FUNDAMENTAL

RESEARCH
Change in Color and Gloss Parameters of
Stained Monolithic Resin-Ceramic CAD/CAM
Materials After Simulated Aging:
An In Vitro Study
Sven Mühlemann, PD Dr Med Dent
Sofia Stromeyer, Med Dent
Alexis Ioannidis, Dr Med Dent
Clinic of Reconstructive Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland.

Thomas Attin, Prof Dr Med Dent

Clinic of Conservative and Preventive Dentistry, Center of Dental Medicine, University of Zurich, Zurich,
Switzerland.

Christoph HF Hämmerle, Prof Dr

Mutlu Özcan, Prof Dr, PhD
Clinic of Reconstructive Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland.

Purpose: To measure the effect of simulated aging on stained resin-ceramic CAD/CAM materials regarding
the durability of color and gloss. Materials and Methods: Test specimens (n = 15 per material) were prepared
out of CAD/CAM ingots from two resin nanoceramics (Lava Ultimate [LVU], Cerasmart [CER]) and a polymer-
infiltrated ceramic (ENA, VITA Enamic) stained with the manufacturer’s recommended staining kit using
photopolymerization. Control specimens were made of feldspathic ceramic (VITA Mark II [VM2]) and stained
by means of ceramic firing. Negative control specimens (n = 15) (no staining) were prepared for each group.
Color and gloss measurements were performed before and after each aging cycle by means of mechanical
abrasion with a toothbrush. Groups were compared using Kruskal-Wallis test and paired post hoc Conover
test. Changes within a group were calculated using Wilcoxon signed-rank test (α = .05). Results: The color
difference (∆E) was statistically significant for all stained CAD/CAM materials after simulated aging: CER (P <
.001, 95% CI: 2.96 to 3.69), LVU (P = .004, 95% CI: 1.09 to 1.46), ENA (P = .004, 95% CI: 0.20 to 0.42), and
VM2 (P < .001, 95% CI: 0.29 to 1.08). Aging resulted in a statistically significant increase in gloss in the LVU
group (P < 0.001, 95% CI: 13.78 to 17.29), whereas in the ENA (P < .001, 95% CI: 7.83 to 12.72), CER (P <
.001, 95% CI: 2.69 to 8.44), and VM2 (P = .014, 95% CI: 0.22 to 1.87) groups, a significant decrease in gloss
was noted. Conclusion: Color and gloss of stained resin-ceramic CAD/CAM materials changed significantly
after aging by means of toothbrush abrasion in vitro. Int J Prosthodont 2021;34:79–87. doi: 10.11607/ijp.7019

T
he esthetic success of an indirect restoration represents a significant challenge in
reconstructive dentistry, as the color and surface quality of a restoration should
ideally match the optical properties of the neighboring dentition. Today, a variety
of reconstructive materials are available depending on the amount of tooth substance
Correspondence to:
that needs to be replaced and the design of the restoration.1 Dr Sven Mühlemann
Traditionally, all-ceramic restorations are designed with a combination of two lay- University of Zurich, Center
of Dental Medicine, Clinic of
ers of ceramic material, including a core material and a veneer layer. The core and
Reconstructive Dentistry
ceramic veneer materials are available in a wide range of colors and different grades Plattenstrasse 1,
of translucencies, influencing the esthetic outcome of a restoration.2,3 Dental techni- CH-8032 Zurich, Switzerland
Fax: +41 44 634 34 54
cians face a challenge when selecting the correct material to achieve an optimal color
Email: sven.muehlemann
match of the restoration with the natural tooth.4–6 Additionally, it is a time-consuming @zzm.uzh.ch
fabrication process. CAD/CAM technologies have increased time efficiency for the
Submitted March 24, 2020;
processing of ceramic materials.7,8
accepted July 1, 2020.
At the same time, this technology has enabled the chairside fabrication of indirect ©2021 by Quintessence
monolithic restorations. These monochromatic ceramic or resin-ceramic restorations, Publishing Co Inc.

