteriafor fabricating For
He has taughiat the Institutefor DentalTechnicians dentaltechnicians,a primary method to improve our
in Savonaand has oresented numerouslecturesand knowledgeof color matching is the study of dental
specialization
coursesin ltalyand aroundEurope. anatomicalfeatures whatelements
to determine dictate
dentalcolor.
He is an activememberof the European Academyof
Esihetic Dentistryand the ltalian Societyof Dental I thinkthat to matchdentalcolor,we needknowledge, a
Ceramics.Specializing in estheticrestorationusing graspof dentalanatomy,andmoreandmoreexperience.
new-generation materials, he has collaboratedwith and passionare
In addition,artisticskills,sensibility,
severalmanufacturerson the designand development important qualitiesthat enable to pay attention
us
of newmaterialsand techniques. to and reproduce the details.lt is also importantto
becomefamiliarwiih the estheiicmaterials with which
Mr Rondoni haspublished articlesin prestigious
several we chooseto do a restoration.
internationalmagazines.He wrote the book Iecnica
di Multistratificazionein Ceramica (Multistratification of naturalcolor,togetherwithextensive
Anunderstanding
Techniques in Ceramic,UTEI 1998), and some of his knowledge
of materials,is an idealcombination.
workwasselected by LorenzoVanini, for inclusion
in the
volume,Conseryative Restoration
of AnteriorTeeth(Acme,
2005).

?B 29
 E
Color
BriefHistoryof Colorin Eentistry
In dental estheticswe look for harmonythat is Colorhasno materralexistence. Toobserveit, we need
obtainedfrom the esthetictriad:shape,texture,and threeelements:lightas a physicalstimulus,the eyeas C o l o rm a t c h i n gr e m a i nsa " trialand error"method,
color. a receiver,
and perception as an individual
factor. i n w h i c ht h e p r o f e s s i onal
placesshadeguidestn the
mouth with the purposeof establishing the best
C o l o r tr ad iti on a llyhas rhree dimensions-h u e , Coloris not reallya true propertyof an objectbut an m a t c h , i g n o r i n gt h e c haracterrstics of color and
c h r o maan , dva lu e -andolheressential aspect st h a r impression in our mind (subjective significance), IVost naturalphenomena that changetoothcolor
arenot alwaysconsidered,
opalescence.
namely,translucency and of thetime,whenwe lookat somecolorwe immediately
idealize
a preview
it; in thai momentwe havecreatedin our minds
o'fthaTcolor,because therers a tendency to
g Sincethefirstcolor shadeguidesmadean appearance
eariy in the 20th century,they were designedto
Factorsto take into accountfor successful restora. choosethe samecolors(eg,A2, B1). Evenbeforelhe I matchthe colorof naturalteethwith no particular
a r r a n g e m e nolr m e t h od(1). In 1929 shadeguides

4I
tion-toothintegration are, in order of importance, shadeguideis placednearthe teeth,we havealready
(1) shape,(2) opacity/translucency, (3) Chroma,(4) formedan ideaof the possible colors.Thisis a mistake were classifiedby tonalities.In 1939 the "Lumin
surfacelexture,/5) enamelValue.(6) intensives, (7) that shouldbe avoidedby observing the objectmore, effect"(colorconsistency) was describedin natural
cha.acterizations. (87 opalescences. and (9) Hue, longer, closer,and moreobjectively. teeth,andthisledto the birthof dentalshadeguides

tT
In manystudieson color measurement, the inten- as we knowthem today(2), providing us sincethat
sives,opalescences, andcharacterizations havebeen Today, oneof the mostreiiable datain shadematching t i m e w i t h i m p o r t a nbt u t limltedinformation.
relegated
believe
to the positionof leastimportance, but we is still the appreciation of the expertobserver.
that thesefactorsare as crucialto the inte. why manyin dentistryconsidershadeselection
Thatis
to be
d Thebest-known shadeguide,the VitaLuminVacuum
grationof a restoration as anyof the aforementioneda n a rt ; we c o n s id eit r a s a v is u a d
l is c ip lin ean, d ,a s i n guide (Vident).has existedsince 1956, and its
characteristics, anydiscipline, the keysto success areknowledge, time, I philosophyis stillrelevant
today.lt wasnotuntil1998
andtraining.Themorewe practicecolormatching, the tF that researchers attemptedto developa different

n,
Toothcolormatchingis one of the most empirical mo ref a milia we r will b e wilh s u b t lec o lo rc h a r t g e s , slradeguide,the Vita 3D Master(3), but the only
misunderstood, and poorly taught disciplinesin changesmade in this new systemwerea different
dentistry.Estheticsis the perfection of restorative lf we say "green"and 50 peopleare listening, we can arrangementof similar colors and a dif{erent
dentistry;attemptsto achievethis goal are often expectto find 50 different "greens"in theirminds,even nomenclature scheme.Electronic colormatchingis
f r u s t r atin ga. n d in adequatecolor matchingis a il wespecify a colorthathasalready beenseencountless showingverypositive and promising data,but much
factorresponsible for manyfailuresin the searchfor timesby eachoneof them.lf thesesamelisteners have technologyremainsto be developedand evolved
exceence. in front of them hundredsof "greens"from whichto beforeperfectlyreliabledata can be obtainedfrom
choosethe colorgreen,eachlistenerwill againchoose thesemethods.
However, this complexity doesnot meanthat color a different colorthanthe others.Visualmemoryis very
is a mystery;we can makereference to hundreds of poor compared to acousticmemory,and,furthermore, Recent attempts to produce a differentcolor
scientificconceptsand physically measurable data, t h en o me n c la t uoref c o lo ris rn s u f f ic ie a
nnt dv a g u e . matchingsystemdate backonly a fewyears.These
suchaswavelength, lighttemperature, spectrum, and includeselective (4) andpersonalized colormatching
so on. Furthermore, color includespsychophysicalIt i c i mnorati vo f^ nr2.+ i .6 W i th model S an d CO I O r ( 5 . 6 ) . b a s e do n s c i e n liliccolorprinciplesand the
a r r u Pr J ,u l u ru B rL a sP rr r J. guides.As professionals, we must learnto distinguish differentiation of the diverse tissuesof the tooth.
between different tonesof toothshades; it is mandatory
to becomean experton this issue. Thefutureof colormatchingin dentistrywill most
l i k e l y i i e i n a c o m b i nationof personalized
color
matchinganddigitalimagingtechnology (7).

31
 MunselI ColorClassification
AlbertHenryMunselldividedcolorinto threemain aspects:
I
Hue,Chroma,and Luminosity (Value);this schemeis univer-
sallyrecognized as the basisfor othercolorsystemssuchas
CIELAB(L+A+B+ colorspace).Application of this classifica
of dentalcolor
tionio ihe discipline matching allowsa better
understanding of the subject.

Hue:The degreeof mixtureof the threeprimarycolors;in

simplelanguage,the name of the color,for example,red,
yellow,
or blue.

purecolorshave
Chroma:The degreeof colorsaturatlon;
andweakcolorshavea lowchromaticity.
highchromaticity

Value:The degreeof color brightness;the whiterthe color

is,the moreValueit has,and the darkerthe coloris, the less
Valueit has.

3? 33
t
 Munsellwheel,in whichcolorsare
classified
according
to theirChroma
Value(y.axis),
(x-axis). and Hue(2.

L' il
E"

ColorClassification
Systemsin Dentistry DentalShadeGuides
CHROMA

Sectionof the lVunsellwheel Therehavebeenmanyattemptsto achieveihe perfectcolor Several colorguidessystemshavebeendeveloped, using

showingthe varietyof one Hue. classification,
including ClaudeBoutet'scolorcircles(1708), fouror fivebasiccolorsthatareusuallythe mostcommon.
accordingto its Value(y-axis) PhilippOtto Runge's colorsphere(1800),JohannWolfgang However, it was not until 1956that comprehensivecolor
andChroma(x-axis). von Goethe'scolor wheel (1810), Wilhelmvon Bezold's organization was established, dividingshadesinto four
(1874),Johannes
Farbentafel ltten'scolorsphere(1922),and majorgroups:A, B, C, and D.
HaraldKueppers' colorcube(1980).In 1915,AlbertHenry
Munsell,in his Atlasofthe MunsellCoiorSystem,proposeda The biggestdifferences we can appreciateamongthe
new systemthat basesthe arrangementof colorson three variousdentalshadeguidesare the physicaland optical
aspects:Hue, Chroma,and Value.This classification has propertiesof the materialswith which they are made
beenthe most acceptedand usefulfor understanding color and the color arrangement within the guide itself.The
in dentistryand manyotherdisciplines. At the moment,no materialsusedto composethe shadeguidesare noi the
classification
d istineu
ishestranslucentcolors. sameas the comoosite resinsand ceramics that areused
for restorations.For this reasoncommercially available
shadeguidesareusefulonlyas a basicreference, because
thereis usuallya substantialdifference
between tabsfrom
the shadeeuidesandthe restorative materials.

31 35
 l:

It is difficultto appreciatecolor differencesin the

four VITAshades,A, B, C, and D, whentabs of mini-
mal chromaticexpression are compared.

The Vita shadeguide is the most commonlyused The most commoncolorsiound in humanteethare
guidein dentistry,
Thesimplecolorarrangement is the in the rangeorange-red.yellow, whichcorresponds io
reason whythisguidebecametheworldwide standard. tonalityA of the Vita shadeguide.Probably90/6 to
Almost everyrestorativesystem basesthe colorson 9516of teeth in healthypatientscorrespond to this
this scaIe. part of the scale,and deviationsfrom this are often
insignificant
or verysimilarto the colorA. Whenthe
The color arrangementwas determinedafter natural teeth correspondto colorsin the shaderangesB and
tooth color was studied and grouped into four C, the marginof error is minimalwhen employing
categoriesaccordingto their incidence;the most a color philosophythat only takes into accountthe
commonis orange-red (A), followedby orange.yellowtonalityA, such as the color theoryof LorenzoVanini
(B), brown.gray(C),and, leastfrequent,brown(D). or the techniquedescribed by DidierDietschi.

Each Hue has subdivisionsaccordingto their Workingwithan A tonality, the usercanachieve some
saturation (Chroma). Withinthe orange-red group,A, finalcolorchanges tricks:(1) mixing
withstratification
the shadeA1 is a delicateexpression of this tonality, compositeswith light.curedstains,(2) placing a ThefourVITAshadesclearlyevidence
differences
in
whileA4 is the strongest colorin this category. lf we middlelayerthat will act as a screen,or (3) playing Huewhentabsof maximalchromaticexpressionare
separate the leastsaturatedtabs,41, 81, C1,and D2, withthe enamelthickness to increaseor decreasethe compared.
the differences arebarelyvisible(1); however,whenwe Value,and in this waybeingableto achieve anycolor.
comparethe mostsaturatedtabs,A4, B'4,C4, andD4, Forexample,shadeC is easilyobtainedby increasing
it is easyto appreciatethe differencesin chromaticity the enamelthicknessto lowerthe Value.
(2,3). .
All moderncolorguidesoperatein a similarway.Other
attempts to organizeshade guides differentlyhave
failedto finduniversal
acceptance but neveriheless
are
usedby someclinicians,

Digrtalenhancementof the same picture (more

contrast,Iessbrightness)
helpsio identifydifferences

HBti 8fitttt'lfifi in Hueevenmoreclearly.

37
 -r-HUe: -Co'liii' cate-g-ory-
to
. . which the'dehtin?ilbody

I."IL.l-i,

I
I

I Value:Opacity,transpar
'
ency,anddegreeof white- 7-
nessof theenamel.
r*\
VAUIJIE

3B 39
 \

O Ei

Experience and extensivestudiesreveal In: The inner layeris exclusively con-

that natural teeth are chromaticallystitutedof dentin,and impartschro-
formed by two main layers,enamel maticity.opacily.light scattering(3).
and dentin. In the vast malorityof fluorescence, and the yellowishtooth
individuals, teeth havetonesthat vary appearance(seechapter2).
fromorangeto yellow(i), colotsLhatare
derivedfromthe dentin(seechapter2). Out: The outer layer is formed by
the enamel,which is responsible for
Enamel modifiesthe dentinal body regulating the tooth'sValue,luminosity,
color,increasing the brightness (Value) andtransparency. Thislayermodifies
the
(seechapter3), and actsas a selective finalcolorof the tooth(seechapter3).
lighifilter.
Mid: The intermediatelayer is used
Unfortunately,the most advanced to reproducespecial features that
dental materials nowadaysare not occurspontaneously in naturalenamel
ableio faultlessly mimicthe opticsand and are locatedin the middleof the
thicknesses of natural
teeth.Westillhave stratification:it providesopalescences,
to adapl to the currentdiscrepanciesintensive effects,and characterizations
betweendentalmaterialsand natural (seechapter4). ,I

tissues. However,rapid evolutionin

industrythroughadvanced research in Beforewestarttalkingaboutlight,color,
ll
dentalmaterialsis bringingthe reality and differentcolorsystems, from both
of trulyaccuratereproduction closer. the dentaland generalpointsof view, I
we want to highlightthe importance
JustasthenaturaI toothhastwooptically of becomingfamiliarwith colorsthat
distinctlayers,whilereproducing teeth composehealthyteethin mostof their
we use seve ra l la y e rs a s we ll (2 ). variations.
While layeringestheticmaterials,we
recognize three layers:the innerlayer
(/n), the externallayer(Out),and the
intermediate layer(Mid).
The FiveBasicColorsof Teeth

Thereare five color shadesthat form a natural

t nnth f h o combination
of thesecolorsenables
p roductionof an incrediblyextensive
chromatic
range.

i:r:1. ir rl ri : i " ,: r ;r :ir : r .11r ,

rr' i t;1 . rr l .ri -r:i r!t : r iL; : i : :, :r j. :,:r r : i:r j : r :{

'

./Oiarrge:Dentin ,, 1 .; i ,,t,,te. C e r v i cIaa n d m i d d l et h i r d s

Enameland internalenamelcharacteristics l\4ammelons, incisalhalo,occlusal andfacialsurfaces
B l ue: Fr ae cnem ol n na locnonno
Blue: lncisaledgeand proximalsurfaces
Anrber: Opalescence,
counteropalescence,
andvariousenameland dentincharacteristics Antber: Incisalhalo,incisaledge,andtacialsurfaces (characteristics)
 I
Color and Light

Light is color Light

lsaac Newton establisheda principle Lightis a physicalphenomenon of electro.
still acceptedtoday: Light is color. In magneticwaves.Thanksto its energy,
1665 Nevutondiscoveredthat sunlight obiect pigments becomevisible to the
passingthrougha prism divideditself in human eye. There is no color without
severalcolors,forminga spectrum.What lighi. Generally,light is white, and the
NeMon discoveredwas the breakdownof best example is sunlighi. When white
light inio spectrumcolors.Thesecolors light breaksdown into anyof its primary
are violet, blue, green,yellow,red, and colors(red, green,and blue) it becomes
purple,This phenomenonis often seen impossibleto breakit downagain.These
when light is refractedat the edgeof a threecolorsarecalledprimaryluminous
vitreousbody,as well as whenrain and colors.Theseprimary colors,properly
sunlightmix;dropsof rainwater perform combined,produceall visiblecolors,as
the sameoperationas the Newtonprism in a televisionor a projector. Primarycolorsfromihe addi.
and shatterlight,producingthe colorsof
tive (luminous)system: red,
the rainbow of whichthere are actually green,and blue.Any mixture
only three(blue,red, and green)(1)-
will resultin a brightercolor;
the mixtureof all of them will
Newtonthenrealized thatlightiscomposed Luminouscolor system
resultin white.
of more than one color.Whenlight hits
an element,it absorbssome colorsand Thereare two colorsystems,the additive
reflectssomeothers.Thisobservation led (luminous) and subtractive(pigment)
to the followingconsensus:All opaque syslems.
materials, when correctly illuminated,
reflectsomepartsor the entirespectrum In the additive(7) or light system,mix.
of the lightthey receive. tures alwaysgive us a lightercolor,and
the mixingof the threepigmentsprovides
Underwhite light, differentobjectsshow white,as in a projectoror a screen(8).
differentcolors,astheyreflectandabsorb
some parts of the spectrumwith more
intensitythan others.Whena light beam
contactsan object,the pigmentsinside
can do oneof threethings:(A) absorball
the coloredbeamsand thereforeproduce
the colorblack(5), (B) reflectall the light Lightcan be brokenintothree Our brain perceivesthe re. A luminous screen display.
beams and produce white (6), or (C) primary colors, red, green, flectedwavesas color.ln the ing the three primary colors
selectivelyabsorband/or reflectdifferent and blue, and in their merg. caseof a yellowobject,it ab. of the additivesystemsepa-
beamsand oroducesome sort of color ing point they producethree sorbsall wavesof lightexcept rately. When the three are
(2,3, 4). Whenwe see a yellowobject, more colors,evidencingwhat red and green.The color we displayedtogetherthe result
for example,we are reallylookingat a we know as a rainbowor perceive is the sum of all the tendsto white.
materialsurfacecontaininga pigment prismlight, colorsreflectedby the object.
that absorbsblueelectromagnetic waves lf we perceive white.it is be-
from whitelight;the remaining pigments cause the ob.,ectreflectsall
(red and green) are captured by the eye waves;if we perceiveblack,it
.'and
decodedby the brain as the color is becausethe objectabsorbs
yellow (4). Paradoxically our object is everyone of them.
everythingbut yellow

15
 Primaryopaquecolors: red, A mixtureof opaqueprima.
yellow,and blue.The combi- ry colors producesthe color
nationof the threegenerates black. These acrylic colors,
black. as with any pigment, are
basedon the subtractivecol.
or system.

Primarytranslucentcolors: When three translucentcol-

red, yelloq and blue. The oredacetatesareoverlapped,
merging of all threeresults the resultingcolor is always
in neutralgray,Dentalmite- darkerthan the initialcolor.
rialsarebasedmainlyonthis
system.

Pigmentcolorsystem
The pigment(subtractive) color systemis especially colors,which"subtract"color,and the final outcome Whenwe are trying to achieveestheticintegrationin
interesting to ihe dentalfield,because the materialswe of the restorationwill give the impressionof being restorations,an understanding of colortheoryis man-
work with, suchas compositeresinsor ceramics,are grayish.This problem is common in daily practice. datory,althoughit may seema topic only for painters
mixturesof pigments, and eventhe mosttranslucent The use of highly opaquemassescan solvethis and artists. Unlesswe understandthe basisof color
materialhas some degreeof opacity.lf we look at problembut will makethe restoration lookartificial, theory,we willfind it difficultto achievethe desiredre.
the basic differences betweenadditive(light) and so it is necessaryto study the outcomeof different sultsin dentistryor,worse,will onlyobtainacceptable
subtractjve (pigment)systems,in the secondsystem, layercombinations. resultsrandomly. Coincidental successis not a goalto
wheneverwe makea mixture,the resultingcolor will aspireto in dentistry.
be darkerthan ihe lightestof the originalcolors. For example,in painted ceramics,to diminish the
luminosityof an excessively white crown, we need
Thisfact is clinicallyimportantbecausewhena tooth to achieveneutralgray.To do this we must ascertain
is stratifiedwe use mass superimposition; if not the dominantdentinalcolor,and thendetermine the
managedcorrectly,the resulttendsto a neutralgray. complementary color(whichis the oppositecolorin
This meansthat the color methodwe are working the colorwheel).Forexample, if the basecolorof the
with is the subtractivetranslucentsystem,subtractive restoration is orange,
thecomplementary coloris blue.
becausewe use pigments that absorb light and Knowingthis, we can be sure that if we add bluewe
translucentbecausethe shadeslet light passthrough will lowerthe luminosityof the restoration, sometimes
to somedegree. for our convenience
andsometimesto avoidaccidents.

lf we start with a very dark base colot the masses To saturate a color we must know the dominant
addedafterwardwill be darkenedby the underlying dentinalcolor.
16
 I

and perception

Thehumaneyeis ableonlyto perceive wave- Conesare responsible for color vision,and As the levelof ambientlight drops,the first Excessive light causescolor confusionand
lengthsincluded in a range between380 there are three types of cones,which are colorsto disappearin the gloomare redand retinalfatigue,generatingpersistentimages
and 760 nanometers(nm). Uliravioletrays sensitiveto red,green,or blue: yellow;blueand violetare moreevident,not and the perceptionthat all colors tend to
(lessthan380 nm) and infraredrays(great. onlybecause of the energythey reflectbut white.In conditionsof high.intensity light,
er than 760 nm) escapethe perceptionof Red: Erythropsin(L), sensitiveto 500 to alsobecauseof the dispositionof receptors appreciationof colorcan be very imprecise.
humaneye. 700 nm (red light). in the eye.Thesemeansthat poor light con, Intenselightingcausesdefectsof perception
Green:Chloropsin(M), sensitiveto 450 to ditionscan misleadour perception. in general.
Colorperception is regulatedby absorption 630 nm (greenlight).
and reflection mechanisms. B lu e : Cy a n o p s in(S ), s e n s it iv et o 4 0 0 t o Poor lightingcreatesdefectsin red.yellow The light shouldbe soft,diffuse,and white
500 nm (blue light). perception,crucialin dentalcolormatching. for best results.
In the eyethere are millionsof specialized
cells able to deteci differentwavelengths Shortwaves(blue)havehighenergyand are Everytlme we attemptto recognizea color,
from the environment; theseare the rods small (S), and long waves(red) haveless issuesof perception
distortion
mustbetaken
and conesthat collect components energyand are bigger(L).
different intoconsideration.
of the light spectrumand transformthem
into electricalimpulses,whicharethen sent
to the brainthroughthe optic nerves.This "Theparadoxof realityis that no imageis
processis responsible for creatingthe color a s c o m p e l l i nags t he onewhichexistsonlyin
sensation. the mind'seye."

Rods and cones are usually present in a ShanaAlexander

10:1 ratio;that is, for every1.0rodsthere
is 1 cone,exceptln the center of ihe reti.
na (fovea).Rodsare especiallysensitiveto
505-nmlight(green-blue lighi). The visible spectrum region,showingthe
visiblecolors.Visiblelight is in fact a tiny
fractionof the total spectrumof electro.
magneticwaves.

Gammarays UItravioletrays Infraredrays FM radio Television Shortwave AM radio

 Lightphenomena
in the teeth Translucency
and opacity

A tooth,as a coloredentity,not only absorbsand Lightabsorption phenomena

and reflection work at T^
reflectslight, it also refracts,diffracts,transmits, the expense
of the object's
translucencyandopacity. ll(
scatters,and createsuniquelightoccurrences in the Transparent
and translucent bodiestransmitlight,
opticsworld: whileooaouebodiesblockit:

. Directtransmission:
The light passesfreelyand . A iransparent
objectallowslightto passcompletely.
findsno obstacle. . A translucent
objectallowslightto passpartially,
andihe remaininglightis reflected. Composite resinsamplesof differ.
. Diffusetransmission:
Lighttakesmanydirections . An opaqueobjectcompletelyblocksthe passage entopacitybutthesamethickness.
a{tor h i++ino the nh ipnt Diffuse of light. Under direct light, the samples
Direct
Transmission revealor hidethe text underneath,
Transmission
. Selectivetransmission:
Only certalnwavelengths Restorativematerialsintended to simulatethe natu- according to theiropacity.
areableto pass. ral tooth colorhavedifferentlysizedparticlesand
diverseopticalcharacteristics; they absorbsome
. Reflection:
Lightis rejected, rayswhiletransmitting and reflecting
others.Thein.
teractionamongthem createsthe colorsperceived
. Refraction:Light travelsat a differentspeedand by the eye.Compositeresinand ceramicenamels
direciionwhenincorporated intoanothervehicle. are materialsthat absorba relativelylargeamount
of light.The dentinsare more opaqueand reflect
. Diffraction:The light siops travelingin straight a significantamountof light.The pigmentshavea
with the beams
linesand createsself.interference c A l a.+ i ,/a.hc ^r^+ i ^n

that havefollowedthis path. Undertransmitted light,the same

samplesshowan amber appear.
ance.Theytransmitllght and re-
Selective Reflection veal or hide the text underneath,
Transmission
accordingto theiropacity.

AA
Yt/
Refraction Diffraction Underdirectlight,a highlytrans.
lucentcomposite(/eft)revealsthe
blackbackground and an opaque
composite(righf) hides the back.
ground.

5S 51
r-- -___lnE .tr
Tonality(Hue)
Compositeresins
A s me n t ion e d p re v io u s ly ,t h e Ch ro maZ o n e c o lo r st a i n , K u r a . are m ixedwith ba-
mostfrequentlyencountered den' ray)witha hybridcomposite resrn sicstainsto match
tal Hueis shadeA, but sometimes (3 , 4 , 5 , 6 ). d ry P , Ld I Jriducr.
teeth show other tonalitiesthat
may be similarto A but havecer' Composite resinsandstainsmust
tain slightd ifferences. be mixedcarefully andveryslowly,
because the incorporation of bub-
Althoughthe majorityof dental bles is a commonproblemwhen
shadesarein the rangeof red.yel. these techniquesare performed
low-orangeHue, supplementa ry (4, 5)
tonalit ie cs a n b e f o u n d .T h emo s t
common are gray ano Drown; Severalshadescan be obtained,
more u n u s u a la re p in k , p u rp le , a s s h o wnrnt h e e x a mpl e st o. h e l p
green ,o r b lu e (1 ). , Co mme rc ia l.ma t c h c o lo rs in a t y pi c a lc a s e s .
ly. il is v e ry d ilI ic u ltf o a c q u ire T h e s ee x a mp le sa re i l l u s t r a t i v e
tonesout of the commonrange (l ): t h e c h ro ma t ic i t yw a s i n .
of colors.A goodtrick is to de- creased to demonstrate the diffen
velopcolorsby mixinga traceof ent shadesthat can be achieved
light-cured stains(2) (eg,Enamel withthistechnique.
PlusTenderStains,Micerium,or
 Metamerism
In a famousfilm, there are sceneswhere
lmaginecombin in gs o c k s wit h Whenit is not possibleto have viewersare taken manytimes and briefly
srmrlarly coloredshoes.At home, a speciallamp,the colorcan be to a greenambientlight.Our brainadapts
we seea perfectmatch,in which capturedunderambientlightand in less than 1 minute to this environment
two differentmaterialsgive the later corroboratedunder anoth- and makes us believethat the lighting is
impressionof being the same er differenttype of lighting.This white.This happensmany times, and yet
color.Whenwe arriveat the of- providean idea of the possible comparingthe real light with the edited
fice, we realizethat the colors variationsthat canhaooen. light,we canseethe enormous difference.
are quite obvio u s lyd if f e re n t i
The same phenomenonhappens
when we placea restorationand
try to blendit in with a iooth,two
completelydifferent materials
that areverysimilarbut,whenin.
adequatelychosen,can causea
failurein colormatching.Toavoid

trE
this undesirable effect,calledme-
tamerism,we needto usecontin. Undercertainlight, objectsmay appearto
uouslightsourcesat a standard havethe same color,but undera different
light temperature(5,500 K). typeof Iighting,the colorsmayturn out not
to be identical.

Samplesmatch Samplesdiffer

8ANaturalIight High-intensity
light

Incandescent
light Neonlight
51 55
LightSources

Not all light sourcesare suitableior color

matching; from candlelight to a high.intensity
dischargelamp (HlD) the differencesare
substantial. lf a lightsourceis warm(red),we
will losethe abilityto perceive and distinguish
the orange-red of dentin.In contrast,if a light
souTce is cold(blue),we will losethe abilityto
locateblue and gray areasof the teeth.Our
brain interpretsmost of the environmental
i l l u m i nati on
as wh itelight.

Lighttemperature is measuredin Kelvin(K)

and is the temperature at whicha blackbody
radiator (nickel-phosphorus alloy or aligned
carbonnanotubes) mustbe heatedto generate
that kindof lighting.

Blackbodieswith temperatures of lessthan

about4,000K appearreddish,whereas those
g r e a t ertha na b o u t7.500K appearbluish:

. C a n dl e:1,00 0K
. Tungsten: 1,800K
. Halogen:2,800K
. N e o n:3,20 0K
. Daylight: 5,500K
. F l a s h:5,77 0K
. Xe n on: 9,30 0K
G lG lli

{ltl ll
,tl
' H I D :1 2 ,00 0K
. Lightning: 30,000K
li
llll/h. ,rl{ I I A l i \ ' llt
I'j i
 r

o !D

o
Theiwo siliconemoldsare An enamelshadeis placed The trasparentsiliconeis
designed to fit perfectly i n i h e w h i t e s i l i c o n ea n d positioned on the guides.
and stamp an enamel spread with an instru- lvlildpressureis applied
shellof veryprecisemea' ment. u n t i l t h e flask remains
surement. closedby itself,

GenericGuides
Personalized
An initial polymerization
is done throughthe sili.
The purposeof personalizing a generic Second,to designa reliableshadeguide, conefor 20 seconds.The
shadeguideis to geta systemas closeas each tab should providea sample of and a
siliconeis removed,
possibleto realitywhenwe createlayers. enameland dentinin overlapped layersof second polymerization
is
To do this we musttake into accountthe differentthicknesses. lt is mandatoryto performed.Thecomposite
followingparameters. superimpose the layersbecause the final shellcanbe meassuredaf.
colorof the toothresultsfromthe interac. terwardif needed.
to knowthe material tion of enameland dentin.
First,it is essential
in detail.lt is idealto performthe color
matchwith a shadeguideprepared from A simplemethodfor fabricatingperson.
the restorative materialthat will be used, alizedgenericshadeguideswill be de-
because eachmaterialhasdifferentphysi- scribed.Thistechniquequicklyproduces
cal and opticalproperties. Eventhe same two.layer samplesand provides a preview
color(eg,A3) in differentbrandscan be of a simplestratification, whichis of great The maximumthicknessin
very dissimilar. However, it is mandatory c linicaI value. thirdis 0.2 mm.
the cervical
thatthe dentallaboratory relyon the same
materialthat will be used in the dental
clinicto ensure consistency.

The maximumthicknessin
t h e m i d dlethirdis 0.5 mm.

The maximumthicknessin
t h e i n c i salthird is 0.7 mm.

Differentbrandcomposite syringes.
Theyareall intendingto be A3 dentin,anddespitethistheyappearcomplete'
Whichoneis the real43?Everycompanyusesits owncolorgradingandcompensating
ly diiferent. methods.
That
materialas trustworthy
is the reasonto usethe samerestoring shadeguide,no matterwhichmaterialwe choose.

5B 59
 Oncethe "sheJl"hasan optimalthickness. it must be posi-
tionedagainin the whitesilicone.Thisstepcan be avoided l{v x'.'t
onceexperience is gainedwiththe flaskingmethod.

Theshellis filledwiththechosencolorof dentinandpolymer. v / WW\ ^ iv l

,r'l Ar AZ A? A{
ized.Thetranparent siliconemoldcanbe turnedupsidedown
to polymerize it throughout andobtaina glossyflat surface.

At AI A( Ar f:
lT J AI AE AX
@nerpdMmx*idl" i{hBer',q,"Ji9 iEr@'riF}'sdliiie|lil
ilircrfiEdk,aidl
ftFcqffia aio tiitiln-hiElv,iiihErilalirinsfredldli oi a dihmqrrll
blri

f ; Aii7l. ii
A snap'onclip is glued to the internalsurfaceof the sample;
this devicewill allow the sample to be attachedto a special
stick on which it will rotate.

A\ A3 AX A1 lj
A' Aq.

After 10 minutes,the sample is ready to be placed on the

stick; prematurepositioningusuallycaLrsestl-resnap on but. Usinga fiveenamelandfiveden.
ton to detach. tin compositesystem,we have
alltheirpossible
f a b r i cated com.
binations. Samplescan be seen
overa blackback ground(/eft)
and a white background(right)
to appreciatethe changesthe
guidesmust be properlydisplayedand or- dominantdentinundergoes with
The customized
ganized; different enamels.The same
specially
designed
systemsareavailableto createa
personalized gLride
(N4y dentins(W,A1, A2, A3, and A4),
neat shade ShadeGuide,SmileLine).
in everypicture.Enamelshades
shownare XL (7), X (8), A1 (9),
A 2 ( 10),andA3 (11).
t------___-l.
,tr tr
6S 6t
 Customized
ShadeGuides

Shadeguidesof varyingthickness- An effectivetechniqueis to stratify

es are probablythe most usefulfor on compositetabsfabricatedfrom a
composite resins,allowingusto see plastictooth(1, 2).A stonetrimmer
in advancethe real stratificationis usedto removethe buccaland
thickness in seconds. palatalfacesto obtaina triangular
slice(3,4, 5, 6). Thiswedgeshould
We use this kind of guidefor higly measure0.2 mm at the incisal
preciseshadematching.This pro. edge(7, 8) and 2.0 mm at the base
cess is facilitatedbecausewe can (9, 10).Thethickness at bothends
oftenmodifytheshadeguides, strat. shouldalwaysbe checkedwith a
ify dentin,applyopalescents andef- metalcaliper.Thisslicewill be du'
fects on top of them, and achieve plicatedin transparent (11)
silicone
a very accuratesampleof the final or hard laboratory silicone(12) to
color.Thiswaywe can quicklypro. createa templateior makingcom.
duce a color samplethat can be positecopies.Thetemplateis kept
usedin boththe clinicand labora- at our disposalto carryout the fol.
tory.As dentistsandtechnicians, we lowingtechnique.
still havethe responsibility
to match
colors;however, in contrastto a few
yearsago,now we followa precise
protocol,not improvising whatso-
ever.

