Color Science and

Shade Selection in
Operative Dentistry

Essential Elements for Clinical

Success
Dayane Oliveira
Editor

123
Color Science and Shade Selection
in Operative Dentistry
Dayane Oliveira
Editor

Color Science and

Shade Selection in
Operative Dentistry
Essential Elements for Clinical
Success
Editor
Dayane Oliveira
College of Dentistry
University of Florida
Gainesville, FL, USA

ISBN 978-3-030-99172-2    ISBN 978-3-030-99173-9 (eBook)

https://doi.org/10.1007/978-3-030-99173-9

© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
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Preface

This book aims to provide information and guidance on color selection and
color matching in Dentistry.
Generally speaking, color science has always been an essential and trend-
ing topic in Dentistry but never fully explored. Color science in Dentistry is
usually briefly explored in book chapters. This book is looking forward to
fully exploring all theories and clinical guidance to fulfill clinical success.
This book is addressed to all groups from undergraduate to postgraduate
students, clinicians, and researchers. The content embraces to attend all
groups but written in a way all groups can understand. The topics include the
basic color science concepts till bleaching, color selection, color matching
using schematic drawings, and the many different restorative techniques
using resin composites and stratifications, and much more.
I appreciate all authors for their contribution to this book, their effort, and
their dedication that made it all possible. It was a pleasure to collaborate with
such an amazing group. Thank you so much for making this book come true!

Gainesville, FL, USA Dayane Oliveira

v
Contents

1 Color Science������������������������������������������������������������������������������������   1

Dayane Oliveira and Mateus Garcia Rocha
2 
Natural Tooth X Composites Biomimetics������������������������������������ 13
Dayane Oliveira, Rodrigo Rocha Maia,
and André Figueiredo Reis
3 
Color Selection in Operative Dentistry������������������������������������������ 21
Vinícius Salgado and Dayane Oliveira
4 
Color Evaluation for Research Purposes�������������������������������������� 37
Camila Sampaio and Pablo Atria
5 
Dental Photography as a Key to Clinical Success ������������������������ 53
Lucas Fernando Tabata, Toni Arcuri,
and Leandro Augusto Hilgert
6 Bleaching Procedures���������������������������������������������������������������������� 75
Vinícius Salgado
7 
Biomimetics of the Natural Tooth Using Composites ������������������ 91
Dayane Oliveira and Vinícius Salgado
8 Finishing and Polishing ������������������������������������������������������������������ 103
Alex J. Delgado
9  olor Mismatch Between the Restoration and the Natural
C
Tooth Over Time������������������������������������������������������������������������������ 111
Luis Felipe Jochims Schneider and Larissa Maria Assad
Cavalcante
10 
Longevity of Resin Composite Restorations���������������������������������� 125
Flávio Fernando Demarco, Luiz Alexandre Chisini, Marcos
Britto Correa, Maximiliano Sérgio Cenci,
and Rafael Ratto de Moraes

vii
 Color Science
1
Dayane Oliveira and Mateus Garcia Rocha

1.1 Color Definition where the surrounding colors trick the human
brain into an incorrect interpretation of color [2].
“Color is defined as the property of producing a Indeed, the visual perception of different col-
visual perception as a result of the way an object ors is a subjective process whereby the brain
reflects or emits light.” Although it seems simple, responds to the stimuli that are produced by
color is best described as an abstract science in color-sensitive cones localized in the human ret-
which it appears to be highly subjective. ina. However, it proves the importance of color
In 2005, neuroscientists from University of education in Dentistry [3].
Rochester had found that the number of color-­
sensitive cells in the human retina differs among
people by up to 40 times; yet people appear to 1.2 Color and Its Dimensions
perceive colors the same way. These findings
indicated that visual perception of color is con- Color can be specified based on three color
trolled much more by the human brain than the appearance parameters, also known as the three
eyes [1]. color dimensions: hue, value (or lightness), and
A practical example of the influence of the Chroma (Fig. 1.2).
human brain on visual perception is shown in
Fig. 1.1. Observing the square, how many shades
do you see? If you see two different shades of 1.2.1 Hue
gray, cover the line blocking the darker and
lighter shading across the middle, and your brain Hue is defined as the visual perception of the
will begin to realize that the cube actually has stimuli of a wavelength. As illustrated in Fig. 1.3,
only one shade. This is a color illusion from Tom the main pure hues are red, blue, and yellow. The
Cornsweet, who is best known for his work in main pure hues are also called primary colors.
visual perception. Color illusions are images However, the mixture of pure hues can generate
different visual perception stimuli, also called
secondary colors. For example, the mixture of
blue (primary color) and yellow (primary color)
D. Oliveira · M. G. Rocha (*)
Department of Restorative Dental Sciences, College generates the visual perception of green (second-
of Dentistry, University of Florida, ary color). The mixture of a primary color and a
Gainesville, FL, USA secondary color can also generate a different
e-mail: [email protected]; visual perception stimulus, called a tertiary color.
[email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 1

D. Oliveira (ed.), Color Science and Shade Selection in Operative Dentistry,
https://doi.org/10.1007/978-3-030-99173-9_1
2 D. Oliveira and M. G. Rocha

Fig. 1.1 Cornsweet

illusion: color illusion
designed by Tom
Cornsweet

1.2.2 Value Clearly, a mistake in translucency may com-

promise the natural appearance of a restoration in
Value, also known as lightness or tone, is referred comparison to the natural teeth as the background
to the lightness or darkness of a color. In other changes. This is the reason why some authors
words, it indicates the quantity of the light that is describe translucency as the fourth dimension of
reflected. color [4].

1.2.3 Chroma 1.3 Color Perception

Chroma is defined as the purity, intensity, or satu- Color is not a property of light, but the visual per-
ration of a color. Thus, a lower Chroma would ception of light by an observer. In order for the
indicate less intensity of the color, as in pastel color to be perceived, three elements must be
colors. In contrast, a higher Chroma is related to simultaneously present: illumination, an object,
more vivid color. and an observer.

1.2.4 Translucency 1.3.1 Light

Translucency is the physical property that allows 1.3.1.1 Concepts of Illumination

light to pass through the material. The material Although white light is colorless to the human
can be considered transparent, translucent, or eye, it contains all colors in the visible wave-
opaque according to the degree of light that is length spectrum (Fig. 1.5). Thus, when the white
transmitted rather than absorbed or reflected light hits an object, the different wavelengths can
(Fig. 1.4). When the material allows most light to be absorbed, transmitted, or reflected. The
pass through it, it is considered transparent. This reflected wavelengths will be responsible for the
means that it is possible to clearly see through it. color perception of the object (Fig. 1.6).
On the other hand, when the material allows However, different light sources can emit dif-
some light to pass through it, it is considered ferent wavelengths. This means that not all visi-
translucent. This means that it is still possible to ble wavelength spectra are being absorbed,
see through it, but not as clearly. Last, when no transmitted, or reflected by the object under dif-
light is able to pass through it, the material is con- ferent light sources. Thus, the color of one object
sidered opaque. This means that it is not possible can look different under different illumination.
to see through it.
1 Color Science 3

1.3.2 Object

As previously explained, when the light hits an

object, the different wavelengths can be absorbed,
transmitted, or reflected, and the reflected wave-
lengths will be responsible for the color of the
object (as illustrated in Fig. 1.6). It means that
when the object is yellow, it absorbs and/or trans-
mits all wavelengths, but yellow, which is
reflected.

1.3.2.1 Light Reflection, Light

Absorption, and Light
Transmittance
As stated by Lavoisier, in nature, nothing is cre-
ated, nothing is lost, everything is transformed.

The understanding of light reflection, light

absorption, and light transmittance through an
object follows this rationality.
The light reflection is the change in the direc-
tion of the electromagnetic radiation at an inter-
face between two different media. Technically,
different media have different refractive indexes.
The refractive index is the ratio of the speed of
light in the vacuum to its speed in a specific
medium. Higher the difference between the
refractive indexes of the two mediums, the higher
the light reflection.
Then, the amount of electromagnetic radiation
that is either not reflected is absorbed or transmit-
ted through the object. The light absorption is
defined as the electromagnetic radiation energy
that is transformed into the internal energy of the
object (also called absorber). The reason the elec-
tromagnetic radiation is absorbed by the object
while trying to pass through the object is that
when it vibrates, the electrons interact with
neighboring atoms in such a manner as to convert
its vibrational energy into thermal energy. Thus,
the light wave with that given frequency is
absorbed by the object, never again released in
the form of light. In contrast, the light transmit-
tance is the electromagnetic radiation energy that
Fig. 1.2 Color dimensions: hue, value, and Chroma
was not reflected nor absorbed, being able to pass
4 D. Oliveira and M. G. Rocha

Fig. 1.3 Hues: primary, secondary, and tertiary colors

Fig. 1.4 Definition of transparency, translucency, and opacity

through the object. And in the end, how an the material can create dichroism, in which the
observer perceives an object’s color depends on material appears blue from the front side (opales-
which wavelengths are reflected by this object. cence), but yellowish-red shines through the back-
side (counter-opalescence) (Fig. 1.7). This
1.3.2.2 Opalescence phenomenon occurs due to a specific type of light
and Counter-Opalescence scattering known as the Tyndall effect. Under the
As previously mentioned, objects can be transpar- Tyndall effect, the longer-­wavelength light, yel-
ent, translucent, or opaque according to the degree low-red, is more transmitted while the shorter-
of light that is transmitted rather than absorbed or wavelength light, blue, is more reflected.
reflected (as illustrated in Fig. 1.4). In highly trans- Enamel is a highly translucent tissue respon-
lucent materials, the light that is scattered through sible for the opalescence of the incisal halo. This
1 Color Science 5

Fig. 1.5 Visible wavelength spectrums and color perception

Fig. 1.6 Light absorption, reflection and transmission, and color perception

effect is not perceptible in the cervical and differently at different angles. This phenomenon
medium thirds of the teeth due to the presence of is called goniochromism [7].
dentin in between, which is highly opaque [5, 6].
However, in the incisal third, it is possible to 1.3.2.3 Fluorescence
observe an opalescent halo that follows the inci- On the other side, the dentin is responsible for
sal outline of the mamelon of dentin. Specific another natural effect in the tooth: fluorescence.
composites called “translucent” or “opalescent” The fluorescence is the emission of a visible
can be used to reproduce this effect. wavelength after absorption of radiation in the
Also, the translucent multilayering character- ultraviolet region of the spectrum, which is invis-
istic of the teeth can make its color be perceived ible to the human eye. Then, when exposed to
6 D. Oliveira and M. G. Rocha

ultraviolet light, the fluorescence of dentin gives Despite called “blue,” “green,” and “red” cone
a distinct color that glows. Thus, if the restorative cells, each type of cell does not sense only one
material did not have this property, the difference color but a broad range of wavelengths in varying
between the natural teeth and the restorative degrees of sensitivity. Because of this, different
material would be perceived when exposed to specific selective cones can be stimulated by sim-
ultraviolet light (Fig. 1.8). However, nowadays, ilar wavelength spectra but in different levels.
all dental composites have fluorescence proper- Thus, when the cone cells are exposed to a cer-
ties due to the addition of rare earths to the tain wavelength spectrum, the most sensitive
composition. cone cell for this specific wavelength spectrum is
stimulated first.

1.3.3 Observer 1.3.3.2 Visual Fatigue

However, as previously mentioned, when a spe-
1.3.3.1 Visual Phenomena cific selective cone is stimulated for prolonged
The human eye is responsible for capturing stim- viewing, it causes the fatigue of these cone cells.
ulus from different wavelength spectra of light Then, the other color receptor, which is not
and discharging nerve impulses that are con- fatigued, receives the stimulus, and the brain
ducted to the brain. There are three types of cone incorrectly perceives the other color.
cells in the human eye that are more sensitive to
either short (blue), medium (green), or long 1.3.3.3 Gender
wavelengths (red) (Fig. 1.9). Human beings are capable of perceiving hun-
dreds of shades equally; however, although find-
ings are ambiguous, gender may have an influence
on color perception. Thus, men and women may
experience the appearance of color differently.
Generally, women are expected to experience
more shades of color than men. What may be
simple “purple” to a man, but it could be “laven-
der” to a woman. Neuroscience says women are
better at distinguishing among distinctions in
color. On the other hand, linguistic researchers
Fig. 1.7 Tyndall effect: opalescence and counter-
opalescence say that women possess a larger vocabulary of

Fig. 1.8 Fluorescence effect of different composites

1 Color Science 7

Fig. 1.9 Different

wavelengths absorbance
of sensory cells on
human retina

directly affect how color is perceived and called.

Thus, although human beings can perceive hun-
dreds of shades equally, as more educated they
are on the topic, they tend to be more attentive,
percept smaller differences in nuances, and even
accept those differences less. Figure 1.10 illus-
trates side by side different shades from a bleach-
ing shade guide with saturation in a crescent
scale; try to identify the differences in Chroma.

1.3.3.5 Age
The sensitivity of retinal cells declines with age,
causing different shades of color to be less notice-
Fig. 1.10 Bleaching shade guide shades tabs with satura- able [10]. At the same time, certain neural path-
tion in a crescent scale ways of the brain compensate it, so color
perception remains constant over some time [11].
shades to describe color than men. But women Because of this, color vision abnormalities are
proved slightly better at detecting tiny differ- very uncommon in people younger than 70.
ences between shades that look the same to men. However, as there is no treatment for this age-­
The scientists believe the answer lies in the dif- related loss of color perception, in mid-70s, den-
ferences in men’s and women’s hormones that tists should be aware of this limitation.
can alter development in the visual cortex. In
contrast, children are more likely to sort the col- 1.3.3.6 Phenomena That Affect Color
ors more randomly. However, the reason is prob- Perception
ably due to the smaller exposure to color groups –– Metamerism
and general education of color [8, 9]. As previously explained, when the light hits
an object, the different wavelengths in it can
1.3.3.4 Expertise be absorbed, transmitted, or reflected. The
As mentioned in the previous topic, exposure to reflected wavelengths will be responsible for
color groups and general education of color the color perception of the object (as illus-
8 D. Oliveira and M. G. Rocha

trated in Fig. 1.6). However, different light than the original color of the teeth. At lower
sources can emit different wavelengths, and intensities, however, the color perception
the color of the object can look different under shifts more toward the red/green axis.
different illumination. –– Stiles–Crawford Effect
In some cases, the color of two different The Stiles–Crawford effect is the phenome-
colored objects can match under one set of non where light reaching the eye near the edge
illumination but fail to match under a different of the pupil produces a lower photoreceptor
set (Fig. 1.11). This phenomenon is known as response compared to light of similar intensity
the metamerism effect [12–14]. It shows the reaching the eye near the center of the pupil.
importance of illumination during color selec- This phenomenon is so vital in Dentistry
tion in Dentistry [15]. because teeth color is multichromatic, and
–– Bezold–Brucke effect depending on the angle that the color is
Hue perception can change as light intensity observed, color perception can vary [18].
varies. This phenomenon is known as the –– Aubert or Abney Effect
Bezold–Brucke shift [16, 17]. As the light The Aubert or Abney effect is also known as
intensity increases, the color perception shifts the purity-on-hue effect. This effect described
more toward blue or yellow, depending on the the perceived hue shift that occurs when white
original color of the object. Then, if the object light is added to a monochromatic light source.
is yellow, it tends to look more saturated than The addition of white light causes a desatura-
it really is (Fig. 1.12). It can influence the tion of the monochromatic light, as perceived
color selection to a more saturated color rather by the human eye. For this reason, this hue

Fig. 1.11 Metamerism phenomenon

1 Color Science 9

Fig. 1.12 Bezold–Brucke phenomenon

shift phenomenon is considered more a physi- –– Opponent-Color Theory

ological effect than a physical effect [19]. The human eyes receive stimulus from differ-
–– Helmholtz–Kohlrausch Effect ent wavelengths by different sensory cells on
The Helmholtz–Kohlrausch effect is another the retina, the cones. There are specific selec-
physiological effect in which colored light tive cones for different wavelength ranges.
appears brighter than white light of the same However, when a specific selective cone is
luminance [20]. This phenomenon can also be stimulated for prolonged viewing, it causes
observed in colored pigments and printing, the fatigue of these cone cells. Then, the
although less pronounced. When the colors opponent-­color receptor, which is not fatigued,
are more saturated, the human eye interprets it receives the stimulus, and the brain incorrectly
as the color’s luminance and Chroma, thus perceives the opponent color. This phenome-
tricking the brain into believing that the colors non is known as the opponent-color theory.
are brighter (Fig. 1.13). This phenomenon can be observed in
Notice that brightness and lightness are dif- Dentistry. As the rubber dam is usually brightly
ferent concepts. Brightness is the intensity of colored, it may alter the color perception of the
the object regardless of the light source. tooth and lead to an incorrect color selection.
Lightness is the brightness of the object with This is the reason why shade selection should be
respect to the light reflecting on it. An excep- made before the dam is applied [4]. Otherwise,
tion to this is when the human observed is prolonged exposure to the bright color of the
red–green colorblind, thus not being able to dam can desensitize a specific selective cone
distinguish differences between the lightness and stimulate the opponent’s specific selective
of the colors. cone when trying to select the color of the tooth
10 D. Oliveira and M. G. Rocha

Fig. 1.13 Helmholtz–Kohlrausch effect

under absolute operatory field isolation. The

opponent colors are blue and yellow, red and
green, and black and white (Fig. 1.14). Toward
a better understanding of this theory, a practical
example is given in Fig. 1.15.
It is worthwhile to mention that the abso-
lute operatory field isolation also causes the
dehydration of the teeth. Natural teeth exhibit
high gloss reflection when wet. Thus, the color
appearance looks vivid. However, in the
absence of saliva, the roughness of the teeth
surface scatters the light, and the color appear-
ance looks more pastel.
–– Von Kries Law Fig. 1.14 Opponent-color theory: opponent colors
Chromatic adaptation the human visual ability to
adjust to changes in illumination in order to pre- The Von Kries law is frequently used in-
serve the appearance of object colors. Various camera image processing. Cameras with no
theories explain the color constancy phenomena adjustments for light may register color differ-
under illuminant changes. The Von Kries law ently. Thus, a correction, also known as white
describes the relationship between the illumi- balance, is used to simulate this feature of
nant and human visual system sensitivity [21]. chromatic adaptation by the human eye.
1 Color Science 11

Fig. 1.15 Opponent-color theory test: practical example

11. Wueger S. Colour constancy across the life span:

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 Natural Tooth X Composites
Biomimetics
2
Dayane Oliveira, Rodrigo Rocha Maia,
and André Figueiredo Reis

2.1 Optical Properties included in the intercrystalline spaces and a net-

of the Natural Tooth work of micropores opening to the external sur-
face. These microchannels allow a dynamic
The tooth color is determined by the absorption connection between the oral cavity outside and
and reflection of the incident light in the different the dentin underneath the enamel. These charac-
natural tooth structures: the enamel and the den- teristics give the enamel a slight whitish color
tin [1, 2]. These tissues have different structural look with high translucency [2].
characteristics and, consequently, exhibit differ-
ent optical properties (Fig. 2.1). 2.1.1.2 Dentin
Dentin is a unique mineralized avascular connec-
tive tissue. It constitutes a hydrated biological tis-
2.1.1 Composition of the Natural sue—composed of 70% inorganic material, 18%
Tooth Structures organic material, and 12% water, by weight—
whose structural properties and components vary
2.1.1.1 Enamel according to the area analyzed. Its inorganic part
The enamel is composed of inorganic and organic consists of crystals of hydroxyapatite, while the
components. The inorganic part is hydroxyapa- organic portion contains mainly type I collagen
tite, 96% mineral by weight, and more than 86% and fractions of type III and V collagen, glyco-
by volume is hydroxyapatite. The hydroxyapatite proteins and proteoglycans, non-collagen pro-
crystals are colorless and organized in a hierar- teins, and water [1]. Different from the enamel,
chical and organized way above the dentin. The the dentin is not colorless; its hue naturally varies
organic constituents are 4–12% by volume water, among yellow, orange, and brown shades with
low translucency. Also, the low translucency of
D. Oliveira · A. F. Reis the dentin compared to the high translucency of
Department of Restorative Dental Sciences, College the enamel is due to the lower amount of inor-
of Dentistry, University of Florida, ganic content and increased amount of organic
Gainesville, FL, USA
e-mail: [email protected]; content.
[email protected]
R. R. Maia (*) 2.1.1.3 Dentin–Enamel Junction (DEJ)
Department of Cariology, Restorative Sciences and The dentin–enamel junction (DEJ) is a thin layer
Endodontics, School of Dentistry, University of constituted of partially mineralized collagen pro-
Michigan, Ann Arbor, MI, USA tein fiber bundles in between the enamel and the
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 13

D. Oliveira (ed.), Color Science and Shade Selection in Operative Dentistry,
https://doi.org/10.1007/978-3-030-99173-9_2
14 D. Oliveira et al.

Fig. 2.1 Natural tooth structures: enamel and dentin layers, and the opalescence and counter-opalescence phenomena
in the tooth structure

dentin that penetrate and connect both tissues. dehydration occurs, then translucency decreases
This junction gives the natural appearance of the [3]. For this reason, it is extremely important to
tooth color, which depends on the hue of the den- evaluate the color of the tooth when hydrated.
tin and the translucency of the enamel [3]. When performing a restoration under isolation,
the tooth dehydrates and tends to look lighter and
opaquer, causing a mismatch in color. For this
2.1.2 Optical Properties reason, it is recommended to wait for the tooth to
hydrate to check the final color appearance.
There are three optical properties that directly
influence on the color of the tooth structure: 2.1.2.2 Fluorescence
translucency, fluorescence, and opalescence. The fluorescence is the emission of a visible
wavelength after absorption of radiation in the
2.1.2.1 Translucency ultraviolet region of the spectrum, which is invis-
Translucency is described as the ability to allow ible to the human eye. Then, when exposed to
an underlying background to show through. As ultraviolet light, the fluorescence of dentin gives
previously described, the enamel has a higher a distinct color that glows. Of course, such prop-
translucency than the dentin [4]. The materials erty is only observed under ultraviolet illumina-
can be considered transparent, translucent, or tion. However, if the restorative material does not
opaque according to the degree of light that is have this property, a difference in appearance
transmitted rather than absorbed or reflected. For between the natural teeth and the restorative
further details, consult Chap. 1. material would be perceived when the tooth is
The translucency of human dental enamel has exposed to ultraviolet light (as previously illus-
been determined by total transmittance at wave- trated in Chap. 1, Fig. 1.8).
lengths from 400 to 700 nm. Total transmission In natural teeth, fluorescence occurs mainly in
of light through human dental enamel increases the dentin because of the greater amount of organic
with increasing wavelength. Human tooth enamel material. However, it is important to mention that
is more translucent at higher wavelengths. the enamel is also fluorescent, although it presents
Translucency is influenced by many factors, a smaller fluorescence index than dentin due to the
thickness (of enamel and dentin), the surface tex- lower amount of organic material in its composi-
ture, and the hydration of the enamel prisms; if tion. Additionally, in many cases, the enamel pres-
2 Natural Tooth X Composites Biomimetics 15

a b

Fig. 2.2 Dental monomers used in the composition of resin composites: (a) BisGMA and (b) TEGDMA

ents higher fluorescence than several of the resin 2.2 Optical Properties
composites available on the market [5]. of the Resin Composites

2.1.2.3 Opalescence 2.2.1 Composition of Resin

and Counter-Opalescence Composites
Opalescence and counter-opalescence are phe-
nomena in which tooth enamel appears one color The resin composites are basically composed of
when refracting light and a different color when three main components: an organic portion, the
reflecting light. As previously explained in Chap. monomers, an inorganic portion, the fillers, and a
1, in highly translucent materials, the light that is coupling agent, an organosilane, responsible for
scattered through the material can create d­ ichroism, linking both organic and inorganic portions.
in which the material appears blue from the front Other than these three main components, addi-
side (opalescence), but yellowish-red shines tives are added to give specific functions or char-
through the backside (counter-opalescence). acteristics to the resin composite, eg.:
The natural opal is an aqueous disilicate that photoinitiators, pigments, and rare earths.
breaks down transilluminated light into nine spec-
tral components by refraction. Opalescence acts 2.2.1.1 Monomers
like prisms and refracts different wavelengths to The organic portion of the resin composites com-
varying degrees. Shorter wavelengths bend more prises the combination of different types of
and require a higher critical angle to escape an monomers, such as the bisphenol A diglycidyl
optically dense material than red and yellow ether dimethacrylate (Bis-GMA), the bisphenol
ranges of the spectrum. In this case, the hydroxy- A ethoxylated dimethacrylate (Bis-EMA), the
apatite crystals of the enamel act as the prisms. triethylene glycol dimethacrylate (TEGDMA),
Thus, when the enamel is illuminated, it will and the urethane dimethacrylate (UDMA),
transilluminate red shades and scatter blue shades among others [6]. The different monomers are
from their bodies; therefore, the enamel appears combined due to their differences in viscosity,
bluish from the front side and reddish from the refractive index, and other properties. However,
backside, even though it is colorless (Fig. 2.2) [5]. all monomers are colorless liquids (Fig. 2.3).
16 D. Oliveira et al.

a b

Fig. 2.3 Dental filler particles used in the composition of resin composites: (a) silica and (b) glass

a b

c d

Fig. 2.4 Dental photoinitiators: (a) camphorquinone; (b) BAPO; (c) TPO; (d) ivocerin

2.2.1.2 Fillers turers can also use different filler particle sizes to
The inorganic portion of the resin composites, on adjust this variable. However, it is known that
the other hand, consists of particles of quartz better polishing, lower surface roughness, and
(SiO2), silica (SiO2), zirconia (ZrO2), barium alu- higher gloss retention are achieved with smaller
minosilicate (BaO·Al2O3·2SiO2), or a combina- particles [8–10]. The reason is that when white
tion of these particles [6]. All these filler particles light shines on any solid, some of the light is
are whitish powders (Fig. 2.4). The different par- directly reflected from the surface and remains
ticles or their combination can be used according white. However, most of it is absorbed and trans-
to the type of monomers used in the formulation mitted, reflecting only a few wavelengths giving
of the resin composite. The reason for this is the perception of the color of the object. As a
because all different monomers and filler parti- result, an extremely rough surface appears lighter
cles have different refractive indexes. than a smooth surface of the same material. The
As previously explained in Chap. 1, the refrac- reason is that most of the white light will be
tive index is the ratio of the speed of light in the directly reflected from the surface. This problem
vacuum to its speed in a specific medium. Higher is associated with unpolished composite restora-
the difference between the refractive indexes of tions that appear lighter and less chromatic
the two mediums, the higher the light reflection. (grayer) before polishing [5].
Thus, the type and amount of these components
can affect the way the light is reflected, absorbed, 2.2.1.3 Coupling Agent
or transmitted [7], thus affecting its color percep- Coupling agents are meant to link dissimilar
tion. It is important to mention that the manufac- materials. As previously described, the resin com-
2 Natural Tooth X Composites Biomimetics 17

posites are composed of an organic portion, the tor, the camphorquinone (CQ). However, CQ is a
monomers, and an inorganic portion, the fillers. yellowed-colored powder (Fig. 2.5a) that can
However, organic and inorganic molecules do not directly interfere with the color of the resin com-
have any interaction or adhesion in between each posite, especially regarding lighter and more
other. For this reason, an organosilane is used as atranslucent colors. For this reason, some manu-
coupling agent in the ­composition of resin com- facturers use alternative photoinitiators, such as
posites [6]. The organosilane contains an organic the bisalkyl phosphine oxide (BAPO) (Fig. 2.5b)
portion in one of its ends which bonds to the and the monoalkyl phosphine oxide (TPO)
monomers. While, on the other end, the organosi- (Fig. 2.5c) that are whited-colored powders [10].
lane has a silane that bonds to the hydroxyl groups It is worthwhile to mention that Ivocerin is
of the filler. Similar to the monomers, the slightly less yellow than CQ, but still, a yellowed-­
organosilanes are colorless liquids. The organosi- colored powder (Fig. 2.5d) that can also interfere
lane liquid is pre-applied to the surface of the with the color of the resin composite [10].
filler particles before mixed with the monomers. These colorful photoinitiators also interfere
with the color matching between the resin com-
2.2.1.4 Photoinitiators posite and the tooth. After absorbing its corre-
The photoinitiator is the component added to the sponding wavelength, it reacts and is consumed.
material that makes it light-curable. The photo- After its consumption, the material becomes less
initiator is a molecule that when absorbs light, yellow. For this reason, it is recommended to
generating free radicals that initiate the polymer- light-cure small increments of different shades of
ization process. Most composites are light-­ the resin composite on top of the tooth to better
activated within the blue wavelength spectrum select color. This technique will be further
(420–495 nm) using a diketone as a photoinitia- explored and explained in Chap. 3.

Fig. 2.5 Resin

composite with different
translucencies: (a)
dentin; (b) body; (c)
enamel; (d) incisal.
(Photography courtesy
of 3M)
18 D. Oliveira et al.

