Received: 23 September 2019 Revised: 15 December 2019 Accepted: 27 December 2019

DOI: 10.1111/jerd.12564

RESEARCH ARTICLE

Comparison of color stability of two laminate veneers

cemented to tooth surfaces with and without preparation

Makbule T. Tuncdemir DDS, PhD1 | Nilgun Gulbahce MD2 | Filiz Aykent DDS, PhD3

1
Department of Restorative Dentistry, Faculty
of Dentistry, Necmettin Erbakan University,
Konya, Turkey
2
Department of Prosthodontics, Faculty of
Dentistry, Necmettin Erbakan University,
Konya, Turkey
3
Department of Prosthodontics, Faculty of
Dentistry, Yıldırım Beyazıt University,
Ankara, Turkey
Correspondence
Nilgun Gulbahce, MD, Department of
Prosthodontics, Faculty of Dentistry,
Necmettin Erbakan University, Konya, Turkey.
Email: nilgungulbahce345@hotmail.com
Funding information
Necmettin Erbakan University, Scientefic
Research Section, Grant/Award Number:
181224002
Abstract
Objective: The aim of this study was to determine the effects of preparation vs non-
preparation of tooth surfaces and the types of porcelain laminate veneers (PLVs) on
color changes after 300 hours of artificially accelerated aging (AAA).
Materials and methods: Forty extracted maxillary central incisors were used. The
teeth were divided into four groups (n = 10) to evaluate preparation methods and
porcelain types: Group A: tooth preparation with IPS e.max computer-assisted design
(CAD), group B: tooth preparation with IPS e.max press, group C: nonpreparation
with IPS e.max CAD, and group D: nonpreparation with IPS e.max press. Veneers
were fabricated and cemented using a dual-polimerized cement. Initial color mea-
surement was performed and repeated after AAA. Color changes were calculated
with the CIEDE 2000 (ΔE00) formula. Color differences were analyzed with two-way
ANOVA (P < .05).
Results: The two-way ANOVA test showed no significant difference among the
groups (P > .05). The highest color change value was observed in group C, followed
by groups B, A, and D.
Conclusion: Preparation of veneers caused more color changes in PLVs than nonpre-
paration. However, IPS e.max CAD systems for fabrication of nonprepared PLVs
increased the color change of the PLVs measured after AAA.
Clinical Significance: The results provide information on the effect of the amount of
preparation and the type of porcelain on color change in porcelain laminate veneers.
In terms of esthetic dentistry, IPS e.max press and non-prep treatment should be
used in the anterior region, where esthetics are important.

KEYWORDS

color stability, IPS e.max CAD, IPS e.max press, nonpreparation, porcelain laminate veneers

1 | I N T RO DU CT I O N discolored or malformed teeth and restoration of minimal orthodon-

Porcelain laminate veneers (PLVs) were first described in the early
1980s.1 PLVs have been used in functional and esthetic dental reha-
bilitation with good results.2 The clinical technique for PLVs includes
bonding very thin restorations to tooth adhesively in order to correct
an unesthetic appearance of the anterior teeth, such as treatment of
tics defects.3,4
A review by Burke, focusing on the amount of preparation, con-
cluded that preparations in the dentin adversely affected the survival
rate of PLVs and that the ideal porcelain veneer preparation must ter-
minate in the enamel.5 No longer is it necessary to remove 1.0 to
1.5 mm of tooth structure to obtain a porcelain restoration with

J Esthet Restor Dent. 2020;1–6. wileyonlinelibrary.com/journal/jerd © 2020 Wiley Periodicals, Inc. 1