62
63
(-l f(:.: tl t e t . : nlI lllc rs f,r.rti y .
it !]l -r1 :Jncll f c nr c r ll ar l | rr-r:rn l r:
\ rll-lllra, S l i : r':Sln lS lr i' ilir a l
irn (l Sp r E ar aiav enly f/ th i r
As an exercise,we haveselecteda crown
S llalLl J Lrrll ihe ' , r l lr :r i: llll
wth muiipe characterizationsrn orosr
l lra! -: l lr f l i illeti.
to pertorm color matching and preparea
custornizedshadeguide for t. The goa is
to previewthe resut ng stratificattonoi
color.
-_ll_n n
---
An acetate sheet rs placedto Firstthe dentin is select.
cover the uncureclcompos ed. In the cervicalthird,
rte. and then a glass sl de rs we choose a chromatic
useclto co|l.lpressthe |llate dentln (ln 5) and n the
naL med um third we choose
a ess chromatic deftln
( n 3).

.l
Whenthe materialis com. In the incisaithird we find
pletelyspread,it is polym. th ree white characteriza
erizedthroughthe glassfor tions. Dista and mesia
40 seconds,and then the characierlzationshave a
acetateis removed. cold white (+), and tlre
centerhas a powerwhite
effect(+++).

Th e s c of e r s bent c ;i re i L r y n the incisa edge, we

i r' -j relll0 V e Iile C . r l l- llJr JSlle . find an amber charac
FrnaLy. excess s tf nlned. terization(Amb), a blue
Overths base.r^iec;in strat opalescenteffeci (opal).
ify rrr.r
meciratcy. and the enamel with a
medium'high Value (Out
2) as a final layer.

65
 After lt has beenfrnished,pollshed,
^ ^-^^-t +1.^ r^t. ^ L Ur r p d r ir I
---t
to the tooth(7). The matchshoud
be perfect;if it is not,a newtab is
fabricated.

Oncethe crownrs lemovedf rom the

l
opaque model, both samples look
alike (8). The comparisonbetween
rhe orig,nalc"owr and lhe tab s an
6v.6llAn+ r^+6rd^-a in ralr, nn
rv I u,y vr r.

The iab can be sent to the labora.

to.y (as a tangiblecl- omalic map)

I or archived for future reference.

Thetabs can be cut in half to reveal
lhe Ihichress ard arralgemeni o'
layers(9),

rs starlecl'vith a tab oi tlle chosenenar.lrecolor.Tllis lond of st fati ficat r or T

The prr,rcc:rs
shoLrldbe q Lrclilyclone.
chronratr,-tty
High cer'.rrcal cientinst[atificatronrs appl ecl
Basechror|aiicttyclentlnstratrflcatron ls ach a'/ccl
Op.ilescenttlass s placedat the lncisaledge
Intensiveancianrbereifectsare app 1ed.
The f nal enanrel ayer ts place,:j.

66 6/
 Effectsof Backgroundon DentalColor

The background behindthe teethwe observe A white background(2) allows differentia-

is essentialfor accurate espe. tion betweentranslucentmassesand study
colorevaluation,
and opalescentmasses. of the amber,orange,and reddishproperties
ciallythe translucent
Contrastors (Flexipalette,
SmileLine)of differ- of teeth,Whenmaxillaryincisorsin occlusion
-9 r
entcolorsareavailable. Eachcolorhasits pros coverthe mandibular incisors,
the background i,/ ''
Y \t
andcons. turnswiiite;this is a commonsituation.

A blackbackground for discrimi. A neutralgray background(3) promoiesdis-

(1) is suitable
nationof dentinand enamelshades,analysis crimination of tonality(Hue).
'l
of shape,and studyof whiteand opalescence
features. Theopalescence andtranslucency of Othercolors(4) generally are usedfor artis.
the incisaledge can be very welldistinguished tic and graphic purposes; they do not havea
whilethe mouthis open.Theabsence of light true utilityin the siudyof color,Thered back-
insidethe oral cavitymakesthe mouthback. groundmakesteeth appearbluer than they
groundblackor similarto black.Thisis what actually are.
we f ind mostof ihe time.

I
i
h

6B 69
 and DentalColor
Photography

photography
lvlodern toolfor communication,
is an amazing
documentation,and color analysis.To use imagesas a
tool.we musttakeseveralparameters into account,such
properexposure,
lightconditions,
as standardized andthe
rightmagniflcation. '' -"=ztt'

High-quality picturesare an excellentcolor transference

vehicle;camerasare ableto capturean extensive variety
An underexposed photographis consideredespecially
of details.Even some spectrophotometers are small
usefulfor revealing the internalcolor featuresof teeth.
digitalcameras, so single.lensreflex(SLR) camerashave
Beforethe pictureis taken,the exposureis reducedto
Thefollowingpicturesshowthe same
an infinitepotential. approximately -0.7/-L3 exposure value(EV)to createan
situationphotographed with the samecamera,the same
underexposed image.Optionally,but not ideally,
thiscanbe
lenses,and in the samemoment, but withdifferent
flashes
doneon the computer, by decreasingthe imagebrightness
anoexposu res. by approximately15/6Io 2O/"

(A).
Thispictureis takenwithpointflashes(lateralflashes) Diffuselightphotography is an interesting illumination
for
Thiskindof flashand its orientationprevent re'
extensive picturepresentation. The velvetyappearance makesthe
Thisis an idealtechnique
flectionon the toothsurface. for resultingimagebeautiful andreveals somefascinating color
documentation and imagecolordetermination. and surfacefeatures.However, it wouldnot be especially
preferred for colorselectionor as a routinepicture,because
diffuselight photographs hide severalessentialaspects
seenin a regularimage.

Witha true ringflash(C) or a pseudo.ring flash(the point This imagehas been digitallymodifiedto increasethe
flashesascloseas possible (B),the lightis
to the objective) contrast(60%)and decrease the brightness(aO/. to 60/").
directlyreflectedby teethtowardthe lenses,flatteningthe Colorfeaturesappearimmediately in a verynoticeableway.
imageand makingthe reflectingsurfacegreater.Therefore, Colorbecomesso strongthat soft tissueslook swollen.
the surfaceandtexture.
it is idealto highlight Thisis one of the most importantimagesthat we should
knowhowto obtain,to enableprecise appreciation of color
characteristics.
-n.-
I
,i!*-:

to the computer(F),
Oncethe colorpictureis transferred In reflective
cross.polarizedlighi photography.
takenwith
programs
several areableto transformtheseimagesto gray speciallydesigneddevice(polar_eyes, www.emulation.gr),
scalemodeto createa blackand whitepiciure.Thissori specularreflection,which obscuresthe fine detailsof
of imagegivesusefulinformation for analysisof enamel dentalstructure, is completelyeliminated,
creatlnga high
opacityand the overallValue;color picturesdistractus contrast/ hypersaturateddentalimagethat can be visually
fromthis DUrpose. analyzedor numerically calibrated.

/s 71
 lmageexposure Choosinga digitalcamera

Lightis the essence of imaging. Veryfewgood'quality dentalpictures canbe obtained The authors have no prefer- in posteriorsegments,intra.
wlthoutartificiallighting.Through'the'lens(TTL)technology is a systemthat makes encefor camerabrands;we orally,or extraorally. Theprod-
the flashfirebeforethe camera the
registers image, measures the amountof lightthat present these options only ucts in the lowerrowrepresent
returnsto the photoelectricsensor,andforces the flashto release the rightamountof becausethey have wireless t h e e c o n o m i c aaln d m i n i m u m
lightfor the finalshot.Moderncamerashaveaccessible features to choosethe right twin-flash compatibility.This equipment for achievingqual-
amountof Iightneeded; EVis an almostuniversalfeature in moderncameras withthe option providesversatilityin ity photogra phy.
symbol +/-. However, changing parametersin a camera without knowledge can make clinicaland siudio photogra.
it impossible to obtainthe rightexposure. phy becauseof the abilityto A cameramust have:
separate the flashesfrom the
bodyand to createa mlnistu. e Wireless f lashcontrol
Moderndigitalcameras witha TTLfunc'
dio intraorallyor extraora lly. : Autocleaning sensor
tion are capableof belngprogrammed .
Theequipmentin the top row TTLcompatibility
to obtain diversedegreesof lighting.
is the idealchoicefor mostsit. . 6lvlPresolution or more
Whena pictureis dark,we say it is un'
uations,in anteriorsegments,
derexposed. slightlyunder-
In dentistry,
exposedimages(-0.7 EVl-1.0EV)reveal
moredetailof the internalstructuresof
the tooth. Althoughdark picturesap'
pearto be deficient,usefulinformation
can be obtained from them. Camera Objective Fl a s h

Thesamepictureas aboveis shownwith

a properexposure.
is correctwhen it
The picturedisplay
the realsitua'
reflects
tion(0.0 EV +0.3EV-0.3 EV).Thistype
of picturecanbe usedin manyways,as
!
(E
o
ee
an originalor as a digitallyeditedim'
+1.0 age,and is idealto showln presenta-
tionsand lectures. N i konD 300s N i ko nVR M i cr o NikonC1
1 0 5 - m mAF 1 :1
+1.3

+1.5
(U
.Q

E
H +2.O
The same sceneis now shownoverex'
o
E
o
(J
posed(+0.7 EV +1.0 EV),with an ex'
tsl cessof lighting.Allfinedetailsaregone,
U

+2.3 and it is no longerpossibleto treatthe

H imagedigitally. The imageappearsun' Nikon M etzwirelessring
+2.5 naturaland has no manifestbenefit. flash
ts Theseimagesare commonlyobtained
+2.7 and paradoxicallyarethe leastuseful.
II
+3.0
EI 73
77
 RetinalFatigue
Althoughit is knownthat retinalcellsare proneto fatigue,the retinal
fatiguemechanisms are not verywell understood. Fatigueis partially
of
the result the firing of rod andcone cellsin the retina afterwe stare
at highlycontrasted areasfor prolonged periods; we subsequently lose
the abilityto makefinedistinctionsandaccurate colorselection.Before
we attemptto matcha color,oureyesmustbe relaxed. Watching neutral
colors,suchas gray,blue,and greenasfor example in the imageon the
right,for at least2 minutesshouldhelp,torestorevisualacuity.

Tips and Tricks

. Takea goodpicturebeforestartingthe color-matching process.
. Ensurethattheteethundergoingcolormeasurement arewellhydrated.
. Alwaysmatchthe colorunderconstantillumination of 5,500K.
'Ask the opinionof a secondobserver; it is amazinghow othersare
ableto providevaluable
informationthat complements ourfindings.
. Placea neutralgraybackground.
. Measurecolorwith the restorative
materialthat will be usedfor the
actualrestoration.

NancyEckels,
Wash
awaytheblues,2010.
Acrylicon paper.
www.nancyecKets.
com

71
 Conclusions

1. Thevastmajorityof teethhavea Huein the rangeof shadeA; evenif

theydo noi, theyappearverysimllarto shadeA, and the difference
usually remainsunnoticed.
J
2. Stainscan be carefully
mixedwith composite
resinwhenteethhave
unusuattones.

3. Colorideallyshouldbe determined
undera 5,500K lightsource,and
the assessmentshouldbe repeated
underotherlightconditions.

4. Expertisein digitalphotography
and imagingwill improveaccuracy
in colormatching.

shadeguidestogether
Personalized picturesarethe
with high'quality
bestmeansof communication
betweendentistanddentaltechnician.

76 77
 Chapter 2

Jordi Manauta. Anna Salat. ClaudiaLeal

Interviewwith Angelo Putignano

tt is not a littl
'oic@
b u t i s m a d eo f
,,

lVlichelangelo
Buonarroti
 lilll
:.:; I to i-l ! i!itll:rlr l'-.1
nto) I

Q: Whichwould be your ideal restorativematerialto

ll
reproducethe naturaldentin?

Angelo Putignano,MD, DDS, holds severaltitles at A: The successof an estheticrestorationis often attrib-
Universityof Marche,in Ancona,ltaly:
the Polytechnic utedto the colorchoice.
Dentistry,Schoolof Dentistry;
Professorof Restorative
Headof Operative Dentistryand Endodontics, School However,besidesthe chromaticcorrespondence, the
and
of Dentistry; Dean,School of DentalHygiene. opacityof the dentinis one of the principalfactorsde.
terminingthe estheticsuccessof the restoration.
He is an active member of the ltalian Society of
OperativeDentistry and the EuropeanAcademyof Theplacementof a dentincompositematerialwith cor.
Esthetic as wellas a foundingmemberof the
Dentistry rect opacity,fluorescence, and Chromawill guaranteea
ItalianAcademyof EstheticDentistry. goodestheticresultthat may also reducethe metamer.
ism, whichis a significaniphenomenon regulatedby
He hasa privatepracticelimitedio restorative
dentistry the variabilityof the light receivedby restorations.
in Ancona,ltaly.
Therefore,lhe ln compositeseems the right name for
An internationallectureron adhesiveand esthetic this complexmaterialusedto substitutefor the denfin,
restorations,Prof Putignanois coauthorof the books ratherthan simplydentin,whichis the nameusually
Guidetinesto AdhesiveiDentistry:The Key fo Success availablein the traditionalcompositeresin systems.
(Quintessence Publishing,2009) and Restauri Estetico- Thenewterm avoidsconfusionand unifiescriteria.
Adesivi lndiretti Parziali nei Settori Posteriori(lndirect
ConservativeRestoratlon ofPosteriorTeeth,UTEI 2008).

B? B3
 The In Layer

We call the dentinthe ,r /ayer,becauseit is Under normal condiiionsthere are two types t
lo c a t edo n tie i nsid eand is lhc deepesln lhe of dentin, the primary dent n, developed
stratification. since the formation of tooth germ, and the
secondary dentin, which usually begins its
The baseChroma(Hueand Chroma)is given formation at the moment of contact with the
b y t h e de n ti n,w hichdominates
the chromatic opposir-rgtooth and continues throughout
nature of teeth. life. The dlfference between developmental
periodschangesthe optical propertiesof both
De n t i n s the m o st abundanttissue in the k nds oi dentin,which is why the desatrration
la ^ l n r qi:nap :na ^l-o-.-or- ^ r^n .c -l-o ^-r-o. Of Tne lOOln S
L U " rP s^. Lr csPL' e more chromatic,and closerto the surfacethe
c' PPd | !' ' r r
'r)
similarityto enamel,dentin is physicallyand dentin becomesless saturated.For example,
opticallycompletelydifferent.Generally,dentin in an 42 tooth, the dentin near the pulp would
i s reddishyellow and has a high chromaticrty likelybe shadeA3.
and a remarkableopacity. lt is also a highly
tissue.becauseol lhe presenceof The gradualchangeof Chroma is also evident
l lLrorescent
certain proteins,such as photochrome. from the cervicalthird to the incisalthird; the
closerto the incisaledge,the moredesaturated
The physiologicaging processcauseschanges and more opaquethe dentin will be.
- -6-1.-2 .-t-" -,/- .p1.. i fe. The den.-nal
th ckness ncreases, whi e the diarneter O-r nei^oos o' st.aT'cat o- e-pra: ze
of the tubules, the volume of the pulp, and accJratereproduct'onof dent.na desat.-:l,or
the permeabilityand opacity of the dentin with restorativematerials.
decrease.

81
 DentinandAging

Dentin.almostas a rule.showsa low chroma. The final outcome of these events is the
ticity whenteeth are youngand increases in transitionfrom an originally
whiteand opaque
chromatic ity as theyage. dentin to a significantly darker and more
translucentdentin.As a consequence, it is
The changein chromaticity,a slow increase logicalto claim that whiledarkerdentinhas
of the orange-redcomponentof the tooth lessopacity,whitedentinhas high opacity.
causedby aging,resultsfrom two phenomena
I'{{ that take place in dentin.First, the dentin Thesechanges occurthroughouilifeand over
l.:, becomesthicker due to a contractionof extended time periods,because accumulation
l,:, the pulp,whichdecreases in volumeand is of waterand pigment is slow,
replacedby appositionof secondarydentin dependenton severalfactors.
progressive,
and

I
i
to occupy the resultingspace; in addition,
sclerosisof the dentinaltubulesmakesthe
dentinlesspermeable. Second,the hydration
of the tooth and the additionof pigments
to the compositionof the dentin affect the
chromaticity.Dentin losesopacity over time
and becomesmore transparent;this is the
resultof a mineralization processnear the
dentinoenameljunction. Changes in the
enamelalsomodifythefinalappearance of the
'! tooth.Enamel,whichdecreases in thickness
and turns smootheras a resultof physiologic
wear,becomesmore translucentover time,
t andtherefore dentinalcoloris morevisible.
,
T

I
'c
j
a

I
I

P I
87
 Physical
Properties,
OpticalProperties,
undEEE@@E@

It is commonlystatedthat dentinis opaque; Scientific studieshavedetermined the trans-

in fact, dentinis moreopaquethan enamel, lucency of 1 mm of humandentinandhuman
but it is alsotranslucent. enamelto rangebetweeni6.4. and i8.7. For
comoarison. the samethicknessof several
To achieve faultlessrestorations, one of the composites showedvaluesbetween6.3 and
most importantfeatureswe must consider 17.2.Highernumberscorrespond to a higher
is the appropriate Ievelof translucency and translucency; in a completely opaquemate-
opacity.The dentinacts as a very efficient rial,the translucency wouldbe valuedat 0.0.
opaquer:lt hidesdarkcolorsbut can let light
passthroughefficiently. Therearesignificant differencesin theopacity
of the dentincomoosites availablefrom vari.
Severalstudieshavereportednumericdata ouscomposite manufactu rers.Understanding
for the translucency andopacityof several re- the opacityand translucency of the different
storativematerials.Thereforeit is relevantto brandsis mandatoryin orderfor the profes.
becomeacquainted withthe translucency pa. sionalto selectthe correctcomposite resin.
rameters of naturalenamelanddentin.Inthis
way,we will be ableto choosethe appropriate
composiie resinin eachclinicalsituation. For
example, if we arefabricating a smallrestora'
tion that will be placedin healthysurround.
ing tissue,we wouldbe lnterested in a more
translucent materialto displayand reflectthe
underlyingtooth structure.For a largeresto-
ration,we wouldsuggestan opaquematerial
for buildup,because lf it weretoo translucent
it wouldbe unableto maskthe blackback-
groundof the oral cavity.

BB B9
 Elasticity

Dentinis the mostresistanthumantlssue,despitenot

beingthe hardest,and is responsiblefor supporting
the enamel,which is a much hardertissue and
brittlein the absenceof its substrate.
Dentinhas a
surprisingresistanceto traction,compression,and
shear forces,

Fluorescence
Dentindisksarranged from thinnestto thickest(iert Dentindisksarranged fromthinnestto thickest(/eft
to right)underdirectlight.Thethickerthe sampleis, to right),undertransmittedlight.The thickerthe A largeperceniageof the lightthat hitsthe dentinis Endodontically
treatedteethlosefluorescence,
so it
the betterit masksthe blackline. sampleis,the lesslightgoesthrough. reflected
back.Thislightis returnedwithmoreenergy is appropriateto restoresomelayersof theseteeth
thantheoriginal,
because suchtissuesarefluorescentwith morefluorescent materials
thanwouldnormally
and possessphotochrome andfluorophore. Deuseo.

lluu
Whatis fluorescence? In dentistryit can be defined The most importantfeatureof the fluorescence
as absorptionof UV light by a structureand the phenomenon is the "innerglow"that contributes to
spontaneous emissionof visible light within the the vitalappearance of the naturaltooth,that is,the
visiblelight spectrum.Whai is responsible for the lightemission from inside.
fluorescence? The dentin layer and its proteins
that bind it io the enamelare the most fluorescentAgingresultsin a decreasein the fluorescence of
compoundsin the body.Enamelis alsofluorescent dentinbecauseof proteinloss,tissuemineraliza-
but to a considerably lesserdegree. tion, and pigmentation. Agedcompositesalsolose
fluorescence but verys lightly

rrrlr1 The fluorescencephenomenonis evident under

fluorescentlight bui still stands out significantly,Various compositeshave different degrees of
althoughlessobviously,
someinvisible
undernaturallight.Because fluorescence,
light is bouncedbackfrom the teeth philosophy

to naturalteeth;a lackof fluorescence

dependingon the manufacturer's
or the material'scapabilities.
with higherenergy(visiblelight),it impartsvitality to choosea composite
We need
with a toothlikefluorescence.
is associated The lighterthe Chroma,the more fluorescent the
Differentbrandsof compositeresln,shownin ihe Different brandsof composite resin,shownin ihe same with devitalizedteeth, pathologic conditions,or materia I becomes.
samethickness of 43 dentin,underdirectlight.The thickness of 43 dentin,underindirectlight.Thediffer. prosthetic teeth.
differences
in Chromaand Hueareobvious. encesbetween theiropacityand lighttransmissionare
revealeo. The use of fluorescentmaterialshas marked a
revolutionin estheticdentistry.In the beginning,
thesematerlalshad a largenumberof detractors,
and manydid not regardfluorescence as havingeven
the slightestimportanceto esthetics.Today,any
restorativematerialthat lacksfluorescence is not II
consideredto be an optimalestheticmaterial.

90 9l
 Differentbrandsof 43 dentin
compositehave been photo.
graphedunderdirectlight.Dif.
ferencesin Chromaand Hue
areobvious.

The same samplesare shown

undertransmittedlight.There
areobvious in opac.
differences
ity, althoughall sampleswere
calibratedto have the same
thickness.

The fluorescence of the dif.

ferent samplesfrom d ifferent
companies is quitevariable.

Naturaltoothphotographed un-
der directlight,blacklight,and
transmittedlight,our standard
modelunderanysituation.
97 93
 junction
Dentinoenamel

Thedentinoenamel junctionis a thin layerconstituted acts as a light transmitterand scatterertowardthe

of partiallymineralized collagen proieinfiberbundles dentin,providing an appearance of depthand vitality
that penetrate the enameland dentin,the two tissues to the tooth,
whereit is located.Thefunctionof the dentinoenamel
junctionis to increase fluorescence and the natural It is importantto reproducethis Iayer in layering
(6) Sectionof a compositetooth
appearance, increaseValue,and provideelasiicity techniques. Thereare composites that simulatethe
betweenlayers.Mechanically speaking.it acts as a propertiesof the proteinlayer(eg, glassconnector fabricatedwith a reproductionof
the proteinlayerbetweenenamel
shockabsorber againststressforcesand prevents the Enamel Plus HFO, Micerium,and DE Connector,
propagation intothe enamel.lt is a highly Ultradent) and must be stratifiedbetween the dentin and dentin.(7) Sectionof a com-
of fractures
positetooth fabricatedwithouta
fluorescent layer,hasa veryhighValue(white),and is and enamel.However, many moderncomposites do
reproductionof the proteinlayer.
highlytranslucent at the sametime. Besidesbeinga not requirethis layerbecausetheir fluorescence is
strongbond betweentwo different tissues, this layer alreadycorrect.

Two differentcompositeres-
ins designedto simulatethe Sametooth sectionsunderblack
dentinoenamel junction are light. (8) The proteinlayer pro.
shownunderUV light to evi' videsextremely highfluorescence.
dencetheirhighfluorescence. (9) The tooth withoutthe protein
layershowslessfluorescence.

Sectionfrom a natu' Sectionfrom a natu- Sectionfrom a natu. Theappearance of a jellyfish

underUV
ral tooth under di- raltoothundertrans- ral toothsectionun- lightis a reminder thatfluorescence is
rect light.The denti- mitted lighi, which der blacklight,used not dependent on thickness or opacity
no e n a m eju
l n cti onis revealsthe lumlnous to evidencefluores- but photochemistry. Themoststriking
evidentas a c learly effect of the con- ce n c e .T h e d e n t in o . examples of fluorescence occurwhen
defined line. Where nectingline between enamel junction shines the absorbedradiationis in the ultra-
the lightis highlydif- enamel and dentin underblacklightbut violetregionof thespectrum, andthus
fused, the dentino- and the strongdiffu. is hardlyd istingu ish- invisible,andthe emittedlightis in ihe
en a m e lj un cti onap - sionthat occurs, able becauseof its visibleregion,as happenswhenteeth (10)Thetoothwitha proteinlayer
n ar ra re r slint thickness. areviewedunderblacklight. appears more fluorescent.(11)
Thetoothwithoutthe proteinlay-
e r h a s a deeperblueunderblack
light.

95
 The compositetooth fabri- The tooth fabricatedfrom The final Value has been The tooth shows less Val.
cated with a reproduction the samecolorsbut with. improvedslightlyafter the ue after placementof the
of the protein layer looks out a reoroductionof the enamellayering(5), which enamel composite (7, 8).
brighter under direct light proteinlayerlooksdarker createsan interestingfea- Generallywhen the proper
(1) and undera fluorescent underdirectlight (3) and ture but does not change materialis selected,accept.
lamp (2). These kinds of under a fluorescentlamp the Valuedramatically.
The ablefluorescence and Value
materialsconsiderably in. (4),eventhoughthemateri. tooth gains some opac. areobtained.lt is important
creasethe Valueof the res- alsarealreadyfluorescent. ity when observedunder to knowthe limitsof "fluo-
toration. transmittedIight(6). rescenceenhancers. "

96
 (/eft)Sampleof dentincomposite
A2. (cente) Compositetooth built
with an esthetic layering tech.
nique. (right) Sample of dentin
composite AO.

Under transmitted light, dentin

showsa certain degreeof trans.
lucency.In the straiified tooth,
translucencycan be appreciated
wheredentinis thinner.

Dissemination of light into the

dentinaltissueresultsfrom the
interactionbetween inorgan ic
andorganicmatter;for example,
hydroxyapatiteis transparent,
Under black light, white dentln and collagenis opaque.The
shows more fluorescencethan tubules are full of fluid and
dark dentin. The fluorescenceof proteinsthat makelight alterits
dentin decreasessignificantlyaf- trajectorywhenpassingthrough
ter it is coveredby an enamellayer. this structure.

Whena laserbeam(a light that

has a very low divergence)is
pointedto the incisaledgeof a
tooth,the beampassesthrough
the enamel and reachesthe
-TITITNT dentin (4). At this point, the
laser that travels particularly
straight experiencesa high
diffusionoverthe dentinalbody.
The laser beam was originally
0.5 mm and after hitting the
dentinreached6.0 mm.

NO i
L
f {,,

i\

& t-
 ri '
l

i'l
"d

t0-l ts5
 !

Selectionof DentinShades
I
for Stratification
l
I

One of the most important parametersin shade

matchingis determinationof the correctsaturation
and
Chromafor the naturaldentin.Mostteeth havea Huein
the A range.Someauthorshaveestimated that this is
the casein 8Ao/6
of teeth.Otherauthorshavemeasured
the Hue to be around580 nm, meaninga red-orange
Huethat corresponds to shadesA2, 43, and A3.5,

lVanymodernestheticcomposites
onlyincludeshadeA
dentinsin their systems.

Ilil57q nm | 590 nm | 6tO nm

Dentin
of a Gomposite
ldealProperties

The color spectrumthat comprises The averageHue of incisorsand ca-

the dentinshades.The areabetween ninesis 580 nm (red'orange),which
the lines representsthe most com. correspondsto the tones42, A3, and
monlyfound rangeof sha.des. A3.5in the Vitashadeguide. A materialwithall thesefeatures
wouldbe
an exactcopy of the human which
dentin,
at present possible.
is not technically

Wherecomposite resins,acrylicresins,and
ceramics fail currentlyis on the efficiency
of lighttransmission; the compositeis not
ableto opacifyeffectively withoutlosingits
translucence and lighttransmission prop.
erties.

Nonetheless,physicalpropertiesare
provingas materialsevolve.Fluorescence
of materlalshas been calibratedto the
naturalteeth,and color propertieshave
improvedconsiderably over the last de.

The choiceof dentincompositecurrently

properties:
is limitedto the following

. Highfluorescence
. Adequateopacity
. CorrectHueand Chroma
. Favorable physicalproperties
 GeneratingColor
with DentinComposite

phenomeno.n,
T0 simulatea des-aturati-oit it i5 Some esthetie composite systefls have varlous The purpose of the superimpositjonof different
important to addchromatjclayersin thedepths dentir shades within the A range, beyond the dentinalcolorsis to achievea more natural,deeper,
of the cavityto the stratification,
to develop conventional A1 to A4, that allowus to dev.elop more and estheticdentinal body, in this way avoiding
whatwecalla chromatie core,Forexampler if a and moreintenseahromaticity. monochromaticeffects and the risk thai the
natural stratificatiqns
toothhasa base. caloroJ A.1,the deeperlayers Proper stratilicationof three dentins according restoration will look like a pateh.
of dentinarelikelyto benearto shade43i to the techniqueadvocatedby Dr LorenzoVrnini
allowsdevelopmentof many more colors than are Veryfewsystemsare optlmalforan idealovellapping
dentinA3 + dentinA2+ dentinA1= AI tooih(4) commercially avarlable.lf we stratifya toothwithA3 dentinalreproduction.
dentin as the deepest layer,A2 dentinas the middle
The largerthe cavitypreparationi the more layer,andA1 dentinas the superficial dentin.we will
colorsshouldbe ine.lud.ed
in the stratification. obtainA1 baseChroma(4).
ln a verysmallcaviiypreparatio-n,
useof one
dentinshadeshouldworkopiimally, As mentioned,stratilicationallows us.to generate
naturalcolorsandshadesthat arenot commercially
Depending on the compisitesystem,dentin available.lf we stratifya tooth with an A4 dentinas
desaturation c.anruintheJinalqutqome.
ln those the deeplayer,43 dentinas the middlelayer,and A1
casesit is betterto workwith only one.dentin as the superfieialdentin,-wewill obtain A1.5 base
evenin largecavitiqs;. Chronra(5),

Large(1), medium (2), and.small(3) cavitiesl A1=A1 +M +43 A 1 , 5 = A 1+ 4 3 + A 4

showiirg tfre .apFroximateamourit of layers
neededto ereaterestorationswith the eorrect
de.saturationeJfect.

lEB 109
 Using the overlappirgdeniin tech.
ninrr e wo .a n .r ea- F 12 r lr lf glgnI
colorsfromthe A spectrum, without
lhe needfor complexcomposrie sys-
tems and with fewersyringes.With
these12 colorsis possible
to match
95/o of Ihe teethwe wouldpoten.
tially needto restore.

Followingare the basic rectpesto

obtain12 degreesof saturation:
A 0= A 0+ 41 + A 2 A 0.5= A 0+ A 2+ A 3 A 1 = A 1 +42- A3

A 1.5= A 1 + 43+ 44 A 2= A 2+ A 3+ A 4 A 2.5= 4 2+A4+45

43= A 3+ 44+ A 5 A 3.5= 43+ A 5+ A 6 44= A 4+A5+A6

A4.5= A 4+ 46+ 46 45= A 5+ 46+ A 6 46= A 6+46+46

tls
Sculptinga CompositeResin
Centrallncisor

V an in i'sstr a t iifc ati ontec hni que

The main objective of this techniqueis to develop A coloredtooth,A2 for example,shouldalwaysbe

the primarystructures of thetoothwiththe aidof an startedwith the help of a siliconeguideusedto
accuratesilicone guide to improveprecision of the constructan enamelshelland facilitateaoplication
modeling of the palatalstructures, reducemodeling of thethreeuniversal dentins(UD),whichcorrespond
time,andfocuson desaturation of dentinsto achieve to A4,A3,and42. fromthe depthto the surface.
naturalchromaticityand precisethicknesses of
enameland dentinin the restoration. Thematerials A t h in (0 . 5 ' mm)la y e ro f me d iu m-V a lue
en a m e li s
wewilluse(Enamel PlusHFOandHRi)weredesigned constructed withthe aid of a siliconematrix,a thin
to be usedwiththistechnique, spatula,dnd naturalbristlebrushes. Oncethis layer
is thin and uniform,it mustbe curedfor at least20 Use of a siliconeindexmakesit
Thebasesfor constructing the dentinalbodyare: seconds. Thenthe proximalwallsare builtwith the easyto fabricatea palatalstructure.
helpof matrixesand wedges,until a heightsimilar Proximal wallsarecreatedwiththe
. A highchromaticity core. to the totalvolumeof the toothis achieved, forming helpof matrixesor freehand when
' C h r o m a ti c de saturation from cervicaltoin c is aal n d a shell that will house
the dentinal body and serve as adjacentteeth are not available.
| |U||rP d rd L d l a reference duringthe stratificationphases,
The aim is to obtaina shellthat
. Placement of multiplelayersto gaindepihand in will act as a container.
thiswayavoidmonochromatic structures.
. Controlof contraction and polymerization through
multi l ayeap r p lication.

Correctorderof composite resin

layers,from dark to light Chro'
ma. Notethe obliquedisposition
of dentinlayers.

