University of Iowa

Iowa Research Online

Theses and Dissertations

Spring 2011

Relative translucency of ceramic systems for

porcelain veneers
Karine Tenorio Landim Barizon
University of Iowa

Copyright 2011 Karine Tenorio Landim Barizon

This thesis is available at Iowa Research Online: https://ir.uiowa.edu/etd/923

Recommended Citation
Barizon, Karine Tenorio Landim. "Relative translucency of ceramic systems for porcelain veneers." MS (Master of Science) thesis,
University of Iowa, 2011.
https://doi.org/10.17077/etd.rmuujxij

Follow this and additional works at: https://ir.uiowa.edu/etd

Part of the Other Dentistry Commons

RELATIVE TRANSLUCENCY OF CERAMIC SYSTEMS FOR PORCELAIN
VENEERS

by
Karine Tenorio Landim Barizon

A thesis submitted in partial fulfillment

of the requirements for the Master of
Science degree in Operative Dentistry
in the Graduate College of
The University of Iowa

May 2011

Thesis Supervisors: Associate Professor Cathia Bergeron

Professor Marcos A. Vargas
 Copyright by
KARINE TENORIO LANDIM BARIZON
2011
All Rights Reserved
 Graduate College
The University of Iowa
Iowa City, Iowa

CERTIFICATE OF APPROVAL
_______________________

MASTER'S THESIS
_______________

This is to certify that the Master's thesis of

Karine Tenorio Landim Barizon

has been approved by the Examining Committee

for the thesis requirement for the Master of Science
degree in Operative Dentistry at the May 2011 graduation.

Thesis Committee: ___________________________________

Cathia Bergeron, Thesis Supervisor

___________________________________
Marcos A Vargas, Thesis Supervisor

___________________________________
Deborah S Cobb

___________________________________
David G Gratton

___________________________________
Fang Qian

___________________________________
Saulo Geraldeli
 To Gustavo, for his love, patience and support, and for always making me move
forward.
To my parents, for their unconditional love and encouragement.
To all my family and friends, who in one way or another participated in this journey.

ii
 ACKNOWLEDGMENTS

I would like to express my deepest gratitude to my mentor, Dr. Cathia Bergeron,

an example as a person and a professional, who I had an immense pleasure to work with.
Throughout my thesis project, she guided me to the best path and helped me to take the
most appropriate decisions.
My sincere thankfulness also goes to my thesis committee which support,
encouragement and insightful comments were fundamental to the completion of my
work.
I would like to deeply thank Dr. Marcos Vargas, my co-mentor in this project, for
sharing his phenomenal knowledge in translucency studies and color science with me.
Thanks for helping me developing the methodology of my research project and my
critical thinking throughout these years.
Special thanks go to Dr. Fang Qian for providing excellent and detailed statistical
analysis. Thanks for the significant guidance on how to report the results in my thesis and
for the suggestions on my presentation. I am also very thankful to Dr. Saulo Geraldeli for
his friendship and suggestions in my thesis project, and to Dr. David Gratton for sharing
his extensive knowledge in ceramics. Thanks also to Dr. Deborah Cobb, who as program

director was always supportive and willing to help not only in my thesis project but also
in the entire master program.
I would like to acknowledge the manufacturers for their donation of materials:
Ivoclar Vivadent AG (Schaan, Liechtenstein), Vita Zahnfabrik (Bad Sackingen,
Germany) and 3M ESPE (St. Paul, MN, USA). A special thank you to Mr. Douglas
Aunan, senior lab technician, who helped me with the fabrication of my specimens.
My gratitude is also extended to all members of the Operative Dentistry
Department, faculty, staff and graduate students, who directly or indirectly helped me

iii
progress through the master program and finish my thesis. Thanks for making my life
easier and my time in Iowa enjoyable.
Finally, I would like to thank my dear husband Gustavo, without a doubt the
reason I am here, for always believing in my potential and for always being there for me.

iv
 TABLE OF CONTENTS

LIST OF TABLES............................................................................................................ vii

LIST OF FIGURES ......................................................................................................... viii

INTRODUCTION ...............................................................................................................1
Purpose of the Study.........................................................................................3  
Research Hypotheses ........................................................................................3

CHAPTER I LITERATURE REVIEW......................................................................5

Porcelain veneers ..............................................................................................5  
Feldspathic Ceramic .........................................................................................7  
Pressable ceramic..............................................................................................7  
IPS Empress Esthetic.................................................................................7  
IPS e.max Press .........................................................................................8  
VITA PM9...............................................................................................10  
Machinable Ceramic.......................................................................................10  
Vitablocs Mark II ....................................................................................10  
Everest G-Blank ......................................................................................11  
Lava Zirconia...........................................................................................11  
Light and Color...............................................................................................12  
Light Transmission and Translucency............................................................14  
Measurement of Translucency........................................................................15  
Instrumental Measurement of Color and Translucency..................................16  
Spectrophotometer...................................................................................17  
Spectroradiometer....................................................................................17  
Colorimeter..............................................................................................18  
Edge-loss .................................................................................................18  
Natural Teeth Translucency............................................................................20  
Ceramic Translucency ....................................................................................22  
Strength vs. Translucency...............................................................................26  
Visual Assessment of Color and Translucency ..............................................27  
Summary.........................................................................................................29

CHAPTER II MATERIALS AND METHODS.......................................................30

Fabrication of IPS e.maxPress Specimens......................................................32  
Fabrication of IPS Empress Esthetic Specimens ............................................36  
Fabrication of VITA PM9 Specimens ............................................................38  
Fabrication of IPS InLine Specimens .............................................................40  
Fabrication of Vitablock Mark II Specimens .................................................42  
Fabrication of Everest G-blank Specimens ....................................................42  
Fabrication of Lava Zirconia Specimens........................................................43  

v
 Specimen Thickness and Finishing ................................................................44  
Colorimeter Measurements.............................................................................44  
Statistical Methods..........................................................................................48

CHAPTER III RESULTS .........................................................................................49

Samples With Identical Thickness..................................................................49  
Contrast Ratio .................................................................................................53  
Translucency Parameters ................................................................................55  
Assessment of Correlation between CR and TP.............................................57

CHAPTER IV DISCUSSION ..................................................................................59

Variables Affecting Translucency ..................................................................59  
Relative translucency of ceramic systems ......................................................64  
Human Perception ..........................................................................................67  
Correlation between TP and CR .....................................................................68  
Clinical implications.......................................................................................68  
Study Limitations............................................................................................71  
Suggestions for future research ......................................................................72

CONCLUSION..................................................................................................................73

APPENDIX........................................................................................................................74

REFERENCES ..................................................................................................................77  

vi
 LIST OF TABLES

Table
1. Products information......................................................................................................31  
2. Press cycle for IPS e.maxPress HT/200g investment ring.............................................35  
3. Press cycle for IPS e.maxPress LT/200g investment ring. ............................................35  
4. Press cycle for IPS Empress Esthetic / 200g investment ring. ......................................37  
5. Press cycle for VITA PM9 / 200g investment ring........................................................40  
6. Firing cycle for IPS InLine. ...........................................................................................41  
7. Descriptive Statistics of Contrast Ratio (CR) by Materials. ..........................................50  
8. Descriptive Statistics of Translucency Parameter (TP) by Materials. ...........................51  
9. Comparisons of Thickness among Materials................................................................52  
10. Post-hot Multiple Comparisons of CR among Materials.............................................54  
11. Post-hoc Multiple Comparisons of TP among Materials.............................................56  
12. Comparison of ∆L*, ∆a*, and ∆b* among Materials. .................................................57  

vii
 LIST OF FIGURES

Figure
1. The acrylic cylinder was sliced with a precision saw machine (Isomet 1000,
Buehler, Lake Bluff, IL) into slices of approximately 1mm thick and 13mm
diameter. ...................................................................................................................33  
2. Sprueing and Investing. a) Acrylic discs attached to 200g investment ring with a
distance of at least 10 mm between the discs and the silicone ring, and at least
3mm between each disc. b) The investment material was poured into the
silicone investment ring. ...........................................................................................34  
3. The white reaction layer present on IPS e.maxPress samples after divestment. ...........36  
4. Silicone matrix and porcelain slurry. a) Silicone matrix lubricated with IPS
Ceramic Separating Liquid (Ivoclar Vivadent AG, Schaan, Liechtenstein). b)
The porcelain slurry was placed into the silicone matrix over a glass slide and
hand vibrated to eliminate internal voids..................................................................41  
5. Excess of moisture removal. a) The excess moisture was removed by gentle
vibration and slight compression with a clean paper tissue. b) Specimen on
glass slide after silicone matrix removal...................................................................42  
6. Porcelain block sliced with diamond discs in a precision saw machine (Isomet
1000, Buehler, Lake Bluff, IL). ................................................................................43  
7. Specimens were finished flat on a grinding and polishing machine (Rotopol V,
Struers Inc., Cleveland, OH) with wet 120-, 240-, 400-, 600-, 800- and 1200-
grit silicone carbide paper.........................................................................................45  
8. Discs’ final thickness was measured with a digital micrometer (Mitutoyo Corp.,
Kawasaki, Japan). .....................................................................................................45  
9. Tristimulus colorimeter (CR-221 Chroma Meter, Minolta, Osaka, Japan). ..................46  
10. Backgrounds and edge-loss control. a) Black and white background used for
translucency measurements. b) Drop of water was placed in between each
specimen and the background in order to reduce the edge-loss effect. ....................47  
11. Correlation between the translucency parameters (TP) and contrast ratios (CR)
for all specimens. ......................................................................................................58

viii
 1

INTRODUCTION

Since the introduction of acid-etched ceramic in early 1980s (Calamia, 1983;

