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4 Color and Shade Matching

a b c

d e f

g h i

j k l
Fig 4-20  Five dimensions of color technique. Facial (a) and palatal (b) views of the clinical situation show a nonvital, discolored, and severely compromised maxillary
left central incisor with a large existing composite restoration. Following root canal retreatment and use of the internal walking-bleach technique with 12% hydrogen
peroxide, the tooth is prepared with a chamfer on the facial enamel (c) and 90-degree butt interproximal and lingual margins (d). (e) A silicone index made from a
mock-up or diagnostic wax-up is used for creation of the lingual wall and is adapted to all involved teeth. (f) A thin layer of universal enamel resin composite allows for
easy reproduction of the natural anatomy of the lingual wall. Dentin body and enamel effects are then created: (g) dentin body is formed with lighter incisal mamelons
(characterization type 1); (h) amber and white resin composite are used at the incisal and approximal margins (characterization type 3); (i) free spaces between margin
and dentin mamelons are filled with opalescent blue (opalescent type 1) to increase the halo effect; (j) a thin layer of intense white is stratified to create a white-spot
appearance (intensive type 2). The stratification is completed on the facial surface with a thin layer (0.8 mm) of universal enamel. In the facial (k) and palatal (l) views, the
intensive, opalescent, and characterization elements give a natural, three-dimensional quality to the completed case. (Courtesy of Lorenzo Vanini, Chiasso, Switze­rland.)

Reproduction and Verification of Color and Appearance 4

a b

c d
Fig 4-21  Natural layering concept. (a) A young patient presents with a healthy dentition but a highly irregular smile line. The patient wants improvement but demands
a conservative solution. (b) Following placement of rubber dam, an index (made from a mock-up or wax-up) will serve to guide proper placement of the two resin
composite layers in three dimensions. (c) The restorations are placed using the natural layering concept. (d) The completed restorations demonstrate the satisfactory
esthetic integration of the direct composite restorations using a modern hybrid material, which exhibits proper color, opacity, translucency, and opalescence. (Courtesy
of Didier Dietschi, Geneva, Switzerland.)

Case A: Five dimensions of color • Characterizations encompass five different types: two in
dentin, mamelon, and band, and three in enamel, margin
The five dimensions of color technique (Fig 4-20) was devel- (younger teeth), stain, and cracks (adult and older teeth).
oped by Lorenzo Vanini primarily for restoring natural color
and appearance of teeth with direct resin composite restora-
tions.60,61 This approach encompasses the following elements: Case B: Natural layering concept
The natural layering concept (Fig 4-21) was developed by
• Chromaticity is related to one hue (universal dentin) and dif- Didier Dietschi for the creation of highly esthetic direct restora-
ferent chroma levels (0, 0.5, 1, 2, 3, 4, 5, and 6). tions.62,63 This method suggests single hue, single opacity, and
• Value (luminosity) is strictly related to enamel, with two main broad chroma scales for mimicking dentin color and appear-
groups: lower value (older tooth biotype) and higher value ance. Enamel and corresponding materials are categorized
(younger tooth biotype). as the following types: young enamel (white tint, high opal-
• Intensives are classified by shape types: spots, small clouds, escence, less translucency), adult enamel (neutral tint, less
snowflakes, and horizontal bands. opalescence, and intermediary translucency), and old enamel
• Opalescents create the blue and amber hue of the incisal halo (yellow tint, more translucency). Only two basic layers, dentin
at the interproximal level and free enamel margin. The author and enamel, are used to enhance tooth and smile anatomy.
describes different shapes: mamelon, split mamelon, comb-
like, windowlike, and stainlike.

