Light And Color In Anterior Composite Lorenzo Vanini, MD Restorations TT As defined by physics, color is light. With this premise, this article highlights the importance of the interaction between light ‘and the hard tissues of the tooth as compared to the interaction between light and composite restorative materials. Based on the philosophy of color interpretation and its subsequent practical application in the development of a fluorescent and opales cent microhybrid composite system, the protocol outlined allows the clinician to achieve restorations with a lightcomposite interaction that closely resembles that of Hight/natural dentition. The learning objective of this article isto present specific diagnostic techniques to establish predictable identification and reproduction of the natural anatomy and nuance color char- acteristics exhibited by natural dentition with composite resin. A detailed evaluation of hue, chroma, opalescence, and fluo- rescence are presented in onder to simplify the composite stratification technique. he aesthetic result of a free hand composite restoration in the anterior region depends primarily on the accuracy of the criteria which constitute and influence the “primary factors” of the restoration, ie, the bearing structure ‘of the two basic elements in dental aes- thetics — shape and color. While shape can be reatily identified and reproduced in great detail through the study of the related aspects of the tooth, ie, size, con- tour, surface macro- and micromorphol- gy, color is more difficult to define, since its “primary factors —hue, chroma, and value — are often elusive. ‘The traditional method for identify- ing and selecting color in dentistry is predicated on the use of a shade guide ‘or chart. The aforementioned three color dimensions of natural dentition are gen- erally defined by a sample of the shade Buide." This method of color selection is extremely limited, since the natural dentition presents unlimited chromatic characteristics as well as a phenomenon linked to fuorescence and opalescence.* Dr. Vanint maintains a private practice emphasizing Periodontics and Aesthetic Dentistry, San Fedele Intelvi, Como, lal Address correspondence to: Lorenzo Vanni, MD Via Provinciale 86 22028 San Fedele Intlv, Como, Italy Tel: 011-39-31-830.646 Fax: 011-39-31-830-413 ‘through enamel and dentin re 1. Stereomicroscopie view: The color originates from the light that propagates Asa result, color selection based on the shade guide has several inherent inade- quacies: The materials used to compare the color guide/chart do not correspond to the composite material; each ‘composite system should include a complete color selection chart. TIE INTERNATIONAL AESTHETIC CHRONICLE 1996 The build-up of the color chart is rot similar to the build-up of the natural tooth; instead, the chart build-up is fabricated of a single material, often thicker than the ‘material used in clinical practice. Bach color chart should be identi fied with the material of which itis PPRA 673 rer arFigure 2. Preoperative view ofthe maxillary incisors exhibiting a Class IV defect. Figure 4, Color of tooth can be deified by its "basic he” deter mined by the mean valve derive from the sum fabricated and the build-up tech: nique utilized + The thickness of the samples should be similar to the build-up thickness ‘adapted for the system in clinical use + Acomplete color chart should in- clude enamel and dentin samples with varying thicknesses. + The enamel and dentin samples should be overlappable in various thicknesses in order to plan the de- tee of translucency of the dentin/ enamel build-up. ‘The reproduction of color and the chal lenges involved must be addressed by the clinician with a less restrictive color- reading technique, which provides com. prehensive information in order to sim plify the achievement of a predictable aesthetic result, 614 NOL8,No.T ee fof coms contsined. tooth surface. READING AND INTERPRETING COLOR ‘The color ofa natural tooth is determined by the correlation of enamel and dentin ‘with light during the lightwave refrac tion and reflection processes (Figure 1). Even the chromatic effect of a restora tion is influenced by the absorption and reflection phenomena that occur be- tween incidental rays and the restorative material. The surface morphology of & tooth or the restoration influences this relationship, especially in brilliance. A rmacro- and micromorphologically rou ened surface diffuses the reflected light ‘whereas a flat surface with minirnal tex- ture significantly increases the surface brilliance of the tooth or restorations (Pigures 2 and 3)" ‘The color of a tooth can be ider fied by its “basic hue,” which is deter~ THE INTERNATIONAL AESTHETIC CHRONICLE 19 Figure 3 Posopeave view presents a surface with acre ad mit logy dt nflvences te absorption and election of Hah Tigre 8 Te color map of chromasdistibued over the ene ‘mined by the mean value derived from the sum of chromas contained and dis- tributed over the entire tooth surface (Figures 4 and 5)." Based on intensity, various chromas of the “basic hue” are present in specific regions of a tooth — the cervical, middle, and incisal thirds ‘These regions comprise the “chromatic ‘map” of the tooth (where the different chromatic expressions of the “basic hue” are to be identified and located, based on their intensity). The basic hue originates from the low-translucency, high-chromatic saturation of inner dentin body. ‘The “chromatic map” also includes the translucent regions ofthe tooth, which “originate from the enamel aspects which are {ree of interposed dentin. Therefore, the “chromatic map” has different ex pressions at the various anatomic levelsFigure 6, Facial view ofthe “chromatic map." Polarization filter is use 0 eliminate the reflex light Figure 8, A. In vito central incisor, exposed to UV light enamel ‘reales the sparkle. B. Dentin body of same tosh without enamel Figure 7. Ultraviolet photography is utilized to evidence the body's Nuorescence In UV light, the entre tooth has a sky-blue fluores ‘ence. B. Dentin body of same tooth without enamel ‘The highest chromas are at the cervical third, which is the area which maintains the highest degree of saturation, due to the presence of a thinner enamel and, therefore, a more visible dentin color. The chromas area slight degree lower at the ‘middle third, At the incisal third in un- ‘worn teeth, the “basic hue” chromas are gradually replaced by the opalescences created by the translucency of the incisal and intraproximal enamel, If reflected light is eliminated by means of a polar ization filter, the “chromatic map” can be viewed with greater intensity, and the inner dentin body and the translucent areas can be clearly identified (Figure 6). Due to its organic components, den- tin presents another phenomenon — fluorescence — which occurs when a body absorbs luminous energy and then ‘ifuses it back to the visible spectrum ~~ (Figure 7)."" For fluorescence to occur, the emission must take place within 10° seconds of activation. In nature, the phe- ‘nomenon is created by the ultraviolet (UV) rays of sunlight, i, short waves, invisible to the human eye. After penetrating the ‘enamel and reaching the dentin, the UW rays excite the photosensitivity of den: tin, Natural teeth exposed to UV light exhibit a fluorescence with an emission spectrum ranging from intense white to light blue (Pigures 8 and 9), On the contrary, the enamel of a natural tooth account fr the opalescence phenomenon, one of its translucent char: acteristics that highlights the short ‘wave components of the light spectrum, that strike it, creating the light blue- ‘fray hues that become clearly visible at the level ofthe incisal halo (Figure 10), ‘Therefore, two elements have to be con: "THE INTERNATIONAL. AESTHETIC CHRONICLE 196 sidered when determining tooth color: ‘The “chromatic map" where the “basic hue” is identified with its different satu ration levels which are related to the thickness ofthe inner dentin body, and the translucent areas of enamel, Activated by light, the inner dentin body and the external enamel layer create the luores- ‘ence and opalescence phenomena," The “chromatic map" ofa tooth, ex- posed to reflected light and wavelengths that cause fluorescence and opalescence phenomena, determine the "chromatic composition” or “chromatic melody” of the tooth: “Basic hue” and related chro- mas, represented by long waves (reds, browns, and yellows), sophisticated in- cisal opalescences, interpreted by short waves (whites, light blues, and grays), and delicate fluorescences with an irdes- cent effect determine the three-dimen- PRGA 675 eetFigure 12 Postoperative view ofthe maxillary central incisors, estore Figure 10. Enamel highlights the shadings of sky-blue. gr ‘white, due tothe opalescence phenomena of the incisal halo. the maxillary central in whit composite reprodacing the proper contour and“chromati melody.” enamel decoration Figure 