RESEARCH AND EDUCATION

Effects of the type and thickness of ceramic, substrate, and

cement on the optical color of a lithium disilicate ceramic
Laís A. Pires, DDS, MSc,a Pollyanna M. R. Novais, DDS, MSc, PhD,b Vinícius D. Araújo, MSc, PhD,c and
Luiz F. Pegoraro, DDS, PhDd

The evolution of ceramic sys- ABSTRACT

tems has allowed the fabrica- Statement of problem. Reproducing the characteristics of natural teeth in ceramic crowns remains
tion of crowns with better a complex and difficult process.
esthetics than those of metal
Purpose. The purpose of this in vitro study was to evaluate the effect of the substrate, cement, type,
ceramic crowns, despite the
and thickness of the ceramic on the resulting color of a lithium disilicate ceramic.
difficulty of matching the op-
tical properties of natural Material and methods. Forty ceramic disks were prepared from IPS e.max Press LT (low trans-
teeth. 1-3
Tooth color is influ- lucency) and HO (high opacity) in 2 different thicknesses (1.5 and 2 mm). The LT groups were
composed of monolithic ceramic disks, and the HO groups were composed of disks fabricated with
enced by factors such as dis-
a 0.5-mm thickness combined with a 1- or 1.5-mm veneering ceramic thickness. Disks made of
tribution of the spectral energy composite resin (R) and alloy (A) were used as substrate structures. The resin cement used was
of ambient light, sensitivity of Variolink II. Color was measured with a spectrophotometer and expressed in CIELab coordinates.
the observer’s eyes, and color Color differences (DE) were calculated. The data were analyzed with ANOVA and the Tukey HSD
of the tooth substrate, all of test (a=.05).
which influence light absorp- Results. When the DE of ceramic disks with both substrates, with and without cement, were
tion, reflection, and trans- compared, the lowest value (3) was obtained for ceramic HO with a 2-mm thickness/alloy substrate/
mission.4 Together, they yield without cement; the highest value (10) was obtained for ceramic LT with a1.5-mm thickness/alloy
a final color that is a combi- substrate/with cement. This difference was statistically significant. When the effect of cement on
nation of reflected light, which the DE of ceramics in both substrates was compared, the lowest value (1.1) occurred with
ceramic HO with a 1.5-mm thickness/resin substrate, and the highest was observed for ceramic
is transmitted and dispersed
LT with a 1.5-mm thickness/alloy substrate (6.4). This difference was statistically significant.
on the dental tissues.5 The
final color of ceramic depends Conclusions. The substrate color, type and thickness of ceramic, and presence of the cement
on its degree of opacity and significantly influenced the resulting optical color. The DE values of cemented HO ceramics were
lower than that of the LT ceramic. (J Prosthet Dent 2016;-:---)
thickness and the color of the
substrate and cement. Also,
the chemical nature of ceramic, the size of the crystal translucency, medium and high opacity), depending on
particles,6 and the optical characteristics of opalescence, the substrate color.8 Some factors such as the surface
fluorescence, and translucency are intrinsic to the mate- texture,9 presence of porosities,10 firing time,11,12 glaze,13
rial and play an important role in the final color. 7
batch,14,15 manufacturer,16-18 number of sintering cy-
Lithium disilicate ceramics are commonly used to cles,11,14 thickness of opaque layer,14 metal surface
fabricate crowns and fixed dental prostheses and are treatment,19 substrate color,1,20 and combination of color
available in 4 levels of translucency (high and low of the substrate/ceramic thickness/cement color20,21 are

a
Doctoral student, Department of Prosthodontics, University of São Paulo, Bauru School of Dentistry, São Paulo, Brazil.
b
Professor, Faculty of Professional Masters in Dentistry, University of Fortaleza, Ceará, Brazil.
c
Professor, University Federal Rural of Pernambuco, Academic Unit of the Cabo of Santo Agostinho, Pernambuco, Brazil.
d
Professor, Department of Prosthodontics, University of São Paulo, Bauru School of Dentistry, São Paulo, Brazil.

