Lasserre Fusion Leseprobe

Jean-François Lasserre
Art and Nature

in Ceramic Restorations
Art and Nature

F U N D A M E N TA L S
Born in 1960 in Bordeaux, Jean-François Lasserre, PhD., DDS, graduated from the
University of Bordeaux 2 in 1983. Following his DEA in anthropology, in 1994 he became
an associate professor in the Prosthetic department of the Dental faculty of the University
of Bordeaux. In 2003 he defended his University Doctoral Thesis on the topic of dental
wear in modern and historical population, developing and introducing a chewing simulator
device to study the in vitro wear of novel ceramic and composite dental materials.
For more than 15 years, he has been teaching Occlusion, to later dedicate himself
to research and teaching of dental esthetics and ceramic restorations. He has authored
numerous articles in national and international magazines and has frequently presented
lectures in France and abroad, dedicated to esthetic ceramic restorations. Jean-François
Lasserre practices at the University Dental Hospital Center but also owns a private clinic
in Bordeaux specializing in dental esthetics, implantology, and prosthetics. He is a founder
of the research and educational group for dental esthetics named “Symbiose.”
For many years Jean-François Lasserre has been a Vice Dean of the Dental Faculty,
in charge of the international relations, and has been granted the Honoris Causa as well
as the title of Associate Professor by the University of Medicine and Pharmacy (UMP) in
Hô-Chi-Minh-Ville in Vietnam. He is also Associate Professor at the University of Medicine
and Pharmacy “Luliu Hatieganu” in Cluj-Napoca in Romania.
IV
V
FUNDAMENTALS
1
In search of
the lost smile
1
4
Form and
function
87
7
Mimetics
and bionics
215
VI
2 3
How to Face and
become asymmetry
an artist in 51
dentistry
31
5 6
From light Biological
to color integration
129 195
8 9
Wear The heart
and aging of ceramic
249 279
VII
Art and Nature CHAPTER
FACE AND ASYMMETRY

3
51
in Ceramic Restorations Jean-François Lasserre, Jean-Philippe Pia, Dimitar Filtchev and Gilles Laborde
EVOLUTION OF THE ESTHETIC CONCEPTS . . . . . . . . . . . . 52

FUNDAMENTALS ATTRACTIVE FACIAL FEATURES . . . . . . . . . . . . . . . . . . . 53
Prioritizing the smile 53
Clinical example 55
CHAPTER 1 ANTHROPOMETRIC AND MORPHOPSYCHOLOGICAL

RULES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
IN SEARCH OF THE LOST SMILE 1 Anthropometry 56
Hélène Lafargue, Jean-François Lasserre, Kamel Gana and Bruno Quintard Morphopsychology 58
BODY IMAGE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Facial references and Ditramax 59
Body image development 2 Virtual smile design using VisagiSmile 60
The human smile 9 NEW DATA FROM NEUROSCIENCES . . . . . . . . . . . . . . . . 65
The onset of body image disorder 12 The self-recognition 65
TYPES OF PATIENTS . . . . . . . . . . . . . . . . . . . . . . . . . . 15 The self-recognition and the memorization of faces 66
Normality and psychopathology 15 The cerebral lateralization 68
Body dissatisfaction and body image disorders 17 The asymmetry of the face 70
The asymmetry of the smile 72
CONSEQUENCES ON TREATMENTS . . . . . . . . . . . . . . . . 20
THE ARTISTIC APPROACH . . . . . . . . . . . . . . . . . . . . . . 75
Consensual recommendations 20
Observation of nature 75
REFER, DEFER, OR TREAT? . . . . . . . . . . . . . . . . . . . . . . . 24
The global approach to composition 78
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Asymmetry and equilibrium 80
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83
CHAPTER 2
HOW TO BECOME AN ARTIST IN DENTISTRY
Luca Dalloca
31 CHAPTER 4
FORM AND FUNCTION 87
ARTIST, CRAFTSMAN, OR CREATOR? . . . . . . . . . . . . . . . . 32 Jean-François Lasserre and Diana Dudea
CREATE A PERSONALIZED SMILE . . . . . . . . . . . . . . . . . . 33 SEEING AND UNDERSTANDING SHAPE . . . . . . . . . . . . . . 88
FREEING THE ARTIST WITHIN US . . . . . . . . . . . . . . . . . . 35 Visual perception 88
We all have creative potential 35 The hypothesis of the unique light source 88
Creativity and rationality 37 The artistic approach to shape 89
Cerebral creativity and well-being 37 Attention and visual organization 90
Phases of the creative process 37 ANALYSIS OF NATURAL TEETH . . . . . . . . . . . . . . . . . . . 95
MECHANISMS OF PERCEPTION . . . . . . . . . . . . . . . . . . . 38 The trilogy of shape 95
From vision to perception 38 Details and hyper-morphology 100
From perception to psychology 38 Arrangement of the maxillary anterior dental arch 104
Order, disorder, and balance 40 Esthetic canons 109
ART AND DENTISTRY . . . . . . . . . . . . . . . . . . . . . . . . . . 41 FORM AND FUNCTION . . . . . . . . . . . . . . . . . . . . . . . 112
The determinants of perceptual weight 41 An indissoluble natural alliance 112
Perception and simplification 46 Human teeth 115
What is an artistic approach? 47 The palatal surfaces of the maxillary central incisors 116
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
VIII
CHAPTER 5 BIONICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Harnessing the power of nature for technology
229
229
From natural teeth to bonded ceramic
FROM LIGHT TO COLOR 129
Jean-François Lasserre, Diana Dudea and Jean-Marc Kubler restorations (BCRs) 230
The use of BCRs to treat amelogenesis imperfecta 232
A COMPLEX DIMENSION . . . . . . . . . . . . . . . . . . . . . . 130
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 246
LIGHT AND VISION OF COLORS . . . . . . . . . . . . . . . . . 131
Physical dimension 131
Physiological dimension
Psychological dimension
136
138
CHAPTER 8
Artistic approach and reality of colored effects 139 WEAR AND AGING 249
COLOR OF THE NATURAL TEETH . . . . . . . . . . . . . . . . . 150 Jean-François Lasserre
The three fundamental dimensions 150 AN INESCAPABLE PROCESS . . . . . . . . . . . . . . . . . . . . 250
The spatial representations of colors 151 TRIBOLOGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
The seven complementary dimensions 153 Coefficient of friction 251
PROFESSIONAL LIGHTING . . . . . . . . . . . . . . . . . . . . . 160 Abrasion 252
Natural and artificial light 160 Erosion 252
Adverse effects of the blue light emitted by LEDs 162 Tribochemical wear 254
Lighting in the dental office 164 Adhesive wear 254
COLOR DETERMINATION AND COMMUNICATION . . . . . 167 Fatigue wear 254
Methods of determination 167 AGE AND DETERIORATION OF TEETH . . . . . . . . . . . . . . 255
Color matching with the shade guides 167 Tooth wear 255
Assisted visual color matching 170 Color and texture 261
Bias that interferes with the color determination 177 Periodontal recessions 263
Tips and tricks to optimize visual color matching 182 AGE AND ALTERATION OF SMILE . . . . . . . . . . . . . . . . . 265
Protocols for communication with the laboratory 184 Effects of time and compensating mechanisms 265
Clinical example 189 Prosthodontic restorations on a weakened periodontium 267
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 AGE AND ALTERATION OF THE FACE . . . . . . . . . . . . . . 269
CLINICAL EXAMPLES . . . . . . . . . . . . . . . . . . . . . . . . . 271
CHAPTER 6 Severe wear

Periodontal weakening
271
273
BIOLOGICAL INTEGRATION 195 Enamel deterioration 274
Jean-François Lasserre REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
BIOLOGICAL INTEGRATION FACTORS . . . . . . . . . . . . . . 196
THE DENTOGINGIVAL JUNCTION . . . . . . . . . . . . . . . . 197
THE EMERGENCE PROFILE . . . . . . . . . . . . . . . . . . . . . 199
CHAPTER 9
Vertical over-contour and sub-contour 200 THE HEART OF CERAMIC 279
Horizontal over-contour and sub-contour 205 Jean-François Lasserre and Ivan Chakalov
THE AXIAL CONTOUR . . . . . . . . . . . . . . . . . . . . . . . . 208 THE ART OF FIRE . . . . . . . . . . . . . . . . . . . . . . . . . . . 280
Harmony of form and function 208 COMPOSITION AND CLASSIFICATION . . . . . . . . . . . . . . 283
Abrams "gull in flight" profile 209 The glass ceramics 283
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 213 Polycrystalline ceramics 287
The hybrid ceramics 289
CHAPTER 7 BIOMECHANICAL PROPERTIES . . . . . . . . . . . . . . . . . . 293