11. Preoperative view of fractured ‘Figure 13. Filtered postoperative views note dentin body without same and dentin of sional color of the tooth, a itis perceived by the eye, The definition of chromatic compo: sition originates from a hypothesis of as- sonance between music and color. In a natural tooth, the light waves produce a ‘mixture of chromatic consonances and discords. A 19th century physicist"*hy- pothesized that colors in dentition were arranged in a natural order, similar to the way musical notes are arranged in scales. The color combinations, like the ‘musical chords, could be discordant. In the color scale, according tothe the physi- cist, the lightest tone was yellow, followed by orange, red, green, green-sky-blue, blue, and dark violet. A restoration is com- pletely integrated when the light/compos- ite material ratio precisely reproduces the chromatic melody of the adjacent teeth (Figures 11 through 13), 6516 Vol 8,No.? COLOR REPRODUCTION | AND COMPOSITE MATERIALS ‘Based on these considerations, the fol- lowing prerequisites are required inorder to create restoration where the light color interaction resembles natural den- tition: 1, Arreading technique for the “chro- ‘matic map” of the tooth to be r stored. Ability to clearly identify the “basic hue” of the dentin body and the regions of translucency to define and plan the “chromatic composi tion” of the anticipated restoration. Low-translucency, high-fluores- cence dentin materials (saturated ‘with ue/chroma). 3, High-transtucency (poor in hue chroma), low-fluorescence enamel [ME INTERNATIONAL AESTHETIC CHRONICLE 1996 ‘materials (high translucency allows the operator to obtain the desired ‘opalescences). 4. Ability o perform a build-up tech- nique that allows the reproduction of the thicknesses of dentin and enamel similar to those found in natural anatomy. 1. A Reading Technique for the “Chromatic Map” The inner dentin body is identified with ‘suitable and constant light source, similar to the solar illumination (eg, 8 standard 5,04) Kelvin lamp), The “basic hue" of the tooth involved is identified with the Vita shade guide. The most ac curate perception of hue (A, B,C, D) is ‘obtained atthe cervical third, where the enamel is thinner and the chromatic sat- uration of the dentin body is enhanced. ‘The author generally selects Vita A and14, Anatomic build-up ofa toth in composite. Dentin mate Fal is used in thin layers and mus have an intense chromatic strength Figure 15. The tooth on the lefts built of composite and evidences uorescence similar to that of the natural tooth on the right, Figure 16. Preoperative view ofthe maxillary central incisors Figure 17. Filtered preoperative view of the same incisors reveals exhibiting surface defects and discoloration. the extent of color saturation, B hues and seeks the dominant chro- | gree of flourescence and observe the | must present a high saturation level matic notes that are typical, ie, brown structure ofthe inner dentin body and (high chromas), since, clinically, the for Aand yellow for B. By careful obser- the extension ofthe free enamel between | chromatic performance of cured com vation of the cervical third ofthe maxil- the mamelons and on the incisal margin, | posite is lower than that of composite in lary canine, the red/brown (A) or rey: The “chromatic map” can be stud- _ its plastic stage low (B) hues can be clearly identified. ied by photographs taken with two small In the build-up application out- After establishing the “basic hue” of lateral flashes, producing a diffused light, _ lined, the dentin composite occupies the the dentition, the number and type of | and an annular flash, equipped with a | core ofthe restoration, The inner dentin chromas present in an area tobe restored polarization filter tat completely elected _ body is the source ofthe “hue chroma’ with the composite must be determined, ight, Ultraviolet photographs can be | of the restoration. Inthe anatomic build The presence of any translucency areas taken wth a sensitive film anda UV amp | UP oF stratification technique, the dentin Accounting for the opalescence phe- | asalight source. The dataand equipment. _ i applied in thin layers and; therefore nomenon must also be ascertained, reviewed assist in the determination of _ Must establish the chromatic strength of For the selection of the “basic hue,” the “chromatic composition” or “chro- __ the restoration (Figure 14). Asa result, itis advisable to work onty with the matic melody" of