JOURNAI.

OF ES’IHFTIC DENTISTKY

Visualizing the Natural Dentition

ROBERT WINTER, DDS*

W e look, but do we really see?

When we look at anterior
teeth, do we form mental visual
images? Are we trained t o process
and interpret what we see into
visual terms?

This article describes a method for

visualizing a final restoration before
it is begun. Visualization of natural
Figure 2. To understand the physical
tooth forms comes with its own characteristics of the natural denti-
vocabulary, which will act as our tion, one must learn how to visualize
form, color, value, relative translucen-
guide and serve as our interpreter cies, and surface attributes in order to
when we communicate with the create natural appearing restorations.
dental laboratory technologist and
the patient (Figure 1).The final chal-
lenge is to convert what has been
seen in nature to dental restorations, A restoration of an anterior tooth provides the clinician with latitude
which is best accomplished when the must satisfy the requirements of and creativity in serving the needs of
clinician has a “vision” of the final form, function, phonetics, and the patient, the concepts of esthetics
creation based on an understanding esthetics. It must be biologically in dentistry echo traditional restora-
of nature’s variations. compatible with the adjacent hard tive tenets, i.e., beautiful esthetics
and soft tissues, while satisfying the imply an inherent sense of realism
expectations and desires of the when reproducing natural teeth
patient. Although esthetic dentistry (Figure 2).

“Private practice, Newport Beach,

California

V O I IJMI: 5 . N U M B F R 1 103
 J O U R N A L OF ESTHETIC D E N T I S T R Y

Visualizing the Natural Dentition

We begin by focusing our attention

on the physical characteristics of
the natural dentition and learn how
to see the subtle nuances of color,
relative opacities and translucency, Figure 3. When incident
light strikes a tooth, a frac-
form or shape, surface texture, and tion of the light is reflected
luster. Once one learns how to
visualize natural teeth, then one can
analyze the smile, facial make up,
character of the patient, and psy- ed, or diffusely transmitted
through the tooth.2
chological factors, all of which are
essential to successful completion of
esthetic restorations.

O P T I C A L PROPERTIES OF Translucency complicates our

T H E NATURAL DENTITION
understanding of how to reproduce
Natural teeth are translucent. natural teeth, because it interacts
Incident light is reflected off them, with color, light and shadow, opa-
absorbed into them, and some is cities, surface textures, and luster,
transmitted through them (Figure both on and within the tooth. The
3).lJ All light entering a tooth is degree of translucency depends on
scattered or refracted, unlike win- the structure and thickness of the
dow glass, which is transparent and enamel and dentin. Translucency
allows light to pass through with alters the quantity and quality of
little change. Opaque materials are the light that is reflected back to
impenetrable t o light (i.e., the light our eyes.
that is not absorbed is reflected and
scattered directly off the surface). Translucency in teeth is influenced
by the way light is reflected and
refracted by the enamel rods and
the condition of the dentin. Enamel
and dentin have different optical
Figure 4. A longitudinal densities; enamel is more than twice
section of a maxillar
central incisor. The Lntin as translucent as dentin2 When
is three to four times as light passes through enamel and
thick as the enamel and
optically denser. The incre- strikes an optically denser dentin,
mental lines of Retzius are more light is reflected back. The
apparent in the enamel.
color saturation and brightness of
the dentin also influence the amount
of light reflected (Figure 4).

104 M A Y i l U N E 19Y3
 Figure 5. The incisal
and gingival one halves
of the maxillary central
incisors exhibit sharp
contrast in relative
translucencies.