2.2.1.5 Pigments Chap. 1). Even different natural teeth might have
The pigment is the component added to the mate- different fluorescence intensities due to differ-
rial to characterize its final color [6]. As previ- ences in dentin and enamel composition and
ously explained, all the resin composite thicknesses [18, 19]. Still, some brands have a
components have different colors that can inter- more similar fluorescence effect to most natural
fere with the final color appearance of the mate- teeth than others [20].
rial. For this reason, different pigments can be
added accordingly to produce the different shades 2.2.2.3 Opalescence
usually needed in Dentistry. The most common and Counter-Opalescence
pigments used in dental resin composites are iron In highly translucent materials, the light that is
oxides (red or yellow) and titanium dioxides scattered through the material can create dichro-
(white). ism, in which the material appears blue from the
front side (opalescence), but yellowish-red shines
through the backside (counter-opalescence). The
2.2.2 Optical Properties natural enamel is a highly translucent tissue
responsible for the opalescence of the incisal
2.2.2.1 Translucency halo. The composites described before as translu-
As previously explained, the dentin and the cent or incisal can be used to reproduce this
enamel have different translucencies. The enamel effect. For this reason, some manufacturers also
is more translucent, while the dentin is opaquer. call this type of resin composite opalescent.
Thus, mimicking these different optical proper-
ties requires different types of resin composites
[11, 12]. Most manufacturers have at least two References
types of translucencies for their resin composites,
conveniently named dentin (opaquer) and enamel 1. Sulieman MAM. An overview of tooth-­ bleaching
techniques: chemistry, safety and efficacy.
(more translucent) shades. Other manufacturers Periodontology. 2000;48(1):148–96.
also have a mid-­ translucency material shade, 2. Ferraris F, Diamantopoulou S, Acunzo R, Alcidi
named as body, which is more translucent than R. Influence of enamel composite thickness on value,
the dentin but definitely much opaquer than the chroma and translucency of a high and a nonhigh
refractive index resin composite. Int J Esthet Dent.
enamel shades. A few manufacturers also have a 2014;9(3):382–401.
transparent shade, also sometimes convenient 3. Brodbelt RH, O'Brien WJ, Fan PL, Frazer-Dib JG, Yu
named incisal. R. Translucency of human dental enamel. J Dent Res.
The techniques applied with the different 1981;60(10):1749–53.
4. Spitzer D, Bosch JT. The absorption and scattering
types of resin composites are further described of light in bovine and human dental enamel. Calcif
and illustrated in Chap. 7. Depending on the Tissue Res. 1975;17(2):129–37.
tooth’s characteristics to be restored, a single or 5. Baratieri LN, Araujo E, Monteiro S Jr. Color in natural
multiple types of resin composites are necessary teeth and direct resin composite restorations: essential
aspects. Eur J Esthet Dent. 2007;2(2):172–86.
to achieve perfect biomimetics [13–17]. 6. Craig RG, Sakaguchi RL, Powers JM. Craig’s restor-
ative dental materials. Br Dent J. 2013;213(2):90.
2.2.2.2 Fluorescence 7. Shortall AC, Palim WM, Burtscher P. Refractive index
As previously mentioned, the dentin and the mismatch and monomer reactivity influence compos-
ite curing depth. J Dent Res. 2008;87(1):84–8.
enamel have a natural fluorescent effect on the 8. Da Costa J, Ferracane J, Paravina RD, Mazur RF,
tooth. In the composition of resin composites, Roeder L. The effect of different polishing systems on
rare earths are added to reproduce this effect surface roughness and gloss of various resin compos-
artificially. However, although, nowadays, all
­ ites. J Esthet Restor Dent. 2007;19:214–24. https://
doi.org/10.1111/j.1708-­8240.2007.00104.x.
resin composites have fluorescence properties, 9. O'Neill C, Kreplak L, Rueggeberg FA, Labrie D,
their intensities can vary depending on the con- Shimokawa CAK, Price RB. Effect of tooth brush-
centration of the rare earths added (see Fig. 1.8, ing on gloss retention and surface roughness of five
2 Natural Tooth X Composites Biomimetics 19

bulk-fill resin composites. J Esthet Restor Dent. 15. Ardu S, Krejci I. Biomimetic direct composite strati-
2018;30:59–69. https://doi.org/10.1111/jerd.12350. fication technique for the restoration of anterior teeth.
10. De Oliveira DC, Rocha MG, Gattia A, Correr (Erratum in: Quintessence Int. 2006 May;37(5):408).
AB, Ferracane JL, Sinhoreti MA. Effect of differ- Quintessence Int. 2006;37(3):167–74.
ent photoinitiators and reducing agents on cure 16. Dietschi D, Ardu S, Krejci I. A new shading concept
efficiency and color stability of resin-based com- based on natural tooth color applied to direct compos-
posites using different LED wavelengths. J Dent. ite restorations. Quintessence Int. 2006;37(2):91–102.
2015;43(12):1565–72. 17. Fahl N Jr. Achieving ultimate anterior esthetics with a
11. Villarroel M, Fahl N, De Sousa AM, De Oliveira OB new microhybrid composite. Compend Contin Educ
Jr. Direct esthetic restorations based on translucency Dent Suppl. 2000;26:4–13.
and opacity of composite resins. J Esthet Restor Dent. 18. Pop-Ciutrila IS, Ghinea R, del Perez Gomez MM,
2011;23(2):73–87. Colosi HA, Dudea D, Badea M. Dentin scatter-
12. Maia R, De Oliveira DC, D’Antonio T, Qian F, Skiff ing, absorption, transmittance and light reflectiv-
F. Double-layer build-up technique: laser evaluation ity in human incisors, canines and molars. J Dent.
of light propagation in dental substrates and dental 2015;43(9):1116–24.
composites. Int J Esthet Dent. 2018;13(4):1–14. 19. Pop-Ciutrila IS, Ghinea R, Colosi HA, Dudea
13. Fahl N Jr. Single-shaded direct anterior composite res- D. Dentin translucency and color evaluation in
torations: a simplified technique for enhanced results. human incisors, canines, and molars. J Prosthet Dent.
Compend Contin Educ Dent. 2012;33(2):150–4. 2016;115(4):475–81.
14. Dietschi D. Free-hand bonding in the esthetic treat- 20. Chirdon WM, O’Brien WJ, Robertson
ment of anterior teeth: creating the illusion. J Esthet RE. Mechanisms of goniochromism relevant to
Dent. 1997;9(4):156–64. restorative dentistry. Dent Mater. 2009;25(6):802–9.
 Color Selection in Operative
Dentistry
3
Vinícius Salgado and Dayane Oliveira

3.1 Illumination the same object can have its color distorted when
exposed to light sources with different color
As previously explained in Chap. 1, different temperatures.
light sources contain different wavelengths. This While low light intensity can affect hue per-
means that the color of the same object can be ception, the high light intensity can cause glare
perceived differently under different and result in fatigue to the eyes. In Dentistry, the
illuminations. recommended standard for color selection is a
People are usually exposed to light sources color temperature of 5500 K, which corresponds
during their routine: daylight, shade or cloudy to the ideal natural daylight. However, natural
sky, fluorescent light, incandescent light, etc. light conditions vary from 3000 to 8000 K
These different light sources have different color depending on the time (sunrise/sunshine) and the
temperatures. The color temperature is related to weather (sunny/cloudy). A practical way to have
the color appearance of the light emitted by the more color matching success regardless of the
light source. natural conditions is to use a standardizing day-
light lamp in the dental office. However, portable
light-correcting devices are also available to
3.1.1 Color Temperature assist chairside shade matching.

The color temperature is expressed in Kelvin (K).

Color temperatures over 5000 K are called cool 3.1.2 Light-Correcting Devices
colors (blueish white), while lower color temper-
atures are called warm colors (yellowish white). Portable light-correcting devices were designed
Daylight, fluorescent light, incandescent light, to assist chairside shade matching in Dentistry
for example, are warm colors, while the shade (Fig. 3.2). These devices consist of a ring with a
and cloudy sky are cooler colors (Fig. 3.1). Thus, window-hole that enables viewing the patient’s
teeth. The ring is attached to an ergonomic han-
V. Salgado (*) dle that allows the dentist to get very close to the
Private Practice, Rio de Janeiro, RJ, Brazil patients’ teeth. Inside the window-hole, LEDs
D. Oliveira simulating different illumination conditions. The
Department of Restorative Dental Sciences, College different LEDs are disposed of so that the teeth
of Dentistry, University of Florida, are illuminated equally from all directions to
Gainesville, FL, USA avoid glare, distortion, and reflection.
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 21

D. Oliveira (ed.), Color Science and Shade Selection in Operative Dentistry,
https://doi.org/10.1007/978-3-030-99173-9_3
22 V. Salgado and D. Oliveira

worthwhile to mention that the use of a polariz-

ing filter does not help shade matching. But it can
help achieve shade matching by identifying
­internal details of the teeth for future character-
ization and layering [1, 2].

3.2 Color Selection Methods

for Composite Restorations

Color selection is the first step before restoring a

tooth. Different methods are described in the lit-
erature to select color in Dentistry. These meth-
ods are mainly categorized as subjective methods
(more commonly known as visual methods) or
objectives methods. The most traditionally used
method is the visual analysis of color.

3.2.1 Visual Methods

The color of teeth is mainly subjectively mea-

sured by the visual comparison method using a
shade guide tab, or material increments placed
close or onto the tooth surface [3].

3.2.1.1 Using Shade Guides

for Ceramics
The Vitapan Classical shade guide (VITA
Zahnfabrik) is the most used shade guide in
worldwide clinical practice. Introduced in 1983,
it is based on VITA previous shade guide, Lumin-­
VACUUM (which was introduced in 1956). It has
16 different acrylic shade tabs empirically orga-
nized by the manufacturer (Fig. 3.4). Each tab
has cervical, body, and incisal colors over an
opaque background, and it is identified and
named according to the body shade. The color
Fig. 3.1 Cool colors and warm colors: color temperature
of different light sources range is divided into four different hue groups
designated by A, B, C, and D letters, representing
reddish–brownish for A hue, reddish–yellowish
Both devices contain LEDs with 5500 K color for B hue, grayish for C hue, and reddish–gray
temperature simulating the outdoor daylight. for D hue. For each hue group, there are different
Other LEDs simulate indoor ambient light from tabs differentiated by an Arabic number ranging
halogen and incandescent light sources. from 1 to 4, with different Chromas and values.
These devices also have a polarizing filter that The higher the number, the higher Chroma and
eliminates reflection and enhance the visualiza- the lower the value. The tabs of the Vita Classical
tion of internal details of the teeth (Fig. 3.3). It is shade guide can also be repositioned in value
3 Color Selection in Operative Dentistry 23

Fig. 3.2 Portable light-correcting devices: Smile Lite (Styleitaliano) and Rite Lite (Addent)

Fig. 3.3 Details’

perception using
light-correcting devices
with and without
polarizing filters
24 V. Salgado and D. Oliveira

Fig. 3.4 Ceramic shade guides: Vitapan Classical (VITA Zahnfabrik)

Fig. 3.5 Ceramic shade guides: Noritake (Kuraray Noritake)

order: B1, A1, B2, D2, A2, C1, C2, D4, A3, D3, and 4 original shade tabs (NW0, NW0.5, NP1.5,
B3, A3.5, B4, C3, A4, C4. In this way, the tabs and NP2.5). The NP hue corresponds to the
will be reordered from the brighter to the darker slightly reddish shades than VITA A hue. The
shade. NP1.5 Chroma is between A1 and A2 shades
There are other shade guides designed for while the NP2.5, between A2 and A3 shades. The
ceramic restorations that follow the Vitapan NW hue was created for whiter teeth (low
Classical color distribution concept. The A–D Chroma and high value) and its two tabs were
shade guide (Ivoclar Vivadent) is the common design to match adjacent bleached teeth.
color standard for Ivoclar Vivadent ceramics The Toothguide 3D-MASTER shade guide
(Fig. 3.5). It also has 16 different acrylic shade (VITA Zahnfabrik), however, is shade guide
tabs. The Noritake shade guide (Kuraray already structured on Value (Fig. 3.7). The
Noritake) is the color standard for Noritake Toothguide 3D-MASTER shade guide is based on
ceramics (Fig. 3.6). It contains 20 different shade the principle of choosing color in three quick steps.
tabs, 16 based on Vitapan Classical color concept First, selecting an appropriate value (from 1 to 5)
3 Color Selection in Operative Dentistry 25

Fig. 3.6 Ceramic shade guides: A–D (Ivoclar Vivadent)

Fig. 3.7 Ceramic shade guides: Toothguide 3D-MASTER shade guide (VITA Zahnfabrik)

according to the patient’s tooth. Then, selecting the shade tabs but with simplified presentation and a
corresponding Chroma into that value. In this step, two-­step shade matching procedure: only 6 (step 1)
it is recommended to choose the middle hue group and up to 7 (step 2) linearly arranged tabs instead of
(M) to determine the Chroma (from 1 up to 3). 29 tabs presented at the beginning of a three-­step
Finally, choosing the final color, checking whether procedure with Toothguide 3D-MASTER.
the patient’s tooth is more reddish (R) or more yel-
lowish (L) in comparison to the guide tab. In order 3.2.1.2 Using Shade Guides
to simplify the color selection of Toothguide for Composites
3D-MASTER, the Linearguide 3D-MASTER shade The majority of resin-based composites colors
guide (VITA Zahnfabrik), was introduced in 2008 are named based on the Vitapan Classical color
(Figs. 3.8, 3.9, 3.10 and 3.11). It contains the same distribution concept. However, several other
26 V. Salgado and D. Oliveira

Fig. 3.11 Ceramic shade guides: second step of shade

Fig. 3.8 Ceramic shade guides: Linearguide 3D-MASTER determination using the Linearguide 3D-MASTER shade
shade guide (VITA Zahnfabrik) guide. Linear arranged group of tabs with the same value
(2), but different hue and Chroma

between the color of a Vitapan Classical tab and

the correspondent resin-based composite. This
color mismatch is mainly explained due to the
translucency difference between the different
materials [4].
For this reason, several resin-based composite
systems have their shade guide. Differently from
color shade guides made for ceramic restorations,
Fig. 3.9 Ceramic shade guides: first step of shade deter-
their tabs have similar translucency of the respec-
mination using the Linearguide 3D-MASTER shade guide. tive composite restorative materials. There are
Six linearly arranged shade tabs that indicate the value different tab shapes and thicknesses with the
(0M2–5M2) color concept based on the individual restorative
system’s color availabilities (Figs. 3.12, 3.13,
3.14, 3.15, 3.16, 3.17 and 3.18).

3.2.1.3 Using Personalized Shade

Guides
When a resin-based composite system does not
have its shade guide, dentists may craft their per-
sonalized color guides [5, 6]. Based on the
selected mastered layering concept of the dentist,
the shade tabs can be monochromatic or have
multiple layers. These personalized tabs can be
craft using a polyvinyl siloxane mold, with
Fig. 3.10 Ceramic shade guides: second step of shade ceramic shade tab shape, e.g., from Vitapan
determination using the Linearguide 3D-MASTER shade Classical (Fig. 3.19). There are some commer-
guide. Taking the linear arranged group of tabs with same cially available custom-made shade guides as My
value from the shade guide
Shade Guide (SmileLine) (Fig. 3.20) or even
from the resin-based composite system itself as
resin-based composites are non-VITA-based, the Estelite composites (Tokuyama) (Fig. 3.18).
having other color concepts and different nomen-
clatures. Shade tabs made from the same material 3.2.1.4 Using Increments
used in the restoration are necessary to avoid of Composites
color mismatch. Despite the same nomenclature, The majority of restorations do not occupy an
the color match is frequently not acceptable extensive area on the tooth. The placement of
3 Color Selection in Operative Dentistry 27

Fig. 3.12 Composite shade guides: dentin shades of IPS Empress Direct system (Ivoclar Vivadent)

Fig. 3.13 Composite shade guides: enamel and translucent shades of IPS Empress Direct system (Ivoclar Vivadent)

increments of the restorative material onto the In this technique, the increments should be
dental surface allows observation of optical prop- large enough to allow proper observation
erties interaction between the material and the (Ø = 1 mm at least). The photoactivation should
dental tissues. Moreover, the thickness of a shade be performed the same as for the “final” restora-
tab is higher compared to most restorations. tion to avoid color misinterpretation due to the
There is no rule for placing the increments onto color change that occurs after cure. Then, the
the dental surface. However, the dentist should tooth and material should be wet, and the obser-
have in mind the layering concept used vation should be performed for no longer than 5 s
(Figs. 3.21–3.23). (Fig. 3.24). The chosen composite colors should
28 V. Salgado and D. Oliveira

a b

Fig. 3.14 (a) Composite shade guides: dentin shades of Miris2 system (Coltene). (Photography courtesy of Coltene).
(b) Composite shade guides: enamel and effect shades of Miris2 system (Coltene). (Photography courtesy of Coltene)

Fig. 3.15 Composite shade guide: Brillant system (Coltene). (Photography courtesy of Coltene)

Fig. 3.16 Composite

shade guide: Opallis
system (FGM)
3 Color Selection in Operative Dentistry 29

be registered as well as the respective color map caused by a decrease in lightness and Chroma
draw (further explained in Chap. 7). after photopolymerization. In general, the
The resin composite that is not polymerized decrease in lightness occurs because the mono-
into the syringe is usually darker than the mers form polymers through the polymerization
­photopolymerized increment used during resin process. This reaction causes the reduction of
placement. These color differences are mainly their refractive indices, thus changing the way the
light is transmitted, reflected, and refracted. The
decrease in Chroma, however, occurs due to the
consumption of the photoinitiator during the pho-
toactivation process. Camphorquinone is the
most commonly used photoinitiator in Dentistry.
However, as a yellow-colored molecule, after
reacting, its consumption leads to a decrease in
composite yellowness.

3.2.1.5 Using the Mock-up Technique

To confirm the selected composite colors, regard-
less of shade selection technique (e.g., using
ceramic or composite shade guide tabs or by
increments of composites), a color mock-up may
be made [7]. It is a non-bonded full shape restora-
tion made free-handed. Then, it is flaked off from
the tooth to observe the layering from both inner
Fig. 3.17 Composite shade guide: Palfique system and outer aspects. It provides the opportunity to
(Tokuyama) “rehearse” the contour and thickness of each den-

Fig. 3.18 Composite shade guide: Estelite Omega system (Tokuyama). (Photography courtesy of Tokuyama Dental)
30 V. Salgado and D. Oliveira

Fig. 3.19 Composite shade guide: Filtek Universal system (3M). (Photography courtesy of 3M)

a b

Fig. 3.20 Personalized shade guides using My Shade Guide (Smile Line): (a) filling a rubber mold with resin-based
composite; (b) pressing to remove excess; and (c) photoactivation

tin and enamel layer and ascertain the color out- natural tooth. This technique also helps to avoid
come from the mixed shades [8, 9]. This technique goniochromism (previously explained in Chap.
allows checking whether the combination of the 1), once the different translucent layers are repro-
different shades that were chosen to do really duced to confirm the final color of the restoration
match with the polychromatic appearance of the from different angles.
3 Color Selection in Operative Dentistry 31

a b

Fig. 3.21 Personalized shade guides using My Shade Guide (Smile Line): crafted tab of resin-based composite, before
(a) and after (b) joining pieces

Figs. 3.22–3.24 Visual color selection for direct restorations using increments of composite according to different
layering concepts
32 V. Salgado and D. Oliveira

3.2.1.6 Visual Color Measurement

Technique
Color from any object, as the tooth and shade
guide tab, is directly influenced by illumination.
Then, it is essential to place the tab equally lev-
eled with teeth to get the same amount of illumi-
nation (Fig. 3.25). To perform an optimized color
measurement, first, patients should be asked to
remove any lipstick or shiny lip balms. The
patient should be asked to sit and tilt his head up,
pointing their smile towards the ceiling light. The
shade guide must be brought close to the smile to Fig. 3.27 Visual color selection for direct restorations
initially pre-select a few coloring tabs. using shade tabs: different shade tabs mirrored placed to
Then, lip retractors should be used to expose teeth without any neutral background
teeth, and a black or gray background should be
inserted behind them to neutralize the reddish
influence of the oral cavity tissues (Figs. 3.26,
3.27, 3.28 and 3.29). Finally, one at a time, the
pre-selected tabs should be mirrored placed close

Fig. 3.28 Visual color selection for direct restorations

using shade tabs: placement of a gray background behind
Fig. 3.25 Visual color selection for direct restorations upper teeth to neutralize the reddish influence of oral cav-
using increments of composite: after photoactivation, ity background
teeth and restorative material should be wet for visual
observation

Fig. 3.26 Visual color selection for direct restorations Fig. 3.29 Visual color selection for direct restorations
using shade tabs: mirrored shade tab placement to teeth in using shade tabs: importance of lip retraction to provide
order to get the same amount of illumination proper illumination to teeth and shade tab
3 Color Selection in Operative Dentistry 33

to the tooth to receive the same amount of light.

Therefore, the tab that most closely matches the
tooth color should be registered. Visual
­observation should not exceed 5 s to avoid color
misinterpretation due to visual fatigue.
As previously described in Chap. 1, several
factors can negatively influence the correct color
measurement by visual methods, including varia-
tions in the type, quality, and intensity of light,
professional’s color blindness or deficiency in
color perception, differences in gender and pro-
fessional’s experience [10–13]. Fig. 3.31 Use of a portable light-correcting device to
color measurement: Smile Lite MPD (Smile Line)
Visual color measurements should be taken at
ideal illumination conditions. As earlier explained
in this chapter, a light source suitable for visual 3.2.2 Objective Measurements
observation should have correlated color tempera-
ture of a full-spectrum balanced light between Clinically, the objective tooth color measurement
5500 and 6500 K. During the visual shade match- can be assessed by different dental shade-­
ing, the light intensity should be diffuse, allowing matching devices that have been brought to the
clinicians to perceive color accurately and com- market to surpass the inconsistencies of visual
fortably. The recommended lighting intensity for shade matching. Examples are the spectropho-
the dental office is 200–300 fc or 500–600 lx [2, tometers [15, 16] and the colorimeters [17, 18].
14]. Light-correcting devices are available to min- The dental spectrophotometers measure the
imize the external lighting interference of dental amount of light energy reflected from the tooth
offices due to variations in the daytime, the season surface at different wavelengths (1–25 nm inter-
of the year, and the resultant mixture between vals) of the visible spectrum and convert the
daylight and fluorescent or incandescent light numerical color values (CIELAB color coordi-
from the room. Handheld light-emitting diode nates) to the equivalent tab from a dental shade
devices with 5500 K of color temperature can be guide. CrystalEye (Olympus America), Vita
used for this purpose as the Rite-Lite 2 and the Easyshade V (VITA), Shade-X (X-Rite), and
Rite-Lite Pro (Addent) (previously illustrated, SpectroShade Micro (MHT) are commercially
Figs. 3.2 and 3.3), and the Smile Lite and the Smile available examples of dental spectrophotometers.
Lite MPD (Smile Line) (Figs. 3.30 and 3.31). On the other hand, dental colorimeters do not
register spectral reflectance; they measure tooth
color according to the tristimulus values (CIE
XYZ) by filtering the reflected light into red,
green, and blue areas of the visible spectrum and
converting these to CIELAB color coordinates,
and then to the correspondent tab from dental
shade guide [19]. ShadeVision (X-Rite) is a
commercially available example of a dental
­
imaging colorimeter.
Colorimeters and spectrophotometers have
broad application in tooth whitening longitudinal
studies, and they can be used clinically to evalu-
ate tooth color variation during the whitening
Fig. 3.30 Visual color selection for direct restorations
using shade tabs: zoomed view of operative field in ideal treatment period. However, clinicians must take
lighting conditions care to avoid inaccurate measurements when
34 V. Salgado and D. Oliveira

Fig. 3.33 Objective color measurement using Vita

Easyshade V. (Photography courtesy of Bryce Brandfon,
Fig. 3.32 Using a phone to register photographically the Franciele Floriani, and Nathalie Sawczuk)
shade matching with the Smile Lite MPD (Smile Line)
even their indication for research studies, its clin-
using these devices. Since they are contact-­ ical use to monitor color change during tooth
measuring instruments, the results can be affected whitening treatments is still a challenge due to its
by the wrong positioning of the measuring probe, complexity (Fig. 3.33).
fogging of the optical lens, ambient illuminant
used, and by the background, while taking the
measurements [20, 21]. References
These devices have different prices, designs,
software, and data output. They can measure the 1. Clary JA, Ontiveros JC, Cron SG, Paravina
RD. Influence of light source, polarization, education
tooth’s overall surface color or in limited areas. and training on shade matching quality. J Prosthet
Overall tooth surface color measurement devices Dent. 2016;116(1):91–7.
such as the CrystaEye, the SpectroShade Micro, 2. Gasparik C, Grecu AG, Culic B, Badea ME,
and the ShadeVision provide a color map with the Dudea D. Shade-matching performance using a
new light-correcting device. J Esthet Restor Dent.
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according to the tooth three thirds: cervical, body, 3. Joiner A. Tooth colour: a review of the literature. J
and incisal. Limited area measurement devices Dent. 2004;32(Suppl 1):3–12.
such as the Easyshade V, and the Shade-X pro- 4. Browning WD, Contreras-Bulnes R, Brackett MG,
Brackett WW. Color differences: polymerized com-
vide the color correspondent the color tab from a posite and corresponding Vitapan classical shade tab.
shade guide according to the 3–5 mm diameter J Dent. 2009;37(Suppl 1):e34–9.
area of measurement of the tip of the probe of the 5. Fahl N Jr. Single-shaded direct anterior composite res-
device. For this reason, to monitor color change torations: a simplified technique for enhanced results.
Compend Contin Educ Dent. 2012;33(2):150–4.
during tooth whitening, for example, the probe 6. Dietschi D, Fahl N Jr. Shading concepts and layering
should be placed in the center of the middle third techniques to master direct anterior composite resto-
from the tooth buccal surface (Fig. 3.32). rations: an update. Br Dent J. 2016;221(12):765–71.
The tooth color can also be objectively mea- 7. Dietschi D. Free-hand bonding in the esthetic treat-
ment of anterior teeth: creating the illusion. J Esthet
sured by image analysis techniques obtained with Dent. 1997;9(4):156–64.
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ners [25–27]. Despite the encouragement of its new microhybrid composite. Compend Contin Educ
use to improve communication with dental tech- Dent Suppl. 2000;26:4–13.
9. Dietschi D. Optimising aesthetics and facilitating clin-
nicians to diminish the color matching disagree- ical application of free-hand bonding using the ‘natu-
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3 Color Selection in Operative Dentistry 35

10. Della Bona A, Barrett AA, Rosa V, Pinzetta C. Visual 19. Chu SJ, Trushkowsky RD, Paravina RD. Dental color
and instrumental agreement in dental shade selection: matching instruments and systems. Review of clinical
three distinct observer populations and shade match- and research aspects. J Dent. 2010;38(Suppl 2):e2–16.
ing protocols. Dent Mater. 2009;25(2):276–81. 20. Chu SJ. Use of a reflectance spectrophotometer in eval-
11. Simionato A, Pecho OE, Della BA. Efficacy of color uating shade change resulting from tooth-whitening
discrimination tests used in dentistry. J Esthet Restor products. J Esthet Restor Dent. 2003;15(s1):S42–8.
Dent. 2020;33(6):865–73. 21. Raoufi S, Birkhed D. Effect of whitening tooth-
12. Pecho OE, Ghinea R, Perez MM, Della BA. Influence pastes on tooth staining using two different colour-­
of gender on visual shade matching in dentistry. J measuring devices—a 12-week clinical trial. Int Dent
Esthet Restor Dent. 2017;29(2):E15–23. J. 2010;60(6):419–23.
13. Samra APB, Moro MG, Mazur RF, Vieira S, De Souza 22. Gerlach RW, Barker ML, Sagel PA. Objective and
EM, Freire A, Rached RN. Performance of dental stu- subjective whitening response of two self-directed
dents in shade matching: impact of training. J Esthet bleaching systems. Am J Dent. 2002;15:7A–12A.
Restor Dent. 2017;29(2):E24–32. 23. Wee AG, Lindsey DT, Kuo S, Johnston WM. Color
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2016;115(4):469–74. son between a new visual method of colour matching
15. Chen H, Huang J, Dong X, Qian J, He J, Qu X, Lu by intraoral camera and conventional visual and spec-
E. A systematic review of visual and instrumental trometric methods. J Dent. 2011;39(Suppl 3):e29–36.
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Int. 2012;43(8):649–59. Pimentel W, Tiossi R. A comparison between visual,
16. Kim-Pusateri S, Brewer JD, Davis EL, Wee intraoral scanner, and spectrophotometer shade match-
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matching devices. J Prosthet Dent. 2009;101(3):193–9. 26. Yoon HI, Bae JW, Park JM, Chun YS, Kim MA, Kim
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18. Karaagaclioglu L, Terzioglu H, Yilmaz B, Yurdukoru 27. Ebeid K, Sabet A, Della BA. Accuracy and repeatabil-
B. In vivo and in vitro assessment of an intraoral den- ity of different intraoral scanners on shade determina-
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 Color Evaluation for Research
Purposes
4
Camila Sampaio and Pablo Atria

4.1 Introduction and evaluated, which favored color matching,

communication, reproduction, and verification in
According to published surveys, color education, clinical and research dentistry. This approach
color training, and shade matching programs are was changed back in 1973 and 1974 when Sproul
receiving increased attention over the last decade, stated that “the technology of color is not a sim-
according to published surveys [1]. This fact is ple matter that can be learned without study; nei-
directly related to patients’ expectations and ther is it a complicated matter beyond dentists’
demands in achieving dental restorations that can comprehension” [5]. After that, a huge effort was
mirror their adjacent natural teeth or improve put on new teaching methods using modern tech-
their tooth esthetical characteristics with colored nology to help dental professionals and dental
artificial restorations [2]. In this topic, color can students to learn about color in an organized and
be underrated, as patients do not often explicitly comprehensive manner. Nowadays, scientific
ask for the “color of their restorations.” Instead, journals have editorials whose objective is spe-
they expect functional, long-lasting, and esthetic cifically to study color and its influences on shade
restorations, with color being put as a back- matching and color changes [2].
ground, unimportant or taken for granted, even Color is defined as the result of the interaction
though it could be the decisive factor in the over- of light with an object, which means that a given
all acceptance of the treatment itself [3]. object’s compositional characteristics greatly
A few years from now, color was not such a impact the way light is absorbed by or reflected
trendy and studied topic, but today it is consid- from this object, as further explained in Chap. 1
ered an ever-expanding field, equally relevant for [6]. The natural teeth are polychromatic, mean-
clinical application, research, and education [4]. ing many colors and optical characteristics can be
Due to advances in color measurement, digital perceived when observed under ideal light condi-
instruments can promote a numerical measure- tions [6]. Since enamel, dentin, and pulp present
ment, allowing color to be metrically recorded different composition, they also interact with
light differently, resulting in an extremely com-
C. Sampaio (*)
plex interaction, which is difficult to be repro-
College of Dentistry, University of the Andes, duced with artificial materials [6]. Differences
Santiago, Chile between younger and older teeth exist regarding
e-mail: [email protected] the color value, Chroma, and transparency. For
P. Atria instance, young teeth present a high color value
Biomedical Engineering, New York University, due to the high quantity of enamel, while older
New York, NY, USA

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 37

D. Oliveira (ed.), Color Science and Shade Selection in Operative Dentistry,
https://doi.org/10.1007/978-3-030-99173-9_4
38 C. Sampaio and P. Atria

However, it is also the most common method

used in dental practice and should not be
underrated.
Visual methods consist of the observer visu-
ally selecting the best match for an object when
this object is compared visually to tooth color
examples such as shade guides. The shade
guides most commonly used in the dental prac-
Fig. 4.1 Color and texture comparison of older (left) and tice, as well as in research, are the VITA
younger (right) teeth. Observe the lower color value pres- Classical shade guide and the VITA Toothguide
ent on the older teeth, while a higher color value is 3D-Master System, both from VITA Zahnfabrik
observed in the younger teeth. Moreover, some regions of (Bad Säckingen, Germany) [1]. The Vitapan
the older teeth can be observed as almost transparent due
to the thickness of the substrate, while in the younger Classical shade guide configuration is also
teeth, the original teeth textures and translucencies can be known as A-to-D arrangement, divided into 16
noted tabs originally arranged into four groups based
on hue and within the groups according to
teeth present a much lower color value than that increasing Chroma [11]. On the other hand, the
which is seen in younger teeth, as it becomes Vitapan 3-D Master shade tabs are arranged
thinner and more translucent over time, some- three-dimensionally, divided into groups
times becoming nearly transparent (Fig. 4.1) [7]. according to lightness, and within the groups
according to saturation (vertically) and hue
(horizontally) [12]. Six different levels of
4.2 Visual Methods to Evaluate lightness were used to create six groups of
Color tabs, from 0 (the lightest) to 5 (the darkest).
There are 3 Chroma levels, from 1 (the least
Color is defined as a combination of hue, Chroma, chromatic) to 3 (the most chromatic) in each
and value. Hue is defined as the name of color group (except in group 1 that has two Chroma
itself, for instance, red or yellow. Chroma is the levels). Intermediate Chroma levels (1.5 and
degree of hue saturation, or the intensity exhib- 2.5) in groups 2, 3, and 4 are associated with
ited by a color. Finally, value is defined as the hue variations—L (less red) and R (more red).
brightness or luminosity of color [8]. Although More recently, the same brand launched the
no single method is considered standard, two Linearguide 3D-Master [11]. Other brands also
methods exist to evaluate color in dentistry, have their A–D arrangements shade guides,
which are visual and instrumental. Several kinds which can correlate (although not 100% accu-
of research compare both methods revealing their rately) to the Vitapan Classical shade guide
pros and cons. One important finding of such [13].
research is that both methods should be used With this being said, when performing visual
together whenever it is possible, as they can com- selection, the final color decision is totally
plement each other and lead to a predictable operator-­
dependent. Studies demonstrated that
esthetic outcome [9]. the color preferences of observers and shade
The visual method is often considered subjec- selection are dependent on: the level of experi-
tive, as it can exhibit a higher level of inconsis- ence of the operator, with education and training
tencies for both intra-rater and inter-rater presenting a statistically significant improvement
comparisons, while instrumental or digital meth- in shade matching [3, 14]; the operator’s gender,
ods can exhibit significantly higher reliability with some studies showing that females are better
[10]; also, it is strongly dependent on the interac- in color match than males [15, 16], while other
tion between light and the dental structure. indicates that this is not a decisive factor [15, 17];
4 Color Evaluation for Research Purposes 39

on the type of color, with darker and more chro- in achieving a more accurate shade selection
matic shade tabs being more often mismatched result.
[3, 17]; on skin shades and gingival shades,
among others [18, 19].
Increased shade matching accuracy can be 4.2.1 Color Blindness Test or
translated into enhanced dental restorations Ishihara Test
esthetics, increased patient satisfaction, and
reduced color corrections [3]. For that purpose, Color blindness, color deficiency, or color vision
manufacturers are launching restorative materials alteration occur when the correct determination
with visual color adjustment potential to blend of the color of an object is altered. It is presented
with the surrounding enamel and dentin, result- in about 8% of the male population and 0.5% of
ing in reduced color differences and, therefore, the female population [22]. This alteration affects
improving the restoration’s esthetic appearance, the ability to identify the red, green, yellow, or
simplifying the shade matching compensating for blue colors in charge of cells located in the retina
any color mismatch [9, 20]. called cones. On the other hand, detecting
When performing visual shade matching only, changes in value or luminosity is not influenced
the only color information provided to the techni- by color deficiencies. It depends on retinal cir-
cian by many clinicians is the laboratory pre- cuits other than photoreceptor cells [22]. When
scription. However, a method to improve shade testing for color blinding, graphic designs and
matching with this technique is by performing a illustrations can be created and used, with tests
color map (Fig. 4.2), which can be simply drawn consisting of numbered colored plates, mostly
in the lab prescription or sent in a photograph. A known as Ishihara plates containing a circle of
simple photograph taken with a smartphone can dots appearing randomized in color and size
be manipulated and improves shade matching (Fig. 4.3).
and decreasing color difference values (ΔE) of In research, except for the studies which have
the comparison between the restoration per- as main objective evaluating people with color
formed by the technician and the tooth color of deficiencies [22], studies on color training typi-
comparison, as observed in a recent study [21]. cally exclude those individuals [17–19, 23, 24].
This subject will be discussed below and can help However, many times color deficiencies are an

Fig. 4.2 Example of Ishihara vision testing chart

40 C. Sampaio and P. Atria

established successfully to correct color in

esthetic restorations [26, 27].

