JPOR-271; No. of Pages 6 journal of prosthodontic research xxx (2015) xxx–xxx
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Original article
The influence of resin cements on the final color of ceramic veneers Xiao-Dong Chen DDS, PhDa,c, Guang Hong PhDb, Wen-Zhong Xing PhDc, Yi-Ning Wang DDS, PhDa,* a The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, School & Hospital of Stomatology, Wuhan University, Wuhan, China b Liaison Center for Innovative Dentistry, Graduate School of Dentistry, Tohoku University, Sendai, Japan c Department of Prosthetics, Dalian Stomatological Hospital, Dalian, China
article info
abstract
Article history:
Purpose: To evaluate the effect of three brands of resin cement on the final color of ceramic
Received 22 October 2014
veneers.
Received in revised form
Methods: 50 disk-shaped ceramic specimens (IPS e.Max, 0.6 mm 8.0 mm diameter) and
15 February 2015
disk-shaped composite resin background specimens (4.0 mm 8.0 mm diameter) were
Accepted 2 March 2015
prepared and divided into 10 groups (n = 5). These paired specimens were bonded using
Available online xxx
ten shades of resin cement (Variolink Veneer, shades LV-3, LV-2, MV, HV + 2, HV + 3; Panavia F, shades light and brown; and RelyXTM Veneer, shades WO, TR, A3). A spectrophotometer
Keywords:
(VITA Easyshade) was used to measure the color parameters (CIE L*a*b* values) of the paired
Resin cement
disks before and after cementation. The color differences (DE values) after cementation were
Color differences
calculated and statistically analyzed by the One-way ANOVA (at the significant level
Ceramic veneers
p < 0.05). Results: The color parameters of the ceramic disks were measured in terms of the increase in L* value, and the decrease in Cab value after bonding with the resin cement. The DE values of ceramic disks after cementation ranged from 1.38 to 7.16. The DE values were more than 3.3 when the ceramic disks were cemented with resin cements in shade HV + 3 (4.90) and shade WO (7.16). One-way ANOVA of DE values revealed significant differences in the resin cement shades. Conclusions: Resin cements can affect the final color of ceramic veneer restorations, and the extent of this effect varies according to the resin cement shades. # 2015 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
* Corresponding author at: The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, School & Hospital of Stomatology, Wuhan University, 237 Luoyu Road, Wuhan 430079, China. Tel.: +86 27 87686318; fax: +86 27 87873260. E-mail address: [email protected] (Y.-N. Wang). http://dx.doi.org/10.1016/j.jpor.2015.03.001 1883-1958/# 2015 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
Please cite this article in press as: Chen X-D, et al. The influence of resin cements on the final color of ceramic veneers. J Prosthodont Res (2015), http://dx.doi.org/10.1016/j.jpor.2015.03.001
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1.
Introduction
Dental veneers are one of the most popular treatments for restoration of unesthetic anterior teeth [1]. The veneer technique is used to close diastemas, restore morphological and structural defects, and improve the appearance of mildly discolored teeth [2,3]. Compared with composite resin materials, ceramic veneers have many advantages, such as excellent biocompatibility, natural appearance, and a reliable clinical success rate [4,5]. The challenge with ceramic veneers is to achieve maximum esthetics by balancing shade matching while providing a thin ceramic restoration [6]. Some studies found that the thickness of ceramic materials and light transmittance were highly correlated [7–9]. The more translucent the material, and greater the influence of the underlying substrate on the final color of the ceramic veneer [10–14]. The final color of ceramic veneer restorations is determined by the combination of tooth structure color, ceramic layer thickness, and cement color. Ideally, a thin translucent ceramic bonded to a less chromatic and non-discolored tooth provides an esthetically pleasing ceramic veneer restoration [15]. However, when the tooth is discolored, the use of an opacious and chromatic ceramic and resin cement is necessary, as well as additional tooth reduction to mask the discolored substructure [15]. Clinicians are frequently faced with a challenge when selecting the color of the cement for ceramic veneers. Resin cements with various shades offer dental practitioners the chance to select an appropriate shade of resin cement and to adjust the final color of the restoration [16]. Several studies have attempted to determine the effect of resin cement shades on veneer restorations. Some studies found that variation in the thickness of the ceramic material and different shades of cement can lead to perceptible color differences in veneer restorations [17–19]. However, Vichi et al. [11] and Azer et al. [20], suggested that the resin cement had no significant effect on the final color of IPS Empress all-ceramic material, and that differences in the cement thickness (0.1 mm or 0.2 mm) only slightly affected the final appearance. Karaagaclioglu and Yilmaz’s study was consistent with these results, finding that the final color difference between ceramics bonded by cement in shades A1 and A3 was not clinical perceptible [21]. The objective of this study was to evaluate the influence of the shade of resin cement on the final color of ceramic veneers. The null hypothesis was that the shade of resin cement does not affect the final color of ceramic veneers.
2.
Material and methods
IPS e.Max ceramic materials and three brands of resin cement were evaluated in this study. The chemical information of ceramic material and resin cements are listed in Table 1.