Because dental porcelains d o The way in which tooth color is Eye

not have hydroxyapatite crystals, perceived depends on the following The retina is the photosensitive
enamel rods, or dentinal tubules, factors: layer in the human eye. It is the
the final ceramic restoration is an contact point between the light and
illusion of the way light is reflected, 1. The quantity of light incident to the brain. The retina reacts to very
refracted, absorbed, and transmit- it. minimal light impulses and can dif-
ted by a multi-layered, complex 2. The spectral energy distribution ferentiate fine nuances of brightness
tooth structure (Figure 5 ) . of the light source (i.e., daylight and color.
or artificial light).
COLOR PERCEPTION 3. The sensitivity of the eye. The cell layer, which reacts to light
The source of all color is white 4. The visual interpretation of the stimulus, is made of rods and
light. Light is electromagnetic radi- perceived color. cones. The rods register the varying
ation capable of stimulating the 5. The particular reflective, absorp- intensity of the light (i.e., they dif-
retina. The eye responds to light tive, and transmissive optical ferentiate between brightness and
wavelengths between 380 and properties from different levels darkness [value]). The cones react
760 111111.~ When an object reflects within the teeth. to the varying spectral composi-
some wavelengths and absorbs 6. The conditions under which the tions of light (i.e., they differentiate
others, the nature of the reflected tooth is being viewed (i.e., in the colors [hue and chroma]). The eye
rays determines the stimulus to the oral cavity, wet or dry, angle and can differentiate up to 300 spectral
eye and the brain, and a color is intensity of illumination, and the color^.^ The cones require consider-
perceived. If an object absorbs all colors of the surrounding ably more light to be activated
light, it will appear black. If it objects). compared to the minimal stimulus
reflects all light, it will appear white, required by the rods. An eye con-
provided a full spectrum of light is In teeth, the dominant wavelengths tains approximately 100 million
incident upon it. reflected are in the yellow-orange rods and 6 million cones.
range.

V O I U M C 7. N ~ I M R F K
3 105
 J O U R N A L O F FS'I'HETIC D F N T I S T R )

Visualizing the Natural Dentition

Light and Shadow It is an objective of tooth reproduc-

Light is necessary to reflect color tion to control the external factors,
from a tooth; the less light, the less such as the quality and quantity of
color. Light and shadow differ from incident light, as well as the condi-
each other not only in terms of tions under which the tooth is being
brightness and darkness, but also in viewed. Training the eyes and
reflected color. When the lip covers brains of the entire dental team will
the teeth, there will be changes in result in predictable color reproduc-
perceived brightness and color. tions for your patients.

A dark or shadowed oral cavity QUANTIFYING COLOR

creates sharp contrast to natural In 1898, A.H. Munsell quantified Hue

teeth and accentuates their bright- the three dimensions of color into Hue is determined by the wave-
ness and form. The silhouette of the hue, chroma, and value, which length of the stimulus and is desig-
incisal edge and incisal embrasures applies best to opaque, nontrans- nated by the convenient family of
are highlighted in front of a dark- lucent ~ o l o r s .This
~ , ~ often creates names we all recognize. The shortest
ened mouth. The light reflecting off much confusion when relating wavelengths are called violet, and
the heights of contours of teeth and these dimensions to translucent the longest are red. The sequence
the corresponding slight shadowing teeth, especially concerning value dictated by wavelength, from short-
interproximally creates depth and (Figures 6 to 10). est to longest, is violet, blue, green,
enhances a 3-dimensional form. yellow, orange, and red.

Therefore, recognition of color is

determined by the stimulus, the
receptor cells of the eye, and the sub-
jective response by the brain. Any
distortion of the stimulus, receptor,
or interpretation results in a misun-
derstanding of the real color. Color
must be perceived, not merely seen.

106 M A Y I I I I N ~I Y Y ?
Figures 6, 7 , 8, 9, and 10.
A 38-year-old female patient. Chroma Value is also called luminance. It is
Notice the chroma and value
changes within each tooth, Chroma is the intensity, concen- a measure of the quantity of light
as well as from tooth to tration, strength, or saturation of reflecting (brightness) from the
tooth. The mandibular ante-
rior teeth exhibit the same the hue. A change in chroma has a tooth, not the amount of grey in the
characteristics as the maxil- corresponding change in value. As color. (Adding the color black to
lary teeth.
the chroma intensifies the value paint is a commonly used technique
decreases. t o decrease brightness in an opaque
material, but that is different than
Value controlling brightness in artificial,
Value is the amount of light,that is translucent teeth.)
reflected (or absorbed) by a tooth.
It is the dimension of color that we
perceive most easily.

VOLUME s, N U M B E R 3 107
Viisiinlixirig the Natural Dentition

Figure 11. In the ingival one

third of the centrafincisor the
inpuence of the underlying
dentin color is predominate,
because the enamel thins to
approximately 0.3 mm at the
d
area o cementoenamel junction.
The c roma and the degree of
calcification of the dentin
increases with age. The pink gin-
giva also affects the hue.