Horn, 1983), porcelain veneers have been largely used in dentistry (Christensen, 2008).
The ceramics ability to match natural dentition, as well as their durable physical and
optical properties (Kelly, 1996), make them the material of choice to restore demanding
esthetic cases. Clinical studies have shown extremely high success rates for this type of
restoration, which supports the clinical predictability of bonded porcelain veneers (Shaini
et al., 1997; Friedman, 1998; Dumfahrt & Schaffer, 2000; Layton & Walton, 2007; Guess
& Stappert, 2008).
For many years conventional feldspathic porcelains have been considered as a
standard material to provide better esthetic results for porcelain veneers (Magne &
Belser, 2002; Roulet et al., 1995). In the past years, advances in dental ceramics have
introduced stronger porcelains, but the compromise between strength and translucency is
still evident when comparing the translucency to the relative strength values among those
materials (Holloway & Miller, 1997; Spear & Holloway, 2008; Chen et al., 2008).
Recently, a promising lithium disilicate glass ceramic was introduced (IPS e.max
Press), which allows for the fabrication of ceramic crowns on the anterior and posterior

teeth without need for veneering (Heintze et al., 2008) along with the possibility of
fabricating extremely thin anterior veneers. This ceramic material is based on the same
strengthening mode (lithium disilicate) than IPS Empress 2, but with higher translucency
(Stappert et al., 2005; Stappert et al., 2005; Heintze et al., 2008). Moreover, it has been
considered as the strongest and toughest ceramic in the Empress line (Esquivel-Upshaw
et al., 2006). A three-year prospective clinical study considered IPS e.max Press clinical
behavior for posterior crowns similar to that of Procera AllCeram and metal ceramic
crowns (Etman & Woolford, 2010).
 2

It has been shown that the apparent color of natural teeth is the result of the light
reflectance from dentin modified by the absorption and scattering through the enamel
thickness (Seghi et al., 1986). Since the translucency of enamel is greater than that of
dentin (Yu et al., 2009), the human tooth color is determined by the color of the dentin
(ten Bosch & Coops, 1995). Restorative materials should approach optical properties of
natural tooth structure as much as possible to achieve optimal esthetic properties.
The translucency of dental ceramics is mostly affected by their thickness
(Brodbelt et al., 1980; Chu et al., 2007; Heffernan et al. Part I, 2002; O'Keefe et al., 1991;
Ozturk et al., 2008; Yu & Lee, 2009), but it can also be affected by the number of firings
(Ozturk et al., 2008), the luting agent (Barath et al., 2003; Terzioglu et al., 2009), the
background shade (Barath et al., 2003; Li et al., 2009) and the illuminant (Yu & Lee,
2009). Since the thickness has an important effect on the translucency, in-vitro studies are
more likely to be clinically relevant if they compare the translucencies of different
ceramic systems fabricated at the minimal recommended thickness (Chu et al., 2007).
Porcelain translucency is usually measured with the translucency parameter (TP)
or the contrast ratio (CR) (Johnston et al., 1995). The CR is defined as the ratio of
illuminance (Y) of the test material when it is placed over a black background (Yb) to the
illuminance of the same material when it is placed over a white background (Yw) (Liu et

al., 2010). The TP is defined as the color difference (∆E) between a uniform thickness of
a material over a white and a black backing (Johnston et al., 1995).
New all-ceramic systems have been introduced in dentistry. The manufacturers
claim translucent properties comparable to feldspathic porcelains along with better
mechanical resistance. However, there is a lack of information in the literature regarding
the translucency parameters of these new systems at the minimal recommended
thickness.
 3

Purpose of the Study

The purpose of this study was to compare the relative translucency of different
types of ceramic systems indicated for porcelain veneers at minimal recommended
thickness, with different shades and opacities. The following all-ceramic systems were
evaluated: IPS Empress Esthetic (Ivoclar Vivadent AG, Schaan, Liechtenstein); IPS
e.maxPress (Ivoclar Vivadent AG, Schaan, Liechtenstein); InLine (Ivoclar Vivadent AG,
Schaan, Liechtenstein), VITA PM9 (Vita Zahnfabrik, Bad Sackingen, Germany),
Vitablocks Mark II (Vita Zahnfabrik, Bad Sackingen, Germany), Kavo Everest G-Blank
(KaVo Dental GmbH, Biberach/Riss, Germany) and Lava Zirconia (ESPE 3M, St. Paul,
MN, USA). InLine served as a positive control and Lava Zirconia as a negative control.
The specific aim of the project was to compare the translucency of the ceramics at
the minimal recommended thicknesses and evaluate if the translucency of the other
ceramic systems were comparable to that of conventional feldspathic ceramic, which is a
standard for porcelain veneers.

Research Hypotheses
Null Hypothesis (1):
There is no difference in relative translucency between conventional feldspathic

porcelain and the other ceramics investigated.

Alternative Hypothesis (1):
There is a difference in relative translucency between conventional feldspathic
porcelain and the other ceramics investigated.
Null Hypothesis (2):
There is no difference in the relative translucency between different shades of the
lithium disilicate ceramic.
Alternative Hypothesis (2):
 4

There is a difference in the relative translucency between different shades of the

lithium disilicate ceramic.
Null Hypothesis (3):
There is no difference in the relative translucency between different thicknesses
of the lithium disilicate ceramic.
Alternative Hypothesis (3):
There is a difference in the relative translucency between different thicknesses of
the lithium disilicate ceramic.
Null Hypothesis (4):
There is no correlation between contrast ratio and translucency parameter values
of ceramic systems evaluated.
Alternative Hypothesis (4):
There is a correlation between contrast ratio and translucency parameter values of
ceramic systems evaluated.
 5

CHAPTER I
LITERATURE REVIEW

Porcelain veneers
For more than 20 years, porcelain veneers have been largely used in esthetic
dentistry. In the literature, several articles can be found showing high survival rates for
this type of restoration over the years.
Shaini et al. (1997) evaluated, in a retrospective study, the clinical performance of
porcelain laminate veneers over a period of 6.5 years. The authors found higher failure
rates for restorations placed by inexperienced clinicians (students) compared to those
placed by experienced clinicians (staff), 39% and 22% respectively. This study pointed
out the importance of operator’s experience in the clinical success of porcelain veneers.
The failure rates were still higher when compared to other studies, which can be
explained by the fact that the veneers were not etched with hydrofluoric acid, which
compromised the quality of bonding.
Friedman (1998), in a retrospective study, observed 7% failure rate for
approximately 3,500 porcelain veneers placed in a single private practice over a 15-year

period. These results suggest that porcelain veneers are highly predictable.
Dumfahrt and Schaffer (2000) conducted a retrospective evaluation of porcelain
laminate veneers after 1 to 10 years of service and observed a survival rate of over 90%
at 10 years. The authors found a strong trend toward an increased failure rate when the
preparation involved dentin or when the patient had clenching or grinding habit.
Layton and Walton (2007) analyzed, in a prospective study, the outcome of 304
feldspathic porcelain veneers placed in 100 sequential patients by the same operator and
that remained in situ for up to 16 years. The cumulative survival (Kaplan-Meier method)
for veneers was 96% ± 1% at 5 to 6 years, 93% ± 2% at 10 to 11 years, 91% ± 3% at 12
 6

to 13 years, and 73% ± 16% at 15 to 16 years. The marked drop in survival between 13
and 16 years was due to the low number of veneers during this period of time. The
authors concluded that feldspathic porcelain veneers bonded to enamel offer a predictable
long-term restoration with low failure rate.
Guess and Stappert (2008) performed a prospective clinical study to investigate
the long-term behavior of all-ceramic IPS Empress veneers with two different extended
tooth coverage preparations. During the 5-year observation period, IPS Empress ceramic
veneers with overlap and full veneer preparation showed promising survival rates of 97.6
and 100%, respectively.
Della Bona & Kelly (2008) reviewed approximately 50 articles based on a
MEDLINE and PubMed search of English-language peer-reviewed literature focused on
research published between 1993 and 2008. The authors reported failure rates for
porcelain veneers of less than 5% at 5 years and less than 10% at 10 years.
In the last few years, with the advent of new porcelain materials, the no-
preparation/thin veneer concept has received more attention (Christensen, 2008). The
typical advertised thickness of no-preparation veneers is 0.3mm. According to
Christensen (2008), these veneers are not for everybody; however, there are some
patients for whom those are indicated. Although no-preparation veneers present some

disadvantages such as limited translucency, overcontoured and monotone appearance,

they can still be indicated when patients present small teeth, diastemas and teeth in
lingual version (Christensen, 2008).
There are a variety of ceramics that can be used to fabricate porcelain veneers,
each one presenting its advantages, disadvantages and indications. The specific clinical
situation will dictate the most appropriate dental ceramic indicated for porcelain veneers.
 7

Feldspathic Ceramic
Feldspathic porcelains belong to a family called aluminosilicate glasses because
they are primarily composed of minerals called feldspar and are based on silica (SiO2)
and alumina (Al2O3) (Kelly, 2004; Kelly, 2008). Glasses are three-dimensional networks
of atoms having no regular pattern of spacing between nearest or next nearest neighbors;
thus, their structure is amorphous (Kelly, 2008). Dental ceramics that best mimic the
optical properties of enamel and dentin have high glass content (Kelly, 2008).
Ceramic fired over a refractory die is the oldest and still the most widespread
method for fabricating a porcelain piece. This technique presents the following
advantages: no special material is required; extremely sophisticated effects of color and
translucency can be obtained through a full-thickness layering technique; traditional
feldspathic porcelains can be used; and when combined with hydrofluoric acid etching
and silanization, they show extremely reliable bonding to resins (Magne & Belser, 2002;
Roulet et al., 1995).