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Clinical Implications
Increasing ceramic opacity and thickness may
minimize the influence of the substrate color. These
properties should be combined to achieve the best
esthetic outcomes in the clinical setting.
also cited as influencing the restoration color. The current
resin cements are available in different colors, including
opaque cements to mask darker dentin substrates or
metallic surfaces, and with different try-in pastes to help
determine the best color combination of the substrate/
cement/ceramic.
Spectrophotometers are instruments used to measure
color in dentistry. Their use increases accuracy by 33%
compared with visual observation and produces 93.3%
success in color determination.22-26 Data collected with
this instrument correspond to the measured spectral
reflectance and may be expressed in the 3 coordinates
(L*, a*, and b*) established by the Commission Inter-
nationale de l’Eclairage (CIE) to indicate difference in
color between objects.27 The coordinate L* represents the
luminosity level of the object and varies from 0 (black) to
100 (white); a* represents green to red, and b* represents
blue to yellow.27 The difference in color (DE) between 2
objects may be determined by the equation: DE
(L*a*b*) = [(DL*)2+ (Da*)2 + (Db*)2]1/2, in which
DL*=(Lsample- Lcontrol), Da*=(asample- acontrol), and
Db*=(bsample- bcontrol). The lower the DE value, the more
similar the objects being compared.
Because the capacity of the human eye to notice dif-
ferences in color varies among individuals, different DE
intervals are used to distinguish differences in color: DE
values < 1 are considered undetectable by the human
eye; values between 1 and 3.3 are considered visible by
qualified operators and clinically acceptable; and DE
values > 3.3 are visible to lay individuals and therefore
clinically unacceptable.3,28-30 Other studies have used
different DE values as clinically acceptable: 2.6 as the
perceptibility limit, 5.5 as the acceptability tolerance,31
and below 3.7 as clinically acceptable.32
Darkening of the dentin substrate or the presence of
metallic posts and cores may create an effect similar to
a shadow.17,33 To overcome this, one study suggested
increasing the ceramic thickness by using less trans-
lucent ceramics or opaque ceramic frameworks covered
by veneering ceramics or by using cements whose color
may mitigate the effect of the substrate on the ceramic
color.32
The purpose of this in vitro study was to evaluate the
color alteration of a lithium disilicate ceramic with
different thicknesses and degrees of opacity, cemented or
not, on 2 types of substrates. The null hypothesis was
THE JOURNAL OF PROSTHETIC DENTISTRY
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that color difference would not be affected by the vari-
ables analyzed.
MATERIAL AND METHODS
Forty ceramic disks were fabricated from lithium disilicate
ceramic - IPS e.max Press (Ivoclar Vivadent AG), 20 with
low translucency (LT), shade A2, with a thicknesses of 1.5
(n=10) and 2 mm (n=10) to simulate monolithic crowns;
20 with high opacity (HO) with a thickness of 0.5 mm to
simulate frameworks covered with veneering ceramic IPS
e.max Ceram, shade A2 (Ivoclar Vivadent AG), with
thicknesses of 1 (n=10) and 1.5 mm (n=10).
The specimens were initially fabricated in wax in
metal molds with diameters of 10 mm and thicknesses
of 2 and 2.5 mm for the ceramic LT and 1 mm for
the ceramic HO. The disks were fabricated following the
manufacturer’s instructions. The surfaces of the disks
were ground and polished in a polishing machine
(EXAKT 400CS Micro Grinding System; EXAKT Appa-
ratebau GmbH Co) with 180, 220, 400, 600, and 2000
abrasive paper grits, under water cooling until thick-
nesses of 1.5 and 2 mm had been achieved for the
ceramic LT and 0.5 mm for the ceramic HO, with a
tolerance of ±0.02 mm. The surfaces of disks were made
parallel and polished. The thickness of each disk was
assessed with a digital pachymeter. Disks of 0.5 mm in
thickness were covered with veneering ceramic following
the technique suggested by the manufacturer. They were
then ground and polished with abrasive paper with the
same aforementioned grits until total thicknesses of 1.5
and 2 mm had been achieved.
To simulate different clinical situations, substrates
were fabricated with composite resin (R) shade A2 and in
copper-aluminum metallic alloy (A). These specimens
were 4 mm thick and 8 mm in diameter and were
fabricated according to the manufacturer’s instructions.
The metallic alloy was used as a coronal foundation
because this material is used to fabricate posts in teeth
with no remaining crown structure.34 The metallic base
alloy was used because it is less expensive than gold-
based alloys. The 2 substrates were finished and
polished with abrasive paper grit 2000 under cooling,
polished with felt and diamond solution (Extec I water-
based diamond permanent polishing suspension; Extec
Corp), and immersed in an ultrasonic cleaner (Ultrasonic
Cleaner Model USC 750; Unique Ind E Com) with
deionized water for 10 minutes.
The following protocol was used to treat the surface
of the resin substrates: 37% phosphoric acid for
30 seconds + water rinsing for 30 seconds and air
drying + application of adhesive Excite DSC (Ivoclar
Vivadent AG) for 10 seconds and removal of excess with
mild air drying + light polymerizing with the unit Optilux
501 (Optilight Plus 60 Hz; Gnatus Equipamentos
Pires et al
- 2016 3