4.2.2 Color Perception × Color

Acceptance Thresholds

A visual threshold consists of perceiving a differ-

ence in color and whether this difference is visu-
ally acceptable or not, or in other words, which
are recognizable and tolerable. Color thresholds
are important not only in the field of Dentistry,
but also serve as quality control for a number of
applications [4]. It also helps evaluating the clini-
cal performance of materials, both in the clinical
practice and in vivo and in vitro research, evalu-
ating and interpreting a clinical outcome, and
Fig. 4.3 Color mapping of teeth, important information
can be reported to lab technicians with color maps, this
standardization. The importance of quality con-
can be done drawn in a lab prescription or in photographic trol in dentistry is reinforced by increased
means, through digital cameras or smartphones, which patients’ and dental professionals’ esthetic
allow color manipulation by both dentist and technician demands [4].
When performing color thresholds, the
underdiagnosed disease, but very relevant in peo- color perception threshold question is: “Can
ple who study Dentistry. you see a difference in color between these two
Participants for research purposes are usually specimens?” If the observer answered “yes” to
screened or tested for their color vision, partici- this question, they were asked the acceptability
pating in an evaluation of perceptibility and threshold question: “Would you consider this
visual acceptability judgments in Dentistry [24], difference to be color acceptable in a patient’s
and need to pass a dental color matching compe- mouth?” The psychometric function is then
tency, according to the ISO/TR 28642:2016 [25]. simply the percentage of “yes” responses as a
For example, participants need to match at least function of specimen color difference; 50%
60% of the pairs of tabs from Vita Classical shade “yes” responses were considered the threshold
guide (below 60%—no competency). Minimum level [24]. Basically, this can be resumed as:
of 60% (10 pairs of tabs), 75% (12 pairs), and when the color difference between compared
85% (14 pairs) corresponded to poor, average, objects can be seen by 50% of observers (the
and superior color matching competency, respec- other 50% will notice no difference), we are
tively [20]. A previous study concluded that talking about the 50:50 perceptibility thresh-
observers with superior color matching compe- old. When the color difference is considered
tence could achieve better color matching results acceptable by 50% of observers (the other 50%
than those with the average color discrimination would consider it unacceptable), this corre-
competence [17]. sponds to the 50:50 acceptability threshold. A
It is important to point out that the human eye color match in dentistry is a color difference at
is more sensitive to changes in luminosity and or below the former threshold; an acceptable
less sensitive to changes in tone. Every person color match is a color difference at or below
should perceive changes in the value before per- the later one [28, 29].
ceiving changes in the hue Chroma of a tooth Paravina et al. investigated the relationship
[26]. Value is a fundamental aspect that must be between “50:50% perceptibility thresholds” and
4 Color Evaluation for Research Purposes 41

“50:50% acceptability thresholds.” They defined 4.3.1 CIE-Lab and CIE-LCh

the terms “50:50% perceptibility threshold” or
“50:50% acceptability threshold” and referred The CIE (Commission Internationale de
to values where 50% of the observers perceive, l’Eclairage) has been traditionally involved in
or still accept, respectively, a color difference. colorimetry for dental materials. It has been
They found differences in shade selection of responsible for introducing the main color sys-
50:50% perceptibility (ΔEab = 1.2, ΔE00 = 0.8) tems, illumination patterns, and color difference
and 50:50% acceptability (ΔEab = 2.7, (ΔE) concepts used in color science [32]. In order
ΔE00 = 1.8) were significantly different [4]. to unify criteria about color and to simplify com-
These results were later implemented in the ISO munication between professionals, the CIE
28642:2016 [25]. developed the CIE-Lab system. With this system,
Although obviously, color matches at or below all colors can be easily captured and described.
the perceptible threshold would be ideal, achiev- The CIE-Lab color space system (Fig. 4.4) con-
ing a non-perceivable match is costly, time-­ sists of describing the colors within the Cartesian
consuming, and frequently not essential on a coordinates as L, a*, and b*, where L* is the
clinical basis [4]. The color difference formulas lightness coordinate (brightness or value), which
are important to allow a better correlation connects an imaginary south pole (0—black)
between visual judgments (perceptibility and with an imaginary north pole (100—white), and
acceptability) and instrumental color difference all gray values are represented in this vertical
values [30]. line. On the sphere’s equator, all other saturated
colors are shown, corresponding to the Chroma
of the colors. The right angles in the equator
4.3 Digital Methods to Evaluate plane, the a*- and b*-axis, that represent the
Color directions of the color valences red–green (posi-
tive–negative) and yellow–blue (positive–nega-
Instrumental methods have been used to improve tive), respectively. Each color has a specific
color selection and communication and have numerical value, thus providing a more objective
been reported to be more reliable than the visual characterization and assisting in color communi-
method used by itself. They became very popular cation [27].
in dental research due to the development of new In research, most of the studies quantify color
technologies that are user-friendly and offer differences using the CIE-Lab color space and
objective information on color specification, as associating with the ΔE, which is related to a
well as magnitude and direction of color differ- color difference formula.
ences [31]. Dental shade matching instruments
can overcome or reduce imperfections and incon-
sistencies of traditional shade matching with
shade guides [28]. However, whenever possible,
visual and instrumental methods should be com-
bined [9], as it should not be forgotten that
patient’s visual judgment on color match or mis-
match is usually the final and decisive one [31].
Advances in color measuring devices may
remove a certain degree the subjectivity of the
color determination and enhance the reliability of
shade matching and shade communication [10].
Also, reliability is significantly better with the
instrumental shade matching method than the
visual method [10]. Fig. 4.4 CIE-Lab color space
42 C. Sampaio and P. Atria

When working with the CIE-LCh system and difference has been used extensively in dental
for more clearness, the Cartesian coordinates (L, research and applications [30]. In the majority of
a*, b*) can be converted into cylinder coordi- dental color studies, color and color differences
nates L, C, ho according to the following are quantified using the CIE-Lab color space and
formulas: the associated ΔEab.

C = a 2 + b2 –– CIE76
Based on the L a*b* values of each color,
b
h o = arctan   , color determination differences can be mea-
a sured and evaluated. The L a*b*—or CIE-Lab
where L remains unchanged, C (Chroma) repre- color space (CIE of 1976) was the first for-
sents the distance from the polar axis and repre- mula to measure color difference (ΔE) accord-
sents the color intensity; and ho is the hue angle in ing to the CIE-Lab coordinates. It is the most
the equatorial plane (Fig. 4.5). Hue angle starts at commonly used in publications and color dif-
the +a* axis and is expressed in degrees (e.g., 0° ferences (ΔEab) and is calculated according to
is +a*, or red, and 90° is +b, or yellow). It has the the Euclidean difference formula [23]:
same diagram as the L*a*b* color space but uses
cylindrical coordinates instead of rectangular
∆Eab = ( L1 − L2 ) + ( a1 − a 2 ) + ( b1 − b 2 )
2 2 2
coordinates [23].

∆Eab = ∆L2 + ∆a 2 + ∆b 2 .
4.3.2 Color Difference Formulas
(ΔE)
–– CIE94
Color difference formulas provide a quantitative The CIE94 formula is defined in the
representation of the perceived color difference L*C*h* color space, showing the color differ-
(ΔE) between a pair of colored samples under a ences in lightness (or value), Chroma and hue
given set of experimental conditions [29]. Color calculated from the Lab coordinates:

2 2 2
 ∆L∗   ∆Cab ∗
  ∆H ab∗

∆E∗94 =   +  + 
 K L S L   K C SC   K H S H 

∆L∗ = L∗1 − L∗2

C1∗ = a∗ 21 +b∗ 21 .

–– CIEDE2000
Different color difference formulas were
launched aiming to improve the correction
between computed and perceived color differ-
ences and reflect the individual subjective
impression of a color difference. Nowadays,
the CIEDE2000 (ΔE00) is the most accepted
and CIE recommended color difference for-
mula in dentistry, providing a better fit than
Fig. 4.5 CIE-LCh color space the previous formulas, and therefore replacing
4 Color Evaluation for Research Purposes 43

them [30]. The CIEDE2000 utilizes the con- importance of the conceptual developments of
cepts of Chroma and hue, reinforcing the Munsell [32]:

2 2 2
 ∆L′   ∆C ′   ∆H ′  ∆C ′ ∆H ′
∆E∗100 =   +  +  + RT .
K S K S
 L L  C C  H HK S K C SC K H S H

It incorporates specific corrections for non-­ vals along the visible spectrum [35, 36]. A spec-
uniformity of CIE-Lab color space (the ­weighting trophotometer contains a source of optical
functions: SL, SC, SH), a rotation term (RT) that radiation, a means of dispersing light, an optical
accounts for the interaction between Chroma and system for measuring, a detector, and converting
hue differences in the blue region and a modifica- light obtained to a signal that can be analyzed.
tion of the a* coordinate of CIE-Lab, that mainly After that, the data obtained from spectropho-
affects colors with low Chroma (neutral colors) tometers must be manipulated and translated into
and parameters accounting for the influence of a form useful for dental professionals [28]. The
illuminating and vision conditions in color differ- instruments’ measurements are frequently keyed
ence evaluation (the parametric factors: KL, KC, to dental shade guides and converted to a shade
KH). The parametric factor ratio was proposed as tab equivalent [37]. Compared with observations
a way to control changes in the magnitude of tol- by the human eye or conventional techniques, it
erance judgments and as a way to adjust for scal- was found that spectrophotometers offered a 33%
ing of acceptability rather than perceptibility. increase in accuracy and a more objective match
Studies on visual judgments performed in textile in 93.3% of the cases [38].
color acceptability and dental ceramics accept- The most used and known spectrophotometer
ability showed that using KL = 2 resulted in color available in the market, used for both research
differences better correlated to observations from and clinical aims, is the Vita Easyshade (Vita
a subset of average observers. Zahnfabrik) (Fig. 4.6). It is a contact-type spec-
When compared, changes in color calculated trophotometer that provides enough shade infor-
with the CIE-LAB and the CIEDE2000 formulas mation to help aid in the color analysis process.
followed similar trends but with different abso- Different measurement modes are possible with
lute values when calculated [33]. this instrument: tooth single-mode, tooth area
mode (cervical, middle and incisal shades), resto-
ration color verification (includes lightness,
4.3.3 Spectrophotometers Chroma, and hue comparison), and shade tab
and Colorimeters mode (practice/training mode) [39].

Spectrophotometers and colorimeters are among

the most used instrumental shade matching meth-
ods in Dentistry and can be used to help over-
come some shortcomings of a visual method by
bringing accuracy and helping with shade match-
ing, communication, and reproduction. Moreover,
color measuring instruments can be valuable in
shade verification (quality control) [19].
Spectrophotometers are among the most accu-
rate, useful, and flexible instruments for overall
color matching and color matching in dentistry
[34]. They can measure the amount of light Fig. 4.6 Clinical use of the VITA Easyshade V
energy reflected from an object at 1–25 nm inter- spectrophotometer
44 C. Sampaio and P. Atria

Colorimeters measure tristimulus values and parameters are wrongly manipulated or when dif-
filter light in red, green, and blue areas of the vis- fusers that filter the illuminant are used [27], for
ible spectrum. Although they have shown good instance, changes in lighting conditions can result
measurement repeatability, they are subject to in changes in perceived color, and an incorrect
systematic errors due to the edge-loss effect digital camera exposure and automatic white bal-
related to sample surface, while spectrophotom- ance can be reflected into an erroneously added
eters precisely measure color from reflectance or cyan to the image to neutralize the high propor-
transmittance data [19, 40]. Colorimeters do not tion of red tones from the gingiva while adding a
register spectral reflectance and can be less accu- tinge of blue to offset the yellow tones from the
rate than spectrophotometers (aging of the filters teeth [44]. For example, in soft tissues, a correct
can additionally affect accuracy) [28, 41]. white balance can distinguish healthy from
When analyzing the pros and cons of instru- inflamed tissues. For hard tissues, correct color
mental and visual methods, one can mention that rendition reveals features such as enamel translu-
instrumental methods such as spectrophotome- cency, caries, erosion and abrasion, and cervical
ters and colorimeters can help standardize color dentin exposure [45].
shade matching. On the other hand, they require Flash photography also present differences
specific and expensive technology, not always within different types of flashes, even when used
available to the clinician. On the other hand, a together with the same digital camera [27]. It was
shade guide used to perform a visual shade demonstrated that the combination of a digital
matching method is always available in dental camera with cross-polarization is the most stan-
offices. However, this method is more subjective dardized colored type of photography, although
and operator dependent. A recent study showed when performing the white balance of photo-
that the spectrophotometer can assist with visual graphs using a gray reference card with known
shade matching but cannot replace it [42]. Ideally, color values, a wireless close-up Speedlight flash
the combination of an equipment and visual showed to promote as standardized colored pho-
shade matching should be used, and the help of a tography as with the use of a filter. The same was
digital camera can promote successful results on not observed for ring flashes, which tends to
shade matching [9, 27]. darken the images if they are not white balanced
[27]. A recent study demonstrated that the prob-
lem caused by different diffusers in digital cam-
4.3.4 Digital Photography eras could be compensated by using a gray
reference card with known color coordinates to
Digital photographs can capture a detailed image white balance the photographs [27], and although
of the tooth, be easily stored and transmitted to a it did improve standardization of a digital camera
technician, providing good quality information when using a ring flash, it did not improve photo-
regarding color across the tooth surface, shape, graphs made with a smartphone.
and characteristic features. As will be further Smartphones are commonly available instru-
explored in Chap. 5, digital cameras have been ments, which have self-contained central pro-
increasingly used in dental offices to document cessing unit (CPU) computing capability,
the pre-operative situation, final results, and enriched functionalities, software applications,
long-term outcomes [9, 27, 43]. A digital instru- wireless connectivity, and can present high-­
ment capable of taking photographs, being it resolution photographic technology [46]. A
either a digital camera or a smartphone, is now recent publication showed that with novel appro-
available in all dental offices; thus, it is a technol- priate light-correction filters, shade selection
ogy that can be widely used. with the smartphone and the digital camera were
Problematically, digital photographs of the comparable, showing to be reliable for shade
natural dentition typically show significant color selection, with ΔE values below the acceptable
alterations of teeth and soft tissue when certain threshold [9].
4 Color Evaluation for Research Purposes 45

Fig. 4.7 Use of the Adobe Photoshop software to describe color values without (upper image) and with (lower image)
the use of a cross-polarizing filter. Observe that total CIE-Lab values greatly vary between the photos

Thus, when using digital photograph, it is or a light-correction filter. This technique is further
important to white balance the photographs using explored in Chap. 5. The use of this software can
a gray reference card with known color values, also describe the color values in different color
which can be done using a software (for example, spaces, such as the CIE-Lab color space (Fig. 4.7).
Lightroom v6.0, Adobe Photoshop CC; Adobe Moreover, both digital camera and smartphone
Systems Inc), or combining the use of a conven- photographs can be easily manipulated to observe
tional photograph with one using a cross-­polarizing tooth color and textures (Fig. 4.8).
46 C. Sampaio and P. Atria

Fig. 4.8 Digital photographs used for digital shade selec- black and white; third row, saturated. Manipulating the
tion taken with a digital camera, after manipulation with a photographs helps on observing different structures of the
digital software in different contrasts. First row: photo- teeth, as well as the luminosity
graph with teeth and substrate shade guides; second row,

4.4 Experimental Designs restoration, which can be graded. For example:

to Evaluate Color from 0 to 4, using the scale based on a previous
study where level “0” means excellent match; 1,
4.4.1 Clinical Trials very good match; 2, not so good match (border
zone mismatch); 3, obvious mismatch; and 4,
When dealing with clinical trials, it is extremely huge (pronounced) mismatch [20, 21].
important to only start the research after obtain- An important aspect when dealing with natu-
ing an approved consent from the participants ral teeth is dehydration. Tooth dehydration makes
and approval of an Ethical Committee. teeth appear whiter due to increasing enamel
When performing clinical trials where shade opacity. The interprism spaces become filled with
matching needs to be obtained, observers need to air instead of water, so light can no longer scatter
be tested and calibrated for color matching com- from crystal to crystal. Therefore, loss of translu-
petence, irrespective of their experience and cency due to dehydration causes more reflection,
demonstrate superior color discrimination com- which masks the underlying color of dentin,
petence according to ISO/TR 28642:2016 [25]. It making the tooth appear lighter. Also, it has a
is important that operators perform blind evalua- negative impact on shade selection, which can
tions, and it is paramount to standardize illumina- affect the final esthetic outcome [47]. Shade
tion and background appropriately, as will be selection procedures should be carried out within
mentioned below. Also, in the visual analysis of the first minute of the procedure and before teeth
color differences, a ranking can be used to com- dehydrate [47]. Although it is frequent to observe
pare, for instance, the color between a tooth and dentists waiting for the tooth to rehydrate for
4 Color Evaluation for Research Purposes 47

shade taking, a recent study observed that teeth 4.4.3 Illumination

do not rehydrate within 15 min after rehydration;
thus, it is important that shade selection is carried For both in vitro and in vivo research, color eval-
out in controlled circumstances before the tooth uation and shade matching should be done using
dehydrates [47]. standardized color temperature illumination. The
specific color temperatures range within 5000
(D50)–7500 K (D75) and are sought because of
4.4.2 In Vitro Studies their universal nature and a broad spectrum of
wavelength [48]. Nevertheless, such conditions
The same as mentioned previously in the clinical are rare to be found since daylight is always
studies, when dealing with in vitro studies that changing and can range from 1000 to 20,000 K,
use human tissues, first of all, it is extremely making it difficult to rely only on natural daylight
important to only start the research after obtain- to provide the “ideal” color temperature during
ing the approval of an Ethical Committee. An shade selection for a restoration [14].
extremely important topic is to always standard- For simulation of the ideal illumination for
ize illumination and background when evaluating research, different apparatuses can be used. For
the in vitro samples, which will be discussed instance, viewing booths and color boxes can
below. be used for standardizing lightning and analyz-
When compared to clinical studies, in vitro ing shade colors [14], handheld lights and pro-
studies have the advantage of simulating specific vide significant improvements on shade
procedures in an aged situation. For instance, the matching [14], cross-polarizing filters (Fig. 4.9)
color stability of different materials can be used together with digital cameras can also pro-
assessed without actually needing to wait years vide more color-standardized photographs [27],
until the material deteriorates. Instead, thermocy- a light-correcting device used with a smart-
cling procedures can be used to assess the color phone also showed to be reliable for shade
stability after simulated aging. Such procedures selection, with DE values below the acceptable
can be performed conventionally, in water, or threshold [9].
even in different types of beverages. While if the
same study was performed in mouth, it would
take a long period of time to deteriorate, when 4.5 Background
aged in vitro, such results can be obtained within
days [48, 49]. Another method of accelerated The background is defined as the surface upon
aging is using ultraviolet light. Studies have which samples are placed along with the environ-
shown a yellowing effect after this type of aging ment [25]. The neutral light gray background has
due to a large positive change in b* [33]. For all been recommended in the literature as the most
these types of studies, both visual and digital appropriate for background and/or surrounding
methods can be used, and color values, as well as area in dentistry [27]. Today, white balance refer-
color differences, can be obtained with the previ- ence cards with known color coordinates are
ously mentioned color difference (ΔE) formulas, available in the market and can be used together
as well as instrumental devices. with dental photography backgrounds. They have
Different software can be used for the evalua- been recommended for improving standardiza-
tion of colors in dentistry in vitro. Among all, the tion and accuracy in recording, communicating,
most commonly used is Adobe Photoshop, which and manipulating color images in dental digital
can describe color values in different color scales, photography [9, 27]. Besides a gray card itself,
such as the CIE-Lab scale. Another interesting and photographic contrastors are also available for
easy access software used in recent research proj- both research and clinical basis; they can be
ects is the Classic Color Meter, which describes found in different colors, such as black, simulat-
color values in the CIE-Lab scale [9, 27]. ing the dark background of the mouth, and gray,
48 C. Sampaio and P. Atria

for a neutral background and white balance pro- ity; nevertheless, there are situations when the
motion (Fig. 4.10) [49]. shade selection is performed against other arti-
In dental practice, the background is repre- facts [17]. A recent study selected different back-
sented most often by the darkness of the oral cav- grounds/surrounding area to simulate the
different clinical situations, such as gray (consid-
ered as neutral and most frequently recom-
mended), white (simulating color of opposite
teeth), black (simulating color selection against a
black contraster), red (imitating the lips and oral
mucosa), and blue (simulating the rubber dam).
Color matching results recorded against the blue
background were statistically worse than to other
backgrounds, while white and black generated
the best results [17].

4.5.1 Sample Size and Statistics

Analyses

Statistical analyses are paramount in both clinical

trials and in vitro studies. There is a necessity to
organize and record the information obtained in
the form of numbers from each sample. The value
that is taken by the variable is called data, which
can be classified into continuous data
(Quantitative) or categorical data (Qualitative)
(Figs. 4.11 and 4.12) [50].
When talking about color evaluation for
research purposes, we will mainly work with
Fig. 4.9 Upper photograph taken without a cross-­ continuous variables, where color values using
polarizing a filter, lower photograph taken with a cross-­ mathematical formulas described in this chapter
polarizing filter. Observe the absence of specular
are made on a scale. This kind of data will be
reflections in the photograph with filter, which allows a
more straightforward and precise observation of natural presented in terms of mean ± standard deviation.
teeth internal structures The recommended way to represent the final out-

Fig. 4.10 Tooth color selection performed against a black background, gray background, and with a cross-polarizing
filter
4 Color Evaluation for Research Purposes 49

Fig. 4.11 Some of the most used statistical tests for continuous data

Fig. 4.12 Some of the most used statistical tests for categorical data

comes of any given test is in the form of tables sample sizes (≥50 samples). In both cases, the
and graphs. null hypothesis is that the data falls within a nor-
The distribution of the data does not have a mally distributed population when p > 0.05. The
relation with the quality of the obtained data null hypothesis is accepted; therefore, the data
itself [50]. Distribution is just the pattern of val- are called normally distributed [52].
ues obtained [51]. Both empirical and theoretical It is key in statistics that all the assumptions of
distributions can be found; the most common the desired test to be performed are fulfilled.
theoretical distribution is the normal distribution, Normality is assumed in correlation, regression,
which is just a name and does not imply normal- t-test, and analysis of variance. Whenever there is
ity. For a normally distributed dataset, the major- a Normally distributed dataset, a parametric test
ity of the sample’s values or observations (95%) can be used; if this condition is not met, then the
will be in the center of the distribution. use of a non-parametric test is required. Non-­
Recommended tests to evaluate the normality of parametric tests include Wilcoxon signed-rank
the data are the Kolmogorov–Smirnov test and test, the Mann–Whitney U test, and the Kruskal–
the Shapiro–Wilk test. Usually, the Shapiro–Wilk Wallis test.
test will be the appropriate method for small Among the most commonly used tests, there
sample sizes (<50 samples), while the
­ is the Bonferroni test, which is intended to use for
Kolmogorov–Smirnov test will be used for larger a small number of comparisons (<5), however,
50 C. Sampaio and P. Atria

when dealing with larger than five comparisons, 6. Felippe LA, Monteiro S Jr, De Andrada CAC, Di
the preferred test is the Tukey test [50]. When the Cerqueira AD, Ritter AV. Clinical strategies for suc-
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Other recommended tests that authors have OB. Direct esthetic restorations based on translucency
and opacity of composite resins. J Esthet Restor Dent.
used in studies involving clinical measurements 2011;23(2):73–87.
are repeated measurements tests, where time-­ 8. Sproull RC. Color matching in dentistry. Part III. Color
invariant unobservable differences between indi- control. J Prosthet Dent. 1974;31(2):146–54.
viduals can be controlled. This allows the 9. Jorquera GJ, Atria PJ, Galán M, Feureisen J, Imbarak
M, Kernitsky J, et al. A comparison of ceramic crown
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viduals. Here is where linear models come into methods: visual, digital camera, and smartphone.
play to fit the data, assuming that the distribution J Prosthet Dent. 2021. https://doi.org/10.1016/j.
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10. Igiel C, Lehmann KM, Ghinea R, Weyhrauch M,
mixed models which are used when there is Hangx Y, Scheller H, et al. Reliability of visual and
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­ instrumental color matching. J Esthet Restor Dent.
side, when a non-parametric test is required, the 2017;29(5):303–8.
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guides. J Dent. 2009;37:e15–20.
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random effects. dards: shade tab arrangement. J Esthet Restor Dent.
This method also assumes that the values are 2001;13(4):254–63.
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 Dental Photography as a Key
to Clinical Success
5
Lucas Fernando Tabata, Toni Arcuri,
and Leandro Augusto Hilgert

Much of dental treatment success relies on effi- pact cameras have become a viable entry level
cient communication between professionals and option for the world of dental photography.
patients, among members of the professional Understanding how a digital camera works and
team, along with the laboratory prosthesis techni- knowing the differences between the various
cian involved in the treatment. Dental photogra- cameras and accessories available is imperative.
phy allows us to capture details and share certain As is acquiring knowledge on their advantages
aspects of a clinical case, such as tooth shape, and limitations, knowing how to adjust the set-
texture, color, and perceived translucency [1, 2]. tings of your equipment, and mastering the con-
Furthermore, it enriches the communication cepts and fundamentals of photography. Grasping
between work team and patient since they enable these core aspects will help you obtain even bet-
us to capture smile harmony, the exposure of the ter images.
incisal edge with resting lips, gingival exposure,
and oral corridor. Photographs have become an
essential tool in dentistry, as they have improved 5.1 Digital Cameras
the way we communicate and relate to people.
Besides documenting cases and assisting in plan- There are currently several types of digital cam-
ning treatments, dental photography also offers eras available for use in dentistry from different
the possibility of reviewing the treatment per- manufacturers. They each bear its own character-
formed to enhance and evolve our skills. DSLR istics, indications, and limitations, and can be
(digital single-lens reflex) cameras are currently classified into five distinct groups as presented in
the gold standard in dentistry for providing high-­ the image below (Fig. 5.1).
quality results, on top of the ease of sharing the
images and videos obtained. However, with tech-
nological development, more straightforward 5.1.1 Smartphones
digital cameras such as smartphones and com-
Smartphone cameras have evolved significantly
L. F. Tabata (*) · L. A. Hilgert in the recent years, as have devices and their pro-
Department of Dentistry, School of Health Sciences, cessors in general. Instead of using lenses with
University of Brasilia, Brasilia, DF, Brazil optical zoom—which would compromise the
e-mail: [email protected] thickness of phones—most manufacturers have
T. Arcuri incorporated multiple lenses. High-end smart-
School of Dentistry, Uniceplac University, phones have three lenses (ultra-wide, wide, and
Brasilia, DF, Brazil

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 53

D. Oliveira (ed.), Color Science and Shade Selection in Operative Dentistry,
https://doi.org/10.1007/978-3-030-99173-9_5
54 L. F. Tabata et al.

Fig. 5.1 Classification of digital cameras

telephoto lens) that can be easily selected accord- turing good quality dental photographs is the use
ing to each specific situation. However, even with of an external continuous light source, such as
the versatility of using multiple lenses, the image LED panels or an LED ring light. This allows
capture sensors in these devices are still small. brighter images to be obtained and avoids high
They tend to obtain more pixelated images when noise in the image by the camera’s ISO (sensitiv-
greatly enlarged or in low light environments. ity) compensation.
Some devices feature a pro mode or manual
mode, which allows for the adjustment of set-
tings. When this function is not present, there are 5.1.2 Compact Cameras
specific downloadable apps for this purpose.
Even though they do not have a dedicated macro-­ Developed to be portable and user-friendly, these
lens, their portability and accessibility make were the first digital equipment accessible to the
them excellent entry option to start capturing general public, that associated the digital technol-
dental photographs, despite their limitations. ogy of the time with affordability. Also known as
Recommendation: if you opt to use a smart- point-and-shoot cameras, they had added features
phone for dental photography, since they do not to facilitate usage. These properties included
include a dedicated macro-lens, we suggest opt- automatic mode, autofocus, retractable zoom
ing for a model with multiple lenses (Fig. 5.2). lenses, built-in flash, and video recording, mak-
Remember to check that one of the lenses is a ing them very popular since the beginning of the
telephoto lens. If your smartphone does not offer year 2000. Nowadays, some compact cameras
a telephoto lens option, you can use the digital even feature a manual mode for configuring cam-
zoom of your device, mindful that this will lower era settings and, along with smartphones, they
the resolution of image. The use of telephoto lens are an excellent entry level choice for the world
or digital zoom causes less image distortion since of dental photography.
wide and ultra-wide lenses tend to change the Recommendations: if present, we recommend
photographed object’s proportion, known as the using the camera in manual mode, with the
barrel distortion. Another critical point for cap- macro-function activated, employing the optical
5 Dental Photography as a Key to Clinical Success 55

Fig. 5.2 X-ray of smartphones showing the digital camera components. (Adapted from https://www.creativeelectron.com/)

zoom lens to reduce image distortion. It is recom- This feature grants users the ability to adapt to
mended to combine it with an LED illuminator or different situations. We recommend using a dedi-
an external flash to synchronize with camera’s cated macro-lens from 100 to 105 mm and a cir-
shutter, whenever available. cular or twin macro-flash.

5.1.3 DSLR (Single-Lens Digital 5.1.4 Mirrorless Cameras

Reflection)
Considered an evolution of DSLRs and cameras,
DSLR cameras are characterized by using a pen- they present the same possibility of using inter-
taprism (reflex mirror) to visualize the object changeable lenses and external flashes. The main
before the photographic record occurs. These are difference is the absence of the pentaprism (reflex
often considered professional or semi-­mirror) inside the camera body, which allows this
professional cameras, which employ full-frame equipment to be smaller and lighter than the
or APS-C type sensors to capture images with DSLRs. Instead of the optical viewfinder, these
excellent resolution and high quality. Another cameras enable digital previewing of the image
key feature is the possibility of adjusting the on a built-in rear LCD screen or an electronic
equipment’s settings to manual mode. This opti- viewfinder (EVF). A disadvantage of mirrorless
mizes the capture of images and grants the opera- cameras when compared to a typical DSLR is its
tor total control over the photograph to be shorter battery life, due to the power consump-
obtained. The use of an interchangeable lens tion of the viewfinder. However, an in-camera
(Fig. 5.3) and an external flash as an auxiliary setting on some models can mitigate this issue.
source of illumination, makes this equipment the With more technology involved, they still have
gold standard for dental photography, especially higher cost, which should become more accessi-
when the goal is to attain high-quality images. ble over time.
56 L. F. Tabata et al.