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 Fundamental Research

Table 1 Chemical Composition and Manufacturers of the Tested CAD/CAM Materials

Brand
Group Type (manufacturer) Composition (manufacturer’s information)
CER Resin nanoceramic Cerasmart (GC) 71 wt% nanoceramic fillers (silica 20 nm, barium glass 300 nm)
Acrylate polymer network (Bis-MEPP, UDMA, DMA)

ENA Polymer-infiltrated VITA Enamic (VITA 86 wt% (65 vol%) nanoceramic fillers (zirconia filler 4–11 nm, silica filler 20 nm,
ceramic network Zahnfabrik) aggregated zirconia/silica cluster filler
10 wt% (35 vol%) acrylate polymer matrix (Bis-GMA, UDMA, Bis-EMA, TEGDMA)

LVU Resin nanoceramic Lava Ultimate (3M 80 wt% (65 vol%) nanoceramic fillers (zirconia filler 4–11 nm, silica filler 20 nm,
ESPE) aggregated zirconia/silica cluster filler)
10 wt% (35 vol%) acrylate polymer matrix (Bis-GMA, UDMA, Bis-EMA, TEGDMA)

VM2 Feldspathic ceramic VITA Mark II (VITA < 20 wt% feldspathic particles (average particle size 4 μm)
Zahnfabrik) > 80 wt% glass matrix

Bis-MEPP = bisphenol A ethoxylate dimethacrylate; UDMA = urethane dimethacrylate; DMA = dimethacrylate; Bis-EMA = bisphenol ethylene methacrylate;
Bis-GMA = bisphenol A-glycidyl methacrylate; TEGDMA = tri-ethylene-glycol-dimethacrylate.

however, often do not meet high esthetic demands.9
To improve esthetic parameters and translucency, the
crystalline part or filler content is decreased, resulting
in lower mechanical properties.10 However, a clinical
study showed that even multicolored CAD/CAM mate-
rials resulted in lower esthetic outcomes compared to
individually stained CAD/CAM materials.11
To increase the color match of monolithic resin-ceram-
ic restorations with the neighboring dentition, staining
may be applied easily and quickly by chemical condition-
ing of the surface and light curing. A median ∆E of 1.8
as a threshold for detecting a color difference (∆E) on
the tooth substance level was calculated.12
Although a clinically excellent color match may be
achieved immediately after placement of the restora-
tion, color change over time is a frequent phenomenon
in clinical practice.13 An in vitro study demonstrated sig-
nificant color changes at clinically unacceptable levels in
composite resin specimens after toothbrush abrasion.14
Another study investigated color stability of inlay restora-
tions produced with two ceramic CAD/CAM materials and
one resin-ceramic CAD/CAM material.15 The highest color
change was seen in the resin-ceramic CAD/CAM material,
with a clinically relevant color change of ∆E = 9.3. Simi-
larly, ceramic CAD/CAM materials showed better color
stability than resin-ceramic materials after UV aging.16 In
contrast, thermocycling showed less color change in resin-
ceramic CAD/CAM materials.17 The surface quality of an
indirect restoration is another important factor that con-
tributes to its esthetic success. Gloss is a measure of the
ability to reflect light and therefore an essential require-
ment for good esthetic appearance.18 Machine-polished
enamel resulted in a mean gloss value of 53 gloss units
(GU), whereas the gloss value of polished zirconia reached
126 GU.19 The higher the gloss of the restoration surface,
the better it may match the neighboring teeth.20 It was
demonstrated that in vitro tooth brushing decreased gloss
values from 69.7–81.3 GU to 18.1–32.3 GU in resin com-
posite materials and that higher filler load resulted in
higher gloss values.21 When CAD/CAM materials were
evaluated, brushing caused only slight gloss reductions
on polished silicate ceramics, whereas in polished ceramic
materials containing polymer acrylate matrix, a 27% to
29% loss of gloss was observed.19
The oral environment may alter the color and gloss of
an indirect restoration due to mechanical stress induced
by mastication and the use of cleaning devices. More-
over, wear of tooth substance and restoration material
is a common phenomenon, where the abrasiveness of
a toothpaste and the type of restoration may have an
influence on the amount of wear.19,22,23
Today, a large variety of different resin-ceramic CAD/
CAM materials exist for the fabrication of monolithic
restorations. Yet, no scientific data are available on the
color and gloss stability of individually stained resin-
ceramic CAD/CAM materials.
Therefore, the aim of this in vitro study was to evalu-
ate the color and gloss changes of stained and polished
resin-ceramic CAD/CAM materials exposed to simulated
aging by means of tooth brushing compared to an all-ce-
ramic CAD/CAM material. The null hypothesis tested was
that simulated aging would not change color or gloss
in any of the stained and polished CAD/CAM materials.
MATERIALS AND METHODS
Three resin-ceramic materials were selected for the
present study: two resin nanoceramics (Lava Ultimate
[LVU], 3M ESPE; Cerasmart [CER], GC) and a polymer-
infiltrated ceramic (VITA Enamic (ENA), VITA Zahnfabrik).