2 TUNCDEMIR ET AL.

frictional retention. A PLV restoration is retained with little or no preparation and type of porcelain used in the fabrication of PLV does
tooth preparation whatsoever.6 The thickness of these non- not affect the color change in PLVs.
preparations or minimally invasive PLVs will not normally exceed 0.3
to 0.5 mm.1 Although there is no consensus as to whether dental
preparations are required for laminate veneers, more conservative 2 | M A T E R I A L S A N D M ET H O D S
preparations are now being advocated.7 Relatively few studies have
been reported in the literature that use survival estimates, which allow Forty extracted maxillary central incisors with completely intact roots
for valid study comparisons between the types of preparation designs and crowns were collected for this study. Teeth of similar size were
used.8 used. The teeth were cleaned and stored in saline solution at room
The results of studies on PLV survival rates were found to be: temperature. Teeth were randomly divided into four groups
Öztürk et al, 91.2% (2 years later), Nejatidanesh et al, 99% (5 years corresponding to preparation design for PLVs and the type of porce-
later), and Arif et al, 97.6% (7 years later).9-11 These results are gratify- lain used in the fabrication of LVs: standard preparation—IPS e.max
ing for patients. In addition, Alhekier et al reported that 82.8% of CAD (group A), standard preparation—IPS e.max press (group B),
patients were satisfied with PLV restorations, but color change was nonpreparation—IPS e.max CAD (group C), and nonpreparation—IPS
12
the most common complaint. Color, shape, and surface texture are e.max press (group D) (Table 1).
very important to characterize and personalize a smile in esthetics.13
Because of the complex optical properties of tooth color, achieving
successful esthetics with restoration is a difficult process for dental 2.1 | Specimen preparation
clinicians. Successful esthetic restorations require some basic princi-
ples and knowledge of the optical properties of restorative mate- In groups A and B, specimens were prepared for PLVs. Self-limiting
rials.14 The production of ceramic restorations with colors similar to depth-cutting burs of 0.3 and 0.5 mm were used initially to define the
natural teeth is a challenge in dentistry.15 Several factors have been depth-cut, and the facial surface was reduced 0.3 mm at the cervical
found to affect the exact color of porcelain restorations, such as fus- third and 0.5 mm at the middle and incisal thirds (Figure 1). A chamfer
ing, glazing, and the powder/liquid ratio.16 Color sustainability of diamond bur (Laminate Veneer Kit, Meisinger USA, LLC) was used to
restorative materials impacts the success or failure of the treatment. refine the preparation. For butt-joint incisal preparation, 0.5 mm was
The adverse conditions in the oral environment may cause changes in reduced in the incisal edge using a fissure diamond bur under water
the physical properties and the color of the material. In addition, coolant. In both groups, proximal finish lines were located facially to
microleakage, tooth preparation and restoration of harmony, surface proximal contacts. The cervical finish lines were established 1 mm
preparation, glazing and polishing, aging, and food consumption are above the cement-enamel junction. All laminate veneer preparations
external factors affecting coloration.17,18 were finished without sharp line angles. The specimens allocated to
Four groups of ceramic systems are currently used for veneers: groups C and D were not prepared. The labial surface of the teeth
feldspathic porcelain baked in the traditional powder-water-slurry
method, castable glass-ceramic, heat-pressed ceramic, and the
computer-aided design/manufacturing (CAD/CAM) technique.19 Lith- TABLE 1 Composition of materials used in this study
ium disilicate glass ceramics display better mechanical properties than
Groups/sample Material Preparation design
feldspathic ceramic and have excellent optical properties with high
Group A IPS e.max CAD Minimal tooth-preparation
translucency. Today, IPS e.max press and IPS e.max CAD, the latest in
Group B IPS e.max Press Minimal tooth-preparation
lithium disilicate ceramics, are produced by pressing and milling tech-
Group C IPS e.max CAD No-preparation
niques to provide the multi-translucency and opacity of the final res-
toration. These restorations are five times stronger than traditional Group D IPS e.max Press No-preparation