The brittleness of the ceramics 293
Hardness and abrasiveness 296
MIMETICS AND BIONICS 215
Jean-François Lasserre OPTICAL PROPERTIES . . . . . . . . . . . . . . . . . . . . . . . . 299
Fluorescence 300
TOWARD NEW RESTORATIVE CONCEPTS . . . . . . . . . . . . 216
Opalescence 303
MIMETICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 217 Color 304
Biomimetic clues 217 Opacity and translucency 307
The maxillary central incisor 221
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 314
IX
Hélène Lafargue Luca Dalloca Jean-Philippe Pia Dimitar Filchev
Gilles Laborde Diana Dudea Jean-Marc Kubler Ivan Chakalov
Hélène Lafargue (France) Jean-Phillipe Pia (France) Gilles Laborde (France). Jean-Marc Kubler (France)
Graduated in the Dental Faculty Graduated in dental surgery at Graduated in Dental Surgery at Has a Master's degree in
of the University of Bordeaux 2. the University of Bordeaux 2. He the University of Aix-Marseille. economic analysis at the
She is a winner of the National is a former assistant professor in An Associate Professor in the University of Strasbourg 1 (Louis
Academy of Dental Medicine the prosthetic department in both Prosthodontic Department in the Pasteur). He is the founder of
Award and formerly assistant hospital center and University of University of Marseille, Gilles is a W&H France and the brand Lisa;
professor at the Department Bordeaux. He holds a DU degree founding member of the Bioteam Degree K and other associated
of Prosthetic Center and at the in esthetics of the smile from Marseille. He owns a private brands. He is an expert in AFNOR
University of Bordeaux. She holds Strastourg. A member of the practice in Marseille. and ISO for lighting in oral
a DU-diploma in pediatric, health research group in dental esthetics medicine.
and society; a Master 2 in research “Symbiose,” he runs a private Diana Dudea (Romania)
in health psychology. A founding practice in Bordeaux. Graduated in Dental Medicine Ivan Chakalov (Bulgaria)
member of the research group in at the University of Medicine Is a doctor in Dental Medicine,
esthetic dentistry “Symbiose,” she Dimitar Filchev (Bulgaria) and Pharmacy of Cluj-Napoca and graduated in the Medical
has her own private practice in Is a doctor in Dental Surgery in (Romania) and is a professor at University in Sofia (Bulgaria). He is
Bordeaux. the University of Medicine in the Faculty of Dental Medicine, also ex-Assistant-Professor in Chief
Sofia (Bulgaria) and Associate Department of Propedeutic at the department of Prosthetic
Luca Dalloca (Italy) professor in the department of of Prosthetic Dentistry and Dentistry and Biomaterials at the
Became a Doctor in Dental Prosthetic dentistry of the Faculty Biomaterials. He is also Vice- Dental Faculty- Sofia; a co-founder
Medicine in the University of of Dental Medicine, Sofia. He Dean of the Dental Faculty of the Sofia Dental Meeting
Pavia (Italy), and specialized in the is a founder of the Sofia Dental in Cluj-Napoca, and heads up Association (SDM); and general
Tufts University in Boston (USA). Meeting association (SDM) and the research team as “Adjunct secretary of the “Association
He studied advanced prosthetic a co-founder of the center of Investigator” of the Houston des dentistes francophones”
dentistry at UCLA (USA). He dental implantology of the Medical center of biomaterials and in Bulgaria. He owns a private
holds certificates by the Dental University Sofia, and an Honorable biomimetic (Dental Branch) at practice in Sofia.
Technology Institute Orange member of Style Italiano Group Texas University (USA). In addition,
County California and The Dental , Bulgarian Society of Esthetic he is: President of the Romanian
Technologia Casati in Milan, and Dentistry and an affiliate member Society of Esthetic Dentistry
is a founding member of the of EAED. He is an instructor at the (SSER) and a member of the
European Society of Cosmetic Zimmer Institute (Switzerland) and following: the IADR; of the Society
Dentistry (ESCD) and a member of owns a private practice in Sofia. of Color and Appearance in
the Oral Design group. He runs a Dentistry (SXAD); of the European
private practice in Milan. Society of Cosmetic Dentstry
(ESCD); and of the Romanian
Society of Biomaterials (SBR). He
owns a private practice in Cluj-
Napoca.
X
Jean-Marc Chevallier Roberto Iafrate Hélène and Didier Crescenzo Stéphane Le Goff
Jean-Pierre Attal Camelia Alb Gil Tirlet Alain Brabant
Jean-Marc Chevallier (France) Didier Crescenzo (France) Jean-Pierre Attal (France) Gil Tirlet (France)
Is a dental lab technician, and ex- Is a dental technician. Is a doctor in Dental Surgery, Is a doctor in Dental Surgery at
demonstrator for Vita company Has a professional competence graduated at the René Descartes the University Paris Descartes;
and GC France. He currently certificate in prosthetics as well University (Paris), and Associate an Associate Professor in
teaches laboratory technology as the CQP in orthodontics. Professor in Biomaterials at the Prosthetic Dentistry at the
at the IPSO school in Aix-en- Member of the Editorial board Dental Faculty at the University Paris Descartes University.
Provence, and is a founding of QDRP magazine, is co- Paris Descartes. He practices He practices at the hospital
member of the research group in responsible for the lab technician at the Charles Foix hospital Charles Foix at Ivry-sur-Seine,
esthetic dentistry “Symbiose.” section of BMC magazine and center in Ivry-sur-Seine, and is responsible for biomimetic
of the prosthetic laboratory also: Director of the Unit for consultation. He is also a
Roberto Iafrate (Italy) section in ID magazine. They Innovative Biomaterial and member of the Bio-Emulation
Is a dental lab technician, and a are a founding member of the interface research (URB2i-EA Group and founder of the
graduate from the E.Medi Institute continuous education society 4462); President of the Raphael Formation and the
in Frosionone (Italy). He studied “Esthetic Oral Formation” and Francophone Society of Dental Bioteam Paris. He runs a private
under Michael Kempton (London), co-creator of the Visual Esthetic Biomaterial (SFBD); Editor in practice in Paris.
member of the Oral Design group. Project (VEP) technique. Chief of BMC magazine; founder
Roberto is a founding member, in of the Raphael Formation group, Alain Brabant (Belgium)
charge of the scientific program Stéphane Le Goff (France) and runs a private practice in A doctor in Dental Surgery,
in dental lab technology, for the Is a technician at the Unit of Paris. Alain graduated from the
IESCD. Innovative Biomaterial and Catholic University in Leuven
interface research (URB2i-EA Camelia Alb (Romania) (UCL). He is Clinic Professor
Hélène Crescenzo (France) 4462), dental faculty of the A doctor of Dental Surgery, at UCL responsible for
Is a dental technician, Esthetic University Paris Descartes. Camelia graduated from the Fixed Prosthodontics and
Oral laboratory. She is a University of Medicine and Implantology. He is also director
prizewinner of the professional Pharmacy in Cluj-Napoca of the prosthetic clinic at the St.
competence award in (Romania). She is also: ex- Luc of Brussel’s University clinic.
prosthetics by the CQP award associate professor in the
in orthodontics, and a member Faculty of dental medicine at
of the editorial board of QDRP the University of Medicine and
magazine; co-responsible for the Pharmacy “Luliu Hatieganu”,
lab technician division for BMC Department of Dental
magazine; and the prosthetic Propaedeutic; a specialist in
laboratory section of ID magazine. Orthodontics; and a member
She is a founding member of the of the Romanian Society of
continuous education society Esthetic dentistry (SSER), the
“Esthetic Oral Formation” and International Association of
co-creator of the Visual Esthetic Dental Research (IADR), and the
Project (VEP) technique. European Society of Cosmetic
Dentistry (ESCD).
XI
DEDICATION
To my wife Christine, for her patience, her encouragement, and her unconditional support.
In memoriam to my father, Guy, and his mother, Simone, both teachers, who have trans-
mitted to me their passion for hard work and travel.
To my daughters, Camille, Romane, and Solène, for developing their talents.
ACKNOWLEDGMENTS
To Christian Knellesen – without his contribution this book would not exist. Thank you
for your precious guidelines and all the contribution until the finalization of the project.
To Stefan Koubi, for his advice and his friendship.
To Huynh Anh Lan, ex-Vice-Dean of the Ho Chi Minh University, in charge of the Interna-
tional Relations, for the proverbs and poems in the beginning of the chapters.
To the laboratory technicians that I had the chance to collaborate and learn from: Marc-An-
dré Leriche, Jean-Marc Chevallier, Olivier Boulé, Hélène and Didier Crescenzo.
To Philippe Bachour and Benoit Cros for their infographic support.
To Stéphane Hette for his support for the macrophotography.
To my students and interns: Marlène Dezert, Axel Large, Imane Ramdani, Mathilde Jacque-
mont, and Yannis Génique for their support with the editing.
XII
FOREWORD
J ohann Wolfgang Goethe once said: “There is no such thing as patriotic art or patriotic
science. Both belong, like all good things, to the whole world, and can be fostered only
by untrammeled intercourse among all contemporaries, continually bearing in mind
what we have inherited from the past.”
For this reason, it is a great pleasure for me to write this foreword. It is gratifying to
know that everyday professionals of excellence, as Dr. Jean Lasserre, worry about the qual-
ity of their work and seek through their publications to share their knowledge. Contempo-
raries who, in the universe of the knowledge, have crossed a path close to mine, which is
based on a new vision of beauty that uses the nature to obtain a result of superior quality.
Dentistry is renewed every day, creating new techniques, treatments, and ways of seeing
the world. Now, it ceases to be just mathematical calculations and art. The contemporary
professional seeks the most perfect techniques for all esthetic requirements, achieving the
patient’s complete satisfaction. Now, the artificial is no longer desired. What is expected
is a rehabilitation that promotes the perfect integration of the patient structures and the
restorations, copying nature into its shape, texture, and function.
This title, The Fusion of Art and Art and Nature Within Ceramic Restorations depicts,
with illustrations, clinical cases of units and extensions rehabilitation, in which a minimally
invasive method is used to restore dental elements.
The philosophy described in the following pages pursues the art through the nature
without leaving aside the science. Prosthetic treatments that result in excellence and char-
acteristics that escape artificiality.
Dr. Jean François Lasserre and collaborators demonstrate techniques to increase
the vertical dimension and ceramic stratification with a focus on mimicking the natural
esthetics.
In addition, it covers concepts such as color, shape, asymmetries, and facial analysis. A
complete book that also describes the action of psychological and physical factors on the
oral structures, such as aging itself. The concepts discussed in this book are extremely use-
ful to oral health professionals. Each page contributes as a reference for a new dentistry
based on nature and enriches the reader’s knowledge.
Paulo Kano
XIII
PREFACE BY ALAIN PERCEVAL
I
t is an immense pleasure and a great honor for me to produce the preface for the
book written by my friend, Jean-François Lasserre. An exceptional clinical practitioner,
passionate about painting, butterflies and Asia – in fact, passionate about everything –
Jean-François is a true artist. So often over-used to describe somebody who demonstrates
brilliance in their work, in this case the term “artist” encapsulates the man perfectly. But
it must be acknowledged that it is sometimes difficult for an artist to transmit his talent
and know-how to others.
There are many talented practitioners whose meticulous and precise work is based
on solid scientific knowledge and who are capable of applying their talents to clinical
practice. There are also many excellent teachers who are able to successfully transmit
their knowledge in a precise and instructive manner. However, not many people manage
to combine the two qualities. Jean-François is one of those people. This book is a labor
of love, completed with the same level of perfectionism he puts into everything he does.
It is the fruit of lengthy, intensive preparatory work to collate and organize information
and clinical case histories gathered over a period of years. These are not “Sunday best
cases” picked out especially for the book, but examples taken from the everyday life of a
dental practice. Jean- François has surrounded himself with the very best people, with the
skills required to support the various chapters. Whether ceramic experts, clinicians, dental
technicians, or researchers, they have all contributed their perspectives, complementing
Jean-François’ own expertise.
As you will see, FUSION is hinged around three main themes: the fundamentals, the
laboratory and clinical practice. A learning philosophy based initially on seeing and know-
ing, understanding, and only then reproducing. Seeing and knowing are the essential foun-
dations underpinning any understanding and it is these fundamentals that are covered in
the first nine chapters of the book. The merry-go-round depicted on the cover of this first
volume gives it an additional symbolic dimension, reminding us that every treatment is
an eternal new beginning in which these same esthetic fundamentals need to be kept in
mind.
I think it was Pascal Magne who said: “the three most important things when carrying
out esthetic restorations are: form, form ... and form.” So it comes as no surprise that Jean-
François Lasserre has begun the fundamentals in his book with an analysis of form, via an
exhaustive exploration of the understanding that each dentist and each dental technician
has of the morphology of human teeth, so important to the esthetic and functional qual-
ity of our restorations. Observation of natural teeth teaches us the function and harmony
of the forms integral to the periodontium, the smile and the face, more generally. This
observation will be taken to its logical conclusion in a study conducted with Jean-Pierre
ABal on mapping of enamel thicknesses in the anterior sector, aimed at examining cera-
mic bonding, and minimally invasive dentistry practices more broadly, on the basis of the
thicknesses available before preparation.
XIV
“Drawing inspiration from nature rather than destroying it” is therefore the motto for
today’s dentistry, which, like many other medical specialties, is becoming less invasive
and less destructive to remaining issue. Mimicry and bionics underpin these new restora-
tive concepts, based on the study of the biological and biomechanical systems of living
things to discover models that can then be applied to technical procedures. But materials
and new concepts are not everything. To successfully accomplish any procedure, a fully
mastered and standardized technique is required, that is well understood and repetitive.
Ceramic bonding – something that barely 25 years ago was a bold treatment offered by
just a few exceptional practitioners – is now becoming a predictive technique, confirmed
by numerous scientific data, as amply demonstrated in the chapter dedicated to this den-
tistry technique. The chapter is without any doubt the best I have ever read on the topic,
thanks to its clear and precise detailing of these constantly evolving protocols. In this
book, the author has achieved the feat of teaching us a working protocol, in an explicit
and structured way. Because, as is the case for any practitioner, the challenge is obviously
to make sure the treatment is a success, not just once but for every single patient, since
technical reproducibility is the key to success in our profession.
To round off, this book will delight all those who are interested in and wish to fully mas-
ter a modern approach to ceramics because each theme is covered in depth and described
in a rigorous, clinical, and instructive manner. That is important not only for practitioners
starting out in their careers but also for experienced ones seeking to further improve
their clinical protocols. For all these reasons, I would like to thank and congratulate Jean-
François once again for having produced this magnificent book and for having passed on
his wealth of experience and knowledge to dental professionals.
Alain Perceval
XV
FUSION - Fundamentals
Fig 2-1 Master glassmaker from Murano, Venice

(photographer: Diyana Dimitrova).
2
How to become an artist in dentistry • 2
How to
become an artist
in dentistry
N owadays, the dental surgeon and their technician must be creative
and artistic, needing both technical expertise and creative genius.
In other words, rationality and creativity must coexist in our abilities.

Luca Dalloca
Academic knowledge, skills acquired through clinical practice, and
continuous training on new technologies, offer the dental team all the
tools for good technical expertise, the one that comes under the rational
control of our brain soliciting the left hemisphere or “left brain.”
On the other hand, new technologies are standardizing dental work,
guided implant surgery, computer-aided design. Manufacturing
(CAD/CAM) prosthesis or Digital Smile Design (DSD)1 previews
perfectly illustrate this standardized and mechanistic approach
to the smile.
What more can we look for when we have all the knowledge and
technological means necessary for our profession?
31
Artist, craftsman, or creator?

The term artist defines anyone pursuing an artistic practice. It includes the term “artist”
in literature from the 14th to the 18th century, along with the terms “author” and “crea-
tor.” In its earliest origin, the concept of author or of creator encompasses the sense of
technical and artisanal expert capable of creating a “Chef d’OEuvre” in its specialty. This
definition prevailed until the 18th century and designated painters, sculptors, and archi-
tects. Vasari (1568), Baldinucci (1681), and Militia (1797) distinguish between the two
terminologies, reserving the term artist to the practice of Fine Arts, whereas the terms
author or creator are reserved for technical arts and crafts (Fig 2-1). The concept of the
artist evolved during the 19th century toward the romantic vision of creative genius. This
is the definition of the artist found in the Treccani encyclopedia(a).2
In dentistry, knowing the rules and protocols is not enough. Development of our artis-
tic abilities under the control of our creative brain (right hemisphere or right brain) is a
necessary complement. The human eye instantly captures the oral sphere because of
its strong involvement in verbal and non-verbal communication. Think of the effect of a
hand placed in front of the mouth when smiling (eg, in the case of a patient who has a
complex): immediately it closes the communication door, our mirror neurons are not acti-
vated and empathy is difficult. Now let’s imagine the possible consequences of a purely
rational approach, for example in a case of an esthetic prosthesis made from a preview by
a Digital Smile Design (Fig 2-2).1 As absurd as it may sound, two people of different age or
gender could have the same teeth and smile – or two friends could smile at each other and
discover that the other one has the same teeth, which certainly would create discomfort.
The smile cannot be industrially manufactured, otherwise it would be symmetrical and
stereotyped (Fig 2-2). It is indeed impossible to find two perfectly identical natural smiles.
(a) Treccani is the name under which we commonly call the “Enciclopedia Italiana di scienze, lettere ed arti,” which was first
published in 1925.
32
(a) Natural smile. (b) Digital smile made by duplicating in (c) Editing a digital face by combining two
mirror the right hemi-smile instead of the right hemi-faces in mirror. The smile and
left hemi-smile, which gives a perfectly the face are then symmetrical.
symmetrical effect.
Fig 2-2 From natural to stereotypical smile.