Fig. 5.3 Schematic illustration of a DSLR equipment. (https://www.dpreview.com/articles/6579860130/canoneos500d)

We recommend using a dedicated macro-lens 5.2 Knowing the Photographic

from 100 to 105 mm and a circular or twin Equipment and Accessories
macro-flash. for Dental Photography

5.2.1 Sensor
5.1.5 Specific Cameras for Dentistry
Sensors are responsible for capturing the light
There is also on the market a digital dental cam- reflected by an object, which will later be pro-
era designed exclusively for dentistry (EyeSpecial cessed to acquire the desired photographed
C-IV, SHOFU, JAPAN), which incorporates the image. There are two main types of image sen-
advantages of DSLR cameras with the simplicity sors for digital cameras and camcorders: CMOS
of compact cameras. It features software with a and CCD. Both are made of silicon and work in
user-friendly interface, touchscreen and the menu similar way. They depend on the photoelectric
offers pre-configured modes. Among its advan- effect, the interaction between photons (particles
tages is the body. Its lightweight unibody con- of light) and the silicon, to move the electrons in
struction in polymer is resistant to moisture and the sensor to capture the image. All these sensors
disinfection protocols, favoring biosafety within are charge-coupled devices and their basic func-
the office space. It features a dual twin flash inte- tions are to capture images and transform them
grated into the camera body, which is selected into electrons (electromagnetic signals) and bits
according to the pre-configured modes. There is and bytes by a microprocessor in an analog-­
also a 28–300 mm lens with the option of adding digital process that generates the image. The
a close-up lens for macro-photography, and an main difference among equipment resides in the
adapter for cross-polarized photography for pho- type and size of sensor used (Fig. 5.4).
tos of color selection. Professional DSLR cameras use full-frame sen-
We advise using the pre-configured modes sors, while intermediate and entry level DSLRs
recommended by the manufacturer, since the use APS-C sensors (1.5–1.6x smaller than the
equipment is specific for dentistry. full-frame sensor). Compact cameras use 1″
5 Dental Photography as a Key to Clinical Success 57

Fig. 5.4 Comparison of

the size of the digital
sensors used in
photographic equipment.
(Adapted from https://
newatlas.com/
camera-­sensor-­size-­
guide/26684/)

s­ensors, while smartphones use 1/3″ sensors, size of electronic components. Larger bodies pro-
almost 50 times smaller than the full-frame vide space for larger sensors and enable better
sensor. handling and grip. In DSLR or mirrorless cam-
eras, it is possible to connect a single lens and
5.2.1.1 How Important Is the Size flashes to the equipment’s body. Not all compact
of the Sensor? cameras include these options, and it is not possi-
A digital camera’s resolution is often limited by ble to exchange lenses. Only a few models offer
the image sensor that turns light into discrete sig- the possibility to connect an external flash to the
nals. Depending on the sensor’s physical struc- camera body. In smartphones, the camera body is
ture, a color filter array may be used, which integrated with the mobile itself, which, like com-
requires demosaicing to recreate a full-color pact cameras, offers little possibility of adapting
image. The brighter the image at a given point on direct lenses and synchronizing flashes as DLSRs
the sensor, the higher the value read for that pixel. and mirrorless do.
The number of pixels in the sensor determines
the camera’s “pixel count.” In a typical sensor,
the pixel count is the product of the number of 5.2.3 Lens
rows and the number of columns. For example, a
1000 by 1000 pixel sensor would have 1000,000 A lens is composed of several optical elements,
pixels or 1 megapixel. In practice, while smaller which can be made of plastic or glass. Optical
sensors tend to produce more pixelated and nois- glass elements generally provide a clearer,
ier images, larger sensors capture more defined higher-quality lens result. Each element has a
images. These present superior color contrast and specific function in focusing the light towards the
performance in a low light situation, lower noise sensor, either generally shaping the light to fit the
at high ISOs, and lower crosstalk. sensor’s size, correcting problems, or providing
the final point of focus. An interesting feature of
these lenses is the automatic focus. In this case, a
5.2.2 Camera Body motor’s aid allows for the final optical element or
collection of some elements to be moved closer
The framework is responsible for maintaining and or farther from the sensor. This enables different
protecting the sensor and processor, along with areas of an image to appear in focus and is one of
supplemental electronic equipment, that together the main aspects of a practical camera system.
allow the camera to function. The body’s size may The lens can be considered the most important
vary between equipment based on the amount and element of a camera. Aspects such as number,
58 L. F. Tabata et al.

size, and configuration of optical elements, mate- 5.2.4 Memory

rial quality, number of blades in the diaphragm,
and electronic components, determine its charac- Some smartphones and most digital cameras
teristics. These characteristics have direct impact store image data on flash memory cards or other
on clarity, maximum aperture, fixed or variable removable media. Most stand-alone cameras use
focal length, whether wide, macro, or telephoto, SD format, while a few use CompactFlash cards,
and manual or autofocus. and some brands opt to use their specific memory
cards. Knowing how files are stored inside your
5.2.3.1 Which Lens Should I Use device is extremely important, as it allows you to
for Dental Photography? better organize. We recommend that photos be
In everyday clinical practice, we need a versatile downloaded or uploaded to cloud storage ser-
lens that allows us to perform portrait and intra- vices more often on smartphones that rely solely
oral close-ups with minimal distortion (Fig. 5.5). on the device’s internal memory. It is important
For this purpose, dedicated macro-lenses for to note that adopting a file organization protocol
DSLR or mirrorless cameras have been the gold is crucial to keep track of your cases. Whenever
standard in dentistry. It is important for the focal necessary, consider using an external hard drive
length to be between 100 and 105 mm, depend- to backup your digital files.
ing on the manufacturer, to allow for a 1:1 mag-
nification. For devices that do not offer the 5.2.4.1 Which File Format Should I Use?
possibility of using interchangeable lenses, such The Joint Photography Experts Group (JPEG)
as compact cameras and smartphones, we sug- standard is the most common file format for stor-
gest using the camera’s optical zoom, whenever ing image data. Other file possibilities include
possible, or the telephoto lens on a smartphone Tagged Image File Format (TIFF) and several
(Fig. 5.6). Otherwise, digital zoom can be used, RAW image formats. Raw image is the unpro-
with the understanding that this will decrease the cessed set of pixel data directly from the camera
resolution of the image. sensor, often saved in a proprietary format. Many

Fig. 5.5 Display of barrel distortion. Barrel distortion is usually present in most lenses, especially at wide angles. The
distortion amount can vary, depending on the distance between camera and object, especially over short distances
5 Dental Photography as a Key to Clinical Success 59

Fig. 5.6 Display of barrel distortion present in smartphones

cameras, especially high-end ones, support a 5.2.5 Lighting Equipment

RAW image format. At first, RAW files had to be for Dental Photography
processed in specialized image editing programs
but, over time, many conventional editing pro- Light is the main ingredient for photography and
grams, such as Google’s Picasa, added support are classified as natural or artificial. In this chap-
for RAW images. Rendering to standard images ter, we will cover those of interest to dentistry,
from RAW sensor data grants more flexibility which are artificial lights. There are four com-
when making major adjustments without losing mon types of artificial light sources used in pho-
image quality or retaking pictures. In general, it tography: incandescent, fluorescent, LED, and
is relevant to consider that the RAW format will flash. For dentistry purposes, we will deal with
be necessary when you intend to enlarge a picture the latter two (Fig. 5.7). In dental photography,
for printing, or even in cases where it is necessary we work with artificial light from lighting equip-
to prove copyright. Another instance when this ment classified as continuous light equipment or
might be needed is to confirm the absence of flash-type equipment. While both options illumi-
image editing, as well as in cases of communica- nate and provide better results in filming and
tion of shade selection with a laboratory techni- photographing, they present some technical dif-
cian. For this purpose, we recommend the use of ferences, such as the “time” in which the light is
a gray card associated with a cross-polarizing available. Continuous light is an option that pro-
filter which will be later explained in this chapter. motes continuous lighting over timer, while with
When sharing patient’s image in clinical routine, flash, lighting occurs punctually. Other factors
JPEG format will suffice. such as color temperature and light intensity
60 L. F. Tabata et al.

Fig. 5.7 Artificial lighting equipment available for use in dental photography

should also be considered when choosing Another interesting possibility of using LED
between these options. equipment is while filming. Whether with DSLR,
mirrorless, compact, or smartphone cameras, a
5.2.5.1 Continuous Light Equipment continuous light source is always needed.
LED means light-emitting diodes. The light
source in such devices is generated by a series of 5.2.5.2 Flash Equipment
light-emitting diodes present in each lamp. These Photographic flash, sometimes referred to as a
illuminators are classified as continuous light strobe or simply a flash, is a device used in pho-
equipment because the light remains on the entire tography to allow pictures of dark areas to be
time and does not flash like a strobe light. Most taken by producing an extremely bright light. This
LED equipment offers brightness adjustment for illumination is not continuous and, in a small frac-
the emitted light, as well as color temperature tion of a second, it bursts outward in large
adjustment option, which ranges from 3300 (yel- amounts. Most photographic equipment includes
lowish light) to 6600 K (white light), for exam- built-in flash, but external flashes will be needed
ple. Since LEDs are not as bright as the light for dentistry purposes since they enhance the
emitted from a flash light, they are not recom- lighting system. A critical factor when using this
mended for taking photographs with DSLR or light source is the need to synchronize the firing
mirrorless cameras. However, it is possible if you of the photographic flash with the digital camera’s
use a high ISO setting (800+) or position them shutter opening, to enable light to be captured by
very close to your subject. the electronic image sensor. In DSLRs and mir-
Despite that, LED illuminators are effective rorless cameras, the mechanism is usually a pro-
with smartphone cameras and compact cameras grammable electronic timing circuit, which can,
(Fig. 5.8) since the camera’s shot cannot be syn- in some equipment, receive input from a mechani-
chronized with the flash device in this case. cal shutter contact or work wirelessly.
5 Dental Photography as a Key to Clinical Success 61

Fig. 5.8 Artistic photography was obtained using studio flash and a DSLR camera equipped with a 100 mm
macro-lens

5.2.5.3 Macro-Flash for DSLRs within the dental office. There are currently dif-
and Mirrorless ferent models on the market, which can be
For dental photographs, based on equipment con- mounted on tripods or attached to the dental
figuration adjustments (which will be later dis- office’s ceiling. These models have greater power
cussed in this chapter), and due to the need to than macro-flashes and work plugged in, allow-
capture close-up photographs of subjects, built-in ing for a faster firing cycle and less variety of
flashes are not recommended as they create shad- light intensity since they do not depend on batter-
ows in the image. Instead, macro-flashes, like ies. Studio flashes are generally combined with
ring light and twin flashes, should be your first softboxes or umbrellas, which help diffuse the
option for such situations. The advantage of these light from the flash, and provide softer shadows
flashes is the ability to position the light source at in the images, with a more artistic appeal
the same plane as the lens, which provides better (Fig. 5.8).
lighting for dental photos. An alternative to
macro-flashes is the use of a pair of conventional
external flashes, mounted on a bracket or on tri- 5.2.6 Light Modifying Accessories
pods, that are activated in remote mode to func-
tion as a twin flash or a studio flash. A critical The main objective of modifying the light of a
factor when using these sources is the need to photographic flash is to soften shadows. Since
correctly set the light’s intensity. This can be con- the photographic flash is a small, high-intensity
trolled automatically or in manual mode by the light source, it usually produces harsh, unattract-
operator, providing greater control over the final ive shadows. Hard light directly affects the pho-
result of the image. tographed object, by causing a well-marked and
sharp shadow. Unlike with hard lights, the shad-
5.2.5.4 Studio Flash ows generated by soft lights are absent of sharp
Another option that has become very attractive to edges, making it impossible to determine exactly
clinicians is the use of studio flash equipment where the shadow begins or ends (Fig. 5.9).
62 L. F. Tabata et al.

Fig. 5.9 Light modification accessories

this, there are devices called brackets available,

5.2.6.1 Softboxes and Bouncers with option for fixed or articulated arms. These
There are two ways to “soften” the light from allow the twin flashes to be adjusted in different
flashes: filtering or bouncing it, by using diffus- positions to increase distance or approximation
ers and reflectors, respectively, that work as light of the light source concerning the subject and the
distribution devices. Flash diffusers soften shad- camera lens. By modifying the flashes’ position-
ows by refracting the light through a translucent ing, indirect or oblique light are obtained enabling
material. When the light is refracted through a better visualization of the tooth’s buccal surface
translucent material, this material becomes the texture. Since it provides more detailed informa-
new and the largest light source, as in the soft- tion for laboratory procedures, this feature
boxes used in studio flashes. A simple and cheap becomes very interesting when communicating
solution is to attach a sheet of white paper over with the laboratory technician. This bracket sys-
the twin flash with tape. In the case of reflectors, tem can be used with conventional external
the light from the flash is directed to the reflec- flashes, along with remote mode and macro-twin
tors’ surface, which then reflects the light on its flashes.
surface, and provides softer shadows. In practice,
it is possible to soften shadows by using a light
modifier that amplifies the light as a larger light 5.2.7 Accessories for Dental
source. This strategy produces a more gradual Photography
transition between deep shadow and full illumi-
nation. The most common misconception is that To perform good dental photographs, especially
spreading the light over a wider area will soften intraoral photographs, it is necessary to keep the
the shadows. This is not the case. You must lips, cheeks, and tongue out of the image The
enlarge the light source to soften the shadows. market has a variety of accessory models avail-
able that can be chosen from according to the
5.2.6.2 Brackets Mount photographic registration needs. Here we will
Another way to modify the light is to change the address some possibilities and their practical
position of the light-emitting source or flash. For applications (Fig. 5.10).
5 Dental Photography as a Key to Clinical Success 63

Fig. 5.10 For front photos, we recommend the use of a graphed) and “C” shaped retractor (for the contralateral
bilateral retractor, also known as self-retracting or unilat- side). For occlusal photos, we recommend using a modi-
eral retractors. For side shots, we suggest the use of an fied bilateral retractor with a mirror or an anterior photo
associated “V” shaped retractor (for the side to be photo- with a black background

5.2.7.1 Mouth Retractors light from the flash is absorbed instead of

Mouth retractors keep lips and cheeks out of the reflected, enabling nuances of the tooth enamel to
image. There are several mouth retractors avail- be observed, especially of the incisal edges and in
able, which can be unilateral or bilateral, with C the transition areas. This is very effective in com-
or V shape, transparent or colored. If necessary, municating with the laboratory technician.
we can modify retractors, mainly to optimize use
when employing mirrors and black backgrounds.
5.3 Fundamentals of Dental
5.2.7.2 Mirrors Photography: The Exposure
A wide variety of mirrors are available for many Square
intraoral situations, differing in size, shape, and
the presence or not of a handle. These are essen- Dental photography is available to everyone.
tial for occlusal photos and can be associated However, some basic principles about the dynam-
with modified bilateral retractors for better ics of the equipment and the light’s behavior are
results. Mirrors with handles help to ensure no necessary and will be addressed in this section.
fingers appear in the image. To prevent the mirror After all, the etymology of the word photography
from fogging up due to the patient’s breathing, does say it all: the art of drawing with light. From
we recommended the use air spray or preheating the Greek “phosgraphein”—“phos” or photo,
the mirror prior to performing the photoshoot. which means “light,” and “graphein,” which
means “to mark,” “to draw” or “to register.” The
5.2.7.3 Black Background term “exposure” appears as a synonym for “mak-
Black backgrounds or contrasters are used to iso- ing a photograph,” and, from a technical point of
late the anterior teeth, especially the upper teeth. view, it represents the amount of light that can
When positioned behind the anterior teeth, the reach the image recording medium [3].
64 L. F. Tabata et al.

5.3.1 Exposure istration of a dark cavity that is not efficiently lit by

ambient light, the use of flash is necessary and
In photographs, exposure is responsible for cap- mandatory. Hence, when the Exposure Triangle of
turing the amount of light that can reach the sen- classical photography literature gains an additional
sor of a camera. That is, it defines how light or pillar in Dentistry, it turns into an Exposure Square:
dark photos will be. For instance, if the result of the flash configuration (Fig. 5.11). All basic set-
the image captured is very bright, it is because tings are interdependent, and each has a remark-
the image was overexposed, indicating “too much able creative impact on the image.
light.” If it is too dark, it was underexposed,
indicative of “low light.” 5.3.1.1 Shutter Speed
Depending on the effect you are looking for, Shutter Speed or exposure time translates into the
this may or may not be a good strategy. If the sen- time that the machine’s shutter (the part that iso-
sor receives a significant amount of light, the lates the light sensor) remains open, letting the
photo will be overexposed, with large white areas photographic film or the digital sensor absorb
and the lack of details. In contrast, if the image light and form an image. The longer the exposure
sensor does not receive enough light, the photo time, the greater the absorption of light by the
will be underexposed, with black areas, yet also sensor, therefore the more exposed the image will
devoid of details. The ideal strategy to avoid be. Exposure time is usually given in 1/x format,
missing details is to find balance. where X represents a fraction of time in seconds.
In classic photography literature, three basic This component of the exposure triangle varies
settings allow you to deal with the exposure of your between 1/8000 of a second (very short time,
photos: Shutter Speed, Aperture, and Image Sensor higher speed) and several seconds (very long
Sensitivity. These three configurations form what time, lower speed). Specifically, we can distin-
we call the Exposure Triangle. In Dental guish the short times (less than 1/60) from the
Photography, because we are dealing with the reg- long times (more than 1/60).

Fig. 5.11 The exposure square

5 Dental Photography as a Key to Clinical Success 65

Although very popular in the photographic Aperture is expressed by a number. The

field, the term speed is not correct. The shutter, as smaller the number, the greater the aperture. It is
we have seen, works with exposure times, in gen- an inversely proportional relationship. For all
eral fractions of seconds, which does not relate to lenses, the smallest aperture number (or
the speed of operation or exposure [4]. f-stop)—1.4, 2, 2.8, or 4, depending on the lens—
represents the largest aperture. The minimum
5.3.1.2 Impact of Shutter Speed aperture is often 22 at minimum focal lengths and
on Image Blur can reach 38 or more.
Shutter speed controls the effects of movement
on your photos. This can occur deliberately, from 5.3.1.4 Impact of Diaphragm Opening
the camera’s movement by the photographer on Depth of Field
while recording an image, or from movements We call Depth of Field (DoF—Depth of Field)
from your subject within your composition. the area of the image that will be sharp, while the
Although fast shutter speeds freeze the action, rest will be blurred. This Depth of Field depends
slow shutters can register the action as a blur. on several factors:
In Fig. 5.12, we can see three photos of the
same pinwheel, taken of the object in motion, 1. The opening of the diaphragm: the more open
though with different exposure times. In conclu- the diaphragm, the smaller the depth of field.
sion, just remember, short exposure time causes a 2. The long focal length: long focal lengths (tele-
freezing effect of the motion of the subject to be photo) tend to decrease the depth of field.
photographed, while long exposure time causes 3. The focus distance: the closer the subject is,
motion blur or background. the smaller the depth of field.

5.3.1.3 Aperture For portraits, for example, a reduced depth of

The camera lens contains a diaphragm, a type of field is preferred so that the subject is sharp, but
membrane formed by a set of metal sheets, which the background completely blurred. To do this,
can be closed more, or less, to allow greater or you need a lens with a large aperture (ex: f/1.8).
fewer light to pass through (Fig. 5.13). The wider We can also use zoom to take close-ups of the
the aperture, the more the image will be exposed. object so that it looks closer. It is a photographic

Fig. 5.12 Impact of the Shutter Speed on motion blur. (Adapted from https://digitalwarehouseblog.wordpress.
com/2016/01/26/when-­the-­lights-­go-­down-­low-­light/)
66 L. F. Tabata et al.

Fig. 5.13 Diaphragm and set of blades

Fig. 5.14 Reduced

depth of field, showing
in focus every tooth until
the canine

technique widely used when it comes to high- sensitivity of the digital sensor to light, and it var-
lighting the subject in the foreground. ies between 50 and 128,000. The higher the ISO,
In short, a large aperture (small number) pro- the lesser amount of light is needed to obtain a
duces a reduced depth of field (small area of correct exposure since the sensitivity of the digital
sharpness). A small aperture (large number) leads sensor to capture light will be grater.
to a greater depth of field (area of deep sharp- The sensitivity of today’s cameras reaches
ness). See Fig. 5.14. 128,000 ISO, and noise is almost invisible up
to 3200 ISO. Noise can be defined as a kind of
5.3.1.5 Sensitivity (ISO) interference in the image that manifests itself
The sensitivity of the image sensor (expressed in in the form of pixels of very different colors
ISO—International Organization for Standardiza- from reality, usually in dark scenes [5]
tion) is the standard that describes the absolute (Fig. 5.15).
5 Dental Photography as a Key to Clinical Success 67

Fig. 5.15 ISO and noise production in the image

However, it is best to keep the ISO as low as These settings adjustments may vary from equip-
possible: 100 ISO for sunny days, 200 ISO for ment to equipment, depending on the type,
cloudy days, and up to 400 ISO indoors. model, and manufacturer. Below you will find a
Nevertheless, if the scene demands it, do not hes- summary of general equipment configurations,
itate to raise the ISO. though it is crucial that you carry out some tests
with your equipment and adjust it according to
5.3.1.6 Impact of Sensitivity on Image your needs (Table 5.1 and Fig. 5.16).
Noise
As previously mentioned, increasing the ISO
sensitivity can make photos lighter, however, it 5.4 Dental Photography
decreases the sharpness because it produces with Gray Card
undesirable noise in the images due to the greater
sensitivity to capture light. Gray cards are designed to help you adjust your
It is recommended to maintain minimum sen- exposure and white balance settings consistently,
sitivity in Dental Photography. The ideal is to providing a reference point. This reference point
work with the ISO as low as possible, preferably will define a white balance or color balance point
in a range of 100–200, aiming to obtain images for a given image and all images subsequently
with the lowest possible level of noise and greater captured. The reference point will ask your cam-
clarity. Any dark or shady area in the oral cavity era to compensate for any illuminating color in
can have its lighting issue resolved by using an the space you plan to shoot, adjusting the white
integrated flash system specifically for this balance and the color profile (Fig. 5.17). With a
purpose. gray card, it becomes possible to correct the val-
ues of color differences of dental elements to
visually imperceptible values. This achieves one
5.3.2 Master the Exposure of Your of the major advances in the standardization of
Equipment photography for color registration. To measure
your reference point, place the gray card in the
As we have seen, the correct adjustment of your area or scene where you intend to capture, with
equipment can favor obtaining better images. the gray side facing the camera. For most accu-
68 L. F. Tabata et al.

Table 5.1 Compilation of your equipment configuration recommendations

Fig. 5.16 Image results from smartphone plus LED (top left). Compact camera plus LED (top right). DSLR camera
with a macro-lens and ring flash (bottom left). DSLR camera with a macro-lens and twin flash (bottom right)

rate results, place the card close to the patient’s repeat a new photo with the gray card whenever
mouth so that it reflects the light from the flash. you change the lighting settings.
Then, adjust the white balance settings on the Another possibility is the post-processing pro-
camera to ensure optimal exposure and focus. cedure of white balance correction in software
Shoot normally, remembering that you must like Photoshop or Lightroom. To do so, merely
5 Dental Photography as a Key to Clinical Success 69

of different photographic processes and the brand

of the equipment. Some of the probable variances
include intensities, degrees of angulation, dis-
tance, the use of modifiers, as well as the configu-
ration of the camera and the differences between
operators (dental surgeons, dental technicians,
and dental assistants).
The human eye does not have the ability to
distinguish between randomly oriented light and
polarized light, and polarized flat light can only
Fig. 5.17 The photograph was taken with a gray card
(left side) and WB adjustment made in photoshop (right be seen through an effect of intensity or color.
side) For example, by the reduced brightness when
wearing polarized sunglasses. In fact, humans
cannot differentiate real high contrast images
open the test image that contains your gray card seen in a polarized light microscope from identi-
in Photoshop and create a Level Adjustment cal images of the same specimen captured digi-
Layer. You will find three droppers stacked next tally (or on film) and then projected onto a screen
to the Levels histogram. Select the middle drop- with light that is not polarized.
per and click on the gray card. Photoshop will The basic concept of polarized light is illus-
automatically adjust the color levels of the image trated in Fig. 5.18 for a non-polarized light beam
for you. If you need to apply these settings to incident on two linear polarizers. Electric field
other images taken in the same lighting condi- vectors are represented in the incident light beam
tions, click on the drop-down menu in the upper as sine waves that vibrate in all directions (360°;
right-hand corner of the Levels column and select although only six waves, spaced at 60° intervals,
“save preset levels.” Name and save the preset, are represented in Fig. 5.18). In reality, the elec-
then open your other files for editing. For each tric field vectors of incident light are vibrating
image, find “load level preset” in the Levels col- perpendicular to the direction of propagation,
umn drop-down menu and select the saved preset with an equal distribution in all planes before
file to apply it. To do this in Lightroom, simply encountering the first polarizer [6].
select the White Balance dropper tool from the The polarizers illustrated in Fig. 5.18 are fil-
Developing Module Basic menu and click on the ters containing long-chain polymer molecules
gray card. Then, highlight all the images you oriented in a single direction. Only incident light
want to color and click on the “synchronize” but- vibrating in the same plane as the oriented poly-
ton in the screen’s lower right-hand corner. Check mer molecules are absorbed, while light that
the “White balance” and click “synchronize.” vibrates perpendicularly to the polymer plane
passes through the polarizer. The polarization
direction of the first polarizer is oriented verti-
5.5 Cross-Polarization in Dental cally towards the incident beam so that only
Photography waves with vertical electric field vectors will pass
through the first polarizer. The second polarizer,
For years, there were uncertainties regarding the subsequently, blocks the wave that passes through
ability of photographic captures to effectively the first polarizer because this polarizer is ori-
register color shades of dental elements. These ented horizontally concerning the electric field
concerns related to the possibility of lighting vector in the light wave. The concept of using
affecting color, and to the potential of variations two polarizers oriented at right angles to each
happening between the various sources of illumi- other is commonly called Cross-Polarization and
nation. This was greatly attributed to possible can be used with transmitted light (Transmitted
variations and discrepancies occurring because Cross-Polarization—TCP) and reflected light
70 L. F. Tabata et al.

Fig. 5.18 Polarized

light concept. (Source:
https://www.
microscopyu.com [7])

Fig. 5.19 Photo with color scale for communication with Fig. 5.20 Photo with the color scale using the reflected
the laboratory. Note that the reflection of the flash inter- cross-polarization. By removing the flash light reflection,
feres with the correct color analysis a better color evaluation of the patient’s smile is possible

(Reflected Cross-Polarization—RCP). In photo- these factors using reflected polarized lighting

graphs using the Transmitted Cross-Polarization, and an absolute gray reference card, also called a
the light passes through the object to be studied white balance card.
and reaches the objective. In photographs using The use of cross-polarized filters for dental
Reflected Cross-Polarization, the light falls on photography allows the elimination of unwanted
the object’s surface to be studied and is then stray light and specular reflection from the dental
reflected towards the lens (Figs. 5.19 and 5.20). structure from the buccal surface. These filters
are incorporated into the flash and are located
perpendicular to another polarizing filter located
5.6 Communication simultaneously on the front of the lens. This
with the Laboratory results in a high contrast image or a supersatu-
rated image, allowing detailed chromatic map-
Color selection in dentistry is considered a sub- ping of the dental element (Figs. 5.21 and 5.22).
jective process, dependent on three factors: light As demonstrated, the use of polarizing filters
source, object (tooth), and observer (dentist/ associated with digital photography is a simple
patient/laboratory technician) [8]. Some studies and direct method used to better understand the
[9–13] have been developed to try to standardize color of the natural anterior dentition, improving
5 Dental Photography as a Key to Clinical Success 71

communication with laboratory technicians, a DSLR camera with twin flash, a DSLR camera
which makes the rehabilitation much more pre- with twin flash and light modifiers, and a DSLR
dictable (Fig. 5.23). camera with twin flash with polar eyes system,
Sampaio et al. [10], compared the perfor- associated with the use of a gray card. They con-
mance of different digital equipment and acces- cluded that the use of gray cards favored results,
sories for color selection. Among them were a optimizing the usage of digital equipment for
smartphone, a DSLR camera with circular flash, color selection. The employment of reflected
cross-polarization with the polar eyes system
showed the best results and, according to this
study, the smartphone was the least accurate.

Fig. 5.21 Polar-eyes® cross-polarization filters. (Adapted Fig. 5.23 Result achieved, harmonizing the element with
from https://www.youtube.com/watch?v=uZwNKHnQyPw) a darkened substrate to the rest of the dental elements

Fig. 5.22 The color taking of the substrate of the dental element, with the aid of reflected polarized light, for esthetic
rehabilitation
72 L. F. Tabata et al.