Figure 12. In the middle one

third the enamel is approxi-
mately 1 mm thick. Due to its
increased thickness, there is
increased scattering of all wave-
lengths of light. The color satu-
ration perceived is less than that
in the gingival one third.

Figure 13. In the incisal one

third there is hi h translucency
at the incisal e 4 e and proximal
areas, because t ere IS little, tf
any, dentin underlying the enam-
el. The enamel is approximate1
0.9-1.2 mm thick at the incisa?
height of the dentin. Internal
dentin mammelons appear as
diffused feather-like structures,
which may appear to be high in
value, with hues ranging from
pink to yelloworange. The
opalescent effect and halo are
also apparent.

Figure 14. The maxillary central incisors

viewed in total. In the middle one third
Hunter-Schre er bands become more
apparent as t i e teeth dehydrate.
 WINTFR

Figure 15. Natural teeth fluoresce predominately white with a slight blue tone.

The value (brightness) of a tooth is Perception of tooth color is a com- ultraviolet light, fluoresce predomi-
influenced by the chroma level, plex phenomenon complicated by nately white, with a slight blue
thickness and character of the the lack of correlation between the tone. Dentin fluoresces much more
enamel, surface texture, and surface hue, chroma, and value of natural intensely than enamel. As the chro-
luster. A change in value is accom- teeth and available shade guides, as ma of the dentin increases, the fluo-
panied by slight shifts in hue or reported by Clark (1931), Sproull rescence decreases. Horsely reported
chroma perceptions. (1973), Lemire and Burke (1975), that the compounds causing fluores-
and Miller (1981).’-” cence in natural teeth are mostly
The perceived color of a tooth organic in nature, possibly proteins,
results from the combination of LIGHT EFFECTS as well as the inorganic matrix
light directly reflected from the Fluorescence (Figure 15).’”15
tooth surface combined with the Fluorescence is a form of photo-
light that has entered the tooth and luminescence, whereby radiant Natural and many artificial light
internally has been refracted, and energy below the visible spectrum sources have ultraviolet components.
then reflected off the dentin back t o (ultraviolet) is absorbed by an When exposed to these light sources,
the viewer. The dentin is the prime object, which then emits the light the fluorescence of natural teeth
source of color and value. It deter- energy within the visible spectrum.l* gives them the quality of “vitality.”
mines the amount of light reflected Natural teeth, when exposed to
back through the enamel. The
enamel modifies the reflected light
by its thickness and translucency
(Figures 11 to 14).

V O L U M E i. N U M B E R 3 109
 J O U R N A L OI. t S T H E T l C D E N T I S T R Y

Visualizing the Natural Dentition

Figure 16. The opalescent Opalescence

effect is apparent in the
incisal edge. A bluish Opalescence is the light effect that
translucency is seen in occurs when light disperses and
incidental light.
refracts on microcrystals or col-
loidal inclusions. This causes short
wavelengths (blue) to be scattered
and longer wavelengths (red/orange)
to be transmitted.

Enamel is a translucent, almost

transparent, colorless entity. The
rods within the enamel and the
spaces between them cause the light
to be scattered. Opalescence will
give a tooth a bluish translucency,
particularly at the incisal edge,
when viewed from the labial aspect.
Figure 17. The transmit- The transmitted light will give the
ted light gives the incisal tooth a reddish/orange appearance,
a
edge a reddisidoran e
appearance. The lig t
source is natural daylight.
when viewed from inside the mouth.
That is why the enamel appears
bluish at the incisal edge even though
it is colorless. There are no blue
particles in the enamel. It is strictly
a light effect (Figures 16 to 19).

Enamel can appear fairly white

over the remainder of the tooth due
to the following possible factors:

1. An increased scattering of all

wavelengths of light, short and
long, will make enamel appear
white or pale blue.
2. The difference in optical density
between enamel and dentin
reflects more light off the dentin
surface. Light reflection off
dentin in young teeth, in particu-
lar, is more intense because the
dentin is high in value and lack-
ing color saturation.

