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Ernst A. Hegenbarth, MDT
Bruchkbel, Germany
CLINICAL APPLICATION
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 1 NUMBER 4 WINTER 2006
340
Esthetics and
Shade Communication:
A Practical Approach
Correspondence to: Ernst A. Hegenbarth
Zen Line Dental GmbH, Innerer Ring 1 d, 63486 Bruchkbel, Germany;
fax: 49 6181 740455; e-mail: hegenbarth@zenline-dental.com.
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HEGENBARTH
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 1 NUMBER 4 WINTER 2006
341
including information regarding the scien-
tific basis of general color science, optics,
and aspects of material science; and pro-
poses a six-step approach to shade analy-
sis in which less emphasis is placed on
shade guide samples in favor of natural in-
ternal structures and surface properties and
their replication in different dentin, enamel,
transparent, and colored translucent, as
well as fluorescent and opalescent,
ceramics.
(Eur J Esthet Dent 2006;1:340360.)
Abstract
Accurate shade analysis and communica-
tion represent one of the biggest challenges
in restorative and esthetic dentistry today,
especially in light of the rapidly increasing
array of ceramic materials available. Tradi-
tional methods of shade analysis have re-
lied upon the use of conventional shade
guides or, more recently, digital shade
measurement. In this article, the author ex-
amines the advantages and disadvantages
of traditional shade analysis; reviews prin-
ciples for optimizing the evaluation process,
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342
mixtures, other methods of shade selection
and color matching must be found. There
are no cut-and-dried solutionsthe chal-
lenge of reproducing natural tooth colors is
certainly best met by a deeper knowledge
of light and color, optical phenomena relat-
ed to the natural tooth, the optical effect of
the materials we use, and systematic pro-
cedures in shade selection and subse-
quent ceramic buildup. But beyond these
rather scientific, logical criteria, we should
not underestimate the importance of a pro-
fessional ceramists experience, sensitivity,
and even intuition in mixing materials and
colors.
Traditional shade selection
methods
The rapidly expanding market for dental
ceramic materials, driven by the increasing
global demand for esthetic restorations,
has seen the development of a number of
new products in recent years, broadening
considerably the range of available ceram-
ic materials (Fig 1). It is doubtful that there
There is hardly any communication be-
tween clinician and dental technician that
is as fraught with imponderables as that of
tooth color communication. But on the oth-
er hand, there is hardly anything in dentistry
that has been as incompletely researched
as the true colors and textures of natural
teeth. Since no manufacturer of ceramic
materials can possibly make all natural
tooth colors available as pre-formulated
Fig 1 (a and b) Modern dental ceramics contribute considerably to the natural appearance of dental restora-
tions, as demonstrated by these laminate veneers on the maxillary central incisors.
Fig 2 None of the current shade guide systems or
concepts is suitable for communicating to the ceramist
data on the distribution and extension of translucency
and opalescence of natural teeth.
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HEGENBARTH
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 1 NUMBER 4 WINTER 2006
343
market position as a common adjunct in
shade selection and color matching.
2,3
The introduction of the Vitapan 3-D Mas-
ter shade guide (Vita Zahnfabrik) for shade
selection and the resulting new materials
was expected to end the role of the tradi-
tional system (still available under the
name of Vitapan Classical) as a standard
frame of reference. However, the author
has always been one of the strongest crit-
ics of established shade systems.
The question today is whether we have
actually fulfilled the prerequisites for solving
the color problem in dental ceramics as
postulated by Bruce E. Clark as early as
1931
4
:
1. Basic knowledge of color science
2. A method for the visual analysis of tooth
shades, a system for specifying the
shade found, and a formula for repro-
ducing this shade in ceramics
3. A corresponding range of pigments
permitting duplication of all tooth colors
In 1979 Lemire and Burke
5
wrote that the
current means of shade selection were out
is a dental professional who can claim
even perfunctory knowledge of the dozens
of new products in the ceramics field alone,
allowing the formation of his or her own in-
formed opinion.
One of the few constants found amongst
most of the materials offered was their ref-
erence to the classic Vita shade guide (Vi-
ta Lumin Vacuum shade guide, Vita Zahn-
fabrik).