113
 The ability to handle compositeresln materials Thecorrectuseof modeling liquidsdemandsknowledge
correctlydependson the use of specificmaterials of the properties of the materialwe are using.These
that preventcomposite from sfickingto instruments.liquidsact as a thinnerof composite resinsand in fact
Goldenor black-coaied instruments and microbrusheshavethe sameorganicfractionas the material.
arenot recommended because thevleavemicroscooic
tracesas they deteriorate. Because modelingliquidslackfillers,theycan reduce
the physical properties of the compos'teand change
We use a hydrophobic resin(EnaSeal, it completely
and filler.free from the opticaland mechanical points
Micerium,or Fortify,Bisco)for two main objectives:of view.Because of theseshortcomings, it wouldseem
(l) as a modelingliquidand(2) to recover the oxygen- logicalnotto suggest the applicationof thesekindsof
inhibitedlayerafterdiamondburs are usedto make materia ls,
correctionson the alreadypolymerized composite.
However, if theyare usedcarefullyand with the right
Two importanttools neededfor delicatemodeling technique, theygivethe brushan optimalconsistency
are the siliconetip brushes,usedfor plugging and that prevents composite from stickingto it, maintains
distributionof compositewithoutthe risk of pulling the bristlesuniformly together, and helpsthe brushto
the comDosite from the site. and the naturalsable slayc tean.
brushes, usedfor surfacehomogenizing andflattening.

ia

111
 Whenii is not possibleto achievea highlyaccurate Theappearance of the compos-
shapeduringmodeling,a correctionis madewith a ite shouldbe as if it had just
coarse(80-pm)diamondbur usedat low speedand been modeledbut with precise
withoutwater.The restoration will becomecovered shapeand contours,especia lly
with white powderwhile the bur is operating.The on the proximal
walls,to prevent
removalof the white,powderydebrisis verysimple. errorsfrom carryingoverto the
Theentiresurfaceshouldbe moistened witha natural followingsteps.
bristlebrushsoakedin modeling fluid.Whenthe fluid
contactsthe powder,it develops the samerefraction No polymerization is neededaf.
index,causingthe powder to disappearoptically. ter the liquidexcessis removed
Chemically, the restoration
becomesclean,but it is withair,
essentialto removeexcessliquidwith plentyof air.

this processrecovers
In addition, the oxygen-inh
ibited
layerpreviouslylostduringthe correction.

116 117
Thenextdentincomposite usedin the stratification
is
a lightershade(A3).Thislayeris alsoplacedobliquely,
covering all the previouslyapplieddentin,occupying
approximately 60/o to 65/o of the total volume,and
reaching iwo-thirdsof the cervical-incisal
length.

l19
The last deniincompositeplacedcorresponds to the
selectedbasecolor(A2),stratifiedin the samewayas
the other layers.lt shouldcoverboth of the previous
dentins.but it is importanlto respectlhe spaceoI
the opalescentmasses(incisaland proximalgaps).
Approximately 90/6 Io 95/o of the final volumeof the
toothshouldbe formedwiththis dentin.

A speciallydesignedspatula(Misura,LM.Arte,LlVl
Instruments)
helpsto calculate
thethickness
of enamel.

Theopalescent massesare placedon the incisaledge.

Thismassshallfill the spacepreviously maintained
for
thispurpose,so its modeling shouldbe a veryeasystep.
lrregularities
must be avoidedin this layer.lVamelons
shouldbe covered just slightlyor not at all.

171
 The processis begun
with a root madewiih
a h igh-Ch roma den.
tin (A4 or A5). When
the processis being
started from scratch,
it is convenientto use
a fiberglasspost to fa-
cilitatethe modeling.

Free-hand
modeling:
Theconetechnique

The same chromatic

Thistechnique is verysimilarto thepreviously described dentinis usedto con.
technique. The main difference is that stratification
is struct a centralcone
developed fromthecenterto the surface. Thistechnique (protocone)that will
is mainlyusedextraorallyand as a teachingmethodto act as the tooth core
explainthe bioarchitecture
of teeth.lts mainapplications and as a referencefor
are in the laboratory,especiallywhenadvancedeffects the upcomingstratifi.
are requiredin the palatalarea.This techniqueis very cation.The p rotocone
usefulas a last resource whena diagnostic wax-upis must fill 50/o of the
not available. facial.palataI volume.

With the centralcone

as a reference
andwith
the same chromatic
dentin, two coneswill
be constructed.The
primaryshapeof the
mamelons is d evel.
nnarl in t h ic c+on

121 125
 A saturated dentin(A4) I||tr 5||dp|| rts srdtstr rs
is usedto connectthe carried on with a less
me s i aal nddistalco nes saturated dentin (A3).
and modelthe palataI More volume will be
surface. In thisway,the added over the mesial
coreis finished. and distal cones. The
architecture is cop ied
from the deep layers,

176 177
 The opalescentmass is
nl r.a.l +^ ra..rorta tha
As a teachingmethod,we are not necessarily hard. o p a l e s c e n c ea n d t r a n s .
will start by showingonly er to achievebut require parency ai the incisal
the basic stratific a t io n great accuracyin control- edgeand middlethird of
(enamel, dentin,and o p a l. lin g t h e t h ic k n e s swh
, ic h t h e p r o x i m aI w a l l s .W i t h
escence). With th is tech. is thekeystone of layerjng. an opalescentmassinvad.
nique,we cansuccessfully i n g t h e i n c i s a lt h i r d , t h e
resolvethe vast majority T h iss k ill is o n ly a c q u ire d e n a m e l w i l l ne c e s s a rily
of cases.After mastering t h ro u g h p ra c t ic eo f t h e becomethinnerandthere.
tho hecinc u,o nen ho. basic stratificationtech- foremoretransparentand
comeacquainted with ad. n iq u e s . naturallooking.
vancedcolor effectsthat

The base dentin (A2) is

usedto complete ihe den-
tinal body shape,creat-
ing the approximate finaI
volumein the facialarea
of the neckand leavinga
spaceof 0.5 mm in the
middleand incisaI thirds.

179
 Oxygen-i
nhibited layer

A frequentlyaskedquestionis the previously oxygen-inh ibited

whethera bondingagentshould layer,and the two layerspo.
be applied betweenlayersto lymerizetogether.Sometimes
bond them together.The an- this layeris lost,if a correction
sweris no.Composite resinthat is ma d ewit h a d ia mo n db u r o r
is in contactwith ambientoxj the compositeis contaminated.
gen is not able to polymerize.This layer is easily recovered
This apparentdisadvantage is by usinga primer-free bonding
the factorthat allowscompos- resinto moistenthe surfaceand
ite to bond from layerto layer. blowingit withair to removeliq.
Newly placed materialcovers uid 'excess.

P r o x i m aw
l a l l sa r e b u i l t w i t h a m e d i u m - V a l ueen amel
to a 0.5-mmthickness. Dividingthe stratification into
smallersteps facilitatesmodellngand ensureshigh
precision,optimal polymerization, and contraction
control.Thesewallsare built incrementally; placement
of the materialin onemassis difficultand imprecise.

Thisstep showsthe modelingof only one half of the

facialenamelsurface. Thisis doneeitherto determine
the volumeof the final layeror to builda crack.Theo-
retically,
the maximumthickness shouldbe at the inci-
sal edge,but the incisaledgein this caseis occupied
mostlyby the opalescent mass.

13S 131
 Polymerization

Manypolymerization lampsand and physicalpropertiesit will

polymerizationtechniquesare have.The most importantlayers
available.To ensuresuccessin withregardto polymerization are
thistask,wemustverifythewave. the innermostlayerand the sur.
lengthsensitivity
of the compos- faceof the restoration.
A layerof
ite usedand verifythat the lamp glycerincan be placedafter the
is capableof generating that final polymerization
to allow a
wavelengthwith enoughpower. long,extra polymerization cycle Once the enamel stratificationis con- modelingof the lastlayer;that practiceis
Composite resins cannot be (1 or 2 minutes).Theuseof glyc.
cluded,the surfacemust be smoothand far from the ideal,but it is still a solution.
overpolymerized;we can affirm erinis helpfulbutnotmandatory;
well extended, free of bubbles,clusters, However,for better accuracy,it is advis.
that the morelightthe material how'ever, a lengthypolymeriza. and elevations, and as closeas possible ablenot to polymerize untilwe arecom'
receives,the better conversion tion time is mandatory.
to the desiredtooth shape.lt is common pletelysurethat the shapeis optimal.lf
practiceto rely on finishingand polish- necessary, the stratificationof a single
ing to mendthe defectsfrom inadequate layercanbe dividedintoseveral steps.

Mechanicalpolishingprovidesa natural It is not advisableto use light-curedpro-

appearance and increased durabilityto tective
coatings.Despite theirinitialshiny,
the definitiverestoration
and is one of cleanappearance, they are a temporary
the most important keys to successful solutionbecausethesetypesof resinde-
estheticintegration. graderapidlyin the oral environment.

ttL 133
 Stratification reeipes for
the simplified tslhnique:

A 0 = A0 + A 1 A0.5=AO+42 41.= '41 + Aa

Simplifiedtechnique

It it possibleio d€schp leSF Suchtechnique!allow:adY€ n'Oe.d

ohromatioally' camplexteeth in users ts ,simp'lifutheir stratifl.
a simpleuay rrS.ingfewerctolors cati.onrhelhnd3and $aveiime,
whlle maintainlnghigh.qualityparticularlyin the lateral.posie.
egthq.tisie5! lts. rior area,
A1.5= 41 +43 A 2= A 2+ A 3 A2.5 = A2 +.M
Geri€rally.thi5 tasft js aehleved .Fotnewu$ers,suchteehniq.udg
by .usingtwodentifi shades] and shouldbe practieedas an intrs.
pne enamsl shadd,depending ductionto laverins. Qncethis
on the sizeof'th€ eayityi technique is macter€dj morc
eolor'sof dentinand lnt€rmedi.
The ute o{ two dgntins qliqws aie lqy€rs'oanbe added, as.ds.
us to obbin hafftsnecolors.Al, seribedin chaptef4.
thuughthe i$lOrsdq no.tend up
asdeepascanbeattained with
the advancedtechnique, their
accu.racyis qu.ite elose to dhe
Ag = UDA+.llB4 A3.5=UD3+UD5 A4=UD4+UDs th io.m4tiqity.
.de-sired

A4 ,5 = A 4 + 4 6 A5=As+46 A 6= A 6+ A 5

EI lJc.
 S c ul pti nga c entrali n c is o rwit h t h e s im p lif ie dt e c h n iq u e

Construction
of an 42 tooth:

The fir cf cfe n ic tn .r a ^ tr ; A Thefinallayercorres ponds

palatalwall and an enamel t o t h e e n a m e l c o m pos-
shell, with the appropriate ite. For this technique,it
corrections, pre-
asdescribed is necessary to use an op.
vrously. tically efficient mass (eg,
trmnroc c D i roe f en a r n -

el, lvoclar,or EnamelPlus

HRi) to obtainopalescent
effectsandhighValuewith-
out effects.

A high-Chromadentin (A4) is T h e r e s t o r a t i o n i s con-

placedobliquelyso that it oc- touredand polisheduntila
cupies60lo of the volume. highglossis achieved (see
chapter 10).

The base dentin (A2) is

placed to fill the remaining
4O/o of Ihe total dentin di-
mension.The contoursof the
mamelons are designed in
this layer.

136 137
 Theincisaledgeshowssubtleopalescent(1) Thecomposite toothfrom the simpli-
both blue and amber, fied techniqueis shown photographed
characteristics,
withoutthe use of any kind of opales. witha flash.(2) Theimagehasbeendigi-
cent masses.Theseeffectswereachieved tally enhanced to revealthe opalescent
throughpropercontrolof thickness and effects.(3) The imagehas beenconvert-
the useof optically enamelcom- ed to blackandwhiteto revealthe Value.
efficient
posrtes.

138 139
 Summaryof Stratification
Techniques

Single dentin and enamel Simplified layering tech- Lorenzo Vanini's technique. Mameloncharacterizatio n
comoosite restoration.Sim- nique.This techniqueuses Three dentin compositesare technique.Moreopaqueand
ple to use, the techniqueis two dentin composites and used to build the dentinal less chromaticmagsesare
indicatedfor noviceusers be. gne enamelcompositeand body. Many advancedeflects usedto enhancethis p€rt ot
cau.se {or the maior'
of its abilityto matcha is appropriate are usedin the.middlelayerto the tooth,regardless
ot the
large numberof restorations. ity of casesin whichwernust achievenaturalrestorati.ons. numberof dentinlayers.
generate
colors,

Radialtechnique.This tech- Personalized block tech- Newton Fahl's technique. Single.shadeteehnique,This Reverse technique. Whiter
niqueusestwoor moredentin nique. Suitable lor trans- This technique consists of technique is recomm€nded dentin compositesare used
composites and one enamel lucent teeth (body) andlor using a chromatic enamel for provisionalrestorations, in the innermostportion for
comoosite.The color is de' opaque teeth (dentin), the (Vita) or body on the mar- some posteriorrestorations, masking,and chromaticden.
rived from the center and technique involvesthe use gin zone and an achromatic and caseswhereestheticsis tin or body compositesare
becomesdesaturatedtoward of a singlemassto build the enamel(non.Vita)on the in- not essential. used near the surfaceto in-
the surface,
Usedfor thefree- wholetooth. The incisaledge cisal portion of the restora- creasethe chromaticity.The
handtechnioue. can be characterized for fur- tion. Fewdentin composites mamelonscan be personal-
ther estheticintegration. are reouired. ized as well. This technique
is indicatedto opacify dark
featuresof teeth.

110 111
 Conclusions

1. Because mostnaturaldentinbelongs to shadegroupA, focusingon

willbethe keyto success.
of thecorrectehromaticity
selection

2. Opacityand the efficiencyof lighttransmissionaretwo of the most

importantparameters for choosinga restorative
material.

3. Fluorescence in a materialintendedto simulatedentin;

is essential
however, excessfluorescence can be opticallydetrimentalto the
restoration.

dentinsconfers
4. Theuseof highlychrornatic a lifelikeappearanceona
restoration theamountof color
andinereases that can be generatad.

in thin layersprovides
5. Stratification highaccuracy
duringmodeling.

6. Alternative can be usedto resolve

techniques specificcasesand are
sometimes solution.
the mostappropriate

112 113
 Chapt er 3
Out
Jordi Manauta. Anna Salat

Interviewwith WalterDevoto
66 To defi nethe
is to

C h a r l e sR o b e r An
t on
 Q: Whatwouldbe the correctwayto considermasses

ll
thattry to imitateenamel?

Dr Walter Devoto graduatedwith honors from the A: We alwaystry to rmitatenaturewith our materials
Universityof Genoawiih a degreeln dentistry. and our stratificationtechniques.

He has heldteachlngpositionsat severaluniversitiesin In that sense, the reproductionof teeth is always

Europeandcurrently works of
withthe University Siena, growingcloserand closerto nature.
InternationalUniversityof Catalon ia-Barcelona,and
Universityof Marseille,wherehe is a visitingProfessor The externallayer is the "skin" of the tooth, a very
in restorative
and estheticdentistrv. complexstructurebecauseof the interactionwith light.

He maintains a orivate oractice in Sestri Levante Manycliniciansdo not understand

the differences
in
with specialtypractices
(Genoa),ltaly,and collaborates of dentinandenamelcomposites.
chromatlcity
in dentalestheticsaroundEuroDe.
Forthisreason, I thinkit is morecorrectto callmaterials
His passionfor conservativeand esthetic dentistry that are intendedto copythe dentin/n composites and
has led him to authoror coauthoFseveralpublications thosethat are intendedto reproducethe outsidelayer
and to speakat nationaland international
coursesand Oufcomposites.
conferences on thesesubjects.
In this way we havemorefreedomin choosing,within
Dr Devotohas been an activemember of the ltalian each system found on the market, the masseswith
Academyof ConservativeDentistrysince1998 and the adequateopacityand translucency.
EuropeanAcademyof EstheticDentistrysince2002.
This rn turn makesus free to superimposethe layers
in accordance with our knowledgeand passionfor
this incredible
materialthat is our bestcompanionfor
everydaywork!

118 119
 T'he"@l"JT'"
layer

We call rhe massesthat are used ro reproduce a way that is similarto the way it travelsin natural
ihe enamel Out layers. teeth. To do this we measurethe refractiveindex
of the enamel and try to find the same in the
Theenamelis primarilyresponsiblefor regulating composites.The refractiveindex is the way the
the Value,or tooth brightness,and is characterized Irghttravelsth|ough an object. rhal is, ils speed
by a high degreeof translucency(comparedwith and its direction.The vast majorityof composite
tlre dentin)and uniqueliglrt effects. massesdo not havethe same refractiveindexas
natural enamel, so if the composite is placed
Enamelis composedmainlyof hydroxyapatite and in the same thickness as the enamel, optical
a lesserpercentageof organicnratterand water. integrationwill not be achieved.Clinicianstry
The crystal structure of enamel prisms ailows to solve the problem through layering,placing
light to passwith little restraint,whilethe organic enamel composite layers that are thinner t han
interprismatic substance shows high opacity. those of the naturalteeth.
Without this interprismaticsubstance,enamel
would appear gray or blue. The composition It is vital to design layering techniques for
of the enamel makes it a unique complex of each specific composite becauseeach one has
refection,transmission,and absorptionof light. different formulation and properties. The final
Theenamelacts as an advancedsystemof optical compositethicknesshas a particularimportance
fibers; it helps to transmit light into the dentin, [or inlegralion ol Ihe restoration. because I
which is then responsiblefor spreadinglight and regulatesthe light and color in the tooth.
consequentlygeneratinga complex combination
of light effects(1), The combinationof the highly Natural enamei is translucentand luminous at
translucentenamel prismatic structurewiih the the sametime, whilecompositesact as a vitreous
more opaqueinterprismaticmatter makesenamel material; this makes it difficult to maintain
both translucentand a high.Value substanceat the preferredlevelsof luminosityand translucencyat
same l'me. lndrslrially it rs still nor possiblero the same time, becauseopacity increaseswhen
al ign two componentsso differentwith the same luminosity does and vice veTSa.This fact has
di spositionand nanometric djmensionsas the hamperedclinical practice.UsLlallythe level of
enamelpflsms. translucency we wouldwish for enamelcomposite
would force the materialto lose brightness,t hus
There is a differencein behaviorbetweendental decreasingthe Valueof the restoration(creating
materials and natural enamel. The goal, of d ts l dy l 5l l aPPc at at tLc ) .
course,is to make light travelon the materialsin

150
 (1) Color phenornenain the (2) Enanrelcryslalline cor'r1.
enalrel are Lrnrclre.Enaifirel ponentsallov./free passageoi
i .i r i c. i .r r ' r - 1,r l- , c\/<f- ln.i light; organic n]atter,tn con
u l j l L .rI f u et 5 { 1|d t r 5 |l tur e upl| trast. blocks lrght. Thrs con.
callyefficert than the denlin. tfadrctloncreatesa com lllex
systemthat absorbs,reflects,
ancl transmits liBht. The or.
ganrc componentcreates an
internaldiffr-rsion
oi liglrt, re.
sultrngIn a whiteappearance.
Without tlre organic conrpo.
nelrt, the enanrel would be
entirely transparentand have
a Sraya ppearance.

(3) Coloreffectsareobtained
throughtwo perfectly aligned
polarizedfilters, causinga
phenomenon of laghtscatter.
ing in the subtletooth sec.
t ro n .

152
 A disadvantage of transparentand translucent
(semitransparent) materialsis that they loseValue
as theirthicknessincreases. Theybecomegrayor
blue, representative of a violentlight absorption
("killinglight").

Compositesbehavesimilarlyto glass;they lose

brightnessas they increaseiir thickness.In con- OP A QU E
trast,in naturaltoothenamel,thicknessis directly
proportional to the total luminosityof the tooth.
Therefore,whenenamelcompositeis usedin high
thicknesses,it develops the so'calledglasseffect,
and the restorationbecomesgray.

Thisdifference in behavloris essentially the result

of the differencein the refractiveindicesof compos.
i+o rpc i n an.l p n a r n el
Translucency is a mainfeatureof n.atural expression of lighttransmissron through
enamel. Thereareverytranslucent enam- materials, allowing a clearvisionthrough
els, almosttransparent, as in abraded them, while translucentmaterialsblur
and fine teeth at the incisaledge,but the background, and opaquematerials
rllllttl they never becomecompletelytrans- totallyblockihe passage
p a r e n t .T r a n s p a r e n ciys t h e m a x i m u m parentmaterials
of lighi.Trans.
do not existin dentistry.

Superimpos itionof differenttransparent

crystalsshowhow the backgroundloses
luminositybut doesnot becomeblurred,

E4 155
Physical
Properties,
OpticalProperties,
andOpacityof Enamel

Lightrefractionand dentalenamel

No natural occurringmovementknown Humanenamelhasa highrefractive index

yet can surpassthe speedof light under comparedto vltreousmaterials. This has
absolute vacuum.In anyotherenvironment,forcedusto placetraditional materials in a
the speedof light is slower.Lightrefraction differentlayerconfigurationthan is found
is the change in speed and direction in the naturalteeth, such as applying
experienced by rays of light passingfrom a thinner layer of enamel composite.
one environmentto another,propagating Normallybetweenone-thirdand half of
Forexample,whenpassingfrom the total thicknessof the enamelshould
differently.
air intowater,lightis bent,meaning that it be reproducedin enamel composite;
is beingrefracted.Thischangein direction th ickerlayersloseValue.
resultsfrom the deceleration experienced
by lieht. Subtle differencesin refractioncause
light to behavedifferently,allowingus to
The subtlechangesin the refractionof appreciateboth materials.The restorative
lightcanbe appreciated by observationof materials ideally should have equal
phenomena as
such the differencebetween refractiveindices to be able to imitate
hotair andcoldair (mirage)or the mixture naturaI tooth layers.
of oil withwater.

Thefaceof the wristwatchis clear.

ly visible,despitehavinga slight
inclinatioh(/eft).Whenthe watchis
immersedin water(right),the light
makestwo directionchanges, and
the reflectionin the glass blocks
sight of the watchface.This dem-
onstratesthe differencesin refrac-
tive indexbetweenair and water.

Becauseof their different refrac-

tiveindices,
we cantell whichair is
hot and whichis cold,eventhough
they have the same color and
transparency.
 Material Refractiveindex

vacuum 1

Air 1.00029

lc e 1 .3 1

Water 1.33

Hu ma nc o rn e a 1 .3 3

Acetone 1.36

A lc o h o l 1 .3 6

Q u a rt z 1 .4 5

Glycerin L47

Methylmethacrylate L4a

Acrylicglass 1 AO

S a lt 1.50

Ceramicenamel 1.50
Fnarnpl .nrn nnc i to 1.51

Silic o no il r .5 2
r .5 2
A fracturedtooth has beenrestoredintentionally with Salt 1 trA

a greaterthicknessof enamelcompositein the whole

incisalthird.Theconseeuences are evident:Thethick Amber 1.55
enamelcompositelowersthe Valueof the restoration
an d make sth e m a rgin visible.lt also produ c e sa terephthalater .5 7
Polyethylene
gray and unnaturalappearance; light diffusiondoes
not occur efficienily,and only light transmission Polyca
rbonate 1.58
increases. This phenomenonoccurs in nearlyevery
Flintglass(pure) t.62
m a t e r i aleve nwh e na high-V alue
enamelcompo s it eis
us e d ,a s in th is ca se. Hu ma ne n a me l 1.62

A lu min u mo x id e L76

S a p p h ire r .7 7
Cub ic z irc o n iu m 2 .r 5
Dia mo n d 2.42
T it a n iu md io x id e 2.49

S ilic o n e 4.01

158
 So far the onlymaterialreportedto
a l l o w t h i c k n e s s essi m i l a rt o t h o s e
of naturalenamelwasdeveloped in
2008;its properties havebeencon.
stantlyimproving sinceits introduc.
tion. lf it showscontinuedsuccess,
we couldbe lookingat the futureof
dentalmateria ls.
A posteriorrestoration
has beenfabricatedfrom a highly
chromatic dentincompositeand a 0.6-mmoptically efficient
enamellayer(EmpressDirect42 Enamel,lvoclarVivadent),
The high luminosiiyand the white effectsare particularly
outstanding, considering
especially that no other mass or
whitestainwas placedto help increasethe Valueand no
bevelswereoreoared.

Somecomposites havea regularrefractiveindex(1.53)but

high opalescence(opticalefficiency).
Thesematerialscan
be placedln greaterthicknesses.
Bothopticaleffjciencyand
indexare provingto be the path to followin the
refractive
evolution
of restorative
materials,

-TIffiIT
An anteriorrestorationhas been
fabricatedfrom a 0.8-mm layerof
an enamelcompositewith a high
index(1.62;EnamelPlus
refractive
Hri,UE1,Micerium). No bevelswere
prepared.

--:
160
 Co m p aredwith dentinall issue s , The synergybetweenthe enamel
enamel structure has a highly and dentin makes the tooth an
translucentappearance, Actually, o b je c t t h a t p la y s wit h lig h t in a
enamelhasa highdegreeof opac. uniqueway,thatallowslightto pass
ity,especiallyin areaswith thicker throughenamel, whereit is stopped
enamel,and only allows partial by dentin.Bothenameland dentin
passage of light. havea completely differentappear.
ance when analyzedseparatelyor
In areassuch as the incisaledge. together.
enamelallowslightto passthrough
very efficiently,providingtranslu-
centand opalescent effectsdespite
the tact that no tooth struclureis
lranspareni.The incisal edge is
wherelessdentinis foundand the
translucency of enamelis bestap.
preciated.

Enamrel
dehydration
lmmediately aftera tooth is isolat- Colormatchingand analysismust
ed from moisture, dentalelements be performedbeforecompleteor
beginto dehydrate,and effectsare even partial isolation,when the
visibleafter only 3 minutes.The teethare fully hydratedt otherwise
lo ssol watermolecules occursim- thereis a highriskof mismatching
mediatelyin the organicmatrix. colorby choosing a whiteronethan
This decreasesits refractiveindex, is appropriate.
resultingin a disparityof the in.
dice so f the organicand inorgan ic
matter.This phenomenonblocks
Ine passageoT gnl as rT occurs
in an e mulsion; enameland dentin
obtainan opaquewhitecolor.l\4axi-
mum toothdehydration is appreci-
ated after 30 to 45 minutes,and
completerehydration of thetissues
cantakebetween 24 and48 hours.

A fullyhydratedtoothhasa deeper
(1a, 1b).
c o l o r a n d t r a n s lucency
Afterjust 30 minuLes o[ moisture
isolation, the tooth losesits color
depthdue to dehydration (2a,26).
Enamelis the tissue that loses
water most rapidly. Dehydration
Li l l c tho nac c :oo nf lio h +

162 163
 opalescence
Spontaneous

Onecomplextask in dentistryis to Thosematerialsthat try to simulate

appreciate the degreeof translu. enamel and have the best optical
cencyof the naturaltoothand cor- propertiesshareone common char.
rectlypair it with its correspondingacteristic:opalescence, an attribute
composrte. We must learn to per. of naturalenamel,characterizedby
ceivethe difterentopacrtres, care- its optimal light transmissionand
fully lookat teeth,and developan unique color effects.With the cur-
appreciation of the diversepatient rentlyavailablecomposites,we can
enamels.We can achievethis pro. reproducesome h ighly opa'escent
ficiencyby becomingexpert ob- restorations(seechapter4).
, e v e l o p r n lgh e a b i l i t y t o
s e r v e r sd Samplesof differentena.
perceiveslight differences among mel composites under
e n a m etlr a n s l u c e n c i e s . transmitted light show
how diversethe opales.
cenceoutcomets.

To appreciatethe opalescenceof a T h ei d e a lc o m b i n a t i ow
n o u l db e a n
material,it is necessaryto observe enamelthat hasthe propertyof be-
at differentangleso'f incidenceand ingwhiteunderdirectlightandam.
transmission(eg, movethe sample ber and orangeundertransmitted
and look at it under direct light light or, in otherwords,the alrility
and transmitted light. Opalescent to looklikean opaquematerialbut As the amount of whiie
enamelsalter the passageof lighl: allowpassage of light in a veryef- in the glassesincreases,
they look blue and white under di- ficientway. opacity alsoincreasesand
rect light (3) and show amber and blockslight transmission.
orange effects when observed un ln manyrestorativemateri'
der transmittedlight (4). als, opacityincreasesVal-
blocks
ue but dramatically
fha nr ccr oa nf lio h +

F :

1 ;:
I
F ;t _
 Enamelthickness

Thenaturaltoothenamelactsas an efficientmask
for thedentinandincreases thetoothValue.In areas
whereenamel is removed (\, 2, 3), the overalltooth
chromaticityincreases dramatically, and thus the
Valuedecreases. Whenthe toothls observed in the
areawhereenamelhasnot beenremoved, dentinis
blocked,andwe cancomparetheenamelValuewith
the Valueof the restof the tooth.

Thethickness of enamelchangesacrossthetooth.In
we
the incisalthlrd cansee increasedtranslucency;
however, thirds,thereis a
in the middleandcervical
boostof opacitydueto the proximityof the dentin.

Wlthincreasing
thicknessof enamel,theValuerises,
and properties
oi the underlying
stratafade.

The blue opalescence of ihe incisaledgeis more

difficult to obtain when enamel thicknessis
increased. With thinner enamel,this blue effect
is more intense.In estheticenamel composite
restorations,thiseffectshouldbe strengthened with
the useof specificmassesespecially designed for
the incisaland interproximal areas.Althoughthe
final enamellayerhas opalescence, this intrinsic
featurehasto be enhanced withspecialcolors,

Enamelthicknessis differentin everytooth (2, 3);

the thicknessdoesnot correlatewiih the toothsize
or shape but correlatessomehowwith the type Enamelcompositediskspreparedin differ.
of tooth.Enamelbecomesthinnerovertime, as a ent thicknesses,increasingprogressively
resultof wearcausedby the actionof the different from 0.1 to 0.6 mm. Underdirectlightwhen
elements in contactwiththe enamelthroughout llfe. the thicknessis increased,brightnessand
opacityare augmented(4). Viewedunder
Fewmaterialshaveproperties
that will increase
the transmittedlight,the disksshow a strong
Valueand preserveits transparency
restoration's counteropalescence phenomenon(5). As
whenwe increase
the thickness. thicknessincreasescounteropalescence is
morepromInent.

h6 h7
 Enamelaging

Enamelbecomesmineralized overtime by Enamelis a permeablestructure. With the

absorbingionsfrom saliva,food,and occa. rightamountof time, it absorbsyellowand
sionallychemicalsin the oral environment,brownpigmentsthat arecapableof produc-
suchas fluoride.However, the enamelalso ing subtlechanges in its color. Black and white pictures
becomessmootherand thinnerbecause of help to detect significant
physiologic wear.The increasein mineral. Enamelwearsout on its surface,causing changesin Valuebetween
izatjonand thinningof the enamelmakeit light to penetratemore efficiently, lookjng different enamel shades
moretranslucent. lesswhite,and revealing the underlying
den. (4), as coloris no longera
tin, whichis morechromaticanddark. distraction.Lightgrayrep.
Beforeerupting into the oral cavity,dental resentshigh Value,while
enamelis structurallydehydrated. Waterab. dark gray representslower
sorptionand its bindingio hydroxyapatiteis Value.
a processthat takesseveral years,resulting
in lossof opacityfrom its structure. Depending on the age of
the tooth,the Valueof the
enamel changes.Restor.
ative materialsshouldbe
ableto reproduce this situ.
ation.lt is not only impor.
tant to observethe mate.
rial and confirmthat the
Valuechanges,it is also
vital to understanddifter-
ences in Value(5), light
t r a n s m i s s i o n( 6 , 7 ) , a n d
the correlation between
opacity(8) and Value(9);
opacityand Valueshould
increase at the sametime.

Enamel mineralization also affects the With passageof time the enamelsurface
brightnessor Value:hypomineralized and wearsout, and the mineralization continues
porousenamelshavea lowerdensity,con. to increase. Theenamelreflectslesslightbe-
ferringless translucency and more bright. causeof its lackof brightness;
this phenom-
nesson the enamel,whichtherefore reflects enonis commonlyseenin olderteeth(3).
much lighi;this is the most commonsitu-
ationin youngand whiteteeth(1). On the Thedegreeof translucency of naturalenam-
otherhand,fully mineralized enamelshave el.canvaryfrom ioothto tooth.Theopacity
greaterdensityand highertranslucency,and dependson the densityandthickness of the
thereforeare very transparent,absorbing enameland thus affectsbrightness.
light moreefficiently(2).

i66
 Value

Humanvisionis much more sensitive

(Hue)(see chapter1). This meansthat

is moreseriousthan selecting
to
light (bright/dark)than to color itself

a small mistakein the choiceof enamel

or dentinValue,chromatically speaking,
the wrong p
rffi shadegu
vitushadeguidr
lllffiltr
ideorderedby tones:A1, A2,A3,
l
c3, c4, D2,D3,D4.
Hue.lf we choosea B shadeinsteadof
an A shade,it wouldbe lessperceptible
to
the humaneyethan if we choosea wrong

ffiilrl
enamelor a less saturateddentin.This
conceptis particularly
pertinentwhenwe
areworkingwith iesschromatic colors.