Pressable ceramic

IPS Empress Esthetic

IPS Empress Esthetic (Ivoclar Vivadent AG, Schaan, Liechtenstein) is a pressable

leucite-reinforced ceramic which belongs to the aluminosilicate glass ceramic family
(Kelly, 2008) and is used for the fabrication of highly aesthetic single-tooth restorations,
as full crowns, inlays, onlays and veneers by means of the PRESS technique (Ivoclar
Vivadent, 2006). IPS Empress Esthetic presents tetragonal leucite fillers (40%-50%) in
its composition, which are incorporated to the amorphous glass phase to improve the
strength and fracture resistance (Giordano, 1999; Kelly, 2004; Chen et al., 2010).
During the fabrication of the IPS Empress Esthetic ingots, the semi-finished
product in powder form is pressed to ingots in a fully automated process, which enables a
 8

maximum of homogeneity. Given the difference in the coefficients of thermal expansion

(CTE) between the glass phase and the crystal phase (leucite), cooling after sintering
produces compressive stress in the glass phase. This mechanism results in an increase in
strength and enables IPS Empress Esthetic to achieve a flexural strength of 160 MPa.
(Ivoclar Vivadent, 2006).
Dong et al. (1992) confirmed this manufacturer’s information. They observed an
improved strength for Empress with the heat-pressing technique (126-171 MPa), and
stated it could be the consequence of a more homogeneous distribution of leucite crystals
in the glassy phase following processing. In addition, they suggested that the resistance to
surface fracture improved as a result of the differences in the thermal coefficient of
expansion of leucite (27 x 10 -6/oK) and the glass phase (10 x 10 -6/oK), which generates
during cooling “tangential compressive stresses in the glass and radial stresses within the
crystal”. These compressive stresses have a positive effect on the resistance to crack
propagation.
Holand et al. (2000) compared the microstructure and main properties between
IPS Empress and IPS Empress 2. Scanning electron micrographs showed quite different
microstructures when both ceramics were compared. Leucite crystals were indentified in
the glass phase of IPS Empress, while lithium disilicate represented the main crystal

phase of IPS Empress 2. The flexural strength of lithium disilicate ceramic (400 ± 40
MPa) was higher than that of leucite glass-ceramic (112 ± 10 MPa). Additionally, the
lithium disilicate ceramic demonstrated translucency (CR = 0.55) comparable to that of
leucite glass-ceramic (CR = 0.58).

IPS e.max Press

The IPS e.max Press (Ivoclar Vivadent AG, Schaan, Liechtenstein) system is a
castable glass ceramic, composed primarily of a modified lithium disilicate glass ceramic.
This glass matrix consists of micron-sized lithium disilicate crystals between which are
 9

submicron lithium orthophosphate crystals (Etman & Woolford, 2010). It is considered as

the strongest and toughest ceramic in the Empress line (Esquivel-Upshaw et al., 2006).
Because of its higher translucency, IPS e.maxPress material can either be used as a core
or to build a full crown, inlay, onlay or veneer (Heintze et al., 2008).
The shades of the Press ingots offered in the IPS e.max system are all coordinated
with each other. They are available in different degrees of opacity and/or translucency.
The selection of the translucency level is based on the clinical requirements (shade of the
prepared tooth, desired tooth shade) presented by the patient, as well as the desired
processing technique. The more opaque HO and MO ingots are predominantly suitable
for the layering technique, while the more translucent LT and HT ingots are used for the
cut-back and also the staining technique (Ivoclar Vivadent, 2009).
In the first year results of a clinical study, Esquivel-Upshaw et al. (2006) observed
that the mean occlusal wear of enamel opposing the lithium disilicate based core ceramic
was significantly higher than the measured wear rate of mature enamel when 3-unit
posterior FPDs were placed. They assumed that the increased enamel wear could be
associated with the surface roughness of lithium disilicate ceramic.
Suputtamongkol et al. (2008) characterized the clinical performance and wear
characteristics of lithium disilicate-based ceramic crowns after one year. The clinical

performance was rated as good to excellent. The mean occlusal wear volume of ceramic
molar crowns was significantly lower than that of the enamel of the opposing teeth. There
was no significant difference between enamel wear of the opposing teeth and that of the
contralateral teeth.
A three-year prospective clinical study considered IPS e.max Press clinical
behavior for posterior crowns similar to that of Procera AllCeram and metal ceramic
crowns. The authors observed that the wear behavior of IPS e.maxPress was better than
that of Procera AllCeram. The manufacturer claims that the rod-shaped crystals in the IPS
e.maxPress ceramic may act as crack stoppers, increasing resistance to crack propagation
 10

and subsequent fracture. This fact may explain the low failure rate of IPS e.max Press by
fracture for this clinical study (Etman & Woolford, 2010).
Heintze et al. (2008) compared the frequency of failures (fractures, cracks) of
molar crowns made of IPS Empress and IPS e.maxPress Exp during dynamic loading in a
chewing simulator and evaluated their fracture behavior when subjected to static loading
in relation to different loading and luting protocols. Considering only static fracture
loads, there was no significant difference between adhesively luted Empress crowns and
GIC-luted e.max Press Exp. During dynamic loading, fractures and/or cracks occurred
only in Empress crowns. The luting protocol was not critical for e.max Press Exp
survival.

VITA PM9
VITA PM9 (Vita Zahnfabrik, Bad Sackingen, Germany) is a pressable ceramic
composed basically of fine-structure feldspar. This material is used for overpressing
yttrium-stabilized colored ZrO2 frameworks, but is also indicated for inlays, onlays,
partial crowns, veneers and anterior crowns. Its fine structure composition provides high
material homogeneity, excellent milling and polishing characteristics in the laboratory
and in situ, homogeneous and dense surfaces, as well as superior esthetics (Ivoclar
Vivadent technical guidelines). No additional data was found in the literature regarding

this material.

Machinable Ceramic

Vitablocs Mark II
Vitablocs Mark II (Vita Zahnfabrik, Bad Sackingen, Germany) is a machinable
conventional feldspathic ceramic made of a fine-grain particle size. This material is
indicated for the fabrication of inlays, onlays, partial crowns, anterior and posterior full
 11

crowns and veneers. According to the manufacturer, this porcelain presents excellent
clinical results, very good translucency characteristics, distinctive chameleon effect,
excellent enamel-like abrasion characteristics to protect antagonist teeth, can be very
easily polished and present superior adhesive bonding due to excellent etchability (Vita
Zahnfabrik, 2010). Omar et al. (2010) evaluated the effect of three different thicknesses
(0.3, 0.5 and 0.7mm) in the final color of porcelain veneers fabricated with Vitablocs
Mark II ceramic when two different cements were used. The authors verified that
increasing porcelain veneer thickness from 0.5 to 0.7mm did not significantly affect the
final color of cemented veneers, while a thickness of 0.3mm presented significant effect
in the final color.

Everest G-Blank
Everest G-Blank is a leucite-reinforced glass ceramic indicated for veneers,
inlays, onlays and full crowns. This ceramic can be shaded with G-Stain or veneered with
G-Ceram, its compatible veneering ceramic (Everest Material’ brochure, 2010).
According to the manufacturer, Everest G-Blank is a very esthetic material, with
excellent translucency and biocompatibility, and presents flexural strength of 125MPa.
No additional data was found in the literature regarding this material.

Lava Zirconia
The Lava All-Ceramic system utilizes CAD/CAM technology to produce a
densely sintered and high-strength zirconia framework with 3% mol partially yttria-
stabilized zirconia polycrystal content. The yttria-partially-stabilized zirconium oxide
ceramic is milled in a presintered condition by using a computerized milling machine
(Lava Form) and sintered in a special sintering oven (Lava Therm) (Piwowarczyk et al.,
2005).
Baldissara et al. (2010) evaluated the translucency of zirconia copings using the
following CAD/CAM systems with respective thicknesses: Lava Frame (0.3 and 0.5mm),
 12

IPS e.max ZirCAD (0.5mm), VITA YZ (0.5mm), Procera AllZircon (0.6mm), Digizon
(0.6mm), DC Zircon (0.5mm), and Cercon Base (0.4mm). IPS e.max Press (0.5mm) was
used as control. A photoradiometer was used to measure the translucency. The IPS e.max
Press showed the highest translucency value. Among the zirconia ceramics, Lava Frame
was considered the most translucent. The Lava 0.3mm group was significantly more
translucent, while the translucency of Lava 0.5mm was higher than that of other zirconia
groups but not statistically significant. The translucency of Lava 0.3 and 0.5mm was
71.7% and 63.9% of that of IPS e.max Press specimens, respectively.

Light and Color

Light is a form of energy. The light that reaches the eye from each point in a
scene is the product at each wavelength of the spectral reflectance of the objects in the
scene and the spectral power of the illuminating light source (Paravina & Powers, 2004).
Light is composed of different wavelengths, and the same object viewed under different
light conditions will exhibit a different color, phenomenon known as metamerism (Watts
and Addy, 2001). Therefore, the specular reflection from the reflective surface of a tooth
reveals more of the color of the light than the color of the enamel. Diffuse reflectance, on
the other hand, reveals more of the object’s color. (O’Brien, 1985)

Knowing that the color of an object is strongly influenced by illumination

(O’Brien, 1985; Ahn & Lee, 2008), Ahn & Lee (2008) evaluated the differences in
translucency parameters (TP) of all-ceramic core, veneer and layered specimens relative
to the CIE standard illuminant D65, A and F2. Discs of the following core materials were
fabricated: In-Ceram Spinell Blanks, In-Ceram Alumina Blanks, ADENS Zi-Ceram,
Digident Digizon, Vita 2000 YZ Cubes, Vitablocks Mark II, IPS Empress 2 and VITA
VM 7 (reference material). The specimens were layered with their respective veneer
ceramics reaching a final thickness of approximately 1.5mm. A reflection
 13

spectrophotometer was used to measure the color according to the CIELAB color scale
over white and black backings. TP values were influenced by the type of ceramic, its
thickness and illuminant. According to the type of ceramic, the TP means were as follow:
A3-layered (4.0 ± 1.5) = A2-layered (3.6 ± 1.5) < core ceramic (10.8 ± 4.3) < veneer
ceramic (13.2 ± 2.1). When comparing the TP values by the illuminant regardless of the
type of ceramic, TP means were D65 (8.2 ± 5.0), F2 (8.7 ± 5.2) and A (8.7 ± 5.2). In
daylight condition (D65), translucency of all-ceramic materials was lower than that of
incandescent (A) or fluorescent lamp TP (F2).
In education, industry as well as dentistry, color order systems have been widely
used as a systematic way to arrange colors in a tridimensional space, facilitating color
description and specification (Paravina & Powers, 2004).
Munsell color system is the oldest color order system and has been used in
dentistry to define color in terms of value, hue and chroma (Paravina & Powers, 2004). In
this visual perception system, the value (V) represents the color lightness or darkness,
running from 0 (black) to 10 (white). Munsell chroma (C) represents the intensity of a
particular hue; it is an open-ended scale ranging from 0 (achromatic colors) to maximum
depending on the hues. Finally, Munsell hue (H) is related to the similarity of the sample
to the perceived colors (eg. red, orange, green, blue) or to the proportions of two

perceived colors (Moser et al., 1978; Paravina & Powers, 2004).