2.1.
Ceramic specimen preparation
For this experiment, 50 ceramic disks (8.0 mm 0.6 mm) were fabricated using a lost-wax technique (IPS e.Max Press, LT A3
shade, Ivoclar, Liechtenstein) according to the manufacturer’s instructions. One surface of ceramic disk was polished with 600-, 800-, 1000- and 1200-grit wet silicon carbide paper (Siawat WA, Switzerland) and the bond surface was polished with 600-grit wet silicon-carbide paper, to achieve a final thickness of 0.6 0.03 mm, monitored by a five-point measurement using a digital micrometer (Shanghai Jiuliang Hardware Tools Co., Ltd., China). The ceramic disks were ultrasonically cleaned in distilled water for 10 min and excess of water was removed by an absorbent paper. The disks were then self-glazed at the recommended temperature.
2.2.
Composite resin background disks preparation
Fifty composite resin background disks (Dentin shade, DC CORE PLUS, Kuraray Medical Inc., Japan) were fabricated using a Teflon mold (8.0 mm 4.0 mm) to simulate the normal background dentin shade. The composite resin background disks were cured using a light-polymerizing unit (Mini LED, Satelec, France) for 40 s on each side of the disk, with a light intensity of 1100 mW/cm2. Wet silicon carbide paper (800-grit) was used to produce a uniform bonding surface, and the thickness of disks was adjusted to 4.0 0.02 mm. The thickness of composite resin background disks was monitored by a five-point measurement using a digital micrometer.
2.3.
Color measurement
A spectrophotometer (VITA Easyshade) was used to measure the color parameters (CIE L*a*b* values) and record the Cab values of the ceramic disks against the composite resin background disks. Butylphthalate was placed between the ceramic disks and the composite resin background disks to provide an optical contact [22]. These paired disks were measured with the glazed surface against a neutral-gray card (X-Rite, Shanghai Color Management Co., Ltd., China). In order to avoid errors in the color measurement caused by a mismatched position, marks were placed at the edge of the trisection of the disks. The CIE L*a*b* values of each pair of disks were registered at three points approximately 1 mm from the marked edge of the ceramic disk, and the Cab values were also measured. The paired disks were cleaned with a 75% alcohol swab to remove the butylphthalate, then rinsed with distilled water and air-dried.
2.4. Bonding between the ceramic disks and composite resin background disks Fifty paired specimens were randomly divided into ten groups. Ten shades from three brands of resin cement were selected in this study. The shades selected were LV-3, LV-2, MV, HV + 2, HV + 3 (Variolink Veneer, Ivoclar Vivadent, Liechtenstein); light and brown (Panavia F, Kuraray Medical Inc., Japan); and WO, TR, A3 (RelyXTM Veneer, 3M ESPE, USA). The bonding process of each resin cement system was undertaken in accordance with the manufacturer’s instructions. The bonding surface of ceramic disks was treated by the ceramic primer after etching with 8% hydrofluoric acid. And the surface of composite resin background disks was also applied the corresponding bonding agent at three cement
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Table 1 – The chemical information of ceramic material and resin cements used in the study. Material
Manufacturer
Composition
IPS e.Max Press
Ivoclar Vivadent, Liechtenstein
Lithium disilicate glass-ceramic (SiO2, Li2O, K2O, P2O5, ZrO2, ZnO, other oxides, color oxide)
Variolink Veneer
Ivoclar Vivadent, Liechtenstein
UDMA, TEGDMA, silicon dioxide, ytterbium trifluoride, initiators, stabilizers and pigments Helibond (Bonding agent): Bis-GMA, Triethylene glycol dimethacrylate Monobond-S (Ceramic primer): 3-methacryloxy propyl-trimethoxy silane, water, ethanol, acetic acid
Panavia F
Kuraray Medical Inc., Japan
Paste A: 10-MDP, silanated silica, hydrophobic aromatic and aliphatic dimethacrylate, hydrophilic dimethacrylate photoinitiator, dibenzoyl peroxide Paste B: silanated barium glass, sodium fluoride, sodium aromatic sulfinate, dimethacrylate monomer, BPO ED Primer A: HEMA, 10-MDP, 5-NMSA, water, accelerator ED Primer B: 5-NMSA, accelerator, water, sodium benzene sulphinate Clearfil SE Bond (Bonding agent): Bis-GMA, MDP, HEMA, hydrophilic dimethacrylate, camphoroquinone, p-toluidine, silanated colloidal silica Clearfil Porcelain Bond Activator (Ceramic primer): MPS, hydrophobic aromatic dimethacrylate
RelyXTM Veneer
3M ESPE, USA
Bis-GMA, TEGDMA, zirconia/sinlica filler AdperTM Single Bond Plus Adhesive (Bonding agent): Bis-GMA, HEMA, poly-alcenoic copolymer, water, ethanol RelyTM Ceramic Primer (Ceramic primer): 3-methacryloxy propyl-trimethoxy silane, ethanol, ethyl alcohol
UDMA: urethane dimethacrylate; TEGDMA: triethylene glycol dimethacrylate; Bis-GMA: bisphenol-A glycidyldimethacrylate; 10-MDP: 10-methacryloyloxydecyl dihydrogen phosphate; BPO: benzoyl peroxide; HEMA: 2-hydroxyethyl methacrylate; 5-NMSA: N-methacryloyl5-aminosalicylic acid; MPS: 3-methacryloyloxypropyl trimethoxysilane.