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 Muhlemann et al

Table 2 Staining Materials of CAD/CAM Materials Used in the Study

Primer Application Composition (manufac- Brand, color Composition (manufacturer

Group (manufacturer) time turer information) (manufacturer) information)
Cerasmart Ceramic Primer 60 s Silane, phosphoric acid Optiglaze Color, color Methylmethacrylate,
(GC) II (GC) esther monomer, methacrylic red brown (GC) multifunctional acrylate, silica
monomer, ethanol filler, pigments, initiator

VITA Enamic 25–50% methylmethacrylate, 25–

Stain Liquid (VITA 50% aromatic urethanacrylate,
Zahnfabrik) < 2.5% diphenyl (1, 4,
6-trimethlbenzol) porphinoxide

VITA Enamic Stain, 50–100% silica, 2.5–10%

1–2 wt% 3-MAOPTM-silane, 3 Brown cristobalite, 2.5–10: titanoxide, <
VITA Vitasil (VITA
300 s 49–50 wt% ethanol, 49–50 2.5% dibenzoylperoxide, <2.5%
Enamic Zahnfabrik)
wt% water dicyclohexylphthalate

VITA Enamic Glaze 20–50% methylacrylate,

10–25% acrylic resin, 2.5–10%
propenoic, 2.5–10% diphenyl
(2,4,6-trimethylbenzoyl)
phosphinoxid
Lava Scotchbond 20 s MDP, DMA, HEMA, Synfony Magic Modified glass powder, 2 methyl-
Ultimate Universal Vitrebond copolymer, filler, Intensivfarben, 3-(trimethoxysilyl)propylester,
(3M ESPE) ethanol, water, silane, no. 13 (3M ESPE) dicyclopentyldimetien diacrylat,
initatiors diurethande dimethacrylate,
glass-ionomer fillers, silane, silica
N/A N/A N/A VITA Akzent Plus Feldspathic ceramic powder,
Effect Body Stains, butanediol, glycerin
VITA Mark no. 556 (VITA
2 Zahnfabrik)
VITA Akzent Plus Feldspathic ceramic powder,
Glaze Paste, no. 581 butanediol, glycerin

Feldspathic ceramic (VM2; VITA Mark II; VITA Zahnfabrik)
served as the control, fulfilling the criteria of being an
all-ceramic material and not in need of further sinter-
ing procedures after computer-assisted manufacturing.
The chemical composition of each CAD/CAM material
is listed in Table 1.
Thirty specimens were cut from each CAD/CAM ingot
(size 14 x 12 x 18 mm3) at a thickness of 2.5 mm with
a saw microtome (SP1600, Leica Microsystem). The cir-
cumference of each specimen was manually rounded by
means of a diamond bur (879L/FG314, Torpedo Lang)
to prevent damage to the brushes during aging. The
specimens were adhesively fixed (ScandiQuick, Scan-Dia)
to the specimen carrier (REM carrier, Zeiss).
In the polished group of each CAD/CAM material,
ground specimens (n = 15) were polished under water
cooling in a standardized manner using a polishing ma-
chine (Planopol 2, Struers) at 300 revolutions per minute
(rpm) and 3 consecutive silicon carbide papers for 15
seconds each (P1200, P2500, P4000 MicroCut, Buehler).
Manual finishing was applied by means of polishing felt
(12 MicroCloth PSA, Buehler) and a polishing suspension
(MasterMet 0.05 µm, Buehler).
In the stained group of each CAD/CAM material, spec-
imens (n = 15) were roughened in a standardized manner
using a grinding machine (Planopol, Struers) at 300 rpm
and 15-µm abrasive paper (custom-made, Intensiv) for
15 seconds. Thereafter, the surfaces of all specimens
were airborne–particle abraded with 50 µm aluminum
oxide (1 bar at 1-cm distance for 10 seconds; Feinstrahl-
gerät FG 2-77, Unitool). Staining procedures were ap-
plied according to each manufacturer’s instructions.
The chemical composition and application procedure
of each staining kit are listed in Table 2. Polymerization
was executed in a standardized sequence with pho-
topolymerization (Bluephase Polywave 380–515 nm,
Ivoclar Vivadent) for 90 seconds, followed by use of
a laboratory polymerization device (Visio Beta Vario,
program 1, 3M ESPE) for 15 minutes under a vacuum.
This allowed standardized conditions, as an in vitro study
demonstrated that photoinitiators or synergists that
have not completely reacted may lead to reduced color
stability due to their further polymerization process.24
In the control group, feldspathic ceramic staining was
achieved in a two-step procedure with stain and glaze
firing (Austromat D4 X, program 2, DEKEMA).