As we mentioned at the beginning of this tion of treatment stages, and enhancing the level
chapter, smartphones and compact cameras are of recorded details.
still a long away from offering the same In our experience, patients enjoy and value
­photographic quality achieved with DSLRs and seeing on a screen (or even on the camera’s LCD)
mirrorless equipment. Nevertheless, these what is being performed during treatment. A clin-
devices work for the entry level path in the world ical picture can be a valuable instrument to
of dental photography and can be used until a increase patients’ understanding of why certain
better equipment can be acquired. Although they procedures are needed, for educating patients on
present some limitations (regarding sensor size required behavioral changes, and for treatment
and absence of a dedicated macro-lens), good planning. A well-known concept that uses stan-
results may be achieved with proper lighting and dardized clinical pictures (and videos) for plan-
configuration setup. And indeed, a simpler pic- ning a dental treatment is the Digital Smile
ture of a clinical case performed with straightfor-Design (DSD). It also allows digitally simulating
ward devices are better than no photo at all. possible treatment results and to visually explain
(show) to the patient what may be achieved. This
tool certainly aids esthetic treatment plan
5.7 Photography in the Daily acceptance.
Practice of Dentistry Post-treatment pictures, with or without an
“artistic touch,” are also very useful. And not
In the last decades, the evolution of digital cam- only for documentation, or to allow long-term
eras and accessories, its user-friendliness, larger follow-ups comparisons, but to reinforce patients’
accessibility, and lower costs, have exponentially perception of the dentists’ work quality, which
increased the role of images in the dental practice increases patients’ fidelity.
quotidian. Before and after photographs may also be
Nowadays, it is possible to affirm that there is used for marketing purposes. Be sure to always
always a feasible way, regardless of budget, of respect local regulations in terms of patients’ pri-
recording dental treatment steps. Either by using vacy and all mandatory legal authorizations.
an always present smartphone or a high-end cam- Well performed dental pictures greatly
era with plenty of accessories, capturing relevant enhance the communication between dental pro-
visual information opens a myriad of uses for the fessionals when discussing treatment plans and
images. Quality will certainly vary according to are valuable assets for educational and scientific
the used equipment and the photographer’s train- purposes. Presenting clinical cases with images
ing and experience. Adjusting the needed equip- rich with relevant information, together with a
ment for one’s routine is an exercise that, if well solid scientific content, is the cornerstone of
performed, will result in finding the best cost-­ many of the best lectures at the main dental con-
benefit for each particular case. gresses of the world.
The first reason to include photography in the For those involved in prosthodontics, enabling
dental practice routine to record patients’ base- the dental technician to see, in detail, the clinical
line and post-treatment images with the intent of case for which an indirect restoration will be pro-
documentation. It is also important for legal pro- duced is truly a must. Tooth color, shape, texture,
tection and for long-term follow-ups. As com- and the singularities of each patient’s tooth can
monly said, an image is worth a thousand words. be easily shared. Digital photography and, in
Nowadays with the availability of electronic files present days, the commonly digital flux of restor-
for patients, digital images can be easily attached ative dentistry have surely increased the quality
and stored to records, enriching the documenta- of exchanged information and reduced distances
5 Dental Photography as a Key to Clinical Success 73

in the dentist/dental technician relationship. The 3. Santos JF. Luz, exposição, composição, equipamento.
Farmalicão: Centro Atlântico; 2010.
use of standardized reference shade tabs, gray 4. Terry DA, Geller W. Esthetic and restorative den-
cards, calibrated monitors, and a good under- tistry: material selection and technique. Chicago:
standing of some of the dental photography con- Quintessence; 2013.
cepts presented in this chapter on both the clinical 5. Peterson B. Understanding exposure, fourth edition:
how to shoot great photographs with any camera.
and the laboratory ends of the process strengthen New York: Amphoto; 2016.
the level of communication [11]. 6. Hallimond F, Taylor EW. An improved polarizing
On the topic of color, standardized digital microscope. III. The slotted ocular and the slotted
photography—particularly those using concepts objective. Mineral Mag. 1948;28:296–302.
7. MicroscopyU. The source for microscopy education.
of exposure adjustment with a gray card and Introduction to polarized light. https://www.micros-
reflected cross-polarization—can be used not copyu.com/techniques/polarized-­light/introduction-­
only to shade selection in prosthodontics [11, to-­polarized-­light. Accessed 21 Jan 2020.
12], but also for the quantification of color in 8. Takatsui F, Andrade MF, Neisser MP, Barros LA,
Loffredo LC. CIE L* a* b*: comparison of digital
clinical research [14]. images obtained photographically by manual and
automatic modes. Braz Oral Res. 2012;26:578–83.
https://doi.org/10.1590/s1806-­83242012005000025.
5.8 Final Remarks 9. Hein S, Zangl M. The use of standardized grey reference
card in dental photography to correct the effects of five
commonly used diffusers on the color of 40 extracted
Dental photography is an inseparable part of human teeth. Int J Esthet Dent. 2016;11(2):246–59.
modern Dentistry. In every dental specialty, pre- 10. Sampaio CS, Atria PJ, Hirata R, Jorquera
dominantly those involved in esthetics, the use of G. Variability of color matching with different digi-
tal photography techniques and a gray reference
images has increasingly gained relevance over card. J Prosthet Dent. 2018;121(2):333–9. https://doi.
the past years. Knowledge of the basics of the org/10.1016/j.prosdent.2018.03.009.
subject, such as required equipment, fundamen- 11. Hein S, Tapia J, Bazos P. eLABor_aid: a new
tals of photography, and some practical training approach to digital shade management. Int J Esthet
Dent. 2017;12(2):186–202.
on achieving useful images, should be part of a 12. Jorquera GJ, Atria PJ, Galán M, Feureisen J, Imbarak
contemporary dental curriculum. M, Kernitsky J, Cacciuttolo F, Hirata R, Sampaio
CS. A comparison of ceramic crown color difference
between different shade selection methods: visual,
digital camera, and smartphone. J Prosthet Dent.
References 2021; https://doi.org/10.1016/j.prosdent.2020.07.029.
13. Bartholin E. Experimenta crystalli islandici disdi-
1. Zyman P, Etienne JM. Recording and communi- aclastici quibus mira & insolita refractio detegitur.
cating shared with digital photography: concepts Munich: The Bavarian State Library; 1669.
and considerations. Pract Proced Aesthet Dent. 14. Schoppmeier CM, Derman SHM, Noack MJ, Wicht
2002;14(1):49–51. MJ. Power bleaching enhances resin infiltration
2. Chu SJ, Tarnow DP. Digital shade analysis and veri- masking effect of dental fluorosis. A randomized
fication: a case report and discussion. Pract Proced clinical trial. J Dent. 2018;79:77–84. https://doi.
Aesthet Dent. 2001;13(2):129–36. org/10.1016/j.jdent.2018.10.005.
 Bleaching Procedures
6
Vinícius Salgado

6.1 Tooth Discoloration Etiology tion during tooth development as metabolic dis-
orders of Alkaptonuria, congenital erythropoietic
The color of teeth is determined by a combina- porphyria, congenital hyperbilirubinemia, ame-
tion of intrinsic color and the presence of any logenesis imperfecta, dentinogenesis imperfecta,
extrinsic colored stain that may form on the tooth molar incisor hypomineralization, other systemic
surface. The tooth discoloration can be classified syndromes, and to inherited disorders which
according to the origin of stain in intrinsic, extrin- involve only the hard tissue forming at the time as
sic, or internalized discoloration [1]. tetracycline staining, fluorosis, enamel hypopla-
Intrinsic tooth color is associated with the sia [2] (Figs. 6.1, 6.2, 6.3, 6.4, 6.5 and 6.6).
light energy interaction with the dental tissues However, intrinsic tooth staining can also
such as reflection, transmission, scattering, and occur after tooth eruption. First, it is related to
absorption optical phenomena [2]. The enamel is physiological aging, which increases tooth color
a highly mineralized tissue (about 97%) mainly darkness. Due to continuous chemical and
constituted of colorless hydroxyapatite crystals mechanical wear of enamel through age, that
in needles-shape that form a complex, hierarchi- becomes thinner and more translucent, i.e., the
cal, and organized microstructure. The enamel dentin will become more visible. Furthermore,
has a slight white color and higher translucency. the darkness of tooth color intensifies due to the
The dentin is a protein-rich bone-like biocom- physiological laying down of secondary dentin,
posite tissue containing a mineral phase (about
70%) mainly constituted by hydroxyapatite, an
organic phase mainly constituted by collagen and
water. Its hue varies among yellow, orange, and
brown shades with low translucency.
The intrinsic tooth discoloration occurs fol-
lowing a change in tooth structural composition
or thickness of the hard dental tissues, altering
the light-transmitting properties of tooth struc-
ture. The intrinsic tooth discoloration may be
related to factors that occur prior to tooth erup-
Fig. 6.1 Intrinsic tooth discoloration related to inherited
disorders that occur prior to tooth eruption: Amelogenesis
V. Salgado (*) imperfecta (Photography courtesy of Dr. Dayane
Private Practice, Rio de Janeiro, RJ, Brazil Oliveira et al.)

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 75

D. Oliveira (ed.), Color Science and Shade Selection in Operative Dentistry,
https://doi.org/10.1007/978-3-030-99173-9_6
76 V. Salgado

which lead to increased chroma and decreased

value of dentin shade [3]. Some inherited disor-
ders that occur after tooth eruption can also leads
to intrinsic staining (Figs. 6.7, 6.8, 6.9 and 6.10)
as pulpal hemorrhagic products following dental
trauma, pulp necrosis, or root resorption [1].
Extrinsic color is associated with the absorp-
tion of darker or high-colored compounds,
Fig. 6.2 Intrinsic tooth discoloration related to inherited
disorders that occur prior to tooth eruption: mild tetracy-
cline staining

Fig. 6.3 Intrinsic tooth discoloration related to inherited Fig. 6.6 Intrinsic tooth discoloration related to inherited
disorders that occur prior to tooth eruption: severe tetracy- disorders that occur prior to tooth eruption: severe fluoro-
cline staining sis staining

Fig. 6.4 Intrinsic tooth discoloration related to inherited

disorders that occur prior to tooth eruption: mild fluorosis Fig. 6.7 Intrinsic tooth discoloration related to inherited
staining disorders that occur prior to tooth eruption: molar incisor
hypomineralization

Fig. 6.8 Intrinsic tooth discoloration related to inherited

Fig. 6.5 Intrinsic tooth discoloration related to inherited disorders that occur after to tooth eruption: element 11
disorders that occur prior to tooth eruption: moderate fluo- with history of dental trauma leading to pulp chamber
rosis staining obliteration and darkening aspect
6 Bleaching Procedures 77

Fig. 6.9 Intrinsic tooth discoloration related to inherited

disorders that occur after to tooth eruption: element 25 Fig. 6.12 Extrinsic tooth discoloration related to deposi-
with pulp necrosis which leads to a gray staining tion of chromogens onto the dental surface

Fig. 6.10 Intrinsic tooth discoloration related to inher- Fig. 6.13 Internalized discoloration related to extrinsic
ited disorders that occur after to tooth eruption: element stain incorporation within the tooth structure due enamel
11 with history of dental trauma. Situation after 5 years of porous surface by dental caries
endodontic treatment and patient’s report of progressively
darkening intensification. Brownish staining due pulp
hemorragic products oxidation metal-containing molecules. The dental extrin-
sic staining is influenced by inadequate tooth
brushing, dietary intake of colored food and
solutions (e.g., coffee, tea, cola soda, and red
wine), exposure to nicotine and other tobacco
products, and use of cationic agents such
chlorhexidine and metal salts (e.g. tin and iron)
[1]. Inorganic chromophores are colored transi-
tion metal ions of iron, copper, manganese, or
tin. In the form of metal complexes, organic and
inorganic chromophores may also be present in
combination, e.g., in h­ emoglobin, where a col-
ored porphyrin ligand is combined with a col-
Fig. 6.11 Extrinsic tooth discoloration related to deposi- ored iron [4].
tion of chromogens onto the dental surface
The internalized discoloration is the extrinsic
stain incorporation within the tooth structure,
named chromogens by the pellicle coating (a mainly those associated with dietary and tobacco
salivary protein film) and to their deposition products chromogens. It becomes more evident
onto the enamel surface (Figs. 6.11 and 6.12). in enamel defects (i.e., fluorosis, dental caries,
There are two different chromogen types: (1) and enamel cracks, hypoplasia, and hypocalcifi-
large organic molecules that have conjugated cation) and in the porous surface of exposed den-
double bonds in their chemical structure and (2) tin [5–7] (Fig. 6.13).
78 V. Salgado

bleaching process may be defined as the chemi-

cal degradation of the enamel and dentin chromo-
gens by reactive molecules as peroxides or
sodium hypochlorite. Currently available
peroxide-­containing materials for tooth whiten-
ing include professionally dispensed products for
supervised at-home use by patients, in-office
products use by professionals, and over-the-­
counter products for sale directly to patients [10].

Fig. 6.14 Intrinsic tooth discoloration related to inher- 6.2.1.1 Hydrogen Peroxide
ited disorders that occur after to tooth eruption: element
11 with history of dental trauma. Situation after 3 years of In general, the bleaching mechanism with perox-
endodontic treatment and patient’s report of progressively ides is considered to be oxidation, although the
darkening intensification. Yellowish/orangewish staining process is not well understood. Hydrogen perox-
due endodontic products oxidation ide is a highly reactive molecule with low molec-
ular weight. It diffuses into and through the
Some restorative materials may have an effect enamel to reach the enamel dentine junction and
on tooth color, as some used for root canal treat- dentin regions, reacting with the organic mole-
ment as eugenol, phenolic compounds, and poly- cules, oxidizing the double bonds in conjugated
antibiotic pastes, which contain pigments that chains and cleaving them. The reaction process
lead to dentin discoloration (Fig. 6.14). Some forms a number of different active oxygen spe-
amalgam alloys may lead to dark grey discolor- cies depending on conditions, including tempera-
ation of dentin due to tin and mercury penetration ture, pH, light activation, and presence of
in dentinal tubules [8]. transition metals [10, 11].

6.2.1.2 Carbamide Peroxide

6.2 Tooth Whitening Techniques The carbamide peroxide is a chemical adduct of
urea and hydrogen peroxide, which, when in con-
Tooth whitening can be described as any process tact with water or saliva, disassociates back into
that increases teeth lightness. It can be achieved hydrogen peroxide and urea. A carbamide perox-
by mechanical or chemical removal of darker or ide at 10% yields close to 3–3.6% of hydrogen
high-colored compounds which are accumulated peroxide and 6.4–7% of urea [10]. While hydro-
on the surface or inside the dental tissues. gen peroxide can be considered its active ingredi-
The extrinsic stain related to the acquired pelli- ent, urea may provide some beneficial side effects
cle on the tooth surface can be removed by tooth because it tends to raise the pH of the solution.
brushing and flossing while those adhered to the
enamel, i.e., dental calculus, by abrasive and polish- 6.2.1.3 Sodium Perborate
ing action of professional dental prophylaxis. The The sodium perborate is an oxidizing agent avail-
control of extrinsic stains formation can be made able as a powder. It is stable when dry, but it
using daily dentifrice containing abrasive agents, breaks down, which when in contact with water
which increases the stain cleaning, or/and chemical to form sodium metaborate, hydrogen peroxide,
agents as phosphate salts and enzymes, which pre- and nascent oxygen. Sodium perborate is easier
vent their aggregation into the surface [9]. to control, and it considers safer than concen-
trated hydrogen peroxide solutions [12].

6.2.1 Bleaching Agents 6.2.1.4 Alternative Molecules

The sodium percarbonate is an alternative hydro-
Bleaching is defined as a discoloration process gen peroxide source. It is used in a silicone poly-
that can occur in a solution or surface. The dental mer containing paint-on gel that is applied onto
6 Bleaching Procedures 79

the tooth surface, forming a durable pellicle for

overnight bleaching [13]. Alternative tooth
bleaching molecules were proposed as sodium
chlorite, peroxymonosulphate, metal catalysts
associated with peroxides and oxidoreductase
enzymes, but their efficacy and long-term accept-
ability require further investigations [10].

6.2.2 Vital Tooth Whitening

There are a number of methods and approaches Fig. 6.15 At-home bleaching: initial situation. Face
that have been described in the literature for photography
bleaching of vital teeth with variation in different
agents, concentrations, times of applications,
product formats, application modes, and light
activation [11]. Vital teeth can be bleached at
home using dentist-dispensed or over-the-­counter
products, and/or in the dental office by profes-
sional application products.

6.2.2.1 Dentist-Monitored At-Home

Bleaching
The original concept of at-home bleaching was
introduced in 1989 by Haywood and Heymann,
also called nightguard bleaching [14]. It consists
Fig. 6.16 At-home bleaching: initial situation. Smile
of 10% carbamide peroxide gel use in a custom- photography
ized tray for at least 2 weeks with the supervision
and guidance of a dentist [14, 15]. Depending on
the tooth darkness and staining type, results are
generally seen 2–3 weeks, and the final outcome
may be complete in 5–6 weeks. Later products
have offered gel concentrations of 1–10% of
hydrogen peroxide and 10–22% of carbamide
peroxide.
Individual custom-fitted bleaching trays can
be made with 0.5–1.0 mm silicon sheets in a heat
and vacuum tray-forming machine over plaster
models. After cooling, the trays should be cut
2 mm above the gingival margins. Then, it should Fig. 6.17 At-home bleaching: initial situation. Intraoral
be tested in the mouth to check their adaption and photography
if any sharp edges bother the tongue and cheeks.
The dentist must demonstrate to the patient the The vital teeth tooth whitening efficacy is
application of the whitening gel on the internal determined mainly by the bleaching agent con-
facial surface of the tray. Patients should be centration and application period, among several
advised to perform oral hygiene before the other factors. Basically, the higher the concentra-
bleaching tray application (Figs. 6.15, 6.16, 6.17, tion, the faster the whitening effect. However,
6.18, 6.19, 6.20, 6.21 and 6.22). low concentrations of hydrogen or carbamide
80 V. Salgado

Fig. 6.18 At-home bleaching: individual custom-fitted Fig. 6.21 At-home bleaching: final situation. Smile
bleaching trays over plaster models photography

Fig. 6.19 At-home bleaching: bleaching trays test to Fig. 6.22 At-home bleaching: final situation. Face
check their adaption and if any sharp edges bother the photography
tongue and cheeks

ored teeth. Tetracycline-stained teeth are the least

responsive to bleaching; depending on the sever-
ity of the stain, mild to moderate stains tend to
respond to extended bleaching regimes of
2–6 months, while severe stains are difficult to
bleach. The darker the initial color, the longer the
treatment time [18].
Adhering to a white diet during the process
Fig. 6.20 At-home bleaching: final situation. Intraoral (e.g., avoid colorful food and beverages) of tooth
photography whitening does not impair the esthetic outcome
[19]. However, patients should be notified to
peroxides can lead to the same efficacy with an avoid the consumption of citrus food or acidic
extension of the treatment period [16, 17]. Also, drinks (due to their low pH) to decrease the risk
the type of intrinsic stain and initial tooth color of teeth hypersensitivity.
plays a significant part in the tooth whitening out- In some countries like in the USA, there are
come. The efficacy of the at-home bleaching mass-market products directly available to the
technique has been demonstrated successful for general public. These products contain low con-
approximately 91% of non-tetracycline staining centrations of peroxide agents (e.g., 3–6% hydro-
teeth but less successful with tetracycline discol- gen peroxide) that are self-applied to teeth in
6 Bleaching Procedures 81

different forms as gum shields, strips, and paint- (Figs. 6.31 and 6.32). Then, a gingival barrier
­on gels. Usually, it requires two daily applica- must be applied on the gingival margins of the
tions by 2 weeks approximately [10, 13, 20]. dental crowns and then photoactivated. Therefore,
the bleaching agent should be applied to the teeth
6.2.2.2 In-Office Bleaching of Vital labial surface, according to the manufacturer’s
Teeth instructions.
High concentrations of peroxide agents are used The bleaching gels may be further activated by
for professional in-office bleaching of vital teeth, light, despite the irrelevance of light activation in
also known as power bleaching. It can result in
significant whitening after just one professional
application, but it requires multiple appointments
for optimum whitening results. For vital teeth,
hydrogen peroxide at 25–35%, or carbamide per-
oxide at 35%, are used in short periods of time,
between 20 and 40 min of application (Figs. 6.23,
6.24, 6.25, 6.26, 6.27, 6.28, 6.29 and 6.30).
Before application of bleaching gel, the soft
tissues should be protected. First, it should be
selected an effective lip retractor that also pro-
tects the tongue and cheeks from contact with the
bleaching gel. A sliced sucker or bite block can
be used to restrain dental occlusion and retract Fig. 6.23 In-office bleaching: initial situation. Face
the tongue if the lip retractor cannot promote this photography

a b

Fig. 6.24 In-office bleaching: initial situation. Smile photography—front (a), right (b), and left (c)
82 V. Salgado

a b

Fig. 6.25 In-office bleaching: initial situation. Intraoral photography and color measurement for incisors (a) and
canines (b)

Fig. 6.26 In-office bleaching: soft tissues protection with Fig. 6.28 In-office bleaching: bubble formation into the
tongue, chicks, and lips retractor and gingival barrier bleaching gel during bleaching reaction
application

periods of time. However, the bleaching efficacy

is not dependent on the technique used [21].

6.2.3 Non-Vital Tooth Whitening

6.2.3.1 Walking Bleaching

The intracoronal or internal bleaching, also
known as the walking bleaching technique, was
introduced in 1967 by Nutting and Poe [22] and
is probably the most popular option for bleaching
non-vital teeth. Originally, this technique involves
filling the pulp chamber with a mixture of
Fig. 6.27 In-office bleaching: application of in-office
peroxide gel over teeth surface 20–30% hydrogen peroxide and sodium perbo-
rate, which needs to be reapplied every 2–7 days
[15]. However, other peroxide agents can be used
the efficacy of tooth whitening. Also, the combi- as hydrogen peroxide (up to 35%), carbamide
nation of in-office and at-home bleaching tech- peroxide (16–37%), or sodium perborate alone
niques can increase the rate of bleaching in shorter (i.e., mixed with water) [12].
6 Bleaching Procedures 83

a b

Fig. 6.29 In-office bleaching: final situation after three appointments: intraoral photography and color measurement
for incisors (a) and canines (b)

a b

Fig. 6.30 In-office bleaching: final situation: Smile photography—front (a), right (b), and left (c)

After the access to the pulp chamber of end- endodontic sealing material. Therefore, the
odontic treated teeth, the sealing material should bleaching agent is placed into the pulp chamber,
be removed close to 3 mm in an apical direction cover with a cotton pellet, and then with a provi-
beyond the clinical crown height to create a space sory restorative material.
for cervical sealing and exposes the dentinal The lower the bleaching agent pH, the higher
tubules directed towards the cervical region of the risk of external cervical root resorption.
the tooth (Figs. 6.9, 6.32, 6.33, 6.34, 6.35, 6.36, Although the isolated use of sodium perborate may
6.37 and 6.38). Then, a 2 mm base of glass-­ be a slower process, it is potentially less destructive
ionomer cement should be applied to protect the to the tooth due to its alkaline pH and hence safer.
84 V. Salgado

Fig. 6.31 Use of sliced sucker as tongue retractor and to Fig. 6.34 Non-vital bleaching: protection of endodontic
restrain dental occlusion sealing material with a 2 mm base of glass-ionomer
cement

Fig. 6.32 Use of bite block as tongue retractor and to Fig. 6.35 Non-vital bleaching: application of bleaching gel
restrain dental occlusion

Fig. 6.33 Non-vital bleaching: after endodontic treat- Fig. 6.36 Non-vital bleaching: covering the bleaching
ment, removal of endodontic sealing material close to gel with a cotton pellet
3 mm in an apical direction beyond the clinical crown
height to create a space for cervical sealing and exposes
the dentinal tubules directed towards the cervical region
of the tooth
6 Bleaching Procedures 85

6.3 Color Measurement

for Bleaching Procedures

6.3.1 Patients’ Whiteness

Perception

The dental color is a frequent concern for patients

and is associated with an increased desire for
esthetical dental treatments. Psychophysical
studies indicate that whitened teeth lead to posi-
tive judgements of personality traits such as
Fig. 6.37 Non-vital bleaching: provisional restoration social competence and appeal, intellectual abil-
with provisional direct composite ity, and relationship satisfaction [25]. The color
and overall visual aspect of teeth is a complex
phenomenon influenced by several factors as
lighting conditions, translucency, opacity, fluo-
rescence, opalescence, iridescence, tooth surface,
light scattering, gloss, and human visual system
[26]. The teeth whiteness perception by the
patients is greatly influenced by the color of their
gums, lips, and skin [27, 28]. The darker the color
of the tissues around the teeth, the higher the
effect of lighter teeth perception. Due to the
lower contrast effect, whiter-skinned patients
may report less satisfaction with the tooth whit-
ening outcome.
Fig. 6.38 Non-vital bleaching: final situation after Data from literature indicate that the percep-
2 weeks of walking bleaching
tion that very white teeth are beautiful signifi-
cantly decreased with the increase of age group,
After the internal bleaching end, the bleaching as well as younger patients expressed a greater
agent should be removed from the pulp chamber preference for white teeth than older patients
with an extended water flush. Then, the pulp cham- [29]. Despite the fact that similar expectations
ber must be provisionally filled with a paste of cal- with tooth whitening could exist among the dif-
cium hydroxide and water in order to render the pH ferent age groups, the standard esthetic prefer-
alkaline in the tooth cervical region [23]. ences are personal. Some patients may seek to
have the whitest teeth color possible regardless of
6.2.3.2 In-office Internal Bleaching their age.
The in-office internal bleaching is considered an
alternative treatment for non-vital teeth bleach-
ing. It involves the application of 30–40% hydro- 6.3.2 Color Measurement
gen peroxide inside the pulp chamber and over Techniques
the external surface of the crown for 20–40 min.
In the past, a heating instrument was used to As previously mentioned in Chap. 3, there are
accelerate the process, but this is strongly inad- two different ways to evaluate the color of the
visable due to the external root cervical resorp- teeth, objectively or subjectively. The objective
tion increased risk [24]. method is based on instrumental color measure-
86 V. Salgado

ments; while the subjective method consists of shade guide was proposed, adding three new tabs
the visual comparison between teeth and shade for bleached teeth 0M1, 0M2, and 0M3 [32].
guides [30]. The tooth whitening effect can be The Bleachedguide 3D-MASTER (Vita
evaluated both visually and instrumentally. Zahnfabrik) is a cross-section of Toothguide
However, the visual method is the most used due 3D-MASTER (Vita Zahnfabrik) with 15 tabs and
its simplicity and reduced cost. a linear arrangement from the highest (0M1) to
The color of teeth is mainly subjectively mea- the lowest (5M3) value (Fig. 6.40). It contains 8
sured by the visual comparison method using a original Toothguide 3D-MASTER tabs and 7
tab from paper, colored porcelain, or acrylic resin interpolated tabs, included to bridge large color
shade guides [26]. These guides are made of a set differences among middle tab (M2) in different
of shade tabs intended to cover the range of col- groups. The lightest part of the Bleachedguide
ors present in human teeth. For tooth whitening 3D-MASTER exhibits subtle color gradation
monitoring, dental shade guides should be used with several tabs lighter than the lightest tab of
to follow the color change. Visual evaluation is Vitapan Classical (B1) [33].
performed by registering the tab that most closely There are other value-arranged shade guides
matches the tooth shade throughout the whiten- exclusively designed for tooth whitening moni-
ing treatment period. toring as the R-20 and R-27 (Vakker Dental) with
20 and 27 tabs, respectively (Fig. 6.41). However,
6.3.2.1 Shade Guides for Tooth no research data is available in the literature
Whitening Monitoring about their use for shade matching in Dentistry.
In worldwide clinical practice, the most com- There are several shade guides made from
monly used dental shade guide is the Vitapan paper, available to purchase by regular consum-
Classical (Vita Zahnfabrik). As mentioned in ers (non-dentists) with different color and white-
Chap. 3, the color range of this shade guide is ness gradations. Its use for tooth whitening
divided into four different hue groups designated monitoring should not be encouraged by clini-
by A, B, C, and D letters, representing reddish-­ cians due to the paper perishability, color differ-
brown for A hue, reddish-yellow for B hue, gray- ences among shade guides due to printing errors,
ish for C hue, and reddish-gray for D hue. For inadequate flat surface of the tabs, or even due to
each hue group, there are different tabs differenti- the absence of detachable tabs.
ated by an Arabic number ranging from 1 to 4,
with different chromas and values. The higher the 6.3.2.2 Visual Color Measurement
number, the higher chroma and the lower the During the tooth whitening monitoring, color
value. For tooth whitening monitoring, it is rec- measurement should be performed in order to
ommended to rearrange the tabs according to the follow the color change. As mentioned in Chap.
value, from the highest (B1) to the lowest (C4) 3, color from any object, as the tooth and shade
(Fig. 6.39) [31]. Recently, a modification for this guide tab, is directly influenced by illumination.

Fig. 6.39 Tooth

whitening monitoring:
rearrange the Vitapan
Classical tabs according
to the value, from the
highest (B1) to the
lowest (C4)
6 Bleaching Procedures 87

Fig. 6.40 Tooth whitening monitoring: bleachedguide 3D-MASTER shade guide

Fig. 6.41 Tooth whitening monitoring: value-arranged R-20 bleaching shade guide

Therefore, it is important to place the tab at an dardized photographs is necessary to show the
equal level with teeth to get the same amount of patient the treatment evolution.
illumination. A photographic protocol is suggested for the
beginning and for the end of tooth whitening: (1)
6.3.2.3 Photographic Register full-face smiling photo; (2) face smiling photo
Taking photographs in the beginning and during with dental shade guide placement just below the
the curse of tooth whitening treatment is strongly smile; smile photos in (3) front, (4) right and left
recommended due to different reasons. (5) sides; (6) and (7) intraoral photos of upper
Sometimes, patients may be demotivated with anterior teeth over a black background with the
the treatment due to self-perception of no effi- tab placement that most closely matches the
cacy. So, beyond registering the color change actual color of the upper central incisors (6) and
throughout the whitening period, taking stan- upper canines (7).
88 V. Salgado

During the whitening progress monitoring, Moreover, the residual oxygen present in dental
the same intraoral photos can also be taken i.e., tissues after the bleaching process decreases the
before-after an in-office power bleaching bond strength to enamel and dentin, because the
appointment and at each at-home whitening con- oxygen inhibits the monomer polymerization that
trol appointments. cures via a free-radical mechanism [38, 39]. For
this reason, it is recommended to delay at least
1 week after the tooth whitening before place-
6.4 Considerations to Bleaching ment/replacement of direct restorations in order
Related to Direct Restorative to the residual oxygen may have sufficient time
Approaches to leach from the dental hard tissues. Optimal
bonding to pre-bleached dental hard tissue could
The bleaching procedures may negatively affect be achieved after a period of about 3 weeks [35].
the marginal seal of restorations in both pre- and
post-operative periods. Meticulously clinical
examination must be performed before applica- References
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 Biomimetics of the Natural Tooth
Using Composites
7
Dayane Oliveira and Vinícius Salgado

7.1 Build-Up Layering and layering concepts with different levels of

Techniques clinical complexity and reliability [1]. They can
be classified according to the proposed number
The current resin-based composites have differ- of shade layers for a restoration, from monochro-
ent degrees of opacity and translucency. It can be matic to polychromatic restorations. However,
nominated according to the areas that should be the dentist should know that the esthetic success
located (i.e., cervical, body, or incisal) and to tis- of its direct restorations is dependent of a learn-
sues that they must reproduce (i.e., dentin or ing curve with the use of some specific composite
enamel). and also with the layering technique.
The layering of resin-based composite direct Before the restorative procedure itself, special
restorations for esthetic purposes started with the attention should be paid to the tooth characteris-
light-curing technology development. The major tics, which are related to the patient’s age, tooth
part of resin-based composites is VITA-based, translucency pattern, tooth wear, and other spe-
i.e., their colors are based on the Vitapan Classical cific characteristics as surface cracks, and opaque
(Vita Zahnfabrik) color concept. They are also spots or lines [1–3].
named in the same way as these shade guide tabs.
First by a letter (A, B, C, and D), which repre-
sents the hue, and then by an Arabic number, 7.1.1 One-Layer Build-Up
which represents the chroma degree, the higher Technique
the number, the higher the chroma. However,
other resin-based composite systems are non-­ This concept was created together with the intro-
VITA-­based, i.e., they have other color concept duction of resin-based composites for direct res-
and different nomenclatures. torations. It is based on the application of just one
Nowadays, there are available several resin-­ shade in all extensions of the restoration.
based composite systems with different shading Although it is unable to fully reproduce the opti-
cal features of dental tissues, it can be effectively
D. Oliveira (*) used in small classes III or even in temporary
Department of Restorative Dental Sciences, College restorations.
of Dentistry, University of Florida, With the development of different opacity
Gainesville, FL, USA materials, the optical features of resin-based
e-mail: [email protected]
composites get an improvement, and new pos-
V. Salgado sibilities have emerged for this concept
Private Practice, Rio de Janeiro, RJ, Brazil

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 91

D. Oliveira (ed.), Color Science and Shade Selection in Operative Dentistry,
https://doi.org/10.1007/978-3-030-99173-9_7
92 D. Oliveira and V. Salgado

Fig. 7.1 Clinical case of one-layer build-up technique: Fig. 7.4 Clinical case of two-layers build-up technique—
initial situation classical two-layering: initial situation

Fig. 7.2 Clinical case of one-layer build-up technique: Fig. 7.5 Clinical case of two-layers build-up technique—
color stratification planning classical two-layering: color stratification planning

Fig. 7.3 Clinical case of one-layer build-up technique:

final situation Fig. 7.6 Clinical case of two-layers build-up technique—
classical two-layering: final situation
(Figs. 7.1, 7.2 and 7.3). The Chameleon technique
is based on the monochromatic build-up of the
restoration with materials of intermediate opacity, restorations. It comprises a monochromatic
also named as “body” composites, and its blend- build-up using “body” masses with the addition
ing with the surrounding dental tissues [4]. of high-translucent materials, also named “inci-
sal” or “transparent,” in the incisal region in order
to reproduce the incisal translucency (Figs. 7.4,
7.1.2 Two-Layers Build-Up 7.5 and 7.6).
Technique
7.1.2.2 Natural Two-Layering
7.1.2.1 Classical Two-Layering This concept relies on the application of two
This concept was developed based on the one-­ masses, which rather tends to replicate the optical
layer build-up in order to improve the esthetic of properties of the dental tissues, allowing a spatial
7 Biomimetics of the Natural Tooth Using Composites 93

Fig. 7.7 Clinical case of two-layers build-up technique—

natural two-layering: initial situation. (Photography cour- Fig. 7.10 Clinical case of multi-layer build-up tech-
tesy of Dr. Monique Solon and Dr. Thais Soares) nique—classical three-layers: initial situation

Fig. 7.8 Clinical case of two-layers build-up technique— Fig. 7.11 Clinical case of multi-layer build-up tech-
natural two-layering: color stratification planning. nique—classical three-layers: color stratification
(Photography courtesy of Dr. Monique Solon and Dr. planning
Thais Soares)

7.1.3 Multi-Layers Build-Up

Technique

7.1.3.1 Classical Three Layers

It comprises a set of three different opacity
masses. First, a high-opacity material, named
“dentin” shades, are used, followed by a low-­
opacity material, named “enamel” (or “body” in
Fig. 7.9 Clinical case of two-layers build-up technique— some restorative systems) shades, and then, by a
natural two-layering: final situation. (Photography cour- high-translucent material, named “translucent,”
tesy of Dr. Monique Solon and Dr. Thais Soares) “incisal,” or “transparent” shades. Different from
the natural layering, this concept implies a poly-
arrangement that copies the dental structure chromatic build-up, with opacity and chroma
(Figs. 7.7, 7.8 and 7.9). Opaque masses, named variations from the inside to the outside of the
as “dentin” shades, with opacity similar to the restoration (Figs. 7.10, 7.11 and 7.12).
natural dentin, are used in the center of the resto-
ration. Covering them are the translucent masses, 7.1.3.2 Modern Three Layers
named “enamel” which may be applied in differ- This concept is based on the natural two-­layering,
ent aspects to reproduce young, adult, and elderly but with the addition of “effect” materials to
teeth [5–7]. reproduce fine anatomic details, placed between
94 D. Oliveira and V. Salgado

Fig. 7.12 Clinical case of multi-layer build-up tech- Fig. 7.15 Clinical case of multi-layer build-up tech-
nique—classical three-layers: final situation nique—modern three-layers: final situation. (Photography
courtesy of Dr. André Reis)

Fig. 7.13 Clinical case of multi-layer build-up tech-

nique—modern three-layers: initial situation. Fig. 7.16 Clinical case of multi-layer build-up tech-
(Photography courtesy of Dr. André Reis) nique—Four or more-layers: initial situation.
(Photography courtesy of Dr. Monique Solon and Dr.
Thais Soares)

lowed by intermediary opacity, named as “body”

shades, then by low-opacity materials, named as
“enamel” shades and then by high-translucent
materials, named as “translucent,” “incisal,” or
“transparent” shades. Like the classical three-­
layering, it implies a polychromatic build-up,
with opacity and chroma variations from the
inside to the outside of restoration. In this tech-
Fig. 7.14 Clinical case of multi-layer build-up tech- nique, the body shades are inserted to stratify the
nique—modern three-layers: color stratification planning. opacity levels between layers in tooth body
(Photography courtesy of Dr. André Reis) regions, facilitating camouflage of transition
zone between the tooth and the restorative mate-
dentin and enamel layers, that can intensify high-­ rial (Figs. 7.16, 7.17 and 7.18).
translucent, and opalescent effects, e.g., blue or
yellow tint composites use (Figs. 7.13, 7.14 and
7.15), making individual characterization to 7.2 Restorative Planning Using
improve the esthetic [8]. Schematic Drawings

7.1.3.3 Four or More Layers It is a fact that the ability to replace the original
It comprises a set of four or more different morphology of the lost tooth structure is essential
opaque/translucent masses. First, the use of high-­ to reestablish function, health, and esthetics.
opacity materials, named as “dentin” shades, fol- However, an optimal understanding of the tooth
7 Biomimetics of the Natural Tooth Using Composites 95

shades. However, body, translucent (or incisal),

and effect shades are also available from a few
manufacturers, such as Tokuyama (Estelite
Omega), 3M (Filtek Supreme Ultra), and Miris 2
(Coltene) (Fig. 7.20a–c). All these different com-
posites have different optical properties to help
mimic any natural tooth structure particularities.

