Received: 28 May 2023 Revised: 8 August 2023 Accepted: 20 September 2023

DOI: 10.1111/jerd.13145

CLINICAL ARTICLE

A step-by-step technique to create an ideal color match, form,

and surface texture to all-ceramic restorations

Amr EL-Etreby BDS, MDSc, DDSc 1 | Edward A. McLaren DDS MDC 2

1
Professor of Fixed Prosthodontics, Faculty of
Dentistry, Ain Shams University, Cairo, Egypt Abstract
2
Retired Professor, UCLA School of Dentistry, Objectives: Although the presence of a chairside CAD/CAM system in the dental
LA, USA
office saves time and cost, it deprives the dentist from the dental technologist' skills and
Correspondence experience. The dentist now has to gain and acquire knowledge and skills about how to
Amr EL-Etreby, Professor of Fixed
Prosthodontics, Faculty of Dentistry, Ain
finish, characterize, stain, and glaze ceramic restorations. The main objectives of this arti-
Shams University, Cairo, Egypt. cle is to teach novel and reproducible techniques for surface color, texture, glaze and pol-
Email: [email protected]
ish for either the chairside or laboratory fabricated indirect ceramic restoration.
Clinical Considerations: A protocol for intraoral characterization of monolithic
ceramics; the “Triple R" protocol for tooth color mimicking was followed. It consist of
three steps: (1) “Recognize” tooth color shapes, (2) “Record” the present color shapes
in the patient dentition by drawing a color map for the color shapes extension and
determine which luster paste stain to be used for replicating them, and (3) “Replicate”
intraorally the recorded color shapes guided by the adjacent natural teeth using low
fusing ceramic pastes (shades and stains) for color shape replication. Also, the final
touch technique was followed to shape, texture and final surface finish of dental res-
torations. It is composed of 5 basic levels which we call dental “micro-esthetics that
define shape, texture, and surface luster.
Conclusions: Following the steps of both; the “Triple R” protocol and the “FINAL
TOUCH” technique will help to reproduce the final shade of the restoration to
create the illusion of a natural tooth to the observer.
Clinical Significance: This article shows how combining two practical methodologies
to record and replicate both color shapes and surface texture of natural teeth may
extend mimicking, that is, step by step natural tooth shade beyond the limitations of
the available commercial shade guides.

KEYWORDS
color mapping, monolithic ceramics, surface texture, the final touch protocol, Triple R protocol,
upper anterior esthetics

1 | I N T RO DU CT I O N and glaze ceramic restorations. A successful lifelike dental ceramic

restoration should be able to mimic and duplicate the natural teeth
Although the presence of a chairside CAD/CAM system in the dental shape, color, and surface texture.
office saves time and cost, yet it deprives the dentist from the dental One of the difficulties that dentists have to face in mimicking nat-
technologist' skills and experience. The dentist now has to gain and ural teeth is shade matching. The use of commercial shade guides usu-
acquire knowledge and skills about how to finish, characterize, stain, ally leads to unreliable and inconsistent results.1–3 To overcome this

J Esthet Restor Dent. 2023;1–13. wileyonlinelibrary.com/journal/jerd © 2023 Wiley Periodicals LLC. 1

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2 EL-ETREBY and MCLAREN

problem, some authors have recommended the use of two or more prepared tooth (Figure 1) and the adjacent teeth to help the dental
shade guides.4–16 Additionally, as the prepared tooth shade influences technician to produce the shade properly.23
the final shade of ceramic restorations (Figures 1 and 2), in an attempt A digital approach to solve the difficulty of shade selection is to use
to mimic the prepared tooth shade, dental manufacturers introduced a clinical color measuring device. It is reported that these devices' reli-
to the market a natural color die material with a special dentin shade ability is 90%, and their accuracy is from 60% to 90%, yet still, some
guide.17–21 Fabricating a custom-made shade guide by using different show clinical results similar to visual shade matching.24–28 Another digi-
porcelain powder combinations might be helpful. But this procedure tal approach is image analysis. A digital camera is used to capture the
results in an infinite number of shades, and is time-consuming, and image, and ideally a calibrated gray card is used in the image (Figure 3)
requires from the dentist specialty skills that are difficult to provide.22 Then using computer software to mathematically adjust known refer-
After selecting the basic tooth shade, a shade distribution chart is ences in the image that will be used to calibrate the unknown image
used to record the chosen tooth shade. The tooth is divided into three components (Figure 4 using PSD). The excellent shade matching
thirds; incisal, middle, and cervical. Independent shade selection is results that can be obtained with combining visual, photographic
performed for each third. Surface characteristics, for example, hairline and computer shade analysis is demonstrated in (Figure 5). An
fractures and hypocalcifications, are marked on the chart and sent to advantage of digital image analysis is that it provides not only rec-
the lab together with a digital image. The image should show the ognition of shade but also translucency and value.8,29,38,39
selected shade tab beside, ideally in the same vertical plane as the Still, surface characterization of human teeth cannot be matched
by available commercial shade guides, or any available digital shade
taking devices. In a trial, to match the different color shapes of natural
teeth the use of porcelain stains was suggested for the