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 Fundamental Research

Table 3 Mean ∆E Values of CAD/CAM Materials After Simulated Aging

CER ENA
Polished Stained Polished Stained
Mean ± SD Range Mean ± SD Range Mean ± SD Range Mean ± SD Range
1y 0.62 ± 0.18 0.31–1.03 0.78 ± 0.25 0.47–1.26 0.23 ± 0.25 0.09–1.08 0.28 ± 0.10 0.14–0.41

2y 0.83 ± 0.28 0.31–1.43 1.47 ± 0.55 1.47 ± 0.55 0.18 ± 0.04 0.14–0.24 0.27 ± 0.13 0.10–0.59

3y 0.90 ± 0.21 0.61–1.18 2.47 ± 0.45 2.47 ± 0.45 0.21 ± 0.05 0.16–0.27 0.35 ± 0.15 0.18–0.68

4y 0.88 ± 0.16 0.71–1.16 2.94 ± 0.61 2.94 ± 0.61 0.23 ± 0.04 0.12–0.31 0.26 ± 0.14 0.16–0.63

5y 0.88 ± 0.20 0.53–1.22 3.35 ± 0.53 2.47–4.14 0.23 ± 0.04 0.16–0.29 0.31 ± 0.15 0.17–0.61

CER = Cerasmart; ENA = VITA Enamic; LVU = Lava Ultimate; VM2 = VITA Mark II.

Aging was simulated by means of tooth brushing in
a custom-made device (ZMB 8, Center of Dental Medi-
cine, University of Zurich; 60 cycles per minute) using a
toothbrush (PARO M43, Esro) at a standardized pressure
of 2.5 N in a toothpaste slurry containing a toothpaste of
100 radioactive dentin abrasion (RDA).25 Toothbrushes
and toothpaste slurry were changed every 3 hours and
every 48 hours of use, respectively. One aging cycle
consisted of 7,300 tooth brushing strokes, and a total
of 5 cycles were applied. It is estimated that 1 year of
clinical service may be simulated by 3,650 cycles (7,300
tooth brushing strokes), assuming that a tooth surface is
brushed with 20 strokes per day.26 Experiments started
with 15 specimens per group, and after each simulated
year of aging, one random specimen was removed for
further microscopic analysis in a separate study. Surface
gloss measurements were carried out before aging and
after each aging cycle using a glossmeter (ZGM 1020
Glossmeter, 45-degree mini-measuring head, Zehntner).
Three measurements per specimen were made in both
the lateral and longitudinal directions, and a mean gloss
value (gloss unit [GU]) was calculated per specimen.
Gloss values may range between 0 GU (perfectly matte
surface) and 100 GU (highly polished reference surface).
The colors of all specimens were measured accord-
ing to the recommendations by the Commission Inter-
nationale de l´Eclairage (CIE).27 This system provides a
numeric description in a 3D color space by means of
three coordinate values (L*, a*, b*). The L* coordinate
refers to brightness and is an achromatic coordinate
ranging from black (0) to white (100) on the y axis. The
a* and b* values are chromatic coordinates representing
the red to green chroma on the x axis and the yellow
to blue chroma on the z axis, respectively.28 A spectro-
photometer (CM-A145, Konica Minolta; SpectraMagic
NX software) was used at baseline and after each aging
cycle. The spectrophotometer was calibrated before each
measurement session. The measurements were made
from each specimen surface. The color difference (∆E)
between two specimens was calculated by the equation:
∆E = [(∆L)2 + (∆a)2 + [(∆b)2]1/2.27
Data were coded in Excel, and statistical analysis was
done with the statistical software R (R Foundation for
Statistical Computing; www.R-project.org), with the
software package PMCMR29 for pairwise post hoc com-
parisons using rank s and software package ggplot2.30
Comparisons at baseline between material groups were
calculated with Kruskal-Wallis test followed by Wilcox-
on signed-rank test. Resulting P values were corrected
with Holm adjustment for multiple testing. Longitudinal
changes for each material group were analyzed using
Wilcoxon signed-rank test, and the respective 95% CI
were calculated. The level of significance was set at α =
.05, and the 95% CI were interpreted.
RESULTS
The mean color difference (∆E) values of the stained
and polished CAD/CAM materials after each aging cycle
are presented in Table 3. Statistically significant differ-
ences were observed after five aging cycles in all stained
groups (CER: P < .001, 95% CI: 2.96 to 3.69; ENA: P <
.004, 95% CI: 0.20 to 0.42; LVU: P < .004, 95% CI: 1.09
to 1.46; VM2: P < .001, 95% CI: 0.29 to 1.08), as well
as in all polished groups (CER: P < .004, 95% CI: 0.74
to 1.04; ENA: P < .004, 95% CI: 0.20 to 0.26; LVU: P
< .004, 95% CI: 0.22 to 0.49; VM2: P < .001, 95% CI:
0.13 to 0.74) after five aging cycles. When interpreting
the 95% CI, clinical relevance was limited to the stained
CER group (2.96 to 3.69) (Fig 1).
The mean surface gloss values of the stained and pol-
ished CAD/CAM materials before and after each aging
cycle are shown in Table 4. Except for the ENA group,
the staining process resulted in significantly lower gloss
values at baseline in the tested CAD/CAM materials (P
< .001).