Compared to the asymmetrical faces (a) and (b), the symmetrical face (c) appears inexpressive and unbalanced. Why then would a symmetrical
smile (b) and (c) be more harmonious?
Create a personalized smile

It is necessary to establish a dialogue between the rational and the analytical part of
our brain and its creative and artistic part. We must train ourselves for this cerebral
complementarity. Arnheim wrote: “We must improve our knowledge and our feelings
through the practice of art and the study of art history literature, more precisely by
understanding the psychology of perception.”3 If we think about a mouth, we visualize
the lips in their shape and thickness, then the size of the smile with the teeth
and gums more or less visible. The layout of the teeth has an infinite number of
combinations between the lines’ orientation, shapes, and colors, which make
each mouth unique, every composition personal and every smile truly natural.
“To hear a hundred
The teeth, like the rest of the body, have a history and a life of their own. They times is not worth seeing once.”
belong to a person singular in his way of being. For Arnheim: “The artist is an Writings from Confucius 551–479 BC
author who has been able to develop his artistic sensitivity.”3,4 An artistic dental
surgeon is one who, when planning an esthetic restoration, is able to take into account
the person he is treating as a whole, to study the composition of the smile in order to
create a totally personal and very close to natural work of art (Fig 2-3).
33
(a, b) The initial state shows a disharmony of shape and color of

the central incisors in the smile and the patient’s face.
a
(c, d, e) You can appreciate the difference after the restoration

in two feldspathic veneers on 11 and 21. They embellish the smile
but also illuminate the patient’s entire face, although they have
d
a significant asymmetry (c).
Fig 2-3 “Natural” restorations of two central incisors.
34
Freeing the artist within us

We all have creative potential
Creativity and rationality, their combination as well as the dominance of one over the
other depend, for each of us, on the constitution of the cerebral hemispheres, and estab-
lished neural circuits. Although the right and left hemispheres appear symmetrical from
an anatomical point of view, each hemisphere has specific functions and differentiated.
Neurologists recognize the control of verbal functions, arithmetic, logical, analytical, and
temporal thinking and rational analysis in the left hemisphere. The right hemisphere
would be responsible for the synthetic, non-verbal, timeless, irrational, intuitive, spatial,
and artistic functions.
It is often mistakenly believed that artistic talent and creative sense are hereditary or
that an individual has a gift, that is, an innate predisposition for art.4 Each one of us actually
has creative potential. Artistic sense is not only linked to gifts and individual aptitudes, but
also to a socio-cultural context that values creative work and allows his constant confronta-
tion with his surroundings and society. The training of creative skills must be seen as one of
the most ambitious goals of education. Translating life into artistic terms is one of the fac-
ulties that every healthy person possesses and which should not be blocked.5 According to
Polacek6: “A child’s creative capacity is conditioned by two environments: the family and the
school. In order to develop a child’s creative abilities, we need to encourage independence.”
This may come as a surprise, but in order to become an expert practitioner or dental
technician in the field of esthetics, we must increase our artistic perception by practicing
an art.3,5 It is a misinterpretation to say that a good esthetic result depends only on a set
of well-defined rules. Although it is essential to understand a number of basic principles
and parameters, limiting our work to pre-established protocols, anthropometric meas-
urements and mathematical rules will only guide us toward a simplistic and stereotypical
smile7–10 (Fig 2-4a, b). In a healthy face and in a natural smile we never find symmetry, and
yet these faces and smiles are harmonious, attractive, and do not generate visual tension
(Fig 2-4c). The functions put in place by natural evolution obey a surprising minimalism
where nothing is wasted and everything that is present is necessary. Leonardo da Vinci
wrote: “Even if human ingenuity can lead us to inventions that lead to the same results as
natural organizations and structures, they will never be more beautiful, simpler or more
accomplished than the works of Nature, because in his invention nothing is missing and
nothing is superfluous.”11
Finally, artistic talent can be defined as an individual’s ability to see things differently
and with greater intensity, to perceive compositions as a balancing act forming a whole,
to have a better overall perception of contours, space, relationships between forms and
effects of shadow and light. It is the theory developed by Gestalt(b) which finds its perfect
(b) The “Gestalt theory” is the psychology of form (in German: Gestalt). It is one of the many currents that have paved the
way for the psychology of perception. The followers of this current no longer consider the phenomena of the psyche as a
sum of isolated elements, but as sets forming autonomous units.
35
Fig 2-4 Stereotypical vs natural smile.
(a) There is a significant improvement before and after the prosthetic treatment but the final smile is far from natural.
(b) This young woman, a fashion model, had ceramic veneers made for her while she initially had a harmonious smile. The final result, perfectly
symmetrical and made under the control of precise esthetic rules, appears artificial and lifeless (documentation: Dr. B. Lesage10).
(c) In this harmonious natural smile the asymmetry of shapes and positions is marked. However, the teeth arrangement does not create any visual
tension on the scale of the smile and the face.
application in the analysis of dental-gingival-facial composition where formal and chro-

matic interactions are capable of generating tensions and movements within the balance
of the smile.12
36
Creativity and rationality

There is a profound idiosyncrasy in accepting that artistic aspects are a fundamental com-
ponent of the treatment phase and of the design and manufacture of prostheses
in the laboratory. The dental world stubbornly seeks to reduce our profession to
its scientific and computerized aspects which, although they are unavoidable,
are totally insufficient to carry out our esthetic treatments. Dentists should “Creativity is more
have a more global approach and understanding of the patients. important than knowledge.
Knowledge is limited, creativity
embraces the world.”
Cerebral creativity and well-being Albert Einstein
Creative thinking goes hand in hand with mental and physical well-being; it could be a
viable alternative to exclude negative thoughts which are a source of psychological dis-
comfort that in the long term contribute to physical alterations and illnesses. It frees the
mind from acquired conditioning, which is particularly important in all those occasions
when psychological and mental maturity is needed to adapt to new situations. It also gives
us the possibility of using the plasticity of the brain in response to a complex event, mak-
ing use of the functional, intellectual, and intuitive pluralities that each of us is genetically
endowed with. Believing in one’s own creative abilities is healthy.
Phases of the creative process

Cognitive sciences have analyzed and documented the creative process but we are still
far from having a clear definition of it. On the other hand, it is accepted that the creative
process uses both cerebral hemispheres and is divided into five stages3 (Fig 2-5).
Primary
Saturation Incubation Illumination Checking
intuition
Right Left Right Right Left

hemisphere hemisphere hemisphere hemisphere hemisphere
Fig 2-5 The five phases of the creative process.
37
Each of these steps, under the control of one or other of the cerebral hemispheres, can
occur at different points in the process, unlike illumination, which appears suddenly as a
“flash of genius.” Primary intuition occurs spontaneously, saturation deepens knowledge,
then comes a phase of stagnation called incubation; then comes the flash of illumination,
followed by a feasibility check or checking phase. The balance between the two hemi-
spheres leads us to acquire the capacity for global perception and to have the intuition of
what is in tension and what is in balance in the analyzed form.
Mechanisms of perception
From vision to perception
It is common to believe that we see with our eyes; of course, the eyes are essential to
vision, but how many of us, perhaps the majority, despite good eyesight, see so little, in
the sense that they do not perceive what they are looking at. We could say that the eye/
brain relationship is essential, but this is not entirely true because there are people with
good eyesight and acute intelligence who, however, do not really see. What allows us to
see is visual perception. The ability to view is a normal function that most of us possess;
animals also watch and they are helped by their natural instinct to see in detail.
Perception involves education, authentic individual training, similar to that of
“Knowledge comes from a pianist student at the music conservatory working on his notes and scales for
perception.”
many years. Sight and thought are not independent.
Leonardo da Vinci
One could say “I see what I think,” which is not a simplistic play on words
but a real awareness of the eye/brain connection. If we look at a painting for the
first time, we will have a global perception more or less rich in details but never a complete
reflection of the reality of the canvas. This first pictorial impression will become a real
knowledge when, in the course of the following glances, we enter into the structure of
the painting (figures, background, dimensions of the masses, relations between the parts)
under the light of our culture and our time. We often select mentally from what we see,
what we are able to appreciate and understand, in a strongly subjective relationship to
reality. This is why each observer can see different things in the same subject. The meaning
changes if the mental attitude changes.
From perception to psychology

To understand what we see, we must also understand how we perceive it. This is the
domain of the psychology of perception.13 One of the many trends that have paved the
way for the psychology of perception is the psychology of form (in German “Gestalt”).
The Gestalt Theory14,15 seeks to prove scientifically that human and animal psychic func-
tions act according to a criterion of perception of the whole that is different from the sum
of its parts. Perception is not a mental assembly of isolated sensations; the elements are
immediately organized in our mind: in a concise and clear form. Applied to esthetic den-
tistry this means that teeth cannot be considered as isolated elements, but are part of a
38
whole integrated in the smile and its facial environment.12 It is this awareness of percep-
tion that will allow the practitioner to progress in the art of composition.
According to Gestalt14, 15 our way of observing can be divided into four phases:
1. Geometric objective visual perception
We first see the teeth without analyzing their structure, considering them only
from the intuitive geometrical point of view; we perceive each tooth with a precise
physiognomy.
2. Psychosensory and psychoaffective perception
Each of us sees teeth from a different point of view and with different emotions
and states of mind. Therefore, some may like them and others may not, depending
on personal taste and one’s own culture of shapes and colors.
3. Overall topological perception
We also see teeth in their context, which is linked to the mouth and face of the
individuals with whom they form a whole.
4. Phenomenological perception
We also look at the material they are made of and the details that characterize
them.
Thus, when we see an object we always see it through these four interdependent filters
of perception. This is called “synchronous development.” It applies to the production of
dental restorations, which will of course be subjected to these different modes of analysis.
39
Order, disorder, and balance

Although human perception involves several aspects such as color, form, movement, dir-
ection, dynamics, and vibrations, it is primarily the result of interactions, of guided ten-
sions between the perceived elements. For example, for each spatial relationship between
forms, there is a precise distance, intuitively decided by eye, which leads to a sense of calm
and balance in the composition and dissipates tensions16 (Fig 2-6).
Our visual attention is always focused on the center because the center is a zone of attrac-
tion or repulsion. In the center of everything, forces are in balance and are perceived as
static, and visual tensions are reduced to a minimum (Fig 2-7). When we use the right hem-
isphere of the brain, the eye has the spontaneous ability to detect and analyze balance.
Apart from the geometrically regular shapes affordable by Euclidean mathematics,
there is no computational system efficient enough to replace the intuitive sense of bal-
ance analysis of the human eye. In order to understand the complex forms of nature, one
must use fractal mathematics(c) which studies the concept of order in disorder. Fractals
are geometric figures characterized by the infinite repetition of the same pattern but with
regressive scales. In nature, for example, the structures of cauliflower, broccoli, fern leaf,
or the organization of clouds are found in fractals, but their mathematical definitions are
still unclear. Fractal mathematics perfectly illustrates the human obsession with rationally
analyzing everything around us, but also the inability to accept that balance and harmony
can be precisely detected by perceptive intuition, whereas they cannot be perfectly set
out in equations.
Fig 2-6 Perception and illusion related to visual tensions. Fig 2-7 Perception and feeling of static balance.
If we look at this white circle very briefly (a few fractions of seconds) by In every spatial relationship of shapes to each other, there is a
blinking, we have the sensation that it has reached the center. This is the precise position where balance is achieved, here when the circle
proof that the mechanisms of perception have a tendency to transform is perfectly in the center of the figure. The eye is soothed and
the image in the direction of the lowest tension level. appreciates it intuitively.
(c) A fractal figure is a mathematical object, such as a curve or a surface, whose repetitive structure is invariant by change
of scale. The adjective “fractal,” from which usage has imposed the noun, “a fractal,” to designate a figure or equation of
fractal geometry, is a neologism created by Benoît Mandelbrot in 1974, from the Latin root fractus, which means “broken”
or “irregular” (Wikipedia source).
40
Art and dentistry

The smile plays a major role in the attractiveness of the face. In a person’s overall per-
ception, the smile accounts for 47%, eyes for 31%, perfume for 11%, clothes for 7%, and
hair for only 4%. These data may surprise and confirm the fundamental role of the smile
in the esthetic aspect. Restoring a harmonious smile is the most important element of
rejuvenation. As such, the practitioner plays a much more effective role than most other
specialists in esthetic medicine.
The determinants of perceptual weight

Weight and spatial depth
An important aspect of dentistry is the understanding of the concept of “perceptual
weight.” Depending on its visual impact, each form can be associated with a subjective
weight that affects the perception of overall balance. Perceptual weight can be related
to the notion of contrast and spatial depth. Some elements will capture visual attention
through their spatial situations and contrasts, such as the eyes and mouth within the face.
Weight and color

A second important element in the perceptual weight of the elements of a face is the color
dimension. White has more weight than any other color, which is why when the mouth is
closed our attention is drawn to the eyes (white of the eyes), but when the person smiles
the attention immediately shifts to the smile because the amount of white exposed there
is greater (Figs 2-8a and 2-8b).
a b
Fig 2-8 Visual weight, spatial depth, and color.

In this portrait, the elements that attract attention are those that create contrast and depth, in this case the mouth and eyes. Depending on the
expression, visual attraction is focused on the eyes (a) or the mouth (b).
41
Fig 2-9 Visual weight vs surface.

The circles with the largest surface area, center circle on the right and then center circle on the left, require
more visual attention than smaller circles.
Fig 2-10 Visual weight and isolation effect.

The isolated circle on the right is the focus of attention.
b c
Fig 2-11 Visual weight and shape.

(a) The two different shapes on the left have a lower visual weight than two identical circles on the right.
(b, c) The asymmetrical left teeth (b) have a lower visual weight than the right teeth more present (c) and
which then seem to project themselves forward.
42
Weight and surface

Another aspect of perceptual weight is the ability of the largest object (the one with the
largest surface area) to attract more attention than smaller surrounding objects. Larger
objects also appear more advanced through perspective (Fig 2-9).
Weight and isolation

The surface effect becomes inoperative when weighed against the isolation of an object,
since the isolated object always has a strong visual attraction (Fig 2-10).
Weight and shape

Shape and contour affect perceptual weight. Thus, two adjacent shapes that are identical
will exert greater attractiveness than two different adjacent shapes (Fig 2-11).
Weight and inversion

The lateralization of form (left or right) is another determining factor in perception. Any-
thing to the right of the observed object (left for the observer) is perceived more acutely
than anything to the left of the object (right for the observer). This aspect is of funda-
mental importance in the way in which we communicate with the patient. If the patient
looks at himself in the mirror, he perceives an inverted image of his face in comparison to
the face as perceived by his surroundings or the practitioner. We do not speak the same
language because what is more present to us will be erased for the patient. This is why it
is recommended to analyze the esthetic result on a photograph or on a computer screen.
In this way, the practitioner and the patient will have the same perceptive point of view16
(Fig 2-12).
a b
Fig 2-12 Visual weight and inversion.

Note how the smile on the left (a), original, is more harmonious than the smile on the right which is its mirror image (b). By the mechanism of
the perception of faces, the notch on the central incisor is less perceptible when it is on the left side of the patient’s face and the disharmony of the
temporary canine is accentuated when it is on the right side of the face.
43
a b
Fig 2-13 Visual weight and arrangement.