F I G U R E 1 A preparation of discolored tooth next to a non-

discolored preparation. Consideration has to be given to depth of
F I G U R E 3 Image using cross polarization to eliminate glare. The
preparation for specific shade change, that is, notice the preparation
two closest visual shade tabs and a whi-bal gray card are in the same
is deeper axially on #8 to allow thicker porcelain to accommodate
shade change. Care must also be taken for ceramic shade selection vertical plane as the natural teeth.
also to blend with underlying tooth structure to give desired final
shade.

F I G U R E 2 The finished case of #8 and #9 which adequately

matches shade with surrounding teeth and each other. FIGURE 4 Using Photoshop to analysis shade.
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EL-ETREBY and MCLAREN 3

characterization of ceramic restorations, but the extensive use of the adjacent natural teeth. Then the ceramic restoration is removed
stains might have an adverse effect on the final restoration shade. It from the patient's mouth and placed in a porcelain furnace.
increases light reflection preventing light transmittance through the Although the “Triple R” protocol provides a strong workflow for
ceramic, it also increase metameric effect, cause loss of fluorescence, color replication, yet tooth surface texture has a very important role
and the stains may wear away by tooth brushing if the restoration was affecting the final shade of the restoration. This article shows how
not appropriately glazed.30–35 Another approach is to customize the clos- combining two practical methodologies to record and replicate both
est matching shade guide tab using a light-cured porcelain staining sys- color shapes and surface texture of natural teeth may extend mimick-
tem. Then the shade tab is used to duplicate the customized shade.8,36 ing, that is, step-by-step natural tooth shade beyond the limitations of
All these approaches remain inconsistent, thus, clinicians who the available commercial shade guides. For this purpose a systematic
have an in-office CAD/CAM system are now required to develop technique process has been developed to create the final form, tex-
methodologies that remain practical. A protocol for intraoral char- ture, and surface luster of ceramic restorations. The technique is
acterization of monolithic ceramics; the “Triple R" protocol, was termed “THE FINAL TOUCH”.
suggested.37 Consisting of three steps: (1) “Recognize” tooth color
shapes, (2) “Record” the present color shapes in the patient denti-
tion by drawing a color map for the color shapes extension and 2 | T H E FI NA L T OU C H
determine which luster paste stain to be used for replicating them,
and (3) “Replicate” intraorally the recorded color shapes guided by The final touch is a technique to shape, texture and final surface finish
of dental restorations. It is based on the author's observation of natural
tooth structure and what in the authors experience is considered natural
esthetics. The general pattern described exists in some subtle variation
detailed below. The authors have observed there are five basic levels
which we call dental “micro-esthetics that define shape, texture,
and surface luster. The five levels of “THE FINAL TOUCH” are;
Level 1 (Primary Anatomy); is the basic outline form—facial, proxi-
mal, and incisal aspects. Level 2 (Secondary Anatomy); are the
major Line angles or what could be called “reflection lines.” Level
3 (Tertiary Anatomy); are the major developmental grooves. Level
4 (Quaternary Anatomy); which are the finer groves. And lastly,
Level 5 (Quinary Anatomy); is the surface luster or final polish.
This article will detail the specifics of the “TRIPLE R PROTOCOL”
FIGURE 5 Image of finished case teeth #7 and #8 showing good and “THE FINAL TOUCH” and demonstrate its application on an
color match. actual case.