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LVU VM2
Polished Stained Polished Stained
Mean ± SD Range Mean ± SD Range Mean ± SD Range Mean ± SD Range
0.31 ± 0.08 0.23–0.41 0.45 ± 0.15 0.20–0.82 0.14 ± 0.11 0.05–0.46 0.62 ± 0.49 0.08–2.06

0.30 ± 0.14 0.13–0.58 0.75 ± 0.28 0.26–1.17 0.18 ± 0.17 0.10–0.75 0.66 ± 0.29 0.14–1.14

0.35 ± 0.19 0.07–0.67 1.05 ± 0.27 0.76–1.57 0.20 ± 0.15 0.10–0.58 0.72 ± 0.64 0.17–2.52

0.35 ± 0.10 0.14–0.46 1.26 ± 0.20 0.97–1.36 0.23 ± 0.24 0.10–0.56 0.64 ± 0.41 0.28–1.74

0.35 ± 0.20 0.09–0.82 1.27 ± 0.26 0.97–1.73 0.32 ± 0.39 0.07–0.28 0.62 ± 0.51 0.21–1.03

Stained Polished

CER
3 ENA
LVU
VM2
∆E

0 1 2 3 4 5 0 1 2 3 4 5
Simulated aging (y)

Fig 1 Color change (∆E) values of CAD/CAM materials over the course of the study. CER = resin nanoceramic
(Cerasmart); LVU = resin nanoceramic (Lava Ultimate); ENA = polymer-infiltrated ceramic (VITA Enamic); VM2 = feld-
spathic ceramic (VITA Mark II).

Within the stained CAD/CAM materials, mean gloss
measurements ranged from 5.6 ± 1.1 (LVU) to 45.3 ±
2.5 (ENA). A significant difference in surface gloss was
calculated among all groups (P < .001). The LVU group
showed the significantly lowest, whereas the ENA group
showed the highest surface gloss. After five cycles of ag-
ing, the mean surface gloss measurements ranged from
21.4 ± 2.7 (LVU) to 35.0 ± 4.3 (ENA) in the stained CAD/
CAM materials. Aging resulted in a significant increase in
surface gloss in the LVU group (P < .001, 95% CI: 13.78
to 17.92), whereas a significant decrease was observed
in groups ENA (P < .001, 95% CI: 7.83 to 12.72), CER (P
< .001, 95% CI: 2.69 to 8.44), and VM2 (P = .014, 95%
CI: 0.22 to 1.87) (Fig 2).
Within the polished CAD/CAM materials, the surface
gloss at baseline ranged from 42.5 ± 4.7 (ENA) to 52.7 ±
1.9 (VM2), and after aging from 47.0 ± 2.3 (ENA) to 52.8
± 0.5 (CER). In the ENA group, the lowest gloss value was
observed, and significant differences were calculated
between groups (CER: P = .004; LVU: P < .001; VM2: P <
.001). No significant difference was found between LVU
and VM2 (P = .610). After five aging cycles, a statistically
significant increase in mean surface gloss was calculated
for the CER (P < .001, 95% CI 2.89 to 5.34) and ENA (P
< .024, 95% CI: 0.37 to 8.76) groups (Fig 2).