Table 1. Means of DE (SD), DL*, Da*, and Db* of difference between

groups
Ceramic Thickness (mm) Substrate Cement DE(SD) DL* Da* Db*
HO 2.0 A N 3.0 (1.3)a -2.6 0.6 -0.8
HO 1.5 R N 3.5 (0.4)a -2.9 0.0 -1.8
HO 2.0 R N 3.6 (0.6)a -2.3 -0.2 -2.5
LT 2.0 R N 3.6 (0.3)a -3.2 0.8 -1.2
HO 1.5 R W 3.6 (0.2)a -2.4 -0.2 -2.7
HO 2.0 A W 3.6 (0.4)a -2.7 0.0 -2.2
HO 1.5 A N 3.8 (0.4)a -3.2 0.2 -2.1
HO 2.0 R W 4.2 (0.7)ab -2.6 -0.4 -3.1
HO 1.5 A W 5.5 (0.3)bc -3.4 -0.6 -4.3
LT 1.5 A N 5.7 (0.8)bc -5.0 0.7 -2.4
LT 2.0 R W 5.9 (0.4)cd -5.2 -0.4 -2.8
LT 2.0 A N 6.4 (1.1)cd -5.2 0.1 -3.6
LT 1.5 R N 6.6 (0.1)cd -4.9 -0.4 -4.3
LT 1.5 R W 7.4 (0.6)d -6.3 -0.3 -3.7
LT 2.0 A W 10.0 (1.2)e -7.3 -1.7 -6.6
LT 1.5 A W 10.0 (0.6)e -8.4 -0.4 -5.7

A, alloy; HO, high opacity; LT, low translucency; N, without cement; R, resin; SD, standard
deviation; W, with cement. Different superscript lowercase letters represent significant
differences (P<.05).

light source D65 (daylight) and calibrated with a black

Figure 1. Scheme of template used for cementation: A, Lower part of
metallic template with central orifice to receive substrate. B, Upper part
of template with 0.1-mm-thick spacers in position. C, Fixation screws to
maintain spacers in position during cementation. D, Cement. E, Ceramic
disk. F, Light polymerization unit.
Médico-Odontológicos) for 20 seconds. The metallic
substrates were cleaned with alcohol. The ceramics
received the following surface treatment: 10% hydroflu-
oric acid IPS Ceramic Etching Gel (Ivoclar Vivadent AG)
for 20 seconds, rinsing and air drying + application of
silane Monobond-S (Ivoclar Vivadent AG) for 60 sec-
onds, and air drying + adhesive Excite DSC (Ivoclar
Vivadent AG). The translucent shade of Variolink II
(Ivoclar Vivadent AG) was used for cementation, and a
metallic template with 0.1-mm spacers was used to
standardize the cement thickness. The substrate was
fitted on an orifice in the lower part of the template,
and the cement was applied to the ceramic surface and
positioned on the substrate under finger pressure until
it reached the spacer, which was positioned on the
upper part of the template. After excess material had
been removed, the specimen was maintained in direct
contact with the light source tip and light polymerized
(Fig. 1).
The color was analyzed by a single operator L.A.P.
with a spectrophotometer (Minolta CM2600d; Konica
Minolta Sensing Americas Inc) equipped with a standard
background in the region of 400 to 700 nm. Five readings
were performed on 5 different points distributed over the
entire surface of each disk, and the mean was calculated
using the software provided with the spectrophotometer.
The DE (difference in color) was obtained by comparing
the baseline group (ceramic disks) with other groups,
namely the disks superimposed on the substrates before
and 24 hours after cementation. The DE between 2 ob-
jects was obtained as follows: ceramic disks versus
ceramic disks superimposed on substrates with cement;
ceramic disks versus ceramic disks superimposed on
substrates without cement; ceramic disks superimposed
on substrates without cement versus those cemented.
The DE results were calculated, and the means were
statistically analyzed using software (Sigma Plot v12.0;
Jandel Scientific). Four-way analysis of variance
(ANOVA) was used to analyze the 4 parameters (ce-
ramics, thicknesses, substrates, and cement), and 3-way
analysis of variance (ceramics, thicknesses, and sub-
strates) was used to evaluate the influence of the pres-
ence of cement on the DE. The Tukey HSD test was used
to evaluate the effect of DE (difference in color) between
the 16 groups for each variable.
RESULTS
Table 1 presents the means and standard deviations of
DE values between the ceramic disks and the other
groups. The 4-way ANOVA (Table 2) revealed significant
differences and interactions among all groups (P<.05).
The Tukey test showed differences between the different
factor levels in the groups (P<.05). The lowest DE (3)
was observed for ceramic HO/2 mm of thickness/