(a) Note in the initial left smile how difficult it is to differentiate (b) After treatment with ceramic veneers to rebalance the shapes, the
between lateral and central incisors. nature of each tooth imposes itself on us.
Weight and layout

The arrangement of the objects is responsible for their apparent forms. It can influence
the shape of an object (and thus its perceptual weight) in relation to those of neighboring
objects. The identification of shape by the eye can become difficult if its apparent contours
are strongly modified (Fig 2-13).
Weight and experience

Our history, and the knowledge we have already acquired, can influence our perception.
The evaluation of the visual weights of objects can then be distorted by prejudices, beliefs,
or sensory memorization of previous experiences (Fig 2-14).
Weight and centering

The centering effect through symmetrical and balanced shapes is probably one of the
strongest visual effects. If the objects in the center of the composition are balanced with
each other, they take up the visual attention. The overall composition will appear balanced,
even if there are tensions and asymmetry in off-center areas (Figs 2-15 and 2-16).
Fig 2-14 Visual weight and acquired knowledge.

By observing these three different shapes we can think that an identical red square is hiding gradually
behind a wall. Our experience can make us imagine situations that are not real.
44
Fig 2-15 Visual weight and centering.

The two large and symmetrical middle circles impose balance on the entire composition. The asymmetry of
the smaller lateral forms has little influence.
Fig 2-16 Visual weight and centering in a restoration of central incisors.
a b
(a, b) Before treatment, the major dental axes of 11 and 21 are strongly deviated to the right, creating a clear imbalance.
c d
(c, d) After the completion of two veneers, the 11 and 21 are correctly centered with respect to the facial references. Their visual weight balances and
illuminates the dental composition, the smile, and the face, without radically changing the expression of the patient.
45
Perception and simplification

Another aspect that brings us back to the principle of minimalism is the innate capacity of
the right brain to analyze and simplify complex forms. Our visual sense, which is in con-
stant activity, tries to break down the image into simple shapes which it associates and
combines until it finds meaning in the object being looked at. The interpretation of the
form is always done by looking for the most logical and simple proposal according to the
visual experiences acquired (Fig 2-17).
Fig 2-17 Simplification and illusion.

From several simple shapes, the brain creates fictitious lines according to principles of extension, closure,
and symmetry. This phenomenon gives rise to illusions of “fictional figures” where we imagine a geometric
figure, suggested by the union of simple shapes.
(a) When you look at these eight white spots, you immediately see a circle (green line). The octagon
proposed on the right (red line) is not the first figure we imagine, because the brain is always looking for the
most logical and simple solution.
(b) The observation of four white dots immediately suggests the fictitious figure of a square (green line)
of which the four sides would connect the white spotlights. The figure of an offset square proposed on the
right (red line) is a form that loses meaning in relation to the initial figure.
46
What is an artistic approach?

Artistic vision is required to perceive the entire area, not as the accumulation of isolated
details but as an intelligent and sensitive construction between all the parts that compose
it. We can make a comparison with a musician who has to compose a song. He does not
put the notes one after the other in a haphazard way in the hope of creating a melody, but
first he has the intuition of the melody, and then he writes the song. The same approach
should apply to our dental treatment plans. First, we need to have a vision of the whole
previewing the final result (complex overall goal), then we will break down the treatment
into simple and partial steps (simple partial goals) that will lead to the final result.
The organization of a dental composition is a creative act based on the perception of
variable and constant elements. In the construction of a smile the central incisors, lateral
incisors, canines, and premolars each play a very precise role. They are involved in the
overall composition of the anterior dental arch.12,17,18 The proportions, size, shape, texture,
and color of the anterior teeth must blend together in a harmonious blend to achieve a
well-balanced smile. The concept of equilibrium is directly related to the concept of per-
ceptual weight previously mentioned. It materializes in the clinical balance that is estab-
lished at the level of the visible teeth, in relation to the horizontal and vertical references
of the face. It is necessary to achieve an effect of stability and balance, without tension,
with nothing more and nothing less than is strictly necessary12,19 (Fig 2-18).
Finally, success is also closely linked to the synergy of investment with the laboratory.
The indispensable minimum is to provide the dental technician with macro photography,
videos, and various casts integrating the prosthetic set-up. This creates the optimal con-
ditions for artistic prosthetic creations.
47
Fig 2-18 Esthetic and psychological impact of anterior restorations.
a d
b e
c f
(a, b, c) In this patient, the initial condition shows significant of (d, e, f) Full rehabilitation is achieved using bonded ceramic restorations
the maxillary (b) and mandibular (c) anterior teeth with a dull and without preparations (additive veneers). The incisal line regains a
saturated color, giving her an aged expression (a). marked convexity thanks to the lengthening of the incisal line made
with maxillary veneers (e). In the mandible, veneers with overlapping
incisal edges also improve proportions and dentogingival harmony
(f). There is a clear rejuvenation of the facial expression (d) and a
psychological fulfillment of the patient thanks to the application of the
rules of natural and artistic esthetics mentioned in this chapter.
48
References
1. Coachman C, Calamita MA. Digital Smile 8. Rhodes G, Proffitt F, Grady JM, Sumich A. Fa- 15. Gurwitsch A. Développement Historique de
Design: a tool for treatment planning and cial symmetry and the perception of beauty. la Gestalt-Psychologie. Paris: Thalès, 1935.
communication in esthetic dentistry. Quint Psychonomic Bulletin & Review 1998;5:
16. Lhote A, Cassou J. Les Invariants Plastiques.
Dent Technol 2012;35:103–111. 659–669.
Paris: Hermann, 1967.
2. Encyclopedia Italiana Treccani. Rome, 1925. 9. Zaidel DW, Aarde SM, Baig K. Appearance of
17. Devin R. La dentogénique d’après Frush
symmetry, beauty, and health in human faces.
3. Arnheim R. Art and visual perception: a et Fischer, une conception actuelle de
Brain Cogn 2005;57:261–263.
psychology of the creative eye. Berkeley, CA: l’esthétique dentaire. Act Odonto Stomatol
University of California Press; 1974. 10. LeSage B, Dalloca L. Approaches to smile de- 1961;53:7–61.
sign. J Cosmet Dent 2012;28:123–145.
4. Chiche G, Pinault A. Esthetics of Anterior 18. Dalloca L, Iafrate R. La fusion de la beauté et
Fixed Prosthodontics. Chicago, IL: Quintes- 11. Cremante S. Leonardo da Vinci: Artist, Scien- de l’Art. Real Clin 2010;21:248–252.
sence Publishing, 1993. tist, Inventor. Roma: Giunti, 2005.
19. Iafrate R, Dalloca L. Esthétique: Art ou tech-
5. Arnheim R. La Pensée Visuelle. Paris: Flam- 12. Lombardi RE. The principles of visual percep- nique? La perception, un outil essentiel pour
marion, 1997. tion and their clinical application to denture la connaissance. Real Clin 2010;21:263–271.
esthetics. J Prosthet Dent 1973;29:358–382.
6. Polacek K. Creatività in: Dizionario di Scienze
dell’Educazione. Roma: Diego, 1994. 13. Guillaume P. La Psychologie de la Forme.
Paris: Flammarion, 1979.
7. Kowner R. Facial asymmetry and attractive-
ness judgment in developmental perspec- 14. Ash M. Gestalt Psychology in German culture
tive. J Exp Psychol Hum Percept Perform 1890–1967. Cambridge: Cambridge Universi-
1996;22:662–675. ty Press, 1995.
49
Art and Nature

C L I N I C A N D L A B O R AT O R Y
CLINIC AND LABORATORY
10
Art and
technique
Conventional
ceramics
1
13
Enamel:
A sacred
tissue
211
16
Metal ceramic
resin-bonded
bridges
353
IV
11 12
Art and Luting the
technique ceramic
Lithium disilicate 127
ceramics
65
14 15
Chips and Ceramic
Laminate resin-bonded
Veneers bridges
263 319
17 18
The crowns Full
387 rehabilitations
and increasing
the VDO
415
V
Art and Nature
STRIVING FOR WHITER TEETH . . . . . . . . . . . . . . . . . . . . 47
Thinner and minimally invasive restorations 48
Harmonized and asymmetric compositions 50
In Ceramic Restorations THE TECHNIQUE OF FABRICATION OF FELDSPATHIC

CERAMIC MATERIAL ON PLATINUM FOIL . . . . . . . . . . . . . 51
The layering technique step by step 51
CLINIC AND LABORATORY
Clinical example 59
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
CHAPTER 10 CHAPTER 11
ART AND TECHNIQUE 1 ART AND TECHNIQUE 65
Conventional ceramics Lithium disilicate ceramics
Part 1: Stained layering technique 2 Part 1: Expertise for ceramic surface textures 66
Jean-Marc Chevallier, Jean-Philippe Pia and Jean-François Lasserre Hélène and Didier Crescenzo
THREE ESTHETICALLY ESSENTIAL ITEMS . . . . . . . . . . . . . . 2 NATURAL SURFACE TEXTURES . . . . . . . . . . . . . . . . . . . 66

Framework design 2 Collections 67
Shape and texture 4 Types of tooth and surface texture 67
Color management 6 Age and surface texture 72
GLOSSARY OF CERAMICS . . . . . . . . . . . . . . . . . . . . . . . 9 TECHNIQUES FOR MAKING SURFACE TEXTURES . . . . . . . . 74
Glossary of powders 9 Chronology of making a pressed ceramic 74
Customized samples and conversion charts 11 Lithium disilicate touch-up toolkit 75
CLINICAL CASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Toolkit for surface finishes 78
FOUR LAYERING BIOTYPES . . . . . . . . . . . . . . . . . . . . . . 15 Means of developing texture 82
Polishing techniques 84
Age a relative criterion 15
Classification of layering biotypes 16 CLINICAL ILLUSTRATIONS . . . . . . . . . . . . . . . . . . . . . . 85
BIOTYPE 1: SIMPLE . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Example 1: young triangular teeth 85
Example 2: aged ovate triangular teeth 87
BIOTYPE 2: OPAL . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Example 3: monolithic technique versus
BIOTYPE 3: DEEP DENTIN . . . . . . . . . . . . . . . . . . . . . . . 22 layering technique 90
BIOTYPE 4: TWO-AREA . . . . . . . . . . . . . . . . . . . . . . . . 26 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Part 2: Lithium disilicate pressed ceramic –
Part 2: White teeth fully stained 32 criteria for the choice of ingot 96
Roberto Iafrate Hélène and Didier Crescenzo
A PATHWAY TO UNDERSTAND AND MIMIC NATURE . . . . . 33 THE LITHIUM DISILICATE REVOLUTION . . . . . . . . . . . . . . 96

THE GESTALT THEORY . . . . . . . . . . . . . . . . . . . . . . . . . 35 CERAMICS FORMED BY THE PRESS-SET TECHNIQUE . . . . . . 97
A PHILOSOPHY OF COLORS . . . . . . . . . . . . . . . . . . . . . 36 Ingots for the press-set technique 97
Know-how versus new materials 36 Properties and applications of lithium disilicate ingots 98
Fabricate white teeth full of shades 36 FABRICATION USING THE PRESS-SET TECHNIQUE . . . . . . 105
Making humble teeth 39 CPC technique 105
Identification of tooth typology 40 Vertical press-set technique 107
Understanding the deep construction of color 40 Horizontal press-set technique 108
TRAINING PATHWAY TO IMPROVE SENSE FINISHES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111
OF PERCEPTION . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Surface staining 111
The artist’s vision 45 Cut back 111
The vision of the prosthodontist and OPTICAL BEHAVIOR OF E.MAX PRESS . . . . . . . . . . . . . . 113
the dental technician 46 Sample calibration 115
The vision of the craftsman 46 Optical assessments 116
MODERN ESTHETIC DEVELOPMENTS . . . . . . . . . . . . . . . 47 Key points 120
VI
CLINICAL EXAMPLES . . . . . . . . . . . . . . . . . . . . . . . . . 122 CHOICE OF A MICROINSTRUMENTATION . . . . . . . . . . . 232
Example 1 122 Magnifying optical aids 232
Example 2 123 Rotary instrumentation 232
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125 Ultrasonic instrumentation 234
MOCK-UP AND PROSTHODONTIC PROJECTS . . . . . . . . . 239
Direct freehand mock-up:
CHAPTER 12 Technique of direct freehand composite (DFC)
Indirect mock-up and virtual esthetic project
240
244
LUTING THE CERAMIC 127 Validation of the mock-up by the patient
Jean-François Lasserre, Ivan Chakalov, Stéphane Le Goff and Jean-Pierre Attal
and retouching 250
THE PROTOCOLS IN THE MIDDLE OF EVOLUTION . . . . . . 128 Mock-up preparation 251
ISOLATION AND RUBBER DAM . . . . . . . . . . . . . . . . . . 129 Transfer of the references from the validated mock-up 257
Cleaning and decontamination of the surfaces 129 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
TREATMENT OF GLASS CERAMICS . . . . . . . . . . . . . . . . 138
Airborne-particle abrasion with alumina
Protocols with hydrofluoric acid
138
144 CHAPTER 14
Protocol without hydrofluoric acid 157
CHIPS AND LAMINATE VENEERS 263
Evolution of the ceramic with silicate Jean-François Lasserre
and and lithium disicate 160
CERAMIC CHIPS . . . . . . . . . . . . . . . . . . . . . . . . . . . 264
TREATMENT OF ZIRCONIA . . . . . . . . . . . . . . . . . . . . . 163
Preparation principles 264
Tribochemical treatment 164 Labial or corner chips 267
Application of a universal primer 164 Maxillary incisal edge extension chips 267
TREATMENT OF DENTAL TISSUES . . . . . . . . . . . . . . . . . 169 Diastema closure chips 273
The etching 169 Chips for the treatment of cervical wear lesions 278
Composition of the enamel/dentin adhesives 174 Failures in the production of chips 290
Classification of the enamel/dentin adhesives 176 LAMINATE VENEERS . . . . . . . . . . . . . . . . . . . . . . . . . 292
CHOICE OF A LUTING COMPOSITE . . . . . . . . . . . . . . . 178 Preparation principles 292
Classification of luting agents 178 Veneers and traumas of the central incisors 296
Examples of adhesive systems for luting 184 Veneers for treating discoloration and
Microstructural analysis of the joint area after luting 186 aging of the incisors 300
POLYMERIZATION AND FINISHING . . . . . . . . . . . . . . . 191 Veneers for treating shape abnormalities and
Removal of excess material 191 agenesis of the lateral incisors 304
Polymerization 191 Veneers for treating severe erosion 309
Occlusal adjustment 203 Technique for removing a laminate veneer 314
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 206 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 317
CHAPTER 13 CHAPTER 15
THE ENAMEL CERAMIC RESIN-BONDED BRIDGES 319
A SACRED TISSUE 211 Single anterior missing tooth
Jean-François Lasserre and Camélia Alb Gil Tirlet and Jean-Pierre Attal
EVALUATION OF ENAMEL THICKNESS . . . . . . . . . . . . . 212 ETIOLOGY AND PREVALENCE OF A

