CLINICAL ARTICLE

Reproducing Optical Properties of AnteriorTeeth after

Ultra-Conservative Preparation
VICTOR CLAVIJO, DDS, MS, Phd*, LEONARDO BOCABELLA, CDT†, LUISA SCHERTEL CASSIANO, DDS, MS‡,
SILLAS DUARTE JR, DD, MS, PhD§

ABSTRACT
Objective: Selecting the appropriate material is essential when restoring color and appearance of esthetically
compromised anterior teeth.
Clinical considerations: Most of the conventional restorative techniques require tooth reduction in order to mimic optical
properties of a natural tooth.Fortunately, bonding techniques associated with improvements on dental ceramics
esthetics allow for highly conservative treatment options in which maximum preservation of dental tissues can be
attained. An analysis of different ceramic materials available and differenttypes of tooth preparation is presented in a
format of a decision tree for treatment planning.
Conclusions: The suggested decision-making aims to facilitate clinicians’selection of the most appropriate restorative
technique for reproducing color and appearance of anterior teeth after ultra-conservative preparation and according
to different clinical scenarios

CLINICAL SIGNIFICANCE
The selection of the appropriate ceramic material for each case is of major importance, since the entire treatment plan
will be determined based on the type of ceramic material that will be used for the f|nal restoration.Each restorative
material has a specif|c tooth preparation requirement, indications, and limitations that shall be respected for maximum
esthetical outcomes.
(J Esthet Restor Dent 28:267^276, 2016)

INTRODUCTION preserve enamel are used, it has been documented

Mastering the concepts of optical properties, form, and
function are important in reproducing the natural
tooth structure adequately with dental materials.1,2
Esthetic restorative materials and more conservative
tooth preparation methods are constantly being
developed with the goal to simplify the daily
practice.3 When preparation techniques that aim to
that a higher success rate can be expected for
bonded porcelain veneers.4 However, the optical
properties and overall esthetic outcome is directly
dependent upon the amount of remaining tooth
structure as well as the appropriate restorative
material selection.1–3,5–7 Thus, it is important to
carefully analyze each clinical situation and to
evaluate which is the most adequate treatment
option prior to treatment.

*Visiting Professor, Advanced Program in Operative and Adhesive Dentistry, Division of Restorative Sciences, Herman Ostrow School of Dentistry, University of
Southern California, Los Angeles, California, USA
!
Dental Technician, Campinas, SP, Brazil
`
Private Practice, Brasilia, DF, Brazil
‰
Associate Professor and Chair, Division of Restorative Sciences, Director, Advanced Program in Operative and Adhesive Dentistry, Herman Ostrow School of
Dentistry, University of Southern California, Los Angeles, California, USA