the tooth and help toes. _ dentin materials are generally opaque, 5,000* Kelvin lamp to eliminate any pe- since they are laden with color pigments iablsh the composite material utilized ripheral source of reflected light. In order E th obstruct light penetration. The forthe restoration, to effectively establish the opalescence chromatic saturation isthe primary cause reading, its advisable to observe the den- 2. Low-Translucency Dentin of the opacity and the lack of vitality of tition from different angles using sun- Materials composite restorations as opposed to light. Then, with a UV lamp as the only Dentin materials with hue coded ac- natural dentition, With the addition of Tight source, itis possible to assess the de- | cording to the Vita scale (A,B, C,D) | the correct degree of pigments that are TME INTERNATIONAL AESTHETIC CHRONICLE 19% PPA 677Figure of different (customized) enamel 18, Postoperative view ofthe maxillary central incisors with epee integration and transhucence similar to natural dentition. Figure 20, Anterior dentition, fabricated with composite material Figure 19. Filtered post central incisors. igure 21. Transillumi entition evidences the operative view of the same manillary nation of the same fabricated anterior "varying degrees of opalescence. photosensitive to the UV spectrum, the ‘material can absorb energy in the form of short waves (UV waves) (Figure 15) and activate the atoms with the compo- sition. “The excitation is followed by the re turn to the fundamental status with the subsequent emission of light. The emis sion is not limited to the superficial layer; it emanates from the inner aspect of the ‘material and creates an aesthetic result that closely resembles the appearance of a natural tooth, Dentin exhibits a higher degree of self‘luorescence than enamel, Increasing the mineralization degree re- duces fluorescence. A number of studies have demonstrated that when dentin is demineralized, self-uorescence increases ‘Therefore, enamel, which isa highly min- eralized tissue, exhibits a very low degree of self-fluorescence when compared to dentin." 678 VOL 8,No.7 3. High-Translucency Enamel Materials ‘A spectrophotometric study" has es tablished that the opacity of hybrid com- posite resins varies with time and gen- A ‘The color is more difficult to define since its “primary actors,” hue, chroma, and value, are often evasive. NN een ee erally increases after 180 consecutive days in vivo, These modifications to the opacity ofthe restoration can be reduced by extending the curing procedure. Micro~ bybrid composite systems are available that maintain a selection of enamel ma “THEE INTERNATIONAL AESTHETIC CHRONICLE 196 terials which exhibit remarkably low ops city as opposed to other dentin materi- als. However, the two elements share the same hues and chromas, and differ only in their degree of translucency. ‘There are also incisal materials that exhibit a higher degree of translucency, despite their enamel composition, The ‘appearance of the degree of opacity ofthe natural enamel changes in every tooth and depends primarily upon the thick- ness of the material, Therefore, itis dif ‘cll to propose an enamel composite with | standard degree of opacity, while itis, ‘more adequate to change translucency during the restorative process, adjusting it to the translucency of the enamel of the tooth involved. In the enamel of the natural tooth, there are visible hues of white, which often appear as transversal lines on the tooth surface. Therefore, in —Figure 22, A. Stereomicroscope section, revealing stratifiation| ‘of the natural tooth. B. Section ofthe “high diffusion layer Figure 24, Tooth particulate removed and placed on a light back ground, observed with an optic microscope Figure 23. The “glass Figure 25. Particulate dentin (ue-violet, yer” or “high diffusion layer” allows the light to orient inside the tooth, ofthe area between the enamel and the restoring enamel surfaces, the clinician is challenged to: ‘Reproduce the same degree of trans lucency in the enamel to he restored Figures 16 through 19) + Place hues of white in the material to customize the restoration (Figures 20 and21), * Reproduce internal and external ‘opalescence with the application of higher translucent materials To address the first two issues, the author uses 3 enamel materials with de creasing degrees of white saturation (White 1, White Il, White III, Enamel Plus HFP, Micerium, Avegno, Italy). ‘The materials are applied in