Five observations on the anatomy SINGLE ANTERIOR MISSING TOOTH . . . . . . . . . . . . . . . 320
of the enamel on anterior teeth 213 INDICATIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 320
THE SUBTRACTIVE PREPARATION TECHNIQUES . . . . . . . 219 FROM TRADITIONAL BRIDGE TO CANTILEVER PRINCIPLE . . . 321
ADDITIONAL ULTRACONSERVATIVE TECHNIQUES . . . . . . 222 Traditional resin-bonded bridge 321
Management of micro-undercuts 223 Cantilever principle 321
The no prep approach in the increase of the VDO 227 Cantilever bridge in ceramic 323
The aprismatic enamel layer 228 PRECAUTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 324
VII
CLINICAL IMPLEMENTATION . . . . . . . . . . . . . . . . . . . 325
Cantilever resin-bonded bridges of CHAPTER 17
high strength ceramics 325 THE CROWNS 387
Cantilever resin-bonded bridges in lithium disilicate 328 Jean-François Lasserre
BEHAVIOR AND LONGEVITY . . . . . . . . . . . . . . . . . . . . 336
BIOMECHANICAL VS ADHESIVE RETENTION . . . . . . . . . . 388
CLINICAL CASES . . . . . . . . . . . . . . . . . . . . . . . . . . . 339
PRINCIPLES OF PREPARATION . . . . . . . . . . . . . . . . . . . 389
Clinical case 1 339
Biomechanical retention 389
Clinical case 2 345
Zenith of the central incisor 395
A RELIABLE ALTERNATIVE . . . . . . . . . . . . . . . . . . . . . . 348 Insertion axis 397
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 350 New procedures 398
OPTICAL CONTINUUM . . . . . . . . . . . . . . . . . . . . . . . 400
16
Discoloration of the supporting teeth 400
CHAPTER Technique of PoM pinlays 400
Opacification of the copings 403
METAL CERAMIC RESIN-BONDED BRIDGES 353
CLINICAL CASE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 405
A minimally invasive concept
Initial motif for the consultation 405
Alain Brabant
The provisional constructions in the heart
AN ALWAYS UP-TO-DATE TECHNIQUE . . . . . . . . . . . . . 354 of the esthetic analysis 407
INSTRUCTIONS CONCERNING TISSUE SAVING . . . . . . . . 354 The importance of adjusting the gingival relations
INSTRUCTIONS FOR A STABILIZING PREPARATION . . . . . . 356 and the occlusion 409
Stabilization and insertion axis 356 REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413
Stabilizing and retentive preparation details 358
ESTHETIC GUIDELINES . . . . . . . . . . . . . . . . . . . . . . . 362
PREPARATION SEQUENCE OF THIN ANCHORING . . . . . . 364 CHAPTER 18
Replacement of maxillary incisors 367 FULL REHABILITATIONS AND
Replacement of mandibular incisors 370
INCREASING THE VDO 415
Replacement of canines 371 Jean-François Lasserre and Ivan Chakalov
Replacement of premolars 372
A GLOBAL APPROACH . . . . . . . . . . . . . . . . . . . . . . . 416
THE CANTILEVER, AN OPTION OF CHOICE . . . . . . . . . . . 376
WHERE TO START WHEN INCREASING THE VDO? . . . . . . 418
INDICATIONS FOR PERIODONTAL SPLINTING . . . . . . . . . 377
The rule of thirds 418
PARTICULAR CASES . . . . . . . . . . . . . . . . . . . . . . . . . 379
Respecting compensatory curves 419
THE IMPACT OF CLINICAL VARIABLES . . . . . . . . . . . . . . 380 HOW MUCH TO INCREASE THE VDO? . . . . . . . . . . . . . . 421
THE CHOICE OF ADHESIVE MATERIAL . . . . . . . . . . . . . . 380 A consensus for a risk-free increase
THE CHOICE OF ALLOY . . . . . . . . . . . . . . . . . . . . . . . 381 of up to 5 mm interincisal distance 422
THE ALL-CERAMIC OPTION . . . . . . . . . . . . . . . . . . . . 382 Anterior evaluation 422
Posterior evaluation 424
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 385
HOW TO INCREASE THE VDO? . . . . . . . . . . . . . . . . . . 426
Various approaches 426
The CLC5 method 428
CLINICAL ILLUSTRATION . . . . . . . . . . . . . . . . . . . . . . 434
Clinical analysis 434
From the prosthetic project to the fixation of the BPR 435
Final occlusal stabilization 438
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 441
VIII
The art of ceramic
After having revised the fundamentals of the esthetic in fixed prosthodontics, this second
volume consists in a manual for learning the ceramic techniques. It is designed for both
dentists and dental technicians since as a complementarity and most of all a continuity
in the knowledge between the clinic and the laboratory should exist. The numerous
methods described in this book are illustrated by numerous clinical examples permitting
to apprehend the criteria for success in their application.
The clinicians can find here an update of the ceramic material, a large chapter of how
to treat and bond different materials, followed by an arsenal of prosthetic techniques.
Adhesive bridges in ceramic, Brabant-bridges, partial veneers, and laminate veneers, por-
celain-fused-to-enamel (PFM) crowns, as well as protocols for full mouth rehabilitation
by increasing the vertical dimension of occlusion. Each section finishes with a synthetic
methodologic diagram.
The lab technicians can find here a detailed description of the traditional layering
technique in order to avoid standardization when applying the ceramic powders. The
techniques to obtain textures and treat the surface, key elements for achieving esthetic
success are also explained in detail. For the lithium disilicate ceramic, where the optimal
utilization necessitates a long learning curve, abundant information is provided regarding
the precise technique and the appropriate choice of ingots according to the various clini-
cal situations.
Throughout this book, the therapeutic gradient, the tissue economy, and the respect to
the enamel within the fabrication of a bonded ceramic restoration (BCR), remain in the
heart of the clinical imperatives. The provided knowledge is precise and evidence-based,
supported by numerous scientific publications and literature reviews in order to protect a
young clinician from the treachery attractiveness of the fashion trends that flourish in the
esthetic dentistry. Indeed the “minimally invasive” dentistry is often misunderstood and
can easily turn in a “maximum iatrogenic” dentistry!
Let us hope that this book will accompany our colleagues and our friends the dental
technicians in their clinical and technical progression. Let us be creative in front of the
protocols and the new materials where the indications are not always clearly defined.
The dentistry of tomorrow is yet to be invented.
IX
FUSION - Clinic and Laboratory
Fig 10-1 Traditional Benjarong ceramic in Thailand.
X
10
Part 1: Conventional ceramics - Stained layering technique • 10
Art and
technique
Conventional ceramics
T he fabrication of conventional ceramic crowns on the front teeth,
historically on metal alloys, has always been the work principally
entrusted to the most experienced and talented dental technicians.

Jean-Marc Chevallier
Jean-Philippe Pia They learned their skills as makers of plaster models, then as
Jean-François Lasserre metallurgists, before handling ceramic materials.
Being able to mimic natural teeth in their optical and colored
complexities through a skillful layering technique requires a long
learning curve and a good talent for observation. The ceramist has to
learn how to master a material that is extremely hard to handle.
This material is worked with a brush and a water-based paste whose
esthetic outcome only appears after a long series of firing steps.
Good mastery of the layering technique gives rise to a subtle balance
between the following characteristics: the value, the chroma, the
range of hues and translucency that must lead to naturally “humble”
restorations.
1
Part 1
Stained layering technique
While digital technology is more accurate, more reliable, and less time-consuming, in
this context the role played by esthetics remains the Achilles heel of digital technology.
Often there is a lack of value and fluorescence of the restorations especially for monolithic
stained restorations. The cosmetic layering technique is still very popular for the most
esthetic sectors in the mouth. A good experience of the layering technique on conven-
tional ceramic material and an artistic sense are necessary assets for the making of ideally
designed all-ceramic restorations.
Three esthetically essential items

Framework design
The design of the frameworks of crowns and bridges must reflect the precise specification
which depends on the selected material (metal alloys or ceramic alloys of high grade) and
which ensures a robust, functional, and esthetic outcome.
Fig 10-2 The ceramist’s toolkit.
Crown frameworks
Generally speaking, for mechanical reasons, the thickness of frameworks
of all-ceramic crowns and porcelain-fused to metal crowns (PFMs) must
not be less than a minimum value that would otherwise be critical: 0.3 mm
for non-precious alloys, 0.5 mm for precious alloys and 0.6 mm for zirco-
nia and lithium disilicate glass-ceramic materials. Regarding the layering
technique two notions are important: the space available for the cosmetic
layers and the homothetic support of the framework.
In the esthetic areas in the mouth, there should be at least 1 mm of
space available for the layering technique. Below this value, the cosmetic
material will be optically influenced by the framework. In the occlusal
areas more thickness is necessary namely about 1.5 mm between the
framework and the occlusal contacts so as to reproduce cuspal morph-
ologies that mimic natural teeth and to avoid chipping of the material.
The homothetic approach consists of fabricating a framework that
fits with the prosthetic project and which keeps sufficient thickness for
the cosmetic material between the outer part of the framework and the
peripheral border.
2
Fig 10-3 The art of the layering

technique of ceramic materials.
Having a good mastery of the
layering technique is a prerequisite
in order to make artificial teeth that
are undetectable compared to natural
teeth. In this case, four bonded
ceramic restorations (BCRs) are made
in the anterior region regardless of
the presence of a complex situation
due to the agenesis of the lateral
incisor (laboratory work and photos:
H and D Crescenzo, France).
The regularity of the thickness of the material allows a homogeneous resilience of
the ceramic material on the framework and ensures good mechanical properties. In the
presence of significant occlusal stress – bruxism, parafunctional habits, overbite, crowns
placed on the second molars – tapered proximal supports have to be made on the frame-
work in order to reinforce the ceramic material and avoid cosmetic material damage due
to shearing.
It is understood that the notion of available space is essential in order to tackle the
layering technique for esthetic crowns (Fig 10-3). This is the opposite of minimally invasive
protocols or the «no prep» protocols currently used where stained monolithic ceramic
materials techniques and cut-back techniques using increments of small thickness, are
used. Consequently, the layering technique imposes conventional peripheral preparations
that require much thickness for the materials being used.
Bridge frameworks
Regarding multiple-unit bridges, the type of material to be selected has to take account
of the number of components to be replaced, the width of the pontics and the available
prosthetic height. The available prosthetic height is impactful for the design of the prox-
imal connectors between the abutments and the pontics. This is a fundamental point for
the fabrication of bridge frameworks.
The precious or non-precious metal alloys make it possible to fabricate
widespan bridges with several pontics. The accurate fit of these widespan
frameworks has been considerably improved by computer-aided design and
“Demand a lot from yourself and
manufacturing (CAD/CAM) technology. Indeed, the problems due to the previ- expect little from others. That way you
ous casting techniques that required the deformed frameworks caused by met- will be spared a lot of trouble.”
alworking to be cut and welded, no longer arise. The surfaces recommended Writings of Confucius
for the proximal connectors are about 6 mm2 in the anterior region and 8 mm2 in the
posterior region.
Regarding the zirconia frameworks, the proximal connectors need to be extended up
to 9 mm2 in the anterior region and 12 mm2 in the posterior region so as to avoid breaking
down the material at the connections. The good mechanical properties of zirconia and
the precision fit guaranteed by the CAD/CAM technology make it possible to fabricate
widespan bridges in the anterior and posterior regions. This is valid provided that the
3
patient does not suffer from muscle impairment (bruxism) because the chipping effect
of the cosmetic material is more significant for zirconia frameworks compared to PFM
restorations.
Regarding glass-ceramic frameworks that are reinforced with lithium disilicate – e.max
Press or e.max CAD – the flexural strength of the material is much lower than that of zir-
conia (see Chapter 9). The risks of fracture are higher.1 In this respect the manufacturer’s
instructions are very cautious.2 Regarding the use of the e.max CAD material, the instruc-
tions recommend its application to three-unit bridges only (with only one pontic) up to
the second premolar. The width of the pontic may range from 9 mm at the premolar level
to 11 mm at the central incisor. The dimension of the connectors recommended for the
pontics is 16 mm2. Such a junction surface requires a very high prosthetic height to allow
proximal dental hygiene. This choice might represent a contra indication for the selection
of a ceramic framework reinforced with lithium disilicate.
Shape and texture