systems. The resin cement was placed on the bonding surface of the ceramic disk, avoiding bubble formation. The ceramic disk and resin cement were gently pressed onto the composite resin background disk using a digital micrometer to form a 100 mm-thick cement layer, and an alignment mark was placed at the edge of the disk [17,23]. The resin cement was then cured using a light-polymerizing unit. Excess resin cement was removed with a slow hand-piece. After the resin cement was cured, the actual thickness of the 50 bonded specimens was 0.09 0.01 mm. The bonded specimens were stored in physiological saline for 24 h at 37 8C to ensure complete polymerization.
2.5.
Calculation of color difference
The CIE L*a*b* values and the Cab values of bonded ceramic disks were measured again according to the same color measuring procedure. Color differences were calculated after bonding with different shades of resin cements. CIE L*a*b* color differences (DE values) were obtained using the 1=2 formula: DE ¼ ½ðL1 L0 Þ2 þ ða1 a0 Þ2 þ ðb1 b0 Þ2 [24], where ‘0’ represents the color parameters of the ceramic disk before bonding and ‘1’ represents the color parameter of the ceramic disk after cementation. The Cab values of ceramic disks were registered in the same way. To determine the effect of the resin cements, a DE of 3.3 was selected as the clinically unacceptable threshold in this study [25].
2.6.
Statistical analysis
DE values were statistically analyzed (SPSS 16.0; SPSS, Chicago, IL, USA) using one-way analysis of variance (ANOVA) to determine the effect of the different shades of resin cement.
3.
Results
The mean CIE L*a*b* values for each group are presented in Table 2. Use of the resin cement shades WO and HV + 3 resulted in significant color differences (DE of 7.16 and 4.90 respectively) both clinically unacceptable color changes (Table 3). The variation in the L* and Cab values of the ceramic disks are shown in Fig. 1. Most shades of resin cement produced an increase in L* value and a reduction in Cab values in the bonded disks. A significant increase in chroma (Cab value) was observed in the Panavia F brown shade after bonding. Variolink Veneer LV-2, Panavia F light and the Veneer RelyXTM A3 resulted in a slight increase in the chroma of the ceramic disks after cementation. The results of ANOVA showed that the shade of resin cement had a significant influence on the color change of ceramic specimens after cementation ( p < 0.001, F = 26.090). Tukey’s test revealed statistical differences between shades HV + 3 or WO and other shade groups, individually ( p < 0.05).
4.
Discussion
The results of this study indicate that some cement shades, namely WO and HV + 3, produced clinically unacceptable color change in the bonded ceramic disks. Therefore, the null hypothesis that the shade of resin cement had no influence on the final color of ceramic veneers was rejected. The color differences of objects can be evaluated by instrumental measurements or visual assessment. Instruments measure color and express it in terms of coordinate
Please cite this article in press as: Chen X-D, et al. The influence of resin cements on the final color of ceramic veneers. J Prosthodont Res (2015), http://dx.doi.org/10.1016/j.jpor.2015.03.001
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Table 2 – The color parameters of the ceramic disks before and after bonding treatment (mean [SD], n = 5). Resin cement system
Shade
Before cementation L*
a*
(0.37) (0.41) (0.33) (0.55) (1.06)
b*
Panavia F
Light Brown
72.84 (0.46) 73.57 (0.30)
1.43 (0.16) 1.53 (0.12)
22.09 (1.11) 21.73 (0.47)
74.76 (0.42) 73.86 (0.61)
0.53 (0.22) 0.61 (0.24)
22.52 (0.85) 23.99 (0.57)
Veneer RelyX
WO TR A3
73.26 (0.48) 73.06 (0.55) 73.39 (0.63)
1.51 (0.25) 1.51 (0.12) 1.42 (0.23)
22.55 (0.69) 22.13 (1.10) 22.13 (0.90)
78.38 (0.85) 74.61 (0.73) 75.61 (1.01)
0.98 (0.25) 1.18 (0.16) 0.97 (0.12)
17.58 (0.20) 20.09 (0.87) 22.41 (0.53)
N
DE
LV-3 LV-2 MV HV + 2 HV + 3 Light Brown WO TR A3
5 5 5 5 5 5 5 5 5 5
1.83 0.34 ab 1.38 0.38 a 2.59 0.73 ab 2.31 0.69 ab 4.90 0.98 c 2.23 0.53 ab 3.16 0.36 b 7.16 1.27 d 2.63 1.03 ab 2.36 0.49 ab
Different superscript letters in the row differ statistically among themselves for the Tukey’s test at the level of 5%.