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 RESTORATIVE TECHNIQUE FOR REPRODUCING OPTICAL PROPERTIES OF ANTERIOR TEETH Clavijo et al
FIGURE 1. a, Preoperative view of intact maxillary anterior teeth
before the patient was involved in a motorcycle accident. b, Observe
the exquisite optical properties of the maxillary anterior teeth.
The most challenging situation for anterior bonded
porcelain veneers is regarding the material selection
when missing tooth structure is presented. Fractured
tooth, diastema, caries with dentin exposure, and space
discrepancies between teeth are some examples of
clinical scenarios in which the material selection and
the restorative technique become highly important in
order to mimic the optical properties of different
dental structures.5,8 Composite resins, feldspathic
porcelain, leucite-reinforced glass-ceramic, lithium
disilicate glass-ceramic, zirconia-reinforced lithium
monosilicate glass-ceramics are few examples of
materials that can be used for esthetic rehabilitation
using conservative bonding techniques. However, the
restored areas where dental structure is missing may
pose a challenge for the clinician when compared to
the restored areas supported by remaining dental
structure. Providing the dental technicians with more
space for ceramic layering through tooth preparation
may overcome this deficiency. However, it may not
necessarily solve the problem, in fact, it would create
another problem on bonding exposed dentin that can
negatively affect the longevity of the restoration.9
The material selection for conservative esthetic
restorations is not a straightforward decision. Thus,
one of the biggest challenge is how to perfectly
reproduce the natural teeth characteristics while
simultaneously preserving pristine dental structures.
The aim of this article is to reflect on the decision-
making process of how to reproduce the optical
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FIGURE 2. Fracture maxillary central incisors from the same
patient teeth on Figure 1.
properties of natural tooth while maintaining the
integrity of the tooth by using a conservative dental
preparation approach, assuming that the shade of the
remaining dental tissues is favorable.
FUNCTIONAL ESTHETIC REHABILITATION
OF FRACTURED TEETH
A 28-year-old woman presented at the office for regular
maintenance appointment. It was noticed that the anterior
teeth presented a peculiar anatomy, so photographs
(Figure 1a,b) were taken to keep a digital record of her
natural teeth. After 16 months, the patient returned to the
office presenting both #8 and #9 fractured (Figure 2a) due
to a motorcycle accident. Clinical and radiographic
examinations were performed together with percussion
and thermal tests, and the teeth were also checked for
mobility. The teeth presented no mobility, but it was
detected the need of endodontic treatment (Figure 2b) in
both teeth due to pulpal necrosis. Intra-radicular posts
were not indicated because there was sufficient remaining
coronal structure and the endodontic access opening was
minimal, so only the filling with composite was performed.
The previous photos taken before the teeth were
fractured were used to aid the treatment planning. As
there was no reference of the actual height of the teeth,
the width of the remaining crowns was measured and, in
association with the previous photos and the models, it
was possible to use the concepts of the Digital Smile
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Design (DSD)10 to determine the height of !10 mm of
the fractured teeth. Based on that measurement, the
diagnostic wax-up (Figure 3) was performed. Before
performing the teeth preparation, photos were taken to
provide a more accurate reference for the color selection,
since the photos were taken before teeth dehydration.
FIGURE 3. Diagnostic wax-up based on the initial anatomical
features. DSD was used to determine the original width/length
ratio of the teeth before fracture.
TABLE 1. Decision-making process when restoring anterior tooth using ultra-conservative tooth preparation
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MINIMALLY INVASIVE ULTRA-
CONSERVATIVE ADHESIVE TOOTH
PREPARATION
Material selection and tooth preservation not
necessarily have a reciprocal relationship. Tooth
reduction, as advocated by different types of ceramics,
may lead to complete eradication of gingival enamel
leaving the margins on dentin. The long-term clinical
success of bonded porcelain veneers is highly
dependent on the quality and amount of enamel for
bonding.4 Therefore, the need for tooth preparation
should be carefully evaluated and conservative
techniques such as ameloplasty, enamel recontouring,
or minimally invasive ultra-conservative enamel
preparation were highly selected as the first options for
treatment.3 Table 1 depicts a decision-making process
used to define the most appropriate restorative
approach.
In the present case, the teeth were then meticulously
and minimally prepared bucal-lingually, without
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 RESTORATIVE TECHNIQUE FOR REPRODUCING OPTICAL PROPERTIES OF ANTERIOR TEETH Clavijo et al
FIGURE 4. a, An ultra-conservative 0.3 mm reduction full-
veneer preparation was selected. Determination of the
marginal finishing chamfer with a round diamond bur
(801.314.016, Komet, USA) and 0.3 mm depth grooves were
created to ensure maximum preservation of enamel using the
following formula: C 5 (BD 2 SD)/2 where, C 5 chamfer,
BD 5 bur diameter, and SD5 shank diameter. b, After creating
the depth grooves to guide the ultra-conservative preparation,
the full-veneer preparation was carefully completed using a
round end cylindrical diamond bur (8881.314.012, Komet,
USA) to ensure 0.3 mm overall enamel reduction and
preservation of gingival enamel. c, The preparation was
finishing using finishing carbide burs (H375R.314.012, Komet,
USA) at 4000 rpm. d, Evaluation of minimal enamel reduction
with a periodontal probe.
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FIGURE 5. Shade selection of the abutment and adjacent
teeth was performed before and after tooth preparation.
breaking into the contact points, aiming for a 0.3 mm
chamfer margin (Figure 4a–d).7 A 0.3-mm ultra-
conservative tooth preparation allowed adequate
enamel preservation, appropriate path of insertion for
the restoration as well as space for the dental ceramist
to restore the optical characteristics of the two central
incisors. Thus, the characteristics of the preparation
were crucial for the selection of the restorative
material.
An ultra-conservative preparation, averaging maximum
of 0.3 mm in thickness, can provide the ceramist with
a reduced space for working. In such minimal space,
zirconia-based materials may not be the material of
choice because of limitation on milling to its proper
thickness and the lack of appropriate bonding
effectiveness.11 Thus, etchable ceramics or composites
should be the materials of choice for minimally
invasive ultra-conservative tooth preparations.
After the preparations were performed, photographs
(Figure 5) were taken to provide the ceramist with a
reference for the color of the teeth abutments. An
impression was taken using double cord and two-step
technique. After taking the impression, the provisionals
were made.
A discussion among the restorative team was then
made to select the appropriate material following the
decision-making guidelines described in Table 1.
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FIGURE 7. a, Application of a body dentin layer at middle