feldspathic porcelain. The low breakage rate of these materials, affi- Abbreviation: CAD, computer-assisted design.
rmed in research, is their biggest advantage.20,21 Also, lithium disilicate
ceramics allow for restorations of up to 0.2 mm in thickness with
greater clinical and laboratory ease and because of their better
mechanical properties, these restorations can be made, finished,
tested, and cemented more safely.22
Nowadays, there are many studies on color change observed in
PLVs. In these studies, the authors focused on cement properties,
ceramic properties, and cementation types. However, there is no
study about the effects of the amount of preparation on color change
of PLVs. The aim of this study is to evaluate the effect on color
change of the amount of preparation and the type of porcelain used
in fabrication of PLV. The null hypothesis is that the amount of FIGURE 1 Preparation
TUNCDEMIR ET AL.
FIGURE 2 Minimal tooth preparation
was smoothed with only a fine diamond-finishing bur to provide seat-
ing for the laminate veneers (Figure 2).
2.2 | Fabrication of the PLVs
An impression was made for each specimen with polyvinyl siloxane
impression material (Zhermack, Italy), in accordance with the manufac-
turer's instructions, to use in fabricating e.max CAD and e.max press
laminate veneers. By pouring the impressions with type IV dental
stone, the master casts were obtained. Stone models are used to
determine which areas of the teeth are ideal for placing the finishing
margins of the PLVs.
Twenty glass-ceramic laminate veneers were machined from IPS
e.max CAD HT blocks (Ivoclar Vivadent) using CAD/CAM technology
(CEREC 3D CAD/CAM; Sirona Dental Systems LLC, Charlotte, North
Carolina). An opaquing powder (IPS Contrast Spray; Ivoclar Vivadent)
was sprayed on to make a uniform layer with an optimal thickness of
32 μm to visualize both the internal line angles of the preparation and
to describe the cavo surface margin. An optical impression of the
sprayed definitive die was made with a laser scanner and then
designed according to the manufacturer's instructions. The veneers
were milled from partially crystallized blocks and then fully sintered
according to the manufacturer's instructions. To fabricate another
20 glass-ceramic laminate veneers, wax veneers were prepared on
their stone models and heat-pressed (IPS Empress EP 600 press fur-
nace) at 920
C and finished flat on a grinder/polisher with wet #400
to #1200 grit silicon carbide paper. Both e.max press and e.max CAD
veneers were then coated on one side with a layer of neutral-shade
glaze and fired at 765
C. The glazed specimens were measured with a
digital caliper (Electronic Digital Caliper; Shan, China). The thicknesses
of veneers were within the range of 0.5 ± 0.05 and 1 ± 0.05 mm. The
specimens were then cleaned ultrasonically for 10 minutes before
cementation.
3
FIGURE 3 Porcelain laminate veneer
2.3 | Bonding the ceramic veneers
All prepared and unprepared teeth were cleaned with a pumice slurry,
rinsed, and dried. Then ceramics were treated by etching with 10%
hydrofluoric acid (IPS ceramic etching gel kit, Ivoclar Vivodent) for
90 seconds, washed, and dried; a silane agent (Prosil, FGM) was applied
for 1 minute, and adhesive (without light-activation) was applied. The
tooth surface was etched with 37% phosphoric acid (Condac 37, FGM,
Joinville, SC, Brazil) for 30 seconds, followed by washing with water
and air jet, and cemented with a dual cement (Cimento Dual Allcem:
FGM). A3 shade of cement color tone is used. The restorations were
seated with the finger pressure of only one examiner and light polymer-
ized with a light intensity of 480 nm and power of 1100 mW/cm2 for
5 seconds. Excess cement was removed to simulate normal intraoral
conditions. The specimens were polymerized for 40 seconds on all sur-
faces. Residual excess cement was removed further with a 15c scalpel.
Diamond burs, polishing discs, and silicone polishers should not be used
to finish the veneers; interproximal floss is preferable to polishing strips
for interproximal sides (Figure 3).
2.4 | Color measurements
Specimens were stored in light-proof boxes until color measurements
were performed. A standardized protocol for color evaluation was
adopted for all teeth, and all color recordings were carried out in the
same room under standardized lighting conditions (D65 daylight fluo-
rescent tubes with a light intensity of 1500 lux). The spectrophotome-
ter used was a Vita Easyshade Compact (Vita-Zahnfabrik, Bad
Sackingen, Germany).15 After probe tip calibration, the Easyshade
compact probe was placed in contact with and perpendicular to the
middle of the top surface of the veneers. Initial color measurements
4 TUNCDEMIR ET AL.
Source of variation SS
Preparation 0.139
Porcelain type 0.258
Preparation × porcelain type 20.478
Total 160.655
Abbreviations: AAA, artificially accelerated aging; Df, degree of freedom; F, two-way ANOVA.
were recorded in the “Single Tooth” mode. Three consecutive read-
ings were obtained for each specimen and averaged. The colors of the
samples were measured before artificially accelerated aging (AAA) as
the same protocol was repeated after AAA for color measurement.
After baseline color measurement, all specimens were aged for
150 kJ/m2, according to accelerated aging conditions previously
described,23 in an accelerated aging chamber (Ci35 Weather-Ometer,
Atlas Electric Devices, Chicago, Illinois). Other test parameters
included a sample surface temperature of maximum 65
C (light) and
38
C (dark) in a relative humidity environment of 65%. For rainy con-
ditions, surface temperatures ranged from 18
C to 38
C. The test
cycle was 108 minutes light at 65% humidity, 12 minutes light plus
water spray, 108 minutes dark at 65% humidity, and 12 minutes dark
plus water spray, for a total of 300 hours 150 kJ/m2 in a single shot.
After AAA procedures, color measurements were repeated.
To calculate the color change of resins, the CIEDE2000 (ΔE00)
formula24 was used:
sffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
 0 2  2  2  
ΔL ΔC0 ΔH0 ΔC0
ΔE00 = + + + RT
k L SL kC SC kH SH kC SC
where ΔL0 , ΔC0 , and ΔH0 are the differences in lightness, chroma, and
hue between the two specimens compared. SL, SC, and SH are the
weighting functions for the lightness, chroma, and hue components,
respectively. KL, KC, and KH are the parametric factors to be adjusted
according to different viewing parameters. In this study, KL, KC, and
25
KH were set to 1.
3 | RESULTS
The data were analyzed using the SPSS software (version 9.1) by two-
way analysis of variance (ANOVA), and the Tukey post-hoc HSD mul-
tiple comparison test at P < .05. The results are listed in Table 2.
Color changes between the groups, according to preparation
types, are shown in Figure 4. The two-way ANOVA test showed no
significant difference among the color changes of all test groups
(P > .05). The highest color change was observed in group C (4.56
± 1.28), followed by groups B (3.94 ±1.07), A (3.31 ± 2.56), and D
(2.793 ± 0.89).
Comparing the standard preparation groups, the ΔE00 values of
group A were lower than those of GROUP B. The ΔE00 values of
group C were greater than those of group D in the nonpreparation
groups. The ΔE00 values in the groups with standard preparation and
nonpreparation were compared; the ΔE00 values of the standard
T A B L E 2 Two-way ANOVA results
Df Mean square F P
for colour change (ΔE00) after AAA
2 0.0694 0.0173 0.983
1 0.258 0.0642 0.801
2 10.239 2.545 0.093
39 4.119
F I G U R E 4 Comparison of the study groups according to the form
of preparation and porcelain types
preparation groups were greater than those of the nonpreparation
groups. The ΔE00 values of the IPS e.max press groups were lower
than those of the IPS e.max CAD groups.