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Table 2. Four-way analysis of variance of combinations of type and Table 3. Means of DE (SD), DL*, Da*, and Db* of the difference between
thickness of ceramic, substrate, and cement groups before and after cementation
Sum of Mean Ceramic Thickness (mm) Substrate DE(SD) DL* Da* Db*
Source Squares df Square F P HO 1.5 R 1.1 (0.6)a 0.5 -0.2 -0.9
Ceramic 197.25 1 197.25 285.21 <.001 LT 1.5 R 1.5 (0.2)a -1.2 0.19 0.5
Substrate 32.37 1 32.37 46.8 <.001 HO 2.0 R 1.6 (0.8)a -0.6 -0.2 -1.2
Thickness 11.74 1 11.74 16.98 <.001 HO 2.0 A 2.1 (0.8)ab -0.6 -0.3 -1.8
Ceramic×substrate 20.02 1 20.02 28.94 <.001 HO 1.5 A 2.2 (0.8)ab 0.0 -0.8 -2.0
Ceramic×thickness 1.23 1 1.23 1.78 .191 LT 2.0 R 3.0 (0.4)bc -2.0 -1.3 -1.6
Substrate×thickness 0.59 1 0.59 0.86 .360 LT 2.0 A 4.2 (1.2)c -2.7 -1.7 -2.7
Ceramic×substrate×thickness 20.74 1 20.74 30 <.001 LT 1.5 A 6.4 (0.3)d -4.2 -1.0 -4.1
Error 22.13 32 0.69
A, alloy; HO, high opacity; LT, low translucency; R, resin; SD, standard deviation. Different
Total 306.1 39 superscript lowercase letters represent significant differences (P<.05).
Cement 66.13 1 66.13 261.32 <.001
Cement×ceramic 21.15 1 21.15 83.56 <.001
Cement×substrate 14.23 1 14.23 56.21 <.001 Table 4. Three-way analysis of variance of combinations of type and
Cement×thickness 0.01 1 0.01 0.04 .846 thickness of ceramic and substrate
Cement×ceramic×substrate 3.67 1 3.67 14.51 <.001 Sum of Mean
Source Squares df Square F P
Cement×ceramic×thickness 0.29 1 0.29 1.13 .295
Ceramic 40.91 1 40.91 94.53 <.001
Cement×substrate×thickness 5.46 1 5.46 21.58 <.001
Thickness 0.07 1 0.07 0.16 <.001
Cement×ceramic×substrate×thickness 0.44 1 0.44 1.74 .195
Substrate 39.11 1 39.11 90.39 .691
Error 8.1 32 0.25
Ceramic×substrate 12.89 1 12.89 29.79 <.001
Total 119.5 39
Ceramic×thickness 0.70 1 0.70 1.64 .210
Substrate×thickness 11.59 1 11.59 26.78 <.001

metallic substrate/without cement; the highest DE (10) Ceramic×substrate×thickness 5.98 1 5.98 13.82 .001
Error 13.85 32 0.43
was obtained for ceramic LT/1.5 mm of thickness/metallic
Total 125.11 39
substrate/with cement. Except for the variable LT/2 mm
of thickness/resin substrate/without cement (DE=3.6),
the lowest DE values were observed for the ceramic HO,
Individual analysis of the ceramics revealed that, for the
regardless of the thickness, substrate, and presence or
ceramic HO, the DE values for both substrates and
absence of cement (DE between 3 and 5.5). The DE of
thicknesses did not reveal statistically significant
ceramic LT varied between 3.6 and 10. Negative values of
differences. For the LT ceramics, the DE values were
DL*, Da*, and Db* in the different groups occurred
similar to those of the 2-mm thickness and statistically
because of the higher values of L*, a*, and b* observed in
significant for the 1.5-mm thickness for both substrates.
the individual analysis of the ceramic disks. The groups
Negative values of DL*, Da*, and Db* occurred because
ceramic/substrates, with and without cement, presented
of the lower values of L*, a*, and b* compared with the
the lowest luminosity values (L*). The values of co-
control group. Positive values of L* demonstrated that
ordinates a* showed a greater contribution of red, and
the specimens exhibited greater luminosity than those in
the values of coordinates b* showed a greater contribu-
the control group. The values of coordinates a*
tion of yellow.
demonstrated a greater contribution of red, and the
To analyze the effect of cement on the color of ce-
values of coordinates b* presented a greater contribution
ramics, the mean DE values (Table 3) of cemented and
of yellow.
noncemented specimens were submitted to 3-way
ANOVA (ceramic, thickness, and substrate) (Table 4),
DISCUSSION
which revealed significant differences for the factors
ceramic and substrates and for the interaction between The present results support the rejection of the null hy-
the variables (P<.05). The Tukey test revealed differences pothesis, in that the DE values were influenced by the
(P<.05) between the different factor levels in the groups. fabrication process, thickness of ceramic, type of sub-
The lowest DE value was obtained for the ceramic HO/ strate, and presence or absence of cement.
1.5 mm of thickness/resin substrate (DE=1.1), and the When the DE values of ceramics were compared
highest was observed for the ceramic LT/1.5 mm of (Table 1), the DE values of ceramic HO were lower than
thickness/metallic substrate (DE=6.4). The lowest DE those of ceramic LT, confirming the importance of the
values were observed for the ceramic HO (DE between optical characteristics (translucency versus opacity) of
1.1 and 2.2), except for the combination LT/1.5 mm of ceramic, regardless of the other variables analyzed.
thickness/resin substrate (DE=1.5), and the highest Therefore, in substrates with different dentin colors, the
for the ceramic LT (DE between 3 and 6.4) (P<.05). clinician should consider increasing the thickness and