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Table 4 Gloss Values of CAD/CAM Materials Before and After Simulated Aging
CER ENA
Polished Stained Polished Stained
Mean ± SD Range Mean ± SD Range Mean ± SD Range Mean ± SD Range
0y 48.7 ± 1.7 46.2–51.3 38.2 ± 6.4 25.0–45.6 42.5 ± 4.7 34.7–49.7 45.3 ± 2.5 41.2–48.6

1y 53.1 ± 0.6 52.4–53.8 33.9 ± 4.1 27.2–40.3 45.4 ± 3.7 39.7–51.1 43.0 ± 3.0 37.2–46.4

2y 52.4 ± 0.8 50.5–53.2 34.4 ± 3.8 25.5–38.1 46.1 ± 1.6 44.2–48.8 40.6 ± 3.1 36.1–44.0

3y 52.3 ± 1.2 49.5–54.5 34.6 ± 4.4 24.8–39.6 46.7 ± 2.1 43.9–50.0 39.3 ± 3.1 34.2–43.8

4y 52.9 ± 0.7 51.7–54.3 34.4 ± 5.0 23.7–40.7 47.7 ± 1.6 45.4–50.5 37.8 ± 3.8 30.3–43.8

5y 52.8 ± 0.5 52.1–53.6 32.7 ± 4.4 24.1–38.4 47.0 ± 2.3 43.6–50.5 35.0 ± 4.3 29.3–42.7

CER = Cerasmart; ENA = VITA Enamic; LVU = Lava Ultimate; VM2 = VITA Mark II.

CER ENA LVU VM2

60 –
52
1
0 77
50 – 3 77
*
Polished specimens (GU)

53 70
*50 50 *
50 50
40 – 50

30 –

20 –

10 –

0–

60 –

50 –
Stained speciments (GU)

40 –

43
30 –
21
86

20 –
66 65
63
*
10 – 56
*
58

0–

0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5 0 1 2 3 4 5

Simulated aging (y)

Fig 2 Gloss values (gloss units [GU]) of CAD/CAM materials over the course of the study. CER = resin nanoceramic (Cerasmart); LVU = resin
nanoceramic (Lava Ultimate); ENA = polymer-infiltrated ceramic (VITA Enamic); VM2 = feldspathic ceramic (VITA Mark II).

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 Muhlemann et al

LVU VM2
Polished Stained Polished Stained
Mean ± SD Range Mean ± SD Range Mean ± SD Range Mean ± SD Range
52.1 ± 5.3 38.5–56.4 5.6 ± 1.1 4.7–7.6 52.7 ± 1.9 50.0–55.8 29.9 ± 3.0 24.3–34.2

50.0 ± 4.3 40.2–55.6 18.8 ± 2.3 13.2–21.0 52.2 ± 0.8 50.8–53.3 29.3 ± 3.4 22.8–34.6

49.2 ± 4.2 40.0–55.5 19.9 ± 2.2 15.7–23.4 50.7 ± 2.4 44.4–53.2 29.1 ± 3.2 22.8–34.6

50.0 ± 3.1 44.2–54.5 21.3 ± 2.8 16.9–26.4 51.4 ± 0.8 50.0–52.2 29.0 ± 3.4 22.1–34.1

51.2 ± 3.4 44.5–54.7 23.1 ± 4.2 16.2–31.1 51.6 ± 1.0 49.3–52.6 28.2 ± 3.2 21.0–32.2

50.3 ± 3.1 42.8–54.7 21.4 ± 2.7 17.7–26.1 51.6 ± 0.4 50.8–52.2 28.6 ± 3.4 22.3–34.4

DISCUSSION specimens of a nanoceramic CAD/CAM material (CER)