1
Generations of young ceramists
have practiced the fine art of replicating
these shade patterns on a day-to-day ba-
sis according to the dentists requests, us-
ing whatever material was specified. It was
not until recently that attempts were made
to recognize the variety and the rich nu-
ances characterizing a natural tooths col-
or and to reproduce them in detail when
creating dental restorations (Fig 2). For cre-
ative ceramists, shade patterns are no
longer as important; natural appearance
and harmonic colors as well as the pa-
tients individual wishes have moved to the
center of attention (Fig 3). Yet, despite all
these attempts at individualization and its
well-known shortcomings, the Vita shade
guides have maintained their dominant
Fig 3 The fulfillment of patients desires for beauty and naturalness in complex dental rehabilitations can best
be met by metal-free all-ceramic restorations. (a and b) Full mouth rehabilitation using Procera NobelRondo
Alumina and Zirconia ceramics (Nobel Biocare). (Case treated by PD Dr S. Holst, University Erlangen, Germany;
ceramics by D. Hildebrandt and E. A. Hegenbarth, Bruchkbel, Germany).
a
b
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VOLUME 1 NUMBER 4 WINTER 2006
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of date and incomplete, based on shade
patterns that were not organized based on
any visual system, and did not utilize the
current knowledge of light and color. The
current author
68
has previously noted that
the field of shade selection continues to be
dominated by traditional shade guides and
patterns, even though these were long ago
found deficient. The result is the develop-
ment of visual habits leading to a mental
fixation on the colors of well-known tooth
colors manifested in standard patterns. In
the observers brain, shade recognition is
unilaterally limited and restricted to the on-
ly available shade patterns, which disal-
lows any true vision of subtle shade nu-
ances (Fig 4).
The Vitapan 3-D Master shade guide is
subject to the same problems. It is true that
this shade selection system is organized
more logically than the previous Vita Clas-
sical shade guide. Here, too, however, prac-
titioners will be guided in the direction of
certain shade groups, quickly resulting in a
preference for a very few specific patterns.
This preference is not related to the actual
incidence of tooth colors, but rather a psy-
chologically understandable desire to use
certain shade patterns thought to yield rou-
tinely good or at least acceptable results.
Previous attempts at improving on con-
ventional shade selection methods have
followed either of two fundamentally differ-
ent approaches:
1. Traditional. Variations on visual compar-
ative shade selection using tooth-
shaped patterns, organized within the
three-dimensional color space in a log-
ical pattern (eg, Vitapan 3-D Master).
2. Color measuring systems. Color meas-
uring systems and spectrophotometers
used in dentistry are mechanical, com-
Fig 4 Subtle details, internal characterizations, and
optical phenomena are rarely taken into consideration
when using conventional shade guide samples.
Fig 5 (a and b) Spectrophotometers (eg, Shade-
Scan, Cynovad) are used to electronically measure
dental shades according to conventional shade pat-
terns.
a
b
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chroma and hue are then determined vi-
sually. This results in a total of 26 patterns
said to be logically arranged in a natural
tooth color space determined by scientif-
ic criteria. Available publications on this
new shade system do not offer any con-
crete explanation of the scientific basis of
the natural color space for human teeth
thus postulated.
This situation contrasts with that for
the electronic measurement methods pre-
sented by M. Yamamoto.
12
In describing
sources of potential errors in visual shade
selection, he stated that visual assessment
was unreliable, regardless of the observer.
Yamamoto also cited the classic Vita shade
guide as the foremost obstacle to precise
shade analysis, listing, among others, the
following two factors: (1) Vita shade guides
specific color system makes correct color
assessment difficult and (2) since the Vita
shade guide does not cover the whole
range of colors present in natural teeth,
there is no method to evaluate and repro-
duce colors outside its range of coverage.
Because of these uncertainties, Ya-
mamoto was in favor of the dental col-
orimeter (M1863d dental colorimeter) de-
veloped by Shofu and Minolta in Japan for
electronic shade measurement.
12
Howev-
er, most of the technological shade sys-
tems are based on conventional shade
guides with all their shortcomings. An ori-
entation on natural teeth and the different
ceramic materials would be an advantage.
In earlier publications the current author
has pointed out that no computer in the
world can take the individual work habits
of a ceramist into consideration in its
analysis. Furthermore, electronic tools
cannot measure optical phenomena such
as opalescence and fluorescence. Even
computer-defined ceramic formulas have
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THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 1 NUMBER 4 WINTER 2006
345
puter-assisted devices that electronical-
ly determine the shade of natural teeth
(Fig 5). They contain light-emitting diode
(LED) light sources with a special design
for each wavelength of light so that the
whole spectrum of visible light is creat-
ed. A charge-coupled device (CCD)
sensor reads data within the range of
about 400 to 700 nm. The internal com-
puter analyzes over 2 million reference
points. Images of hue, value, chroma,
and translucency are created in different
mappings (Fig 6).