F I G U R E 6 (A) Color shapes

location and distribution in an
upper central incisor (B) color
shapes demarcated.
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4 EL-ETREBY and MCLAREN

2.1 | “Triple R” protocol for mimicking tooth color

shapes

To mimic the natural tooth appearance, a ceramic restoration should repli-

cate basic tooth shade as well as tooth color shapes' shade and location.
Natural teeth color shapes results from the interaction between light and
the tooth composition (enamel and dentin) as well as its surface texture.37
The three steps of the “TRIPLE R PROTOCOL” are “Recognize,
Record, and Replicate.”

2.2 | Recognize

If we take the upper central incisor as an example to describe the six

basic color shapes in an inciso-cervical direction (Figure 6A, B).

1. The Incisal Halo

A halo is a prismatic illusion that marks the incisal edge. It results FIGURE 7 The views of primary anatomy.
from convergent angle incisal edge enamel that is unsupported by
dentin. It has a white and/or vanilla hue that extends from tooth con-
tact point to contact point, with various thicknesses.
2.3 | Record
2. Translucent zone
After recognizing the color shapes of the upper right central incisor to
Cervical to the incisal halo, a translucent area with a blue-gray be mimicked, it is important to record these shapes extension and hue
hue of different shape may be recognized. It extends from mesial to and determine which luster paste stain (or in the case of layering
distal contact and from below the incisal halo cervically in between choose the correct shades of porcelain to place in the build-up) to be
the developmental grooves. used for their replication by the aid of the following:

3. Mamelons a. Selecting the basic tooth shade using an A-D classic commercial shade

The mamelons are the most incisal aspect of the developmental It is recommended by the authors to choose one base shade
lobes that offers the first incisal enamel support. They extend incisally brighter that the measured shade, as the application of surface
into the translucent zone. They may have the same shade as the body colors is a light subtractive effect which lowers the value of the
of the tooth or may have a different shade of orange, vanilla, or final restoration.
salmon. Sometimes each mamelon may have a different color and its
projections may be “tipped” with white. b. Color mapping

4. Interproximal enamel The process of color mapping is to first draw the outline of the
tooth to be mimicked and then as precisely as possible draw and col-
It appears as a translucent wash of blue and/or gray that is present orize with colored pencils the six basic color shapes.
proximal to the developmental lobes and extends in a cervical direction.
It may be considered as a prismatic illusion seen from an oblique view. c. Calibrated photography

5. The tooth body The authors strongly recommend using calibrated photography,
with very specific settings and the use of a Whi-bal (Figure 3) gray
It is the shade of the tooth body and cervical areas that may be card to obtain shade imagery. Please refer to a detailed article
simplified as being whitish, yellowish, or orange.39 where the authors describe in detail the photographic shade analy-
sis and Photoshop technique.39 But, the authors have found in their
6. The tooth neck personal experience and in the experience of teaching their Gradu-
ate Students, and Continuing Education Students that the exercise
This is the area of dentin close to root and is covered with mini- of color mapping and drawing the color zones “recognized” from
mal or no enamel. It varies in hue from ochre, copper, orange, khaki, the visual tooth shade analysis, significantly helps improve their suc-
to sunset yellow. cess as dental artists.”
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EL-ETREBY and MCLAREN 5