The shape is of paramount importance for the success of the esthetic outcome.3 Success
relies upon having a talent for observation of natural teeth and accurately reproducing
the transition lines on teeth in addition to all the surface micro details. All this represents
the texture.
Transition lines
At the dental laboratory the typology of the anterior teeth always includes the outline
of the transition lines. Regarding the crowns, the transition lines determine the passage
from labial walls to proximal walls of the teeth (Fig 10-4 a). They are always drawn by the
dental technician with a red pencil on the reference teeth in addition to the bisque-baked
crowns so as to guarantee the best symmetry (Fig 10-4 b,c). These lines are not clearly
designed. Instead, they are blurred and progressive.4 It is the reason why the dental techni-
cian O. Brix5 has introduced the idea of a “transition area” and the “non-visible tooth wall.”
Indeed, he has described six axial walls instead of four. He has added the mesial labial wall
and the distal labial wall, which are not visible.
The outlines that are drawn on the model are the best way to capture the transition
areas, the curvatures, the well-rounded surfaces, and the vanishing sides on the crown
contours. Labiolingually, the outlines are helpful to assess the depth of the interdental
spaces and for the precision of location of the proximal contact surfaces. In summary, the
dental technician should be able to “volumize” the whole architecture of the tooth to be
replaced. In fact, the prosthetic outcome has to mimic nature from all angles.
Texture
The texture is optically connected with the color. The texture can have an impact upon the
color by modifying the phenomena of light absorption and light reflection on the surface.
This finishing step is performed by means of special rotary instruments (see Chapter 11,
part 1). For example, flame diamond burs, or sharp tips having the shape of a nose cone
4
are used to create horizontal wavy effects, waves and fine grooves that recall the natural
incremental growth lines of enamel (Fig 10-4b, c).
The «patina» finish is a surface finishing step that gives the ceramic material a matte,
satin-like, and bright effect. Brightness may be the result of the final firing with the addi-
tion of the glaze material. Nevertheless, the satin-like effect is more appreciated with
diamond polishers which enable the marked grooves to be blurred, then to enhance some
well-rounded surfaces and some transition areas. The final polishing with a diamond paste
gives a more natural aspect than that obtained with the glaze firing, which is brighter.
Fig 10-4 Transition lines and texture.
(a) Enhancement of a mesial transition area on the ceramic bisque of the central incisor.
b c
(b, c) Outline of the transition lines with a red pencil on two feldspathic laminate veneers that are fabricated. The surface texture is visualized with
colored carbon papers that display the irregularities and cavities on the ceramic bisque.
5
Color management
The dental technician’s perspective

The way in which the color chart is sent to the dental laboratory has been described in
Chapter 5. Regarding the layering technique, the identification of the tooth shade goes
beyond the 3 D color mapping of the reference tooth namely the value, the chroma, and
the range of hues as per the Munsell color system.6 Regarding the art of ceramics that
includes glassy materials and semi-translucent materials, there is another optical dimen-
sion that is essential for the shade profile, namely the dimension of translucency and
opacity. Indeed, the shade of a ceramic material cannot be measured as for the even and
opaque shade of the plane surface of objects such as car bodywork, wall paintings, and
floor tiling. Regarding teeth, the complexity of their shade is that their buccal wall is con-
vex and irregular. It is also heterogenous due to the various constituent tissues and has a
semi-translucent surface with shaded effects that appear in depth.7,8 The more opaque the
material is, the more it returns light. And the more translucent the material is, the more
it absorbs light and its value diminishes and it becomes more grayish. The natural central
incisor displays both characteristics. It is both transparent and shaded at the incisal third
and opaque with a high degree of light reflection in the dentin core.
For the dental technician there is another issue namely the management of the optical
rendition of the shaded characterizations, such as the spots, the food infiltrations, and
the high translucency of the incisal angles. In this case the dental technician should be
precise, moderate, and parsimonious in his work especially for the effects that are highly
translucid, highly chromatized, or opaque, otherwise the outcome might result in a cari-
cature of the tooth.
Fig 10-5 Creating the shades

with ceramic powders.
a b
6
The conversion into a chart of powders

Most of the time the dental technician receives only the shade of the tooth identified
by the prosthodontist as a reference to the shade guide. The most popular shade guide
is the Classical Vita shade guide.9 Sometimes this choice is completed with the colorim-
eter or spectrophotometer that are helpful objective instruments in resolving complex
prosthetic cases.10,11 Photographs taken at the dental office or at the dental laboratory
are essential to have a good understanding of all the shade details and to have a precise
idea of the characterizations. Photographs include: the facial view, the smile, and a focus
upon two teeth.
This first step helps the dental technician in analyzing the colored composition of the
tooth namely its value which is essential, tinges of shades that will help for the build-up
of the tooth and for the cutback. Moreover, all this is helpful for the chromatic effects and
characterizations on the surface of the tooth and the deep chromatic effects that appear
on the whole surface or part of the surface of the tooth. The objective is to capture the
right shades that will make it possible for the dental technician to select the right powders
and mixtures related to the clinical case (Fig 10-5).
Color composition
Even though the outcome is clearly identified, dental technicians have to find and combine
the right ceramic powders in order to reach the objective. This is one of the main issues
for dental technicians. They have to transpose their analysis into the selection of dentin
powders, cervical translucent powders, opalescent powders, transparent powders, differ-
ent qualities of enamel materials, and alternate the firing steps until they get a ceramic
crown that mimics nature.
Determination of the shades of frameworks

The identification of the shades of frameworks is foundational for the outcome.
• Regarding metal frameworks, the opaque layer should completely mask the metal
material. For this reason, it has a covering function. Normally two firing steps are
necessary in order to neutralize the gray effect of the alloy. The reflecting power of
the opaque layer is extremely high. Consequently, it is impactful for the shade of the
ceramic that covers it. Several types of opaquers can be used. If there is almost no
thickness for the layering technique, from the beginning some areas can be stained
with intensive opaquers.12
• Regarding zirconia frameworks, the staining process is performed with stains just after
the milling process of TZP (tetragonal zirconia polycrystal) presintered zirconia discs
or blocks and just before the sintering thermal treatment which gives the dimensions,
the shades, and the final resilience of the material. Nowadays zirconia materials are
available with various grades of translucency and chromaticity which makes it possible
to avoid hand-made staining13 (see Chapter 9).
• Regarding glass-ceramic frameworks, reinforced with lithium disilicate and concerning
their fabrication either with the press set technique (eg.: e.max Press from Ivoclar) or
with the CAD/CAM technique (eg.: e.max CAD from Ivoclar) there is a wide choice of
7
ingots or blocks. These blocks associate different levels of opacity, translucency, and
chromaticity. The range of products is wide enough to satisfy all the clinical situations:
for example, a deeply discolored stump for which the HO (high opacity) framework
would fit; or a vital non-discolored stump for which the MO (medium opacity) or LT
(low translucency) frameworks would be more appropriate.
Opacity versus translucency
Generally speaking, the first step of the layering technique consists of assessing the opa-
city of the selected framework. A high opacity is necessary in the buccal middle area in
order to maintain a high degree of value. At the beginning of the layering process a much
too high opacity is better than too much translucency that would decrease the brightness.
Conversely the translucency effect should be emphasized on the cervical and incisal areas.
In the cervical area translucency promotes the integration with the surrounding gingival
tissues. In this case special powders such as the cervical powders, the margin powders, or
the shoulder powders can be used. They are available with some ceramic kits or can be
prepared and mixed directly according to the manufacturer’s instructions.
Regarding the sub-surface and during the layering process, the emphasis is put on
the translucency and transparency in order to create several stained effects in depth
(Fig 10-6). The condition is that the reference natural tooth be characterized with such
effects because sometimes natural teeth are very opaque.
Brightness
Regarding metal ceramic frameworks, the adjustment of the brightness has to be done at
an early stage with the firing process of the opaque layer that has a high covering power.
Regarding all-ceramic frameworks, the liners, the hyper fluorescent dentin powders,
and the enamel powders make it possible to adjust the brightness. However, the value
build-up has to be all in depth. The right choice of liners and dentin powders will guar-
antee the success of the value build-up. The liners are used as a sub-layer to partly or
totally cover the all-ceramic framework. They are initially selected according to the value
of the shade guide (Vita 3D Master). Several liners are fluorescent and make it possible to
increase the value of the tooth like a natural light and to compensate for the absence of
fluorescence of zirconia.
Recently all ceramics manufacturers have developed hyper fluorescent dentin powders.
They have a high masking effect, and enable the value to be adjusted and the chromatic
range selected at the beginning to be accentuated. At the cervical areas these powders
promote the transmission of light toward the roots and avoid unsightly shade effects.
Finally enamel powders are of paramount importance since they help in adjusting the
final value of the tooth while increasing or decreasing the opacity and the grayscale. The
selection of enamel powders has a relative impact upon the bright effect of the incisal
third in addition to the opaque or transparent rendition of the incisal edge. Some enamel
powders like the Incisal, the Transparent, and the Edge materials have a high degree of
opalescence. In other words, they create a light reflection within bluish wavelengths and
an orange transmission of light like the optical properties of a natural tooth. These pow-
ders have a real impact upon the final value of the tooth build-up.
8
Fig 10-6 Creation of translucent and transparent effects.
a b
(a) Layering process of feldspathic ceramics on refractory dies for the (b) Following the firing process, appearance of the usual shrinkage of the
fabrication of BCRs. feldspathic ceramic material about 15 to 20% of the volume. One can
see the translucent glassy layer (TN = transparent neutral) that covers
the tooth surface and whose objective is to diffuse light.
Glossary of ceramics
Sometimes the dental technician cannot do an excellent job due to some constraints.
Indeed, the first problem is due to the fact that the dental technician does not have the
opportunity to meet with the patient in order to proceed with the shade identification and
to draw a color chart related to the ceramic powders. The second problem is the difficulty
for the prosthodontist of communicating with the dental technician about the optical and
ceramic effects to be obtained. Consequently, a common glossary of terms is absolutely
necessary between the clinician and the dental technician.
Glossary of powders
Opaque powders or opaquers
Powder or paste opaquers are used for the metal ceramic technique. They have a high
covering power in order to mask the metal material. They are used for the two firing pro-
cesses: the first one is dedicated to the wash layer and the second one to the opaque layer.
Dentin or base dentin powders
The dentin powders provide the basic hue to the dentin core. Their sometimes, over-
marked translucency necessitates an association with sub-layers that are more opaque
and more stained.
Opaque dentin or deep dentin powders
These powders are more opaque than the conventional dentins. However, they are of the
same shade. They are not automatically used but they can be used in order to capture the
right rendition of the shade in the event of low available thickness.
9
Intensive powders
The INTENSIVE powders are fluorescent and deeply colored. They have the same phys-
ical properties as dentins. They are normally mixed with dentin powders in order to alter
the shade. They can also be used alone to reproduce colored effects identified during the
shade identification.
Underlayer (or liner) powders
These powders can replace the opaque dentin powders. They replace them advanta-
geously to cover the frameworks. They are deeply fluorescent and provide a higher value
during the layering process.
Transparent powders
These powders are as transparent as glass. They give relief to the prosthetic restorations.
Whenever they are used alone, they increase the gray effect and reduce the value. Trans-
parent dentins and enamels are available.
Translucent powders
Translucent powders have the same effect as airborne-particle-abraded glass. They diffract
light and largely diffuse it while increasing the value. Due to their neutral aspect, they
reduce the chroma of dentins. They have different shades – bluish, amber, brownish and
orange, or white – and can be used for the chromatic characterizations of enamel or as
enamel.
Opalescent powders
The opalescent powders interact with light in the same way as natural enamel. Whenever
the light is transmitted, they provide an orange and amber effect. Whenever the light is
reflected, the effect is bluish. The opalescent powders also increase the value of teeth.
Their resilience is a little unstable after firing which might reduce the expected outcome.
Enamel or incisal powders
These powders are classified according to a decreasing order from the whitest to the
grayest shades and present different opacities and hues. Regarding the layering technique,
one can use up to six types of enamel powders. They are helpful in adjusting the value at
the end of the layering process.
Stain or effect powders
These are intense stains that reproduce effects and natural characterizations on the sur-
face or sub-surface. They can be fluorescent. The effect powders can be selected according
to their optical behaviors as the opal effect or the pearl effect.
Glaze powders
This is a layer of transparent glass which is applied at the last firing process in order to
block the ceramic porosities and to obtain a luster effect on the surface. Its melting tem-
perature is lower than that of dentin and enamel powders.
10
Customized samples and conversion charts