9
Both of these approaches are based on the
three-dimensional Munsell color system
(hue, value, and chroma). However, be-
cause natural teeth are partially permeable
by light, this set of three-dimensional pa-
rameters needs to be supplemented by a
fourthoptical light transmission. This
optical property, called transparency or
translucency, may be defined as the ratio
between the visible light passing through
an object and the total incident light from a
given fixed light source.
Aspects of relative translucency and rel-
ative opacity are not sufficiently addressed
by any of the shade selection methods
mentioned so far.
10
Studies by the Aus-
tralian dentist and material scientist N. R.
Hall, published in Australia as early as
1991, are considered the scientific founda-
tion of the Vitapan 3-D Master shade
guide.
11
Hall described the shortcomings
of the classic Vita shade guide and devel-
oped a concept based on a logical system
of arranging colors and a tooth color atlas
with evenly distributed colors. In this new
group orientation, the value is determined
first. This value leads to one of five equidis-
tant shade value groups. Within the deter-
mined group, the (reddish or yellowish)
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VOLUME 1 NUMBER 4 WINTER 2006
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to be mixed and built up. However, in this
age of global cooperation and communi-
cation, dentistry is making use of digital
photography and Internet communication.
Electronic transmission of CAD/CAM da-
ta and electronic shade selection is going
to come into increased use in the future. If
electronic shade measurements are tak-
en, they should be supplemented by pho-
tographs in order to include individual de-
tails in the restoration.
Principles of optimal
color analysis
Natural tooth properties
and color perception
The various approaches to shade selec-
tion for natural teeth illustrate that there still
is no generally accepted standard proce-
dure for approaching this difficult problem.
Both electronic measurements and visual
shade selection claim to determine hue,
chroma, and value of a tooth. Some sys-
tems also include translucency to some
degree. However, the tooths individual
characteristics remain largely beyond con-
sideration. The study of natural teeth shows
an almost unlimited array of possible col-
or variations (Fig 7). In this flurry of colors
and optical phenomena, it is obviously
very difficult to derive any regularities and
rules that could serve as a foundation for
determining and organizing tooth colors.
Tooth colors are not really constant, nor
can they be determined objectively. The
physiological and neurological process of
color vision itself continues to be a scien-
tific enigma, and the psychological as-
pects connected to our ability to perceive
color can hardly be underestimated.
13
It
was not until 1995 that American re-
searchers were able to watch the brain
see using functional magnetic resonance
imaging techniques. The team at Memori-
al Sloan-Kettering Cancer Center in New
York discovered the brains image-pro-
cessing center by observing local varia-
tions in the bloodstream and oxygen con-
centrations during image perception and
processing.
14
Color exists only as a sensual percep-
tion, in the eye of the beholder, whose vi-
sual organ is only an accessory; that is, we
do not see color, but color is created in the
visual center of our brain. This is why the
perception of tooth color is a highly sub-
jective process. It is not possible to assign
natural teeth to any set color categories
since color nuances will vary depending
on the nature of the incident light. Part of
the light reaching a tooth will be absorbed,
while another part is allowed to pass
through (transmitted). Light that is not ab-
sorbed or transmitted is reflected by the
tooth and perceived by the eye as a color
stimulus. The color nuances perceived are
thus only a residual portion of the incident
light that reaches our eyes by way of the
tooth. The spectral composition of this col-
or stimulus will vary depending on the
spectral composition of the incident light
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VOLUME 1 NUMBER 4 WINTER 2006
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Fig 6 Natural left central incisor and Procera crown on the right central incisor (a). Spectrophotometric meas-
urement of the crown (b to d) and the natural tooth (e to h) show an almost perfect color match regarding hue,
value, and chroma, but a slight deviation in the translucency at the incisal edge of the crown (d and h).
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light conditions by re-tuning the retinal
receptors. This is why colors can still be
judged fairly adequately despite differ-
ences in lighting conditions. Nevertheless,
the use of a standardized light source for
shade selection and color matching in
dental ceramics remains a requirement. In
order to create a color-corrected environ-
ment independent from other artificial light
sources new devices were developed with
a constant color temperature (eg, Tru-
shade, Optident). A small portable light
source with a broadband spectrum of light
(5,500K) and a high linear optical trans-
mission in the visible range guarantees
uniform light conditions. Two lamps with
adjustable illumination intensity arranged
at an angle of 45 degrees to eliminate
specular reflections and a coated lens with
2x magnification conform to color meas-
urement standards (Fig 8).