and incisal thirds. b, Cutback of the dentin body layer to
create the mammelons.

FIGURE 6. a, Fabrication of a layered feldsphatic full-veneer

in refractory die: Application of an opaque dentin powder. b,
Feldsphatic ceramic opaque dentin layer immediately after
crystallization. c, The opacity of the ceramic opaque dentin
layer visualized through a transmitted light.

REPRODUCING OPTICAL PROPERTIES IN

ULTRA-CONSERVATIVE PORCELAIN
VENEERS

The models were made following the Geller Model

technique and the refractory dies were created. The
ceramic application was guided using a silicone guide as a
reference for the orientation of the height of the
restorations. A decision was made to use layered
feldsphatic porcelain to restore dentin chromaticity, and FIGURE 8. a, Application of opalescent and mammelons
effects in the incisal third to reproduce the incisal edge optical
translucency and value of natural enamel. An opaque
properties. b, Opalescence of the incisal third visualized
dentin (Figure 6a–c) was applied to reestablish missing
through transmitted light.
dentin structure in the middle and incisal thirds of the
restoration. The stratification using the dentin body exhibited appropriate chroma and value to impart a
powder (Figure 7a) was performed in the middle and natural optical outcome. Cut back (Figure 7b) was
incisal thirds. Importantly, dentin porcelain was not used performed using burs to reproduce the mammelons and
at the cervical third of the veneers, since this area to create space for the incisal characterization. The

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 RESTORATIVE TECHNIQUE FOR REPRODUCING OPTICAL PROPERTIES OF ANTERIOR TEETH Clavijo et al

FIGURE 9. a, Application of translucent enamel powder. b,

Confection of the maxillary central incisor morphology.

FIGURE 10. a, Correction of the reflection areas.

b, Confection of the primary and secondary anatomy using
diamond burs. c, Finishing with appropriate ceramic burs.
d, After glaze, polishing was manually performed with diamond
paste and polishing discs.