It is essential for the dental technician to have a better understanding of the ceramic pow-
ders and the firing parameters which have a direct impact upon the optical outcome after
the firing process. In this respect the dental technician can fabricate customized samples
by means of a special mold. Consequently, he obtains a customized shade guide of all
the powders that are appropriate for the firing parameters. These customized samples of
ceramic powders are a prerequisite which helps the dental technician to determine the
expected effects in a more objective way.
The dental technicians who use several brands of powders sometimes for the same lay-
ering process have the possibility to use «conversion charts» recommended by the man-
ufacturers with the following indications: the degree of opacity/translucency; the level of
chroma and the range of hues. They are very useful in order to have a better understanding
and to quickly identify the various powders to be used (Fig 10-7).
name opacity LeveL chroma hue inDication
EL2
8 2 Ivory mamelon liner
Vita
EC5
6 8 Orange intensive dentin
Vita
Sunset
2 3 Amber translucent
Dentsply
Dentine 2R1,5
4 4 Dentin powder 2 R 1.5/A2
Vita
ST 35 Yellow/orange shoulder or
4 5
GC margin
EE10
2 3 Bluish translucent
Vita
EO2
3 1 White/amber opalescent
Dentsply
WS White opalescent
5 1
Dentsply translucent
Clear/Neutral
1 0 Neutral
Dentsply
TC
0 0 Super transparent
Dentsply
Power Chroma
6 8 Orange fluo liner
Dentsply
Fluo Dentine 92
8 5 Deep yellow fluo liner
GC
Fig 10-7 Example of a conversion chart for ceramic powders.
11
Fig 10-8 Esthetic rehabilitation of a clinical case for a patient having multiple caries.
a b
(a, b) The initial situation shows severe multiple caries (a). However, the central incisors (teeth 11 and 21) are still vital (b).
c d
(c, d) All-ceramic crowns with subgingival margins are fitted on the maxillary central and lateral incisors and canines. The teeth are kept vital despite
their severe initial conditions. The pulp chamber of tooth 22 has been removed. An inlay core which was made opaque after two firing processes was
applied on tooth 22.
e f
(e, f) The surface of the all-ceramic crowns is bright – Shade 1 M1 of the Vita 3D Master Shade guide – and has a young texture (e). The patient is
happy again and displays a nice smile that looks sound and natural (f).
12
Clinical case
This young 26-year-old patient presents for an esthetic improvement of his teeth. He is
affected with severe multiple caries of behavioral and dietary origins (Fig 10-8a, b). Follow-
ing an emergency dental treatment, the root causes are analyzed. The prosthetic rehabili-
tation starts with the posterior region in order to stabilize the occlusion. Several implants
are placed in the posterior region. All-ceramic crowns are fabricated for the maxillary
anterior teeth while trying to keep them as vital as possible (Fig 10-8c–e). At the mandible,
laminate veneers and all-ceramic crowns are applied on the central and lateral incisors in
addition to the canines. The all-ceramic crowns are fitted on the most damaged teeth. The
crowns are fitted on zirconia frameworks (Fig 10-9b) with the build-up of a thin cosmetic
ceramic material – Vita VM9 (Fig 10-9c–h). With a thermal expansion coefficient (TEC)
ranging from 8.8 to 9.2, the ceramic material is particularly well adapted to zirconia whose
TEC is 10.5(a). A ten-year follow-up confirms the clinical stabylity of the case (Fig 10-8e–f).
Fig 10-9 (a, b) Layering process of the maxillary incisors.
a b
(a, b) The subgingival finishing lines leave some room for the ceramic material - about 1.5 mm – on the axial walls the irregularities correspond to
areas of infiltrated dentin which have been cleaned and prepared (a). The zirconia frameworks are milled (b).
The cosmetic ceramic material should have a thermal expansion coefficient (TEC) not higher than that of the framework
(a)
material. During the cooling period the ceramic material fits with the thermal behaviour of the framework material while
maintaining its cohesive bond with a slight tangential compressive constraint due to the low TEC difference between both
materials. This is a constraining effect of the cosmetic material upon the framework. If the TEC difference is too high cracks
will appear due to radial tensile effects (TEC of the cosmetic material much too high) or tangential compression (TEC of the
cosmetic material much too low).
13
Fig 10-9 (c–h) Layering process of the maxillary incisors.
c d
(c) Build-up of the VM 9 Base Dentin (1M1) totally covered with the (d) The VM9 Enamel is applied on the incisal third by alternating the
Transparent Dentin VM9 with a cutback that leaves room for the deep effects with the Mamelon and Transparent powders. The Pearl
enamel material. Effect powders are added on the cusps and the crown is slightly over-
contoured to compensate for the shrinkage after firing.
e f
(e) The bisque-baked crowns after the first firing. (f) Rectifications with the contribution of VM9 Base Dentin and Enamel.
g h
(g) After the second firing the proximal contact surfaces are adjusted on (h) The last glaze firing process with the glaze material that highlights
the study cast. the surface texture and the effects of young enamel on the incisal edges.
14
Four layering biotypes

Dental technicians have produced many ceramic restorations and undertaken many
assessments with the prosthodontists. It seems evident that some types of layering pro-
cess are recurring. It is clear that a certain number of teeth cannot be classified. However
apart from age, a new classification of teeth seems to be necessary. Each family or biotype
can include teeth that are somewhat similar or different. Unclassifiable teeth are teeth
that due to natural changes in their shape, hues or effects stand between two families.14
Such classification relies upon four distinct biotypes based on different layering pro-
cesses, that are directly related to dentinogenesis and amelogenesis. Moreover, most of
the natural teeth belong to such a classification. Superficial characterizations such as
spots, cracks, and surface texture are not taken into account in the determination of the
biotypes.
Age a relative criterion

Among the four biotypes, age is not taken into account even though it is considered as
a common classifying criterion in order to customize artificial ceramic teeth – for exam-
ple the Klaus Mutherties classification.15 Obviously, age is an essential criterion which
increases the chroma of the tooth, smudges away the texture, and changes the shape of
the tooth due to wear. However, it is not uncommon to observe young patients who have
worn teeth due to poor dietary habits or conversely old patients with teeth enamel that is
almost pristine and with a young surface texture. In this respect age is a relative criterion
(Fig 10-10).
Fig 10-10 Which are the young teeth?
a b
(a) These central incisors which have maintained a marked texture and a (b) These central incisors have a totally sleek and mat surface in addition
bright surface are of an 80-year-old female patient. to a loss of volume. This young female patient is only 22 years old. The
issue is that every day she eats raw lemon, which has caused severe wear
of her teeth.
15
Classification of layering biotypes (Fig 10-11)

Biotypes are defined by five criteria:
1. Dentin core: hue, tinges, and value
2. Dentin surface of the incisal third: visibility and stains
3. Tooth enamel: whiteness, transparency, and opalescence
4. Enamel on proximal contacts: shade
5. Incisal edge: effects of white line, halo, or stains.
Biotype 1 Biotype 2 Biotype 3 Biotype 4

Layering criteria " Simple " "Opal" "Deep dentin" "Two area"
20% 30% 40% 10%
Single dentin more Dentin of several shades

Deep dentin with several Dentin that's rather
or less chromatized, with even gradation and
Dentin core shades with more or less chro- bright, even, and opaque
with smooth and without deep chromatized
matized effects in the cervical area
even gradation effects
Detectable with golden and Slightly detectable to

Dentin surface Undetectable Hardly detectable
amber effects on the cusps highly detectable
White with non- Grayish from brownish

Moderate transparency
detectable transpa- Marked transparency with mild gray to amber-gray in the
Enamel with marked incisal bluish
rency with simple opalescence incisal area. Marked trans-
opalescence
gradation parency or opalescence.
Enamel at the proxi-

White Bluish Bluish gray Varying color
mal contact points
Off-white or amber enamel

Incisal edge Mild effects line which emphasizes the Gray amber halo Multiple varying effects
incisal edge and angles
Fig 10-11 Classification of layering biotypes.
Biotype 1: Simple
The enamel is conventional, without any particular effects and slightly white. The dentin
has a smooth and even shade gradation and can be more or less chromatized (Fig 10-12).
This biotype represents 20% of the central incisors.
Regarding biotype 1 layering process, a hyperfluorescent and chromatic liner or under-
layer covers the zirconia framework. It allows adjustment of the range of hues, the chroma,
and the adapted value. Then the layers are applied on the tooth up to its final volume thanks
to the dentin powders. Then cutbacks are performed in order to leave some space for the
enamel. A very thin layer of transparent is placed between the dentin and the enamel and
creates slight deep effects. The incisal enamel has to be bright and semi-opaque. It is simply
applied with increments on the whole surface of the tooth (Fig 10-13 and 10-14). This bio-
type is the one that is provided by manufacturers on their shade guides.
16
Fig 10-12 Examples of biotype 1 "Simple."
(a) One can appreciate the smooth effect of these

two central incisors that are devoid of unsightly shade
gradation and that are nicely bright with delicate
a
incisal effects.
b c
(b) Regardless of a marked texture and a high chroma these teeth (c) These two central incisors have a high value with an even surface
belong to biotype 1. The cervical shade gradation is delicate. The devoid of shade gradation. The only effect is on the opalescent incisal
opalescent translucency on the incisal edges is moderate. edge.
d c
(d) The incisal edges of these aged central incisors are worn due to (e) The surface of these central incisors is bright and even with discrete
exogenous discolorations. The cervical recessions expose the yellow effects on the incisal edges.
dentin. Due to its uniformity, this tooth belongs to biotype 1.
17
Fig 10-13 Build-up of biotype 1.

This is a simple build-up using four powders (Cercon Ceram Kiss Dentsly with a TEC of 9.2.)
a b
(a) The framework is covered with the Power Chroma 3 liner (PC3) (b) A single dentin – A2 shade – (DA2 Vita Classical shade guide) is
which provides fluorescence to the tooth. applied up to the almost final volume of the tooth.
c d
(c, d) Following the cutback, a thin layer of TC is applied on the mamelons and the incisal third so as to diffuse the light.
(e) A bright and high-coverage S1 or S2

enamel powder is gradually applied in
e
order to finish the tooth morphology.
18
Biotype 1 « simple »
TC
TC
TC S1 and S2
TC
S1 and
S2
DA2
DA2
PC3
PC3
Ceramic hand layering in 4 masses – Ceramic Cercon Ceram Kiss by Dentsply
Underlay Power Chroma 3 (PC3)

Mass Unique Dentin A2 (DA2)
Fine layer of Transparent Clear for the incisal 1/3 (TC)
High value enamel for the 2/3 of the tooth (S1 and S2)
Fig 10-14 Biotype 1 “Simple” layering technique.
Biotype 2: Opal
The marked bluish opalescence of the enamel on the incisal edge is the main character-
istic of Opal Biotype 2. Moreover, the enamel is sufficiently transparent or opalescent.
The optical effect of a «white line» often appears on the edges and the incisal angles. The
dentins are characterized by several shades. They display regular tinges with moderate
deep and chromatic effects (Fig 10 -15). This biotype represents 30% of the color mapping
on central incisors.
The layering process of this group is more complex. The fluorescent underlayer pro-
vides the initial range of hues that manages part of the value of the tooth. Several dentin
powders with various hues and chromas are used – for example A3 with B2 and B1. They
represent a set of cervical gradations which extend down to the fading dentin surface.
The enamel creates opalescent effects among the proximal contacts via the incisal edge.
At this point a transparent can be alternated with a bluish opalescent. The finishing step
consists in a mixture of enamel and amber opalescent which emphasizes the off-white
halo of the incisal edge made with the base dentin of the tooth (Fig 10-16 and 10-17).
19
Fig 10-15 Examples of biotype 2 "Opal".
(a) The bluish opalescence of the angles and

incisal edges of these central incisors is noticeable.
The dentin is characterized by beautiful
gradations which end up on a clear dentin
a
surface.
b c
(b) The dentin tinges are highly chromatized. The dentin surface is clear (c) These central incisors have a more grayish aspect. The dentin is
and surrounded by a very opalescent incisal enamel. The effect of white sufficiently stained and the opalescent effect of the incisal edge is
line on the incisal edge is specific to biotype 2. outstanding.
d e
(d) These central incisors are very bright. The dentin tinges start with (e) The dentin of these central incisors is even. The amber hue of the
a bright hue and end up with clear mamelon effects. The enamel enamel creates a marked opalescence beyond the dentin cusps that are
opalescence and the white line effects are outstanding. detectable here.
20

The build-up includes seven powders (Cercon Ceram Kiss Dentsply).
a b
(a) The framework is covered with the Power Chroma 4 underlayer (b) Two dentin powders DA3 (a) and DB1 (b) promote the chromatic
(PC4) that stretches up to the incisal edge. It promotes fluorescence and effect and the cervical gradation of the dentin core. Then a cutback is
value. performed on the powders.
c d
(c, d) The complex incisal edge is layered. The Opal Effekt Ocean (OE Ocean) powders promote the bluish effect (c). Then some light effects on the
cusps are alternated with the Shoulder 2 Powder (SM2) (c) with the TC (d).
(e) Enamel powders with amber opalescent (S2 + 0S2) in a

decreasing thickness starting from the incisal edge to finish
the crown morphology and dentin A3 accentuates the off-
e
white halo at the extreme edge.
21
Biotype 2 « opaL »
SM2 SM2 DA3

DA3
TC OE
TC SM2
Ocean
S2 + OS2
TC TC S2 + OS2
OE DB2
Ocean
DA3
DA3
PC4
PC4
Layering of 7 powders – Ceramic Cercon Ceram Kiss by Dentsply

Dentin Mass A3 (DA3) + B2 (DB2) with a gradient of the color
Opal Effect Ocean (OA Ocean) from the incisal edge to the contact points
Fine layer of super transparent and clear transparent in the incisal 1/3 (TC)
A strip of clear dentin with effect of lobes in Shoulder Mass 2 (SM2)
Enamel (S2) + Opalescent Amber (OS2)
White halo interrupted in the incisal edge area in Dentin A3 (DA3)
Fig 10-17 Biotype 2 “Opal” layering technique.
Biotype 3: Deep dentin

Teeth that pertain to this biotype are characterized by a deep dentin. The amber dentin surface is well detect-
able. The enamel is very transparent with or without a bluish effect and an amber halo appears on the con-
tour of the incisal edge (Fig 10-18). Biotype 3 encompasses a majority of teeth observed, that is, about 40%.
This type of layering technique is complex and combines several internal effects. These deep effects are
located in the dentin core and they also appear on the incisal edge. These effects are obtained by mixing
a translucent cervical powder which is lightly stained with the dentin. On the incisal third the effects are
obtained by covering the mamelons with a thin layer of transparent powder. It is the base for the amber
dentin surface obtained by applying stained fluorescent powders. Once a small quantity of blue is applied
on the contact points, the structure is covered with a layer of transparent and the cusps are marked again
with the same stained fluorescent powder that has already been used. Finally, the structure is covered with a
series of vertical increments of opalescent and transparent enamel (layering technique). The effect of depth
on the well-rounded cervical area is finalized with the application of a cervical translucent powder. An equal
mixture of dentin and amber cervical powder is applied on the incisal edge of the tooth in order to promote
the halo effect (Fig 10-19 and 10-20).
22
Fig 10-18 Examples of biotype 3 "Deep dentin".
(a) Underneath a transparent enamel, the dentin of

the central incisors is characterized by a specific depth
and chromaticity. On the incisal third the effects of the
amber dentin surface are outstanding. The incisal edge
a
is deeply transparent with a beautiful pearly halo.
b c
(b) Here the dentin gradation is brighter than that on the previous picture. (c) Underneath the surface characterizations that are whitish one
Here there is a cervical pinkish glint. The incisal enamel which is very observes the dentin chromatic effects. The amber golden enamel has a
opalescent and amber gray with numerous effects covers the dentin surface. bluish opalescence on the angles.
d e
(d) These central incisors have very beautiful effects of dentin surface that (e) These two central incisors are highly chromatized with a marked
are golden and orange on the incisal third. The effects alternate with amber cervical gradation. The enamel hue is amber and creates opalescent
transparent areas. The dentin which is highly chromatized is covered with a effects on the angles.
thick and translucent layer of enamel which decreases the value.
23