Another commonly used color specification system was developed by the
Commission Internationale de l’Eclairage (CIE, International Commission on
Illumination) (Judd et al., 1933; Paravina & Powers, 2004). The CIE system implies the
collection of reflectance data in the visible region of the spectrum, and, by means of
tristimulus colorimetry, the conversion of these data to a set of numerical coordinates,
which define the color of the object measured (Moser et al., 1978). The CIE first
recommendation in color specification was done in 1931. Although it has been revised
over the years, the main principles of this system remain the same. The CIE
 14

recommendation defines three components for perceiving a color: illuminant, object and
observer (Paravina & Powers, 2004).
The CIE has selected incandescent (A) lamplight and daylight (D65) as standard
illuminants, representing the most common illuminating lights in daily life (Ohta et al.,
2006). The most important illuminant is D65 with a correlated temperature of 6500K
(Russel et al., 2000).
In the CIE system, the color sample’s spectral distribution curve and the spectral
power distribution of the selected illuminant are combined to obtain three stimulus values
X, Y, Z. These values can be transformed to L*, a* and b* values which represent a
uniform color space. L* is a measure of lightness similar to Value (V) in the Munsell
system. The a* and b* values represent positions on a red/green and yellow/blue axis,
respectively (Russel et al., 2000).

Light Transmission and Translucency

Translucency is the relative amount of light transmitted through the material
(Brodbelt et al., 1981). In a natural tooth, translucency is identified when a noticeable
amount of light passes through its proximal and/or incisal aspect due to the presence of
only enamel or a high proportion of enamel compared to the underlying dentin. In the

cervical aspect of the teeth, where the dentin is thicker, the light transmission will be
reduced (Goodacre et al. Interactive Learning).
The translucency of the enamel and dentin is wavelength dependent; the higher
the wavelength, the higher the translucency value (Yu et al., 2009; Cook & McAree,
1985; O'Brien, 1985; Watts & Addy, 2001; Paravina & Powers, 2004). Material thickness
is another factor that affects the translucency (Brodbelt et al., 1980; O’Keefe et al. 1991;
Heffernan et al., 2002 Part I; Shokry et al., 2006; Ozturk et al., 2008; Yu et al., 2009).
O’Keefe et al (1991) measured the spectral transmittance of porcelain veneers with
 15

different thicknesses and opacities. They found that the thickness of a porcelain veneer
was the primary factor affecting light transmission and not the opacity.
Surface gloss also interferes with the correct identification of tooth and porcelain
color due to specular reflection (O’Brien, 1985). There are two forms of transmittance
(specular and diffuse) and each one depends upon the method of measurement. In the
diffuse transmittance, the measurement includes all the light passing through the material
plus all the light scattered in a forward direction. For the specular transmittance, the
measurement excludes the proportion of scattered light that does not reach the detector.
(O’Keefe et al., 1991)
Li et al. (2009) evaluated the optical influence of different colors of core build-up
composites on the resultant color of ceramic-composite combinations, and compared the
color difference between this resultant and Vita Lumin shade guide. IPS Empress 2, In-
Ceram Alumina and Vitablocks Mark II were evaluated. Disc-shaped composite
specimens were fabricated using 10 colors of build-up composites, and then combinations
of ceramic and composite specimens simulated all-ceramic restorations. ∆E values of 53
out of a total of 60 combinations fell within the clinically unacceptable color range (∆E >
3.7) (Johnston & Kao, 1989). The authors concluded that the final color of all-ceramic
restoration was the blend of shade of ceramic and composite core. The results indicated

that the translucency of ceramic would significantly affect the final color of all-ceramic
restorations.

Measurement of Translucency
There are two common parameters used to measure the translucency of dental
materials: Contrast Ratio (CR) and Translucency Parameter (TP).
Contrast Ratio is the ratio between the reflectance of a specimen over a black
background to that over a white background of a known reflectance (Miyagawa et al.,
 16

1981; Liu, 2008; Yu et al., 2009). The CR values are calculated according to the equation
CR = Yb/Yw, in which Yb represents the spectral reflectance of light of the specimen
over a black background and Yw over a white background. The CR value of a totally
transparent material is 0, while the value of a totally opaque material is 1 (Liu, 2008).
Translucency Parameter represents the color difference between a material of
uniform thickness over a black and a white background, and corresponds directly to a
common visual assessment of translucency (Johnston et al., 1995). The Commission
Internationale de l’Eclairage (CIE, International Commission on Illumination)
recommended calculating color difference (∆E) based on CIELAB color parameters
(Commission Internationale de l’Eclairage, 1986). The CIELAB is a nonlinear
transformation of the tristimulus space to agree with Munsell spacing (Paravina and
Powers, 2004) and has been largely used to compare translucency among materials. The
TP values are calculated by using the following equation: TP= [(Lb* - Lw*)2 + (ab* - aw*)2
+ (bb* - bw*)2 ]1/2, where letters “b” and “w” refer to color coordinates over the black and
white backgrounds, respectively.
Thus, the quantitative measurement of translucency is obtained by comparing the
reflectance of light through the specimen over a backing with high reflectance (white
backing) to that of high absorbance (black backing). The recorded measurement is a

result of the light that is reflected back to the measuring device by the backing, after
being transmitted through the specimen.

Instrumental Measurement of Color and Translucency

Various instruments can be used to measure color and translucency of dental
materials, such as spectrophotometers, spectroradiometers or colorimeters.
 17

Spectrophotometer
Spectrophotometers are widely used to measure surface colors. They are
designated to measure the ratio of the light reflected from a sample to the light reflected
from a white reference across the visible spectrum at intervals of 5, 10, or 20 nm. The
results are expressed by spectral reflectance function (Paravina and Powers, 2004).
Spectrophotometers present as advantages the ability to analyze the principal components
of a series of spectra and the ability to convert spectrophotometric measures to various
color measures (Johnston, 2009).

Spectroradiometer
Spectroradiometers were introduced as an alternative to spectrophotometers to
measure color in dentistry. They are designated to measure radiometric quantities:
irradiance (W/m2) and radiance (m2Sr) (Paravina and Powers, 2004). Their units are
expressed by luminance (cd/m2) and illuminance (lux) for spectral radiance and
irradiance, respectively (Paravina and Powers, 2004).
Lim et al. (2010) compared the translucency parameters (TP) of core, veneer and
layered ceramics determined by spectrophotometer (SP) measurements and by
spectroradiometer (SR) measurements. The authors suggested that for both SR and SP
measurements, color-measuring mechanisms appear to be similar. The SR-based TP

values were higher than those measured by the SP. This finding was related to the fact
that SR measurement used a large illuminating area that could result in more reflected
light over the white backing. Materials with high translucency showed larger differences
between the SR- and SP-based measurements, which can be explained by high-
translucent materials having greater edge-loss effect over white backing in the SP-
measurements. Furthermore, the SR illuminating configuration is not restricted through
an aperture, so it can reflect better the human visual perception in clinical conditions.
 18

Although there was a significant difference between the TP values measured by SR and
SP, the measurements were highly correlated (Lim et al., 2010).

Colorimeter
Tristimulus colorimeters can measure color only in terms of tristimulus values
under a fixed set of illuminant and observer conditions. These devices can be very useful
for quantifying the color difference between a pair of specimens for color quality control
purposes (Paravina & Powers, 2004), offering convenience and simplicity for
quantification of the optical properties of esthetic dental materials (Johnston et al., 1996).
Segui et al. (1989) evaluated the performance of three spectrophotometers and
one colorimeter to measure the color of opaque and translucent dental porcelain
materials. Among the devices tested, the colorimeter showed the best performance with
respect to absolute color measurements on both opaque and translucent materials.
Davis et al. (1994) investigated the applicability of the Kubelka-Munk (K-M)
reflectance theory to the porcelain-veneer substrate system using a colorimeter. This
theory is one of the most frequently used theories to predict color matches because it
provides a reflectance model for translucent materials placed on backings of different
colors (Raigan & Johnston, 2001). In their study, Davis et al. (1994) found a good
agreement between the predicted and observed reflectance obtained with a colorimeter,

which demonstrates that the K-M theory offers an accurate prediction for the resultant
colorimetric parameters of veneer porcelain bonded to colored backings. They affirmed
that accuracy of K-M theory adds credence to the continued investigation of a
colorimeter device as a clinical tool in restorative dentistry.