2.4 | Replicate important to note that there are infinite forms, textures, and lusters,
but after years of observation there are rules that if followed will end
1. Replicating Color in an what is perceived as an esthetic result and natural looking tooth.
Level 1 (Primary Anatomy): primary anatomy defines the outline
Replicating tooth surface characterization is the art of reproducing form of the tooth or basic shape. Teeth are three-dimensional and all
natural defects. Since copying the exact characterization will allow the dimensions of a dental restoration thus needs to mimic nature. There
ceramic restoration to blend with the adjacent teeth, thus, replicating are three views that need to be observed facial, proximal, and incisal
the natural surface characterization intra-orally will ensure the best views (Figure 7).
results. To replicate natural tooth color of monolithic restorations ide- The aspects of an esthetic central from a facial view that are the most
ally low fusing ceramic pastes (shades and stains) e.g. (GC initial IQ lus- important are1 the aspect ratio that should be between 75% and 85%
ter paste NF—GC America, USA) was used for color shapes replication. width to length ratio. The lateral incisor in the same patient should have
These are three-dimensional ceramic stains developed to bring color an aspect ratio 5 to maximum 10% less than the central incisor, thus a
deepness and lifelike translucency to ceramics. They are based on fine 80% central should have a lateral between 70% and 75% with to length.
ceramic particles with a thixotropic property enabling a thicker applica- The lateral is always slightly more tapered than the central incisor.2 The
tion compared to conventional stains. mesial of the Central is always straighter than the distal but is never per-
fectly straight—“there are no straight lines in nature, don't make any.” The
2. Replicating Form, Texture, and surface luster lateral has the same pattern as the central but with slight increase in radius
to the curves as the central.3 The distal of the central and lateral incisal
The five levels of “THE FINAL TOUCH” as introduced above have edge is more rounded than the mesial and the lateral has what appear to
very observable and consistent features that can be defined. It is be two planes to the incisal edge. From the incisal view; increasing

FIGURE 8 (A) Incisal views (B) Facial views, and (C) Proximal views of typical and “esthetic” shapes and relationships of central lateral and canine.
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6 EL-ETREBY and MCLAREN

FIGURE 9 Creating Level 1 outline form.

F I G U R E 1 2 Level 3 anatomy, major developmental grooves. This

central depicts a fairly routine groove/ major ridge pattern. Notice
there is a constant subtle flowing pattern of subtle changes in depth
and width, almost like on the side of a hill where there has been an
erosive pattern from water run-off.

F I G U R E 1 0 Level 2 anatomy, line angles, Converge to a point

apical to the CEJ 10–12 mm on a central, 5–7 mm on a lateral, and 3– curvature on distal relative to mesial aspect of tooth, increasing curvature
5 mm on a canine. Pattern of Line angles give a major influence on from central to lateral to canine From proximal view the central has three
the perception of shape and tooth angulation.
planes while the lateral has two planes. (Figure 8A–C).
To create outline form in ceramics it is best to use a medium size
and grit-tapered diamond creating guidelines for primary shape dis-
cussed (Figure 9).
Level 2 (Secondary Anatomy): Are the Line angles or major ridges
on teeth, the can give the illusion of shape—squarish, rectangularish,
ovalish, and triangularish. They taper from central to lateral to canine.
They converge on point on root that points to root tip (Figure 10).
It is ideal to draw the Level 2 line angles where you want them
and then shape outside them. We use the same or slightly smaller dia-
mond for this as for Level 1 anatomy (Figure 11).
Level 3 (Tertiary Anatomy): major developmental grooves between
and connect the major ridges (line angles)—width and depth are constantly
changing and there is and erosive look like on the side of a hill where there
FIGURE 11 Drawn line angles and small tapered diamond. is subtle changes of contour or sort of an orange peel effect (Figure 12).
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EL-ETREBY and MCLAREN 7

F I G U R E 1 3 Using tapered diamond from three dimensions on the main developmental grooves (A) the main direction of the groove, (B) from
the top of the ridge to the bottom on one side and (C) the top of the ridge to the bottom on the other side.

horizontal grooves that many times are no longer visible on the main
ridges as they have been worn away by toothbrush abrasion, but they are
usually visible in the depths of the main and supplemental grooves. They
are slightly wavey, come very close together, but never cross (Figure 14).
Perikymata are created with small almost needle point carbide
with very light pressure with wavey movements mesial-distal with the
lines as close as possible. If you choose to do this the authors recom-
mend at least 80 lines (Figure 15).
Level 5 (Quinary Anatomy): This is the final surface luster, which
the main characteristic is it is “DIFFERENTIAL,” that is, smoother and
more reflective on ridges, and duller and more matt at the depth of
the ridges (Figure 16).
F I G U R E 1 4 Cross-polarized image of central incisor, clearly
visible is the horizontal fine grooves called Perikymata, most times To create differential surface luster after glazed, a feather light pink
they still exist in the depths of the major grooves. They contribute to single thickness spoked knife edged disc is used to “knock off” the overly
light diffusion from the surface of the tooth. glassy surface and then polish only the line angles back to high reflec-
tance with a diamond paste (Figure 17A, B).
Figure 18A, B demonstrates a before and after of case where
poor surface characteristics and form clearly make it obvious it is arti-
ficial and how much better the final esthetic results blends optically
with similar surface texture and reflectance of the adjacent teeth.
The “Triple R” protocol consists of three steps “Recognize,
Record, and Replicate.” These steps will be illustrated through a
case of an upper left central incisor with a discolored composite
veneer (Figure 19A, B).