The tooth build-up is composed of 11 powders (Cercon Ceram Kiss Dentsply).
a b
(a, b) Once the framework is covered with the Power Chroma 4 underlayer (PC4), the build-up consists in applying a mixture of Dentin A3 (DA3)
with Opal Effekt Sunset (OE Sunset) (a). Starting from the incisal third, the pure dentin powder A3 (DA3) is applied in order to reinforce the
chromatic effect (b).
c d
(c, d) The cutback is performed to leave some space for the Transparent and enamel powders (c). On the incisal edge, powders of Opal Effekt Ocean
(OE Ocean) promote the bluish effect. The effects on the cusps are followed by Shoulder Powder 4 (SM4) with the TC (d). On the cervical area the
opalescent powder (OE Sunset) covers the first dentin layer in order to accentuate the hue (d).
(e) The final enamel layer is applied with a

layering technique: by alternating the enamel
powders (S2) with the amber opalescent (OS2)
and TC. On the incisal edge, the halo is made
with a mixture of Dentin A3 (DA3) with an
e
Opalescent Effekt Sunset (OE Sunset).
24
Biotype 3 « Deep dentin »

DA3 +
OE Ocean
OE Sunset DA3 +
TC
OE Sunset
TC OE Ocean
OE SM5
Ocean SM5 SM5 OS2
S2
TC
S2
DA3 S2
DA3
DA3 + OE Sunset DA3 +
TC OE Sunset
OE Sunset
OE Sunset
PC4
PC4
DA3 + OE Sunset
Layering with 11 powders – Ceramic Cercon Ceram Kiss by Dentsply

Dentin Mass A3 (DA3) and B2 (DB2) on top with color gradient
Mass Dentin A3 (DA3) + Opal Effect Sunset (OE Sunset)
Opal Effect Ocean (OE Ocean) from the incisal edge to the contact points
Fine layer of Super Transparent and Transparent Clear on the incisal 1/3 (TC)
Opal Effect Sunset (OE Sunset) presenting an opalescent cervical mass
A strip of Dentin with effects for the lobes in shoulder mass 5 (SM5)
Enamel (S2)
Opalescent Amber (OS2)
Transparent Clear (TC)
Halo of finishing the incisal edge in Dentin A3 (DA3) + Opal Effect Sunset (OE Sunset)
Fig 10-20 Biotype 3 “Deep dentin” layering technique.
25
Biotype 4: Two-area
The biotype 4 teeth have much character and can be observed in about 10% of the
patients. The rather opaque dentin is characterized by distinct values. The cutback is clear-
cut and deep and creates two distinct layering areas. The contact point areas are rather
bluish. The dentin surface which is highly stained goes down to the worn incisal edge. The
enamel is very transparent with a low value. Its aspect is gray, brownish gray, or amber
gray with sometimes the appearance of cracks on the enamel (Fig 10-21).
The layering technique is complex. It is characterized by a chromatic underlayer split into
two parts. The first part which is less stained and brighter is located in the cervical area
of the crown. The second part which is more stained is located on the incisal edge. It is
necessary to take account of the different values of these two areas from the beginning
of the tooth build-up. Both areas are covered with several layers of dentin, which are more
opaque and brighter in the cervical area and darker and more stained on the incisal third.
A deep cut is performed on the incisal part and leaves much space for the enamel effects.
The different effects of the dentin surface which are amber or gray are laid in depth on
the cut area after the cut area is covered with a thin layer of Transparent Clear (TC). They
possibly appear on the worn incisal edge. The incisal edge is covered or partly covered with
a mixture of TC and bluish Opalescent Effekt (OE Ocean) which goes down to the middle
of the tooth. The effects of the dentin surface are covered with an enamel of low value
which is gray, brownish gray, or amber gray. The enamel is made out of three mixtures of
powders which are vertically incremented as per the layering technique. It is usual for the
enamel to have cracks. These cracks are reproduced with stains in an alternating way. Then
the paste build-up is completed with an amber halo on the contour of the labial incisal
edge (Figs 10-22 and 10-23).
26
Fig 10-21 Example of biotype 4 "two-area."
(a) The dentin of these two central incisors shows two

distinct stained areas. The cervical half of the tooth is
bright while the incisal part is amber gray. The effects are
subtle with a dentin surface alternating from yellow to
a
opalescent gray.
b c
(b) The different shades that appear on these eroded central incisors (c) Teeth with a marked surface texture have a distinct colored separation
are outstanding. The cervical area is very bright while the incisal part is on the incisal third. The central and cervical areas are very bright. The
deeply stained and yellow especially on the worn incisal edges. incisal third is composed of a complexity of highly chromatized stains,
transparencies, opalescence, and effects on the dentin surfaces.
d e
(d) These central incisors are discolored due to the tetracyclines. The (e) On these incisors there is a clear-cut separation between the bright
orange and bright cervical areas contrast with the enamel of the incisal cervical dentin gradation and the dentin core which is rather bright with
third which is gray and rather opaque. the complex effects of the incisal areas that are opaque white, orange,
transparent, and opalescent.
27
Fig 10-22 Buid-up of biotype 4.

The tooth build-up is performed with 13 powders (Cercon Ceram Kiss Dentsply).
a b
(a, b) The zirconia framework is covered with the Power Chroma 2 underlayer (PC2) at the bottom of the tooth. The chromatized Power Chroma
3 underlayer (PC3) is applied on the incisal half. A rather opaque dentin powder composed of a mixture of dentin A2 (DA2) and Shoulder Powder
1 (SM1) is applied on the well-rounded cervical area (a). Following a marked cutback more chromatized dentin powders composed of a mixture of
Dentin A (DA3) and Shoulder Powder (SM3) are applied on the incisal third (b).
c d
(c, d) The complex layering process of the incisal area includes the blue opalescent on the proximal contact points (OE Ocean), TC, intense effects
of dentin surface obtained with a mixture of Shoulder Powder 5 (SM5) and Powder Chroma 4 (PC4) (c). The build-up is covered with a thin layer
of Opal Effect Ocean powder (OE Ocean) and TC. Then the enamel powder is layered with powders of gray enamel (S5), Opalescent Effekt Sunset
powders (OE Sunset) mixed with TC, Opalescent Effect Sunset (OE Sunset) and a light brown surface stain (d). On the incisal edge powders of Opal
Effect Ocean (OE Ocean) give a bluish effect. The cusp effects are obtained with Shoulder Powders 4 (SM 4) mixed with TC. On the cervical part the
opalescent powder (OE Sunset) covers the first layers of dentin in order to provide a deep effect to the shade (d).
28
(e) The final layer can include several surface stains (white, yellow, brown) in order to obtain the effect of
stained cracks in the transparent enamel.
Finally on the incisal edge the halo effect is made with a mixture of dentin A3 (DA3) and the Opalescent
Effect Sunset powder (OE Sunset).
29
Biotype 4 « The two-area »
DA3 + OE TC + OE
OE Ocean Sunset Sunset DA3 +
OE Sunset OE
OE Sunset
Ocean
+ Brown SM5 + PC4
OE S5 Surface S5
Ocean S5 Colorants
TC
SM5 + PC4
OE Ocean + TC
TC DA3 + SM3
PC3
OE Ocean + TC
DA2 + SM1
DA2 + SM1
PC2 PC2
Layering in 13 powders Ceramic Cercon Ceram Kiss by Dentsply

Dentin Mass A2 (DA2) + Shoulder Mass 1 (SM1) to increase the value
Dentin Mass A3 (DA3) + Shoulder Mass3 (SM3) to increase the saturation
Opal effect Ocean (OE Ocean)
Fine layer of super transparent + Transparent Clear for the incisal 1/3 (TC)
A strip of Dentin with an effect of lobes supported by Shoulder Mass5 (SM5) + Power Chroma 4 (PC4)
Opal Effect Ocean (OE Ocean) + Transparent Clear (TC) surrounding the dentin strip
Gray Enamel (S5)
OE Sunset (OE Sunset) + delicate brown staining
Transparent Clear (TC) + OE Sunset (OE Sunset)
Halo for finishing the incisal edge in Dentin A3 (DA3) + Opal Effect Sunset (OE Sunset)
Surface colorants to mimic cracks
Fig 10-23 Biotype 4 “The two-area” layering technique.
30
References
1. Kheradmandan S, Koutayas SO, Bernhard M, 6. Munsell AH. A Grammar of Color. New York: 11. Chu SJ, Devigus A, Paravina RD, Mieleszko A.
et al. Fracture strength of four diff erent types Van Nostrand Dreinhold, 1969. Fundamentals of Color: Shade Matching and
of anterior 3-unit bridges after thermo-me- Communication in Esthetic Dentistry, ed 2.
7. Lasserre JF. Les sept dimensions de la couleur
chanical fatigue in the dual-axis chewing Chicago, IL: Quintessence, 2010.
des dents naturelles. Clinic 2007;28:1–14.
simulator. J Oral Rehabil 2001;28:361–369.
12. Kuwata M. Théorie et Pratique des Restaura-
8. Sieber C. Motivation. Berlin: Vita Siggset;
2. http://www.ivoclarvivadent.fr/zoolu-web- tions Céramo-Métalliques. Paris: CdP, 1982.
2005.
site/media/document/.../IPS+e-max+-
13. Mainjot A. Dental ceramics: classification and
CAD+bridge. 9. Lasserre JF, Pop Ciutrila IS, Colosi HA. A
indications. In: Esthetics in Dentistry. Berlin:
comparison of a new visual method of color
3. Katoaka S, Nishimura Y, Sadan A. Nature’s Quintessenz, 2016: 254–268.
matching by intra oral camera with conven-
morphology. An Atlas of Tooth Shape and
tional visual and spectrometric methods. 14. Ubassy G. Analysis. The new way in dental
Form. Chicago, IL: Quintessence, 2002.
J Prosthet Dent 2011;39 suppl 3:29–36. communication. Paris: Teamwork Media,
4. Lasserre JF, Leriche MA. L’illusion du naturel 2003.
10. Lasserre JF, Pop IS, D’incau E. La couleur en
en prothèse fixée. Cah Prothese 1999;108:
odontologie: déterminations visuelles et 15. Müterthies K. Incisives céramo-métalliques,
7–21.
instrumentales, 1ère partie. Cah Prothese modelage en fonction des quatre saisons de
5. Brix O. Faszination Vollkeramik. Berlin: Team- 2006;135:25–39. la vie. Paris: CdP, 1991.
work Media, 2013.
31
ISBN: 978-1-78698-137-0
www.quintessence-publishing.com

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Jean-François Lasserre

Art and Nature

Art and Nature

FACE AND ASYMMETRY

EVOLUTION OF THE ESTHETIC CONCEPTS . . . . . . . . . . . . 52

CHAPTER 1 ANTHROPOMETRIC AND MORPHOPSYCHOLOGICAL

CHAPTER 6 Severe wear

CHAPTER 7 BIOMECHANICAL PROPERTIES . . . . . . . . . . . . . . . . . . 293

Gilles Laborde Diana Dudea Jean-Marc Kubler Ivan Chakalov

Jean-Pierre Attal Camelia Alb Gil Tirlet Alain Brabant

Fig 2-1 Master glassmaker from Murano, Venice

and artistic, needing both technical expertise and creative genius.

In other words, rationality and creativity must coexist in our abilities.

control of our brain soliciting the left hemisphere or “left brain.”

On the other hand, new technologies are standardizing dental work,

guided implant surgery, computer-aided design. Manufacturing

(CAD/CAM) prosthesis or Digital Smile Design (DSD)1 previews

perfectly illustrate this standardized and mechanistic approach

technological means necessary for our profession?

Artist, craftsman, or creator?

Fig 2-2 From natural to stereotypical smile.

Create a personalized smile

(a, b) The initial state shows a disharmony of shape and color of

(c, d, e) You can appreciate the difference after the restoration

Freeing the artist within us

Fig 2-4 Stereotypical vs natural smile.

application in the analysis of dental-gingival-facial composition where formal and chro-

Creativity and rationality

Phases of the creative process

Right Left Right Right Left

Fig 2-5 The five phases of the creative process.

From perception to psychology

Order, disorder, and balance

Art and dentistry

The determinants of perceptual weight

Weight and color

Fig 2-8 Visual weight, spatial depth, and color.

Fig 2-9 Visual weight vs surface.

Fig 2-10 Visual weight and isolation effect.

Fig 2-11 Visual weight and shape.

Weight and surface

Weight and isolation

Weight and shape

Weight and inversion

Fig 2-12 Visual weight and inversion.

Fig 2-13 Visual weight and arrangement.

Weight and layout

Weight and experience

Weight and centering

Fig 2-14 Visual weight and acquired knowledge.

Fig 2-15 Visual weight and centering.

Fig 2-16 Visual weight and centering in a restoration of central incisors.

Perception and simplification

Fig 2-17 Simplification and illusion.

What is an artistic approach?

Fig 2-18 Esthetic and psychological impact of anterior restorations.

Art and Nature

In Ceramic Restorations THE TECHNIQUE OF FABRICATION OF FELDSPATHIC

THREE ESTHETICALLY ESSENTIAL ITEMS . . . . . . . . . . . . . . 2 NATURAL SURFACE TEXTURES . . . . . . . . . . . . . . . . . . . 66