110 M A Y i l U N t 1991
 WINTER

Figures 18 and 19. The opalescent effect is most prominent in the lateral incisor. The incisal halo creates contrast between the
oral cavity and the bluish translucency. The cuspid generally does not exhibit much opalescence.

3 . When teeth dehydrate, air The light entering the incisal edge is
replaces the water between the reflected toward the inside of the Little or
no light
enamel rods, changing the refrac- tooth. Little or no light is transmit- transmission
Incident light creates the
tive index and making the enamel ted through in this case, because of
appear opaque white. the angle of the lingual surface at
4. The strong fluorescent quality of the incisal edge (Figure 20). incident light reflection
dentin increases the amount of
light being emitted from it. The yellow-orange color often
apparent in this halo is due to light
Therefore, even though the enamel reflecting from the dentin, off the
is highly translucent and is colorless, lingual surface of the incisal edge,
it can appear bluish toward the and through the labial incisal edge.
incisal edge (no dentin underlying),
because of the opalescent effect. The width of the halo varies with
The remainder of the tooth appears the angle of the incisal edge. The
white. halo creates contrast between the Figure 20. The incisal halo ap ears
shadowed (dark) oral cavity and R
to be a slightly opacified edge ecause
there is little or no light transmission.
Halo the bluish translucency in the The reflected yellow-orange color
incisal edge. Without it, the incisal from the dentin often gives the halo a
The appearance of a slightly opaci- slight coloration.
fied border at the incisal edge of the edge has less definition and blends
tooth, framing the translucency, is more easily into the background.
attributable to near total light
reflection.16 It is called the halo.

VOLUME 5, NUMBER 3 111

 O F EFTHr11< D f i N T I S T R Y

Visualizing the Natural Dentition

Figures 21 and 22. These young teeth exhibit the rod ends in the gingival one third. This creates a very rough surface
and increased diffuse reflection. The lateral incisor and cuspid generally have less surface texture. Hunter-Schreger
bands are apparent in all the teeth.

SPECIAL CONSIDERATIONS Figures 23 and 24.

Young teeth exhibiting
Surface Texture and Luster perikymata. They are
The surface topography of teeth moreapparent in the lat-
era1 incisor, when viewed
alters the quantity and quality of slightly from the incisal.
light reflected directly off them, as
well as that which penetrates the
surface, The topography and luster
of a tooth affects perceived hue,
chroma, and value.

The luster (gloss) on the surface is

related to the relative amounts of
specular and diffuse ref1ecti0n.l~A
smooth surface, like a mirror, will
exhibit specular (regular) reflection
without diffusion. An irregular or
rough surface will exhibit diffuse
reflection, scattering the light in
many directions.

The surface of young teeth is

covered with rod ends and periky-
mata. Perikymata are transverse,
wave-like grooves believed to be the
external manifestations of the striae

112 MAYIJUNI: I V Y 3
 W I N T F I?

of Retzius.18 They are parallel to Figures 25 and 26. The

central incisors have a
each other and to the cemento- stippled surface texture.
enamel junction. These incremental The cuspid generally
exhibits a smoother sur-
lines are the SUCceSSiVe apposition face, higher chroma, and
of layers of enamel during crown PoSsib1~a different hue
than the central incisors.
formation. They represent varia- All the teeth have a high
tions in structure and mineraliza- luster.
tion, either hypomineralized or
hypermineralized.

Very fine white bands may be

apparent in the tooth. These become
more distinguishable as the tooth
dehydrates. The change in the
direction of the enamel rods is
responsible for the appearance of
these Hunter-Schreger bands
(Figures 21 to 26).18

As teeth age, the surface wears and

the perikymata gradually disappear.
This first occurs on the heights of
contour; shallow or concave areas
often retain a rough or stippled sur-
face. Eventually, all the surface tex-
ture may be lost. The tooth surface
will be smooth with either a high or
dull luster (Figures 27 and 28). Figures 27 and 2s. These teeth are relatively smooth with a few surface cracks in
the enamel. The teeth have a low or dull luster. This 28-year-old female patient
exhibits the classic interdental contacts, embrasures, and gingival architecture.
 l O U R N A l OF ESTIIETIC O P N T I S T R Y

Visualizing the Natural Dentition

Figures 29 and 30. An example of

an older dentition. Gingival reces-
sion exposes the roots of the teeth.
Less translucency is apparent in the
incisal one third because the enamel
is worn to expose the dentin. The
color of the reparative dentin will
influence the perceived color in the
incisal one third, when viewed from
the labial. Cracks are the outer
edges of lamellae and are apparent
on all teeth, of all a es, and on all
surfaces. Most crac s a pear to be
% /
colorless, but some pic up stain
and appear a variety of colors.