Fig. 1 – Distribution of the L* and Cab values of ceramic disks after cementation.
values (L*, a*, b*), which locate the object’s color within the CIELAB color space [26]. The L* coordinate represents the brightness of an object, the a* value represents the red or green chroma, and the b* value represents the yellow or blue chroma [25]. The color difference (DE) of two objects can then be determined by comparing the differences between respective coordinate values for each object [27]. Visual assessments represent detectable color difference (perceptibility) or
72.58 74.08 73.55 74.33 77.49
(0.41) (0.22) (0.39) (0.44) (1.55)
0.11 0.94 1.48 1.01 0.97
(0.29) (0.10) (0.25) (0.19) (0.18)
b*
72.73 73.36 73.47 72.98 73.31
Shades of cements
(0.66) (0.99) (0.80) (0.72) (1.11)
a*
LV-3 LV-2 MV HV + 2 HV + 3
Table 3 – The color difference (DE values) of the ceramic disks after cementation using ten resin cement shades (x¯ s).
21.95 22.07 22.03 21.94 21.95
L*
Variolink Veneer
1.51 1.41 1.61 1.49 1.48
(0.10) (0.51) (0.18) (0.14) (0.25)
After cementation
21.89 21.71 19.55 20.21 19.67
(0.90) (0.67) (1.24) (0.41) (0.51)
unacceptable color difference (acceptability). It is of clinical significance to determine the magnitude of color difference that is visually perceptible or acceptable [25]. The literature provided different values of color change for the perceptible and acceptable thresholds under in vitro/in vivo conditions. The perceptible DE threshold in different investigations ranges from 1.0 to 3.7, and the acceptable DE threshold ranges from 1.7 to 6.8 [25,28–31]. In this study, the DE of 3.3 was selected as the clinically unacceptable color difference threshold [25,31,32]. The thickness of ceramic material is an important factor for achieving accurate shade matching [14,33]. However, the thickness of veneer restorations is limited by the amount of tooth preparation. As a conservative restoration, ceramic veneers are bonded preferentially to enamel to ensure a durable bond [34]. The recommended reduction of tooth structure for veneer restorations is 0.5–0.8 mm. Moreover, anatomical studies have found that the enamel thickness of maxillary anterior teeth is approximately 0.4–1.3 mm, with the gingival third being thinner and the incisal third being thicker [35]. Therefore, ceramic veneer restorations 0.5–1.0 mm thick are usually bonded to prepared enamel [18]. To evaluate the esthetic effect of cement shades on the final color of ceramic veneers, a disk thickness of 0.6 mm was selected in this study. In the current study, we found that the shade of the resin cement can affect the final color of a ceramic disk. The similar shades of resin cements in three cement materials had the similar influence on the color changes of ceramic disks. The translucent shades of resin cement (TR and MV) slightly increase the brightness and decrease the chroma of ceramic disks (Fig. 1). The yellow shade LV-2 and A3 have little influence on the color changes of ceramic disks (Fig. 1 and Table 3). The shades HV + 3 and WO were white opaque materials, which obviously resulted in an increase in the brightness and a decrease in the chroma of the ceramic disks (Fig. 1). These results are consistent with several previous studies. Niu et al. [36] analyzed the effect of five cement shades on the color change of e-Max ceramic blocks. They found that the color differences of the ceramic blocks ranged from 2.21 to 4.63. Chang et al. [37] found in their study that resin cement materials can create perceptible color differences with particular combinations of background color, cement and ceramic crown. Previous studies also showed that the effect of the shade of the resin cement on the final color of veneer restorations was related to the thickness of the restorative material [17]. As the
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ceramic thickness decreases, the ceramic translucency increases [11,19]. The light is transmitted within the restoration through to the surface of the cement, and the shade of the cement can reflect back affecting the color of the ceramic. Accordingly, opacious resin cement can significantly change the esthetic effect of veneer restorations by masking the underlying tooth color and decreasing the translucency of the veneer. Recent investigations have demonstrated that a thinner ceramic layer could affect the final color of a veneer restoration as the DE values are lower for a 1.0 mm ceramic thickness than for a 0.5 mm ceramic thickness [18,19]. The present study did not completely simulate a clinical situation because the disk-shaped specimens were tested rather than ceramic veneer restorations. Another limitation of this study is the color measuring instrument. The parameters of specimens measured by VITA Easyshade might be susceptible to the lighting of environment. Therefore, for a complete assessment of the esthetic effect of resin cement shade on the final color of ceramic veneer restorations, a clinical study should be conducted including the factors of ceramic thickness and different color of tooth structures.
5.
Conclusions
Within the limitations of this in vitro study two conclusions were drawn. Firstly, different shades of resin cement produced obvious effects on the final color of ceramic veneers. Secondly, the resin cement shades HV + 3 and WO can increase the brightness and reduce the chroma of ceramic veneers, whereas the resin cement shades LV-3 and brown tend to increase the chroma.
Conflict of interest The authors declare no conflict of interest.