Edge-loss
The edge-loss is a phenomenon that occurs with translucent materials whenever
the light within the sample is scattered to the edges without being absorbed (Bolt et al.,
1994; Yu et al., 2009). Therefore, this lost light is not detected by the sensor of the
 19

spectrophotometer (Bolt et al., 1994; Yu et al., 2009) resulting in loss of accuracy in

color measurements (Ragain & Johnston, 2001).
According to Johnston et al. (1996), the amount of edge-loss is dependent of
several variables: the beam size of the illumination, the direction of the illumination, the
observation geometry of the optical device, the optical characteristics and thickness of the
translucent layer, and the reflectance of the opaque backing.
According to Bolt et al. (1994), as the absorption and scattering properties are
wavelength dependent, consequently the edge-loss is wavelength dependant. The authors
observed that the edge-loss was affected by the window size, as well as the absorption
and scattering properties of the sample. The edge-loss decreased significantly by
increasing spectrophotometer’s window size. However, the window size is limited by the
dimension and shape of the specimens (Bolt et al., 1994), since it was showed that the
observation port should be at least two to three times larger than the beam size to correct
for edge-loss (Hsia, 1976).
Another way to minimize and control the edge-loss is ensuring that the specimen
is in optical contact with the backing, which can be obtained by an interface layer of
aqueous solution in between the specimen and the backing to seal the air space. For that
purpose, some studies have used index-matching liquids, such as a sucrose solution

(Johnston et al., 1996; Davis et al., 1994; Ragain & Johnston, 2001), optical fluid (Ahn &
Lee, 2008; Segui et al., 1989), glycerol and water solution (Molenaar et al., 1999; Wayne
& McAree, 1985), or immersion oil (Liu, 2008), whose refractive index of approximately
1.5 would match that of the backings.
To control the edge-loss effect, some studies have also used a stainless steel
spectrophotometer specimen holder (Johnston et al., 1996; Ragain and Johnston, 2001).
This device surrounds the edges of the samples in a way that they are in optical contact
with the polished aluminum holder and maintain the optical contact with the backing.
 20

Moreover, its mirror-like surface reflects the light flux exiting the edges of the specimen
back into the specimen. (Johnston et al, 1996; Ragain & Johnston, 2001)

Natural Teeth Translucency

Natural teeth are typically composed of a variety of colors, and a gradation occurs
in an individual tooth from the gingival margin to the incisal edge depending upon the
ratio between enamel and dentin thickness (Watts and Addy, 2001). Furthermore, tooth
color is not constant throughout lifetime. Teeth become darker with aging in consequence
of secondary dentin formation, incorporation of extrinsic stains and gradual wear of
enamel allowing a greater influence on color from the underlying dentin (Watts and
Addy, 2001).
The human tooth structure scatters much of the incidental light. In such light
scattering media, the intensity of the incidence light flux is diminished as the light passes
through the medium. The enamel and dentin are not totally homogeneous at the
histological level, which affects scattering and absorption of the light (Paravina &
Powers, 2004).
The translucency of human enamel is also a function of the moisture content, so
that it can be significantly altered by dehydration and fully restored by rehydration

(Brodbelt et al., 1981; O'Brien, 1985). According to Brodbelt et al. (1981), this occurs in
consequence of the replacement of water around the enamel prisms by air and the
difference between the refractive indices of these two components. The refractive index
of dental enamel is 1.7, while that of water and air is 1.33 and 1.00, respectively. This
larger difference will produce a greater scattering at an enamel-air interface (Brodbelt et
al., 1981). Wet enamel presents higher translucency than dried or desiccated enamel.
Drying of enamel would affect its incisal appearance and the color of enamel-dentin
double layer (O’Brien, 1985).
 21

Cook and McAree (1985) investigated the applicability of the Kubelka-Munk (K-
M) theory combined with corrections for surface reflection to composite resins and dental
ceramics. According to the K-M theory, the wavelength dependent parameters K
(absorption) and S (scattering) should be independent of specimen thickness. They found
that K-M theory appears to apply equally well to specimens with either a gloss or matte
surface and that the theory is capable of accurately predicting the reflectance spectra and
color for different specimens thickness with varying backgrounds. The value of ceramics
and composite resins is lower than that of natural dentition, while the chroma is higher.
Most of composite resins and ceramics are capable of matching color (under illuminant
C) of the hard tissues. The contrast ratio for composite resin is ranged between that of
enamel and dentin, as it is required for a material that replaces both tissues in a
restoration. In other hand, the contrast ratio for enamel and dentin type ceramics is lower
than that of their natural analogues, which presumably attempts to compensate for the
opaque backing used in the crown fabrication (Cook & McAree, 1985).
A recent study by Yu et al. (2009) determined the translucency of human tooth
enamel and dentin using two spectrophotometers with different apertures (3mm round
and 3x8mm rectangular). Translucency parameters (TP) and contrast ratios (CR) were
calculated. The authors reported that the bigger the spectrophotometer aperture was, the

higher were the TP values. Furthermore, they identified negative correlation between TP
and CR. TP values increased in direct proportion with wavelength and inverse proportion
with thickness. Human enamel showed lower CIE L*a*b* values than dentin of same
thickness, which means that enamel is darker and more reddish and yellowish in color,
compared to dentin. However, the authors reported that this difference in TP between
enamel and dentin was very small; therefore that tooth color was determined mainly by
dentin, considering the fact that dentin is much thicker than enamel (Yu et al., 2009).
According to Ryan et al. (2010), human dentin presented more variation in
translucency than human enamel. The authors’ intention was to position a representative
 22

enamel or dentin translucency value within the range of all composites studied. However,
they recognized the limitations of having pure enamel or dentin samples of adequate size
and shape to provide accurate translucency measurements. The TP mean (11.6 ± 0.3) of
human enamel was comparable to that of composite resins “enamel” shades, for 2mm
thickness samples. The TP mean (6.6 ± 2.2) of human dentin was between the composite
resins “dentin” and “body” shade groups.
Li et al. (2010) also compared color and translucency of translucent composites
and human enamel. The authors reported significant differences in color parameters
among human enamel and composite resins. These differences varied according to
different brands and ranged from 3.92 to 9.43, which is greater than the clinically
acceptable threshold for color difference. The mean of human enamel translucency
parameter was 28.45 ± 2.2 for 1mm thickness samples.

Ceramic Translucency
Brodbelt et al., (1980) evaluated the translucency of porcelains used in porcelain-
fused-to-metal restorations and conventional feldspathic porcelains. Porcelain specimens
were prepared using four PFM porcelains and one feldspathic porcelain. To assess the
relationship between thickness and translucency, three sections of varying thicknesses

(1.4, 1.0, and 0.8mm) were cut from one of the porcelain samples. The authors noticed
that the transmission of light through dental porcelain was dependent on its thickness.
The multiple scattering (dispersion) of light in dental porcelain affected its translucency.
Most dental porcelains incorporate opacifiers, such as tin oxide, as scattering centers to
provide a translucency appearance by diffuse transmission and scattering, improving the
esthetics of porcelain restorations.
Heffernan et al. (2002 Part I) compared the translucency of 6 all-ceramic systems
core materials at clinically appropriate thicknesses. Five discs (13mm diameter and 0.5
 23

mm thickness) were fabricated for the following systems: IPS Empress dentin; IPS
Empress 2; In-Ceram Alumina; In-Ceram Spinell; In-Ceram Zirconia and Procera
AllCeram. Two additional groups of IPS Empress dentin and IPS Empress 2 were
fabricated according to the minimal thickness recommended by the manufacturer
(0.8mm). Vitadur Alpha dentin and Porc. 52 SF served as controls. All specimens were
fabricated in a corresponding shade to Vita Lumin A2. A spectrophotometer was used to
measure the luminous reflectance (Y) of the specimens over a black (Yb) and white (Yw)
backing to calculate the contrast ratios (CR = Yb/Yw). Significant range of translucency
was found among groups (Difference in CR). Ranking from most translucent to least,
(CR) was: Vitadur Alpha (0.60) > Empress (0.64) > In-Ceram Spinell (0.67) = Empress 2
(0.68) > Procera (0.72) > In-Ceram Alumina (0.87) > In-Ceram Zirconia (1.00) = SF52
alloy (1.00). When Empress and Empress 2 were compared at 0.8mm thickness, the
ranking was different (CR): In-Ceram Spinell (0.67) > Empress (0.72) = Procera (0.72) =
Empress 2 (0.74) > In-Ceram Alumina (0.87) > In-Ceram Zirconia (1.00) = SF 52 alloy
(1.00). Differences in thickness resulted in significant differences in opacity when
comparing Empress and Empress 2 with different thicknesses. The thickness of core
materials can affect its translucency. The authors affirmed that for reliable comparisons
among systems, specimens should be fabricated at clinically appropriate thickness.

The second part of Heffernan et al. (2002) study evaluated the effect of veneering
and glazing on the translucency of all-ceramic systems. The materials and methods were
as described in part I (Heffernan et al. part I, 2002); in addition to the previous methods,
the veneering and glazing process of core porcelain discs were performed achieving a
final thickness of 1.5mm. A glass disc was included as positive control. Quantitative
translucency measurements were performed before and after the glazing process.
Significant differences (CR) were found among veneered specimens, and between glazed
and nonglazed specimens. The glass disc (0.06) and Vitadur Alpha (0.71), IPS Empress
(0.75), In-Ceram Spinell (0.76), and Procera (0.80) glazed specimens were significantly
 24

more translucent than their corresponding nonglazed specimens, 0.27, 0.73, 0.78, 0.78,
0.83, respectively. No significant difference was found in the opacity of glazed and
nonglazed specimens of IPS Empress 2 (0.77 / 0.78), In-Ceram Alumina (0.90 / 0.91), In-
Ceram Zirconia (1.00 / 1.00), and metal-ceramic (1.00 / 1.00). Glazing cycles decreased
the opacity for all veneered materials, except for In-Ceram Zirconia and metal-ceramic
specimens.
Barath et al. (2003) investigated the effect of background color and luting agents
on the final color of IPS Empress 2 and VITA In-Ceram Alumina. Zinc phosphate
(PhospaCEM PL), Glass ionomer (Ketac-Cem) and Resin luting (COMP) agents were
used. The authors verified that IPS Empress 2 was more translucent than In-Ceram
Alumina and that luting agents in combination with the background shade influenced the
final restoration color. Zinc phosphate cement was considered the least translucent, resin
cement the most, and glass ionomer intermediate.
In 2006, Shokry et al. evaluated the effect of varying core and veneer thickness on
the color parameters of IPS Empress (Shade B2) and In-Ceram Spinell (Shade A2). Color
parameters of each porcelain-layered disc against a neutral gray background were
measured with a tristimulus colorimeter. IPS Empress presented higher b* values
(indicating more yellow color) and In-Ceram Spinell presented higher a* values