4 Color and Shade Matching

a b e

c d

h i
Fig 4-22 Combined visual-instrumental technique. A 32-year-old woman presents with missing maxillary lateral incisors. She wants to replace them with single
implants and crowns. (a to d) Two narrow-diameter bone-level implants are placed, and zirconia all-ceramic crowns (Lava, 3M ESPE) are fabricated with Vita VM9
layered porcelain (Vident). (e) Although the color of the crowns is symmetric, a perceivable difference in the peri-implant soft tissue appearance is observed between the
two implant-supported crowns. (f and g) Color mapping of the peri-implant tissue around the maxillary right lateral incisor shows that it has blanched, which can also be
seen in the linked image. (h) At the 1-month follow-up appointment, an improvement in the optical properties of the peri-implant soft tissue of the maxillary right lateral
incisor compared with f is observed. (i) The digital camera image shows an excellent color match of both maxillary lateral incisor crowns and an improved appearance
of the peri-implant soft tissue. (Courtesy of Shigemi Nagai, Boston, Massachusetts.)

References 4

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8. Paravina RD, Kimura M, Powers JM. Evaluation of polymerization- mance of five commercially available tooth color-measuring devices. J
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Program for Esthetic Dentistry. Society for Color and Appearance in four dental shade-matching devices. J Prosthet Dent 2009;101:193–199.
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11. Goodacre CJ, Paravina RD, Bergen SF, Preston JD. A Contemporary the colour characteristics of healthy gingiva. Int J Dent Hyg 2007;5:22–
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Caries Management:

Diagnosis and Treatment
Bennett T. Amaechi
J. Peter van Amerongen
Cor van Loveren
Edwina A. M. Kidd

Traditional caries management has consisted of the

detection of caries lesions followed by immediate
restoration. In other words, caries was managed pri-
marily by restorative dentistry. However, when the
dentist removes tooth structure with a handpiece,
an irreversible process begins. Placing a restoration
does not guarantee a sound future for the tooth; on
the contrary, it may be the start of a restorative cycle
in which the restoration will be replaced several times
(Fig 5-1). This is reflected in the philosophy of Dr V. Kim
Kutsch: “I get to the cause of the disease, instead of
just treating the symptoms. When you’re focused on
Fig 5-1 Iatrogenic damage caused by repeated treatment
just treating the symptoms surgically, which tradition- procedures.
ally is what we’ve done in dentistry, you never catch
up. You never get ahead.”1 Caries is like every other
bacterial disease, and restoration without removal of
the causative factors is like placing a new roof on a
burning house. order to establish the individual patient’s caries risk.
A new paradigm for caries management, patient- The information collected from the comprehensive
centered caries management (PCCM), is recommend- assessment is synthesized into a personalized treat-
ed.2 PCCM is enabled by the International Caries ment plan, composed of preventive and noninvasive
Detection and Assessment System (ICDAS) clinical treatment options, operative and minimally invasive
visual scoring system for caries detection and activity.2 treatment options, and maintenance care involving
When integrated into the caries management by risk recall appointments for reassessment and monitoring
assessment (CAMBRA),3,4 treatment of caries is a pro- (Fig 5-2). The treatment options recommended for
cess that can be controlled so that lesions may never specific caries lesions and patients will depend on a
form or, if they do, lesion progression can be arrested. variety of prognostic factors, including lesion activity,
The PCCM strategy involves a comprehensive assess- and the monitoring of lesion behavior over time. It is
ment and includes evaluation of the caries risk and important to mention that preventive regimens will
protective factors, detection and diagnosis of caries, arrest the caries process by redressing the imbalance
and determination of the activity of existing caries in between demineralization and remineralization.5

5 Caries Management: Diagnosis and Treatment Strategies


Tooth/surface Patient

Clinical Lesion Lesion Caries risk Behavioral

visual lesion detection activity assessment assessment
detection aids assessment

Synthesis and
decision making

Lesion Lesion Prognosis for

diagnosis prognosis patient

Integrated personalized treatment planning

Preventive Operative
treatment treatment Maintenance care
options options

Fig 5-2 Algorithm for PCCM. (Modified from Pitts and Richards2 with permission.)