Shade selection
for metal-free restorations
The objective in dental shade matching, in
addition to reproducing the hue, is to imitate
the structure of natural teeth and create bal-
anced color harmony and color nuances by
contrasts and individual characterization.
The systematic approach to color analysis
presented later in this article requires a
planned and logical procedure. There are a
number of prerequisites:
1. Basic knowledge of color science (hue,
value, and chroma)
2. Knowledge of the optical properties of
natural teeth (optical scatter and refrac-
tion, translucency, fluorescence, opales-
cence, etc)
3. Study of the tooths internal structures
(mamelons, secondary dentin, discol-
orations, etc)
during shade selection. Tooth colors can
only be compared if ambient light condi-
tions were identical when the colors were
determined. Neutral northern daylight or a
corresponding artificial light source (color
temperatures of 5,000 to 5,500 K) is con-
sidered ideal for shade selection. Our visu-
al organ possesses adaptive mechanisms
that attempt to adjust incoming stimuli to a
steady average, thus compensating, to a
certain degree, for differences in ambient
Fig 7 Cross sections of natural teeth lead the way to
the study of optical phenomena and structures within
the different layers of a tooth, making them worthy of
further investigation. Light reflection from the surface,
refraction within the enamel, and absorption and light
transmission add to the complexity of this subject.
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rience has shown that accurate informa-
tion is best obtained by shade selection
modalities individually tailored to the
restorative procedure contemplated. In
case of metal-free restorations the color of
the substrate, eg, nonvital teeth or posts
and cores, also may influence the optical
appearance of a restoration. Even the var-
ious degrees of light transmission of differ-
ent core materials must be taken into con-
sideration. The peculiarities of the materials
to be used, but also the individual ce-
ramists work habits, are factors that need
to be given more attention.
4. Knowledge of the texture and structure
of dental enamel and the correspon-
ding ceramic materials
5. Knowledge of the optical results of sur-
face properties (eg, multi-hued mother-
of-pearl effects)
All shade selection methods described
thus far are being used, regardless of the
type of restoration to be provided. Whether
the shade selection can be identical for dif-
ferent types of restorations such as metal
ceramics, laminate veneers, or all-ceram-
ic crowns remains open to question. Expe-
Fig 8 (a to c) Trushade artificial light source with
color-corrected dimmable light (5,500 K) and 2x mag-
nification.
a b
c
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equipped with a 100-mm macro lens with
a twin flash system (eg, Canon Macro Twin
Light, Nikon Macroflash) provide images
with a more three-dimensional appear-
ance.
16,17
A special flash holder (eg, Novoflex
flash holder) allows individual positioning of
the two flashes. The rendition of tooth
brightness is more constant in the manual
mode (M) and an aperture stop f22.
Six steps for successful
shade analysis
The following procedure for shade commu-
nication, which is easily applicable to daily
practice,
1821
will be presented using the
Procera system and the new NobelRondo
porcelain as an example of a computer-
aided design/computer-assisted manufac-
ture (CAD/CAM) all-ceramic system. Using
this method, shade analysis is performed
incrementally. The well-established shades
of the classical Vita shade guide are ar-
ranged logically into six new shade groups
(Super Bright, High Value, Warm Chroma,
Sunny Chroma, Pearl Chroma, and Low
Intraoral digital photography
and color communication
Intraoral photography is usually consid-
ered one of the less reliable adjuncts for
reproducing the shades of teeth. The im-
ages obtained and the conclusions drawn
may vary greatly depending on the type of
camera and flash used, on the film mate-
rial, and the mode of processing. Howev-
er, digital photography combined with dig-
ital shade measurement tools may play a
more prominent role in the future.
15
Pho-
tographs are practically indispensable for
creating structures, contrasts, and individ-
ual crown characteristics. The use of digi-
tal images is greatly enhanced by calibrat-
ing the computer monitor for correct color
reproduction.
The primary advantage of images is im-
proved communication between dentist
and ceramist. Photographing shade pat-
terns on their transparent discs along with
the teeth gives a clearer indication of col-
or mixtures and characteristics.