WhenValueis determined, three condi-

tions-age,degreeof mineralization,

Thepatient'sagehelpsto determine
and
enamelsurfacetexture-areimportantcon.
siderations.

tooth
Value.TheValueof naturalteethis highin
Whenassessing

massesto overlap
resented.
the Valueof teeth,it is usefulto com.
parethe naturalenamelwiththe shadeguidefrom the
restorativesystemto be used.lf the guideallowsthe
(1, 2) a morerealsituation
willbe rep.
lt is idealto makecustomoverlapping enamel b y l u m i n o s i t yB: 1 ,A 1 ,
I
83, A3.5,84, C3, 44,C4.
theteethof youngpeople, andof adultsin anddentincomposite shadeguides(seechapter1).
whomenamelis wellpreserved, and lowin
the teethof olderadults,especially
teeth A0.5 A1 A1.5 A2 A2.5 A3 A3.5 A4 44.5

cmt
<-t
withabradedenamel.

t til illlt rl
I
el n
The enamelof primaryteeth is very po.
rous and slightlymineralizedand there,
sb-

t
foreis whiterand hasa veryhighValue.In
contrast,the enamelof permanentteeth
is mineralizedoverlongerperiodsof time
and becomes moretranslucent,smoother, Compositeshade guides fabricatedwith the same
and darker.
restorativematerialenableus to overlao shadesoriorto
stratificatlon,
as witha snapshellovera dentincore(1)
E or in iabs that havedifferentthicknesses Blackandwhiteimageof Vitashadeguideorderedby luminosity: 81, A1, 82, D2, A2,C1.,C2,D4,A3, D3,
acrosstheir [r
E
length(2). Both solutionshaveprovento be effective, 83. A3.5,84, C3.A4. C4. lt is easierto ditferentiate
theValuesin this image.
but a problemstill to be solvedis the fragilityof thin
shadeguides.Formaximumprecision, it is mandatory
to build a personalized shadeguide to obtainmore The ideaoi Valuein colortheoryis misunderstood.A helpfulapproachto train our sightto distinguish
realistic
thicknesses. We understand Valueas the amountoi whitethat a colorsis to rearrange the colorguidesby luminosity
colorhas.Whileit is truethatan A1 toothhasgreater (4),that is,reorganize
fromthelightest to thedarkest
Valuethan an A2 tooth,this is a cumulative effect, color.Thismethodis usefulfor two things:first,as
because whenthe chromaticity is increased
we can an exerciseto distinguishcolorsand, second,to
observe a darkertooth,whichhasnothingto do with locatethe intermediate chromaticitvof teeth(5)
the lackof brightness of the object,althoughin the
finalresultit seemsthat it does(3).
7S v1
 Gomposites
for EnamelReproduction

).
*,.
,tr
Because of currentimprovements in com-
'', \ posite formulations,it is importantto
understandthat many classifications of
ri compositeresinsexist,according to their
particles(microfilled, hybrids, nanohy-
'i brids,nanofilled,etc),the degreeof trans-
':i'tl lucency(body, incisal,opaque,enamel,
dentin,etc),or their locationin the resto.
i i. ..r ration(opalescent,
' cervical,
liner,etc).
o ,o
.\--rtr .--
:.,!
Composites for enamelreproduction are
moretranslucent than are thosefor den.
tin and haveopalescentfeatures,Thebest
materialsare the ones that imitatethe
opalescence and translucencyof natural
Different
brandsof medium-Value enamel Whenthe samedisksare observed under enamel.
composite(0.5-mmdisks)are observed transmittedlight (2), it is evidentthat
underdirectlight(1). The threesamples eachcomposite transmitslightdifferently, Enamels, whenclassified in a system,can
are completelydifferent,althoughthey The compositeon the left has very poor h a v ea n u m e r ical
designation(I,2, or 3),
supposedlyshouldhavea verycloseap- opticalproperties.The compositeon the a shadeguidedesignation (Ai, 28, 3lvl3),
pearance. right,despitebeingverybrightand more
an alphabetical designation(XL, L, D) a
opaquewhenobserved underdirectlight, q uaIifying designation(light, medium,
majntainsa perfectbalancebetweenthe
dark),or evena name(pearl,ivorywhite,
amount of whitenessand translucency
facialenamel).Most enamelcomposites
withoutturningopaque.
are pairedwith a corresponding dentin
composite (eg,41 dentinandA1 enamel),
whilein othersystemsthe materialsare
sortedby Value(seepage247).

t._ -
n

172 173
 Incisaledge

The incisaledge is one of the most excitingareas Depending on the translucency found on the incisal
to study and understand. becausein this area are third,the shapeof the dentinmustbe adaptedto that
concentrated mostof the opticalphenomena we can situation.A thin dentinalcoreis requiredfor a highly
observein a tooih. translucent effect(1a, 1b), a mediumthicknessis
neededfor normaltranslucency (2a. 2b). and a thick
The jncisaledgeis formedexclusively of enamel,but layeris neededwhen this area is opaque(3a, 3b).
thirdcloseto themiddlethirdalsopossessesThesethicknesses
the incisal will determinethe spaceavailable
dentin.tvlanydegrees of translucency arefoundin this for opalescentmassesand enamel.
area,strongly dependent on the ratioof enamel-dentin
thickness,Toreproduce theincisalarea,we haveto play
withthethickness of thedentinal body.

171
 When opalescentmasses are In. Opalescent
masses:The beautybehindthe enamel
serted, immediatelylight is trans
mitted more eJficiently throughev.
ery laye( g ving the incisa third a Unfortunatelythe productionof a cornpositeresinmaterlalv/iththe same
,l fer p'ope'ues :" i'e e-a-e c-'re'rt r s sl ll o 7 a p'o- se. Opa esce^ce
tle der' ^o'P s t' .1). Pe rs a- -r'r1s c c"a.acter s: c oi rle ralL'a erd'r-er.Spec'c opalescert
-re'
oard or 'L o tl-,'" - < n OS. (arl ._ .
-F,ooucel-ese eire- s especa r ,,r e-'tl-ey
err - 6 c< r n :cca < cl1 ^ | .1 htr

sible lo pre,i5ely drstinBLrish the are strongiy present. i\4anymanufacturersclaim that their enamelshave
end of the dentinalbody (1, 2, 3). natural opalescence,but scientificand clinical data indicatethat these
statementsdo not correspondwith reality.

It is essentialto use highlytranslucentcolorsto simulatethe opalescent

effects. Use of colored stains to reproducingthe effects hampers the
usual passageof light; the result will be an unnaturaleffect.When an
opalescentmaterial is placed,it imparts furtlrer lifelikequalitiesto the
incisaledse and tl.reentlrerestoration,

176
Underdirectlightthe sectionsre.
vealthe diversecolorsof the dif.
f e r e n tlayers(4a,5a,6a).A btack
and whitepicturereveals the loss
of Value betweenthe different
thicknesses (4b,5b, 6b).Thefinal
enamellayerjncreases the tooth
Valueand slightlysmoothesthe
gray-blueopalescenteffect,pro.
v i d i n ga naturalappearance thatis
especially visiblewithlightinterac.
t r on .

l@:li.dEilEtrtrl;

179
 Conclusions

1. Enamelcompositeshouldbe only half or lessthan half of the natural

enamelthickness,in most situations.

2, opalescenceand translucencyare two essentialcharacteristicsin

selectionof enamelcomoosite,

3. Glassy effect can be preventedby using high-refractiveor optically

efficientenamelcompositesand accuratelycontrollingthickness.

4, Enamelcompositeswith a high refractiveindexcan be placedin thick

layerswithoutlosingValue,but someinternaleffectswill be masked.

5. The nomenclaturefor enamelcompositeresinscan be confusingin

somesystems,lt is necessary
to understandand analyzeeachsystem
thoroughlybeforeuseto avoidabsurdor seriousmistakes,

160 18r
 Chapter 4
Mid
Jordi Manauta. Anna Salat

Interviewwith LorenzoVanini

)
ll
' '
II IS nottruethatwe cansolveproblems
withmoreresources;
whatis neededis
moreknowledge."

TffiVeE€;*
- t\ r'A\.rl- /l\
(t4+\\;
rq

SteveCowley
 tnEll
.r l :- il- :o !; r ;i

Q: Opalescences, intensives,
and characterizations:
Howdid you cometo developthesetheoriesand gain
theiruniversa
I acceptance?
I

A: The Munselltheory does not considerintensives,

opalescences, and characterizations, and I don't
V
ll understandhow it is

withoutconsidering
possible
to determinethe color
and to build a good restoration

colorchart,with my classlfication
in the anteriorteeth
these importantdimensions.
on the reverse
l\4y
side,
allowsprofessionals to communicate using numbers
and letters.Nothingsimilaris foundanywhere in the
internationalliterature,which meansthat everybody
Prof LorenzoVaninigraduatedwith degreesin medicineand
surgeryfrom the Unrversityof Paviaand has speni the last 30 speaks about color using only their personal
yearsworkingas a specialist with particular
in estheticdentistry, impressions-this is not scientific!
interest in the conservativerestorationof anterior teeth and
research relatedio compositeresindentalmaterials. Color determinationis the basis of and the most
important step in estheticrestorativepractice.From
He conceived a new methodfor colordetermination in dentistry this theory,I developed the iechniqueof anatomical
and a particular
anatomicalstratification
technique for composite (1995)andthe composite
stratification systemEnamel
materials,widelyesteemedin the iniernational field todayand Plus,thefirstfluorescent composite.I introducedtheuse
adoptedas a teachingmethod by numerousuniversities in of the heaterto increasethe comoositetemoerature and
Europeandthe UnitedStates.At the sametime he hasworked,in therebyeliminatebubblesand improve polymerization
collaboratlon
withGerman firms,on researchto develop innovative of the material.Most importantly,however,I wrote a
dentalmaterials.
bookin whichI described all mytheoriesandtechniques;
He is an activememberof the ltalianSocietyof Conservative all the materialin the book is original,born from my
Dentistry,ltalian Academyof ConservaiiveDentistry,and the brain.Nowwe arestillworkingon the newHRi,the first
AmericanSocietyfor Dental Aesthetics.He gives advanced enamelcompositewith refractive indexof 7.62, and
proficiencycourses, bothlocallyand on an international level.He we are rapidlyimprovingthe physicalpropertiesand
is a professor
of restorative
dentisiryat the UniversiiyLa Sapienza, the qualityof this material.This is all I havedone:I
Rome,and visitingprofessor in esthetics at the Universityof the havecreateda colordetermination method,a layering
Mediterranean, l\4arsei
lle. technique, and a reallynewmaterial.

Workingwiththe chemistDr ThomNiem,ProfVaninihasplanned But now I havea questionfor you: I wouldliketo find
and developed the new EnamelPlusHRi composite(Micerium), out whatothershavedone.Whataretheir methodsfor
which has the same refractive indexas naturalenamel.he rs colordetermination,
theirtechniques for stratification,
the authorof numerouspublications and coauthorof the book
andtheircomposite systems?
ConservativeRestoiationof Anteriorleeth (Acme, 2005). He
maintainsa privatepracticein SanFedele,
ltaly.
I thinkthat answering
will be reallydifficult!

186 187
 In naturalteeththereis a borderbetween Althoughwe siratify these three effects
enameland dentin,a highlyfluorescent between enameland dentinmaterials, jn
organiclayercalledthe dentinoenamelnaturalteeththesefeaturesnormallybe-
j un c t i on . long to the enamel.In somesituations,
can be part of the
thesecharacteristics
Forthe purposesof stratification, there dentinor in contactwith the surface. To
is also an intermediate layer(lvlid)that simplifythis concept,we will treatthese
is createdafterthe dentinalbodyand be- propertiesas part of the intermediaie
iorethe finalenamellayer. layer(Mid).

In the Mid layer,threekindsof masscan IVorecomplexfeaturesderivedfrom the

be inserted-intens in c h a p .
ives, characteriza. midd lela y e rswill b e e x p la in e d
+ i ^ nc 2 n.l
^nalo<..pn.pc
ters 7 and 8,

. Intensives:Intensewhite featuresor
spots
. Opalescences: Specialoptical proper.
tiesof transparenceand iridescence
. Characterizations:
Specialcolorproper-
tiesof certajnregionsof the tooth

IBB
 0;oalescence

Opalescence is an optical phenomenonCounteropa lescenceis the

derivedfromthe ultrastructure
u ralen a m ecomplex.
l
of the nat. that causesamber, orange,
gleamsto appear.This is q6:r *
dent under transmittedlight
It is definedas the iridescent appearanceteetharein occlusion. lt is well
of an illuminated bodyunderradiaiionin backgrounds al{ect opal
the visiblespectrum.lridescence changes foreteethin occlusionswitchfrom
the color andlor brightnessof a mate. background to a white one. When
r i al,e sp e cia lly
whenthe angleof light is wavesfindan internalreflection ooint
cnangeo, bounceback,orange-amber opalescence r
occurs.Whenbothwavelength groupsare
This phenomenon, as demonstrated by reflected, opalescence doesnotoccur.The
observatjons with the scanningelectron interaction oi opalescence and lightin the
microscope, resultsfrom visiblelight re. teethprovides opticaldepthandvitality.
fractionin uniformthree-d imensionaI ar-
rangements, suchas sphericalbodiesor Althoughmany enamel masses show
arrangements separatedby octahedraI spontaneous opalescence, highly trans.
structures.0palescence is expectedin lucentand oDalescent massesare an en.
the naturalenamelbecauseof its three. hancement forthefinallayerswhenwe are
dimensional organization, pronounced
tryingto re-create blueareas.

Thanksto translucency, the opalescenceThereare many philosophies regarding

phenomenon is possible;lightis absorbed the useof opalescent masses. In addition,
and redistributed withinthe enamel.De. diverserestorative systemsofferdifferent
pendingon the typeof particleson which possibilities and strategiesto re.create
lightimpactsor passesthrough,different theseeffects. lt is possible
to re.create
the
color wavelengths are created.Opales. opalescence with stains.However, we do
cenceoccursall overthe enamel,but this not recommend useof the stainingtech-
observable fact is moreevidentin the in. nique becauseit resultsin opacityand
cisalthirdwherelightcrossesthroughthe an unnaturalappearance. Therefore,we
full enamelthickness withoutinterferencehighlyrecommended the use of specific
fromdentin,creatingbluegleamsas a re. massesto re'create what is probablythe
sultof tinyhydroxyapatite crystalsthatIet mostimportantfeatureof teeth.
the long.wave spectrum(red,orange, am.
ber)passthrough,Whenthis occurs,our
eyesdetectonlythe reflected light,which
arethe shortwaves(blue,gray,violet).

19S
 To achieveinconspicuous incisaledges,opal- Opalescentcomposite characteristics:
escenceshouldbe a phenomenon occurring
naturallyin the material,withoutblue pig. Restorative materials shouldhavelightreflec.
ments,to be ableto reflectblue light under tion propertiessimilarto those of natural
directlight(1, 3, 5) andgenerate amberglints teeth. ldeallythe restorative materialmust
undertransmittedlight(2, 4, 6). Thedynam. have:
ic propertyof thesematerials(changingas
lightingdoes)enablesus to achievesubtle . Oneor moresmallinternalphases(fillersof
or intenseopalescence with a singlemass 380 io 500 nm) dispersed in the material.
simply by addingmore material.Examples . Highdispersion of all the internalphases.
of composiies specifically designed to repro- . Verydifferentrefractiveindicesbetweenthe
duceopalescences are TransOpal(Empress matrixandf iller.
Direct,lvoclarVivadent), OBN (EnamelPlus . Hightranslucency.
HFO,lVicerium), XT (Adonis,Sweden& Mar- . No stainsor pigments.
tina),and EffectBlue(lVliris 2, Colt6neWhale- . Compatibility wilh the restorative system.
dent)(7). The organicmatrixof composites
shouldserveas a freespacefor lightto travel Werecognize fivekindsof opalescence, classi-
freelyafterbeingscaiteredby composite fill' fiedfromtheyoungest to the oldestteeth.The
ers.To optimizelightdispersion, particlesiz- typesdependon the dentinalshape,whichwrll
es shouldbe slightlygreaterthanthe incident containthe opalescent masseson the incisal
wavelength (380to 500 nm). edgeand between mamelons.

The efficiencyof opalescence is judged by the

amountof blue that a materialcan expressunder
directlightand the amberfeaiuresthat it can show
undertransmitted light.

Amonga translucent amber(left),a pureopalescent

(center),and a transparentmaterial (rlght), it is ntli8 \
-lrntd"\
evidentwhichis opticallythe most efficient,being
bluish under direct light (5) and amber under 'tt
\tt
transmittedlight(6). I I i-
\5
\

192
 Thefiveopalescent
types

The incisalportionof the dentinhas mamelons i !'l . : : r | !t:,r i _!J :l tl r r :

that are responsiblefor giving shape to the
opalescence; the enamellocatedin the incisal Type3 is a multiple.mamelon effectin whicha
edgelets light passfreely;this areais a critical physiologic divisionthat hasoccurredin the three
pointwhereopaquedentinandtranslucent enamel lobesresultsin an opticaleffectof 6 to 10 (or
coexistand interactto form the most interestinpmore) mamelons.This type of opalescence is
areaof a tooth. commonin the teeih of middle.aged adultsand
olderadults,althoughthis can vary significantly
, ' 1 .: ri :r:r:rl ri :l ,l ':: at anyage.

Consisting of threemamelons, thisopalescence

is
commonin newlyeruptedteethandteeththathave fi i 'J: r ! i i ri t:!1ri :r i r;r'
not beenwornyet.Eachmameloncorresponds to
onedevelopmental lobe.Patienis withopenbiteor This type of opalescence marksthe conclusion
inabilityto haveincisorcontactstypicallypresent of changesin mamelonsovertime. The enamel
this three-mamelon shape throughoutlife. The opacitydecreasesand allowslight to travelmore
mamelons d ifferin size: efficientlyalong the incisaledge.This type of
. Mesial:Vertica lly longest opalescence is also detectableat earlierages
. Central: Horizonta lly widest in individuals whoseteeth do not havemarked
. Distal: Smallest developmental lobes.Type4 opalescence is seen
as a straightlineon the incisaledgethat signals
l ' , ,l i l : : r ti r: ! t:!j .r:l i t,r : the outlinedendof the dentinwiihoutmamelons.

Thistypeis characterized by four mamelons or by 'i ,'r,t: ; !t,rri :!f i :l i t,i :

threemamelons withthe centralmamelon,which
is the widest,dividedin two, at leastoptically, Type5 is proximalopalescence, normallypresent
creatingthe effect of four mamelons.Type 2 is in all teeth, regardlessof their incisal edge.
frequentlyfoundin theteethof childrenandyoung Sometimes it existsaloneand frequently
is found
adults.The divisionof the centralmamelonis in conjunction withtheothertypesof opalescence.
causedby enamelhydration and physiologicwear.
The mesialand distalmamelonsare still visible
andfrequently symmetric. Opalescence is evident
on the distaland mesialareas.whilethe center
looksmored iffuse:
. Mesial:Longestandwidest
. Central:Appearsseparatedinto two or more
mamelons, and theirindividualsizesare usually
smarl
. Distal:Mediumsized
The same opalescentmass will be placed Although hundreds of opalescentshapescan
on top of eachdentinal core,demonstrating be found in nature,
a five.group
division
seems
that the shapeof the dentinalcoreis essen. to be an easyto understand classification
be-
tial for the incisaledge.With a high-qualitycauseof the commoncharacteristics shared
opalescent mass,everytypecan be correctly by mostteeth.Eachtooth has its individual
recreated. opalescent shape.and it can be expressed
from its mosisubtleformsto the strongest.

191
 lmtems
ives

Inten sive white

s. accumulations in teeth , For integrationof a restoration it is es-
areauthentic proofof the imperfect
beau. sentialto reproduce thesewhitefeatures,
ty of teeth.Unfortunately, peopleusually whichmeansthai the understanding and
associate thesespotswith diseases and reproduction of sucheffectsleadsresto.
enameldefects.Therealityis that, in the rationsto a muchhigherlevelof esthetics,
absenceof pathologic conditions,which
is mostof the time,thesewhitespotsand Whitespots are found basicallyfor the
clustersarecommonand oftenharmonic, following reasons: hypoplasia,hypominer.
playinga key role ln the composiiion of alization,tissued isorganization,and dif-
dentalesthetics. ferencesin densitybetweentissues.Dif.
ferentauthorshaveuseddifferentierms
Althoughwhiteeffectscan havea 30/o to io referto thesefeatures, suchas bright
8016 opacity,the vast majorityof these areas,colorislands,and decalcifications.
whitefeatures aresemitranslucentandlack We believeit is morecorrectto callthem
opalescence. In addition,aithough
intensivelntenslves due to the powerfuland intense
masses reflectmostlight,theyalsoabsorb natureof theirproperties.
andtransmitit.
Achievingcompleteintegration of a res.
Colorsintendedto reproduceintensive torationwhen the tooth is smooih and
featuresare almost pure white. Some- monochromatic becomesa reallydifficult
times theselight shadesincludea trace task.Whenintensive arepresent,
features
of yellow.orange, alwayson a whitebase. integrating a restoration
becomes easier.
These characteristics are presentedin
manyintensities; whenthesearelightand Classifying them, on the other hand. is
subtletheyresemble the colorof pearls. slightlycomplexbecausewe must take
and whentheyare intensetheyresemble jnto accountfirst the shape,secondthe
th e colo r of milk. intensity,
andthirdthesize.However, once
the classification
is learned,it becomes
<.i rn n l e +n ?ccacc taath

196
 We recognizethree basic pat. Cloud:Thereis a diffusewhite
ternsin intensive shapes: area,wlthsmallintense andweak
clusters.The limitsof theseare
1. Spot imprecise and not easilylocated.
2. Cloud Thesearethe mostfrequently ob-
3. Band servedintensivefeaturesand are
presented in variousintensities.
Spot: Thereis a uniformwhite
area.The borderof the spot is Band:Bandsshowa texturedpat-
welldefinedand insideits limits ternof whitebandsthat run hon-
is an uninterrupted or barelyin- zontaland parallelto eachother,
terruptedwhite spot. Spotsare normallyextending thefull length
associated with the most pow- of the facialor buccalarea.The
erful types of intensive;in other spacesbetweenthe bandsand
words,strongwhitetonesusually theirthicknesses areuneven. The
correspond to thistypeof stain. marginsbetweenthe bandsare
usuallyslightlyblurred,andwhen
they are sharpthey givethe im-
pressionthattheyareunnatural.

198 199
 +: This categoryis the least in. +++: This is the most intense
tenseand most translucent white white normallyfound in the ab.
of the iniensives.Theuseof such senceof pathologic conditions.lts
masses is clinically interesting.coloris similarto that of milk.De-
Whenusedin subtlethicknesses,spiteits opaqueaspect,it allowsa
it enhances the Valueof the area, smallpercentage of lightto pass
and if usedin higherthicknessesthrough.Generally thesekind of
it is ableto reproducewhite"con- massesare used in subtleincre'
fused" spots. ments.

++: Intermed iate white, more ++++: Thistype is an opaqueand

opaque,and slightlymore power. powerfulwhitefor strongintensive
ful, this intensive
is capableof re. stains,normallypathologic.lt is
producingboth subtleand strong almostopaque. evenin thin layers.
white characterizations, depend-
ingon the thickness applied.

Intensive massesareobserved un-

oooo
Intensivemassesareobserved un-
der directlight.Althoughthey all der transmittedlight.Whitesatu-
lookwhite,differentwhitesatura. rationof compositespromotes the
tions are found.The differentin- existenceof differentopacities.
tensities,++++, +++, ++, and + Despitetheir whiteness,intensive
(lefttoright),makethe blackback. masseshavea certaindegreeof
groundmoreor lessmanifest. translucencylikethatfoundon the
naturalenamel.

Intensivemassescan be gener-
ated by mixinga bieachmass
(XW body, Filtek,3M) with a
whitestain.Wecanincrease the
strengthof the whiteby adding
morestainand areevenabieto
createparticular shades.

20s 2S1
Thethree intensivesizes Small Medium Large

The intensivescan coverbiggeror The intensivesoccupy less Theintensives occupy half or The intensivesoccupymore
smallerareasof teethwhilepreserv. thanone-third
of the coronal slightlylessthan half of the thanhalf and as muchas the
ingtheirintensity
andlorshape. rur rdLe \ rdu rd r/ uuLLd rr. coronalsurface. entirecoronalsurface.

Theyare dividedinto small(S), me-

dium(M),and large(L).

Summary
Whenwe understand the characteristics
of these intensive
(shape,size,and intensity),
features it becomeseasyto make
of the spotswe find in naturalteeth.
an accuratedescription
makingcommunication betweencliniciansand technicians
extremelyprecise.
almostmathematic, but stillsimple,

cateeories
We can use the aforementioned to describethe
featuresin the drawinEs:

(i) 2S++
(2)2 M++
(3)2L++

This formulaconsistsof a number(shape),a letter(size),

and plus signs (intensity).The three examplesaboveare
as follows:2S++ meanscloud intensives,
interpreted small
sizeand mediumintensity (1); 2M++ meanscloudintensives,
mediumsizeand mediumintensity (2);and2L++meanscloud
intensives,
largesize and medium (3).
intensity

203
 t-

The intensive masses should be placed

beforethe enamelfinal layer,so the spots
become more diffuse and hldden and
therefore less powerfuL

Placingthe opalescentmassesfirst allows

us to stratifythe white spotsin a flat surface.
Layering intensives in rough areas can
result in undesiredwhite accumulations,
as often occurs betweenmamelons.With
the placement of opalescentmasses we
will be able to flatten the surface of the
mamelons and the incisal edge area,
achievingan ideal site to stratify intensive

(1) Stratifythe dentinalcore. (6) Stratifythe dentinalcore.

(2 ) P la c ea n d s mo o t ht h e o p a le s c e n l . (7) Stratifythe intensives,
(3) Stratifythe intens ives. (B)Placethefinalenamellayer.
(4) Placethe finalenamellayer
(5 ) P o lis
h.

2S1 2S5
 l . ai: , :r 'il .rtyr
g i :,e
i l i rte'.i s ri rJ es

To performour intensivedesignil
is importantto havea completely
smooth surface,which is accom.
plishedby layeringthe dentinsand
+ho nnel p<noneec nr on i c al w

Hybridcomposites allowus to build

subtleflat layersand "draw"the de.
sired shapeswith the instruments.
Thistaskbecomes extremelydifficult
whenworkingwithflowableeffects.

mffitrl
-I

206
 Layering
type 3 intensives

This type of white spot is

probablythe most d ifficult
to createby meansof strati-
ficationand requiresgreat
skill.We proposetwo tech-
niques for predictableand
precisemodelingof white
oanos.

Mi l l i ngtec hn iq u e Modelingtechnique

(1) lVodela uniformdentinalcore. (6) Modela uniformdentinalcore.

(2) With a new flame diamondbur, grind down about 10 (7) Placea small-to.medium
intensive
increment.
parallelgroovesin the desiredshapeand followingthe (8) With a spatulaand brush,spreadthe materialas uni-
samepath. fnrrnl v ac nnc c i hl e

(3) Witha brushsoakedin modelingliquid,remove the white (9) Witha sharpspatula,modelbandswiththedesiredshape.

debris.Remove the liquidexcessby blowingair strongly. A pecking moticjnis imperativeto achievethis effect.
(4) Condensethe intensivemass with a spatulainto the Finishmodelingwiththe brush.
grooves.
(5) Remove the excessmaterialcarefullywith a spatulaand
smooththe toothwitha natural-bristlebrush.

2SB 209
 Layeringcombinedi ntensives

Theintensives classification
is especially
convenient
for caseswithdifferentintensive types,
differentintensities,
and sizes.As an example,we will developa tooth with threedifferent
intensiveeffects.

(1) Modelthe dentinalandopalescent masses.

(2) Develop the 1S+++intensive (spottype,small,strongwhite).
(3) Develop (cloudtype,medium,lightwhite).
the 2M+ intenslve
(4) Develop (bandtype,medium,mediumwhite).
the 3lvl++intensive
(5) Placethefinalenamellayer.
(6) Finish and polish.

210 211
 friill
r;11,
{;.d 1
i:''tta.:
- .' f) a.':
s-
5r.-

Characterizations are probably

the most frequentlyoverlooked
featuresof teeth.Theyincludethe
restof dentalcharacteristics
that
do not belongto the intensives
and opalescentclassification.
Sometimesthese characteriza-
tionsareevident, and sometimes
theyarenot apparent.

Theseproperties basicallyappear
in white,amber,and brown.lt is
importantnot to confusewhite
characterizationswith intensives.
Accordingto the LorenzoVanini
classification,
therearefivekinds
of characterization:

1. Differentiatedmamelons
2. IVliddlethirdtonalitychange lr'.,;
3. IncisaI halo :.:i'r
4, Amber/brown spot
5, Fissures ':'a

Thefirstcharacierization belongs
to the dentin,and the re ma in in g
four belongto the enamelstruc'
ture.

.u,1

if1.
 The first characterizationcompris.
es the bodylayerin the mamelons
area,whichis chromatically distin-
guished from restof the dentin;this
colorchangemaybe amberor white
and is oftenfoundin young(white)
and adult teeth (amber).The best
methodfor achievinga successful
lype I characterization
is the useof
bleachdentinsandhighlychromatic
dentins.

Type1 White Type1 Amber

(1) I\4odela dentinalcore (7) Model a dentinal core

that leaves enoughspace that leaves enough
for the massesthat will cnaep fnr fhp me < < o <
Suggestedshades: Suggestedshades:
characterize the mamel. that wili characterize
A 0 , A 0 . 5 , ' r-,+ + A6, 47, Amber
ons . themamelons.
(2) lndividually develop each (8) Individually develop
mamelonwith a precise each mamelonwith a
form, in this case us- preciseform, in this
ing an A0 bleachdentin ..ac a rrc i no an A6 nr

composrte. 47 chromatic dentin

(3) Modelthe mamelons ac- comp0srte.
cordingto the mamelon (9) Model the mamelons
shapedesired. according to the mam.
(4) Placethe whitemass. al ^ n c hrna.l ac i ra.l

(5) Place the final enamel (10) Place the high chro-
layer. maticitymass,
(6) Finis ha n d p o lis h . ( 1 1 ) P l a c et h e f i n a le n a m e l
layer.
( 1 2 ) F i n i s ha n d p o l i s h .

211
 Type 2 characterizationin-
volvesthe middlethird of the
buccalsurface.A subtlecolor
change,whichmay be amber
or white,can be appreciated.
Thistypeis verysimilarto the
but witha
type 1 classification
differentlocation.Thesefea-
tures lead to an increaseor
a decrease in chromaticityof
the tooth, dependingon the
colorof the characterization.

In this iype of characteriza-

tion, two differenttypes of
srroopci p.l <.ha.l cc'
stratification are useful.The
f i r s t i s t h e m l l l i ngtechnique,
A0, A0.5.+. ++
usedwhenlittlespaceis avail-
ahl o :nrl + ha <4.^n.l ic +he

modeling technique, used

Millingtechnique whenmorespaceis at our dis.
posal.
(1) Modelthe dentinalcore.
(2) With a roundNo. 4 diamondbur,
createa half-pipe spaceof 0.5 mm,
(3) Remove the whitedebriswith mod.
e lin gliq u id .
(4) Placethe white characterization,
in t h is c a s eb le a c hd e n lin(A 0 ).D e - S r roopc tp.l c h:.l ec
ncn.lino nn lhF sna.P fhi5 jgnlin
A6, A7, Amber
r . a n h e f l a t n r n r n t r r r r i p O 6 m m to r
a strongereffeci.
(5) Placethe opalescent mass in the Modelingtechnique
incisaledge.
(6) Placethe finalenamellayer. (8) lvlodel the dentinalcore.
(7 ) F inis ha n d p o lis h . (9) Stratifythe amber character-
ization,46 in this case,with
0 . 5 - m mt hi c k n e s s .
( 1 0 ) P l a c et h e a m b e r m a s s i n t h e
m i d d l et h i r d .
( 1 1 ) P l a c et h e f i n a le n a m el a y e r .
( 1 2 ) F i ni s h a n d p o l i s h .

216 217
This characterizationcorre. Whitehalo:An opalescence phe-
s p o nd sto th e i ncisalhalo,which nomenonoccursat the incisal
is an opticalphenomenon arising edgewhenthe whitelight is di.
fromthe opalescence itselfor to- videdin two: red (absorbed) and
getherwith counteropa lescence. blue(reflected),Whenprismsare
Physically, it doesnot exist. ableto reflectboth red and blue
light,a whiteeffectwill be manr-
As wasexplained previously (see fested.Normallythis occurson
page 190), when Iight hits the the outlineof the incisaledge.
incisaiedge,the longwaves(red
liohl) .ro sc th e eniir c c nar 4gl Amber halo:Whenprismshave
wilhoutbeingreflected eitherin. a particulararrangement, some-
ternallyor externally, while the timesbluelig h twill b e t ra n s mit -
short waves(blue light)are re. ted andredlightreflected, result-
flectedbackto our sight,result. ing in an am b e rh a lo ,a s h a p p e n s
ing in the commonlyobserved in the counteropalescence phe,
blueincisaledges. nomenon.

lnnic rl a.lope ara

- n-"..,_
n iica y Opticallyefficientmaterialshave
complexareaswithstrategic light opalescence characteristicsand
d y n a m i cs;i n th is area,prisms are capablegeneratinga little
c o n V er g ei n a pa rticular way, blueopalescence andhaloeffect.
c r e a tin g e xtr ao r dinaryopticaI Unfortunately, to date, dentaI
effects: materialsare not able to repro-
ducethesephenomena precisely
as strong as natural enamel;
iherefore i t ic necessarvto in-
clude some opaque masses to
reproduce the incisalhalo.