FIGURE 11. a, Morphological characteristics reproduced as

they were found in the natural teeth (compare with Figure
1a). b, Translucency, opalescence, and opacity were
individualized using feldspathic ceramic over refractory die.

transition area between the enamel and dentin was

performed with incisal effects and the opalescent layer at
the incisal edge was reproduced using a ceramic powder
with opalescent effect. The mammelons were then
covered with an enamel powder with an orange effect
and the connection between the mammelons and the
incisal edge was reproduced with mammelons effects FIGURE 12. Veneers were bonded under rubber dam, resin
(Figure 8a), the last layer applied, over the dentin and the excesses were removed with scapel 12, and the final polishing
is performed.
previous effect layers, was a translucent and opalescent
enamel powders (Figure 8b). The cervical third was
covered only with an enamel powder with pink was applied to the cervical third, once this area had a
undertone to reproduce the interaction between the favorable chroma and opacity. Thus, the enamel ceramic
natural teeth and the gingival tissue. No dentin powder powder was used to recreate value and translucency.

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FIGURE 13. a, Final outcome of the bonded full-veneer restorations. b, Close up of the restorations. c, Aspect of the restorations
under transmitted light. Note the translucence, opalescence and opacity effects created and the integration thanks to bonded
technique. d, Distal view of the restorations. e, Note soft tissue response and the morphology created.

Transmitted light (Figure 8c) was used to verify the
correct position of the ceramic layers in the means of
translucency and opacity, after the first bake. The
palatal guide was placed to check the height.
Internal staining was then performed to reproduce the
small horizontal striaes and to evidence the mammelons.
A transmitted light was used again to check the
opalescence effect. Before performing the second bake, a
neutral value enamel layer was confectioned aiming to
reproduce the final morphology (Figure 9a,b). To
reproduce the opaque halo in the incisal edge, an opaque
powder was applied in the incisal-palatal region. The
second bake was then performed.
The areas of light reflection were then evidenced and
corrected (Figure 10a). Diamond burs (Figure 10b)
were used to create the primary and secondary
anatomy. Finishing strips (Figure 10c) were used for
the finishing and polishing. Functional occlusal
adjustments were made using an articulator. The final
glaze was then performed. For the final polishing, a
diamond paste was applied and manually polished with
ceramic polishing discs (Figure 10d).