ΔH0
kH SH 4 | DI SCU SSION
On the basis of the obtained data, the null hypothesis tested in this
study can be partially accepted: an increase in the amount of prepara-
tion affected the color change. Also, the effect of porcelain type on
color change after AAA was accepted.
The expectation of an increase in the esthetic perception of soci-
ety has led to wider use of PLVs in modern dentistry. As PLVs contin-
ued to evolve, a minimally invasive approach was developed to
provide a more esthetic and biologically compatible restoration. Fur-
ther protection of the tooth structure, painless treatment, no need for
temporary restorations, and not causing dentin sensitivity problems
make this method preferred. Enamel conservation is important,
required by the fact that adhesion to enamel is better and conserves
structural unity, whereby the tooth and restoration act as a unit, opti-
mizing strength and long-term durability.26-28 PLVs were made with
minimally invasive preparation and nonpreparation in this study. The
amount of preparation did not exceed 0.5 mm.
The color differences were evaluated by comparisons with 50%:50%
perceptibility and 50%:50% acceptability thresholds. The values of per-
ceptibility (0.81 units) and acceptability (1.77 units) for CIEDE2000 (1:1:1)
were obtained from a recent study.29 According to the results of this
study, color change was observed in all groups after AAA.
Aging-dependent color changes were calculated using the new
CIEDE2000 formula. The formula contains three weighting functions:
lightness, chroma, and hue. The CIEDE2000 system was considered a
TUNCDEMIR ET AL.
better indicator of human perceptibility and acceptability of color dif-
ferences between tooth colors.30,31
Barizon et al found that conventional feldspathic porcelain was
considerably more translucent than any shade of lithium disilicate at
the same thickness. The biggest advantage of lithium disilicate
ceramic is that it can be made thin without compromising strength,
and can be used to produce highly translucent and exceptionally
esthetic prostheses,32 making it possible to create a thin covering
without sacrificing the strength or esthetics of the restoration. Kurt
et al found that lithium disilicate ceramic was more successful than
monolithic zirconia ceramic, in terms of color stability and translu-
cency.20 Therefore, lithium disilicate porcelain (in both IPS e.max press
and IPS e.max CAD) was evaluated in this study.
Studies on color change in PLVs provide information about the
causes affecting color change. Kahm et al and Kim et al found that the
glazing process influences color change of lithium disilicate ceramic
veneers.33,34 Alhekier et al reported that the major cause of color
change was dentist malpractice, such as removal of the glazed layer
after finishing and polishing or failing to clean the pulp chamber from
sealers or gutta percha after root canal treatment on previously
cemented PLVs.11 According to a study by Lee et al, ceramic and
resin-cement systems affect the color stability of laminate veneers.
Transparent cement is recommended over cements of other shades
for luting highly translucent ceramics.23 There is no study on how the
preparation affects color change. Glaze treatment and cementation
processes were the same for all groups in this study.
Turgut et al reported that the final color and color changes of PLVs
are affected by the thickness and color of resin-cement and laminate
restorations.35 In addition, resin-cement and ceramic properties affect
the adaptation of PLVs. The adaptation of PLV is important for the
manufacture of thin PLV with a very thin layer of cement. Thick cement
layers due to poor adaptation of thin PLV cause anterior positioning
and may impede esthetic correction, even if ultrathin PLV can be fabri-
cated.36 The lack of adaptation may cause cement solubility, plaque