The treatment goal in caries management should be to development has changed over time, as has the way we diag-
prevent new lesions from forming, to detect lesions sufficiently nose and manage the disease. The initiation of the develop-
early in the process so that they can be treated and arrested ment of dental caries by the concurrent action of three primary
by noninvasive means,5 and to educate patients on the cause factors (the tooth, dental plaque, and diet) were presented in
of the disease to gain their cooperation with recommended the 1960s in a model of overlapping circles.6 Since then, the
preventive strategies. model has been supplemented with factors that modulate
the actions of the primary factors to determine the manifesta-
tion and clinical severity of caries7 (Fig 5-3). At first sight, these
The Caries Process circles constitute a simple model to explain caries risk, which
is represented by the overlap of the three inner circles. When
Our understanding of the nature of any disease determines one of the risk factors increases, the respective circle becomes
how we diagnose it and how we manage it. This general princi- larger, as does the overlap of the circles, indicating increased
ple also applies to dental caries. Through scientific research, our caries risk.
understanding of the nature of caries and factors relating to its

The Caries Process 5


Saliva Income
Education • Buffer capacity
• Composition
• Flow rate
Antibacterial Dental
agent Time Protein insurance

Dental sealants
in dental
plaque Sugars
• Type/nature
Behavior Time Time • Clearance rate
• Oral hygiene Fluoride Caries • Frequency
• Snacking Diet Tooth • Amount
• Smoking Composition Composition
Frequency Mineralization Dental
Texture level visits
Chewing Calcium ions
gum Time
Phosphate ions
Oral health
Plaque pH
Microbial species
cultural beliefs

Personal factors
Oral environmental factors
Primary factors for caries development

Fig 5-3 Factors influencing the equilibrium between the three prerequisites for the caries process as first described by Keyes and Jordan.6 (Modified from Selwitz et
al7 with permission.)

Dental plaque quite complicated and requires the support of a microbiologic

laboratory. It is easier to count mutans streptococci and lacto-
The prevalence of mutans streptococci and lactobacilli is asso- bacilli in saliva, and kits are commercially available for this pur-
ciated with dental caries.8–10 Streptococcus mutans is involved pose. However, these counts do not give site-specific informa-
in caries lesion formation from its initiation, while lactoba- tion and are poor predictors of high caries activity in general,
cilli flourish in a carious environment and contribute to caries although low counts or absence of mutans streptococci are
progression. Dental plaque may be more cariogenic locally good predictors of low caries activity.11
where mutans streptococci and lactobacilli are concentrated, High numbers of mutans streptococci and lactobacilli are
but in everyday practice it is difficult for the dentist to identify probably the consequence of a high sugar intake and the
cariogenic plaque to make this knowledge useful in treating resulting periods of low pH levels in dental plaque.12,13 Inversely,
individual patients. Plaque can be sampled and mutans strep- it has been shown that restriction of sugar intake reduces the
tococci and lactobacilli levels quantified, but the procedure is numbers of mutans streptococci and lactobacilli.12,14 In one