A tooth entirelymodeledwith
an opalescentmass shows a
b l uishcolor under direct light
( 1 ) . Whenthis sametooth,illu-
m i natedwith the samelight,is
rotated 30 degreestoward us
(2), a full light reflection
occurs
in the incisaledgearea.A white
s t r ip will appearwhereactually
no while pigmentwhatsoever is
p resent.

219
 St r a i g h i h al o b u i l d u p i e chnique

( 1 ) lV odelthe desireddenlina ls h a p e .
leaving enoughspacefor the incisal
halocharacterization.
(2) Placea small incrementof white
mass(+) in the incisaledgeof the
restoration.
(3) With a microspatula (Applica,LM
instruments), contour this mass
fromthe insideandoutwardto give
a unilormand continuous appear.
ance.In this caseonly half of the
halo is placedand then polymer.
lzed.
(4) Completethe incisalhalowith the
samewhite mass,

Ou tlined ha lo buildup techn iq u e

Thesametechniqueis usefulwhenthe
incisaledgeis not completely
straight.

(5) Modelthe desireddentinalshape,

leaving enoughspacefor the incisal
halocharacterization.
(6) Buildthe incisalhaloin increments.
(7) With an 80-pm diamondbur, re.
movethe excessthat comes out
01 the incisalportionand createa
subtleshape.

220
 Suggested colors:
A0, A0.5, ++
+,

White halo Amberhalo

A tooth that displaysan incisal I n c i s ahl a l o sm a y v a r y I n c o l o r .

h a log a in sa n a t u raal p p e a ra n c e d e p e n d i n go n t h e d i r e c l i o no f
becauseit createsthe illusion light. Althoughit is true that
of dynamiclight effectsat the there is no specificuniversal
incisa I edge. m a s sf o r h a l o s ,c h r o m a t i cd e n .
lins come as closeas we cur.
A t o o t hwit h a n in c is a h
l a loh a s rentlyhaveto beingone.
beenreproduced with a bleach
dentincomposite. A toothwith an incisalhalohas
been reproduced with a chro.
With an underexposed pholo- maticdentincomposite (A5).
graph(1),wecanappreciate the
contrastand color differences With an underexposed photo.
at the incisaledge.The mate- graph(3),wecanappreciate the
rials haveblendedin a perfect contrast andcolordifferencesat
integration, despite beingcom- the incisaledge.The materials
pletelydifferentcolors,With a achieve a perfectintegration
de.
d ig ila llye d it e dp ic t u re(2 ) s h o v u - spitebeing completely different
ing less brightnessand more colors.With a digitallyedited
contrast. we can appreciate picrure(4) showinglessbrighr.
exactlyeachof the threestruc- nessand morecontrast, we can
turesthat form the incisaledge clearlydifferentiateeachof the
(mamelons.blue opalescence. three structuresthat form the
a n d in cis aI h alo ). incisal edge (mamelons,blue
opalescence, and incisalhalo).
Althoughthe use of opaqueor
stainedcomposites to construct Incisalhalos often show both
a n in c is a lh a lo is n o t t h e id e a l w h i t e a n d a m b e r c o l o r s ,s o i t
s c e n a rioit, is t h e o n lyo p t io na t is helpfulto layeropaquewhite
the present. first and then translucent am.
ber.

772 273
 Chro m a ti sp
c o t:
accumulationof pigments,
Eitherbyleakage, d isharmonies
in the enamelprismsstructure,or any combination of
amberor brownspotscan appearon
thesesituations,
the facialenamel.Thesespotsareoftenlocatednearthe
incisaledge;theyalwayshavea translucent appearance
and highchromaticity.

I :
-L+rL v^ lLl u
Lt Et . ^t ^r t^d+L: t^t J^P
^ ^vL
+ ,.

(i) l\4odel
the deniinalbodyand opalescent effects.
(2) Placea mixtureof translucent amberandlightbrown
stainin a roundedshape. Suggestedcolors:
(3) Placethe facialenamel,polymerize, and polish.
ambermixedwith
(4) Digitallyenhanced pictureof the finishedtooth.
lightbrown

Abrasionon the incisaledge can causeexposureof

dentin. lf this eventoccurs,infiltrationof pigment
throughthe proteinlayeris a possibility, evento the
point of occupyingan entirethird of the crown(9).
Someauthorshaveclassified this kind of phenomenon S rrooc c tprl /' nl nrc '
differently.We have includedthis kind of internal
Amber,Orange, lightbrown,darkbrown
stainingasa type4 characterization
notonlyto facilitate
understanding but also becauseboth havea similar
locationandetiologyand arestratifiedin the sameway
andwiththe samecolors.

Darkchromaticspot:
(5) Modelthe dentinalbodyand opalescent effects.
(6) Placea mixtureof translucent amberanddarkbrown
stainin a roundedshape. Suggestedcolors:
(7) Placefacialenamel,polymerize, and polish. ambermixedwith
(8) Digitallyenhanced pictureof the finishedtooth. dark brown

271 225
 Fissures,cracks,and fractures
are probablyone of the
Type5 characterizations
featuresof teeth,be'
leastfrequentlyreproduced
causemanylackthe knowledge to reproducethem
methodto reproduce
or usean inaccurate them.

Cracksand fissureshavean incredible varietyof

The followingillus-
shapes,colors,and locations.
trationsshowa largecolorvarietyand the masses
that can be usedto reproducemostsimilartypes
of cases.
Color:Opaquewhite Color:Opaqueamber
to get acquainted
It is interesting with colorvariet. Mass:45/46 dentin
Mass:++++
iesanddistinguish the form and location.
Probably
the mostimportantthingis to learnthe fabrication
techniques proposed in the followingpages.

Color:Transparent Color:Lightwhite Color:Transparentamber Color:Orange

Mass:Opalescentblue Mass:+ or ++ Mass:Opalescentamber Mass:Orangestain

Color:Strongwhite Color:Lightbrown Color:Darkbrown

Ma s s :+ + + Mass;Lightbrownstain Mass:Darkbrownstain

276 727
 Forthesetechniques it is importantto takeadvantage
of probably oneof the mostimportantadvantages of
compositeresins,whichis the abilityto hardenthe
materialat the chosenmoment.

The development of this Thenan enamelincrement

characterizationresides that will coverhalf of the
exclusivelyon the enamel. buccalsurfaceis placed.
Thestartingpointis a pre- It shouldbe placednear
cisedentinalbodymodel. the areawherewe wantto
ing with a type 4 charac. locatethe crack.
terizationcreatedwith a
mixtureof opalescentam-
berand lightbrownstain.

This enamel must be Before curing, we must

spreadfirst with a spat. model the fractureline.
ula and smoothedwith a This is done by using a
natural bristle brush to No . 1 1 s c a lp e lb l a d e o r
obtaina smooth,regular a sharp microspatula to
surface.lt shouldbe ex- removeexcesscomposite
tended slightly past the that hascrossedthe loca'
areawherewe wantto lo- tion of the crack.
catethe crack.

It is mandatoryto obtain
a wall as perpend icular
as possibleto the buccal
surface. Soft composite
resins are not ideal for
this technique because
they melt easilyand give
r ^ ,,n .la .l ahr nac

DI

728
 The secretof this techniqueis to place the facial
enamellayerin variousincrements,dependingon
the number of crackswanted.

Afterthe dentinalcoreis A very small amount of Crackscan be locatedin

stratified, the p roximaI A0 dentinis placedin the differentplaces,as is found
walls areusedto develop wall of the new crack.lt in natural teeth. ln this
crackscloseto the proxi- ic irnnnrt2n+ nni +^ n ^ - stepa whitefissurewill be
mal surface.A sm a ll in - lymerizeuntil we press developed onlyin the cervi-
crement of o palescent the compositeagainstthe cal third,
blue is placed in b o t h wall with an instrument
walls and polymerized. ru | | r dr l c r L d5 u I| | d5 pu5-

sible .

A small increment of Gani l o nrpccrrro nn tho Once tho inr rp mp n t i< nn.

enamel compos it e is compositeallows us to lymerized,an ambercrack

placedto closethe first ma k e it re a llyt h i n . l t i s just be
will be developed
crack.Todevelopthe sec- imporiantnot to use ex- lowthe lastone.
ond crack,we must mod.
el it gentlyand extendit ucr rruy u rs
to obtain a smooth sur- importantto removethe
face.lf we lookcarefully, excessthat comesto the
the crack createdin the surfaceandthenpolymer-
previousstep is visible. izo fhp e nm nnc i +a

Themicrocomposite spat- To generatea crack on Thesamestepsarerepeat-

ula is usedto givea conve- the oppositewall,we can ed to build a crackin the
nientshapeto the enamel repeatthe samestepsex- oppositeside,butthistime
composite and remove actly.ln the process,we withan orangestain.
the excess.ln this casea can vary the shapesand
straightshapewas devel. used ifferentcolors.
oped, leavinga vertica I
walland polymerizing it to
enableplacement of stain
for the nextcrack.

23S 231
 We can developas many The tooth cracksare illu-
cracksaswewantor aswe minatedwith direct light
can fit in the restoration, (4), transmitted light
according to the needs.In at I1Ole (5), transmit-
the naturaltooth,multiple ted light al 75/o (6), and
fissures are often trans- transmittedlight at 25%
parentand white. (7). The cracks are ex-
presseddifferentlyunder
variedlighting.

Brown and dark brown

cracks are often longer
and locatedin the center
of the tooth.

The last step closes the

stratification. The com-
positeplacedclosesthe
lasttwo fissures.Afterthis
step, we can proceedto
the finishingand polish-
Ingstage.

Thelightpasses throughthe entireenamel,and its fissurescomefrom

inside; theamber,orange,
therefore white,transparent,andbrowncracks
changeappearance whenobserved angles(8a,8b,8c).
from different

737 733
 DevotoW Cllnicalprocedurefor producingaestheticstratified
composite resin restorations.Pract Proced Aesthet Denl 2OO2;
I4:541-543.

DevotoW, PansecchiD. Compositerestorations in the anterior

performances.
sector:Clinicaland aestheiic PractProcedAesthet
Dent2OO7;19:465470.

Conclusions Thekeyto naturalesthetics.

DuarteS Jr.Opalescence: Quintessence
DentTechno| 2OO7 -2O.
;3O:7

DuarteS Jr, PerdigaoJ, LopesM. Compositeresinrestorations-

and protocol,we must find nearlya
1. With the aid of classification Naturalaesthetics
and dynamicsof light.PractProcedAesthetDent
mathematicmannerof communicating dentalcolor; improvisation 2OO3;15:657-664.
mostoftenendsin failure.
FahlN Jr. A polychromatic
compositelayering
approachfor solving
2. Reproductionof opalescence must be accomplished with highly
a complexClasslVldirectveneer-diastemacombination.
1. Pract
translucent
specificmasses;the use of stainsor coloredmaterials
ProcedAesthetDent2006;18:641-645.
must be avoidedas muchas possiblewhenreproducing opalescent
features.
Lee YK, Lu H, PowersJlV. Measurement
of opalescence
of resin
composites. 4.
DentMater2005;2I:1068-107
3. Stainsabsorba considerableamountof light;mostof themareopaque
and do not allowpropertransmission
of light.
PrimusCl\4,Chu CC,ShelbyJE,BuldriniE, HeckleCE.Opalescence
4. Flowablematerialsare difficultto use in the middle layer.Hybrid of dental porcelai n enamels.Qui ntessencelnI 20O2;33:439449.
massesare preferable, becausethey exhibitbetter handlingand
greaterstabilityand canbe modeledin anyshape. TerryDA,GellerW,Tric O,AndersonlVJ,Tourvillelvl,Kobashigawa
A.
Anatomical
form definescolor:Function,form and aesthetics.Pract
It is as importantto reproduce
the middle layeras it is to avoid ProcedAesthetDent2002;14:59-67.
exaggeratingit.
VaniniL, ManganiE Deiermination and communicationof color
of teeth.PractProcedAesthetDent
usingthe fivecolordimensions
2O0I;I3:19-26.

VaniniL, ManganiE Klimovskaia Restoraiion

O. Conservative of
Viterbo,
AnteriorTeeth. ltaly:
Acme,
2005,

231 235
r
I
I

Chapter5
Class
ification
Jordi Manauta. Anna Salat

Interviewwith DavidKlaff

!ilu
"Orderis pleasure
of the reason,
but disorderis
delightof the imaginatio n."

PaulClaudel
 II-IT
qr Lrll'r'ritfl r,-Ji{i

ri
II
Q: Howhasyourpracticechanged withyourknowledge
of the correctclassification
of teethaccordine
to their
color features?

\SMZZ
riF
A: The abilityto communicate
and discussthe shade
ZZBN of a toothhasalwaysremaineda complexanddifficult
process,whetherbetweenpatientanddentistor dentist
and dentaI technician.

RonGoldstein wrote,"lf the eyesarethe windowof the soul,then Determining the shadeof a particulartooth using
the smileis the windowof the heart." classicshadeguideshasalwaysprovedto be inaccurate
and imprecise,evenwith the development of more
Dr DavidKlaff has spent 42 years in dental practice,first as a gu
scientific ides.
generalpractitioner,thenas a prosthodonticspecialist,
developing
the skillsto perfectthe smilesof his patients.Overthe years,he Digitalshade-charting
equipment,
althougha promising
hasestablished expertisein restoringnaturalstructure,
form,and currentlyremainsjustthat,promising.
iechnology,
functionand providing naturalesthetics.
Theintroduction
of a classification
systemhasnarrowed
He hasbecomerecognized as a leaderin adhesivedentistry,and the alternatives
in the choiceof shade matching,
his skills includefully comprehensive diagnosisand treatment whichis a highlydesirablesituation,improvingboth
planning, expertisein restoring singleand multiplejmplants;and communication and accuracy.
)i designingrestorations that provide excellentlongevity
and ultimate
ii estheticresults. Distinctanddefinitive
choicescanbe madein thetooth
matching process;the variations
in tooth morphology
Dr Klaffis a memberof the BritishAcademyof AestheticDentistry, and opalescenteffectscan be mappedin a fashion
the European AcademyofEstheticDentistry, theAmericanAcademy understandable by all involvedin producingthe
of EstheticDentistry,and the AmerrcanAcademyof Restorative restoration.
Dentistry, and currentlyhe is the treasurerof the lnternational
Federation of EstheticDentistry.He teachesnumerouscoursesin systemshavedefinitelyeasedthe process
Classification
adhesionand compositerestorations everyyear. of toothmatchins.

i zqs 711
 VaniniColorChart*

The contentsof this chapterare basedon the

classificationproposedby Dr LorenzoVanini,
On one side of the chart (1) are foundthe five
dimensions of dentalcolorand the composites
suggested to reproduce them.On its reverse (2),
the charthasdrawingsand pictures to illustrate
eachcharacteristic.This chart was developed in
1995and is stilla referencetoday.

Thechanges proposedin this chapterarean at.

tempt to simplifythe understanding of some
characteristics,both for thosewho alreadyare
familiar withthis methodandfor first-timeusers.

* Usedwith kindpermission Avegno,

of Micerium, ltaly.

717 713
 IN

For dentinselection,we emphasjzethai it is best to

choosethe colorA rangeand ignorethe rest of the
proventhat othercolors
Hues.lt has beenclinically
areveryrarelyneeded.

We recognizemanydegreesof chromaticity,ranging
from the lightercolors,A0 (bleach),
to dark47. The
mostfrequentlyusedareA2 and A3.

Composite someof the following

resinsysiems.use
on the manufacturer.and
depending
classifications,
howtheynametheirmaterials.

Vita: AO,A1,42, A3,A3,5,44, A5,A6

ln: In0,ln1, ln2, In3,In4,ln5, I n 6 ,ln 7
Dentin: AiD, A2D,A3D,A4D
Universa
I Ddntin: UDO,UD1,UD2,UD3,UD3 . 5 UD4 , ,UD5 ,I J D6
Shade: s1,s2,s3,s4,s5,s6,s7
Opaque: 0A0,0A1,oA2,OA3,OA3.s,OA4,OA5,046
lntensity: XLdentin, L deniin,M dentin,D dentin,
XDdentin
Numberi I,2 ,3 , 4 ,5 ,6
lVanufacturen IR5,IR6,IVA5,IVA6

In 0 ln 1 ln 2 In 3 ln 5

211
UUI I Out 2 Out 3 Out 4

OUT

Fourenamelvaluesare recognized:

. 1 (bleach;+++)
. 2 (young;++;
. 3 (adult;+)
. 4 ( e l d e r l y-;)

Systems generallyareclassifiedintothreevalues. Werecom.

mend a yellow-light brownpigmentation for the low.Value
enamel,becauseenamelsare often made with white,and
they tend to opaci{ythe material,or, on the contrary,they
becomegray becauseof too much translucency.Enamel
compositeresin systemsmay use some of the following
classifications,
depending on the manufacturer:

Translucent shade:TS1(+++),TS2(++),TS3(+)
Out:Out1,Out2,Out3,Out4
Universal Enamel:UE1(+), UE2(++),UE3(+++)
GenericEnamel:GEl (+),GE2(++),GE3(+++1
Incisal:lL (+++),lM (++),lD (+)
Translucent: TL (+++),TN (++), TD (+)
Vita:Ai (+++),A2 (++),A3 (++),43.5 (+), A (-)
E n a m e l : A 1 (E+ + + ) ,4 2 E( + + ) .A3E(++).43.5E(+),A E (-)
Intensity: XL (++++),L (+++),lvl(++),D (+)
Manufacturer: pearl,ivory,neutral,clear,etc

217
 QFsles,cenee,

.q&hrava Jivc,qeLeg.Eqnqe.
distlng!,,it-t1ad tl.pqtqxqe{Ke'
L Thr€slT!.€lrektnc
A mu,i,ttiiB lorit*
types,sorted by age.Althoughthe aetng OFale6:seiia.e,
fuctor is highly varisble,opalescenc€ ,hlesqnee &' M$ltiplernamdlo. nF
ty.pe 1 usually. co.r'r'espandsto newly OlEilesseilee.4,:.
Ab.€ci{t
tisr.jno]$frS
ej'uptedkstfi lidlbqulBsrpatie$$,.rbnd Pfoxlf|Alopa'lp'efenee,
Op,a:tr6q*fire.,&i
i! fbundir teeth inw,htbh,theirsir
typ-e.,5
,salF.d€p
haswoi.n!n tngdultp.c0ettts.
.Sramoauthors.dFferen*iatenpahscenee
,wg
hf dalbrlnto grgy"anlb,eiblqe.€tdi
qnly.di'stin€qtrsh
one,,whit*rls *re natcl'
rat h!1€.d4rFM fidnl xhes!-friplqlicht
inler:aetton
in rlhd]frEpenamei.

Opalescence
X .OFaleseenee,S 3
Qpalescence Opalescerrce4 0pfile*9]cerr$e
5

21s
 t

lntensives lntensive
2

Theenameloftenhaswhitespotsthat As discussed in chapter4, eachoneof

are created durlng tooth formaiion, thesetypeshas difterenisizes(small.
called hypoplasticspots. They are usu- medium,or large)and intensities (+ is
allynot pathologic,that is, theyusually ljght;++ is medium;and+++ is strong).
do not requiretreatment.
Onlywhenthe stainsare opaqueis it
Reproductron of white spots during possibleto distinguish a greaterinten-
stratification is very importantfor es- sity(++++).Because it hassuchIimited
thetic integration,becausethey are use,we havedecidednotto includeit in
part of the enamel.In our experience.the classification.
we havefoundvariousshapesof white
spots,whichareclassified as follows: With this.classificaiion, we can distin. ive3
lntens
guish 28 differenttypes of intensives.
ln+aneiv a c t v n o l e n n t Thesetypes may be combinedin the
lntensives type2: Cloud sametooth.lf we learnto distinguish
Intensives type3: Bands theirdifferentkinds,sizes,and intensi-
ties,the numberof stainswe cancom-
municatebecomes enormous.

25S 251
 Characterizations
I
The classificationof characterizations correspondsCharacterization type 3: Incisalhalocharacterization.
exactlyto Vanini's
colortheory. Theeffectcan be white,amber,or the combination of
both.Manymassesand manycolorscanbe used(see
Characterizaliontype 1: lvlamelonsdisplaya different chapter4),
colorfrom the rest of the dentinalbody,The varieties
are white,amber,and a combinationof both. This Characterization type 4: Chromaticspot. The color
followstheshapeof ihe opalescence,variety may range from a translucentamber io a
characterization
withthree,four,or multiplemamelons. translucent dark brown.They may come in various
sizes;the largestspotsusuallyarefoundin the elderly
Characterizationtype 2: Colorincreasesor decreases and aredueto pigmentinfiltration.
in the middlethird.Thecolorcan be whiteor amber,
but colorcombination rare.It is possible Characterization
is extremely
to find a powerful,almost-brownamber, usually in different
type5: Cracks,fissures,andfractures
shape,sizes,and colors.
L--l t*-rJ
associated withpathologic conditions.
Characterization
type 3 white Characterization
type 3 amber

L.J LJ .fr
Characterization type 1 white Characterization
type 1 amber type 4
Characterization

type2 white
Characterization type2 amber
Characterization Characterization
type 5

252 253
 GoircNusions

intensives,
Colormust be takenin order-ln, Out,opalescences, and
characterizaiions-toprevenimistakes.

Small variationsthat may exist,if they do not strayfar from the

musi be treatedas the closestcharacterisiic
classification, found.

Evencomplexteethcanbe classified.

.:,A colorchartshouldbe printedfor chairside This

useand note'taking.
mustbe Dracticeduntilthe chartis memorized.

is the most precisetool for communication

5, A good photograph of
color.

?56 257
 Ch a p t e r6
PalataI Features
Jordi Manauta. Anna Salat

Interviewwith SmileAcademy
ll Perfection
is achieved,
notwhenthereis flOth ing
moretO add, ort whenthere
isnothing
tot?ke aW ay "l ,

Antoinede Saint-Exup6ry
 lffirll

Tffi Q: Arecolorandfunctioncompaiible?

The Smile Academywas createdby three practitionerskeento A: Thepalatalsurfaceof the maxillaryanteriorteethis

and passionfor estheticdentistry.
sharetheir knowledge of greatimportance for lateraland anteriorguidance.
Thesecontacts takeplace,notat the cingulumlevel,but
The SmileAcademyis a well-known professional trainingfacility mainlyat the marginalridges,
that has beenrecognized and certifiedby the Frenchgovernment.
Its objectiveis to providepractitioners with the knowledge It is clear that their creationor reproductionis an
necessary for the implementationof smilerehabilitation. lt is the essentialelementof occlusalfunction.Thisis why the
brainchildof threemenwithgreatexperience in esthetic
dentistry stratificationmethodology for compositeresins,which
and training. usesa silicone guidebasedon a functionalandesthetic
wax-up,is ableto satisfythesemorphologic criteria.
Parisis the mainauthorof the bookTheAesthetic
Jean-Christophe
Gulde,whichformsthe backbone of the teachingprograms,and of an enamellayerplaced
As a first step,the presence
holdsa diplomaand a postgraduate degreein estheticdentistry on a palatallevel answerstwo needs:a functional
fromthe University as wellas a postgraduate
of Marseille, degree morphology associated of light.
withdistribution
from NewYorkUniversity. He has a high-qualityprivatepractice
and is a sought.after
lecturer.
His determinationand enthusiasm The opalescence of the enamelshadesleadsto the
havecemented the SmileAcademv. reproduction of the first colorparameter:
Value.This
qualityis reinforced
by the creationof marginalridges,
Andr6-Jean Faucher and Jean-LouisBrlouillet
followeda common whicharethe basisof the proximalsurfaces.
paih in theirclinicalandeducationalcareersat the department of
restorativedentistryof the Universityof Marseille.As professors, of composite
Wecanthereforesaythat the stratification
they havetaughtthis discipline to manystudents,suchas those resins for anteriorrestorations, as initiatedby Dr
following continu programs.
ing education LorenzoVanini,helpsto createa definitecorrelation
between functionand color.
As associatesin a privatepracticefocusedon estheticrestorations,
they have published manyarticlesand held many lectures. The
SmileAcademyprovides a naturalwayin whichto coniinuetheir
role as teachers.

762 263
 'i

,''t.
I
il
ll

The palatalsurlacerepresents, in conjunction with the incisal

e dge.the mechanical
afeaoI lh e a n le rio tre e t h .

The palatalsurfaces
of maxillaryteethhavea closerelationship
with posterior
disocclusion
and cuttingmovements.

In recentyears,conservative of the palatalsurfaces

restoration
ol abradedand,/orerodedteeth,as in the three.steptechniq.le
developed by Vailati,hasbecomeverypopular. ij, la

In one of the most important steps, the palalal surlacesof lhe

affected teeth are rehabilitated successfullvwith comDosite
resroTalro
ns.
ri ':|,':
1' ,ti
Therecoveryof the palatalanatomy
andreinstatementof function
throughrehabilitationare of essentialimportancein modern i: - . 1
restorative
dentistry. .':

The Iayeringtechniquein the palatalsurfacesnot only is usefulfor

obtaininginterestingcolor effects,but also usessmall composite
resin incrementsthat will enahleus to .rcale nrc.ise sinr.lures
and a beautifulanatomy.

t_

,''s,. .

't

761 t.l
 'r'vi:e /-1.
Flat palatalanatomy. Thereare
very slight differencesbetween Differentiatedpalatal anatomy
the variousanatomicalstruu- I ridgeand two lin-
with a lingua
tures;the lingualfossa,the cin- gualfossae.
gulum,and the proximalridges
arenotverywelldiscernible.

Tir r-ro ?
T1,pe5
Minimalpalatalanatomy. There
are slight differencesbetween DifferentiatedpalataI anatomy
the variousanatomicalstruc. withtwo linguaI ridgesandthree
tures.Thelingualfossa,the cin. linguaI fossae.
gulum,and the proximalrldges
are roundedand not very differ-
entiated.

Type3
"l.y;:e5
Differentiated palatalanatom
Structuresare more o itterenti- palaiaI anatomy
Differentiated
ated.Thelingualfossaendsin a withthreeor morelingualridges
pit, and the cingulumis split by andfouror morelingualfossae.
the linguaI groove.

266 767
 A s t a nda r d d e n tin The marginalridgesare l I i c nra{orahl o +n hrri l rl Internal gradient layers lVamelonsare character- Afterthe intensive is even'
stratificationis needed increasedwitha lesschro- one ridge at a time. will be dev-.loped fromthe izedwithan lightintensive ly distributed,this effeci
to startthe palatalsur. maticdentin. bottomof the lingualpit white(+) effect. provides a naturalappear-
face. u s in ga b ro wns t ai n . ance,

A mixture of opales. A mixtureof opalescent An r nhar

^n,l a<.an+
An orangestainor a cervi- The surface is covered Characterization startswith A l i g h t b r o w n s t a i n i s In the center of the
ce n t a m be ra n d a d ark amber and a light brown mass is appliedto extend cal mass can be usedto w i t h t h e m e d i u m . V a l uf ie. an orangestain,whichis placedto outlinetheridges lingual pit,a darkbrown
brownstain is applied stainis placed,extending to the middle third. The increase the Chromasig- n a te n a m em t ass. almostinvrsible andshould internally. This stain will stain will be placed,
to coveronly one-third slightlyfurther ihan the effectwill be subtle but ef- nificantly. n n f h a n n l v mo ri z o rl n n + h a n n l v mo ri z o rl mixedwith the previous
of the palataI surface. prevrous layen fective. stains,andpolymerized.

The opalescentmass Marginalridges are en- T h e c in g ulu m a n d lin g u a l It is importantto create F l ni s hi n g i s a c c o m p l i s h e d Polishing is accomplished
i s p l a c edi n th e i ncisal hancedwith a whiteopal. ridge are also modeled t h e lin g u a lp it s if s t a i n s witha diamondbur, w i t h d i a m o n da n d a l u m i .
edge. escentenamel. with white opalescent haveto be addedin later n,rrn
^Y i .l a
nrc + ae

e n ame t . steps.

268 769
 The startingpoint is a correctly Opalescent massis modeledin the An orangestainis p la c e din t h e l i n . The marginalridgesand cingulum It is also importantto modelthe A dark brownstain is placedin
stratifieddentincore. incisalarea.It is importantio re. BU dt tu55d dt gd l a subtlelayerof are coveredwith a subtlelayerof enamelby sectors.As the incisal the crackarea.ln the incisalabra-
spectthe facialshapeas well, a b o u t0 . 2 mm. enamel.lndependentlayeringof edgeis approached, it is important sion, a hybrid compositemixed
each area allowsformatlonof a to modelthe desiredshape,in this with brownstainmusi be placed.
c r a c ki n t h e c i n g u l u m . casean aDraston. Stainsarenot idealfor largeareas.

Thefinishedtoothshowshow,with
little space,we can reproducea
highlycharacterized restoration.
it
i s a l m ostlikea stainingtechnique
but withthe addedbenefitof cre.
atingdepth.
Oneby one,the lingualridgesand Independentmodeling of each Marginal ridges are constructed
the cingulumare modeledwith a structureallowsgreateraccuracy. with ihe same white color (either
white or a bleach
light intensive dentinor intensive),
dentin.

2/8 7/1
 Thefollowing a richpalata
seriesdetailshowto develop andpolishing
I surfacebyfinishing
with bursand abrasive
materials. Thenecessaryinstruments aredescribed in detailin
chapter10.

Marks are extendedwith Diamond grooves are A 3-pm diamondpolish ing

the roundedbur. erased with an abrasive pasteis appliedwitha goat-
rubberpoint. hair brushto provideinitial
g loss.

The lingualfossa area is A naturalconcavityis cre- A flame.shaped bur is used

markedwitha pencil. atedwith a roundedNo. 1 to developa lingualgroove
bur. t h a t will s p lit t h e c in g u lu m
sIightly,

A l - p m d i a m o n d p o l i s h - F i n a l l ya 1 . p m a l u m i n u m The resultshouldbe a rich

ing pastei s a p p l i e dw i t h a oxidepasteis appliedwith palatalmorphology with a
goat.ha ir brushto enhance a felt wheelfor highgloss. high polish.
the gloss.

grooves
Developmental are T h e o r n n vp c :r e ch: no.l Lingual ridges will be
marked near the incisa
I delicately, to preventthe shapedto producea type5
edge. creationof violentmarks. palataI anatomy.

relIrnl
277 2/3
 Conclusions

r. Thepalatalsudacesmustbegenerated througha diagnostic

wax'upin
mostcases.at leastwithdirectrestorations.

2 . Coloris notas importantasthe shapeandanatomyin thisarea,but is

a helpfultoolto understand
both.

5. of materialallowgreateraccuracy
Smallincrements in modeling.

4. A stratifiedpalatalsurfaceclarifiesrestoration
thicknessand if the
tooth hassufferedwear.

characterization
5. Successful of a palatalsurfaceis
and integration
synonymouswithexcellence.

7/1 275
 Chapter 7
Posterior Teeth
Jordi Manauta. Anna Salat

Interviewwith FrancescoMangani
3 3 Gi v em e a
a n da p l a c et o s t a n d
a n d I w i l l m o v eth e world.),
Arch i me d e s
 i
I
I ilnil importantin posterior
Q: Whyis stratification
it doneonlyto improveesthetrcs?
teeih?ls

It is wellknownamongclinicians that,evenif thereare

no unequivocal data,all methodsfor placingcomposite
resinin a cavityaim to increasethe free surfaceof the
materialand to decrease the configuration factor(C
factor).This is independent of the horizontal,vertical,
or oblique (which is my favorite)layeringtechnique
applied.The choiceto layeris mandatory, both when
ihe final cavitydesignis deeperthan 2 mm (as often
occurs in the lateroposterior sectorsof the mouth)
and whenthe clinician,followinga minimallyinvasive
approach, preparessmallcavities that arecomplexand
difficultto restorebecauseof awkwardlocation.