Acknowledgements The authors thank Dr. Shao-Pu Zhang and Dr. Kang-Ru Zhan for their help in the preparation of the manuscript. The authors appreciate the technical supports provided from Chang-Jun Guan and Da-Hai Li.
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ScienceDirect journal homepage: www.elsevier.com/locate/jpor
Original article
The influence of resin cements on the final color of ceramic veneers Xiao-Dong Chen DDS, PhDa,c, Guang Hong PhDb, Wen-Zhong Xing PhDc, Yi-Ning Wang DDS, PhDa,* a The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, School & Hospital of Stomatology, Wuhan University, Wuhan, China b Liaison Center for Innovative Dentistry, Graduate School of Dentistry, Tohoku University, Sendai, Japan c Department of Prosthetics, Dalian Stomatological Hospital, Dalian, China
article info
abstract
Article history:
Purpose: To evaluate the effect of three brands of resin cement on the final color of ceramic
Received 22 October 2014
veneers.
Received in revised form
Methods: 50 disk-shaped ceramic specimens (IPS e.Max, 0.6 mm 8.0 mm diameter) and
15 February 2015
disk-shaped composite resin background specimens (4.0 mm 8.0 mm diameter) were
Accepted 2 March 2015
prepared and divided into 10 groups (n = 5). These paired specimens were bonded using
Available online xxx
ten shades of resin cement (Variolink Veneer, shades LV-3, LV-2, MV, HV + 2, HV + 3; Panavia F, shades light and brown; and RelyXTM Veneer, shades WO, TR, A3). A spectrophotometer
Keywords:
(VITA Easyshade) was used to measure the color parameters (CIE L*a*b* values) of the paired
Resin cement
disks before and after cementation. The color differences (DE values) after cementation were
Color differences
calculated and statistically analyzed by the One-way ANOVA (at the significant level
Ceramic veneers
p < 0.05). Results: The color parameters of the ceramic disks were measured in terms of the increase in L* value, and the decrease in Cab value after bonding with the resin cement. The DE values of ceramic disks after cementation ranged from 1.38 to 7.16. The DE values were more than 3.3 when the ceramic disks were cemented with resin cements in shade HV + 3 (4.90) and shade WO (7.16). One-way ANOVA of DE values revealed significant differences in the resin cement shades. Conclusions: Resin cements can affect the final color of ceramic veneer restorations, and the extent of this effect varies according to the resin cement shades. # 2015 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
* Corresponding author at: The State Key Laboratory Breeding Base of Basic Science of Stomatology (Hubei-MOST) & Key Laboratory of Oral Biomedicine Ministry of Education, School & Hospital of Stomatology, Wuhan University, 237 Luoyu Road, Wuhan 430079, China. Tel.: +86 27 87686318; fax: +86 27 87873260. E-mail address: [email protected] (Y.-N. Wang). http://dx.doi.org/10.1016/j.jpor.2015.03.001 1883-1958/# 2015 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
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1.
Introduction
Dental veneers are one of the most popular treatments for restoration of unesthetic anterior teeth [1]. The veneer technique is used to close diastemas, restore morphological and structural defects, and improve the appearance of mildly discolored teeth [2,3]. Compared with composite resin materials, ceramic veneers have many advantages, such as excellent biocompatibility, natural appearance, and a reliable clinical success rate [4,5]. The challenge with ceramic veneers is to achieve maximum esthetics by balancing shade matching while providing a thin ceramic restoration [6]. Some studies found that the thickness of ceramic materials and light transmittance were highly correlated [7–9]. The more translucent the material, and greater the influence of the underlying substrate on the final color of the ceramic veneer [10–14]. The final color of ceramic veneer restorations is determined by the combination of tooth structure color, ceramic layer thickness, and cement color. Ideally, a thin translucent ceramic bonded to a less chromatic and non-discolored tooth provides an esthetically pleasing ceramic veneer restoration [15]. However, when the tooth is discolored, the use of an opacious and chromatic ceramic and resin cement is necessary, as well as additional tooth reduction to mask the discolored substructure [15]. Clinicians are frequently faced with a challenge when selecting the color of the cement for ceramic veneers. Resin cements with various shades offer dental practitioners the chance to select an appropriate shade of resin cement and to adjust the final color of the restoration [16]. Several studies have attempted to determine the effect of resin cement shades on veneer restorations. Some studies found that variation in the thickness of the ceramic material and different shades of cement can lead to perceptible color differences in veneer restorations [17–19]. However, Vichi et al. [11] and Azer et al. [20], suggested that the resin cement had no significant effect on the final color of IPS Empress all-ceramic material, and that differences in the cement thickness (0.1 mm or 0.2 mm) only slightly affected the final appearance. Karaagaclioglu and Yilmaz’s study was consistent with these results, finding that the final color difference between ceramics bonded by cement in shades A1 and A3 was not clinical perceptible [21]. The objective of this study was to evaluate the influence of the shade of resin cement on the final color of ceramic veneers. The null hypothesis was that the shade of resin cement does not affect the final color of ceramic veneers.
2.