A high-quality digital camera system is
recommended for professional dental pho-
tography (Fig 9). Digital single lens cameras
Fig 9 (a and b) Digital photography with a lateral flash system enables the reproduction of high-quality im-
ages with reasonable color accuracy (Canon 10D, Canon Macro Twin Light, Novoflex flash holder).
a b
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Step 2: Basic hue
Experience has shown that spontaneous
selection of a shade group and basic hue
with conventional shade guides within the
first 20 to 30 seconds usually provides a
good starting point (Fig 11). However, expe-
rienced ceramists or dentists will not even
need a shade guide; they can rely on visu-
al experience. Of course, the conventional
shade guides should still be consultedit
will frequently confirm the accuracy of the
hue spontaneously chosen by freehand
selection. On closer observation, however,
the clinician will often discover differences
between the tooth and the closest available
shade pattern selected. These differences
must be recognized and interpreted cor-
rectly, which leads to the next logical step.
Step 3: Variations
in color intensity or chroma
Variations in chroma between a shade pat-
tern and natural teeth are relatively fre-
quent. Sometimes chroma must be en-
hanced by adding some chromatizer from
the corresponding shade group. A com-
parison of the dentin shade patterns, which
are made of the actual material and
mounted on transparent trays, with the nat-
ural tooth demonstrates this more clearly
than a comparison with conventional
shade guides, which are made of a differ-
ent material (Fig 12). The necessary in-
crease in chroma can be documented by
checking the corresponding box on the
shade registration form. The ceramist fa-
miliar with high-chroma porcelains will
add between 5% and 20% of a chromatiz-
er, harmonizing the hue to the body mate-
rial (eg, Dentin A3 + Chromatizer Warm
Chroma 10%20%; Dentin B3 + Chroma-
tizer Sunny Chroma 10%20%; Dentin D3
+ Chromatizer Pearl Chroma).
Value). The increasingly popular bleached
shades (Super Bright) are already includ-
ed in the basic kit in order to fulfill modern
patients desires for brighter or lighter
teeth.
The six-step shade evaluation method is
opening new paths of communication re-
garding dental esthetics amongst patients,
dentists, and ceramists. The patient is a
major player and is involved in a specific
way. It is the esthetic expectations of the pa-
tient that should be the focus, not a strict ori-
entation to traditional color designs with all
their limitations. Modern possibilities of dig-
ital photography and image communica-
tion can be integrated simply into the con-
cept. Basically the six steps follow the way
a ceramist will build up a crownfrom the
inside to the outside. Even surface charac-
teristics are implemented in this method. Vi-
tal-looking all-ceramic restorations require
procedures in which less emphasis is
placed on shade guide samples in favor of
natural internal structures and surface
properties and their replication in different
dentin, enamel, transparent, and colored
translucent, as well as fluorescent and
opalescent, ceramics.
Step 1: Shade group selection
The selection of a shade group is not only
determined by the characteristics of a
shade (eg, Warm Chroma for A2 to A4
shades), but also by the patients prefer-
ence. Thus psychological aspects are im-
plemented into this concept as well. The
main characteristics of the shade groups
are expressed in their names (Fig 10): Su-
per Bright (A0, B0), High Value (A1, B1),
Warm Chroma (A2 to A4), Sunny Chroma
(B2 to B4), Pearl Chroma (D2, D3), and
Low Value (C1 to C3).
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character of a tooth is determined by sub-
tle internal structures deep inside of the
tooth or crown. Internal characteristics like
mamelons, discolorations, or wear facets
will be selected carefully with the original
ceramic samples of internal modifiers (Fig
13). Any discoloration detected at the in-
cisal edges during shade selection should
be addressed. Sketching these incisal
Step 4: Internal structures
The first three steps primarily addressed
the basic dentin shade and its modifica-
tions. At this stage, internal tooth character-
istics and tooth structures must be consid-
ered. A tooths character is determined, to
a large extent, by the changes it undergoes
during its life. This is a functional aspect
that must never be neglected. The natural
Fig 10 The NobelRondo ceramic shade tabs are
arranged on six transparent disks, organized as dentin,
enamel, modifier, or stain (a and b), corresponding to
the arrangement of the bottles on the tray (c).
a b
c
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Step 5: Value, translucency,
enamels, and contrasts
Within the three-dimensional color space
of a color scale, value is usually expressed
in grayscale terms, that is, on a scale be-
tween black/dark and white/bright. Teeth,
however, being semi-translucent objects,
characterizations on the tooth outline on
the shade registration form gives the ce-
ramist important information about the lay-
ering of these structures. In this manner, a
two-dimensional drawing assists in a
crowns three-dimensional design (ie,
depth layering).