7.2.1 One-Layer Build-Up

Fig. 7.17 Clinical case of multi-layer build-up tech- Technique
nique—Four or more-layers: color stratification planning.
(Photography courtesy of Dr. Monique Solon and Dr.
Thais Soares)
As previously described in this chapter, the one-­
layer build-up technique consists of applying just
one shade in all extensions of the restoration.
This technique is highly effective in small resto-
rations or places where esthetics are not really
demanded.
Of course, for this specific technique, sche-
matic drawings are not necessary. However, still,
color matching can be challenging. Although the
most indicated shade for this technique are body
shades [4], esthetic regions where only enamel
was lost, enamel shades are usually a better fit.
Fig. 7.18 Clinical case of multi-layer build-up tech-
nique—Four or more-layers: final situation. (Photography Specifically for this technique, some manufac-
courtesy of Dr. Monique Solon and Dr. Thais Soares) turers started fabricating what is now called uni-
versal composites. The universal composites
consist of a resin-based restorative material for
morphology can help visualize and better plan the single-shade technique. These composites
the restorative procedure. Schematic drawings come in a universal opacity similar to the body
have been highly used and recommended for shades (Fig. 7.21).
crown fabrication. Most laboratory prescriptions Some books and authors also call this tech-
already come with a shade instructions section, nique the Chameleon technique due to the
including schematic drawings to be chosen or monochromatic build-up of the restoration with
drawn to improve the communication between a single shaded material [4]. However, the
dentists and laboratories and facilitate color Chameleon effect is known as the phenomena of
matching. perfectly blending with the surrounding back-
In direct restorative dentistry, schematic draw- ground. However, of course, such situation only
ing can also facilitate the color match. In order to happens when color matching is perfect. For
perfectly achieve biomimetics of the natural this reason, some manufacturers are now fabri-
tooth, not only the correct shades need to be cho- cating and claiming some composites have a
sen, but each shade needs to be placed correctly true chameleon effect. These composites are a
and perfectly mimicking the contralateral tooth single uncolored shade able to blend with the
(Fig. 7.19a). If correct shades are chosen but surrounding tooth structure perfectly. The man-
incorrectly placed, perfect color matching does ufacturers claim the target refraction of light
not occur (Fig. 7.19b). creates structural color in the yellow–red range
As previously described, all conventional and reflect the surrounding real tooth color.
composite manufacturers offer dentin and enamel Examples of chameleon effect composites are
96 D. Oliveira and V. Salgado

Fig. 7.19 Example of correct shade selection with: (a) correct layering placement and (b) incorrect layering place-
ment, and color matching

the Omnichroma (Tokuyama) (Fig. 7.22a). The ture as the multi-layer build-up technique.
Omnichroma composite also offer a blocker However, they do have a high clinical color
shade to be used over dark discolored tooth matching acceptance [9–12]. It is worthwhile to
structures and facilitating correct color match- mention that these composites are also helpful in
ing (Fig. 7.22b). simplifying color selection and minimizing clini-
The literature shows these composites cannot cal errors when the one-layer build-up technique
perfectly blend with the surrounding tooth struc- is indicated.
7 Biomimetics of the Natural Tooth Using Composites 97

a b

Fig. 7.20 Conventional composites: (a) Estelite Omega (Tokuyama); (b) Filtek Supreme Ultra (3M); and Miris 2
(Coltene). (Photography courtesy of Tokuyama Dental, 3M and Coltene)

7.2.2 Two-Layers Build-Up

Technique

The two-layers build-up technique is sub-­classified

into two categories: the Classical two-­layering
and the Natural two-layering. The main difference
between these two categories is the type of opaque
and translucent composites combined to mimic
dentin and enamel. Regardless of the terminology,
what will dictate what composite will be used is
the one that better mimics the color and the trans-
lucency properties of the natural tooth being
reconstructed. For this, a quick mock-up with the
two shades layered can help to identify the more
appropriate combinations (Fig. 7.23a) before the
final restorative procedure (Fig. 7.23b).
As illustrated in Fig. 7.24a–f, the schematic
drawings for the two-layer build-up technique is
focused on where the dentin or body will be
placed and shaped following the morphology of
Fig. 7.21 Filtek universal composites (3M).
(Photography courtesy of 3M) the natural dentin and its characteristics.
98 D. Oliveira and V. Salgado

a b

Fig. 7.22 Chameleon effect composite: (a) Omnichroma (Tokuyama) and its (b) blocker. (Photography courtesy of
Tokuyama Dental)

Fig. 7.23 (a) Mock-up technique prior. (b) Final restorative technique
7 Biomimetics of the Natural Tooth Using Composites 99

a b

c d

e f

Fig. 7.24 (a–f) Schematic drawings of two-layers build-up technique examples

7.2.3 Multi-Layers Build-Up also called incisal or transparent depending on the

Technique manufacturer. For this technique, the schematic
drawing is focused on where the dentin, enamel, and
7.2.3.1 Classical Three Layers translucent shades will be placed, as well as how the
This technique comprises the use of three different dentin is shaped following the morphology of the
opacity masses: dentin, enamel, and translucent, or natural dentin and its characteristics (Fig. 7.25).
100 D. Oliveira and V. Salgado

7.2.3.2 Modern Three Layers

The main difference between this technique and
the two-layers build-up is the addition of “effect”
materials between dentin/body and enamel/trans-
lucent layers to reproduce anatomic details for
individual characterization.
For this technique, the schematic drawing not
only focuses on where the dentin or body will be
placed and shaped but where the effect material
will be placed and shaped following the anatomi-
cal defect or characteristic that is being repro-
duced (Fig. 7.26a–c).

7.2.3.3 Four or More-Layers

This technique comprises the use of four or more
Fig. 7.25 Schematic drawing of classical three-layering different opacity masses: dentin, body, enamel,
technique example and translucent. For this technique, the schematic

a b

Fig. 7.26 Schematic drawings of modern three-layering tive carious lesion on the neck following the contour of
technique examples: (a) using white effect to mock a the gum line; (c) using blue effect to mock opalescence of
hypoplasia defect; (b) using white effect to mock an inac- incisal halo
7 Biomimetics of the Natural Tooth Using Composites 101

include where the effect material will be placed

and how it will be shaped following the anatomi-
cal defect or characteristic that is being repro-
duced (Fig. 7.28).

References
1. Dietschi D, Fahl N Jr. Shading concepts and layering
techniques to master direct anterior composite resto-
rations: an update. Br Dent J. 2016;221(12):765–71.
2. Dietschi D. Layering concepts in anterior composite
restorations. J Adhes Dent. 2001;3(1):71–80.
3. Bayindir F, Gozalo-Diaz D, Kim-Pusateri S, Wee
Fig. 7.27 Schematic drawing of classical four or more-­ AG. Incisal translucency of vital natural unre-
layers technique stored teeth: a clinical study. J Esthet Restor Dent.
2012;24(5):335–43.
4. Fahl N Jr. Single-shaded direct anterior composite res-
torations: a simplified technique for enhanced results.
Compend Contin Educ Dent. 2012;33(2):150–4.
5. Dietschi D. Free-hand bonding in the esthetic treat-
ment of anterior teeth: creating the illusion. J Esthet
Dent. 1997;9(4):156–64.
6. Ardu S, Krejci I. Biomimetic direct composite strati-
fication technique for the restoration of anterior teeth.
(Erratum in: Quintessence Int. 2006 May;37(5):408).
Quintessence Int. 2006;37(3):167–74.
7. Dietschi D, Ardu S, Krejci I. A new shading concept
based on natural tooth color applied to direct compos-
ite restorations. Quintessence Int. 2006;37(2):91–102.
8. Fahl N Jr. Achieving ultimate anterior esthetics with a
new microhybrid composite. Compend Contin Educ
Dent Suppl. 2000;26:4–13.
9. Abreu JLB, Sampaio CS, Jalkh EBB, Hirata
R. Analysis of the color matching of universal resin
Fig. 7.28 Schematic drawing of classical four or more-­
composites in anterior teeth. J Esthet Restor Dent.
layers technique including “effect” material
2021;33(2):269–76.
10. Iyer RS, Babani VR, Yaman P, Dennison J. Color
drawing is focused on where the dentin, body, matching using instrumental and visual methods for
single, group, and multi-shade composite resins. J
enamel, and translucent shades will be placed, as Esthet Restor Dent. 2021;33(2):394–400.
well as how the dentin is shaped following the 11. Sanchez NP, Powers JM, Paravina RD. Instrumental
morphology of the natural dentin and its charac- and visual evaluation of the color adjustment
teristics (Fig. 7.27). potention of resin composites. J Esthet Rest Dent.
2019;31(5):465–70.
It is important to point out that “effect” mate- 12. Optical behavior of one-shaded resin-based compos-
rials can also be applied in this technique. In ites. Dent Mater. 2021;37(5):840–8.
these cases, the schematic drawing should also
 Finishing and Polishing
8
Alex J. Delgado

8.1 Finishing and Polishing bide burs, (2) diamond burs, (3) coated aluminum
Importance oxide disc, (4) rubber impregnated rubber cups,
points, and discs, (5) interproximal strips, (6)
Finishing and polishing composite restorations is polishing brushes, wheels, and felts, and (7) pol-
an essential procedure for the longevity of the ishing pastes. The most studied and common
restoration and the tooth [1, 2]. A well-contoured, instruments for contouring a restoration are the
finished, and polished restoration will promote fluted carbides, diamond burs, coated aluminum
oral health, serve functionality, and preserve discs, and impregnated rubber cups, points, and
esthetics. Finishing is the gross reduction of the discs. These finishing and polishing instruments
restorative material to obtain an anatomical con- are often offered in different degrees of abrasive-
tour of the restoration and make the margins ness, come in sets, and should be used in the
undetectable, while polishing makes the surface proper sequence, working gradually from the
smooth and lustrous [3, 4] (Figs. 8.1 and 8.2). course to the finest [1, 2]. The clinician must also
Finishing and polishing goals are to obtain the take into general consideration factors such as the
desired anatomy, proper occlusion, and function- type of handpiece (friction grip or latch), the
ality, reduce roughness, and increase surface rotation per minute recommended by the manu-
smoothness to recreate nature. facture, and the pressure applied to each of these
Appropriate instrumentation must be selected instruments. Also, local considerations must be
according to the specific surface being contoured considered, for instance, the grit of abrasiveness,
[5]. Lack of proper finishing and polishing proce- the number of blades, if the instrument is dispos-
dures can compromise marginal integrity, leading able or if it should be in a dry or wet condition [6,
to staining and discoloration of the restoration, 7]. It is also worth mentioning that it is crucial to
gingival inflammation or irritation, and plaque know the effect of polishing direction on the mar-
accumulation that could result in recurrent caries ginal adaptation of the restoration. A study dem-
(Fig. 8.3) [1]. onstrated a significant difference in the marginal
Instrumentation for finishing and polishing adaptation when polishing is accomplished from
available to the clinicians include (1) fluted car- resin-based composites to tooth structure instead
of tooth to resin [8].
A. J. Delgado (*) Obtaining an anatomical contoured of the res-
Department of Restorative Dental Sciences, College toration will provide better oral health preventing
of Dentistry, University of Florida, gingival inflammation and plaque accumulation
Gainesville, FL, USA because the proper anatomy will help the spillway,
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 103
D. Oliveira (ed.), Color Science and Shade Selection in Operative Dentistry,
https://doi.org/10.1007/978-3-030-99173-9_8
104 A. J. Delgado

Figs. 8.1 and 8.2 Clinical case before and after finishing and polishing of the composite restoration. (Photography
courtesy of Dr. Dayane Oliveira et al.)

Finishing and polishing techniques are under the

clinician’s control and are essential to achieve
good marginal integrity.
No minimum marginal gap has been identified
as acceptable for composite restorations. The lit-
erature is controversial in this regard. A study
reported that a gap of less than 1 μm is required
to prevent bacterial infiltration. However, some
toxins can still harm the tooth [11–13].
Over the past decades, the importance of esthet-
ics dentistry has become more evident. In current
clinical treatment, many types of restorations are
Fig. 8.3 Discoloration and gingival inflammation due to
marginal discrepancy of the composite restoration.
available for the replacement of lost tooth struc-
(Photography courtesy of Dr. Vinicius Salgado) ture. The introduction of composite restorations
introduced a new concept in esthetic dentistry and
the development of many types of resin-based
which are grooves, embrasures, or channels composites and techniques that can completely
through which food particles may pass from occlu- mimic the different characteristics of the natural
sal surfaces of the teeth during the masticatory tooth (see further details in Chaps. 2 and 7).
process and adds in the self-cleansing process [9].
Staining and discoloring the restoration might
be a consequence of the lack of fine finishing, 8.2 Finishing and Polishing
which is the process to remove scratches and Concept
improve the surface smoothness sufficiently
enough to polish. Finishing and polishing proce- Finishing and polishing can be divided into four
dures can be detrimental to the surface of restora- steps: Gross finishing, Contouring, Fine finish-
tion and, more importantly, to the marginal ing, and Polishing (Fig. 8.4).
integrity. Marginal integrity defects can lead to Gross finishing is the removal of the resin-­
microleaking in the enamel and dentin interface based composite gross excess to create a close
[10]. The marginal gap can accumulate external shape to the tooth’s contour. This step is typically
staining from extrinsic sources and result in mar- accomplished by using coarse grits instruments
ginal leaking, recurrent caries, and affecting the (green and blue stripe).
pulp tissue [11]. Therefore, it is important for the Contouring is the step that involves establish-
tooth vitality and the longevity of the restoration ing the outline and functional form of the restora-
that possible marginal gaps are prevented. tion. In this step, the margin integrity should be
8 Finishing and Polishing 105

Fig. 8.4 Steps for finishing and polishing resin-based composite restorations

smooth and non-detectable. This step is usually

accomplished with fine grist (red strips).
Fine finishing is the removal of scratches and
defects from the surface. This step does not alter
the restoration’s form and shape, and the step is
completed when the surface is sufficiently
smooth to polish. This step is merely complete
with superfine instrumentation (yellow strips).
Polishing is the final step, which creates high
luster or shines to the restoration and buffers any
imperfection. For this step, the instrumentation
should be ultrafine (white strips).

8.3 Finishing and Polishing

Systems
Fig. 8.5 Fluted carbides burs. Red (8 μm), blue (12 μm),
8.3.1 Fluted Carbide Finishing Burs yellow (30 μm), and white (40 μm). (Photography cour-
tesy of Dr. Fernando Haddock)
Fluted carbide finishing burs are made of tung-
sten carbide, a more rigid metal than steel, and
can withstand high temperatures. The fact that without becoming dull very easily. However, car-
these burs are made of such rigid and resistant bides burs under high pressure can become brittle
metal, they can maintain a sharp cutting edge, and therefore fracture. Fluted carbide burs come
keeping the cutting efficiency after many uses with 8, 12, 15, 16, 20, 30, and 40 flutes (Fig. 8.5).
106 A. J. Delgado

These burs can be used for any direct restorative

material. The greater the flutes, the less aggres-
sive the instrument is. For contouring, the 8 and
12 fluted burs are typically used, but their use
does not result in a well-polished surface. The
use of 15–30 fluted burs will result in fine finish-
ing, leaving the surface ready for the polishing
step. 40 fluted is the final step and will polish the
restoration without altering the final surface.
Fluted carbide burs have various shapes ­available,
and each shape is designed for a specific purpose.
The most common shapes used during finishing
and polishing are the footballs and the flames.
Two commercially available fluted burs in the Fig. 8.6 Diamonds burs showing the difference in the
market are the ET series (Brasseler USA) and the grits from coarse to superfine. (Photography courtesy of
SE series (SS White). Dr. Fernando Haddock)

Series (Brasseler), the NTI Diamonds (Axis

8.3.2 Diamond Finishing Burs Dental), and the Solo Diamond (Premier).

Diamond burs consist of a metal-based blank sur- 8.3.2.1 Fluted Carbide Finishing Burs
face coated with powdered diamond abrasive vs. Diamond Finishing Burs
particles bonded by a metallic adhesive. Diamond The clinician must understand the difference
is the harder cutting material in Dentistry, and it between both instruments. Fluted carbides burs
is superior in its cutting efficiency over other fin- remove restorative material by slicing or shaving
ishing and polishing instruments. Unlike fluted away the composite while diamond burs grind
carbide burs, diamonds rely on the grinding by away the material. In the end, both instruments
abrasiveness particles rather than blades cutting can achieve a smooth surface.
action. Diamonds’ particles can vary in size and
shape. Thus, allowing finishing and polishing 8.3.2.2 Finishing Burs Shapes and Their
results in a shorter period. However, their life Applications
span is shorter than fluted carbide burs. The dia- There are several bur shapes accordingly to
mond particles eventually are flaked off from the ­different applications. The most used ones are the
metal-based blank surface due to the friction over taper finishing, the flame, and the football. The
time. Coarse diamond burs have a range of taper finishing is mainly indicated for flat surfaces,
50–150 μm, while medium grits are usually including facial and margin areas. The flame is
40 μm, fine grits are 25–30 μm, the extra-fine are mainly indicated for occlusal areas. The football is
usually 12–15 μm, and superfine 7–8 μm mainly indicated for occlusal (pointed football)
(Fig. 8.6). The clinical performance of diamond and cingulum areas (round football).
burs depends on the size and shape distribution of
the diamond particles, but its hardness is suffi-
cient for polishing direct and indirect materials 8.3.3 Impregnated Aluminum
[3, 14–16]. The manufactures recommend using Oxide Discs
gentle wiping strokes with these instruments and
with water irrigation, preferably, to avoid heat. Impregnated aluminum oxide discs are fabricated
Some of the most common diamond burs com- by securing abrasive particles of a chemical com-
mercially available in the market are the ET pound of aluminum and oxygen to a flexible
8 Finishing and Polishing 107

Fig. 8.7 Sof-Lex discs (3MESPE) and Super Snap

(Shofu)
Fig. 8.8 Cups, discs, and flames silicon impregnated rub-
ber. (Photography courtesy of Dr. Fernando Haddock)
backing material that could be paper or mylar
(Fig. 8.7). These particles are retained on the disc
by a polymeric adhesive coating layer. Aluminum grits ranging from 40 to 6 μm for polishing [14,
oxide can be used to finish and polish compos- 15]. The main indications for discs are for use in
ites, ceramics, and even enamel [2]. The most proximal and facial surfaces, while points are for
common examples of impregnated aluminum use in occlusal and cingulum surfaces, and cups
oxide discs commercially available in the market are for use in cusp tips are and overall flat
include the Sof-Lex discs (3M ESPE, St Paul, surfaces.
MN) and the Super Snap discs (Shofu Dental A few companies have developed a one-step
Corp, Menlo Park, CA). Both discs have a coarse polisher, such as the PoGo (Dentsply Sirona), the
disc with about 80–100 μm, a medium of around OneGloss, (Shofu INC), or the OptraPol (Ivoclar).
40 μm, fine with 24 μm, and superfine with 8 μm. These are single-use, diamond-impregnated, or
One advantage of the discs is that they are posi- aluminum oxide polishers for the final polishing
tioned in a mandrel, making it easier to exchange of composites, and they are available in cups,
the discs when needed. The Sof-Lex has the flames, and discs shapes.
advantage of being flipped to address different
surface areas. Still, a significant drawback is that
they will flatten surfaces if not positioned with 8.3.5 Interproximal Strips
caution and cannot be used in concave areas.
Their main applications are for use in proximal Interproximal strips are flexible strips made of
and facial surfaces. mylar (polyester) or metal with an aluminum
oxide particles coating. Finishing strips are made
for the interproximal areas and facilitate the fin-
8.3.4 Impregnated Rubber Cups, ishing of any margin discrepancies or roughness
Points, and Discs to avoid plaque accumulation in the proximal
surfaces. Finishing strips are suitable for flat and
These instruments come in different shapes, such convex surfaces. These strips come in two differ-
as cups, points, and discs. They are made of rub- ent sizes, regular and narrow, to give the dentist
ber or elastomeric materials with bonded abra- flexibility to be working in the interproximal
sive coatings such as aluminum oxide, silicon areas in different clinical scenarios. The narrow
dioxide or silicon carbide, zirconium oxide, or strips are excellent to avoid removing or opening
diamond particles. The most popular abrasive the proximal contact and protect the soft tissue
coating is aluminum oxide. These instruments from damage while using the strips near the
can be used in all types of composites and ceram- gums. If the contact is broad or too tight, these
ics. These instruments possess a low cutting effi- strips are ideal for lightening the contact. Usually,
ciency but can be used for contouring. The cups, the regular can be used in patients with bone loss
discs, and points come in latch-type and should or gingival recession. The strips should be curved
be used under 10,000 RPM with water irrigation over the restoration in an “S” motion (Fig. 8.9) to
(Fig. 8.8). These instruments come with different ensure correct contour. These strips come in dif-
108 A. J. Delgado

Fig. 8.9 Polishing strips. (Photography courtesy of Dr.

Dayane Oliveira and Dr. Mateus Garcia Rocha)

ferent grits of abrasiveness from medium to fine

and intend to remove resin material excesses.
Before using these strips, the interproximal area Fig. 8.10 Impregnated brushes: flame and cup shapes.
(Photography courtesy of Dr. Fernando Haddock)
should be assessed visually and tactile with the
explorer, and thin and unwaxed floss should be
passed between the contacts to ensure that the large, and in two different shapes, cups, and
floss does not fray or catch. These strips have a flames (Fig. 8.10). These brushes are indicated for
center part where no abrasive is present to facili- composites, ceramics, and enamel. The manufac-
tate passing through the contact area and reach- turer recommends using the brush at a maximum
ing the proximal surfaces without removing or speed of 3000 rpm and intermittent or dabbing
opening the proximal contact. The metal strips brush movements. Water irrigation can be used,
are far more aggressive than the polyester strips, but it is not mandatory. Some examples of impreg-
and they come with coarse to superfine grits, and nated brushes commercially available in the mar-
they also have serrated strips to open contacts. ket are the Jiffy (Ultradent), Groovy Diamond
More caution should be used with these products. Polishing Brush (Clinician Choice), and the Jazz
Examples of polishing strips commercially avail- Polishers (SS White Dental Inc) [16].
able in the market are the Sof-Lex (3MESPE),
the FlexiDiamonds Finishing Strips (Cosmodent),
the EPITEX (GC America), and the NTI Diamond 8.3.7 Impregnated Wheels
(Kerr) [16].
Polishing wheels are pre-mounted on mandrels
and come impregnated with diamond particles.
8.3.6 Impregnated Polishing They are very popular in the market and come in
Brushes different abrasiveness. Lately, a new type of wheel
has come out in the market, and those are the flex-
The brushes intend to reach deep grooves, fis- ible wheels, which are rubber fingers with embed-
sures, and depressions without removing the res- ded particles throughout the wheel, making it very
toration’s anatomy. These brushes have bristles efficient and easy to use (Fig. 8.11). Examples of
impregnated with various abrasiveness particles, flexible wheels commercially available in the
as mentioned previously in this chapter. The market are the Sof-Lex Spiral Wheels (3M ESPE)
brushes come in two different sizes, small, and and the BioShine (Brasseler USA) [15].
8 Finishing and Polishing 109

8.3.9 Liquid Polishing Systems

Liquid polishing systems are also commercially

available in the market. This system is a low vis-
cous light-cured resin that contains high molecu-
lar weight monomers diluted in a solvent. Thus,
this low viscous liquid is capable of infiltrating
the surface porosities of the restoration. This
way, after photo-activation, the restoration has a
smoother and glossy surface. Although these liq-
Fig. 8.11 Impregnated wheels. (Photography courtesy of uid polishing systems have an easy and low-time
Dr. Dayane Oliveira and Dr. Mateus Garcia Rocha) consuming technique and excellent initial smooth
and gloss results, they have low wear resistance
that leads to lower gloss retention compared to
the other polishing systems over time. Thus, for
esthetics, the most important is not only to choose
an adequate type of resin composite according to
esthetical and functional needs but also to per-
form adequate finishing and polishing
techniques.

8.4 The Artistic Element

in Finishing and Polishing

8.4.1 Illusion Effects

Composite restorations have achieved an impor-

tant milestone in Esthetic Dentistry, but there is
Fig. 8.12 Polishing wheel felt and polishing pastes. an area where nature can be brought closer.
(Photography courtesy of Dr. Fernando Haddock) Sometimes, the clinicians can incorporate texture
or simply modify the symmetry or proportional-
8.3.8 Felts and Polishing Pastes ity of the final restoration. Creating illusions of
length is an artistic element that can be incorpo-
The felts are made of fine white wool, and they rated and made by different instruments already
are designed to be used in combination with pol- mentioned above. A tooth may look longer if the
ishing pates to buffer polishing imperfection gingival height of contour is moved closer to the
(Fig. 8.12). Polishing pastes are typically gingival margin or shorter if the same is moved
glycerin-­based with suspended diamond particles more incisally. An illusion of the width can be
or ultrafine aluminum oxide particles. The parti- created by moving the mesial and distal line
cle sizes are usually not greater than 6–7 μm, and angles closer (narrowing) or apart (widening).
the majority are less than 1 μm. These pastes Surface texture will make the restoration more
should be used with water irrigation to avoid the natural because natural teeth are not entirely flat
crystallization of the silica. The crystals could or free of defects. They possess concavities, con-
scratch the surface, resulting in a rougher surface vexity, scratches, and areas of stippling. Different
[17, 18]. tooth structures have different optical properties.
110 A. J. Delgado

That is why it is crucial to understand how the marginal integrity of resin-based composite and resin-­
modified glass ionomer restoration. J Esthet Restor
light is reflected by different types of composites. Dent. 2015;27(4):184–93.
Still, the light reflection is different when you 7. Maresca C, Pimenta LA, Heymann HO, Ziemiecki
have texture on the surface, and it is essential to TL, Ritter AV. Effect of finishing instrumentation on
assess the light reflection and propagation after the marginal integrity of resin-based composite resto-
rations. J Esthet Restor Dent. 2010;22(2):104–12.
the final polishing. Adding texture to the restora- 8. St-Pierre L, Bergeron C, Qian F, Hernández MM,
tion may improve this phenomenon. Kolker JL, Cobb DS, Vargas MA. Effect of polish-
ing direction on the marginal adaptation of com-
posite resin restorations. J Esthet Restor Dent.
2013;25(2):125–38.
8.4.2 Surface Texture 9. Ash MM. Wheeler’s dental anatomy, physiology, and
occlusion. 10th ed. Amsterdam: Elsevier; 2015.
Younger teeth have significant characterization, 10. ADA Council on Scientific Affairs. ADA Council
while older patients have less anatomy and tex- on dental benefit programs. J Am Dent Assoc.
1998;129(11):1627–8.
ture because of the gradually physiological wear. 11. Taylor MJ, Lynch E. Marginal adaptation. J Dent.
In younger patients, teeth carry wavelike grooves 1993;21(5):265–73.
in the cervical and mid area from the mesial line 12. Soncini JA, Maserejian NN, Trachtenberg F, Tavares
angle to the distal line angle called perikymata. M, Hayes C. The longevity of amalgam versus
compomer/composite restorations in posterior pri-
These stripes never cross each other, and they are mary and permanent teeth: findings from the New
circumferential, and they will create a great deal England Children’s amalgam trial. J Am Dent Assoc.
on the reflection of the light [19]. 2007;138(6):763–72.
13. Bernardo M, Luis H, Martin MD, Leroux BG, Rue T,
Leitão J, DeRouen TA. Survival and reasons for fail-
ure of amalgam versus composite posterior restora-
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 Color Mismatch Between
the Restoration and the Natural
9
Tooth Over Time

Luis Felipe Jochims Schneider

and Larissa Maria Assad Cavalcante

9.1 Color Change in Resin teeth) and esthetic dental restoration with mini-
Composite Restorations mal loss of dental tissues [4]. With these advances
has come a greater demand for esthetic-related
Resin composites represent a significant advance treatment, which has guided the development of
in the field of restorative, conservative, and dental materials in recent years. For example,
esthetic dentistry and today are the most-used resin composites with different degrees of opac-
direct material worldwide [1]. This has not always ity [5] and simplified optical characteristics facil-
been the case, however, and early problems asso- itate improved clinician ability to match the resin
ciated with the adhesion process, unsatisfactory composite to the natural teeth, as is seen in uni-
physicochemical properties, high polymerization versal color system technologies [6].
shrinkage, and excessive wear have necessitated While the aforementioned advancements have
an evolution in resin composite manufacturing allowed for greater clinical applications, over
techniques [2]. Miletic [3] reported that the sig- time resin composite restorations experience
nificant advances in resin composite technology deterioration of texture and gloss as a result of a
encompass modifications in (a) the curing path- complex degradation process [7] (Figs. 9.1–9.3).
way (between the mid-1960s and late-1970s), (b) While early in the development of dental tech-
the filler particles (between the late-1970s and nologies the primary goal was to achieve a resto-
mid-2000s) and, recently, (c) the resin matrix ration that was minimally resistant to wear and
(between the mid-2000s and mid-2010s). mechanical forces, currently the major challenge
Improvements in resin composite technology is the search for maintenance of the esthetic com-
have made possible a wide variety of additional ponents of dental materials. This chapter will
applications, particularly in cosmetic dentistry address intrinsic and extrinsic factors associated
(e.g., closing diastemas, transforming conoid with resin composite discoloration, with the goal
of reducing the need for early replacement.
L. F. J. Schneider (*)
School of Dentistry, Federal Fluminense University,
Niterói, RJ, Brazil 9.1.1 Discoloration Due to Intrinsic
Veiga de Almeida University, Rio de Janeiro, RJ, Brazil Factors
e-mail: [email protected]
L. M. A. Cavalcante 9.1.1.1 Monomers
School of Dentistry, Federal Fluminense University, The color changes arising from the intrinsic pro-
Niterói, RJ, Brazil cesses of resin composites are commonly associ-
e-mail: [email protected]

© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 111
D. Oliveira (ed.), Color Science and Shade Selection in Operative Dentistry,
https://doi.org/10.1007/978-3-030-99173-9_9
112 L. F. J. Schneider and L. M. A. Cavalcante

Figs. 9.1–9.3 Resin composite restorations degraded at different levels

Fig. 9.5 BisGMA:TEGDMA (50:50 et%) monomer

Fig. 9.4 BisGMA:TEGDMA (50:50 et%) monomer blend exposed to ambient light and air for 6 months at
blend freshly removed from the bottle (Photography cour- room temperature (Photography courtesy of Dr. Dayane
tesy of Dr. Dayane Oliveira) Oliveira)

ated with the curing initiator system. Chemical have been shown to influence the optical charac-
alterations in the resin matrix can generate a yellow- teristics of composites [9]. Multiple studies have
ing effect in restorations, primarily due to the pos- reported that vinyl-groups can react with oxygen
sible degradation of carbon–carbon double bonds in to form pigmented peroxides, a process that is
the unreacted monomers (Figs. 9.4 and 9.5) [8]. accelerated by UV irradiation [10]. In this way,
Thus, the chemical structure of the monomer the composition of the resin matrix may influ-
and the physical characteristics of the three-­ ence physical property degradation and color sta-
dimensional polymeric structure are factors that bility of dental resin composites. Fonseca et al.
9 Color Mismatch Between the Restoration and the Natural Tooth Over Time 113

[11] investigated the influence of monomers reg-

ularly used in commercial resin composite for-
mulations on the degree of conversion, water
sorption, water solubility, and optical properties
and found that all composites showed statisti-
cally significant differences in color stability
after water aging. After 2 months in water stor- Fig. 9.6 Pure camphorquinone (CQ) (Photography cour-
age, composites formulated with traditional base tesy of Dr. Dayane Oliveira)
monomers (BisGMA, BisEMA, and UDMA)
presented ΔE values lower than 3.3, a clinically
acceptable value [12]. The lowest ΔE values
were achieved by the base monomer BisEMA
(1.0 ± 0.2), followed by UDMA (1.4 ± 0.2) and Fig. 9.7 Pure ethyl-4-dimethyl amine benzoate (Photography
courtesy of Dr. Dayane Oliveira)
BisGMA (2.5 ± 0.5).
tem based on the use of an alpha-diketone as a
9.1.1.2 Photoinitiator System composite component capable of absorbing light
The influence of the photoinitiator system on in the visible spectrum. Since then, camphorqui-
color change in resin composite restoration is a none has been used in the formulation of the vast
recurrent theme and has consistently affected the majority of dental adhesives, restorative compos-
development of composite materials. Resin com- ites, and luting agents available on the dental
posites emerged for clinical use as self-curing market worldwide (Fig. 9.6). When irradiated by
systems that require the mixture of two pastes, blue light, this molecule enters into an excitatory
which hinders the homogeneity of the compo- stage and, upon meeting an amine-type co-­
nents and often causes the problematic incorpo- initiator (Fig. 9.7), abstracts a hydrogen atom
ration of bubbles into the mixture. Moreover, a from it and generates aminoalkyl radicals, which
significant level of amines is required for the are then responsible for the chain polymerization
polymerization process. According to Ruyter process [15].
et al. [13] the unreacted amine components Although efficient and widely used for many
remain active in the polymeric network and can years, there has been speculation regarding the
react with atmospheric oxygen or other aromatic potential drawbacks of the photoinitiator system
compounds and increase the absorption of visible based on the combination of camphorquinone
light. As a result, a significant color change can and amine. Scientific articles commonly suggest
occur during the restoration. that the concentration of camphorquinone in the
In order to overcome this drawback, photoac- resin composite formulation should be limited
tivated systems using ultraviolet (UV) energy due to the intensity of the yellow hue it causes.
were developed. This evolution was a significant However, it must be considered that when cam-
technological breakthrough as it also allowed cli- phorquinone interacts with an efficient hydrogen
nicians to control working time. However, sys- donor, either an amine co-initiator or a specific
tems activated by UV-light have a low curing monomer (such as UDMA, which will be dis-
depth due to the thickness of the materials and cussed in the section on amine-free systems), a
high concentration of inorganic fillers. In addi- change in its molecular structure occurs causing
tion, the use of ionizing radiation can cause a a lightening, or photobleaching, effect [16].
number of health problems for both the patient The combination of camphorquinone and an
and the operator. Thus, it became necessary to amine is a binary system that depends on the
search for an efficient and biologically safe pho- interaction between two components to generate
toinitiator system. free radicals capable of initiating the chain-­
In 1971, Dart and Nemmeck [14], researchers reaction polymerization process. Thus, the photo-
at Imperial Chemical Industries, patented a sys- bleaching process of camphorquinone is
114 L. F. J. Schneider and L. M. A. Cavalcante

dependent on several factors. First, since the vis-

cosity of the material can influence molecular dif-
fusion, the photobleaching potential of
camphorquinone may be affected by factors such
as mass, temperature, and material composition.
An additional factor, in theory, is the method by
which the blue-light energy employed in the exci-
tation process of camphorquinone is ­delivered.
An activation process that employs a high amount
of light energy in a short time due to the fast and
cyclic interaction process between the cam- Fig. 9.8 Pure 1-phenyl-1,2-propanedione (PPD) (Photography
phorquinone and the amine may lose efficiency courtesy of Dr. Dayane Oliveira)
due to a lack of sufficient time for recombination.
On the other hand, a low concentration of light could, in theory, be used for formulations
energy delivery for a longer time may lose effi- intended for highly whitened teeth or those
ciency by increasing the viscosity of the material treated with bleaching agents [22]. However, this
and consequently limiting the degree of mono- system fell into disuse due to the development of
meric conversion by reducing the molecular diffu- exclusively blue diode (LED) light sources,
sion process. Thus, the counteracting effect of which do not activate compounds that have maxi-
photobleaching may be limited, leading residual, mum light absorption at wavelengths below blue
unreacted camphorquinone molecules to produce [23]. With an increasing availability of LED light
a material with a yellow color shift [16]. sources capable of emitting light at more than
In addition to the possible disadvantages asso- one wavelength, research on alternative non-­
ciated with the use of camphorquinone, the need camphorquinone photoactivator systems began
for an amine-type co-initiator system is also again, with special attention paid to the possibil-
thought to be a limiting factor. Issues related to ity of enhancing the color stability of restorative
the toxic potential of these components aside, materials.
unreacted amines that are trapped inside the The use of 1-phenyl-1,2-propanedione (PPD)
polymeric network can be sensitized by UV irra- was proposed by Park et al. [24]. According to
diation or chemical oxidation and generate com- the authors, this component had the potential to
pounds capable of causing color change that is reduce the color change limitations associated
perceptible to observers [13, 17–21]. As a result with photoactivated resin composites (Fig. 9.8).
of multiple drawbacks to the camphorquinone However, no improvement in the photobleaching
and amine co-initiator system, alternative photo- effect was detected when PPD was compared to
initiator systems have been studied and devel- camphorquinone after photoactivation [17, 18].
oped in recent years. Schneider et al. [17] determined the polymeriza-
tion potential and the yellowing effect of resin
Alternative Photoinitiator Systems composites formulated with PPD, camphorqui-
The partial or complete replacement of cam- none, or camphorquinone/PPD at different con-
phorquinone by other components is not new in centrations and found that the use of PPD did not
research and innovation as well as commercially reduce yellowing and also reduced surface hard-
available clinical applications. In the late-1990s, ness. Later, the same research group evaluated
for example, due to the popularization of tooth the effect of amine ethyl 4-­dimethylaminobenzoate
whitening, the company Bisco launched the (EDMAB) ratio on the curing behavior, degrada-
Pyramid Enamel Neutral resin that comprised a tion resistance, and color change over time in
photoinitiator system based entirely on the use of experimental resin composites formulated with
monoacylphosphine oxide (TPO), which is effi- camphorquinone, PPD, and camphorquinone/
ciently activated by halogen light sources and PPD and found that the use of PPD did not reduce
9 Color Mismatch Between the Restoration and the Natural Tooth Over Time 115

yellowing and negatively affected hardness [18].

De Oliveira et al. [25] studied the influence of
PPD on yellowing and chemico-mechanical
properties of experimental resin composites pho-
toactivated by light curing and found that PPD
alone did not achieve satisfactory results when
compared to camphorquinone and camphorqui-
none/PPD. Furthermore, though there was a sta- Fig. 9.11 Ivocerin™* (Ivoclar Vivadent). (Photography
tistically significant reduction in the yellowing courtesy of Dr. Dayane Oliveira, Dr. Mateus Rocha and
effect (CIELab parameters), the mean values Dr. Jean-François Roulet. *Kindly donated by Ivoclar
Vivadent)
were similar and only a small effect was detected
in the final esthetic appearance.
Phosphine oxides are among the most toinitiators with light absorption peaks located in
researched alternative photoinitiator systems in shorter wavelengths negatively impacts the depth
dentistry. Several studies involving experimental of polymerization of resin composites [19].
resin composites have been performed using the The possibility of using germanium deriva-
ohotoinitiators bysacylphosphine oxide (BAPO) tives as a substitute for camphorquinone and
and TPO [23, 26–31] (Figs. 9.9 and 9.10). Studies amines has been studied and composites with
have found that the use of TPO, alone or with these components are commercially available in
camphorquinone, promoted less yellowing and dental materials under the registered name
improved color stability in restorative materials Ivocerin™ (Fig. 9.11) [35–37]. When employed
[27, 30, 32]. Although research on novel photo- in experimental composites, the germanium
initiator systems should be encouraged in the derivatives benzoyltrimethylgermane (BTMGe)
search for improved color stability, the traditional and dibenzoyldiethylgermane (DBDEGe)
system based on the joint use of camphorquinone showed higher color stability than materials for-
and amines continues to be a reliable formulation mulated with a camphorquinone and amine-­
for dental composites [33]. In fact, some studies based system when exposed to UV irradiation
indicate that systems using camphorquinone and [36]. However, in a study conducted with resin
amines maintain better color stability over time composites available for clinical use, Salgado
than materials formulated with BAPO and TPO et al. [35] found that resins formulated with the
[34, 35]. Furthermore, the use of alternative pho- Ivocerin system showed the highest color varia-
tion after accelerated degradation testing by stor-
age in water and coffee.
Another strategy that has been evaluated is the
use of systems, with or without camphorquinone,
omitting amine co-initiators not only to improve
color stability but also to eliminate a component
that is commonly associated with toxicity [38].
Fig. 9.9 Bysacylphosphine oxide (BAPO) (Photography Asmussen et al. [16] found that camphorquinone
courtesy of Dr. Dayane Oliveira) oxidizes UDMA monomer and that the radicals
derived from the UDMA monomer via hydrogen
abstraction are highly reactive toward double
bonds, achieving a similar level of double-bond
conversion. The use of iodonium salts has been
considered as a total or partial substitute for
amine components and has shown interesting
Fig. 9.10 Monoacylphosphine oxide (TPO) (Photography results in experimental resin composites [39, 40].
courtesy of Dr. Dayane Oliveira) Very recently, sulfinates and sulfonates were
116 L. F. J. Schneider and L. M. A. Cavalcante

evaluated as total replacements for amine that the selection of the material may affect the
­components and produced materials with high color stability of the restoration. Studies have
polymerization ability and color stability [40]. shown that lighter and more translucent resins are
The same research group has designed and tested associated with greater color change [35, 45, 46].
alternative hydrogen donors for camphorquinone
and found excellent photobleaching effects and 9.1.3.2 Material Handling
color stability [41–43]. Although resin composites may inherently con-
Amine-free materials are currently available tain small amounts of micro-bubbles due to the
for clinicians in the form of dual-cure resin manufacturing process [47], it is during the
cement and have demonstrated superior color sta- manipulation of the composite that the highest
bility compared to traditional cement that is for- risk of introduction of large amounts of air inside
mulated with high concentrations of amine the material occurs. This not only causes struc-
components [44]. In this study, however, it was tural defects and subsequent mechanical failure
evident that other factors can have a more signifi- but also reduces the polymerization potential and
cant effect on color stability, including the acts as a reservoir for pigment accumulation by
amount of filler present in the system. One must absorption (which will be discussed in the fol-
also consider that commercially available materi- lowing sections). Thus, the clinician should be
als employ UV-light stabilizers, which have an aware that the maintenance of the optical proper-
excellent ability to reduce the potential discolor- ties of the restorative material is affected by the
ation caused by the amine components. manner in which each resin increment is manipu-
lated (Fig. 9.12).
During the process of sculpting the restora-
9.1.2 Discoloration Due to Extrinsic tion, an increase in the viscosity of the material,
Factors and consequently the inclusion of air bubbles,
may occur due to exposure of the material to
The scientific literature on extrinsic factors asso- light. For this reason, the clinician must avoid
ciated with color change in resin composites exposing the increments for prolonged periods to
commonly involves the long-term degradation ambient light or worse, to light from the
process associated with pigment absorption. reflector.
Color changes can be caused by the absorption of Modeling liquids are commonly employed in
solvents of the organic matrix and/or the increased clinical practice to improve the sculptability of
surface roughness that occurs for a number of restorative materials (Fig. 9.13). Several studies
reasons. However, it is necessary to consider that have been conducted to determine whether this
a series of events carried out during clinical prac- practice has any impact (positive or negative) on
tice can be instrumental in the maintenance of
optical characteristics in the long term. For this
reason, this section will address the extrinsic fac-
tors, separated into immediate (originating from
clinical practice) and long-term factors, associ-
ated with material degradation.

9.1.3 Clinical-Related Factors

9.1.3.1 Material Selection

A wide variety of resin composites that produce
excellent functional and esthetic results are avail- Fig. 9.12 Increment of resin composite correctly
able to clinicians. However, one must be aware removed from the syringe
9 Color Mismatch Between the Restoration and the Natural Tooth Over Time 117

also for the longevity of restorations performed

with resin composite [61, 62]. In addition to pro-
moting a smooth surface, which hinders pigment
accumulation and abrasiveness, the finishing and
polishing steps are responsible for removing the
oxygen-inhibited layer. Failure to perform these
steps, or inaccessibility of cutting or abrasion
instruments to specific areas of the restoration,
will cause a thin layer of the unpolymerized mate-
rial to be directly exposed to a series of processes
responsible for accelerated deterioration or pig-
mentation [63]. One caution that needs to be
heeded is that rotary instruments should be used
Fig. 9.13 Brush impregnated with modeling liquid to
manipulate the increment with composite resin in conjunction with lubricants, as the resin matrix
can degrade if elevated above 200 °C in finishing
and polishing procedures [59].
the physicochemical properties of resin
­composites, with particular emphasis on optical
properties. However, the results of these labora- 9.1.4 Material-Related Factors
tory studies are limited due to a lack of standard-
ization of either the evaluation processes, 9.1.4.1 Degradation Process
materials or treatments performed [48–55]. of the Resin Matrix
Considering the available literature, hydropho- It should be noted that the polymerization pro-
bicity appears to affect the efficacy of the model- cess of composite materials takes place under
ing agent [56]. That is, an undesirable effect is extremely challenging conditions. The presence
more likely in cases where hydrophilic modeling of oxygen from the environment, low atmo-
agents such as simplified adhesives are used. spheric pressure, low ambient temperature, high
material viscosity, and short time-limit to per-
9.1.3.3 Photoactivation form the tasks make it difficult to achieve a com-
The photoactivation process is directly associated plete polymerization process. Thus, the
with maintaining the esthetic aspects of resin monomers are never fully converted. Furthermore,
composite restorations over time [57]. A higher when exposed to the oral environment, the resin
degree of material conversion leads to lower con- matrix comes into contact with a series of agents,
centrations of residual monomers susceptible to primarily saliva, which can act as solvents to
leaching processes and higher resistance to sol- leach the unreacted molecules and penetrate
vent penetration [58]. Thus, the more efficient the between the polymeric mesh formed, causing its
activation process of the material is, the more separation and swelling and leaving the material
efficient the establishment of covalent bonds softer and less resistant to wear [64]. Specific
between the resin matrix with the silane and filler enzymes such as esterases can break the ester-­
particles will be [59]. Furthermore, an efficient type bonds commonly found in resins, further
activation process is fundamental for the correct weakening the material [59, 65].
photobleaching effect of the camphorquinone Resin composites are formulated by ceramic
and amine system [60]. particles that are treated with a bonding agent and
kept together by an agglutinating agent, the resin
9.1.3.4 Finishing and Polishing matrix, which is usually formulated by methacry-
Procedures late monomers. Among the most-used methacrylate
The finishing and polishing steps are fundamental monomers, both in research and industrial applica-
not only for the maintenance of color stability but tion, is bisphenol A-glycerolate d­imethacrylate
118 L. F. J. Schneider and L. M. A. Cavalcante

(BisGMA), a high-viscosity monomer with a stiff, 9.1.4.3 Degradation Process

aromatic central core, which can form a strong of the Silane Layer
polymer network when associated with diluent co- Silane bonding agents act on the bonding process
monomers, usually triethylene glycol dimethacry- between the inorganic filler particles and the
late (TEGDMA). Other base monomers include resin matrix, making the material more resistant
UDMA and ethoxylated bisphenol A dimethacry- to stress transfer from the occlusion process and
late (BisEMA). Many studies have been performed to degradation by hydrolysis. The most important
on the influence of monomer composition on factor in determining the quality of the silanizing
numerous properties, though little consideration has treatment is the thickness of the silane film. If a
been given to the effect of resin matrix composition single silane layer sufficiently covers the filler
on the optical properties of resin composites. particle and promotes a bond with the resin
Fonseca et al. [10] found that the use of BisEMA matrix, additional silane layers may promote a
promoted less resin composite color change over disorganized, brittle, and breakable layer [59].
time, which was likely associated with BisEMA’s Thus, recent studies have sought to better under-
lower affinity to water and lower volumetric expan- stand the effect of the silane layer on the degrada-
sion [66]. tion process and optical properties of dental
Considering the facts mentioned above, the composites [73]. Recently, specific components
amount of resin matrix used plays a key role in or treatments like thiourethane filler functional-
the color stability of resin composites, with mate- ization have been evaluated as substitutes to the
rials formulated with higher inorganic content traditional one [68, 74].
showing less color change [47]. As a result, great
effort has been made to increase the resistance of
the resin matrix to degradation by using mono- 9.2 Methods to Minimize
mers free of ester components or antimicrobial Discoloration
agents [67, 68]. Unfortunately, the products that
have been launched and made available for clini- 9.2.1 Oral Hygiene
cal use have not been shown in the research to be
advantageous in maintaining optical properties As previously mentioned, color changes in resin
[9, 47, 67]. composites can be caused both by clinician
choices and practices and by degradation mecha-
9.1.4.2 Degradation Process nisms inherent to the composition of the mate-
of the Filler Particles rial. With this in mind, some methods can be
The content of inorganic fillers present in resin employed to minimize discoloration caused by
composite material is directly associated with its pigmentation.
resistance to degradation [68–72]. Although The habit of oral hygiene is fundamental for
occurring at a much lower rate than that of the the maintenance of both oral and general health,
resin matrix, the filler particles are also subject to and thus should always be encouraged. By
degradation processes. Water present in saliva removing the biofilm that accumulates on both
can break down the filler particle surface through the dental structure and the restorative material,
the process of hydrolysis and cause subsequent the patient is actively removing pigments left as a
component leaching. In glass particles, for exam- result of diet and/or habits. While studies are
ple, sodium atoms are removed and penetration inconclusive regarding the effect of toothpaste or
of hydrogen atoms by water molecules takes mouthwash on the degradation process of resin
place. Since the hydrogen atoms are smaller in composites [75–80], it is up to the professional to
size than the sodium atoms, a stress phenomenon guide the patient regarding the need to avoid
can occur and thus break the surface [59]. overly abrasive toothpaste or brushes, which may
9 Color Mismatch Between the Restoration and the Natural Tooth Over Time 119

cause excessive wear of both the tooth structure discrepancy between the tooth and restoration, it
and the restored area when used incorrectly. is a possibility and thus necessary that the patient
be informed that this may occur and that a subse-
quent replacement of the restoration(s) may be
9.2.2 Periodic Professional Cleaning required for esthetic reasons. Furthermore,
although a bleaching effect may occur on the res-
Periodic appointments are important to monitor toration due to the removal of pigments deposited
the patient’s oral health and to check the condi- both on the external surface and inside the mass,
tion of previously placed restorations. This may studies indicate that there may be a subsequent
include occlusal adjustment, contouring, or the increase in the darkening of the restoration due to
need for a one-time addition of resin composite. an increase in its roughness after exposure to a
In these appointments, rotary instruments such as bleaching gel [87–89]. Moraes et al. [90] raised
Robinson brushes, rubber cups, or specific jets the question regarding potential bleaching effects
are commonly employed so that effective clean- on the surface integrity of exposed substrates,
ing can be accomplished in the upper and lower particularly with regard to the application of a
arches in a short period of time. Studies have highly concentrated solution. Although direct
been conducted to determine the effect of differ- clinical effects depend on the actual in vivo con-
ent cleaning methods, with special attention to ditions, bleaching procedures should not be car-
those based on air-polishing powders, on the sur- ried out indiscriminately when restorations are
face properties of resin composites. Sodium present.
bicarbonate, glycine, and erythritol have been
tested [80–85]. Despite conflicting results and
dependence on the material being evaluated, 9.3.2 Repolishing vs. Replacing
some studies point to glycine as being less harm-
ful to the surface of restorations [83, 86]. As seen throughout this chapter, resin composites
Yap et al. [81] evaluated the effect of different undergo a constant degradation process in the
cleaning methods on the surface of multiple oral environment that may vary in speed and
direct-use restorative materials and suggested intensity depending on aspects related to both the
that it may be necessary to perform repolishing of patient (behavioral, physiological) and the clini-
the restored surfaces due to a potential increase in cian. Thus, the decision regarding what should be
roughness. Guller et al. [84] has provided similar done with a restoration over time needs to con-
guidance. sider both the patient’s wishes and the practitio-
ner’s experience. When considering an
esthetically unsatisfactory restoration, it is essen-
9.3 Methods to Correct tial to identify the source of the problem.
Discoloration If the origin of the problem is staining due to
external pigments (e.g., coffee, wine, etc.) accu-
9.3.1 Bleaching mulated on surfaces that have become rough over
the years, it is likely that a finishing and repolish-
Tooth whitening has become an increasingly ing procedure is sufficient to restore the mini-
accessible and routine practice in dental offices. mum conditions necessary for this restoration to
Although proven safe, questions remain regard- remain in the mouth [91]. Restorations made of
ing the effect of bleaching agents on preexisting resin composites formulated with small-sized
restorations. Thus, it is essential that patients and filler particles are likely to obtain a bright and
clinicians are aware of the unpredictable nature smooth aspect easily [10]. On the other hand, if
of whitening treatments. While it is not guaran- the discoloration occurs uniformly throughout
teed that a bleaching treatment will cause a color the restoration and at a rate that is different than
120 L. F. J. Schneider and L. M. A. Cavalcante

the remaining tooth structure, the cause is likely ites by UV-irradiation and staining food. Dent Mater.
2006;22(1):63–8.
intrinsic in origin, which would necessitate a 11. Fonseca AS, Labruna Moreira AD, de Albuquerque PP,
complete replacement. de Menezes LR, Pfeifer CS, Schneider LF. Effect of
Material fracture and secondary caries com- monomer type on the CC degree of conversion, water
prise the primary causes of failure of resin com- sorption and solubility, and color stability of model den-
tal composites. Dent Mater. 2017;33(4):394–401.
posite restorations requiring replacement. Color 12. Vichi A, Ferrari M, Davidson CL. Color and opac-
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though is slightly more significant in studies per- 2004;20(6):530–4.
13. Ruyter IE, Nilner K, Moller B. Color stability of den-
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be considered that the demand for direct and indi- Mater. 1987;3(5):246–51.
rect restorations for esthetic purposes has become 14. Dart EC, Cantwell JB, Traynor JR, Jaworzyn JF,
greater in recent years and continues to be on an Nemcek J, (Invs.). Curable dental filling com-
positions. US-PS 4,110,184, Imperial Chemical
upward trajectory. As such, it is essential that Industries; 1978.
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continued development of clinical practice and JP, Lalevée J. The camphorquinone/amine and cam-
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 Longevity of Resin Composite
Restorations
10
Flávio Fernando Demarco, Luiz Alexandre Chisini,
Marcos Britto Correa, Maximiliano Sérgio Cenci,
and Rafael Ratto de Moraes

Composite resin restorations have been the first esthetic demand), and socioeconomic status
choice by clinicians and patients for direct anterior might play essential roles in the longevity of
[1] and posterior restorations [2] mainly due to composites [10]. Tooth structure or composite
optical characteristics, high longevity, adhesive fractures are important factors for restorations
properties, and preservation of sound tooth struc- failure, while esthetic demands could account for
ture [3, 4]. Resin composite restorations have pre- restoration replacement in anterior teeth [11].
sented a lower annual failure rate (AFR) ranging To improve dental restorations’ longevity and
from 1 to 3% in posterior teeth and 1–5% in ante- under a minimally invasive dentistry philosophy,
rior teeth [5]. Recent publications have shown that repair has been proposed as an interesting strategy
this material can be used to rehabilitate severely over the replacement, avoiding the repetitive restor-
worn teeth with acceptable clinical success, with ative cycle [12]. Removal of the sound dental struc-
AFR ranging from 0.4% for microhybrid compos- ture occurs when the complete restoration is
ites to 26.3% for microfilled materials [6]. replaced. When the restoration needing replace-
Similarly, a network meta-analysis found an AFR ment is near the vital pulp tissue, the risk of pulp
of 2.2% for use in large posterior restorations [7]. exposure is elevated and can result in unnecessary
The main reasons for failure in posterior resto- endodontic treatments [13, 14]. Therefore, resin res-
rations, both in adults [8] and children [9], are torations can be repaired when a considerable part
fractures and secondary caries. It has been dis- of restoration presents good condition to be main-
cussed that material properties had a minor effect tained. Repair of defective restorations has exhib-
on longevity. At the same time, clinical-related ited good clinical performance, increasing dental
factors (such as the position of the tooth in the restorations’ longevity (Fig. 10.1) [10, 15] and dis-
tooth arc and dental type), the operator (age, playing better cost-effectiveness than replacement
country of qualification, and employment status), [16]. In this chapter, we will discuss the longevity of
patient (caries risk, bruxing habits, parafunction, esthetic composite restorations, the reasons for fail-
ure, and exploring the repair of defective restora-
tions as a treatment option to the replacement.
F. F. Demarco (*) · M. B. Correa · M. S. Cenci
R. R. de Moraes
Department of Restorative Dentistry, College of
Dentistry, Federal University of Pelotas, 10.1 Expectation vs. Reality
Pelotas, RS, Brazil
L. A. Chisini Resin composites have undergone constant
Department of Restorative Dentistry, College of development, becoming the most used direct
Dentistry, Federal University of Juiz de Fora,
Governador Valadares, MG, Brazil restorative material [2], mainly because of their
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 125
D. Oliveira (ed.), Color Science and Shade Selection in Operative Dentistry,
https://doi.org/10.1007/978-3-030-99173-9_10
126 F. F. Demarco et al.

a b

c d

Fig. 10.1 Clinical phenotypes of resin composite resto- restorations were repaired and still presented good clinical
rations in posterior teeth after at least two decades of clini- performance after several years in the mouth. In (d), res-
cal service. In (a) and (b), the restorations show typical torations were repaired and subjected to polishing, which
signs of aging including loss of anatomical form, surface removed the extrinsic staining and improved appearance.
and marginal staining, color instability, and wear. In (c), (Photography courtesy of Dr. Paullo Rodolpho)

esthetic properties, preservation of tooth struc- highlight that several systematic reviews are
ture, and the high success rates [3, 17]. based exclusively on prospective clinical trials,
Considering the results from clinical studies including low-risk patients. On the other hand,
about the longevity of composite restorations, practice-based studies have displayed AFR
clinicians frequently expect a longevity of more higher when patients with high risk are included
than 20 years for their restorations. However, [8, 35]. In 11 Dutch general practices, a Practice-­
despite the excellent results showed in the litera- Based Study evaluated 31,472 restorations
ture, dentists should be aware that different observed an AFR of 7.8% at 2 years [35]. A simi-
aspects involving themselves, the tooth/cavity, lar practice-based retrospective study that
and the patient can interfere with the durability of assessed the survival of resin composite restora-
a restorations. The understanding of these factors tions in posterior teeth found that 30% of the res-
can help professionals to predict better the prob- torations failed, of which 82% were found in
ability of failure of a given restoration. patients with high-risk factors, being secondary
A vast number of systematic reviews have caries the main reason for failure [8].
been published in recent literature presenting the The expectation of longevity is often deter-
AFR/success rate (SR) of resin composites [10, mined by empirical criteria or measures, such as
11, 18–28] (Table 10.1). In general, the system- the average age of a failed restoration. There are
atic reviews have presented similar results: AFR several factors associated with restorative fail-
ranging from 1 to 3% in posterior teeth and from ures that are important to be evaluated for each
1 to 5% in anterior teeth [5]. The AFR increases clinical situation and can more accurately predict
when endodontic treated teeth are investigated: the longevity of restorations. The clinician’s
ranging from 2 to 12.4% [10]. It is important to expectations should be based on the assessment
10 Longevity of Resin Composite Restorations 127

Table 10.1 Results from systematic reviews on the clinical performance of resin composite restorations
Factors associated with Mains reason to Follow-up AFR/survival
Study Tooth type failure failure (years) proportion (SR)
Arbildo-Vega Class I, II and V NR NR 0.5–10 NR
et al., 2020 [29]
Veloso et al., Posterior NR Caries, fracture, 1–6 SP: 94.4%
2019 [30] (class I and II) sensitivity, bulk-fill; 96.7%
anatomical shape, conventional
marginal composite
discoloration
Azeem and Posterior NR NR 1–11 NR
Sureshbabu, (direct and indirect)
2018 [31]
Afrashtehfar Posterior Number of restored NR 3–10 SP: 89.7%
et al., 2017 [18] endodontically surfaces, restorative (3 years); 92.4%
treated teeth material, and technique (5 years)
Afrashtehfar Posterior Number of restored NR 3–6 SR: 50–100%
et al., 2017 [19] surfaces
Ahmed and Anterior (tooth Occlusal Fractures of 0.5–10 SR: >90%
Murbay, 2016 wear) restoration (2.5 years); 50%
[20] (5 years)
van de Sande Posterior Patient age, gender, Caries and fracture 3–21 AFR: 1.7–5.2%
et al., 2016 [28] caries risk, and SP: 72–95%
parafunctional habits
Angeletaki Posterior NR Fracture and 4.5–11 SR: 83.2%
et al., 2016 [21] (inlay/onlay) cohesive restoration (5 years)
failure
Moraschini Posterior (class I NR Fracture (tooth or 1–10 AFR: 3.17%
et al., 2015 [26] and II) restoration) and
caries
Mesko et al., Several worn teeth NR NR 0.5–12 AFR: 0.4%
2016 [6] (microhybrid);
26.3%
(microfilled)
da Veiga et al., Posterior None Fracture (tooth or 2–11 NR
2016 [24] (class I and II) restoration)
Demarco et al., Anterior Adhesive technique, Fracture of tooth/ 3–17 AFR: 0–4.1%
2015 [11] (class III and IV, composite resin, restoration and SR: 100%
veneers and retreatment risk, and esthetic qualities (3 years); 53.4%
reanatomization) time required to (15 years)
build-up the restoration
Heintze et al., Anterior Cavity type, restorative Bulk fractures and 2–12 SP: 95%
2015 [25] (class III and IV, material, bonding caries (10 years—class
diastema closures) strategy III)
90% (10 years—
class IV)
Astvaldsdottir Posterior NR Caries, fracture, 4–12 SP: 93%
et al., 2015 [22] and restoration loss (4 years); 91
(5 years)
Opdam et al., Posterior Patient caries risk, Caries and fracture 6–22 AFR: 1.8%
2014 [27] (class I and II) presence of lining (tooth or (5 years); 2.4%
cement, number of restoration) (10 years)
restored surfaces,
composite filler
loading
Rasines Alcaraz Posterior Restorative material Caries, fracture, 5–7 NR
et al., 2014 [32] and restoration loss
(continued)
128 F. F. Demarco et al.