Material and methods
IPS e.Max ceramic materials and three brands of resin cement were evaluated in this study. The chemical information of ceramic material and resin cements are listed in Table 1.
2.1.
Ceramic specimen preparation
For this experiment, 50 ceramic disks (8.0 mm 0.6 mm) were fabricated using a lost-wax technique (IPS e.Max Press, LT A3
shade, Ivoclar, Liechtenstein) according to the manufacturer’s instructions. One surface of ceramic disk was polished with 600-, 800-, 1000- and 1200-grit wet silicon carbide paper (Siawat WA, Switzerland) and the bond surface was polished with 600-grit wet silicon-carbide paper, to achieve a final thickness of 0.6 0.03 mm, monitored by a five-point measurement using a digital micrometer (Shanghai Jiuliang Hardware Tools Co., Ltd., China). The ceramic disks were ultrasonically cleaned in distilled water for 10 min and excess of water was removed by an absorbent paper. The disks were then self-glazed at the recommended temperature.
2.2.
Composite resin background disks preparation
Fifty composite resin background disks (Dentin shade, DC CORE PLUS, Kuraray Medical Inc., Japan) were fabricated using a Teflon mold (8.0 mm 4.0 mm) to simulate the normal background dentin shade. The composite resin background disks were cured using a light-polymerizing unit (Mini LED, Satelec, France) for 40 s on each side of the disk, with a light intensity of 1100 mW/cm2. Wet silicon carbide paper (800-grit) was used to produce a uniform bonding surface, and the thickness of disks was adjusted to 4.0 0.02 mm. The thickness of composite resin background disks was monitored by a five-point measurement using a digital micrometer.
2.3.
Color measurement
A spectrophotometer (VITA Easyshade) was used to measure the color parameters (CIE L*a*b* values) and record the Cab values of the ceramic disks against the composite resin background disks. Butylphthalate was placed between the ceramic disks and the composite resin background disks to provide an optical contact [22]. These paired disks were measured with the glazed surface against a neutral-gray card (X-Rite, Shanghai Color Management Co., Ltd., China). In order to avoid errors in the color measurement caused by a mismatched position, marks were placed at the edge of the trisection of the disks. The CIE L*a*b* values of each pair of disks were registered at three points approximately 1 mm from the marked edge of the ceramic disk, and the Cab values were also measured. The paired disks were cleaned with a 75% alcohol swab to remove the butylphthalate, then rinsed with distilled water and air-dried.
2.4. Bonding between the ceramic disks and composite resin background disks Fifty paired specimens were randomly divided into ten groups. Ten shades from three brands of resin cement were selected in this study. The shades selected were LV-3, LV-2, MV, HV + 2, HV + 3 (Variolink Veneer, Ivoclar Vivadent, Liechtenstein); light and brown (Panavia F, Kuraray Medical Inc., Japan); and WO, TR, A3 (RelyXTM Veneer, 3M ESPE, USA). The bonding process of each resin cement system was undertaken in accordance with the manufacturer’s instructions. The bonding surface of ceramic disks was treated by the ceramic primer after etching with 8% hydrofluoric acid. And the surface of composite resin background disks was also applied the corresponding bonding agent at three cement
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Table 1 – The chemical information of ceramic material and resin cements used in the study. Material
Manufacturer
Composition
IPS e.Max Press
Ivoclar Vivadent, Liechtenstein
Lithium disilicate glass-ceramic (SiO2, Li2O, K2O, P2O5, ZrO2, ZnO, other oxides, color oxide)
Variolink Veneer
Ivoclar Vivadent, Liechtenstein
UDMA, TEGDMA, silicon dioxide, ytterbium trifluoride, initiators, stabilizers and pigments Helibond (Bonding agent): Bis-GMA, Triethylene glycol dimethacrylate Monobond-S (Ceramic primer): 3-methacryloxy propyl-trimethoxy silane, water, ethanol, acetic acid
Panavia F
Kuraray Medical Inc., Japan
Paste A: 10-MDP, silanated silica, hydrophobic aromatic and aliphatic dimethacrylate, hydrophilic dimethacrylate photoinitiator, dibenzoyl peroxide Paste B: silanated barium glass, sodium fluoride, sodium aromatic sulfinate, dimethacrylate monomer, BPO ED Primer A: HEMA, 10-MDP, 5-NMSA, water, accelerator ED Primer B: 5-NMSA, accelerator, water, sodium benzene sulphinate Clearfil SE Bond (Bonding agent): Bis-GMA, MDP, HEMA, hydrophilic dimethacrylate, camphoroquinone, p-toluidine, silanated colloidal silica Clearfil Porcelain Bond Activator (Ceramic primer): MPS, hydrophobic aromatic dimethacrylate
RelyXTM Veneer
3M ESPE, USA
Bis-GMA, TEGDMA, zirconia/sinlica filler AdperTM Single Bond Plus Adhesive (Bonding agent): Bis-GMA, HEMA, poly-alcenoic copolymer, water, ethanol RelyTM Ceramic Primer (Ceramic primer): 3-methacryloxy propyl-trimethoxy silane, ethanol, ethyl alcohol
UDMA: urethane dimethacrylate; TEGDMA: triethylene glycol dimethacrylate; Bis-GMA: bisphenol-A glycidyldimethacrylate; 10-MDP: 10-methacryloyloxydecyl dihydrogen phosphate; BPO: benzoyl peroxide; HEMA: 2-hydroxyethyl methacrylate; 5-NMSA: N-methacryloyl5-aminosalicylic acid; MPS: 3-methacryloyloxypropyl trimethoxysilane.