2.5 | Recognize

The tooth to be mimicked is the upper right central incisor and our first
step will be to recognize its color shapes. In an inciso-cervical direction,
the following color shapes may be recognized (Figure 20A, B):

F I G U R E 1 5 Placing perikymata with a needle point carbide only

in depths of grooves. 1. An Incisal Halo that has a vanilla hue and extends with various
thicknesses along the incisal edge from mesial to distal tooth con-
tact point.
To create the subtle change in contour, use a medium or small
tapered diamond from three different directions (Figure 13A–C) 2. A definite translucent zone with a blue-gray hue extending proxi-
Level 4 (Quaternary Anatomy): Quaternary anatomy is the smaller mally from contact to contact and cervically in between the devel-
horizontal grooves that have been termed Perikymata. They are very fine opmental grooves.
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8 EL-ETREBY and MCLAREN

F I G U R E 1 6 Four different teeth

representing the 4 seasons in the age and
color of a tooth. Notice the subtle
different “surface luster,” that is,
reflectiveness where teeth are more
reflective on ridges and a little less on the
depths of grooves. Also, as teeth age
there is a general increase in smoothness
and reflectivity.

FIGURE 17 (A) using feather light pink single thickness spooked knife edged disc (B) polishing with diamond paste.

FIGURE 18 (A) Pre-op of case report of final touch technique (B) Completed case.
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EL-ETREBY and MCLAREN 9

3. Three Mamelons that have same body shade of the tooth with a 6. The tooth neck with a copper hue (increased chroma from the
pinkish tinge. basic body shade—that has an orange/ yellowish hue may be rec-
4. A translucent wash of blue Interproximal enamel present in the ognized; some measure of reddish hue can be observed but in the
mesial and distal line angles proximal to the developmental lobes authors experience the reddish hue is a reflection for the gingiva
and extends in a cervical direction was recognized. and not actually present in the tooth).
5. Using an A-D classic shade guide (VITA, Germany), the tooth body 7. In addition to some white perikymata horizontal lines that extend
shade for this tooth was B1 (Figure 21). throughout the tooth in the middle and cervical thirds, and few
horizontal orange lines in the incisal.

2.6 | Record

The second step after recognizing the color shapes of the natural
teeth to be mimicked is to record these shapes extension and hue and
determine which stains to be used for replicating them by both of the
following steps.

F I G U R E 1 9 A normal photo for upper two central incisors

(B) increasing the contrast of the photo helps the visualization of its F I G U R E 2 1 Tooth body shade selection using A-D classic VITA
color shapes. shade guide to determine the basic tooth shade.

FIGURE 20 Location and extension of color shapes in both (A) normal and (B) high contrast photo of the upper central incisor to be
mimicked.
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10 EL-ETREBY and MCLAREN