Fig 11 Spontaneous visual selection of the shade group (Warm Chroma) and
basic hue (A3) using a common shade guide.
Fig 12 The ceramic samples provide accuracy for
determining the basic dentin shade and variations in
color intensity (chroma).
Fig 13 Samples of the internal modifiers (eg, Ivory
and Flamingo for mamelons) are useful for determin-
ing internal characterizations.
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to understand that this constitutes an at-
tempt to increase the overall range of avail-
able tooth colors by a considerable mar-
gin. By adding suitable amounts of
chromatizers and transparent materials
harmonically adapted to the selected hue,
it is possible to obtain well-defined inter-
mediate shades (ie, variations in chroma).
Opacity is increased by using more fluo-
rescent inner core material. Translucency
is increased by adding transparent porce-
lain (up to 30%)a much more frequent
occurrence. Note, however, that adding
transparent porcelain to the body without
first modifying its chroma may result in re-
duced value, making the crown appear
darker. These examples show how the var-
ious body, transparent, and intensifier
porcelains may interact. Clinicians and ce-
ramists are strongly encouraged to con-
duct their own trials including the firing of
samples of the porcelain mixtures.
The enamel layer above the dentin is of
decisive importance for the optical appear-
ance of the tooth (McLean JW, personal
communication, September 1998). This is
where the difference in structures and light
refraction factors of the natural tooth enam-
el on the one hand and those of our ce-
ramic materials on the other is most
painfully obvious. The refractive index of
ceramics is 1.5 and that of natural enamel
is 1.65. Whether the enamel layer is thick-
er or thinner, whether it has a higher value
(is brighter), whether it is grayish in ap-
pearance or shows colored transparen-
cyall these factors can substantially influ-
ence the overall appearance of a dental
restoration. The enamel patterns of the No-
belRondo ceramic color patterns, the col-
ored translucencies (eg, CT Melon, CT Pa-
paya, CT Lemon), and the opalescent and
transparent porcelains of the NobelRondo
should not be forced into a grayscale. Ob-
serving optical phenomena (more light or
less light) must be at the center of attention.
Brighter means more reflected light, while
darker means more absorbed light. This
means that the value of a ceramic materi-
al is influenced by certain optic effects. An
increase in value (high value) may be cre-
ated by adding bright fluorescent materi-
als inside the crown or by using strongly
opalescent materials (eg, Opal Enamel 0
or Opal Enamel 1, also Mother-of-Pearl
materials from NobelRondo porcelains) to
the body porcelain. A decrease in value
(low value) may be obtained by adding
transparent materials (eg, Transpa Neutral,
Special Enamel Smoky, or Grey) or by us-
ing master kit modifiers with a low value
(eg, Pearl, Taiga, Caramel). Here, too, com-
munication is simplified by placing a
checkmark on a scale between Low Value
and High Value on the shade registration
form.
Using internal modifiers or highly
opalescent enamels will influence the
tooths relative opacity or translucency.
Translucency, the fourth dimension of tooth
color, deserves special attention since it
cannot be captured using any of the con-
ventional shade guides. Between low
translucency (high opacity) and high
translucency (low opacity) are many vari-
ations. In general, we can increase translu-
cency by adding Transpa Opal or Transpa
Clear to the dentin porcelain; however, this
may lead to a slight decrease in value. All
these examples clearly demonstrate that
we cannot look at one aspect of color in
isolation. Chroma, value, and translucency
are always interacting.
This system of dentin modifications is
not a set of recipes for reproducing exist-
ing shade patterns. Rather, it is important
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light. Objects whose surface is even when
seen through a microscope will reflect light
very directly, resulting in a high degree of
gloss (glaze). If, by contrast, the surface of
the object is more highly structured, the re-
sult is greater light refraction, so that it ap-
pears semi-glossy or semi-matte. Still
more highly structured or rougher surfaces
with a lower degree of glossiness will ap-
pear to have a matte finish.