5 Caries Management: Diagnosis and Treatment Strategies

study of Weight Watchers clients who complied with a non- between sugar consumption and caries prevalence, the caries-
cariogenic diet, the numbers of mutans streptococci and lac- preventive effect of sugar restriction was small. For instance, in
tobacilli were reduced by half.15 A comparable reduction was Basel, Switzerland, wartime restriction reduced sugar supply
found in subjects who reduced their sugar intake frequency from about 48 to 16 kg per person per year, but the number
from 7.2 to 1.8 times per day.16 However, the decrease in of caries-free children rose only from approximately 3% to
mutans streptococci was more pronounced on buccal than on 15%.25,26 At that time, the improvement seemed impressive,
proximal tooth surfaces, and, interestingly, the pH response to but it was dwarfed by the effect of nationwide optimum fluo-
glucose was reduced in buccal but not in interdental plaque.16,17 ride administration, when the number of caries-free children
Six weeks after completing the sugar restriction period, the rose from approximately 7% to more than 50%, with a reduc-
numbers of mutans streptococci increased again.16 tion of sugar supplies from approximately 42 to 39 kg per per-
The oral flora colonizes on teeth continuously, but it takes son per year.25 Obviously, fluoride administration was far more
up to several days before the dental plaque contains enough effective in reducing caries than lowering sugar supplies. With
acidogenic bacteria to lower plaque pH to the level that causes this evidence, the role of dietary counseling in caries preven-
demineralization.18 Theoretically, plaque removal every sec- tion should be reexamined. This does not negate the value of
ond day would be sufficient. If the dentition is professionally diet analysis and advice for patients presenting with multiple
cleaned, an even lower frequency of home-care cleaning has caries lesions, but the importance of the proper use of fluoride
been demonstrated to prevent caries.19,20 But considering the should always be emphasized.
caries prevalence in the prefluoride era, it is obvious that few Information gathered with the reliable pH-telemetry meth-
people are capable of cleaning their teeth to a level adequate od has revealed that a pH drop induced by eating may last for
to prevent caries. hours if there is no stimulation of the salivary flow.18,27,28 Even
the consumption of an apple can depress the pH for 2 hours or
longer.18 Long pH depressions will be most prevalent in areas
Teeth where saliva has little or no access, and these areas are the
Teeth consist of a calcium phosphate mineral that demineral- most caries prone. It is unknown how much additional harm
izes when the environmental pH lowers. As the environmental is caused by a second sugar intake during such a period of low
pH recovers, dissolved calcium and phosphate can reprecipi- pH or how beneficial it is to omit a second sugar intake during
tate on remaining mineral crystals. This process is called remin- that period. Foods believed to be “good” for teeth may not be
eralization. Remineralization is a slower process than deminer- better than foods that are supposedly “bad.” A chocolate and
alization. When remineralization is given enough time, it can caramel bar might be considered bad because it feels sticky. In
eliminate the damage done during demineralization, but in the reality, however, the caramel dissolves and leaves the mouth
absence of this, the caries process will progress and a lesion relatively quickly, whereas potato chips, generally considered
will develop. Dentin is more vulnerable than enamel because less harmful, take a longer time to clear from the mouth.29
of structural differences and greater numbers of impurities in During this retention, the carbohydrate fraction may be hydro-
the crystal lattice, which facilitate its degradation in an acidic lyzed to simple sugars, providing a substrate for the acidogenic
environment. For many years, much emphasis was given to bacteria.30
the preeruptive effect of fluoride improving the quality of the All the uncertainties about the determinants of the cario-
dental hard tissues. However, it is now clear that posteruptive genicity of foods make it impossible to provide strict dietary
use of fluoride is far more protective against caries.21–23 Enamel guidelines. To snack in moderation, limited to 3 or 4 snacks a
in primary teeth is less mineralized and more variable than per- day, is the only wise recommendation.
manent enamel. Optically it is more opaque, which may repre-
sent greater porosity. It gives the clinical impression of wearing
more quickly and being less resistant to caries.24 Time
Time affects the caries process in several ways. When caries
was considered to be a chronic disease, time was introduced
Diet to indicate that the substrate (dietary sugars) must be present
Dietary carbohydrates are necessary for the bacteria to pro- for a sufficient length of time to cause demineralization.31 Now
duce the acids that initiate demineralization. In general, dietary we know that caries is not a chronic disease and that its effects
advice for caries prevention is based on three principles: (1) the can be arrested or completely repaired if enough time is given
drop in pH lasts for approximately 30 minutes; (2) the fre­quency for remineralization. Finally, it is clear that caries lesions do not
of intake is more important than the quantity; and (3) the develop overnight but take time; in fact, it may take years for a
stickiness of foods is an important factor in their carioge­nicity. caries lesion to develop a distinct discontinuity or break in its
It has become obvious, however, from many epidemiologic surface integrity (otherwise called cavitation). This potentially
studies where fluoride is used daily, that sugar consumption gives the dentist and the patient ample time for preventive
and caries prevalence have become less tightly related for treatment strategies.
many individuals. Even when there was a significant correlation