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The final result (Figure 13a–d) shows that is possible
to achieve an acceptable esthetic result using the
feldspathic ceramic over a refractory model.
ADHESIVE BONDING TECHNIQUE
The ceramic restorations (Figure 11a,b) were tried-in
and some minor adjustments at the contact points had
to be performed. The layered feldspathic porcelain
veneers were etched following the manufacturer
recommendations: 9% hydrofluoric acid for 90 seconds;
cleansing at the ultrasonic cleaner with alcohol for 5
minutes; application of a thin layer of silane and
waiting for 60 seconds; application of a thin layer of
adhesive and air-thinned and left uncured.
The teeth were isolated with rubber dam. The
remaining dental structures were roughened using
aluminum oxide jet with 50 mm size particles (bar).
Then the teeth were etched using phosphoric acid at
37% for 30 seconds in enamel and for 15 seconds in
dentin. A universal adhesive system was applied
actively with a micro-brush for 20 seconds and then
air-thinned. The adhesive was left uncured.
A light curing resin cement was inserted into the
intaglio of the restorations, placed into the correct
position, and the cement excess carefully removed
using a fine sable brush. The restorations were light-
cured for 40 seconds on each tooth side (lingual and
buccal). The remaining cement excess was removed
using a 12D blade. The polishing of the margins
(Figure 12) was performed with ceramic diamond
points and polishing inter-proximal strips. The final
outcome (Figure 13a,b) showed that it is possible to
achieve a natural esthetic result using the feldspathic
ceramic over a refractory model.
DISCUSSION
The selection of the restorative approach is of
paramount importance for long-term success of
treatment planning proposed and execution of the
case. The method of delivery of the restoration
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(adhesive or cemented) and type of ceramic guide the
tooth preservation and preparation. The latter must be
clearly observed to establish the ideal space for the
ceramist to be able to create the restoration,
reproducing the characteristics of natural teeth and
obtaining satisfactory esthetic outcome.
Maximum preservation of enamel is essential for long-
term success of bonded restorations. Techniques such
as direct composite restorations, partial bonded
veneers, bonded porcelain veneers, or full veneers are
preferable than conventional crown preparations since
these aforementioned techniques are highly
conservative. 3,12–14
Different restorative materials result in differences on
optical properties. Composite resin restoration may be
employed for anterior teeth esthetic rehabilitation; but,
in order to restore translucency, chroma, and value,
composite stratification techniques should be used.
Unfortunately, layered composite restorations are time
consuming and the clinicians, as well as patients,
should be aware of the limitations encountering with
composite stratification techniques as well as their
longevity.15 Conversely, the costs for direct composite
restorations are usually lower than that of indirect
restorative procedures and easier to color match.
Ceramics are also appropriate materials to esthetically
restore anterior teeth, but the myriad of ceramic with
different compositions and properties can make the
process of material selection complex. When
correlating enamel preservation and ceramic selection,
glass-ceramics are ideal materials since their intrinsic
characteristics are to be etched and bonded. Glass-
ceramics are also highly translucent; however, its
translucency depends on their crystalline composition
and thickness.16 For instance, feldspathic porcelains
have higher translucency than that of milled lithium
disilicate or leucite-reinforced glass-ceramics. Another
important decision regarding ceramic selection is the
method of fabrication of the restoration: layered or
monolithic, pressed or CAD/CAM milled. A recent
study found no statistical differences in the L*, a*, and
b* values between monolithic lithium disilicate glass-
ceramic pressed (e.max Press) or milled lithium
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disilicate glass-ceramic (e.max CAD), but they differed
significantly from the feldspathic porcelain commonly
used for layering (IPS e.max Ceram).17 Milled ceramic
restorations may also be translucent depending on the
composition, thickness, and inherent translucency of
the CAD blocks.18 An increase in lithium disilicate
glass-ceramic thickness may minimize the influence of
background color due to an increase in opacity of the
restoration.19 However, any increase in restoration
thickness would require more aggressive tooth
preparation. Sacrificing intact dental structure because
of dental materials own limitations does not justify
nowadays and alternative techniques that can benefit
from bonding strengthening techniques should be the
first choice of treatment when planning esthetic
rehabilitations.
Feldspathic glass-ceramics using refractory die
technique may be the most esthetic restorative
material considering that these ceramics allow the
ceramist to layer translucent and opaque areas
adequately, even if the space for the restorative
material is reduced.9 Conversely, porcelain
stratification techniques require years of training for a
skilled ceramist to attain superior optical properties. It
is interesting, however, to note that patients not
necessarily would perceive the differences in
translucency, chroma, and value when different
veneers fabricated with different ceramic systems
(pressed followed with stratification or monolithic and
stained) are tried-in.5 However, ceramic layering
techniques would allow the ceramist to reproduce the
natural dentition with more fidelity by incorporating
different optical properties such as fluorescence,
translucency, and opalescence of enamel and dentin
into the restoration.
Clinical scenarios where the discrepancies between
different opacities and translucencies are found are
still challenging for clinicians and ceramists.
Fractured tooth, diastema, caries with dentin
exposure, and restoration of space discrepancies
between teeth requires the restorative team to wisely
analyze the advantages and limitations of different
restorative approaches before deciding on a
treatment sequence. Any selected restorative
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technique must be discussed with the patient, who
should be clearly educated on the anticipated
esthetic outcomes. The clinician, ceramist, and
patient should agree as a team to maximize the
esthetical outcomes and to provide realist
expectations to all team members. Ultra-conservative
minimally invasive preparation should be employed
as frequently as possible to ensure long-term
bonding effectiveness to enamel.
DISCLOSURE
The authors do not have any financial interest in the
companies whose materials are included in this article.
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Reprint requests: Dr.Victor Clavijo,Rua Cerqueira Cesar,1078
Indaiatuba, S~ao Paulo,Brazil13330- 005; email: vc_028@usc.edu
DOI 10.1111/jerd.12266 V
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