Toreducetheintrinsiclimitations of thecomoosite itself.

ll the use of adequatepolymerization

highestdegreeof conversion
to guaranteethe
is of primaryimportance.
It is now knownthat the physicaland mechanical
featuresof a compositeresincan be negatively affected
by insufficientpassage of the curinglightthroughthe
material,evenfor thicknesses slightlygreaterthan 2
Prof Francescolvlanganiholdsdegreesin mediclneand general mm. Moreover, the uncuredmonomerresultsin biologic
surgery and a postgraduatecertificatein odontostomato logy. problemsof tissueleakageand acts as a plasticizer,
At the Universityof RomeTor Vergata,he holds the titles of increasingthe hygroscopicity of the material:This
AssociateProfessor,Facultyof Medicineand Surgery;Chair of results in an early loss of the estheticpropertiesof
Restorative
EstheticDentistry,Schoolof Dentistry;and Chairof the material,whichis subjectto morevariations and
DentalAesthetics,Schoolof DentalHygienists.
in addiiion,Prof chromatic changes.
Manganiservesas Head,Sectionof Restorative
EsiheticDentistry,
TorVergataUniversityClinicalHospital. The excellentopticalfeaturesof the new composite
resinmaterials, together withthe useof correctlayering
He is an activememberof the ltalianAcademyof Conservative techniques, allowus to providean estheticappearance
Dentistry,the ltalian Societyof Endodontics, and the ltalian to somethingthat must be, first of all, functionally
Societyof Conservative Dentistry,as well as an activemember correct.BecauseI've beenpraciicingdentistryfor 30
and cofounder of the ltalianAcademyof EstheticDentistry. His years,I can affirm that the pleasureof and the search
researchand clinicalactivityare focusedon restorative
dentistry, for estheticscannottake precedence overwhatwe have
esthetics,
andendodontics. to consideras the primaryaim and the targetof all
our restorativeinterventions:The restorationof correct
Prof lVlangani is theauthoror coauthor of morethan260 scientific function.
publicationsabout conservative dentistry and endodontics,
includingthe textbooksManuale di Dlsegno e ModellazioneDentale Thus,in brief,layeringis necessary:first,to compensate
(Textbook of DentalDesignand Morphology, Martina, 1999) and for the intrinsiclimits resulting
from the chemistryof
Guidelines forAdhesiveDentistry:TheKeyto Success (Quintessence, composite materials,andsecond, butnolessimportantly,
2009) and the multimediabook Conseryatlya Esfeticadei Seffori becausethereis not and thereneverwill be function
Latero-Posteriori: RestauriAdesivi lndiretti in Compositonei Denti withoutmorphology,regardless of the esthetics.Citing
Trattati Endodonticamente (ConservativeEsthetic Restorations for my ieachers,I wantto emphasize that nobodyshould
Endodontically TreatedPosteriorTeeth,UfEf, 2008). He lectures everforgetthat last point. Reproduction of the correct
extensively at congressesall overthe world. anatomyvia layeringis the targetto achieveeverytime
we restorea cariousor traumatizedtooth.

2BE 281
 lntroduction

A correciunderstandingof toothstructuresand
spatialvisualization
of enameland dentinallow
us to performaccuratereconstruction of the
dentitio
n.

Functionand esthetics
aresynonymous, andthe
proofof thisassertion
is the posterior
teeth.

287
 , 'ca ci i nr ' , : - , . ^i" r' -i .r1 a ' i -i ;;; t:= ri rri r n-r.

Thesecretto fabricatingesthetic
andfunctional posteriorteethis to generatecorrectand precise
occlusalanatomy. lt has beenwell proventhat single.shade stratification
techniques solvethe
majorityof casescorrectly.Toachievea corTect anatomy throughlayering,we propose a sectional
modeling technique in whichoneincrement is usedfor eachcusp,Eachoneof theseincrements, Once the transveTseridge is po-
whencorrectly modeled, resemble pizza slices.Theprocedure is startedwiththe simplestcusp, lymerized, the distolingual cusp is
andthenonecuspis addedat a timeto acquiremoreanatomical referencesto definetheremaining modeled, and the distal sulcus will
and moredifficultstructures.Thechoiceof the firstcuspandthe orderof layering arepersonal, be defined at the same time.
butwesuggest startingwith theeasiest(mostregular-shaped andmedlum.sized) cuspandworking
towardthe mostdifficult(irregularly
shapedand large.or verysmallsized) cusp.

Thelargercusp(mesiolingual), which
at the beginningwas the most diffi'
cult to model,nowwill be easyto de.
velopfrom all the previously
created
anatomical references,

A sectioned on a max-
stratification The mesiobuccalcusp is initiated
illaryleft molarwill be performed witha smallincrement
of compos-
in whitecomposite as an example. l Lc l c5l l l . l rl l s l5 tl l e ca5l esl UUSp
The procedure will be startedon on lhis molar becauseo[ ils regu-
an occlusal ClassI cavitywithvery lar shape. Before polymerization,
fewanatom icalreferences. slopeswill be developed,and the
limits,whichmust be locatedat the
main sulcuswhere the rest of the Thefinalappearance shouldbe a mo.
cuspswillconverge,will be detined. lar with richanatomy,
multipleeleva-
tions and depressions,
and a harmo-
ni nr rc rpor rl ar < ' rrfa.p
i/'h I
iwl lVodeling
of an occlusalsur-
face requiresthree specific
instruments:

(8a) A roundedmicroplug-
oar + ^ . la \ / a l^ n c l^ n a (

(Bb)A sablebrushsoakedin
modelingliquid to smooth
the slopes and remove
roughness.

(8c) A very subtlespatula,

n n. a lhp fir<+ nrrcn ic nrrred th o When all the buccalanatomical the tip of the Fissurainstru-
nextis modeled. lt is notnecessary re[erences the palatal
arefinished. ment (LN{-Arte, LM Instru-
to worryaboutdeformation of the cuspsare developed, in this case ments),or a No. 11 scalpel
previouscusp.Beforepolymerrza- ridge.
the transverse bladeto createa groove.
iion th-. hrrcr:alsrrlr:r
rs must be
defined.

781 285
 Mesial BuccaI Palatal
T ho mociel hrrn-

Ld r, dru pdrdrdl

dJP rL L> ur d prdr.

tic die that will

act as a base for
th is exercise are
shown.

A h igh.ch roma.
ticity dentin(46)
ic n lr . o . l in +hp

n eck, fading in
the middle th ird.

CompleteCrownConstruction

Complete anatomical stratificationis critical to

mediumand largerestorations.
reproduce A long cone is
sculptedfor each
Knowledgeof themeansto achieve completeanatomical cusp, with the
reproductionof the entirecrownnot onlyallowsus to same high-chro-
createmorecomplex it alsoopensthedoor
coloreffects, maticity dentin
posierior
to advanced morphology and biomechanics. (A6). This simu-
lates the normaI
It is crucialto carryout the stratification
in segments. anatomy.
This createsa varretyof densitiesin lhe inlerior.
resultingin a mechanically efficientand contraction-
freerestoration.
The chosenbase
Severalauthorssupportcompositeresinas the first- color dentin(A3)
choicematerialfor total cuspcoverage,
because of its is used to creat-.
clinicalperformance,
excellent especially
that of hybrid thebuccaI andlin.
composrtes. gual walls, prop-
erlyd ividedbythe
buccalsulcusand
palataI sulcus,re-
spective ly.

Wallsareconnect.
ed with the same
dentin(A3) while
the marginalridge
is modeled.

786 287
 The previoussteps leavea Thefirst layerof the occlu. The spatulais usedto draw TheoDalescent materialis olacedon the axialwallsof eachcuspand blendedfromthe top
circumferential structure sal surface!s madewith a a sketch of the occlusal of the cuspto about2 mm in an apicaldirection.Thepresence of the opalescence
should
and emptyocclusalsurface. high-Chromadentin com- anatomy.Now the material be unnoticeable.
posite(A6),whichis nol po- ;c
^^l \/m ar i ?p.l
lymerizedyet.

A small incrementof the The mass is modeledin Finally, onceagainturningthe occlusalsur-

the enamellayeron the outerwallsis modeled,
basecolor dentincompos- placewith a roundedplug- face into a voidspacewherewe can freelystratify.
ite (A3)will be placedin the gerand polymerized.
ridge of each cusp, which
shouldnot be polymerized
yet.

2BB 7E9
 @

The previoussteps createda Thelayering of theocclusalenam. Distobuccalcusp buildup is Therestoraiion is shownafterthe finalenamelcompositemodelingand beforethe finishingand polishing
circumferentialstructure("fish el compositeis started.The sec. complishedwithout invad ing stage.Althoughsomeglossis apparent, this effectis the resultof the uncuredcompositein the oxygen.
mouth") that leavesspace for tional (pizza)technrqueis used, naturallimit (buccalgroove). inhibitedlaver.
the occlusal
surface. siarting with the mesiobuccal
cusp,whichis the easiest.

Transverseridgebuildupis conr. Distopalatal

cuspbuildupand dis- Mesiopalatal cusp buildup,main polishing
Afterhigh.gloss the final appearanceshouldshowa regularsurfaceand naturalshine.Notethe
pleted with the same enamel tal groovemodelingare complet- s u lc u s mo d e lin g ,a n d o c c l u s a l chromaticaspectof the externalwalls.Thecervicalareahasa powerful
colorthatvanishes
towardthetip of
ed. stratificationarecompleted. the cusos.whicharetranslucent.

The polished occlusal surface

gainsnaturalnessand shouldnot
loseanatomyor textureat the fin.
ishingstage.Withonlyfourcolors,
it has been possibleto achieve
a highly characterizedposterior
tooth.

A brown.orangesulcus(seepage
295) has been developed with
brownin the centerand orange
in the periphery.

29S 291
 a

Afierdentinis modeledand before Cuspsmust be characterized one Theocclusalsurfacegainsnatural- Withthe properorder,all the buc- As cuspsaremodeled, morerefer. The completionof siratification
the enamellayeringbegins,small at a time. Each cusp can hold nesswhenmanyof thesemicroin. udr L u -p r d rs B c i rs r d L c u , e n c e sa r eg a i n e dt.h u ss i m p l i f y r n g shouldbe easyafterall cuspshave
increments (+)
of white intensive manyrolls,depending on its size, .rarnan+c rra nl r.prl thosethat werethe mostcomplex heon n r e v in , r c lv n n : . lo
are placedin a "roll "shape(see but normallythereareoneto four. at the beginn ing.
I2a, IZb).

Enamelcompositeis placed on Withthe sameenamelcomposite, After polymerization the next cusp A brown-ocher stainis developed, F i n i s hingand polishingare com-
the externalwallsto createa fish each cusp is coveredone by one, alwaysgenerating
is characterized, withbrownin the centerandocher pleted.
mouihand enablebuildingof the startingfrom the easiest,in this the sulcusthat will determine their in the periphery.
occlusalsurfacewith the sectional casethe mesiobuccalcusp. d ivision.
technique.

Incrementsmust be done in a
white composjteresin,placedin
For highly characierizedoccrusaI very small amountswith a fine
surfaces,we suggestthe use of rP arurd drru d r u|| 5 dP tr.

white effects,especia
lly in areas
is
whereenamel th icker.

iIII I
 An occlusalstain is generally, in. 0i ange:A slightchromaticstain
terpretedasthe resultof persoh.al that blendswith the dentinand
perspective and is a difficulttaSk looksalmosttransparent. A flow'
t.
that oftenfails. able43 compositeis suitableas
we .
The classificationwe propose Ocher:An intermediate.intens ity
10 types of stain.
distinguishes stainthat is visibleas a reddish
whichare generatedfrom a two. (lightbrown)stain.
one
color mixture, in the center Brown:A hrgh.intensity brownslain
andonein the periphery. thatis the mostcommonstain.
Bla c k :T h eh ig h e s t . in t e n ssitt ya in .
representing the most opaque
mass,normallymodified.

OcclusalStainClassification

291 795
 It is important to distinguish
occlusal characterizations not
only by color,but also by shape,
location,anddispositlon if we are
to simulatethemcorrectly.

(i) The vast majorityof stains

are found in the main occlusal
sulcus,usuallyfrom the cenier
to periphery.but sometimes their The use o{ ceramic powdersto reproduceor
continuityis interrupted,looking modifystaincolorshas interesting potential. In our
likea dashedline.Stainsarerarely experience,for example, it is difficultto find suitable
locatedin supplementary sulcior blackstainsfor occlusalcharacterizations. Generally
outsidethe centra I grooves, the slains are pure black and havesome degree
of translucency, which givesthem an unpleasant
appearance oncetheyarelayered.
(2) Incorrectlyplaced occtu5aI (3) Correctlyplaced occlusa I
stainsoftenresultin a smear ef. stainscreatea sharpand clean
For those reasons,the brownstain of our choice
fectandfadingspots. sulcus.Thecolorbecomes stron-
(4), whichis opaque,dark,and chromatic,can be
ger,andthe effectlastslongerbe'
intensjfiedwith blackceramicpowder(5) to obtain
causethe layerof stalnis thicker
an ideal,almost-black (6) characterization
likethat
found in naturalteeth.

796 797
 Non-edge
Technique

Describedby Dr DarioAdolfi,this techniqueis indicatedespecially

for ceramic A recentlybakedceramicres. A mapof the maingrooves
is Becauseof the hardnessof
crownsthat havelost their anatomybeforecementation.Thissituationcan result toration demonstratespoor drawnwitha pencil. tungsten,the bur is able to
from overfiring
of ceramics,largeocclusaladjustments,
or deficientmodeling.In anatomy. heatthe ceramicsurfaceand
thesesituations.
the anatomvshouldbe redefined. penetrateit, creatingsharp
grooves.

An old tungstenbur is modifiedwith a A roundedNo. 1/2 diamond The mainsulci are redefined The restoration is sandblast'
diamonddisk. Both instrumentsmust bur ls used to developthe a secondtime withthe modi' ed at 2-har pressure from a
be rotatingduringthis procedure; trim- slopesthatcharacterize
each fied bur. 1O'cmdistance to remove the
min g s h o u ldc o n t in u eu n t il a f ine t i p i s ridgefrom eachcusp,widen. d e b r i sf r omthe milling.
created. ing from ihe bottomto the
surface.

Small add-onmass correc- The anatomyof the crown

tionsare appliedto enhance has beenrestored.
the anatomy,and stainis ap-
pliedbeforethe glazefiring.

798 299
 Workingwith Ceramics

Ceramiclayeringis particularlydifficult,becausepostfiringshrinkagemust be takeninto account.

Naturalposterior
anatomydependsprimarilyon twofactors,sharpreliefandwell-defined grooves.

This is performedwith appropriatespacedistrlbution,makingthe tooth anatomicallycorrectand

thereforemoreesthetic.lf we havecorrectlydefinedthe so-calledfish mouth (perimeterlimit of
the occlusalsurface),it is mucheasierto managethe occlusalarea.In this way,modelingbecomes
more predictable.lt is alwaysadvisableto start with the externalportionof the cuspsand close
the perimetercuspby cusp.As with composite, whenceramicsare usedthe occlusalsurfaceis
developed usingthe sectional techniquewithjust minormodifications regarding the handling.

Morphology:Fora naturalposterioranatomy,it is necessary

to workwith an extremelyfine.tipped
brush(N.Era,SmileLine),whichwill allowus to reachany areain the occlusalsurface.The mass
must be providedwith optimumtexture,so the ceramicmass has to be malleableand have
plasticity.
In thiswaywe can reproduce anydesireddetailby addingsmallincrements of ceramic
and packing jt with the brush.

Grooves: Correctdefinitionof the sulciwith the fine-tippedbrush is essentialbeforefiring.There

is a high risk of postfiringceramicseparationwhenthe sulci are definedwith sharp instruments
suchas endodontic filesor blades.

Surfacetexture:The smoothingof raw ceramicswith an extra-smooth brush allowscreationof

a very precisesurface.For a magnificentfinal effect, a mixture of 5OToElazingpowderand 50/o
ceramicwill be placedon the ridgesto highlightand enhancethe anatomyof the internalportion
of the cusDs.

Ceramicdehydration: Whenmodelingtakestoo long,ceramicmassesstart to dry. Thereare two

I
waysto recovermoisture:The first is to havean atomizerwith distilledwater available,and the
secondis to createa capillaryeffect by connectingthe crownto our liquid containerwith an
I absorbentstrip of paper;the lattertechniquemaytake longerbut the hydrationis moreeffective.

Ceramist:FerranPuig,Mollerussa,
Lerida,Spain,

306 307
 Conclusions

1. Incrementalapplicationof the stratification

layers is obligatory,
whena freehandmodelingtechniqueis usedin posterior
especially
teeth.

and polymerization
2. Materialcontraction deptharestillproblems. New
materialsthai promisethe abilityto applythick layersarejust more
transparentand containa greateramountof catalyst,whichmeans
that theyarelessestheticand haveinferiormechanical properties.

3. The seciional(pizza)technlqueallowsa systematicapproachto

development of a three-dimensional
shape,color,and contraction
siresscontroiin occlusal
surfaces.

4. Stainapplication
becomesan involuntary
self-education
to modela
correclsutcus,

5. Modelingwith bursand corrections

with rotatinginstruments
should
as muchas possible.
be avoided

3SB 309
 Ch a p t e rB
Physiolog
ic Phenome n a
Jordi Manauta. Anna Salat

Interviewwith SerhiyRadlinsky
 <:a4
,=? \)
,-',/v-"
,^ 9"

ye,.=a"--= (^
l,--d>*-fl
-* ),-*O-gFh-;'.'
.;:-o.-.>''=^'=1-_-ta-,q--' '=L{ :
.
'
t; --.-- -L>-
.-?

')-.--/v ^:
f-X'lt'x--- -+W- -',\

.>i-
\)

V i.
\\ \)
C.../v
 ruTilil

Q: For completeintegration
of estheticrestorations,
sometimes physiologic
defectsof teethmustbe repro-
duced.In whichcasesdo you thinkthis is the correct
aooroach?

Dr SerhiyRadlinsky and graduated

wasbornin NemirovUkraine, A: The terms physiologicdelects and even further
with honorsfrom the Ukrainian
MedicalStomatological
Academy reproductionof physiologicdefectsare rather confusing.
in Poltava. Any defects are pathologicconditions per se. The
term age-relatedphysiologicchanges seems to be
After he graduatedfrom his postgraduatecourse,Dr Radlinsky more appropriate.Thesechangesare only physiologic
taught pediatric dentistry.At present, he teaches restorative when there is no interferencewith tooth integrityor
dentistryin the Postgraduate
Department of the Ukrainian
Medical periodontalhealth(changes in the toothcolor,enamel
Stomatological Academy.He headsApollonia,a privatedental wear,or gingivalrecession).
clinic,studio,and trainingcenterin Ukraineand is editorof the
dental magazineDentAft.Dt Radlinskyconceived,organized,and A dentalrestorationis a resultof cooperationbetween
continuesto run the Prisma.Cha mpionsh ip project,a seriesof the dentist and the patient.The patient presentshis
" lnternational
Clinical
Competitions "
in theArt of ToothRestoration. or her expectations.The dentist,beingboth a smile
designeranda clinician, presents the rangeof possible
With professionaljnterestsfocusedon estheticsand technique restorative
solutions.
of directrestoration, Dr Radlinskyis a memberof the National
Academyof EstheticDentistry(Russia),an affiliatedmemberof All patientsunderstandably want to look younger.
the EuropeanAcademyof EstheticDentistry,VicePresldentof the However,this maycontradictthe principles
of minimal
Ukrainian Associationof PrivateDentists,
and an HonoredDoctor interventionwhenit comesto dentalrestorations.
He is'the authorof a textbook
of Tbilisi State MedicalUniversity.
and more than 50 cliniealand scientificarticleson restorative Whenwe performa dentalrestoration, we needto match
dentistry. the artificialoartof thetoothto the naturaltissuesand
so reproduce age.relatedphysiologicchanges.

Do we need to reproducethe "physiologicdefects"?

My answeris "Yes,by all means!"I am happythat my
patientsare not interestedin havingthe teeth from a
masazinecover.

311 315
 P henomena
Phy siologic Delicatemixingwill generatetwo indispensable colors,opaqueorangeand
opalescentbrown.More colorscan be generateddependingon the case,
althoughthesetwo colorswill sufficefor the majorityof cases.

This chapter makes no attempt to classifythese

phenomena of theteeth.However, we believe that many
of thesephenomena play a key role ln the patient's
appearance whentheyarevisibleand sometimes must
be reproduced if we do not seekto
ln our stratification,
eliminatethesedefectsfrom all naturalteeth.

The phenomena shownare thosethat occurwith the

"use"of the teeth,at a physiologic
level.Theseinclude
wear,abrasion, and pigmentation:
attrition,erosion, To createopaqueorange,ocherand Mixtures shouldturn out homogenous
orangeare mixed with the A2D den- and must be verywell protectedfrom
. Wear:Lossof toothsubstance as a resultof friction tin. A mixtureof brownstainand OBN light.Theshelf-life of the mlxesis lim.
againstanotherdentalelement. opalescent is usedfor the opalescent ited.Usuallytheywill last2 weeks,at
. Abrasion:Loss of tooth substanceas a resultof brown. most,if storedin idealconditions.
frictionagainsta foreignoralelement.
. Attrition:Microdetachment of tooth substance as a
resultof flexionand compression of the teeth. Compositeresin storage
. Erosion:Loss of tooth substanceas a result of
Severalsolutions for composite
areavailable resinstorage.
Themostimportant
chemicalactlon,from eitherthe insideor outsideof
thingis to preventlightexposure.
the organism.
. Pigmentation: Accumulationof chromatic substances
The solutionwe normallyrecommendconsistsof black compartments,
as a resultof anyof thesephenomena or aging.
preferably
with ditferentfunctions,
to isolatecomposite from light
completely
(CompoCubo).Whitetraysdo not protectcompositescorrectly,
evenwithblack
covers.

of age-related Materialsrequired:
for reproduction
Reasons
changes:

. Tomatchthe remaining naturalteeth . Opaquecomposite dentin(A2DFiltekSupreme, 3M)

. To attain a thoroughunderstanding .
of c o lo r Na t u ra lO p a le s c e nct o mp o s it e(HF Oe n a m e lOBN,
and stratification Micerium)
. Forartisticreasons(costumes,
movies, theater) . Darkbrown,brown,and orangestains(brown,ocher, Trayfor primer/bonding,modeling Stainstray.
and orange;Chromazone, Kuraray) Iiquid,and a brushdryer.
. Mixingpalettewith light protection(CompoCubo,
S mileL in e )

Mixingtray. All of our composites

correctlystored.

316 317
 Cervicaldefects:Attrition,Abrasion,and Pigmentation

These features are clinically dif-

ficult to apply; these defects are
reproducedas an exerciseto learn
the color properties of the teeth
and for other reasons previously
mentioned.

By followingthe layeringtechnique
correctly,we can easily create a
cervical defect with a diamond
disk. This milling will uncoverthe
deep chromaticlayersand achieve
Naturalopalescent is layeredin the The final enamel layer must be Thefinishingstagedefinesthe pri.
the color effectswe are seeking.
fr a p <n e .a
l a fi i n i h a i n .i c.a l a n d smoothand as closeas possible to maryand seconda ry anatomy.
proxtmaI areas. fha fi nrl .l ac i ra.l c h2na

Afterthe palatalenamelis layered, This baseis covered

with a highly The remainingdentinalbody is S l i l l d u r i n g l h e t i n i s h i n gs l a g e .a The remainingdebrisis removed
a s ma lld e n ti ni ncr ementis placed chromaticdentincomposite(A5). finishedwiththe chosenbasecol- s h a r p d i a m o n dl a b o r a t o r yd i s k i s d u r i n gthe polishing stage.
and polymerized to act as a base This dark feature is efficiently or,Thepreviously layeredinternal usedto cut a wedgeout of the cer.
for the "pigmented pulp,"whichis maskedby just a subtlelayerof characterizationswill be uncov- vicaI area.
constructed with a brownopales- dentin. eredafterward.
centmass.

318 319
CervicalDefects:Erosionand Pigmentation CervicalDefects:Erosion,Pigmentation,
and IncipientCaries

The exercise is started This exercise is started

from a completelystrati. from a completelystrati-
fied tooth (1). A rounded fiediooth(11).A rounded
diamondbur is used to diamond bur is used to
create a cervical defect create a cervical defect
(2), and the resultingde- (12),and the resulting de.
bris is removed with mod- bris is removed with mod-
e lin gliq u ida n da i r ( 3 ) . e l i n gl i q u i da n da i r ( 1 3 ) .

Whenthe cavityis ready,a To create a decalcified

smallincrement of opaque enamelarea,a milky ef.
orange (10b) is placed fect is layered(14).Some
(4). After polymerization, blueopalescent is layered
more opaque orange is on the cervical wallof the
placed obliquelytoward cavityto reproducescle.
the incisalregion(5).Then roticdentin(15).Opaque
transparentbrown (10a) orange (20b) is placed
is placedfrom incisalto obliquelyfrom cervicalto
cervica| (6). i n c i s a(l 1 6 ) .

The opalescent brown Opalescent brown(20a)is

(1Oa) can be placed in placedin an incisalto cer-
one or two layers(7). The vicaI direction(i7). The
defect margins can be finishingstage (18) and
coveredslightlywith the polishing stageare com.
sameenamelas the facial pleted,leavingthe defect
wall(8).Thefinishingand especially smooth(19).
polishing shouldleaveihe
defect especially glossy
(e)

Hybrid composite restn Hybrid composite restn

massesmixedwith D T O WN masses mixed with brown
(10a) and orange (1 0 b ) (zoa) and orange (20b)
staIns. stains.
 WornIncisalEdgeStratification

lVodified opaque dentin

T massesplay an rmpor-
tant rolein increasingthe

T chromaticity of the ex-

posed dentin. The etfect

Ii -.-l is highly dynamicwhen

the tooth is illuminated
frontally (12a) or from
I
I
d ifferentangles( 12b).

g lls Thewallscanbeincreased
I
A dentincoreof the de- The palatalwall is creat. Wh ilet h e re ma in inwa
siredcoloris obtained. ed with a medium-Valueare built,the dentincore moreif necessa ry.
enamel. should be surrounded by
t h e in c is ael n a me l.

The buccalaspectof the

I incisa
I edge is shown
(13a). When opalescent

I masses are useo as a

"screen,"the chromatic
masses placed in ihe
l inside are not revealed
throughthe buccalenam-
el composite(13b).

Correctionscan be made Debris producedduring A smallincrement of nat- This layer is imporiant

to obtain a thinnerand correction is removed uralopalescent is applied becauseit will providea
moreprecisestructure. with modelingliquida n d as a thin internalscreen. transparent halo effect
air. and will act as a lightde-
flector.

Thepalatalviewof the in'

cisaledgeshowsa correct
morphologyand natural-

T lookingdefect(14a),but
the strongcoloris not evi'

I dent throughthe enamel

com nocitp r/l 4h\

I
I
A chromaticdentin(A6) A dark brown stain is The incisal edge is filled
is placed,and a grooveis placedto fill ihe groove. with the modified opaque
modeledin ihe center. orangedentin.

322 323
 Erosion Fignrentation

the firstsignsof dentalerosionby intracorporeal

Typically, chemr- Naturalteethacquirepigmentsand are infiltrated
by stainswhile
cals(acidrefluxor chronicvomiting) aresmalldepressions
in the aging;substanceloss can contributeto this phenomenon. This
cusDtios of the mandib u lamo
r la rs . pigmentationusuallyoccursat the cervicalregion,at the incisal
edge,and lessfrequently
in someareasof the buccalsurface.
Paradoxically,
the most mineralized
structuresare locatedin this
area;mineralizeddentalsubstancesare more susceptable
to acid
attack.Dentinis threetimesmoreacidresistant
thanthe enamel-

The first step to de- A ro u n d e dd i a m o n d

velopan erosionde- bur is used to pre-
fect is to obtain a pare a cavityof ap-
molarusingthe usu- proximately 1.5-mm
al stratification
tech- depthon the tip of
nique. everycusp.

Afterthe millingde- lf a strongereffect

bris is removed,if is n e e d ed ,a s m a l l
stratif
icationwascar- amount of opaque Froma conventiona I stratifica. A brown modified opalescent While the final enamellayer
riedout correctly,
the orange dentin can tion,an agedtoothwithsome is placedon the incisaledge, is modeled,a brown fissure
erosioneffectsshould be layered insidethe of its typicalfeaturesis cre. and somesoftwhiteintensives will be developed with a dark
be subtleand suffi- cavlty. dr e prdLs u ar uur ru rl . brownstain,
crent.

rr
The fissureis closedwith the A high.glosspollsh must be
remaining facialenamel.Once achieved. Theabsenceof tex.
the composrteis polymerized tures and incisal irregular-
the modifiedopalescentbrown ity are importantto replicate
will be placedin the cervical agedteeth.

321 325
 Conclusions

1. Theabilityto analyzethenaturaI dentition

isfundamental
to reproducing
its most intimatefeatures.

2, Modification of hybridcompositeresinswiih stainsopensa huge

potentialfor estheticintegrationof restorations.

3. Withthe existingmaterials stainsshouldnot be usedto paint;instead

they must be integratedin the restorationstructure.

Reproduction of smalldefectscan ensurecompleteintegration

of a
restorationand prevent
overtreatment.

of dental defecis is the best trainingto increase

5. Stratification
understanding of colorand layering.

3?6 327
 Ch ap t e r 9
Pathoog ic Phenome n a
Jordi Manauta . A nna S al at

l ntervi ew w i th B ernd K l ai ber

 CC l{trriter,er 1;oo do m{rq :seern in-igni{ictni.
but it i- nrost importrtrtt ttrrit r1oo do it.
,)

altltlrrtm(| G(rndl}i

H,A
P=ft'6i{RiaHe
@c'JSg
IF$*il''e.R'ru
rTrFHt'ffFBfiFffiF-iffi
i^i^.?^l^EEbii^^;
'ff
ttff Si^tii4^d[itTI]..i+^.T,*
6'#, tr
 ETTIIil
:1: i.

Q: lt is controversialto advocate of
the reproduction
pathologicphenomenain restorations. Why do you
thinkit is imoortantto knowhowto do it?

Prof BerndKlaiberwasbornin Karlsruhe,Germany, andcompleted A: The locationand form of the restorationare, in my

his doctoraland postdoctoral
studiesin dentistryat the University opinion,of outmost importancewhen we consider
of Freiburg. whether to mimic pathologicphenomena.Therefore,
the imitationof stainedfissures,opaquespots, or
Prof Klaiberwas honoredwith the AnnualAwardof the German evencariesin the functionalzone may be regardedas
in 1980 and 1998.
Societyfor Dentistryand Orallvledicine irrelevantor overtreatment.

He wasappointedProfessor at the University

of Freiburgin 1981. However, we may take a differentvrewin the esthetic
Award
In 1986,Prof Klaiberwonthe Walther-Engel of the Academy area. In particular,when adjacentteeth revealsmall
for DentalStudies,Karlsruhe. aberrations such as opaqueness, staining,or enamel
cracks,it is critical to imitatethese characteristics
in
He hasservedas directorof the Departmentof Operative
Dentistry the restoration.
and Periodontology,
University Germany,since1987.
of WUrzburg,
In these situations,an immaculateand ideally
reconstructed singletoothwill alwayslookartificialor
unnatural.lf crownsor veneerscan be identifiedas
restorations,and thereforeas fake, we havefailed to
performour job properly.

33? 333
 In a course,during the hands-ondemonstrations,I asked,"Whathaveyoudone?
participantsgenerally At onecourse,
aremorerelaxed.
a participantcameto me and askedme a very,very "Well,I havetriedto restoreit withverydarkcolorslike
q uestio
interesting n: a C4,but alwayswith an unsatisfactory outcome."

"Howwouldyoustratifya tetracycline-stained tooth?" "Givemea coupleof weeksto thinkaboutit. Remember

that my answermaybe unsatisfactory too.I havenever
My answerwas: "Theseare the most difficultcases. doneit before. Wewill keepin touch."
lMasking tetracycline stainsis difficult,becausethe
grayishbrowncan be seenthroughthe composite, Twoweekslater,I sent her a photograph (1) with the
especially if it is translucent.Therefore you must use following "MixanA2 dentinwithan orange
instructions:
opaque white composites... " stainandthe sameA2 dentinwitha brownstain.Keep
saturatingbothmasseswiththe stainsuntilyoumatch
At that point she interruptedme: "Sorry.I did not the color.Try also to mix in a tiny amountof black
explainmyselfcorrectly.I needto restorea fractured stainif ihe tooth is verygray."
tooth in a patientwith tetracycline staining.He does
not wantveneeTs or crowns." Theanswerin 10 dayswas:"l havefinallysolvedthe
caselI will sendyou pictures."

I responded,"li was a greatpleasure.lt was a very

adventure;
interesting we shouldwritea book."

thosepicturesl
Note:I am stillawaiting
Note2: the picturescamewhilethis bookwas being
f inishe d .

Pathologic
featuresin teethoffera wide rangeof colors
rarelyseenin healthyteeth.

Stratifyingthesecharacterisiics,notonlyto solvebizarre
cases,but alsoto acquirea deepappreciation of dental
color,increases our abilityto identifycolorand become
skilledln stratification
and modellng.

Thereare hundredsof artists in the entertainment

world(theater,movies,photography)whoareconstantly
manufacturing alteredteeth,suchas a vampirecanines
or rottendentitions.Thesepeoplehavesurprisedus
immensely withtheirabilityto understanddentalcolor
in an amazingway.

331
 Beforethe enamel layer of a An incrementof a milky white
posteriortooth is placed,a car. compositeis placedwith a de-
ies lesionwill be stratifiedon a pressionin the middleto house An incrementof a milkywhite To highlight the effect, an An ocherstainis placed,slight-
proximalsurface. the stains. compositeis placedwith a de- opaque white stain is placed ly coveringsome of the areas
pression in its centerto house in some areasof the created of whitecharacterization.
the stains. crrcte.