combine. tion with dentin materials to modify the ‘opacity of the restoration, The modifica tion is achieved by mixing approximately — 1 part of high-transluceney “enamel ‘material’ (selecting saturations accord ing to the intensity of white required) with approximately J part of “dentin ‘material” in the same basic hue. By ad- bY Three regions of a tooth — the cervical, middle, and incisal thirds — create the “chromatic map" of the tooth . bey justing the proportions, the opacity ofthe customized enamel shade and the inten- sity of white can be increased or d creased. Using this method, a material can be obtained that exhibits the same “basic hue” ofthe restoration which dis THE INTERNATIONAL AESTHETIC CHRONICLE 1996 plays the translucency, brightness char- acteristics, and hues of white that are typical of the natural enamel, Working with small increments of material al lows the clinician to obtain an effective mixture without trapping any ai. To achieve opalescence, use enamel ‘materials only: Clear T and Clear Il for light gray and light blue hues, Gray I for fray hues, Ivory I for light yellow hues, Lory II for light brown hues. These hues appear in the form of veiled and delicate ‘opalescences, due to the extremely thin diameter of the filling particles which allow a diffusion of light, similar to that ‘obtained with natural enamel, The enamel materials of the system utilized exhibit a low degree of fluorescence asa result ofa higher percentage of photosensitive color that reduces the translucency required for the incisal, approximal, and inner ‘opalescences. While itis clinically impos- FPGA 67r previous Class 1V restoration Figure 28 Creation of the interproximal rest contact point with a ‘wooden wedge and an acetate matrix sible to tur a high-fluorescence opaque ‘material into a igh-translucency mate- rial without changing its properties, itis possible (starting with a high-translu- cency and low-Aluorescence material) to ‘obtain a material with desired refraction, chroma, and fluorescence by mixing it in diferent proportions with an opaque, highly duorescent material 4. Availability of an "Anatomic Build-Up” Technique Enamel and dentin constitute the natu: ral tooth, The reflected and refracted light (the latter diffuses inside) highlight an area of high translucency between enamel and dentin (Figure 22), which ceramists term the “glass layer” or “high diffusion layer” (Figure 23)" This layer is visible in the sections that are transilluminated under the stereomicroscope in the form ‘ofa white/sky-blue line and can be iden- tified histologically asa highly concen: (690 Vol 8,No.7 ire 26. Preoperative view of maxillary central incisors trated protein matrix. This matrix (Figures 24 and 25), formed presumably by ena lines or amelogenines, is normally de- sgraded over time, although some teeth retain characteristics of high light re- fraction and diffusion, In order to per TT Experience has demonstrated that only knowledge and personal artistic skills result in understanding of the color phenomenon. a form a correct “anatomic build-up,” itis a requisite to reproduce the thicknesses and transluceney of enamel and dentin. In cases of seriously compromised dentin (Class IV, complex restorations), Figure 27. Facial enamel stratification oi Figure 29. Fabrication ofthe internal dentin body. use of a matrix is advised. The matrix reduces operating time, allowing. the clin {cian to maintain support for the build-up ‘of material from the lingual o palatal s- pect while developing the occlusal anal ‘omy and support which resemble the an ticipated restoration (Figures 26 through 28). The matrix can be prepared on @ wax "up model or intraorally by restoring the defects with composite, without cavity preparation or etching, The material is shaped with a small spatula and light cured. The composite material adheres to the tooth, permitting the occlusal evaluation. At this stage, an impression is recorded with medium viscosity sit ‘cone. Once hardened and removed, the silicone is accurately trimmed to elim nate the facial wall and obtain the ma- trix which must also fit securely upon the rubber dam, The materials used for the matrix preparation are removed “THE INTERNATIONAL AESTHETIC CHRONICLE 1996 in, co, ans adi int rar and nal ral ada high Clea creat mar enti mateFigure 30 Fluid resin application to create the facial “high diffsion layer” the resin must not impinge on the enamel bond. Figure 32. Postoperative facil view ofthe