(indicating more red color), findings consistent with the manufacturer’s information.
Observing the influence of ceramic thickness on contrast ratio (CR) and L* value, it was
clear that translucency of dental ceramics was associated with lower L* values. L* values
(brightness of the specimens) decreased for both systems as the total thickness of the
specimens increased. The L* values of Empress were independent of the core and veneer
thickness; however, the core thickness had significant influence on the In-Ceram Spinell.
The authors concluded that increasing ceramic thickness reduced brightness and
increased the red and yellowish appearance of ceramics.
 25

Chu et al. (2007) compared the contrast ratios (CR) and masking abilities (∆E) of
three types of porcelain veneers (Procera, Empress 2 and Vitadur Alpha). Bilayer veneer
discs were fabricated in Procera and Empress 2, and conventional monolayer veneers
were fabricated in Vitadur Alpha. All specimens (8mm diameter x 0.7mm thickness)
were fabricated of shade A2. A colorimeter was used to measure their illuminance (Y)
and color difference (∆E) over white and black backings. The CR were significantly
different among the ceramics studied as follow: Procera (0.50 ± 0.02) > Empress 2 (0.46
± 0.05) > Vitadur Alpha (0.39 ± 0.02). The color difference (∆E) of the three materials
was as follow: Vitadur Alpha > Procera = Empress 2. Vitadur Alpha was found to be the
most translucent material with the weakest masking ability. Although Procera and
Empress 2 presented higher CR and masking ability, their clinical application may still be
limited when tooth discoloration is too intense.
Ozturk et al. (2008) evaluated the effects of various dentin ceramic thicknesses
and repeated firings on the color of lithium disilicate glass ceramic (IPS e.max Press) and
Zirconia-oxide (DC-Zirkon) all-ceramic. VITA Easyshade was used to measure the color
differences on 4mm diameter ceramic discs. The authors found that the L*a*b* values of
ceramics systems were affected by the number of firings (3, 5, 7 or 9 firings), ceramic
composition, and ceramic thickness (0.5, 1 or 1.5mm). The L* values increased with

higher number of firings, resulting in darker specimens for both all-ceramic systems
evaluated. As the ceramic thickness increased, significant reductions in L* values were
recorded.
Terzioglu et al. (2009) determined the effect of different shades of luting agents
and different thicknesses of IPS Empress ceramics on the final restoration color. A
colorimeter was used to measure the specimen’s color. A color shift (∆E > 3.7) was
observed for all specimens after application of cement layer. Statistically significant
differences in ∆E values were observed between baseline and postcementation; however,
no significant difference was found when different cement shades (A1, A3) were
 26

compared. The composite resin luting cement and increased ceramic thickness reduced
specimens’ brightness.

Strength vs. Translucency

It has been shown in the literature that ceramics with high strength tend to be
more opaque and pose a challenge when trying to match natural tooth color, but they can
mask discoloration when it is present (Spear & Holloway, 2008).
The dispersion of reinforcement particles is the most prevalent method to
strengthen core ceramics. Some reinforcing particles are exceptionally opaque, and the
compromise between strength and translucency becomes evident when comparing the
translucency and the relative strength values of each material (Holloway and Miller,
1997).
Chen et al. (2008) evaluated the relative translucencies and flexural strengths of
all-ceramic core materials and verified that as strength increased, translucency decreased.
The authors measured a translucency range from the most to the least translucent as
follow: IPS Empress 2 dentin (0.78 ± 0.03) > In-Ceram Alumina (0.94 ± 0.01) > In-
Ceram Zirconia (1.00 ± 0.01) = Cercon Base (1.00 ± 0.01). The biaxial flexural strength
(MPa) means from the strongest to the weakest material were as follow: Cercon Base

(910.5 ± 95.3) > In-Ceram Zirconia (592.4 ± 84.7) = In-Ceram Alumina (514.0 ± 49.5) >
IPS Empress 2 dentin (355.1 ± 25.7). The IPS Empress 2 was considered the most
translucent but also the weakest material, which is why it is clinically recommended for
restoration of anterior and premolar teeth when appearance is important and occlusal
forces are not excessive.
Segui and Sorensen (1995) measured the flexural strength of six ceramic
materials and two controls. The modulus of rupture (MPa) means of the tested materials
were significantly different according to the following range: VITA VMK 68 (70.78 ±
 27

6.91) < glass control (92.24 ± 13.04) = IPS Empress polished (97.04 ± 19.11) < Mark II <
(121.67 ± 11.30) = IPS Empress glazed (127.44 ± 17.55) < Dicor MGC (228.88 ± 17.55)
< In-Ceram Spinel (377.62 ± 64.80) < In-Ceram Alumina (446.42 ± 63.97) < In-Ceram
Zirconia (603.70 ± 66.86). Feldspathic porcelain showed the lowest strength among the
tested materials.

Visual Assessment of Color and Translucency

The perception of color by an observer is very subjective, resulting in variations
and unpredictable differences in color evaluation and matching among clinicians
(Ishikawa-Nagai et al., 2009).
There are many factors that can affect the visual color evaluation, like spectral
distribution of the color stimulus, its size, shape and structure; the surroundings of the
stimulus; the state of the observer’s visual system and the observer’s experience
(Ishikawa-Nagai et al., 2009). Clinically, those elements can be identified as change in
ambient lighting, color of the patient’s complexion, make-up, clothing, distribution of the
appearance of the other nearby teeth, and contour and finish of the restoration (Johnston
& Kao, 1989).
Johnston & Kao (1989) evaluated the relationship between two visual criteria and

instrumental colorimetry for color measurement of dental composite veneer restorations.

They found an average CIELAB color difference of those ratings judged as match by the
visual criteria (USPHS) equal to 3.7. Likewise, in Ruyter et al. (1987) study, the
compiled data from the acceptability judgment showed that 50% of the observers
considered that sample pairs were unacceptable when the color difference ∆E*ab was
approximately 3.3.
Liu et al. (2010) evaluated the capability of human subjects to detect differences
in the translucency of ceramic materials determined by a spectrophotometer. Unshaded
 28

feldspathic porcelain 12-mm diameter discs with incremental changes in opacity were
fabricated. The luminous reflectance (Y) of the specimens with a black (Yb) backing and
a white (Yw) backing was recorded and contrast ratios (CRs) were calculated. Thirty-one
observers were recruited to assess the translucency between porcelain discs, divided into
three groups according to their training experience (freshman dental students,
prosthodontic residents, senior faculties). Tests were performed in two light conditions
(reflected or transmitted light), using a GTI light booth, which provided D65 artificial
daylight. The mean Translucency Perception Threshold (TPT) (ΔC) varied for each range
of porcelain opacities, different lighting conditions, and the level of experience of the
observer. The mean TPT (ΔC) observed for the faculty group (0.04) was significantly
lower than that of the student (0.09) and resident groups (0.08). The mean TPT of the
inexperienced subjects was 0.09; therefore a CR difference less than 0.09 may be
considered clinically undetectable to lay people. The overall mean TPT of all subjects
was 0.07, which led to conclude that differences in CR greater than 0.06 between ceramic
restorations and natural teeth may be perceived by 50% of the population. Increased
experience improved the ability to perceive differences in translucency. Neither viewing
conditions nor porcelain opacity affected the TPT.
Ishikawa-Nagai et al. (2009) performed a clinical evaluation of perceptibility of

color differences between natural teeth and all-ceramic crowns. Eleven all-ceramic
crowns (LAVA/Cerabien CZR) for maxillary central incisors with intact contra-lateral
incisors were investigated. These crowns were considered to be “Perfect/Excellent Color
Match” by three experienced experts in color science. Data from twenty patients with
natural intact maxillary central incisors were used as baseline color difference between
virgin central incisors. A dental spectrophotometer was used to determine the color
difference (∆E) between all-ceramic crowns and contra-lateral teeth. The authors
concluded that ∆E = 1.6 represented a color difference that could not be detected by
human eye. This standard for color difference was set for ideal esthetic color matching
 29

for maxillary central incisors; it was not the authors’ aim to establish a perceptibility
threshold that can be generalized for all clinicians.

Summary
Over the years, the number of porcelain materials has increased tremendously in
the market. Several studies have been performed in order to evaluate mechanical and
physical properties of those materials. Since esthetic represents an important factor for
the current society, optical properties like translucency of porcelain materials is the object
of a large number of publications in the literature. Dental materials manufacturers have
invested great effort to come up with new materials that combines esthetic and strength.
Although several studies have been performed to compare translucency among porcelain
materials, no studies comparing the new lithium disilicate ceramic and ceramics indicated
for porcelain veneers were found in the literature. In this context, this study compared the
translucency of different types of ceramic systems indicated for veneers, with various
shades and opacities.
 30

CHAPTER II
MATERIALS AND METHODS

Five discs, 13mm in diameter and 0.7mm in thickness, were fabricated for each of
the following all-ceramic systems: IPS Empress Esthetic (EE); IPS e.maxPress (EP); IPS
InLine (IL), VITA PM9 (VPM), Vitablocks Mark II (VMII), Kavo Everest G-Blank
(KEG) and Lava Zirconia (LZ). IL served as a positive control and LZ as a negative
control. For EP group, additional discs were fabricated to include different shades (BL2,
BL4, A1, B1), a different thickness (0.3mm), as well as different translucencies (high -
HT and low - LT). All other ceramic discs were fabricated with the shade corresponding
to A1 in the Vita Shade Guide (Vita Zahnfabrik). (Table 1)
A total of 60 discs (n=5 per group) were finished flat with 1200-grit wet silicon
carbide paper to provide a high shine. The thickness of each specimen was measured with
a digital micrometer to ensure consistency within the groups and between the groups. The
sample size was determined from a pilot study, in which 5 specimens per group was
sufficient to reveal statistically significant differences, thus adequate statistical power to
reject the main hypotheses.
The luminous reflectance (Y) and color coordinates (CIE L*a*b*) were measured

with a colorimeter (CIE illuminant D65, 2-degree observer function) with the specimens
placed on black and white backgrounds. Contrast ratios (CR = YB/YW) and translucency
parameters (TP= [(LB* - LW*)2 + (aB* - aW*)2 + (bB* - bW*)2 ]1/2) were calculated.
 31

Table 1. Products information.