THE JOURNAL OF PROSTHETIC DENTISTRY Pires et al

- 2016
opacity of the ceramic to mask any possible change in the
ceramic color.
When the DE values of groups without and with
cement were compared (Table 3), the ceramic HO pre-
sented similar DE values between substrates and thick-
nesses. This demonstrates that the thickness of 1.5 mm
for this more opaque ceramic is sufficient to mask the
effect of the framework, regardless of the type of sub-
strate. In addition, it maintains the mechanical properties
of the framework and protects the dentin-pulp complex
by decreasing the amount of tooth reduction. A metallic
alloy substrate is not indicated for the ceramic LT,
regardless of the thickness of the ceramic, because of its
greater transparency.
However, when the DE values between the groups
before and after cementation (1.1 to 6.4) (Table 2) were
compared with those of other studies that considered
values of DE<5.520,31 as clinically acceptable, the only
combination that can be considered clinically inadequate
was ceramic LT/1.5 mm thickness/metallic substrate
(DE=6.4), which exceeded the clinically acceptable
threshold of DE.
According to the manufacturer of these ceramics,
preparations for anterior teeth should include a reduction
of 1 mm in the cervical region, 1.2 mm at the axial walls,
and 1.5 mm at the incisal/occlusal aspect; in posterior
teeth, the reduction should be 1 mm in the cervical re-
gion and 1.5 mm at other aspects.8 This seems insuffi-
cient to mask the color of ceramic cemented on a darker
substrate. Increasing the thickness of ceramic increases
its opacity, hinders the transmission of light, favors light
scattering, and reduces the translucency of ceramics, thus
minimizing the influence of the substrate color.17,35,36
However, because this aspect was not observed for the
ceramic LT, a greater reduction of vital teeth could
compensate for a darker substrate color but could also
jeopardize pulp health; therefore, a more opaque ceramic
should be indicated in these patients.32 The use of try-in
pastes may help determine the cement color, thereby
avoiding changes in the definitive restoration color
because of the color of the cement and/or substrate.
When the thickness of ceramic was 2 mm, the variables
substrate and presence or not of cement did not statis-
tically influence the DE values. These results are in
agreement with those of other authors,1,16,32 who
showed that a ceramic thickness of 2 mm or more is
effective in masking the dentin substrate color or metallic
foundation material.
Because the cement seems to influence the restora-
tion color less than the ceramic thickness and substrate
color32 and considering that the cement eliminates air
bubbles between the ceramic and substrate, which may
minimize the influence of light refraction,10 a translucent
cement was used in the present study so that this vari-
able would not influence the others.
Pires et al
5
Considering the limitations of this in vitro study, the
present results should be analyzed and clinically applied.
Other types of ceramics with different opacities and
colors, substrates, and cement colors should also be
evaluated.
CONCLUSION
Within the limitations of this in vitro study, the following
conclusions were drawn:
1. The substrate color, type, and thicknesses of ceramic
and the presence of cement significantly influenced
the resulting optical color.
2. The DE values of cemented HO ceramics were lower
than those of the LT ceramic.
3. On a metallic alloy substrate, the ceramic crown
should be fabricated only with high opacity ceramic.
The translucent ceramic is indicated for dentin or
resin substrate.
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Corresponding author:
Dr Laís A. Pires
Department of Prosthodontics
Bauru School of Dentistry
Alameda Octávio Pinheiro Brisola, 9-75
Bauru, SP 17012-901
BRAZIL
Email: lais_pires@hotmail.com
Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.

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