restoration, Nove natural integration and color. stratification Figure 31. Postoperative facial view of the completed enamel Enamel Bonding Dentin ‘Figure 33, Schematic drawing ofthe proposed anatomic with a carver, and the cavity is prepared, The restoration is developed from the lingual or palatal enamel in the prepared cavities. If the wall is preserved, the miss- ing tissue is replaced with appropriate composite increments, respecting the anatomy of the tooth, The build-up must adhere to the external shape from the internal aspect (Figures 29 through 31), Particularly the macromorphology (lobes and grooves), and must replicate inter- nal dentition, mamelons, and the natu- ral characteristics of the affected and adjacent teeth. To obtain these effects it is advisable to place small increments of highly translucent material (Clear I, Clear 11, Ivory 1, Ivory Il, designed to Create internal opalescences, in the groove marking the mamelons (Figure 32). During the restoration of the inner dentin body, it is advisable to use dentin ‘materials with two chromas over the “basic hue.” If, for example, the “basic /hue” is A3, then AG and AS materials are tobe used to obtain suitable inner chro- ‘matic strength, The composite system, tused by the author includes these chro- ‘mas. To facilitate light diffusion within identified with a suitable and constant light source, similar to the solar illumination, the internal aspects ofthe restoration, in addition to opalescence, an attempt is ‘made to reproduce the protein layer with high translucency resin material termed the “glass layer.” A thin layer of fluid THE INTERNATIONAL AESTHETIC CHRONICLE 1996 resin (approximately two brush strokes) is applied between enamel and dentin on the lingual and facial aspects and ‘cured (Figure 33). In this build-up, the incremental phase is alway initiated from the palatal aspect to reproduce enamel and dentin with the same arrangement and thickness present in the natural tooth. In addition to joining enamel and dentin, the layer permits a high light diffusion in the internal aspect of the restoration. Light passes through the “glass-connector,” changing only its di rection of propagation, thereby originat ing the “light diffusion” process, CONCLUSION ‘The challenge of creating color harmony in free-hand composite restorations has existed since the introduction ofthe ma, terial. Most clinicians have attempted to address the challenge by exploiting theirFigure M, Preoperative view of endodontically west maxillary Figure 36. Po erative view of the restored maxillary central Faare 6 poet interaction between color and Tigh Figure 35. Postoperative view of the maxillary central incisors, restored with composite resin, re 37. Restored maxillary cena incisor. Viewed with UV light, ‘the entre tooth has a iuorescence imparting the sky-blue colo. ‘own artistic ratvily. Today, numerous nang til cnsier the aesthetic result fo be determined by the validity of the personal clinical techniques, based on the eertiseatistc sil of single dents using rious materials. However, clinical experience and failures have ‘demonstrated tat only a combination of accurate knowedée, materials and per onal artistic sills result ina compre- hensive undersanding and interpreta- tion ofthe pheamenion of color (Figures 34 through 37 ACKNOWLEDGMENTS ‘Phe author would like to thank Dr. Fabio Toffet and Professor Mario Mantignon rt suggestions and con- tinuous supp ond Professor Domenico Cocca of th Rsearch Laboratory, Uni- versity of Rom Tor Vergata, aly; for the eal misos2Py images supplied. oa Wi.g.n7 REFERENCES REFERENCES Mn Color Co The Mansel Book of Clr Som car Stam Ie Qasr, 188 3. Lemire PA, Bask BB, Color in Dentistry ream L:Quitesence, 1988 5. Winter Vaualising the matral dentition, Methebent sgsn03.18 5. ones TD, Te Ait of ight a Color New York Aiton Naan Rit, 173 7. Mage Mage M, Ber Natural and ves thera ete Pat: Rllonae and Ten 161173, inn The portance of sapere Proven the 4. Ubessy 6 Forme e Coon Resch ities roa a Reeare e100 ut eat Fo cee ete nl Use del materia comport. Guadeent Tie Myr Lach Sh. Qt. Date En Re rs 1878908. . Sem Ie IMME INTERNATIONAL AESTHETIC CHRONICLE 1996 Aang pate ton aod enti eaten chembae fom the raion i goede th ne Prc Nl Aad Se simian 2688 owns 1. Shay of ans tert eth. Sta oof ON. Modern Chromatis: Stu Teta ofl opt ane Tre New or Tabu) Om! Si oe dE in Der Ven MH, Ten Bench bert Uor agian of ot srace mies Lchenoch iy anche CM, ele Saat oun oa feted ania to