Material Manufacturer Batch number Shade Thickness

(mm)
Ivoclar Vivadent AG,
IPS InLine M73577 T1 I 0.7
Schaan, Liechtenstein

Ivoclar Vivadent AG,

IPS e.maxPress N01269 HT BL2 0.7
Schaan, Liechtenstein

Ivoclar Vivadent AG,

IPS e.maxPress M73986 HT BL4 0.7
Schaan, Liechtenstein

Ivoclar Vivadent AG,

IPS e.maxPress MM0305 HT B1 0.7
Schaan, Liechtenstein

Ivoclar Vivadent AG,

IPS e.maxPress N10076 HT A1 0.7
Schaan, Liechtenstein

Ivoclar Vivadent AG,

IPS e.maxPress N10076 HT A1 0.3
Schaan, Liechtenstein

Ivoclar Vivadent AG,

IPS e.maxPress N09932 LT A1 0.7
Schaan, Liechtenstein

IPS Empress Ivoclar Vivadent AG,

M45216 ETC 1 0.7
Esthetic Schaan, Liechtenstein

Vita Zahnfabrik, Bad

VITA PM9 1550 ENL P-HT 0.7
Sackingen, Germany

Vita Zahnfabrik, Bad

Vitablocs Mark II 7913 A1C/I12 0.7
Sackingen, Germany

Kavo Everest G- KaVo Dental GmbH,

051002 KT 1 0.7
Blank Biberach/Riss, Germany

ESPE 3M, St. Paul, MN,

Lava Zirconia 359290 N/A 0.7
USA
 32

Fabrication of IPS e.maxPress Specimens

The IPS e.maxPress discs were fabricated by the lost wax and heat-press
techniques, according to the manufacturer’s recommendations. Each IPS e.max Press
group was pressed individually with all five specimens in the same investment ring. One
small IPS e.maxPress ingot was used to press each group.
A silicone-based material (Template Ultra Quick, Clinician’s Choice Dental
Products, Inc., New Milford, CT) was used to form resin patterns to fabricate the IPS
e.maxPress specimens. Pattern resin (Pattern Resin Ls, GC America Inc., Alsip, IL) was
flowed into the silicone matrix resulting in a cylinder. The acrylic cylinder was sliced in a
precision saw machine (Isomet 1000, Buehler, Lake Bluff, IL) into slices of
approximately 1mm thick and 13mm diameter (Figure 1). The acrylic discs were finished
manually with 600-grit dry silicon carbide paper to provide a smooth surface and
thickness of approximately 0.85mm.
Sprueing and investing were done following manufacturer’s instructions. A 10
gauge, 4mm long wax sprue was attached close to the edge of each acrylic disc in an
inclination between 45o and 60o. Five discs were invested per 200g silicone investment
ring, with a distance of at least 10 mm between the discs and the silicone ring, and a
distance of at least 3mm between each disc. The maximum height of the discs and sprue

did not exceed 16 mm (Figure 2a).

Investing was carried out with IPS PressVEST Speed investment system
according to its specific instructions. Two hundred grams of IPS PressVEST Speed
powder was mixed with 32mL of IPS PressVEST Speed liquid and 22mL of distilled
water. It was initially mixed manually for approximately 30 seconds to incorporate all
the powder in the liquid, then mechanically vacuum spatulated for an additional 60
seconds. The investment material was poured into the silicone investment ring with slight
vibration of the ring on a dental vibrator. It was filled up to the marking and the ring
 33

gauge was positioned with a hinged movement, then the investment was allowed to
bench-set for 30 minutes undisturbed (Figure 2b).

Figure 1. The acrylic cylinder was sliced with a precision saw machine (Isomet 1000,
Buehler, Lake Bluff, IL) into slices of approximately 1mm thick and 13mm
diameter.

After removal of the silicone ring, the plastic base and the gauge, the investment
ring was placed in a burnout furnace at 1562 °F for 60 minutes with the opening facing
downward.
The Programat EP 5000 (Ivoclar Vivadent AG, Schaan, Liechtenstein) press
furnace was turned on ahead of time to ensure completion of the self-test and preheating
phase. The press program for IPS e.max Press and 200g-investment ring was selected
according to the ingot shade (high or low translucency) (Table 2 and 3).
 34

a b

Figure 2. Sprueing and Investing. a) Acrylic discs attached to 200g investment ring with a
distance of at least 10 mm between the discs and the silicone ring, and at least
3mm between each disc. b) The investment material was poured into the
silicone investment ring.

After the preheating cycle for the investment ring was completed, it was removed
from the preheating furnace. A cold IPS e.max Press ingot at the desired shade was
placed into the hot investment ring, along with a cold IPS Alox Plunger coated with IPS
Alox Plunger Separator. The completed investment ring was placed in the center of the
hot press furnace, and the previously selected program was started. As soon as the cycle
ended, the investment cylinder was removed from the furnace and placed on a metal grid
to cool evenly to room temperature.
When the investment cylinders were completely cool, the samples were divested.
The length of the Alox plunger was estimated and was recovered by sectioning the
investment ring at the appropriate level using a separating disk. Divestment was carried
out with glass beads at 4 bar (60 psi) pressure.
 35

Table 2. Press cycle for IPS e.maxPress HT/200g investment ring.

Stand-by  Firing  Stop speed

temperature oC o
C/min. temperature min.

700 60 915 25.00 300µm/min

Table 3. Press cycle for IPS e.maxPress LT/200g investment ring.

Stand-by  Firing  Stop speed

temperature oC o
C/min. temperature min.

700 60 917 25.00 300µm/min

After divestment, the reaction layer formed during the press procedure was
removed using IPS e.max Press Invex Liquid. The pressed samples were immersed into
Invex Liquid and cleaned ultrasonically for 15 minutes. Then, the samples were
thoroughly rinsed with water and dried. The white reaction layer (Figure 3) was removed

with type 100 Al2O3 at 2 bar (30 psi) pressure. The sprues were removed with a thin
diamond disc in a laboratory handpiece, with repeated water cooling to avoid ceramic
overheat. The area where the sprue was placed was smoothed with a diamond bur in a
high-speed handpiece with water coolant.
The specimens were then finished, polished, and the measurements were obtained
according to a protocol that will be described later in this chapter.
 36

Figure 3. The white reaction layer present on IPS e.maxPress samples after divestment.

Fabrication of IPS Empress Esthetic Specimens

The IPS Empress Esthetic discs were fabricated by the lost wax and heat-press
techniques, according to the manufacturer’s recommendations. All five specimens were
pressed in the same investment ring. Two IPS Empress Esthetic ingots were used to press
each group.
A silicone-based material (Template Ultra Quick, Clinician’s Choice Dental

Products, Inc., New Milford, CT) was used to form resin patterns to fabricate the IPS

Empress Esthetic specimens. Pattern resin (Pattern Resin Ls, GC America Inc., Alsip, IL)

was flowed into the silicone matrix resulting in a cylinder. The acrylic cylinder was

sliced in a precision saw machine (Isomet 1000, Buehler, Lake Bluff, IL) into slices of

approximately 1mm thick and 13mm diameter (Figure 1). The acrylic discs were finished
 37

manually with 600-grit dry silicon carbide paper to provide a smooth surface and

thickness of approximately 0.85mm.

The sprueing and investing processes followed the manufacturer’s directions. A

10 gauge, 4mm long wax sprue was attached close to the edge of each acrylic disc in an

inclination of approximately 60o. Five discs were invested per 200g silicone investment

ring, with a distance of at least 10 mm between the discs and the silicone ring, and a

distance of at least 3mm between each disc. The maximum height (discs + sprue) did not

exceed 16 mm (Figure 2a).

Investing was carried out with IPS PressVEST Speed investment system,

following an identical protocol than the one used for IPS e.max Press specimens (see

previous section for complete description).

The silicone ring, plastic base and gauge were removed, and the investment ring

was placed in a burnout furnace at 1562 °F for 60 minutes with the opening facing

downward. Two IPS Empress Esthetic ingots and an IPS Alox plunger were pre-heated

along with the investment ring.

After the Programat EP 5000 (Ivoclar Vivadent AG, Schaan, Liechtenstein) press

furnace completed the self-test and preheating phase, the press program for IPS Empress

Esthetic and 200g-investment ring was selected (Table 4).

Table 4. Press cycle for IPS Empress Esthetic / 200g investment ring.

Stand-by  Firing 
temperature oC o
C/min. temperature min. Stop speed

700 60 1075 20.00 250µm/min

 38

Once the preheating cycle for the investment ring was completed, the ring was
removed from the preheating furnace and two hot IPS Empress Esthetic ingots along with
a hot IPS Alox plunger were placed into the hot investment ring. The completed
investment ring was placed in the center of the hot press furnace, and the program was
started. As soon as the cycle ended, the investment cylinder was removed from the
furnace and placed on a metal grid to cool evenly to room temperature.
When the investment cylinders were completely cool, the samples were divested.
The length of the Alox plunger was estimated and the investment ring was sectioned with
a separating disc to recover the plunger. Divestment was carried out with glass beads at 4
bar (60 psi) pressure and at 2 bar (30psi) for fine divestment. The sprues were removed
with a thin diamond disc in a laboratory handpiece, and the samples were repeatedly
immersed in water to avoid overheating the ceramic. The area where the sprue was
placed was smoothed with a diamond bur in a high-speed handpiece with water coolant.
The specimens were then finished, polished and the measurements obtained.