lu et al reported
retention, microleakage, and color change. Karagözog
that their test group of PLV without tooth preparation exhibited a
lower marginal gap value, and that their PLV with tooth preparation
group exhibited a lower internal adaptation value.37 In this study, PLVs
made of IPS e.max press porcelain on teeth with preparation for LV
showed more color change than IPS e.max press porcelain groups with-
out preparation. This result may be related to higher internal adaptation
and low marginal gap in the nonpreparation group.
Chunling et al reported demonstrated that maximizing both
remaining enamel thickness and porcelain thickness were important in
preventing catastrophic failure. However, nonpreparation veneers
may have significant advantages in preventing catastrophic failure and
avoiding dentin exposure, along with the concomitant risks of micro-
leakage, sensitivity, and debonding.38 The reason IPS e.max press por-
celain with preparation group showed more color change than groups
without preparation may be related to high risks of microleakage, sen-
sitivity, and debonding.
Ogura et al in the study of the role of enamel thickness and
refractive index (n) in tooth color; reported that enamel thickness
5
plays a role in determining tooth color. And found an increase in color
change with decreasing enamel thickness.39,40 However, there are
few published research on the effects that refractive index of enamel
and its thickness may have on tooth colour. This result explains the
observation of color change in the prepared groups.
The highest color change among all groups was observed in the
nonpreparation group with IPS e.max CAD. Although no preparation
was made, IPS e.max CAD showed more color change than porcelain
preparation groups. Aboushelib et al reported better marginal gap
and lower cement film thickness of laminate veneers made by
pressed ceramic than CAD/CAM veneers, and that compressible
ceramic laminate veneers produced improved marginal adaptation,
homogeneous and thinner cement film thickness, and improved
resistance to microleakage, compared to CAD/CAM veneers.41 The
reason IPS e.max CAD porcelain shows more color changes than IPS
e.max press may be related to lower marginal adaptation and higher
microleakage.
In this study, PLVs made with IPS e.max CAD porcelain showed
more color change in the samples without preparation, whereas in the
samples with preparation, the PLVs with IPS e.max press porcelain
showed more color change. This result may be explained by the lower
marginal adaptation and higher microleakage in both minimal tooth
preparation and IPS e.max CAD porcelain. The highest color change
among all groups was observed in the nonpreparation group with IPS
e.max CAD. This indicates that the color change affects IPS e.max
CAD porcelain regardless of the amount of preparation. Therefore,
IPS e.max press porcelain should be used instead of IPS e.max CAD, if
there is no preparation procedure in the anterior region where
esthetics are important.
There are certain limitations in this study. The findings are based
on an in vitro experimental design. Only the color change seen after
AAA was examined. A porcelain laminate in the oral environment is
subjected to several factors, such as hot and cold beverages, acids
from foods, saliva effects, oral biofilm, and the influence of brushing.
These factors also affect color change. Conducting in vivo studies to
include these parameters may lead to more accurate results.
5 | CONC LU SIONS
Within the limitations of this study it can be concluded that:
• In the preparation groups, IPS e.max press was more susceptible to
color changes than the IPS e.max CAD group.
• In the nonpreparation groups, IPS e.max CAD was more suscepti-
ble to color changes than the IPS e.max press group.
• The use of IPS e.max CAD for PLVs increased their color stability
after AAA.
• Preparation caused more color changes than nonpreparation.
ACKNOWLEDG MENT
This article was supported by the Necmettin Erbakan University,
Scientefic Research Section with 181224002 project number.
6 TUNCDEMIR ET AL.
ORCID
Makbule T. Tuncdemir https://orcid.org/0000-0002-0608-3412
Nilgun Gulbahce https://orcid.org/0000-0001-9707-023X
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How to cite this article: Tuncdemir MT, Gulbahce N,
Aykent F. Comparison of color stability of two laminate
veneers cemented to tooth surfaces with and without
preparation. J Esthet Restor Dent. 2020;1–6. https://doi.org/
10.1111/jerd.12564