systems. The resin cement was placed on the bonding surface of the ceramic disk, avoiding bubble formation. The ceramic disk and resin cement were gently pressed onto the composite resin background disk using a digital micrometer to form a 100 mm-thick cement layer, and an alignment mark was placed at the edge of the disk [17,23]. The resin cement was then cured using a light-polymerizing unit. Excess resin cement was removed with a slow hand-piece. After the resin cement was cured, the actual thickness of the 50 bonded specimens was 0.09 0.01 mm. The bonded specimens were stored in physiological saline for 24 h at 37 8C to ensure complete polymerization.
2.5.
Calculation of color difference
The CIE L*a*b* values and the Cab values of bonded ceramic disks were measured again according to the same color measuring procedure. Color differences were calculated after bonding with different shades of resin cements. CIE L*a*b* color differences (DE values) were obtained using the 1=2 formula: DE ¼ ½ðL1 L0 Þ2 þ ða1 a0 Þ2 þ ðb1 b0 Þ2 [24], where ‘0’ represents the color parameters of the ceramic disk before bonding and ‘1’ represents the color parameter of the ceramic disk after cementation. The Cab values of ceramic disks were registered in the same way. To determine the effect of the resin cements, a DE of 3.3 was selected as the clinically unacceptable threshold in this study [25].
2.6.
Statistical analysis
DE values were statistically analyzed (SPSS 16.0; SPSS, Chicago, IL, USA) using one-way analysis of variance (ANOVA) to determine the effect of the different shades of resin cement.
3.
Results
The mean CIE L*a*b* values for each group are presented in Table 2. Use of the resin cement shades WO and HV + 3 resulted in significant color differences (DE of 7.16 and 4.90 respectively) both clinically unacceptable color changes (Table 3). The variation in the L* and Cab values of the ceramic disks are shown in Fig. 1. Most shades of resin cement produced an increase in L* value and a reduction in Cab values in the bonded disks. A significant increase in chroma (Cab value) was observed in the Panavia F brown shade after bonding. Variolink Veneer LV-2, Panavia F light and the Veneer RelyXTM A3 resulted in a slight increase in the chroma of the ceramic disks after cementation. The results of ANOVA showed that the shade of resin cement had a significant influence on the color change of ceramic specimens after cementation ( p < 0.001, F = 26.090). Tukey’s test revealed statistical differences between shades HV + 3 or WO and other shade groups, individually ( p < 0.05).
4.
Discussion
The results of this study indicate that some cement shades, namely WO and HV + 3, produced clinically unacceptable color change in the bonded ceramic disks. Therefore, the null hypothesis that the shade of resin cement had no influence on the final color of ceramic veneers was rejected. The color differences of objects can be evaluated by instrumental measurements or visual assessment. Instruments measure color and express it in terms of coordinate
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Table 2 – The color parameters of the ceramic disks before and after bonding treatment (mean [SD], n = 5). Resin cement system
Shade
Before cementation L*
a*
(0.37) (0.41) (0.33) (0.55) (1.06)
b*
Panavia F
Light Brown
72.84 (0.46) 73.57 (0.30)
1.43 (0.16) 1.53 (0.12)
22.09 (1.11) 21.73 (0.47)
74.76 (0.42) 73.86 (0.61)
0.53 (0.22) 0.61 (0.24)
22.52 (0.85) 23.99 (0.57)
Veneer RelyX
WO TR A3
73.26 (0.48) 73.06 (0.55) 73.39 (0.63)
1.51 (0.25) 1.51 (0.12) 1.42 (0.23)
22.55 (0.69) 22.13 (1.10) 22.13 (0.90)
78.38 (0.85) 74.61 (0.73) 75.61 (1.01)
0.98 (0.25) 1.18 (0.16) 0.97 (0.12)
17.58 (0.20) 20.09 (0.87) 22.41 (0.53)
N
DE
LV-3 LV-2 MV HV + 2 HV + 3 Light Brown WO TR A3
5 5 5 5 5 5 5 5 5 5
1.83 0.34 ab 1.38 0.38 a 2.59 0.73 ab 2.31 0.69 ab 4.90 0.98 c 2.23 0.53 ab 3.16 0.36 b 7.16 1.27 d 2.63 1.03 ab 2.36 0.49 ab
Different superscript letters in the row differ statistically among themselves for the Tukey’s test at the level of 5%.