Table 10.1 (continued)

Factors associated with Mains reason to Follow-up AFR/survival
Study Tooth type failure failure (years) proportion (SR)
Fron Chabouis Posterior Restorative material Fracture (tooth or 3–10 SP: 73.7% for
et al., 2013 [33] (inlays and onlays) (ceramic better than restoration) and composite inlays
composite) caries
Heintze and Posterior Bonding strategy, Bulk fractures and 2–9 SP: 90%
Rousson, 2012 (class I and II) restorative material, caries (10 years)
[34] operative procedure
Demarco et al., Posterior Clinical, operator, Fracture 5–22 AFR 1–3%
2012 [10] patient, (restoration or
socioeconomic, tooth) and
material secondary caries
NR not reported, AFR annual failure rate, SR cumulative survival rate

of risk factors, which may help a more accurate tions are not appropriate, in general, anterior
estimate. Thus, when the restoration is placed on restorations behave differently from posterior
a patient with risk factors (sometimes more than restorations, presenting reduced failures for “loss
one) it is expected that the durability of this res- of restoration” or caries. At the same time,
toration may be less than average observed. On esthetic appearance plays a prominent role in the
the other hand, when few risk factors are found patient’s desire to have a restoration replaced.
clinically, greater longevity can be expected. To
predict better the likelihood of restoration failure 10.1.1.1 Dental Caries
and make the expectation closer to reality, we Secondary caries are reported to be the main reason
need to discuss the main factors associated with for restoration’s failure. By definition, secondary or
the failure of composite materials. recurrent caries are “lesions at the margins of exist-
ing restorations” or “caries associated with restora-
tions or sealants” (CARS) [53, 54]. It is important
10.1.1 Long-Term Survival to note that restoring a tooth is not the definitive
and Reasons for Failures treatment for caries disease—but it may be a part of
the treatment. To be clear, it is necessary to control
Data on composite resin restorations’ survival all the etiological factors that are causing the dis-
have been widely explored for posterior teeth, ease [55]. The understanding of the causal factors
while data of anterior teeth is more limited in the for caries development and their respective control
literature [11]. The main reasons for failure in is necessary. As it is well-established, caries is a
posterior restorations seem to be secondary caries sugar-biofilm-­ dependent disease, and epidemio-
and the fracture of teeth/restorations [3, 26, 27] logical studies have shown that sugar consumption
(Table 10.2). When high-risk patients are included, in the life course is associated with caries lesions
secondary caries commonly is reported as the [56, 57]. In addition to diet, fluoride consumption,
main reason for restoration failure [8, 35, 51]. hygiene habits, socioeconomic factors, among oth-
Fractures are frequently linked with premature or ers, are essential to be investigated and influence
long-term (fatigue of material) failures, while car- restoration’s survival through secondary caries fail-
ies is related to long-term follow-ups [52]. ures. Considering these aspects, it is possible to
Fracture and esthetic demand have been treat caries disease properly, preventing the occur-
reported as the main failure reasons for anterior rence of secondary caries.
esthetic restoration. Indeed, when the anterior The failure to interrupt the caries disease can
restoration is placed for an esthetic reason, the contribute to the failure of the restoration [58].
likelihood main reason for failure will be related After 18 years, a retrospective study found that
to esthetics (such as color match, anatomical 68.4% of failures were due to secondary caries
form, or surface stain) [11]. Although direct com- [59]. Posterior restorations placed in children
parisons between anterior and posterior restora- with high DMFT index displayed a high risk to
10 Longevity of Resin Composite Restorations 129

Table 10.2 Summary of main factors involved in longevity of composite restorations and their respective effect
measures
Factor Effect
Tooth type – Molars present 2.3 times higher risk of failure than premolars [36]
– Upper central incisors have 1.3 times higher risk of failure than lower lateral
incisors [37]
Cavity size – Each restored surface’s addition leads to an increase of 40% in the risk of
failure [38]
– For premolars, each surface included in the restoration introduces an increase
of 50% on the risk for failure, while for molars, this risk is increased by 24%
for each surface [27]
Previous endodontic treatment – Veneers made in non-vital teeth had a higher risk of failure (178% greater)
over time compared to those made in vital teeth [39]
– Endodontic treatment increases the risk of failure in posterior teeth (HR 25.3)
[40]
Selective caries removal – Selective caries removal does not affect the longevity of restorations, and due
to the fact that it reduces the risk of pulp exposures, it should be chosen
[41–43]
Substrate type There is no consensus in the literature:
 – Higher AFR was observed for class II restorations with glass ionomer bases
compared with restorations without a base material [38]
 – No significant differences were observed after 18 years of posterior
composite survival with and without glass ionomer cement as a base [44]
Caries risk – AFR was 4.2% in the high-risk group and 0.9% in the low caries risk group
[45]
– Presence of unsatisfactory restorations was 5.3 higher in children at high risk
of caries in the permanent dentition than children classified at low risk [46]
Bruxism and/or parafunctional – Restorations in individuals with high occlusal-stress presented 2.6 times higher
habits risk for failure than individuals with no occlusal-stress [8]
Socioeconomic status – Posterior restorations’ failures are 2.2-fold more prevalent in low-income
individuals [47]
Operator – Important variations in the longevity of composite restorations were observed
according to the dentist [48]
Material – To observe the effect of materials properties on annual failure rates long
periods are needed [5, 10, 17]
Esthetic demands – Anterior restoration placed for esthetic reasons presents a higher likelihood to
be changed due to esthetics-related factors such as color match, anatomical
form, or surface stain [11]
Rubber dam isolation – The use of rubber dam seems not to be decisively provided that good isolation
with cotton and suction is achieved [49]
Enamel beveling – Enamel beveling does not affect the clinical performance of the restoration
[34]
Adhesive system – Gold standard dental adhesive technique is the use of a mild two-step, a
self-etch adhesive system with selective phosphoric acid enamel etching [50]
Direct vs indirect composite – Direct and indirect composite restorations have similar performance and
longevity [24]
HR hazard ratio, AFR annual failure rate

fail [60], corroborating with a systematic review anterior region compared to posterior teeth.
that observed caries as the main reason for the Practice-based studies have already corroborated
failure of posterior restoration in primary teeth, these findings [37, 61, 62].
independently of restorative material [9]. On the
other hand, considering anterior composite resto- 10.1.1.2 Fracture
rations in permanent teeth, caries has a low con- Tooth/restoration fracture has been highlighted
tribution in failures in a systematic review [11], as the main reason for failure in anterior teeth. In
probably due to a low incidence of caries in the a systematic review that evaluated the longevity
130 F. F. Demarco et al.

of anterior restoration, the fracture (tooth/restora- Color alterations, marginal mismatch, and sur-
tion) was the most common reason for failure face staining are some of the motifs for patients
among all studies [11], with rates varying from to require replacement of their veneer restora-
25 to 100% of all failures observed in the included tions [67]. However, for posterior teeth, the
studies. esthetic demand is a less important factor to some
Bruxism of parafunctional habits probably patients. When evaluating restorations after
plays a significant role in the fracture of the tooth 27 years in clinical service, the ones carried out
or restorations via tooth-restoration complex with chemical-cured resin composite (which
fatigue, resulting in a fracture as a long-term out- presents accelerate deterioration of color match
come. In addition to the complex etiopathogenic linked to the non-color stable initiators of the
mechanisms of bruxism, which hinder its correct peroxide-initiated curing mechanism) were 59%
diagnosis, in general, studies do not use reliable non-acceptable to the researchers who evaluated
instruments for their assessment. Also, quite often, these restorations, while only 6.3% of light-cured
studies excluded bruxism patients. Restorations materials were classified as non-acceptable.
performed in participants with severe tooth wear However, these restorations were not classified as
presented negative findings when compared to a failure because no patients requested replace-
participants without bruxism habits in a clinical ment of non-acceptable color restoration, which
study with patients with severe tooth wear [63]. were in function [49].
Indeed, when restorations are placed in individuals
presenting bruxism symptoms, more failures due
to fracture could occur [64]. In a practice-based 10.1.2 Factors Involved in Esthetic
study, when patients showed “occlusal-stress,” Restorations Failure
there was a 2.6-fold risk of failure than in individu-
als with “no risk” [8]. Whereas most of the attention in the clinical stud-
ies in restorative dentistry is given to the restora-
10.1.1.3 Esthetic Demand tion’s longevity and the failure causes, it is of
Modern society has increased the demand for utmost importance to study all the factors affect-
esthetics [65]. Especially the anterior teeth must ing the restoration’s failure. I this context, even if
be well-aligned and white, which impacts the most clinicians give quite some importance to the
oral health-related quality of life [66]. The high dental material and dental techniques, factors
visibility and the importance of the smile’s related to the characteristics of the patient, opera-
appearance expose the anterior restorations to a tor, and tooth are critical in assessing the long-­
greater risk of undergoing interventions due to term survival of restorations [10]. Also,
esthetic demands. In this region, small marginal population studies found that socioeconomic and
pigmentations observed with the natural degrada- demographic factors influenced the choice of
tion of the hybrid layer or small natural changes restorative materials, the patients’ risk status,
in color or shape resulting from the natural aging and, consequently, the longevity of the dental res-
of composites can result in early interventions in torations [58].
these restorations. Especially in patients who
exhibit a high esthetic demand. Unlike the poste- 10.1.2.1 Tooth Factors
rior region, where color changes appear to be less Restoration survival depends on several clinical-­
important [49]. It is clear that these changes are related factors for their longevity, including the
linked to factors related to patients and may tooth position in the dental ark, tooth type, cavity
depend on cultural and contextual factors of these size, previous endodontic treatment, and sub-
individuals, which are incredibly subjective. strate type [3, 10, 27].
Upper front teeth restorations exhibited a Restorations in premolars have shown better
higher risk for failure when compared with lower survival results than those placed in molars, and
front teeth, especially in young patients [37]. the explanations are related to higher masticatory
10 Longevity of Resin Composite Restorations 131

forces observed in the molar region [8, 10, 38, cement used could explain the different results
68–70]. After 10 years, general practitioners’ res- observed [10, 44]. Therefore, there is no consen-
torations have a hazard ratio of 2.3 to fail in molar sus in the literature about the influence of GIC
than premolar [36]. Similar results have been under composite restorations.
reported in other studies [8, 10, 38, 68–70]. After The endodontic treatment represents a chal-
27 years, class II restorations in molars presented lenging situation for restoration longevity in both
a failure risk almost 5 higher than premolars [49]. anterior and posterior teeth. The significant loss
However, some studies did not find significant dif- of dental structure in these teeth could be related
ferences [45, 71]. For restoration in anterior teeth, to the main reason for reducing the success rate.
failures were more frequent in upper central inci- A 13-year clinical trial comparing restorations in
sors and upper canines, when evaluating both vital and endodontic treated teeth observed AFR
children and adults in a practice-based study [37]. of 0.08 and 1.78%, respectively [40]. An AFR of
The increase in the number of surfaces 4.9% was observed in vital teeth and 9.8% in
involved in the restorations has been associated non-vital teeth in evaluating anterior composite
with a higher risk of failure [10, 36, 38, 72]. veneers. Veneers made in non-vital teeth had a
Posterior restorations fail 3.3 times more often in higher risk of failure (HR 2.78; 95% CI 1.02–
teeth with fewer than 2 remaining walls than 7.56) over time compared to those made in vital
those with 4 [73]. For premolars, each surface teeth [39].
included in the restoration introduces a hazard The selective carious tissue removal of soft
risk of 1.5, while for molars, the risk is 1.24 [27]. dentine has also been discussed. It is important to
Opdam et al. [38] estimate that each restored sur- consider that selective caries removal decreases
face’s addition leads to an increased 40% risk of the risk of pulp exposition [41] and can improve
failure. Similarly, it was reported that every extra the longevity of restorations [42]. A 5-years ran-
missing wall increases the failure risk from 30 to domized trial observed that selective caries
40% [74]. Thus, class II restorations present a removal to soft dentin in deep caries did not
higher risk than Class I. Also, class III restora- affect the restoration survival when compared to
tions tend to fail less than other anterior restora- stepwise excavation [43]. A systematic review
tions types [11]. Collares et al. [37] observed a observed that selective caries removal have simi-
high-risk of failure in anterior restorations with lar results in restoration longevity than stepwise
three or more involved surfaces (Class IV) than excavation and result in fewer pulp complications
class III restoration, highlighting that restoration [42]. Similar results were observed in a multi-
size is an important predictor of failure risk also center clinical trial considering primary posterior
in anterior teeth. teeth. The longevity of restorations was similar
Glass ionomer cement sandwich-type restora- between non-selective and selective carious tis-
tions are frequently used to perform indirect pulp sue removal over 33 months [78]; but a system-
protection in deep caries lesions. Using a GIC atic review with a limited number of included
liner or base under composite resin restorations articles with a high risk of bias have observed
has shown divergent results in the literature. In that—in primary teeth—selective caries removal
several studies, the use of an intermediate GIC decrease the restoration longevity [79]. Thus, for
liner negatively influenced the restorations’ sur- primary teeth, no definitive conclusion about the
vival, resulting in more fracture of composite influence of selective caries removal on restora-
resin [10, 27, 38, 75, 76]. An AFR of 3.8% was tion longevity can be performed.
observed for class II restorations with glass iono-
mer bases while observing an AFR of 1.4% for 10.1.2.2 Patients’ Related Factors
restorations without a base material [38]. In The focus of a vast number of clinical trials
opposite, other studies observed no effect on res- investigating the survival of restorations is lim-
toration longevity when using GIC liners [44, 68, ited to comparisons between technic or materials
77]. The thickness and type of glass ionomer [80, 81] while patients-related factors are not
132 F. F. Demarco et al.

investigated. The contribution to patient-related risk patients when the restoration is placed may
factors on restoration survival cannot be ignored provide a reasonable estimate, such as the lesion
[11, 27, 28]. When patients are not mainly activity assessment [85].
selected for inclusion criteria in clinical trials, Bruxism and parafunctional habits have been
some studies have observed that failures are reported as factors that overload the restorations
linked to certain participants, independently of and increases the likelihood of restoration/teeth
restorative material used [82]. Similar results are failure due to fatigue. Fracture of restorations is
observed in epidemiological studies where caries frequently reported as the second main reason for
is the central factor in explaining the failure and restorations failure. Fracture is the main failure
replacement of dental restorations [83, 84]. of patients with habits of grinding and clenching
Corroborating, a birth cohort study, observed that teeth [8]. 70% of the restoration’s fractures
unsatisfactory restorations at 24 years were more occurred in patients with the parafunctional habit
prevalent in individuals that presented a high in a long-term follow-up (30 years) [71]. Patients
number of decayed teeth at 15 years [58]. with bruxism were also associated with a 37-fold
Caries risk of patients has been associated more failed restoration or catastrophic fracture
with higher restorations failure. Restorations occurred whether the teeth presented root canal
placed in the high-risk group showed a lower sur- treatment [40]. In a practice-based retrospective
vival rate than the low-risk group after 5 and study that evaluated the survival of resin compos-
12 years. Considering 12 years of evaluation, ite restorations in posterior teeth, individuals
AFR was 4.2% in the high-risk group and 0.9% with high occlusal-stress displayed three times
in the low caries risk group [45]. In a clinical higher risk to failure than individuals with low
trial, corroborating that after 30 years, 64% of occlusal-stress; moreover, individuals with
restorations that failed due to secondary caries occlusal-stress and caries risk showed a cumula-
were observed in the high-risk group [71]. A tive effect and eight times more failures than indi-
review observed that caries risk was associated viduals no risk [8].
with decreased restoration survival, including Instruments for assessing bruxism habits used
amalgam and composite resin [28]. In a cohort in studies that evaluate restorative materials are not
study evaluating posterior restorations (compos- objective, and they do not present standardized
ite or amalgam), it was observed that individuals cutoff points, which limit their inference [10]. The
who had a higher trajectory of caries during their most recent International Consensus [86] pro-
life were more likely to present failed restora- posed a system for evaluating bruxism, consider-
tions in adult life [47]. In another cohort study, in ing that possible bruxism during sleep is based
children at the age 12, the chances of presenting only on the author’s report (report of patients),
unsatisfactory restorations were 5.3 higher in probable sleep bruxism (with clinical inspection
children at high-risk for untreated dental caries in such as the presence of tooth wear), and definitive
the permanent dentition than children at low risk. sleep bruxism (based on instrumental assessment,
If the parents have received orientation from pro- such as polysomnographic). Furthermore, brux-
fessionals on preventing caries development in ism’s etiology is considered to be multifactorial,
their offspring, the children exhibited a 91.0% and several underlying mechanisms may play a
less chance of having an unsatisfactory restora- role in triggering and perpetuating events [87].
tion than children whose parents never received Post-operative sensitivity was one of the
information [46]. Decayed, missing, filled teeth-­ causes of patient-related failures in the first clini-
surfaces (DMFT-S) have been used to evaluate cal studies evaluating composite restorations;
caries experience, even as the component D of however, such aspect is not observed in modern
DMFT. Also, the number of the previous restora- studies, primarily due to the improvements in
tion was used to access caries risk. However, the adhesive systems [88] and restorative technique
use of a cumulative indicator could overestimate [89]. Several studies have found that participant’s
the caries risk. Therefore, identifying high-caries age significantly influences restoration longevity
10 Longevity of Resin Composite Restorations 133

[37, 90, 91]. The explanations are directed to the of medium and high socioeconomic status [48].
influence of age in other co-variables like dental Some studies have corroborated with the discus-
caries, patient cooperation, among others, and it sion of the influence of socioeconomic and
is not recommended to be considered as an iso- behavioral factor on the survival of composite
lated factor [5]. Caries activity has been reported resins [93–96].
to be the more frequent reason for making a den-
tal restoration in the young population. 10.1.2.4 Restorative Material
Consequently, these restorations would be sub- Although in vitro studies have found consider-
ject to higher risk due to individual factors. A able differences between the properties of com-
study that followed 4355 restorations placed by mercially available restorative materials [97, 98],
115 dentists in the Public Dental Health Service these findings are limited in predicting the clini-
in Denmark observed that posterior composite cal behavior of restorations [76]. In fact, in vitro
resin restorations placed in children presented and clinical studies have presented contradictory
more likely to fail than those placed in the adoles- evidence of direct restorations’ clinical perfor-
cent group [90]. mance in posterior teeth [24]. Perhaps differ-
ences observed in laboratory tests will take
10.1.2.3 Socioeconomic Status decades to be observed clinically [17]. Yet, the
Limited studies have investigated the influence of differences can be so minor in clinical outcomes
socioeconomic variables and their influence on that they may not be statistically significant [71].
the longevity of composite restorations. Most For posterior teeth, a retrospective study with
studies evaluating the longevity of restorations data from one dentist’s private clinical practice
are carried out in private dental clinics or are per- followed two types of composites for long peri-
formed under high control in randomized clinical ods. No differences in performances were
trials, excluding patients with high-caries risk observed 17 years; however, after 22 years of
[10]. Frequently only individuals with high follow-up, midfilled (70 vol% inorganic filler
socioeconomic status are included. However, the loading) composite showed superior performance
findings of studies that investigate the influence than minifilled (55 vol% inorganic filler loading)
of socioeconomic status suggest that it influences [17]. Similar tendencies were observed to ante-
dental restorations survival via dental caries. One rior restorations: only after 10 years of follow-up
study carried out in a birth cohort investigate the significative differences between restorative
influence of socioeconomic trajectory in the life composites were clinically observed [61].
course and found more unsatisfactory restora- Another study that retrospectively evaluated
tions in the low trajectory group. Individuals who for up to 20 years the longevity of restorations
always lived in the poorest stratus presented more placed by one operator under rubber dam isola-
failures than those who lived in the wealthiest tion and patients with regular check-up visits did
layer [58]. A more recent follow-up of this cohort not find differences between the composites
reported that posterior restorations’ failures were placed in posterior teeth [99]. Similarly, after
significant associated with socioeconomic status 30 years of another controlled trial, no differ-
at age 30, with a prevalence ratio of 2.21 (95% CI ences between composite resins placed with
1.19–4.09) in low-income tertile [47]. In the chemical-cured and light-cured resin composite
same way, a recent study assessing restorations were observed regarding survival rate. Thus, to
performed in the Brazilian public oral health ser- compare the clinical survival of restorations is
vice found that people with lower access to pub- necessary long-term studies. Moreover, these
lic services presented lower survival rates of studies’ results are with materials that were
composite restorations [92]. A practice-based developed decades ago and are expected to be
study also observed that restorations performed inferior to the composite resins recently
by clinicians located in the more deprived region developed.
presented higher AFR than those found in areas
134 F. F. Demarco et al.

A wide number of composite materials have and bevel are not indicated because they does not
been introduced in the market, and the clinical tri- affect the clinical performance [34]. Moreover,
als’ design to compare these new materials pres- the use of rubber dam isolation does not seem to
ent few years of follow-up. The main modification affect the longevity of restorations, as long as it is
in the inorganic formulation of composites was applied effectively with cotton rolls and suction
the introduction of nanofiller composites. These devices. Although some studies have observed
materials were created to provide superior polish better performances of restorations applied under
and gloss retention. A randomized 10-years trial rubber dam isolation [9, 34], the evidence shows
of class II nanohybrid and conventional hybrid that restorations placed using cotton rolls and
resin composite observed an overall AFR of 1.9% suction device can also survive for long periods
and no significant difference between the com- [49] and the use of appropriate suction device
posites [100]. In another study, the overall success and working with the aid of a dental nurse are
rate was 100% after 6 years of clinical evaluation even more important for achieving good isolation
for nanohybrid and hybrid composite [101]. At from humidity in case rubber dam is not used.
8 years, the success rate was 98.5%, with no dif-
ferences observed between materials [102]. 10.1.2.5 Operator
A recent development in resin composite tech- Dentist-linked factors, such as operator skills, are
nology was the introduction of “bulk-fill” resin considered important factors that influenced the
composites. Bulk-fill composites can be cured in survival of composite resin restorations [5].
up to 4 or 5 mm layers and include both low as Although a wide part of results is explained
high viscosity materials. A randomized clinical solely on the training level and accuracy of work,
trial compared to class I and II restorations com- the decision-making process also can influence
pared flowable bulk-filled resin composite (in restoration survival and could combine as a com-
increments up to 4 mm as needed to fill the cavity plex process, ranging among clinicians according
and 2 mm short of the occlusal cave surface with to co-variables, such as the type of practice, reim-
the occlusal part completed with nanohybrid bursement system, competition environment
resin composite) and resin composite-only placed among dentists, patients’ views and opinions,
in 2 mm increments. After 5 years of evaluation, and cultural aspects.
bulk-filled presented an AFR of 1.1% and the The dentists are the ones who place the resto-
resin composite-only restorations of 1.3%, with rations, those who evaluate them, and, ultimately,
no significant differences detected between the decide when the restoration needs to be changed.
materials [102]. Variability on diagnostic and decision-making
Although the comparisons of direct and indi- has been elevated among dentists that frequently
rect composite restorations have similar perfor- adopt an invasive approach to intervene in resto-
mance and longevity [24], other factors related to rations, especially when they were performed by
the restorative technique have been reported to other professionals [13]. Invasive behavior
influence the clinical performance of composite toward restoration replacement results in a
materials. Adhesive systems are frequently evalu- decrease in the survival of restoration. Chisini
ated in Class V restorations and also influenced et al. [106] observed that the decision-making of
the longevity of these restorations [103], even dentists was influenced by patient skin color.
though, for anterior restorations, the degradation Clinicians choose more to replace ill-adapted res-
of the hybrid layer could affect more the esthet- toration in white patients while they decide not to
ics, while such aspect seems not to be relevant for intervene in restoration from dark-skinned indi-
posterior composite restorations [88, 104, 105]. viduals [106]. Dentists frequently choose to
Regarding longevity or restorations, the gold replace restorations with a small sign of marginal
standard dental adhesive technique is the use of a degradation or staining because they then con-
mild two-step, self-etch adhesive system with found with secondary caries. After 27 years of
selective phosphoric acid enamel etching [50] follow-up on posterior chemical-cured resin
10 Longevity of Resin Composite Restorations 135

composite with the high color changed (classified on the dentist’s clinical expertise rather than on
as non-acceptable research evaluators) were strict criteria. Thus, dentists adopt different
maintained in function and classified as satisfac- approaches (repair or replacement) in cases of
tory to the patients [49]. Even secondary caries imperfect restorations [112], although the litera-
kept restricted in the enamel can be maintained ture presents a consensus that, when possible,
and treated with non-operative treatments [107], repaired restorations presents benefits and are
and the repair can—preferably—choose if opera- more cost-effective than replacement [16].
tive treatment is required.
Despite clinical studies with trained and cali-
brated operators maybe not observe significant 10.2.1 Long-Term Survival
associations between operator and success, and Reasons for Failures
practice-­based studies have observed that age, of Repaired Restorations
country of qualification, and employment status
of the operator could influence the survival of Replacement of a failed restoration is still one of
restoration [5]. Data from Washington dental ser- the most frequent treatments performed in dental
vice observed that restorations placed by efficient practice [113]. While most dentists state to per-
dentists survive almost 5 months more than resto- form repairs, and the vast majority of dental
rations performed by inefficient dentists, and no schools teach repairs, the proportion of truly
differences between the restorations were repaired restorations is still very low [16]. A clin-
observed when efficient dentists performed than ical trial assessed the longevity of repaired resto-
[108]. Similarly, the longevity of restorations rations and showed similar longevity than
placed by more experienced clinicians was better replaced restorations after 12 years of follow-up
than those placed for less experienced ones [109]. [15]. Repaired and replaced restorations pre-
Restorations placed by the dentist with less prac- sented similar behavior in marginal adaptation,
tice workload presented a success rate of about marginal stain, teeth sensitivity, anatomic form,
twice than those slightly busy clinicians [110]. A and luster parameter, although roughness was
geospatial analysis carried out in Canada significative was significantly worse in the group
observed more aggressive treatment choices were of repaired restorations [15].
performed by dentists who feel under great com- Casagrande et al. [114] estimated the reduc-
petitive pressure and in low dentist density areas tion in AFR when repaired restorations were not
[111]. Therefore, all these issues and the differ- considered as a “true failure” and observed that
ences in the decision-making process on judging repair increases the longevity of direct posterior
restorations intensification the risk for replace- restorations. When repair was not considered as a
ment restorations and decrease the survival rates. failure, the survival of restoration changed from
83.1 (AFR = 3.6%) to 87.9% (ARF = 2.5%) at
5 years and from 65.9 (AFR = 4.1%) to 74.6%
10.2 Repairing Esthetic (AFR = 2.9%) at 10 years of follow-up. Reduction
Composite Restorations of AFR from 1.83 to 0.72% in composite resins
repaired restorations after 12 years of follow-up
Patients that changed the dentist have an increased was observed in another study [115]. A study that
chance to replace their restorations [93–96]. In follows for 22 years posterior composite restora-
fact, a cross-sectional study that included 194 tions performed by one dentist observed that a
dentists of the Dental Practice-Based Research reduction from 1.9 to 0.7% on AFR when restora-
Network observed that the decision to repair tions repaired were not considered as failures
defective restoration instead to replace is influ- [10, 17].
enced by who place the original one: clinicians A study that evaluated 880 restorations placed
are less demanding when evaluating their work in posterior and anterior teeth observed that
[13]. The decision to replace a restoration relies repair increases the survival of restorations even
136 F. F. Demarco et al.

after previous repairs or replacements [116]. A 10.2.3 Repairing Benefits Over

recent long-term practice-based clinical study Replacing Restorations
carried out in a private dental practice followed
class III and class IV for 15 years, and veneer The comparison of the survival of replaced ver-
restorations for 10 years. For class III and class sus repaired restoration may be unfair. A repaired
IV restoration, AFR was 2.9%, and for veneers restoration is comprised mostly of the older and
9.2% when the repair was considered as failure. aged part of a restoration. It presents already
When repair was not considered as failure, class signs of fatigue, differently from a replaced fill-
III and IV presented an AFR of 2.4% and veneers ing that is entirely new. Thus, a repaired and
of 6.3% [117]. Thus, direct comparisons between older restoration may fail before the replaced
the treatments (repair and replacement) presented one. But even in this case, the survival of the
comparable results. original restoration is increased, and the removal
In this way, secondary caries was the main of tooth tissue is postponed, which could be the
reason for failure in both repaired and replaced main direct benefits. If the repaired restoration
restorations [15] while Opdam et al. [115] fails, the replacement is indicated and can be car-
reported tooth fracture as the main reason for ried out without further problems. Repair is con-
failure in the repaired restorations (41.1%) fol- sidered an approach of minimal intervention
lowed by dental caries (24.2%) [115]. These two dentistry, being an alternative to easy, fast, and
reasons are the same observed for non-repaired low-cost treatment [16]. The clinical time spent
restorations both in permanent [8, 10] and pri- to replace a restoration is reported to be higher
mary teeth [9]. than the time required to repair the same restora-
tion. Additionally, the repair of restoration seems
to be more cost-effective than replacement, and
10.2.2 Factors Involved in Repaired thus repairs are drawn as an important strategy
Restorations Failure for public health services [16].

Regarding the main reasons for failures, studies

have shown, in general, that the same factors 10.2.4 When Repairing Is Not
known for non-repaired restorations seem to a Solution?
influence repaired restorations as well.
Casagrande et al. [114] found that endodontic Repair of defective restorations is not always
treatment, molar teeth, use of a prosthesis, and possible. Like this, the Academy of Operative
age were important risk factors for restoration Dentistry European Section has indicated the res-
failure. On the other hand, in one study, only sex toration replacement when (a) restoration has
was reported as associated as a risk factor to fail- unaccepted qualities (deterioration/secondary
ure in repaired restorations, in which women pre- caries); (b) repair is contraindicated; (c) benefits
sented a risk of failure twice higher when of replacement are less than possible harm; (d)
compared to men [115]. Cox regression analysis prospects for an acceptable clinical outcome are
in a practice-based study found that class III and favorable; and (e) patient consents [118].
IV restorations placed in the upper jaw had a
higher risk for failure compared to the lower jaw.
Central incisors also had a higher failure risk for 10.3 Replacing Esthetic
failed repaired restorations. Also, the type of Composite Restorations
composite influenced the survival rates [117].
The presence of endodontic treatment is a factor As previously discussed, composites have shown
associated with a higher risk of failure for both considerable improvements since their introduc-
repaired or replaced restorations [116]. tion in the 1960s. Due to the improvement of the
10 Longevity of Resin Composite Restorations 137

properties of the material, nowadays, most of the motion environment, emphasizing preventive
failures are related to factors related to the patient practices. The adoption of healthy behaviors by
and the operator. When small changes in color, patients will consequently led to “healthy” resto-
shape, or fractures are observed, repair should rations, increasing the longevity of treatments.
always be the first choice. However, in some situ- The adoption of minimally invasive dentistry for
ations where the remaining restoration is inte- the management of deteriorated restorations,
grally degraded, replacement of the restoration such as refurbishment or repair restorations,
can be indicated. should be considered in routine practice. In this
way, dentists should react less in front of small
defects of restorations, indicating replacements
10.3.1 Restorations Do Not Last only when other alternatives are not plausible.
Forever

Composite resin restorations are materials that, References

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