Particle sizes and light refraction indices
of different ceramic materials used to cre-
ate enamel structures have a considerable
influence on their optical appearance. The
structure of the NobelRondo porcelains
permits an optimized surface structure
through proper firing cycles and its ex-
tremely fine grain structure. Mechanical
surface treatment using different polishes
will become an exceptional step and will
only be performed to achieve a particular
type of surface gloss. The ultra-fine parti-
cles included in the ceramic materials in-
fluence both the absorption and the refrac-
tion of the incident light. If particles are
used whose refraction index is high (eg,
basic kit as well as the opalescent Mother-
of-Pearl modifiers (eg, Oyster White, Light
Coral, Pale Shell, and Pink Pearl) from the
master kit help capture many enamel vari-
ants quickly and easily (Fig 14).
Contrasts such as bright spots, colored
translucencies in the tooths cervical third,
exposed root segments, or pronounced
bluish opalescent regions in the tooths in-
cisal third can also be captured using the
original ceramic shade patterns (eg, Spe-
cial Enamel Opal Blue, Opal Blue Light). A
mesial line angle of a central incisor may
appear more prominent by using a bright,
highly opalescent material like Oyster White
because of the light-reflecting character of
this specific material. To increase the illu-
sion of more concavity on the distal aspect
of a crown, colored translucencies with
more light-absorbing quality can be used.
Step 6: Surface structure
and gloss
The next step is to determine the color nu-
ances and characteristics of the tooth sur-
faces. Surface staining techniques should
be restricted to exceptional cases. Minor
characterizations, however, may well en-
hance the illusion of a natural-looking crown.
It is regrettable that the connection be-
tween the surface structure of a tooth and
its optical appearance has been given on-
ly scant attention to date. The color of
opaque objects is determined by the ex-
tent (quantity) of light reflected from the
surface of the respective object in different
regions of the visible light spectrum. This
is, however, only an illusion in the case of
translucent objects such as dental enam-
el, since the light does in fact enter the ob-
ject to some extent and is refracted by the
microscopic structure of the substances
before leaving the object again as diffuse
Fig 14 The correct selection of enamels will lead to
better control of lightness (value), translucency (amount
of light transmission), and opalescence. The interaction
between these aspects should not be overlooked.
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Conclusion
The system of shade selection presented
here (Fig 15) is based on the authors
many years of experience with the Cre-
ative Color system he developed. With the
introduction of the Procera system, this ba-
sic concept was developed further and
adapted to all-ceramic restorations. The
scientific basis of general color science,
optics, and aspects of material science, as
well as the development of a logical sys-
tem, laid the groundwork for making the
NobelRondo shade registration fit for
everyday clinical practice. Successful co-
operation with clinicians abroad has
shown that the system is practical, even if
the patient him- or herself was unavailable
for shade selection or shade adaptation in
the laboratory.
A spirit of cooperation between ce-
ramist, clinician, and patient; consistent im-
plementation of the shade selection and
color-matching concepts for metal-free
restorations; high-quality photographic
procedures and image communications;
and also patience and understanding in
the event that perfect success is not imme-
diateall these will result in more success-
ful results in dental esthetics.
refractive index of zirconium oxide = 2.3,
aluminum oxide = 1.8), strong light reflec-
tion will result, and the crown will appear
brighter. This is the case, for instance,
when using strongly opalescent enamel
porcelains (eg, Opal Enamel 0, Opal
Enamel 1, Mother-of-Pearl). Utilizing non-
opalescent enamels and Transpa Neutral
will lead to a lower value and higher
translucency, since more light will be trans-
mitted and absorbed in deeper layers of
the ceramic restoration.
The examples given show how the sur-
face structure will influence the value as
well as the opacity and translucency of a
crown. Excessive glazing or polishing of a
crown will result in restorations that tend to
look unnatural. A subtle reduction in glossi-
ness using a felt wheel and somewhat
coarser polishes (porcelain/pumice mix-
tures) yields better results. The best way of
showing the surfaces of models or crowns
is to use a silver or gold powder. Another
way of highlighting the surface structures is
by taking photographs from a slightly later-
al angle and using black-and-white film.