2.6.1 | COLOR MAPPING thixotropic property enabling a thicker application compared to con-
ventional stains.
In the color map (Figure 22), the tooth outline was drawn precisely To replicate color intra-oral, it is best to isolate the upper lip by a
the same as the tooth to be mimicked so as not to affect the location piece of gauze, then a thin layer of the shade/stain liquid was applied
and extension of the color shapes. Each color shape location and using no. 00 LP porcelain brush (GC initial LiSi Press, GC Co, Tokyo,
extension was drawn, and its hue was determined. Japan) to the tooth to be mimicked (upper right central incisor) to
form a protective coat, preventing dehydration till the characterization
procedure was completed. Excess liquid was removed by a dry porce-
2.7 | Replicate lain brush no. 2 LP (GC initial LiSi Press, GC Co, Tokyo, Japan)
(Figure 25).
A lithium disilicate glass–ceramic veneer, Medium Translucency MT, Luster paste stain (initial IQ luster paste NF, GC America, USA)
shade B1, (GC initial LiSi Press, GC Co., Tokyo, Japan), was fabricated was applied using no. 00 LP brush (GC America, USA) for each color
to restore the upper left central incisor. Replication of size form and shape replication as follows (Figure 26A, B):
surface texture was done following the five levels of “THE FINAL
TOUCH” protocol (Figure 23 A, B). Intra-oral checking and verification • Incisal halo replicated using (L-1, Luster Enamel Effect-1 Vanilla +
was done to insure proper seating (Figure 24). Low fusing ceramic L-2, Luster Enamel Effect-2 White).
pastes (shades and stains) (GC initial LiSi Press, GC Co, Tokyo, Japan) • Translucent zone replicated using (L-4, Luster Enamel Effect-4 Dark
was used for color shapes replication. These are three-dimensional Gray + L-6, Luster Enamel Effect-6 Dark Blue in a ratio of 2:1).
ceramic stains developed to bring color deepness and lifelike translu- • Mamelons replicated using (L-7, Luster Enamel Effect-7
cency to ceramics. They are based on fine ceramic particles with a Incisio).

F I G U R E 2 2 Color map of the

upper central incisor to be
mimicked, each color shape hue is
recorded with the suggested 3D
stain to be used for color
replication.
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EL-ETREBY and MCLAREN 11

FIGURE 23 Replication of size form and surface texture was done following the five levels of “THE FINAL TOUCH” protocol (A) Labial view
(B) side view.

F I G U R E 2 4 Intra-oral checking and verification was done to

insure proper seating.

• Interproximal enamel replicated using (L-5, Luster Enamel Effect-5

F I G U R E 2 5 Application of a thin layer of the shade/stain liquid
Light Blue). using no. 00 LP porcelain brush.
• Tooth body B1 enhanced using (L-B, Luster Body B).
• Tooth neck replicated using (diluted L-A, Luster Body-A).
• Horizontal perikymata in the middle and cervical thirds replicated “Recognize” color shapes and be able to understand how these
using (L-2, Luster Enamel Effect-2 White). shapes affects the final outcome of the shade. The second step is to
• Horizontal orange lines in the incisal third replicated using (Luster “Record” the present color shapes in the patient dentition by selecting
Enamel Effect-9 Orange). a basic shade using commercial shade guides then drawing a color
map for the color shapes extension and hue and determine which
The veneer restoration was then removed from the patient's stains to be used for replicating them. The third step is to “Replicate”
mouth and placed in a porcelain furnace (Ivoclar Vivadent, the recorded color shapes intraorally guided by the adjacent natural
Liechtenstein). After sintering, the veneer restoration was inserted into teeth using luster paste stain kits that are available in the market.
the patient's mouth for the final check of the shade (Figure 26). The This protocol helps identify color shapes and provides the clini-
veneer restoration was then cemented using light cure resin cement cian with guidelines that increase their ability to customize ceramic
(Variolink N, Ivoclar Vivadent, and Liechtenstein) (Figures 27 and 28). restorations intraorally.
Although the “Triple R” protocol provides a strong workflow, still
natural dentition is rich of colors that represent an everyday challenge
3 | DISCUSSION for the clinician. Tooth surface texture also has a very important role
affecting the final perceived shade of the restoration. Adding “the
The “Triple R” protocol presented by the authors consists of three final touch” of natural surface texture and surface luster, to the cor-
steps: (1) Recognize, (2) Record and (3) Replicate. The first step is to rect expression of Color in the final restoration as outlined in the
 17088240, 0, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jerd.13145 by Universidad San Sebastian/Library, Wiley Online Library on [02/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
12 EL-ETREBY and MCLAREN

FIGURE 26 Application of Luster paste stains for each color shape using no. 00 LP porcelain brush (A) incisal halo (B) translucent zone.

CONFLIC T OF INTER E ST STATEMENT

The authors do not have any financial interest in the companies
whose materials are included in this article.

DATA AVAILABILITY STAT EMEN T

The data that support the findings of this study are available on
request from the corresponding author. The data are not publicly
available due to privacy or ethical restrictions.

OR CID
Amr EL-Etreby https://orcid.org/0000-0003-3731-3847
F I G U R E 2 7 The ceramic veneer inserted into the patient's mouth
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