An ocherstain is placedin the A dark brownstainis olacedir. Finalenamelplacement should

center of the depressionand regularly,allowingsomeof the slightlydull the powerful
effect
extendedto cover some of the ocherstainto remainvisible. of the stains. A dark brownstain is placed Thefinalenamellayerwill dull Finishingand polishingcan
whitearea. to characterizethe center ir- the effectsof the stainsslight. be used to make the effects
regularly,allowingsome of ry. emergeagainor not, depend-
the ocherto remainvisible. ing on the needsof the par-
ticularrestoration,

Normallythese lesionsare not reproducedin posteriorteeth

becausetheyare hiddenor, if by chancethey arevisible,they do
not playa role in estheticintegration.

However, somelesionsof a completedifferenietiologyarefound

in anteriorteeth,and some of them must be reproduceo ro
achieve successful integration
of the restoration.
Thetechnique
internaleffectswill become
on howmuchenamelis removed,
Duringthe finishingstage,depending for their stratification
is exactlythe same as shownin these
morevisible,someevenreaching the surface. exampres.

336
 This type of characterization
the
has only two applications,
artistic and the educational.
However,these photograPhs
are the ones that arousethe
most curiosltyin lecturesand
coursesbecause of the appar-
ent complexity of the restora
tion.

A milky white composite resin An orangestainis also placed After polymerization is com-
is placed inside the ename as a liner,io beginenhancing pleted,an ocherstainis placed
wall for a decalcificationeffect, the Chromato the maximum in the sameway,this time in-
A high.Chromadentin (A6) is tevet. creasingthe amountof mass
placedas a liner in the floor of andthusthe innervolume.
the cavity.

A recentlystratifiedand pol' A No. 2 round e dd ia mo n db u r An irregularshapeis maoe Io Darkbrownstainis usedto fill A blackstainis placedas the Thecavityis closedwith milky
ished composiieresin tooth is usedat low speedto create improvethe naturaI appear- mostof the cavityand saturate finalchromaticlayer.
Themass white and enamelcomposite
will be transformed. a cavity,leavinga thin layerof anceof the lesion. the lesionbody. used in this case was dark resins. This effect cannot be
the facialenamel. brownstain mixedwith black m echanicallypolished.
ceramrcpowder.

338 339
 Thissituationis probablywherewe find the strangest
colorsand the mostcomplicated chromaticmaps.lt
is importantto knowhowto reproduce thesestainsfor
the followingTeasons:

. lt is highlyprobable a patient
that we will encounter
withsuchstains(depending on the country).
. lt helpsus to understand dentalcolor.
. lt improves our abilityto stratify.

A root is constructed We mustlearnto develop The mixture of dentin, Corrections can be car- Betweentheamberspots, Somenaturalopalescent The same opalescentis An orange stain is used
from a dentincomposite many dentin intensities. now saturated with dark ried out to obtainthinner some white intensiveis is placed in the incisal usedto developa type 2 to make the division be-
massmodifiedwithocher ln ihi< eaco laee
^.har
brown, helps to create wallsor structures. placedto createopaque a r e aa n d p r o x i m awl a l l s . characterization to create tween bands more evi-
s t a i n .T he p a la talw all is stainand a smallam o u n t a band typical in these enamelaTeas. a transparentband that dent.
formedwith a high-Va lue of brown stain we re teeih. will act as a filter,
enamelcom ite. pos mixedwithihe dentin.

A mixtureof dentin,or- A n amber o pale s c ent Near the proximalarea, Forthe final layera high' The finalized stratifica- Theflnishingand polish-
d | |B g 5 c d||t, d ||ri d r||r dr l u ssu tu prdut lntensivespotsare mod' valueenamelcomposite tion reveals how every ing make ihe interna I
amountof brownis used some c ha racter izations eledin a stripedshape. is used to developtwo mass behaves underthe characterization
evident
to buildthedentinalbody. in ih e in ci< a I p r lo e whitefissures. tr||d|| rer LU ,|| P U r rrc . again.

340 311
 M i l d f l u o r o si s Strongfluolosis Severefluorosis

A cientrncore with a
four-mamelon (type 2)
upd tr5s tr||Le \La. LU ,
2.\ ic { .:hf i .r+ arl Thi c

can vary,depending on
the tooth that is being
reproouceo.

Three hinds of inten'

sivemassesare Lrsedto
"draw" the map of de-
calcificationsthat mLrst
he renrnrl rc prl Thp

strongerintensives
are
prdLc u u|| LU p uL L||tr
lighter intensives(3a,
3b,3c).

Three types of mixture

can be nrade with the
natural opaJescentand
placed on the tooth ac.
cording to the location
and the shapeof the ef-
fect, which is Lrsuallyir-
Fluorosis
regr:lar.
Opalescent+ orange(4a)
Teeththat suffer this pathol ogiccondition usually look sirnilarto the
O n: l e< ee n+ + nrhor /4h\
tooth ln the image (i). They show decalcifications,structuraldisarray,
and accumulationsof prgment. Generallythese effects are tound on
Opalescent+ brown(4c)
the top layer,and thereforeour clinical efforis should focus on their
conservative removal.The col or propertiesof theseteeth are basedon:

Poweri ntensive
features The last enamel com-
nnc i l o l l ,or;c n l r.a.l
Dark brown
/6a 5h 5,^\ nv prqharl -
Transparentbrown
O n :n r r c rrr: n oe owing the u nderlying

A composite speaking,
mixtureis not ideal,chemically andthesemasses where enamel is miss.
are not corrmerciallyavailable. requirelong curing
Thesetechniques ing, a modified dentin
. ^ rn n n q i t a rp c i n .2n
polislirg .
l i 14esandexhaustive
d ||||dr rd y e '

3-13
 Conclusions

The study of pathologicconditionsis essentialto understanding

normality.

provideus with self.confidence

2. Thesetechniques to tackledifficult
cases.

3. Toothdefectsarereproduced purposes.
for artisticand educational

4. Learning for generating

the techniques newcomposite
colorsavoids
the needto havemassivecolorsystems.

5. Eachstain has a differentopacity;the darkerthe stain,the more

opaqueit shouldbe. Stainsalso vary considerably from brandto
Drano.

316 317
 Ch a p t e r1 O
Surfaceand Po ishi n g
Jordi Manauta. Anna Salat

Interviewwith RicardoMitrani
 ":-'
lfl@t"

..losefA.inann
 lrlilll

Q: Whatis the importance of surfaceand polishingin

l*l
the correctintegration
of an estheticrestoration?

A: To strive for predictablesuccess when dealing

with esthetic restorations,the clinician(or clinician.
After completing his degree in dentistry from the Technical
technicianteam in the case of indirect restorations)
Universityof Mexico,Dr RicardoMitrani receiveda certificatein
prosthodontics must be able to momentarilyisolate the different
as well as a master'sdegreefrom the Universityof
dimensionsof estheticsin orderto ultimatelyintegrate
Washington, in Seaitle,wherehe servedas the assistantdirectorof
them.
the graduateprosthodontics programsin 2001.
the paramount
Undoubtedly contour andcolorrepresent
He currentlyholds academicaffiliationsat the Universityof
dimensions for such an endeavor (alongwith optical
Washington, the Universityof Valencia(Spain),and the National
properties such as fluorescence,opalescence,and
AutonomousUniversityof Mexico. He is a member of the
translucency);however,surface texture and luster
AmericanCollegeof Prosthodontists, AmericanAcademyof Fixed
couldultimatelybecomethe differencebetweena "nice
Prosthodontics,and InternationalCollegeof Dentists.He also
restoration"and an "inconspicuous
restoration."
serves on the editorial board of PracticalProcedures& Aesihetic
Dentistry
in the lmplantologysection.
This is particularlycritical when we are restoringa
singlecentral incisor,regardlessof the natureof the
Dr Mitranihas authorednumerousscientificpublications in the
prosthodontics designand materialsof the restoration(compositeor
fieldsof implant and estheticdentistryand has
ceramiclaminateveneer,complete-coverage crown,or
He maintainsa private
lecturednationallyand internationally.
practicelimitedto prosthodontics an implant-supported restoration).Once the color is
and implantsin MexicoCity.
matchedand the contour is mirrored,surfacetexture
and lusterbecomethe "fingerprint"of the restoration.

I believethat surface texture and luster should be

regardedas the "trademark"of the restoration;they
representthe proprietaryirregularities that contribute
to inconspicuousresults,not only becausethey may
influencethe opiical properties(light reflection)of the
restorationsbut also becausethey providea senseof
continuityin the arrangement of the anteriordentition,

352 353
ri;
t:.'

Suggested m
Armamentariu

. Burs:Periocare diamondbur831.524(Dentacare)
. Disks:OptiDisc (Kerr)
. Rubber:OneGloss Set (Shofu)
. Brush:Goat-hair brush(Micerium)
. Felt:Feliwheel(Micerium)
. Pastes:ShinyA (Micerium),ShinyB (Micerium),
ShinyC (Micerium)

Bur: A 75-pm flame-shapeddiamond bur is used, at low speed

(10,000rpm),to carryoul9OToof finishing
work,including
definition
of shapeand primaryand secondaryanatomy.

Disks:Disksare usedto defineproximalareasand transitionangles,

in the areaswherethe bur is not able to reach.Theseinstruments
also are probablythe most comfortableand accuraiefor defining
the incisaland proximalshapes.Fourgrits are available: coarse,
medium,fine, and superfine.We recommendthe medium grit for
removingexcessand the fine grit for subtlemodifications.

Rubbertips: Theseare used to eliminatethe groovesthat the bur

and the disk leave.They havetwo main functions:Whenthey are
used firmly, a smooth abrasionresultson the compositesurface,
and when they are used delicately,they are able to prepolish.The
finishingstageis improvedwith this kind of instrument.Thecorrect
speedsare 10,000rpm for finishingand 5,000rpm for polishing.

Brush and paste: When a goat-hairbrush rotary instrument is

combined with3. and 1'pmdiamondpastesfor the initialshinestage,
the result is a high gloss.The hardnessof the brush permits the
surfaceto be polishedat highspeedand deepzonesto be polishedat
lowspeed.Thesebrushesgeneratesignificantheat;theycan be used
at 1,000 rpm with a gentletouch and withoutwater and at 10,000
rpm underabundantwaterspray.

Feltand paste:A felt wheel,whichis a verysoft material,is usedwith

a 1-pmaluminumoxidepasteto achievea very high gloss.These
wheelsgeneratesignificantheat.Theycan be usedat 1,000rpm with
a gentletouchand withoutwaterand at 20,000rpm underabundant
waterspray.
 Finishingand polishingappliances
and their alternatives
o

Periocare Burcoatedwith75-pmmedi. OptiDisc(Kerr):Polyester

(Dentacare): diskscoatedwith aluminum Brownie(Shofu):Synthetic
rubberpolisherwith silicon OptilStep(Kerr):Syntheticextrahardrubberd isks
um-gritdiamondabrasiveparticles(831'524). oxideabrasive
oarticles. particles.
carbideabrasive with diamondand aluminumoxideabrasiveparti.
cles.

Sof-LexPop-on(3M):Vinyldiskscoatedwith alumi- Swissflexdisks(Diatec):Vinyldouble-sided

diskscoat- Dia-Finish(Renfert):Diamond.im- Opticlean (Kerr):Siliconmatrixpolisher Astrobrush(lvoclar):Poly-
numoxideabrasiveparticles. ed withaluminumoxideabrasive oarticles. pregnatedhardfelt polisher. aluminumoxideabrasive amidepolisherwithsillcon
with extrafine
particles. partlcles.
carbideabrasive

-\
'?

\/

Q,'
.=
G

OneGloss(Shofu):Siliconpolishers
with aluminum ldentoflex(Kerr):Rubberpolishers withdiamondabra. ShinyG (Micerium):
Naturalgoat.hair
brush. Cerium(lV) oxide(Generic). N

particleson removable
oxideabrasive stainless
steel siveoarticleson stainless
steelfixedmandrels. ShinyF (Micerium):
Softfelt disk. C|
(,
manoret5. J
 Sgqndhiy andis,i-ry

Toothmorphology

(1) Outline:The tooth's physicallimit is responsible

for determining the globaltooth shapeand is closely
relatedto ihe primaryanatomy.

(2) Primary anatomy:The anatomicalcrown shape

givenby the transitionanglesdetermines
the curvature
andthe finetoothshape.

(3) Secondaryanaiomy:This is the macrosurface,

a consequence of tooth development. Growthlobes
becomeevidenton the surfaceas large,undulating
areasthat coverthe entireenamel.Thisis also known
l- as vefticaltexture,but the wide horizontaltexturealso
involvethe seconda ry anatomy

(4) Tertiaryanatomy:This is the microsurface,

where
the developmentalgrooves becomeevidentas small
lt is
linesthat crossthe buccalsurfacehorizontally.
knownas hotizontaltexture
as well.

359
 Ovoidtooth

Properlies:
. Roundedridges
. RoundedproximaI areas
. Straight,/ovalcervix
. Short appearance
. Strong texture
. Rounded,unevenincisal edge
. Ro u n d edangles

Associatedwiih:
. Youngteeth
. Feminine teeth
. Nonwornteeth
. Textured teeth

Ceramist: AlbertoViIlanuev
a, Zaragoza,Spain.
360
 tooith
Rectamgurlar

Properties:
. Parallelridges
' Paralel proximalareas
. Straighicervix
. Shortappearance
. Softtexture
. Flatincisaledge
. Straightangles

Associated with:
. Olderteeth
. lvlascu
lineteeth
. Wornteeth
. Slighttexture

Ceramist: AlbertoViIlanueva,
Zaragoza,Spain.
367
 Triangulartooth

Properties:
. Converging
ridges
. Converging
proximalareas
. Roundedcervix
. I nno an n a : r r n . o

' Soft and smooth texture

. Fl a t i n c is aledge
. Stra i g htand r oundeda n g l e s

Relatedto:
. Adult teeth
. Feminine teeth
. Largeteeth
. Gi n g i vallos s

Ce ra mi st :A lber t o V illan u e v aZ, a ra g o z a S

, pain.

361
 r...af ,
i.::*:i:,, ={}, (*.-o-to-,,
r::Y:/!:::
, rz,n.sil, .
uIc;r
rvat .,t., , )),' , 0^-- t Vt'^
i ." ?,' :., cvacl:
) ;r;-t" r , , \,' -,' -t' ' ,
tsasicFolishimgFrocedures I zu*r . = tOLt, , r - t,.- :i ,
- p\.a..e 1v '- '

F i n i s hinagn d po lishing is undoub t - Oneof the mostdifficulttasksrelatedto polish-

a restoration
edly the secretfor successful integrationand ing is to obtaina regularand smoothsurface.
longevity. Fortunately compositematerialsper- Wehavefoundthat havinga hugevarietyof pol-
mit " reinterventions, " not only regardingcolor ishinginstruments is not the secretto obtaining
and layersbut for surfacetextureas well. paradoxically
glossyrestorations; the secretis
a comprehensiveand accurate finishingstage,
+h:+ i c. fhp "rnrroh" ci :oc

: t,,r , r '.
'r; .'l '-i' ;-.
.{(.,],..1 r{
- i'"c1'sf-' '' 'r'.- A 3-pmdiamondpasteis em- A 1 - p md i a m o n dp a s t ei s e m . A 1.pm aluminumoxidepaste
ployedwith a naturalgoat-hair ployedwitha naturalgoat-hair is employedwith a felt wheel
brushusedat 1,000rpm with brushusedat 1,000rpm with u sedal I,000 rpm with no wa-
no water and ai 10,000rpm no water and at 10,000rpm ter and at 20,000 to 30,000
with abundantwater.A high withabundant water.lf no high rpm with abundanlwaler.An
gloss should be noticea ble glossis evidentaftercomplete extremely highglossshouldbe
after this step. Prophylaxis removalof the paste,we must evidentafter this step.lf it is
brushesare not suitablefor returnto the abrasiverubber nol,we musfreturnto previous
this task. poInts. stages.

A whiiecomposite tooihwitha A regularand smoothsurface Oncethe desiredpreliminary

nonideal surfacehasbeencre- is obtainedwithonlythe useof surfaceis achieved,abrasive
aiedfor didactjcpurposes.The the diamondbur.As expected, rubber points are used to
finishingphasewill beginafter the surfaceis notshinyyet,but eliminatethe groovesresult.
completepolymerization. it is meticulously
even. ingfrom the diamondbur and
A- I '*r'. l0 ooal't-r'J abrasivedisks and to obtain
( l-,'l o r,o" ! C!^
a n in it ia sl hin e .
. - FI' / r ( 4 9

TI
Toemphasize thetoothsurface The resultis plainlyevident:a
and what we have achieved. perfectlypolished composite
the toothhasbeencoatedwith restoration that will resistthe
silverpowderto makesurface passageof time and the hos-
textureevident.ln this case,a tile oral environment more ef-
f lat toothwascreated. fectively.

366 367
 Advancedponishing
step hy step

u0 The nextstep is to start The lobescan be divided Thesecondary anatomyis It is possibleto generate
reproducing the second- witha finediskor a modi- drawnwith a pencil.The grooves withthe dlamond
ary anaiomy,in this case fi e r l h r r r r /n ao e 2 a R \ groovesand depressions bur, moved gently from
.q,
the divisionof the lobes. of the lobesareshown. mesialto d istaL

A white compositetooth The critical phase con- At this point, transition

with a nonidealsurface sists of smoothingthe angles are drawn. Their
b! has been createdfor di' surfaceuntil an evensur- direction and curvature
dacticpurposes. The fin. faceis achieved.Thisis al- dependson the desired
i shin g phase will begin waysaccomplished witha shape.
after completepolymer- 75-pmdia mo n db u r u s e d
ization. at 10,000rpm. Disksare
usefuI for proximalareas.

A rubber point can be The same rubber point A npnc i l ic rrc a.l ln The pencil lines are re-
usedto smooththe rough is usedto givean initial draw some developmen- produced,one by one,
textureleft by the bur. glossto the restoration. tal grooves:parallel, nar- with the bur tip, whichis
row,and winding. movedcarefully, following
the samehorizonta I paih.

Th e tr ansition angles Contourlng of the incisa I Theincisaledgeis shaped iR

are contoured, preferably edge is imperative. Once with the abrasived isks
witha diamondbur when the precise shapeis drawn andthe diamondbur.Low
proxrma I areas are eas- with a pencil, the contour- speedand delicatemove-
ily accessible.lf proximal ing is a c c o mp lis h ewit
d h ments are necessary for
the bur a n dd is k s . high precis
ion.
disksa n d polishing strips
should be used.
Afterthe pencilis erased The restorationis pol- The restorationis pol- The restorationis pol-
the restoration
musthave ishedwith 3-pmdiamond ishedwith 1-pmdiamond ished with 1-pm alumi-
the desiredlook, or the pasteappliedwitha natu. pasteappliedwitha natu- num oxidepasteapplied
nextstepsshouldnot be ral goat-hairbrush used ral goat-hairbrush used with a felt wheelusedat
undertaken. at 1,000and 10,000rpm. at 1,,000
and 10,000rpm. 1,OOO and 10,000rpm.
368 369
 [;l
,l "t-"I T
resin, presumed
The final appearanceshowsthe high gloss we can achievewith hybridcomposite
polishable." 5ilver powder evidencesthe anatomy,surface,curvatures,and sub e textures.
by many authorsto be "not

It is szridthat hybridcom posite resins are clifficult It is true that a hybrid compositerequiresmore The naturalappearance of a restoratiorr
is largely A snrooth surface will let light pass through
to po sh and nraintaln.The clin ca rea ty s that inr a'd,"tler'o- d-"'rg pol s'i g I . deterrninedby the sLrrface nrorphology.The vrzry eas ly. vlhi e a texiured surface,,vil create rnore
-r rges.
it is possibleto obtain ideal surfaceswith such not easy lo oblarn ,r high gloss,bJL.once a hr6h rn which light interactswith a smooth surfztce rellections,thereforesignificantlyinfluencing the
materials,ancl, becauseof their conrposition, gloss is obtained, hybrid materials have been is completelydifferentfrom the way in which it coior appearanceof the tooth.The manufacturer
they provideoptirnalstabilityovertime. shown to be more stable than microfilledand interactswith a texturizedsurface. does not reconrendthe intraoral use of this
nanofilledcomposites. powoer.

3/tJ
?,/t
 Folishingand color

lmmediately a toothmayseemcorrectat firstglance.

afterstratification, However, the
lastlayer,whichis in contactwith oxygen, polymerized
is not completely until it has
,(, c' .,,- ,r^4pct' n-^^t t;'o-.'r,ut The secondaryanatomyis es. Verticalgroovescan be as long
\" 1r-F! -" tablished,in the form of ver. as neededand can be made
tical grooves.They are made bit by bit. Horizontal
anatomy
with gentle, balancedmove. also can be shapedat this
mentsfrom mesialto distalio Itme.
createa true depression
and to
avoidcreationof a notch.

The importanceof the finishingstepswith abrasive in this caseapplied

materials,
witha diamondbur usedat lowspeed,cannotbe overemphasized. Onlyafterwe have
obtainedan idealpreliminary surfacecan we start thinkingaboutfurtherspecific
details.

After the secondaryanatomy Thereis an alternativeway to

is created,
the bur marksmusl producethetertiaryanatomy. A
be erased with an abrasive coarsediamondbur is passed
rubberpoint,whichis applied manually(withthefingers)in a
gentlyto erasethe markseffi. ntaI direction.
horizo scratching
cientlyandgivean initiaI gloss. the surface.This processwill
leavebeautifulm icrogrooves.

377 373
 The initialsituationshowsa fake glossihat correspondsto the oxygen-inhibited
layer;
Goat.ha ir brush Goat'hairbrush Feltwheel
the rarycompo;ite resin on the su-rfac.e
degradesextremelyfast.
+ 3- p mdiamond + 1-pmd ia mo n d + 1'pm aluminum oxide i\sl/r: 'cL('t' c
r-''" q
11t{,.'-.1-, 'r'(1
?,a.u. -

Afterpolishing, the restoration showsa highglossand a naturaltexture. Volumeloss

The nextstep is to the carryout progressivepolishing f r o m m e c h a n i c af iln i s h i n ga n d p o l i s h i n sg h o u l db e m i n i m a l .
with polishing pastes. allowstheachieve-
Thistechnique
ment of a high polishwithoutthe risk of ruiningthe
previously developed as frequentlyhap-
microtexture,
pens if rotaryabrasivematerials,such as fine disks,
are used.In otherwords,afterreproduction of surface
texture,it is not idealto useabrasive
devices,

Silverpowderhighlights whichplaya fundamental

the surfaceandtexture, rolein the
intesration
of the restoration.

371 375
 A stone cast ready to receivethe
estheticwax'up. lt is important
to have a well.trimmedand well-
presentedtype 4 stoneprepared.

Diagnostic
Wax-upAs a Toolfor Morphology
and Layering

The first layer,which corresponds

to the internaldentinalbody,con-
sists of an opaquechromaticwax
(CreationWaxSet,YetiDental). This
layer, which establishesprimary
morphology. is appliedat hightem.
peraturewith an electricspatula
(120"c).

The second layer establishes the

s h a p e o f t h e d e n t in a lm a m e l o n s
witha lighterdentinmaterial.In the
cervicalarea.a high-Chroma cervi-
cal waxwill be placedat 120"C.

Wax-up:
LuisAlbertoVillanueva,
Zaragoza,
Spain.
376 377
 dentinwithamberandwhite
Surface
(characterization
1) provides
colorto
the mamelons.This is done at low
(108"C).
temperature

A highly transparentwax (clear

enamelwax)between mamelons and
an incisaledgeportion(opalescence
2) are incorporated
at low tempera-
ture(108"C).

Me d iu m. V a lueen a me lis p l a c e da t
a verylow temperature (98"C)so it

V
meltsdelicately with the underlying
d e n t in .O n c ec o o le d t, h e w a x - u pi s \
contoured witha sharp,hardspatula
(Nystromll, LM Denta l),

ProximalareasaTedefinedwith a
No . l1 s c a lp e l.T h e in it ialg l o s si s
obtainedwith a toothbrush and wax
lubricant(lVicrofilm, Kerr).For the
highgloss,a dry microfiber clothis
nreae.l tha c,,r{r.o
^vor /

Wax-up:
LuisAlbertoVillanueva,
Zaragoza,
Spain.
378 379
 Esthetic
Wax-up

" M i m i c k i n tgh e t o o t h ' sn a t u r am

l o r p h o l o gaynd internal
characterizalron is challenging. lt becomesevenmore
difficultwhencoloris addedto the equation. An accu.
rateesthetic wax-upnotonlyservesas a diagnostic tool,
but it can alsobe usedto informand evenimpressthe
patient. "
TylerP Lasseigne

"Onceyou masterwax-ups,workingon anyothermate.

rial becomesan achievable
craft."
Luis AlbertoVillanueva

"Diagnostic
wax-upis, at the sametime,the beginning
andthe endof a successfultreatment."
DanieleRondoni

"Waxf iguressometimes
speak."
JordiManauia

Wax'up:LuisAlbertoVillanueva,
Zaragoza,
Spain.
380 381
 Conclusions

1. Thefinalappearance
of a restoration
is directlyaffected
by its shape
and surface.

2, Instrumentselectionis relatedto a simple protocol.The fewer

instruments the polishing
used,theeasierit is to masterandimprove
technique.

3, Progressivepolishingisthekeyto avoiding
damage
to therestoration's
textureand surfacecharacteristics.

4. The use of polishers,brushes,and pasteswithoutan excellent

finishingstageis useless,
andthe surfaceis condemned
to failure.

ln the majorityof cases,the finishingand polishingprotocolis

carriedout in exactlythe sameorder.

382 383
 Chapter11
RedEsthetics
DanieleRondoni. FerranPiug . Jordi Manauta. Anna Salat

Interviewwith GalioGurel
ErnestHemingway
 Iffi.TI

Q: ln whichmethoddo you think gingivalrestoration

materialsare moredifficultto use,in the stratification
techniqueor in the correctapplicationin the mouth?

A: Asyouknow,we areusingthe "pinksolution"in esthetic

caseswhenwe havedeficientsoft tissuethat cannotbe
regeneratedwith a seriesof surgicalapproachesor for
restoration
of mismanaged softtissuesandlormisplaced
implants.
Dr GalipGurelgraduated from the University of lstanbulDental
Whensuchcompromised gingivaemustbe replaced with
Schoolin 1981 and continued his postgraduate educationat the
a restorative
material,unfortunatelymostof the time this
Universityof Kentucky, Department of Prosthodontics, and at missingareais filledwith whiteestheticsthroughthe use
YeditepeUniversityin lstanbul.Dr Gurel is the founderand the of extremelylong crowns.This solutionruinsthe crown
honorarypresidentof ihe TurkishAcademyof AestheticDentistry' proportionsand createsa hugeestheticdeficiency. The
idealsolutionfor restoringthistypeof caseis to buildup
HehasbeennamedPresident Academy
of the European of Esthetic the areawith idealcontourand lengthandto restorethe
Dentistrytor 2OIl- and 2012. Dr Gurelis also a memberof the missingpart with pink materials.
AmericanSocietyfor DentalAestheticsand an honorarydiplomate
of the AmericanBoardof AestheticDentistry.He is the editor'in' In some casesthis pink regionhas been restoredwith
chief of the Turkishedition of Quintessence lnternationaland on pink porcelain,which providedadequateresults but
could not simulatethe naturalcolor blendwith the soft
the editorial boards of lhe Journalof CosmeticDentistry,Practical
tissues. Lately we have seen that restoringthat area
Procedures& AestheticDentistry,and EuropeanJournalof Esthetic
with a pink compositeresinprovides the most natural.
Dentistty. lookingestheticresults.In its simpleform,rebuilding
the
deficientareawith pink compositeis no differentthan
Dr Gurelhas lecturedon dentalestheticsall overthe world and buildingup a compositeoverthe tooth surface. Just as
is a visitingprofessorat NewYorkUniversity(USA),Universityof we layerdifferentValuesand Huesof compositethat we
MarseilleDentalSchool(France),and lstanbulYeditepeUniversity placeon the teeth to mimic the tooth color and create
(Turkey). He is the author of Ihe Scienceand Art of Porcelain the most naturaleffect,we do exactlythe samefor the
Laminate Veneers(Quintessence Publishihg,2003),whichhasbeen pinkareas.
translatedinto 10 differentlanguages.He has practicedin his own
clinicin lstanbul,specializing since1984.A
in estheticdentistry, The buildupof the pink is also performeddirectlyin
renowned sportsman, Dr Gurelhasbeenthe captainof the Turkish the mouth after the main Hue is chosen.The details
NationalWaterPoloTeam110 times,a world championin the are incorporated with stainsand colorsto matchthe
restorationcolor with the individualgingivalcolor
CamelTrophyrace,anda participant in the Paris-DakarRally.
for eachpatient.In the beginning,
specifically handling
the pink compositefeels strange;however,after a few
restorationshavebeencompleted,it feelsas comfortable
as placingtooth.colored
compositeoverthe naturalteeth.

3BB 389
 Normalgingivais cl.raracterized
clinically byits pinkcolor,firm
consistency, scallopedmargins,firm interdental papillaethat
fill thespacebelowthecontactareas,andabsence of bleeding
on gentleprobing.Specialconditionsoccur,especiallyin
complicated implantcases,that requirea materialthat can
imitateDerFectlvthe lostnaturaltissue.

[?edEst["retics

Today,estheticsdoes not only haveto be white;an increased

knowledgeof anatomyand evolutionof materialshavegiven
us the abilityto solvecomplicatedestheticproblemsaffecting
soft tissues. We all know we can produce a mimetic pink
esthetic restorationwith ceramics and acrylic resins, Now,
however,we have to considerthe compositeevolution.The
propertiesfound in the new-generation materialshave been
provento be idealfor more and more prostheticapplications.

390
 Observingnatureclosely, chromatic
wecannoticedlfferent features
in theanatomy
of pinkareas,and eachdetailcorresponds
to a naturalfeature. A
e
4
It is importantfor us to havea completematerialssystemthat can imitateall
of the naturalopticaleffectsand at the sametime is simple,so we can achieve
excellentresultsin a fewsteps:

Thisis a highlytransparentpink massthat reproduces

areawheregingivacoversdentaltissue.In combination
the cervical withwhiteor
red stain,TPTcan reproducethe frenulum,whosecoloringhasa highcontrast
withothergingival
colors.

' i':l:: r:,r' . '--ir Thisis a lightpinktransparent

massthat reproduces
the tight
apicalroot area,whereihe gingivais moretenseand whiteand acquiresthe
typicallightcolorreflected by the underlying
bone.

. Darkpink (TPD):Thisis a violet-pink transparent massusedto reproduce the

lesstensegingivalarea,whichis lessadherent to the bone.Becausethe blood
the colortendsto a bluishHue.Darkpinkcanbe used
flowin this areais higher,
in combination with blueand red stainsto imitaiethe naturalgingivalcolorof

'Pink-orange(TP):Thisopaqueand chromaticmasscan be usedio createthe

layerandareascloseto the gingival
firstcomposite
withbluestainto reproduce
wellin combination
margin.lt canbe appliedas
ihe apophysis. -{
c/)
T' -U T' -{
r T' €
" Whitestain(SW):Thisstainincreases
opacityand re-creates
gingivaor the apophysis.
of ischemic
the typicalcoloring
-{ e
. Redstain(SR):Thisstainincreases of pinkcomposite,
thechromaticity imitating
the bloodflow and more evidentbloodvessels.
When mixedwith masses,SR
imitatestissueswithheavybloodflowas happensin the presence
of gingivitis.

. Blue stain (SBL):This stain increases

the typicaleffectof the smallvessels
andfornix,whenusedin deeplayers. Whenmixedwiih composiie, SBLimitates
melanoticfeaturesand bluegingiva.

. Brownstains(SBRand SBR2):Thesestainsincrease the Chromato simulate

melanotic heavybloodflow,and deepareas.
features,

It is importantto havestainsavailable
to reproduce
individual Theycan
effects.
be mixedwith the compositemassesor useddirectlyunderthe pinkcomposite
restnmasses.

397
 NormalGingiva

An acrylicresinmodelwitha boneshapewill On tha rnnt c rrrfac p TP rr P ra L t ru dJ d|' Forthe deepgingiva,

TPDis usedto enhance
of the softtis.
be the basisfor stratification opaquelayerto develop
the bonestructure. Chroma.
suethickness. All materialsthat will act as a
baseshould be sandblasted.

A correcibondingagentand a light-curing SWwill be usedto createsomewhitecharac. It is oossibleto develoosomeblue character-

adhesive areappliedto the sandblastedsur- terizations to makethe gingivaappearmore izationsfor the areasof lowbloodflow.
face and polymerized for 1 minute.lf the tlght in theseareas.
area is large,polymerizationtime must be
increased.

begins.ln t h is
Marginstratification A layerof TPT is placedas a final layerto Inthefinalstep,thefrenulumis createdusing
TPLis usedto developa light createan impressionof naturaldepth. a mixtureof TPTand redandwhitestains,

Technician:
Daniele
Rondoni,
Savona,
ltaly.
391 395
 Melanotic(Pigmented)
Gingiva

Bluestainis placedalongthe toothand root Forthe deepgingiva,TP is usedto createan

An acrylicresinmodelwitha boneshapewill melanotic placed
contoursto developsomestrong opaquebase.lt is as a roll and then
be the basisfor stratification
of the softtis-
effects. extendedwitha brush.
suethickness. All materialsthat will act as a
baseshould be sandblasted.