The present study showed that simulated aging signifi-
cantly changed the color of stained resin-ceramic CAD/
CAM materials. Thus, the null hypothesis was rejected.
When considering clinical relevance with a threshold
value of ∆E = 1.8,12 only one resin-ceramic CAD/CAM
material exceeded this threshold. In addition, surface
gloss was significantly affected by simulated aging in
stained CAD/CAM materials.
Dental restorative materials must withstand mechani-
cal abrasion induced by mastication or tooth brushing, as
well as temperature changes and constant exposure to
moisture. Depending on the specific product, change in
the esthetic properties of a material may occur over time.
It was demonstrated that the esthetics of all-ceramic
materials changed depending on the mechanical prop-
erties of the material, the variables during processing,
and the environment.5,31 Several aging protocols have
been developed to simulate the optical behavior of re-
storative materials over time. The majority of these tests
included exposure to moisture, temperature changes,
and/or irradiation. In the present study, specimens were
mechanically aged by means of tooth brushing. How-
ever, simulated aging did not include thermocycling and/
or irradiation, which may have affected the results of
the present study.
Statistical analysis indicated significant color differ-
ences (∆E) for all CAD/CAM materials after simulated
aging. A previous study demonstrated that spectropho-
tometric color evaluation shows rather significant results
compared to visual shade matching.32 Therefore, 95%
CI must be considered in the present study in order to
draw clinically relevant conclusions. On the level of tooth
substance, a threshold value of ∆E = 1.8 was postulated
for dentists as well as for laypeople.12 Consequently, clini-
cally relevant color changes were limited to the stained
with a 95% CI between 2.69 and 3.69.
Color change after simulated aging is a common phe-
nomenon. An in vitro study applying aging by means
of thermocycling showed a mean color change of ∆E
= 1.29 for lithium disilicate glass-ceramic specimens
with glazing compared to a color change of ∆E = 0.85
for the same specimens without glazing.33 In contrast,
color changes were reduced with zirconia specimens
when a glazing layer was applied, assuming a protective
effect against aging.34 In the present study, however,
color changes were more pronounced in the stained
specimens compared to the polished specimens.
The present study also demonstrated that unstained
CAD/CAM materials showed color changes after aging. It
may be assumed that the material properties themselves
are influenced by aging, resulting in a color change. The
present study confirms the results of previous in vitro
studies evaluating the color stability of ceramic materials
after aging. It was demonstrated that lithium disilicate
glass-ceramic for CAM processing showed higher color
stability (mean ∆E = 0.85) compared to feldspathic ce-
ramic (mean ∆E = 1.61) after thermocycling.33 Ultraviolet
aging induced a statistically significantly higher color
change in zirconia specimens (∆E = 5.03) compared to
lithium disilicate glass-ceramic specimens (∆E = 0.41).34
Generally, the reported color changes of resin-ceramic
CAD/CAM materials after aging are higher than the ones
observed in the present study. The mean ∆E for the resin
nanoceramic material ranged between 3.22 and 5.22
(LVU) and between 1.9 and 4.53 (ENA) after thermocy-
cling.17 The higher ∆E values in the present study may
be contributed primarily to the different study set-up
including artificial aging by means of thermocycling and
the effect of different resin cements used.
Gloss of restorative materials is also an important
parameter in determining the esthetic success of indirect