Fig. 1 – Distribution of the L* and Cab values of ceramic disks after cementation.
values (L*, a*, b*), which locate the object’s color within the CIELAB color space [26]. The L* coordinate represents the brightness of an object, the a* value represents the red or green chroma, and the b* value represents the yellow or blue chroma [25]. The color difference (DE) of two objects can then be determined by comparing the differences between respective coordinate values for each object [27]. Visual assessments represent detectable color difference (perceptibility) or
72.58 74.08 73.55 74.33 77.49
(0.41) (0.22) (0.39) (0.44) (1.55)
0.11 0.94 1.48 1.01 0.97
(0.29) (0.10) (0.25) (0.19) (0.18)
b*
72.73 73.36 73.47 72.98 73.31
Shades of cements
(0.66) (0.99) (0.80) (0.72) (1.11)
a*
LV-3 LV-2 MV HV + 2 HV + 3
Table 3 – The color difference (DE values) of the ceramic disks after cementation using ten resin cement shades (x¯ s).
21.95 22.07 22.03 21.94 21.95
L*
Variolink Veneer
1.51 1.41 1.61 1.49 1.48
(0.10) (0.51) (0.18) (0.14) (0.25)
After cementation
21.89 21.71 19.55 20.21 19.67
(0.90) (0.67) (1.24) (0.41) (0.51)
unacceptable color difference (acceptability). It is of clinical significance to determine the magnitude of color difference that is visually perceptible or acceptable [25]. The literature provided different values of color change for the perceptible and acceptable thresholds under in vitro/in vivo conditions. The perceptible DE threshold in different investigations ranges from 1.0 to 3.7, and the acceptable DE threshold ranges from 1.7 to 6.8 [25,28–31]. In this study, the DE of 3.3 was selected as the clinically unacceptable color difference threshold [25,31,32]. The thickness of ceramic material is an important factor for achieving accurate shade matching [14,33]. However, the thickness of veneer restorations is limited by the amount of tooth preparation. As a conservative restoration, ceramic veneers are bonded preferentially to enamel to ensure a durable bond [34]. The recommended reduction of tooth structure for veneer restorations is 0.5–0.8 mm. Moreover, anatomical studies have found that the enamel thickness of maxillary anterior teeth is approximately 0.4–1.3 mm, with the gingival third being thinner and the incisal third being thicker [35]. Therefore, ceramic veneer restorations 0.5–1.0 mm thick are usually bonded to prepared enamel [18]. To evaluate the esthetic effect of cement shades on the final color of ceramic veneers, a disk thickness of 0.6 mm was selected in this study. In the current study, we found that the shade of the resin cement can affect the final color of a ceramic disk. The similar shades of resin cements in three cement materials had the similar influence on the color changes of ceramic disks. The translucent shades of resin cement (TR and MV) slightly increase the brightness and decrease the chroma of ceramic disks (Fig. 1). The yellow shade LV-2 and A3 have little influence on the color changes of ceramic disks (Fig. 1 and Table 3). The shades HV + 3 and WO were white opaque materials, which obviously resulted in an increase in the brightness and a decrease in the chroma of the ceramic disks (Fig. 1). These results are consistent with several previous studies. Niu et al. [36] analyzed the effect of five cement shades on the color change of e-Max ceramic blocks. They found that the color differences of the ceramic blocks ranged from 2.21 to 4.63. Chang et al. [37] found in their study that resin cement materials can create perceptible color differences with particular combinations of background color, cement and ceramic crown. Previous studies also showed that the effect of the shade of the resin cement on the final color of veneer restorations was related to the thickness of the restorative material [17]. As the
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ceramic thickness decreases, the ceramic translucency increases [11,19]. The light is transmitted within the restoration through to the surface of the cement, and the shade of the cement can reflect back affecting the color of the ceramic. Accordingly, opacious resin cement can significantly change the esthetic effect of veneer restorations by masking the underlying tooth color and decreasing the translucency of the veneer. Recent investigations have demonstrated that a thinner ceramic layer could affect the final color of a veneer restoration as the DE values are lower for a 1.0 mm ceramic thickness than for a 0.5 mm ceramic thickness [18,19]. The present study did not completely simulate a clinical situation because the disk-shaped specimens were tested rather than ceramic veneer restorations. Another limitation of this study is the color measuring instrument. The parameters of specimens measured by VITA Easyshade might be susceptible to the lighting of environment. Therefore, for a complete assessment of the esthetic effect of resin cement shade on the final color of ceramic veneer restorations, a clinical study should be conducted including the factors of ceramic thickness and different color of tooth structures.
5.
Conclusions
Within the limitations of this in vitro study two conclusions were drawn. Firstly, different shades of resin cement produced obvious effects on the final color of ceramic veneers. Secondly, the resin cement shades HV + 3 and WO can increase the brightness and reduce the chroma of ceramic veneers, whereas the resin cement shades LV-3 and brown tend to increase the chroma.
Conflict of interest The authors declare no conflict of interest.
Acknowledgements The authors thank Dr. Shao-Pu Zhang and Dr. Kang-Ru Zhan for their help in the preparation of the manuscript. The authors appreciate the technical supports provided from Chang-Jun Guan and Da-Hai Li.
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