TheTP must be overlapped slightlyoverthe A smallamountof TPDmixedwith redstain

A correctbondingagentand a light.curing layerof stainto hidesomeof the strongblue is usedlo buildthe gingivalmargin.
adhesiveareappliedto the sandblastedsur.
colorand givea preciseshape.
face and polymerizedfor I minute.lf the
areais large,polymerizationtime must be
increased.

'- . , ,i\:' L
'r! i.-. I
r I ',!r: l
': .ill'! I
;'.. I
il:
i
!

A mixtureof TPDwith redand bluestainsis A finallayerof TPTis placedto maskthe ef-

A layerof TPD is placedto ucvcrutr d uar^
placedto develop
the frenulum. fectsto the desiredlevel.
gingiva
I ridge.

Daniele
Technician: Rondoni,
Savona,
ltaly.
397
396
 SwollenGingiva

An acrylicresinmodelwitha boneshapewill On the rootsurfaceand the bone,the blood A mixtureof TPDandSWis usedfor thefren-
of the softtis-
be the basisfor stratification vesselsare characterizedwith SBL and SR, ulumto enhance the ischemic
effect.
suethickness. All materialsthat will act as a SWis usedto createsomeischemic features.
baseshould be sandblasted.

A correctbondingagentand a light-curing A layerof TPT ls placedto hide the blue and In addition,a thin layerof TPT is appliedto
adhesive areappliedto the sandblastedsur. red effects slightly. hidethe whitespotsnearthe margin.
face and polymerized for 1 minuie.lf the
area is large,polymerizationtime must be
tncreased,

An incompletemixtureof T P L a n d S R is n fruf fuy",ot TPDis placedio opacityrtre lf it is desirableto showthe effectsmore

placedio createthe effect of bleedinggin- featuresas muchas neededto hidethe un- clearly, TPLis usedfor the finallayerinstead
giva. derlyinglayers(rightside). (left side).

Technician:
Daniele
Rondoni,
Savona,
ltaly.
398 399
 PinkCeramics

Theframewax-upmust be preparedverypre- Oncethe metal frame is completed,a thin, Then the pink ceramicsare stratifiedin a After the secondfiring, the outcomecan be
ciselyaccordingto the final shapedesired. opaquelayeris placedand fired in the oven. way very similarto that usedfor composite assessed,and correctionmasses can be
resins.Thefinal dentallayersare carriedout added,as necessary, in orderto proceedto
with the desiredeffects. the finishing stage.

The dentinalbodyand the incisaledgeare This bodywill act as a framefor further and Low.speed greenstonesand diamondburs Afterglazingand firing,mechanical
polish.
preparedfirsi. moredelicatelayering. are usedto definethe final shaoeand ore. ing is stillneeded.
parethe teethfor the finalglazing.

To achievea naturalgingiva,we needto heeda few requirements,

all of them necessaryto
enhanceour techniques:
. Weshouldchoosefrom a narrowselectionof materials.Therangemustextendfrom intense
reds to softer oinks.
. We must masterthe internalstainingtechniqueto achievecomplexfeaturesin very small
spaces.Thesetechniquescan greatlyfacilitatethis work.
. To enhancethe texturewhilemodelingceramics, we cut a brushin half to enableus to
reproducethe "orangepeel"effectof the attachedgingiva.

Noritakepink ceramicshadeguidewith all the colorsavailablefor gingivalstratification.

100 101
 Younggingivaltissues A d u ltg in g iv atlis s u e s El d e r l yg i n g i vatil ssu e s

To createthe appearance we haveappliedvarioustypesof pink

of youngergingivaltissues, ln thesegingivae A very soft textureand a wider rangeof Hues(red and
we usesofterpinkshadesand moreintensetexture.ln tonesto achieve a moreintensered.Thetexturemust brown)characterizethis case.To achievethese colors,
this case,we havereproducedbloodvesselswith an be softerbecause of erosionand tissuerelaxation. we must make adjustmentswith internalstains.
internaI stain.

Lerida,Spain.
FerranPuig,l\4ollerussa,
Ceramist:

102 103
 A, NohlE Theprosthetic
AlaniA, lvlaglad of gingivalaesthetics.
management
Br DentJ 2011;210:63-69.

Barzilay l, lrene T Gingival prostheses-A review J Can Dent Assoc

2003;69:74-78.

Coachman C, Van DoorenE, GurelG, CalamitaMA, CalgaroM, de Souza

NetoJ. Minimallyinvasivereconstruction The prosthetic
in implanttherapy.
gingivalrestoration. DentTechnol
Quintessence 2010;33:61-75.
Conclusions
Coachman C,SalamaM, GarberD,Calamita M, SalamaH,CabralG.Prosthetic
gingivalreconstruction in a fixed partial restoration.1. Introductionto
colorrange;theirprimarycolors
1. Oralsofttissueshavean enormous artificialgingivaas an alternative
therapy.Int J Periodontics
Restorative
Dent
arered,white,blue,and brown. 2009;29:471477.

2, Thetransparency and opacityof pink materialsplaya fundamental Coachman C,SalamaM, GarberD,Calamita M, SalamaH,CabralG.Prosthetic
rolein integration
of restorations. gingival
reconstructionin fixedpartialrestorations. procedures
3. Laboratory
and maintenance.
lnt J Periodontics Restorative
Dent20i0:30:19-29.
of pink masseswith primarystains(blue,red,white,and
3. l\4ixture
brown)allowsthe creationof anycolor. KimTH,Cascione D,KnezevicA, Nowzari usinggingiva.colored
H. Restoration
ceramicanda ridgelapponticwithcircumferential
pressure:
A clinicalreport.
4. Underlying effectsplaya fundamental
rolein the naturalappearance J ProsthetDent2Q1O;1.O4:7I-76.
of the softtissues.
Polackl\4A,
MahnDH.Theaesthetic replacementof mandibularincisors
using
lVixingmasses,makinga customshadeguide,and takingnoteof an implant.supported
fixed partialdenturewith gingiva
l.coloredceramics.
the mixingratiowill allowus to repeatrestorations
with a reliable PractProcedAesthetDent2OO7:79:597-603.
method.
RondoniD. lmportanzae fondamenti
dellamorfologia
nel restauroestetico
dentale.DentLabor2010;16:27-38.

SalamaM, Coachman C,GarberD,Calamita M, SalamaH,Cabralc. Prosthetic

gingivalreconstructionin the fixed partial restoration.
2. Diagnosisand
treatmentplanning.
Int J PeriodonticsRestorativeDent2009;29:573-581.

Small BW.Theuseof pinkporcelain for gingivaldefectsin restorative

dentistry:
A casereport.GenDent207O:58:285-287 .

101
1S5
I

Chapter 12
Analysis
Jordi Manauta. WalterDevoto

with LuizNarcisoBaratierl
!ntervie.w
ttNottutnghwrfts
arTrewtmth
TTnorethalnroITr
o[d ewor.))
I ahann Wa[ffgmngntanGaethe
 ruIIffi
Q: In a deepanalysis
of composite
resinmaterjals,
whatis
the mostimportantthingto assess?

A: In my opinion,besidesthe outline,contour,and surface

texture,which should be consideredimportantaspects
for achievingestheticexcellence with compositeresinsin
anteriorteeth, there are other insertiontechniquesand
material-relatedaspects.Actually,there are a coupleof
asoectsof comoosite resinsthat I considerrelevant:

1. Thedegreeof translucency or opacrty,

whichwill allowor
blockvisualization
of thetoothstructure
andadiacent lavers
nf c nrnnnc i tp rpc i n

Prof LuizNarcisoBaratieri
wasbornin ihe smalltownof Capinzal, 2. Theopalescence. Opalescence canbe definedin a simple
SantaCatarina,in southernBrazil. mannerastheobject's abilityto reflectlightwithshort(blue)
wavelengths and to transmitlightwith large(red,orange)
Hegraduated witha degreein dentistry
fromthe Federal lJniversity wavelengths. Opalescent materialspresentthe abilityto
of Santa Catarina,Brazil.in 1976. He has a certificationin changeHue, Chroma,and Valuewithoutchangingtheir
periodontics
and completedhis master'sand doctoraldegreesat translucency. As a consequence, transparent or translucent
the BauruSchoolof Dentistry in SaoPaulo,Brazil.He obtaineda materials canappeartotallyopaque, evenin tinythicknesses
postdoctoral
degreefrom the University of Sheffield,
England,in s u c ha s 0 . 1 t o 0 . 5 m m , d e p e n d i nogn t h e m a n n e ri n w hich
2000. lighthitstheirsurface, andcan presenta numberof colors.

Prof Baratierihas publishedmorethan 15 textbooksand more Considering that in the stratiiicationtechniquecomposite

papersin several
than 100 scientific languages. He is a well-known resinsarelayereddifferentlywhen stainsareused,opalescent
of
lectureron the subject operativedentistry
and has presented materials yieldmorevivid(brighter) colors,evenwhenthey
more than 1,000 lecturesworldwide.In addition,he is editor- are clear (colorless).Accordingly, such materialsshould
Journalof Brazilian
in-chief of Lhe JournalClinica-lnternational offercounteropalescence, a ohenomenon that is observed
Dentistry. in naturalteeth,especially at the mamelontips in anterior
teeih.The shadesproducedby thesecomposites present
Prof Baratierlis professorand chairof OperativeDentistryand variableintensitydependingon moistureand lighting
coordinatorof the Graduate Programin Operative
Dentistry
at the conditions,unlikerestorations that incorporatesiains.This
FederalUniversity of Catarina, Brazil.He maintains
Florian6polis, givesthe restorationsa dynamicbehavior, verysimilarto the
a privatepracticein Florian6polis. surrounding sound toothstructure.

Thus,in spite of my beliefthat the outline,contour,and

surfacetextureshouldbe considered fundamental aspects,
I would like to stressthat the opalescence is the most
importantproperty that compositesshould presentto
simulatetheamazingpolychromatic effectsof naturalteeth.

110 111
 Yetothermanufacturers propose systemsthat contain Certainconclusions may be drawnfrom this general
lVlanufacturers
of compositeresinsusuallydesign
only general dentinand enamelmaterials.Usually, analysis:Manufacturers have a tendencyto offer
kits madeup of a numberof syringes that contain
dentincomposites in thesesystemsare veryintense, systemsthat are, at leasttheoretically, increasingly
dentinand enamelmaterials. The dentinmaterials
and the enamelcompositemodifiesthe basecolor simplifiedto speedup and optimizethe final result,
are dividedinto colorgroups(A, B, C, and D) and
with white or amber nuances.Thesemanufacturers"Globalization" in deniisiry leads manufacturers
different
Chromaaccording to theircolorsaturation.
suggestidentifyingthe requiredenamelaccording to develop products that can be accepted by
to the age of the patientand the thicknessof the differentmarketswith diverseneedsand operational
Thedifferenttonesof chromaticityarethenindicated
residualenamel,whichphysiologically losesValueor o h i l o s o o h i e s .
by numbers,the highestnumbercorresponding to
whitenessovertime,allowing thedentina I basecolorto
the darkestdentincolor.Thereare two trendson
showthrough.In addition,almosteverymanufacturer
the marketat present.First,some manufacturers
offers"specialeffects"enamelsfor reproduction of
simplifytheirsystemsand eliminateall dentinHues
highlytranslucent layers,suchas the orangeor blue
exceptA. Onthe basisof reportsin the literature
and
opalescence of the incisalthirdof naturalteeth.
the authors'clinicalexperience,
thiswouldappearto
be a wisedecision.

The Americanmarket and its demandscan be a TheEuropean market,on theotherhand,tendsto be

Second,severalsystemsrecommendlinklngenamel has less color saturationin order to aooearmore
principalexampleof this phenomenon. The American moreconservative and endeavorsto find materials
and dentinmaterials of the sametype(eg,A2 dentin translucent, as if enamelweredilutedby dentinrather
marketfocusesits attentionon materialsihat favor that will iniegratea restorationwith the patient's
compositewith A2 enamelcomposite). This choice thanthe otherwayaround.
smileuniformity
and brilliance,usuallyobtainedby the natural smile. Cliniciansworking in Europeare
seemsto be basedmainlyon the desireto simplifyour
useof whiteandchromatically "simple"materialssuch attentiveto detailand to the nuancesof colorand
manipulationandcomprehension of the systemrather Somemanufacturers includein theirsystemsa product
than on scientificresearch. dentins(sometimes
as low-saturation lessthanA1)and effectsthat areobtainable withmoderncomposites.
In reality,as has already calledbody.Accordingto the instructions,a layerof
been highlighted,
enamelsthataresuitablefor postbleach
ingrestorations.
enamelmodifiesthe color of the ratheropaquemissingdentaltissueshouldbe builtup
dentinalbase,and its influence is directlylinkedto the with a corresponding layerof bodymaterialand later
naturalenamelthickness; the thickerthe enamelis, covered by a layerof enamel.Thisbodyshadeseems
the whiterand moreopaquethe toothis. Presumably,to be a materialof intermediate translucencyand is
the aforementioned productsare characterized by a sometimes knownas universal (a singleproductused
chromatic contrastbetween dentinandenamel,which to realizea completeone-shade restoration).

117 113
 of Materials
ObjectiveAssessment
Objectively,it is clear that when we compare
Thereis, therefore, muchopportunity for confusion. compositesamplesthat are the "same" color and
Experience showsthat the instructions that come eventhicknessbut differentbrands,the Chromaand
with productsare oftenof littleuse.Whatis more, translucencyare completelydifferent.This accounts
ofte nfa ll i ntothetrap of dividingmate ria ls
c l i n i c i ans for the need to create an individual color scale,
into thoseconsidered "simple"and thosedesigned especiallyif we use differentcompositesystems.
for the "esthetically obsessed," as if there might
be patientsor dentistsinterestedin esthetically
displeasing restorations. IVloreover,
clinicians
request
m a t e r i alswith cha meleon.like properties. as if a
i_
,'E''
syringe could possibly containsucha m iracleproduct.
n
However, methesed ifficulties:
therearewaysto overco
il &
a
Tobe perfectlycIear,themiracleproductdoesnotexlst. -3
lf used badly,eventhe most esthetically favorable
materialcan giveterribleresults,just as the worst
material,in the right hands,can give satisfactory
results.Consequently, continualpracticewith the
materialof choice,construction of varioussamples,
and applicationof different
stratification
techniques Just one shade of translucentor semiopaque
i e +ha nr+ h +^ c, r..pce
compositematerialwill changecolor dramatically
depending on its thickness. A fundamental exercise
The firsl lhinp lo srrppeslis constructionof a to understand the role of thicknessis to prepare
personalized shadeguide.Too often,color guides e n a m e ld i s k s o f 1 . 0 m m , 0 . 7 m m , 0 . 5 m m , a n d
presented by a manufacturerare unrealistic. 0.3 mm and overlapthem with a dentin disk to
Moreover,theyareoftenmadeof a differentmaterial a nnre. i 2+ p + ho.h:noa
suchas plasticor paper,or sometimes are missing
completely.

Thereare manyinstruments on the marketthat can

be usedto creatediskswitha precisethickness
(eg,
CeramicSampler, SmileLine),Suchdiskscan give
properties,
us a clearideaof a material's suchas
opacity, and pigmentsaturation.
translucency,

An lnteresting exercise
is to try to decidewhethera tube
containsa dentinor an enamelshadeof composite
resinwithoutlookingat the label.Somesyringes turn
out to be of littleuse,and othersofferthe possibility
of successfulintegrationinto differentrestorations.
Naturally, this experiment doesnot revealeverything,
but it is a goodbeginning for a criticaland analytical
evaluation.
115
 The nextstep is io focuson the physicaland opticaI Oncewe havecompleted thissimpletrial,wecanpredict
propertiesof the composites we more preciselythe thicknessesneededwhen that
eralscalefor correctguidance. particularmaterialis used.Thestrategywe proposeis
to usethe CeramicSampler, in this casefor composite
resins,to prepareuniformdisks of the approximate
Composite
thicknessesof everyshade.Wewill buildthe following
restn Dark Light Deep Memelon
features Enamel Dentin Opalescence
Intensity starns stains dentin masses d i sk s :

. D e n t i n s2: . 0 m m .
Fluorescence . B o d i e s0: . 3 m m , 0 . 5 m m , a n d 1 . 0 m m .
Hybrid . E n a m e l s0:. 1 m m , O . 2m m , 0 . 3 m m , a n d 0 . 5 m m .

Opalescence Depending on thesystem,andthe numberof colors,we

Nanofilled will obtainan average
of 30 to 40 disks.

Microfilled Oncewe haveorganizedeverysample,we will start

Flowable L 4 I overlapping disksstartingwith a dentin,then a body
(if present),and finallythe incisalenamel.li is very
The table showssome mechanical, structural,and Forthe first attemptto "discover"the systemcolor importantto placeglycerinbetweeneverydisk,or we
opticalproperties, in relaiionto the restoration
area we intendto analyze, we needto understandwhatwe mayobtaina colorthat is too light.Westartoverlapping
and necessity (on a scaleof 0 to 5). Someproperties are dealingwith;to this end,we shouldmakea deep the lightestcolorsand switchingthe deepestlayers,
are absolutelynecessary(5, 4), while others are studyof the available shades,colors,and opacities. untilwe achieve a colorsimilarto the Vitashadeguide
(
ap p e a l i ng 3 ,2) or useless (1), and some ma y b e Fromthat varietyof options,we mustchoosethe right (A2) in the middleof the sample(bluecircle).
damaging (0). shadesto stratifvcorrectlv

Manytrialsareneeded, butthisis easierthanstratifying;

disks are immediately replaceableand switchedwith
verylittletimeandeffort,and no materialis wasted.

Afterwe haveoverlappedthedisks,wewiil writedownthe

thlcknessesof the bestmatchesfor eachtab in the Vita
shadeguide,and thereforecreatea recipeto obtain a
determined colorwitha particular
composite system.At
the moment,thistechnique providesthe mostadvanced
The first step to follow CervicaI third:Theshades Mid d let h ird : Us u ally t h is lncisalthird: The shades andfaithfulshadeguide.
is to takethe A2 shade that usually match this third is the resultof over- are less chromaticand
tab from the Vitashade thirdarechromaticcolors lappingdentinand enam- translucent. we are preparedfor straiification
Throughthis exercise,
guide(Vident) andselect witha highopacity. el shades;somesystems or to makepersonalizedtooth-shapedsamples.
theclosest shades to the havp hnrl v chadec

differenttooththirds.

Oncewe obtainthe approximate shadesfor eachthird,

we musttry samplestratifications
onthetab.Perform ing
thisexercisebeforewe startusinga materialin patients
cansavea lot of time and materialin the futureand is
an excellentexercisefor one of the most challenging
diastemac losure.
restorations,

116
IT TI
 but aboveall on clinical dentinthai makesup the mostimportantlayerfrom a
Basedon the recentliterature,
experienceandpassion forthefield,we haveattempted volumetric andchromatic pointof view,andrepresents
to set up a systemfor evaluatingthe composite the cruciallayerfor the finalrestoration for integration
materialspresenton the market.Whileconcentratingwith the restof the teeth.At ihis point,it is possible
on the anatomicalform of the naiuralteethand with to modelthe dentlnalbodythreedimensionally, as has
the previouslyanalyzeddisks, it is possibleto make beenshownbefore, limitingmassesof dentinto two at
somesuggestions on the layerthicknesses.lt is in fact mostandexoloitins
thethicknessvariationof thetooth.

\ST
A rigid siliconeimpression

dtA
was takenfrom an intact
naturalincisorto allowthe reproductlon of a copy
in composite. of the basedentinalmass
Fabrication
was followedby application of the seconddentinto
simulatedifferentmamelonanatomies. (leftto right)
Basemassandyoung,adult,and old teeth.

Thiscopywasusedto dividethetoothintothreelayers:
dentinalbody,dentin(to createfeaturesof internal
anatomysuchas mamelons andopalescence),
andthe
faciaI superficia
I enamel.

Composlteteeth immediatelyafter removalfrom

(0.1 mm) is
the f lask.Theexcessenamelcomposite
easilvremoved mechanicallv

Thefinishedand polishedsamplesare readyto be

a t t a t y z c (l ,
 ril

Toothcoloris derived fromthedentin,butthe roleof the By carefully adjusting thethickness of theenamelon

enamelis of fundamental importance,as can be seen the incisors,it is possibleto reproduce the natural
from thesespeciallyconstructed compositesamples. opalescence without the additionof transparent
It is the thicknessof the enamelthat determines the c o m p o s i l ea n d l o c h a n gethe " age"ot lhe toolhas
d ifferentdentaI ases. we ,

Mastering enamelthickness isthekeystone to excellence Nevertheless, with the instrumentsand guides

in estheticsandconservative dentistry.
Today, composite that have been analyzedin the presentchapter,
A1 Vita: 2.O-mmA2 dentin,0.3- A2 Vita:2.0-mm42 dentin,0.5-mm A3 Vita:2.0-mm43 dentin,0.3-mm materialsallowcliniciansto realizerestorations that stratification techniques canbe keyto the long-term
mm 41 body,and 0.3'mm high' A2 body,and 0.3-mmmedium-Val- A3.5 body,and 0.2-mm low-Value arehighlyesthetic yet minimallyinvasive, affordable for successof restorations from both the clinicaland
V a l u ee nam e l. ue enamel. e n a me l. patjents, andlonglasting.ln addition,theassociated risk esthetic points of view.This enablesus to avoid
levelovertime is lowandmanageable. Reintervention is shortterm disappointments that requirerefacing
relativelyeasyand cheap,andfracturesor defectsthat and wastetime. It is crucialto understand that a
mayappearovertimecanbe repaired withoutremaking successful restoration beginswiththe correctchoice
thewholerestoration, whichprovides tooth-conservative of material.However, there is no miraclematerial
andfinancialadvantages for patients. on the market,and the final resultis fundamentally
linkedto our manualskillsand,moreover, ourability
. Everycomposite resinsystemon the marketcan be Clinicjans
andspecialized
dentaltechnicianspossess Doubtsthat some cliniciansmay have about these to choosethe correct techniquesthat simplify
reduced to a limitednumberof syringesthat areuse" an extraordinary
amountof knowledge andexpertise techniques are usuallyassociated with the amountof everyday workin this profession. Success shouldnot
ful in all naturalteeth.Any exceptions
can be man- concerningthe problemslinkedto reproducing the chairtimerequiredas wellas the difficultyin achieving be measured solelyby excepiional resultsin certain
agedby usingspecialeffectmassesand supercol- naturaltoothcolorandthe suitablematerials
for this goodestheticresultseveryday.As a consequence, more casesbut ratherby a good everyday standardfor
ors, whichare suitablefor emphasizing particular purpose. invasive techniques such as ceramicrestorations are t i m e m a n a g e m e natn d l imitinglong.termrisk,
translucencies and individual
features. favored.We believe that operation times are inevitably
By listening
to the suggestions of dentalprofession' linkedto certainobligatorysteps(preparation, adhesion
. To optimizework with the chosencomposite,it is als andanalyzingmaterials withthe colormeasuring phase,buildupwith limitedquantities of composite to
to constructa personalized
imperative shadeguide instrumentsthatareavailable today(spectrophotom- reducecontraction, and correctcuringtimesfor each
withevenand knownthickness to identifythe correct eter),manufacturers couldfurthersimplifytheirsys- materialIaver).
tems,whichwouldbe extremely advantageousfor the
everyday practiceof dentistry.lndeed,it wasfound
that the materialswith the best performance were
produced withthiscollaborative spirit.

42S 121
43 Teethreproduction
with differentcomposites

rl
\,) LU

lVajesty

Ena me l

FiltekXT
 ComcIursions

1. lt is mandatoryto understand the color of any compositeresin

perfectlypriorto use,evenif thisonly involves
openingandcomparing
the syringes.

2. Shadeguidesincludedin mostcomposite systemsare not suitable

for colormatching, if theyarenot manufactured
especially withthe
samecompostte.

3. Layering resindiskshasprovento be oneof the most

of composite
effective methodsfor creatinga personalized
and leastexpensive
shadeguide.

4. Therelationsh
ip of enamel.dentin
thicknesses
is thekeyto successfu
I
layeflng.

5. All modernmaterialshaveexcellentproperties,
but theyalwayshave
at leastonepropertythat is markedly
detrimental
io another.

1?1 125
 Ch a p t e r1 3
I
tn o
Jordi Manauta. Anna Salat

Interviewwith LuisJane
 a2"0///

t/"t /rp"r,/a, orf ,'o,uror,

.n or/ru, y'u o/o,f.

JLou( alotgt."

Zm'
@,oo'r
 ffirltlll

I Q: Do you believethat stratification

techniquesare
advanced proceduresmeantonlyfor specialistsor do
#i youthinktheymustbe taughtto everydentist?
I

Dr Luis Jan6 has spentthe last 25 yearsof his life trying to A; To claim that stratificationtechniquesshouldbe
understandhow to reproducethe beautyof a smile. Biologyand used exclusivelyby specialistsis to ignore anatomy,
integration havebeenthe mainphilosophies of minimallyinvasive biomechanics,and cosmetic dentistry. To ignore
dentalrehabilitation,whichhasguidedhim all this time in both stratification
techniques in undergraduatetrainingand
his privatepracticeand histeachingroles,first at the University
of continuingeducationfor generalpractitioners is to
Barcelona and recentlyat the International
Universityof Catalonia promotemonochromatic teethwithpoorbiomechanical
as directorof the Operative and EstheticDentistryDepartment. properties.lt means overlooking the shrinkageand
curingstressproblemsin resins.Stratification is much
Lecturerat numerouscourseswithin and outsidethe university morethanhighlighting an incisaledgeor buildingsome
in Spain,Europe,and SouthAmerica,Dr Jan6 has published mamelons. Todisregard theseprinciplesis the sameas
numerousarticlesand bookchaptersaboutcosmeticdentistry. ignoringall the beautythat naturegaveus alongwith
the mandateof preserving and reproducing it.
Heis a memberof numerousnational
andihternational
academies,
includingthe EuropeanAcademyof EstheticDentistryand the Ultimately,limiiing knowledgeof stratificationtech-
SpanishSocietyof Prosthodontics. niquesto specialists is like restricting
the knowledge
of humananatomyto surgeons. Paraphrasinglvlichel.
angelo,we can say that insideany compositecase
residesthe beautyof a tooth;we just needto knowhow
to stratjfyit.

130 131
No dentalprofessional we haveknownhasan instinctive
lt is true that
talent for dental color comprehension.
some of them havesharperskills, but the height of
excellence is gainedaftersomepractice.

Professionalslinked to any color discipline,such as

painters,plasticproducers,photographers, and dress
designers,among others,are incrediblytalentedwhen
iryingto understanddentalcolor.

Laypersons(not linked with a color discipline)have

amazed us when we have asked them to organize
a sha d e gu id e with its numeric data h id d e n ,
demonstratingoutstandingfacultieswith no previous
knowledgeof dentalcolor.This fact meansthat if no
physicalimpedimentis present,anyoneis capableof
understandingthis discipline.An employeefrom the
bakerywhereI am a frequentclient in my hometown
did an outstanding job of arrangingthis sameshade
guidewithan 87lo accuratematch.

At the present,image technologiesare growingand

developing at a fiercespeed.Someday,technologywill
be an excellentaid for our work, but in the meantime
it is imperativeto understandbasic color theory for
a correctuse of this machineryand to keep learning
aboutit for futuredevelopment.

This being said, it is time to take some action and

becomeregularreadersabout color, art, painting,
photography,or anysubjectconcerning image,light,or
color,We must handle composite resinswith no fear of
the complexcodesappearingin the syringes,classify
them, analyzethem visually far from the patient's
mouth, discovertheir propertiesand play with them,
and build our own shadeguides.In this bookwe have
describedfour differentwaysto do that, and noneof
them requiresexpensive technologyor specialskills.

We can say that any disciplinerequirestraining,and

trainerwouldsurelysuggesta soft but
any professional
regularstart.Herearesomesuggestions...
 I

Out
Dentincompositeresinis the key to achieving a Enamel composite resin provides the beauty of
perfectrestoration. be chromatic
lt shot-tld (yellow' a restoration,and the secret is to learn the right
orange)and fluorescent, but most of all it needs amountof enamelto be placed.Toomuch will result
to havethe rightopacity.Spendall your time and in a graytooth,and too littlewill resultin an opaque,
whichdentincompositels the
effort discovering fake-lookingtooth. Play with the thicknessesof
right one, Learn how to layer it perfectly.Four enameland dentin to discoverthe endlessesthetic
layeringtechniques havebeendescribedin detall pcssibilitiesof any compositematerral.
andanothersixwerementioned.
Mid Classification
fverything placed betweenthe dentin and the The most difficult casesfor color matchingare
enamel will give the tooth its personalityand the ones that you do not understand.Learn to
uniqueness.The featuresof nafural teeth and placethese conceptsin order,and they will help
the classificationof naturalphenomenaare the you to analyzeand understandeveryfeatureof
most important conceptsto learn, becausethe anytooth.This informationwill be usefulnot only
placementof these masses is not technically for reproducingthe tooth but for communicating
complicated. and keeprecordof the slightestdetails.
 Features
Pafatal PosteriorTeeth
In recentyearspalatalrestorations havegained Stratification is not optionalin posteriorresto.
considerable importancefor rehabilitatjon of rations;it is mandatory, evenwhenthe single.
erodedand abradeddenlLrres. Accuraterepro- shadetechniqueis used.Layeringis the most
ductionof shape,anatomy, and functionin this powerlulweaponin the battleagainslcontrac.
areawill provide
function.Color,whichmaynot tion and stress.Start stratifying one shadein
appeartoo important,will provldeexcellence manylayers,and soonyou will be ableto add
and a senseof thickness that will be veryhelp- more and more colors to your restorations.
ful in the presenttreatmentand in futureyears. Stratifyingin posterior restorationsmeans
p e a c eo f m i n d .
 Phenomena
Physiologic Pathofoeic
Phenomel3
Understanding how teeth behaveover time will Reproducethem for fun or for artistjc reasons,but
permityouto predictthefutureof naturalteethand at least Lry.as a challenge,to do these exercises,
the waythey behavewith or withoutrestorations. to understandcolor complexity,to gain skills, and
Learning to stratifythesefeatures notonlyprovides lose fear of complex stratifications.Once you see
knowledgebut also representsa step toward that pathologicphenomenaare not as complexas
i n t e g r a ti ng
difficulirestorations
in specialca s e s . you had imagined,color analysisof healthyteeth
will becomean easv and oleasanttask.
 Pgl::hiig
suf1991na
Becausea perfectstratificationis only half of the
work,the surfacemust be as perfectas possible.A
beautifulrestorationsimply does not existwithout
perfectpolishing. Takea low.speed fine diamond
bur and start exploringtooth geography. Then,with
the other materialssuggested in this book,make
anycomposite shine.Thisis the onlywayto ensure
long.lasting
restorations.
 ln daily practice,compositeresinsare the materials
most commonlyused for restorative dentistry.They
are used for preventiveseals, minimally invasive
restorations,buildups,and complexdirectand indirect

ffis
restorationsin anteriorand posterior
teeth.

Indeed,it is in the anteriorsectionswherecomposiie

resinshavetraditionally beenusedto greatesteffect,
enabling cliniciansto carry out complex, direct
restorationswith notableestheticand clinicalresulis,
especiallywhenthe techniques shownin this bookare
tearneo,

Recentproductdevelopments combinedwith clinical

research havemadeit possible
on stratification to utilize
new composites that haveexcellent
characteristicsof
opalescence and providean excellent
and fluorescence
colorrangeto choosefrom.

It is, however,a commoncomplaintamongclinicians

that the layeringtechniquesare rather complex
and that it is difficultto makethe right colorchoice.
Paradoxically, they say that the appearance on the
marketof sophisticated materials,designedto give
evenbetterresultsin the mediumand longterm, only
makesit moredifficultto makethe correctdecision.

lndeed,manyof thesecolleagues, afterthefirstbuzzof

enthusiasm, giveup on the layering
techniques andopt
for materials thattheyclaimare"simpler," "chameleon-
l i k e , "o r " m i m e t i c . "

However, predictability
of resultsis more important
than simplicity,becauseit is the factorthat provides
advantages in termsof bothworkqualityand economy
andpaiients.
for clinicians Toconquer estheticdentistry
(beauty,function, and predictability)professionals
shouldbe analyticalandpreclse andadhereto protocol.
Everydentistshouldpractice estheticdentistry,
because
thereareno patients
askingfor unesthetictreatments.

All of these techniquesare constantlyundergoing

updatesanddevelopment. Followus at:

www.styleita
llano.org

rsivier'.a
ru..ooon.com Iran" q@siytet
tattano
Fil G!
 Lovers
An Atlasof CompositeResinStratification

Artwork

Page4 Lapostaby AnnaSalatand ManuelRuizAlfaro

Page16 Claoby JordiManauta
Page22 NatureLayerc by JordiManauta
Page26 ColorMachinery by ManuelRuizAlfaro
Page75 WashAwaythe 8/uesby NancyEckels
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Page146 Fashion RuizAlfaro
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Page213 CostaErayaby AnnaSalatand JordiManauia
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page429 Goldenyearsby ManuelRuizAlfaroand walter Devoto