Fig 15 (a) A patient presented with four insufficient porcelain-fused-to- metal crowns. Her chief complaints were
gingival recessions and the discoloration and unnatural appearance of the crowns. (b) Initial shade selection us-
ing the classical Vita shade guides. (c) More reliable determination of the basic shade with NobelRondo dentin
samples (A1, A2). (d) Selection of internal structures (Ivory internal modifier). (e) Selection of enamels (Opal Enam-
el 2, Enamel 3, Opal Blue Light). (f) NobelRondo shade communication form. Digital images can be printed on
this simple form, which also includes information on hue, value, chroma, translucency, and surface characteris-
tics. (g) The individual CAD Procera densely sintered alumina copings have excellent fit and optimized translu-
cency. (h) The provided shade information guides the ceramist in the creative ceramic buildup. (i) The four Pro-
cera alumina crowns veneered with NobelRondo alumina ceramics after glazing. (j) Marginal fit, function, form,
texture, and color reproduction are verified at try-in of the crowns. (k) The Procera crowns from the lingual as-
pect after cementation. (l to n) Dental esthetics has many individual aspects, and the patient is our focus. The
importance of ethical aspects and the beauty of a happy smile can never be underestimated. (Case treated by
Dr C. Meyding, Wetzlar, Germany; ceramics by D. Hildebrandt and E. A. Hegenbarth, Bruchkbel, Germany.)
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Acknowledgments
The author would like to express his gratitude to the cre-
ative team of ceramists in his laboratory and to all clini-
16. Bengel W. Mastering Digital
Dental Photography. London:
Quintessence, 2006.
17. Bengel W, Devigus A. Prepar-
ing images for publication: Part
2. Eur J Esthet Dent
2006;1:112127.
18. Hegenbarth EA. Procera alu-
minum oxide ceramics: A new
way to achieve stability, preci-
sion and esthetics in all-
ceramic restorations. Quintes-
sence Dent Technol
1996:19:2134.
19. Andersson M, Razzoog ME,
Odn A, Hegenbarth EA, Lang
BR. Procera: A new way to
achieve an all-ceramic crown.
Quintessence Int
1998;29:285296.
20. Hegenbarth EA. The Develop-
ment of NobelRondoAes-
thetics, Science and Ergonom-
ics of a New Generation of
Ceramics. Quintessence J
Dent Technol 2004;2:502516.
21. Sadan A, Hegenbarth EA. A
simplified and practical
method for optimizing aesthet-
ic results utilizing a new high-
strength all-ceramic system.
Pract Periodontics Aesthet
Dent 1998;10(suppl):49.
9. Paul S, Peter A, Pietrobon N,
Haemmerle CHF. Visual and
spectrophotometric shade
analysis of human teeth. J
Dent Res 2002;81:577582.
10. Zena RB, Hegenbarth EA.
Transparenz - die vierte Farb-
dimension. Quintessenz Zahn-
technik 1993;19:10911109.
11. Hall NR. Tooth colour selec-
tion: The application of colour
science to dental colour
matching. Aust Prosthodont J
1991;5:4146.
12. Yamamoto M, Scholten I. Die
Entwicklung des Vintage-Halo-
CCS-SystemsComputerges-
teuerte Farbbestimmung und
innovative Keramikwerkstoffe.
Berlin: Quintessenz, 1998.
13. Huxley A. The Art of Seeing.
London: Hatto & Winous, 1943.
14. Hirsch J, DeLaPaz RL, Relkin
NR, et al. Illusory contours acti-
vate specific regions in human
visual cortex: Evidence from
functional magnetic resonance
imaging. Proc Natl Acad Sci
U S A 1995;92:64696473.
15. Chu S, Devigus A, Mieleszko
A. Fundamentals of Color:
Shade Matching and Commu-
nication in Esthetic Dentistry.
Chicago: Quintessence, 2004.
References
1. OBrien WJ, Boenke KM, Groh
CL. Coverage errors of two
shade guides. Int J Prostho-
dont 1991;4:4550.
2. Miller L. Organizing color in
dentistry. J Am Dent Assoc
1987;115(special
issue):26E40E.
3. Preston JD. Current status of
shade selection and color
matching. Quintessence Int
1985;16:4758.
4. Clark EB. An analysis of tooth
color. J Am Dent Assoc
1931;18:20932103.
5. Lemire PA, Burke B. Farbe
und Zahnersatz. Berlin: Quin-
tessenz, 1979.
6. Hegenbarth EA. Color com-
munication between office and
laboratory. Color selection and
color production in dental
porcelain [in German]. Swiss
Dent 1982;3:2527.
7. Hegenbarth EA. Monotonie
oder Vielfalt die Problematik
konventioneller Farbsysteme in
der Dentalkeramik. Quintes-
senz Zahntechnik
1992;18:13031323.
8. Hegenbarth, EA. Creative
Ceramic Color: A Practical
System. Chicago: Quintes-
sence, 1989.
cians supporting the documentation of the clinical cas-
es presented in this publication.

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