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 Fundamental Research
restorations. It has been demonstrated that an indirect
restoration matched the neighboring teeth better when
gloss was present as opposed to unpolished restora-
tions.20 In the present study, the gloss values of the
polished specimens ranged between a mean of 42.5 and
52.7 GU at baseline and between a mean of 47.0 and
52.8 GU after aging. In contrast, an in vitro study showed
a significant decrease of gloss in a resin nanoceramic ma-
terial (CER) from 90.7 to 65.9 GU after toothbrush abra-
sion.35 The initially higher gloss values may be attributed
to the standardized polishing procedure. Manufacturers
of resin-ceramic CAD/CAM materials, however, recom-
mend specific polishing sets, which were not applied
in the present study in an attempt at standardization.
Taking machine-polished enamel with a mean gloss of
53 GU19 as reference, the tested CAD/CAM materials
may be recommended as restorative materials.
The results of the present study, however, showed that
the application of a staining layer significantly reduced
surface gloss, with the exception of one CAD/CAM
material (ENA). Thus, it may be concluded that staining
cannot be recommended for ceramic materials contain-
ing polymer acrylate matrix. However, in the ENA group,
a glazing process was instructed by the manufacturer
after application of the staining layer, whereas in the CER
and LVU groups, no such corresponding product was
available. Moreover, in the LVU group, an even applica-
tion of the staining color was difficult to achieve due to
its rather viscous texture. Because manufacturers do not
provide details about the composition and percentage
of each ingredient, it is not possible to provide a more
detailed explanation for the results in the LVU group.
The aging process resulted in a statistically significant
increase of surface gloss in the LVU group. In this group,
simulated aging induced a polishing effect, whereas in
the other groups, gloss values were significantly reduced.
Again, when interpreting the results and considering
95% CI, a clinically relevant effect was limited to the
resin-ceramic CAD/CAM materials. Unfortunately, no
similar study is available evaluating the gloss retention
of staining layers applied on resin-ceramic CAD/CAM
materials subjected to aging procedures.
CONCLUSIONS
From this study, the following could be concluded:
• Simulated aging significantly affected color change
in the resin-ceramic CAD/CAM materials tested.
• Clinical relevance with a postulated threshold
value of ∆E = 1.8 was limited to one stained resin
nanoceramic CAD/CAM material (CER).
• The application of a staining layer resulted in
significantly lower gloss values, with the exception
of one CAD/CAM material (ENA).
86 The International Journal of Prosthodontics
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NO PART MAY BEREPRODUCED ORTRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THEPUBLISHER.
• Except for feldspathic ceramic, simulated aging
decreased or increased the surface gloss of individually
stained resin-ceramic CAD/CAM materials.
Clinical Implications
The capability for color retention of individually stained
resin-ceramic CAD/CAM materials may be clinically ac-
ceptable, whereas surface gloss may be affected by
aging, depending on the material type.
ACKNOWLEDGMENTS
This study was supported by the Clinic of Reconstructive Dentistry,
Center of Dental Medicine, University of Zurich, Switzerland. Study
materials were provided by GC Corporation, VITA Zahnfabrik, Ivoclar
Vivadent, and 3M ESPE. The authors report no financial interests re-
lated to any products involved in this study and no conflicts of interest.
S.M.: contribution to conception and design, analysis and interpreta-
tion of the data, preparation of the manuscript, approval of final ver-
sion of manuscript; S.S.: acquisition of data, analysis of data, approval
of final version of manuscript; A.I.: contribution to conception and
design, revision of manuscript, approval of final version; T.A.: contri-
bution to conception and design, revision of manuscript, approval of
final version; C.H.: contribution to conception and design, approval
of final version; M.O.: contribution to conception and design, analysis
and interpretation of data, preparation of manuscript, approval of
final version of manuscript.
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Literature Abstract

Success of Surgical Interventions for Direct Dental Implant-Related Injuries to the Mandibular Nerve: A Review
To the best of the authors’ knowledge, there are no guidelines regarding the surgical management of dental implant–related injuries to
the mandibular nerve. This review aims to investigate the success of different surgical interventions. Neurosensory injury to the mandibular
branch of the trigeminal nerve can occur during administration of a local anesthetic, elevation of the flap, preparation for osteotomy, and/
or placement of the implant. Surgical interventions include extraction of the implant, external decompression, internal neurolysis, excision of
a neuroma, neurorrhaphy, nerve grafting, and low-level laser therapy. The following electronic databases were searched: MEDLINE, Embase,
and the Cochrane Library. Primary outcome measures included patient-reported outcomes such as pain and altered sensation. A total of
185 publications were obtained, 21 of which were included in the qualitative synthesis (2 randomized controlled trials, 9 controlled cohort
studies, and 10 case reports/series). All included studies were screened for exclusion criteria and appraised using the Cochrane Risk of Bias
tool, the Newcastle-Ottawa scale, and the modified Newcastle-Ottawa scale. Results were triangulated to evaluate their level of agreement.
The extraction of dental implants less than 36 hours after injury to the mandibular nerve resulted in the most successful resolution of
neurosensory dysfunction. Various microsurgical techniques have shown less success in obtaining neurosensory recovery than extraction
of the implant. However, microsurgery is worthwhile, as it improves neurosensory dysfunction and reduces dysesthesia in the majority
of patients. Direct suturing and external decompression can result in good neurosensory recovery, and nerve grafts are also successful
whenever tension-free direct suturing is not possible. Low-level laser therapy has been shown to achieve some neurosensory improvement.
Fee LM. Br J Oral Maxillofac Surg 2020;58:795–800. References:28. Reprints:LM Fee, 22 The Crescent, Clontarf, Dublin 3, Ireland —Tony Pogrel, USA

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