114 MAYIJUNF. I Y Y ~
 I O L J R N A L OF F S T H E T I C D E N T I S T R Y

The gingival embrasure is deter- REFERENCES 14. McDevitt CA, ArmstronE WG. InvestiEa-
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Balekjian AY. Phosphorescence of enamel
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ceramics. Vol. 11. Carol Stream, IL: 1967; 461368.
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esthetics. Chester, PA: Schiffer, 1988.
17. Dinsdale A, Malkin F. The measurement
4. Ernst B. The eye beguiled. Cologne, of gloss and special reference to ceramic
Germany: Taschen, 1986. materials. Trans Br Ceram Sac 1955; 43:94
The labial and lingual embrasures
are viewed from the incisal edge 5. Clark BE. The Clark tooth color system. 18. Orban’s oral histology and embryology.
Parts I and 11. Dent Mag Oral Top 1933; 10th Ed. St. Louis, MO: Mosby, 1986.
and are simply formed by the inter- 50:139.
19. Frush JP. Fisher RD. How dentogenic
dental contact and the transitional 6. Munsell color Co. The Munsell book of restorations interpret the sex factor. J
line angle. The form of the proxi- color. Baltimore, MD: Munsell Color do. Prosthet Dent 1956; 6160.
Val. I. 1929, Vol. 11, 1943.
mal aspect of the teeth dictates the 20. Abrams L. Consensnal study on dental
7. Clark BE. A n analysis of tooth color. J sexual dimorphism. Presented at the
contact area and establishes the A m Dent Assoc 1931; 18:2093-2103. Annual Meeting of the American Academ)
of Esthetic Dentistry, San Francisco,
3-dimensional appearance of the August 1981. Personal communication
8. Sproull RC. Color matching in dentistry.
tooth arrangement. Part 1.J Prosthet Dent 1973; 29:416424. with Leonard Abrams.

9. Sproull RC. Color matching in dentistry. 2 I . Stein RS, Kuwata M. A dentist and a den-
CONCLUSION Part 11.J Prosthet Dent 1973; 29556-566. tal technologist analyze current ceramo-
metal procedures. Dent Clin North Am
We must learn to form mental visu- 10. Lemine PA, Burk AAS. Color in dentistry. 1977; 21:729.
Hartford: J.M. Ney Go., 1975.
al images of natural teeth if we are 22. Weinberg LA. Esthetics and the gingiva in
11. Miller LL. Perspectives in dental ceramics. full coverage. J Prosthet Dent 1960; 10:
to successfully communicate what Carol Stream, IL: Quintessence, 1988. 737.
we see. We have focused our atten- 23. Shelby DS. Anterior restoration, fixed
12. Wilson HJ. Restorative materials and
tion on the physical characteristics ultraviolet radiation. Br Dent J 1969; bridgework and esthetics. Springfield, IL:
126345. Charles C. Thomas. 1976.
of the maxillary anterior teeth. It is
the challenge of the dental team t o 13. Horsley HJ. Isolation of fluorescent ma-
terials present in calcified tissue. J Dent
use their creativity in providing a Res 1967; 4 6 1 06. Reprint requests: Robert Winter, D.D.S.,
360 San Miguel Drive, Suite 204, Newport
beautiful esthetic restoration that Beach, CA 92660
attempts t o reproduce nature O1993 Decker Periodicals Inc.
(Figure 31).

116 MAYiJUNF, 1993

 WINTER

VOLUME s. N U M B E R 3 117
 Figure 1. Single tooth
replacement abutment
seated on osseointegrated
implant.

Figure 2. Labial view of

completed implant crown.

118 M A Y I I U N E 1993