Fabrication of VITA PM9 Specimens

The VITA PM9 discs were fabricated by the lost wax and heat-press techniques,
according to the manufacturer’s recommendations. All five specimens were pressed in

the same investment ring. One VITA PM9 ingot was enough to press the entire group.
A silicone-based material (Template Ultra Quick, Clinician’s Choice Dental
Products, Inc., New Milford, CT) was used to form resin patterns to fabricate the
specimens. Pattern resin (Pattern Resin Ls, GC America Inc., Alsip, IL) was flowed into
the silicone matrix resulting in a cylinder. The acrylic cylinder was sliced in a precision
saw machine (Isomet 1000, Buehler, Lake Bluff, IL) into slices of approximately 1mm
thick and 13mm diameter (Figure 1). The acrylic discs were finished manually with 600-
 39

grit dry silicon carbide paper to provide a smooth surface and thickness of approximately
0.85mm.
The sprueing and investing processes followed the manufacturer’s directions. A
10 gauge, 4mm long wax sprue was attached close to the edge of each acrylic disc in an
inclination of approximately 60o. Five discs were invested per 200g silicone investment
ring, with a distance of at least 10 mm between the discs and the silicone ring, and a
distance of at least 3mm between each disc. The maximum height (discs + sprue) did not
exceed 16 mm (Figure 2a).
Investing was carried out with IPS PressVEST Speed investment system,
following an identical protocol than the one used for IPS e.max Press specimens (see
previous section for complete description). According to VITA PM9 manufacturer’s
direct information, the IPS PressVEST Speed investment system is compatible with their
porcelain and safe to use with the same protocol.
The silicone ring, plastic base and gauge were removed, and the investment ring
was placed in a burnout furnace at 1562 °F for 75 minutes with the opening facing
downward.
The Programat EP 5000 (Ivoclar Vivadent AG, Schaan, Liechtenstein) was
programmed according to VITA’s recommendation (Table 5). After completion of its

self-test and preheating phase, the previously set press program was selected.
Once the preheating cycle for the investment ring was completed, the ring was
removed from the preheating furnace, placed in the center of the hot press furnace and a
VITA PM9 ingot along with a IPS Alox plunger were placed into the hot investment ring,
and the program was started. As soon as the cycle ended, the investment cylinder was
removed from the furnace and placed on a metal grid to cool evenly to room temperature.
 40

Table 5. Press cycle for VITA PM9 / 200g investment ring.

Stand-by    Firing  Stop speed

temperature oC min. min. o
C/min. temperature min.

700 0.00 6.00 50 1000 20.00 300µm/min

When the investment cylinders were completely cool, the samples were divested.
The length of the Alox plunger was estimated and the investment ring was sectioned with
a separating disc to recover the plunger. Divestment was carried out with glass beads at 4
bar (60 psi) pressure and at 2 bar (30psi) for fine divestment. The sprues were removed
with a thin diamond disc in a laboratory handpiece, and the samples were repeatedly
immersed in water to avoid overheating the ceramic. The area where the sprue was
placed was smoothed with a diamond bur in a high-speed handpiece with water coolant.
The specimens were then finished, polished and the measurements obtained.

Fabrication of IPS InLine Specimens

The IPS InLine powder (Ivoclar Vivadent AG, Schaan, Liechtenstein) was mixed
with IPS InLine build-up liquid (Ivoclar Vivadent AG, Schaan, Liechtenstein) on a glass
slab with a metal spatula to form a thick slurry. A silicone matrix with approximately
15mm in diameter and 1mm thickness was obtained from a silicone-based material
(Template Ultra Quick, Clinician’s Choice Dental Products, Inc., New Milford, CT). The
silicone matrix was lubricated with IPS Ceramic Separating Liquid (Ivoclar Vivadent
AG, Schaan, Liechtenstein) and placed over a glass slide (Figure 4a). The porcelain
slurry was placed into the silicone matrix and hand vibrated to eliminate internal voids
(Figure 4b).
 41

The excess moisture was removed by gentle vibration and slight compression
with a clean paper tissue (Figure 5a, 5b). The specimens were placed in a porcelain
pillow and fired in the Programat EP 5000 (Ivoclar Vivadent AG, Schaan, Liechtenstein)
with a firing program recommended by the manufacturer (Table 6). All five specimens
were fired in the same cycle. The specimens were then finished, polished, and the
measurements obtained.

Table 6. Firing cycle for IPS InLine.

Stand-by Closing time  Firing 

temperature oC min. o
C/min. temperature oC min.

403 4.00 60 910 1.00

a b

Figure 4. Silicone matrix and porcelain slurry. a) Silicone matrix lubricated with IPS
Ceramic Separating Liquid (Ivoclar Vivadent AG, Schaan, Liechtenstein). b)
The porcelain slurry was placed into the silicone matrix over a glass slide and
hand vibrated to eliminate internal voids.
 42

a b

Figure 5. Excess of moisture removal. a) The excess moisture was removed by gentle
vibration and slight compression with a clean paper tissue. b) Specimen on
glass slide after silicone matrix removal.

Fabrication of Vitablock Mark II Specimens

The Vitablock Mark II specimens were obtained by slicing the blocks with
diamond discs in a precision saw machine (Isomet 1000, Buehler, Lake Bluff, IL) into
12mm x 10mm slices of approximately 0.78mm thickness (Figure 6). The specimens
were then finished, polished and taken to the final thickness of approximately 0.7mm.

Fabrication of Everest G-blank Specimens

The Everest G-blank specimens were obtained by cutting the blocks with
diamond discs in a precision saw machine (Isomet 1000, Buehler, Lake Bluff, IL) into
12mm diameter slices of approximately 0.78mm thickness (Figure 6). The specimens
were then finished, polished and taken to the final thickness of approximately 0.7mm.
 43

Figure 6. Porcelain block sliced with diamond discs in a precision saw machine (Isomet
1000, Buehler, Lake Bluff, IL).

Fabrication of Lava Zirconia Specimens

The Lava Zirconia specimens were obtained by cutting CAD-CAM blocks with
diamond discs in a precision saw machine (Isomet 1000, Buehler, Lake Bluff, IL) into
19mm x 15mm slices of approximately 1mm thickness (Figure 6). The slices were
manually finished with 400-, 600-, 800- grit dry silicon carbide paper until a thickness of
approximately 0.85mm was obtained. During this process, the thicknesses of Lava
Zirconia slices were repeatedly checked with a micrometer (Mitutoyo Corp., Kawasaki,
Japan). The specimens were sintered in a special furnace, the Lava Therm (approximately
8 hours including heating up and cooling phases), by 3M ESPE Division (St Paul, MN).
After shrinkage occurred during the sintering process (20%), the final thickness of the
slices was 0.7mm. The Lava Zirconia specimens were not polished following sintering.
 44

Specimen Thickness and Finishing

All the specimens were finished flat on a grinding and polishing machine
(Rotopol V, Struers Inc., Cleveland, OH) with wet 120-, 240-, 400-, 600-, 800- and 1200-
grit silicone carbide paper used in sequence to provide a high shine (Figure 7). For the
feldspathic specimens, a 60-grit silicone carbide paper was used at first to eliminate
irregularities and reduce the thickness of the raw specimens to approximately 0.85mm.
During this process, the porcelain discs were repeatedly checked with a digital
micrometer (Mitutoyo Corp., Kawasaki, Japan) to ensure a final 0.7mm thickness. The
discs were cleaned in an ultrasonic bath with distilled water for 5 minutes and the final
thickness was measured (Figure 8). The measurement was done three times close to the
center of each specimen and the mean was considered the final thickness. The specimens
were not glazed because it could introduce inconsistent thickness and increase the
variation within groups. Glazing may also close open porosities, resulting in a smoother
surface and increasing specular reflection (Liu, 2008; Liu et al., 2010).

Colorimeter Measurements
The luminous reflectance (Y) and color coordinates (CIE L* a* b*) of the
specimens were measured with a tristimulus colorimeter (CR-221 Chroma Meter,

Minolta, Osaka, Japan), using CIE illuminant D65 lighting condition, a 2-degree observer
function8,9 (0.0 = transparent; 1.0= opaque) and zero-degree viewing angle geometry
(Figure 9). The dimension of the window (measuring area) was 3mm diameter,
representing less than 50% of the diameter of the specimens. The output for each of the
independent readings was an instrumental average of three successive measurements
made automatically by the colorimeter.
 45

Figure 7. Specimens were finished flat on a grinding and polishing machine (Rotopol V,
Struers Inc., Cleveland, OH) with wet 120-, 240-, 400-, 600-, 800- and 1200-
grit silicone carbide paper.

Figure 8. Discs’ final thickness was measured with a digital micrometer (Mitutoyo Corp.,
Kawasaki, Japan).
 46

The measurements were performed at the center of each specimen over a white (Y
= 74.01 / CIE L*= 88.81, a*= -4.98, b*= 6.09) and black backing (Y = 0.61 / CIE L*=
7.61, a*= 0.45, b*= 2.42) (Figure 10a). The specimens were placed in the center of the
measuring port and were kept in the same position for the two backings. Consistent
positioning was possible by placing the specimen against a fixed 90o template. All
specimens were measured in sequence at the same period of the day, and the colorimeter
remained in the same position during all measurements. Before and after each series of
measurements for each group, the instrument was calibrated with a standard glossy white
calibration plate (CR-A45; Minolta, Osaka, Japan) to validate the reliability of the
instrument.
In order to reduce the edge-loss effect, a drop of water was placed in between
each specimen and the backing (Figure 10b).

Figure 9. Tristimulus colorimeter (CR-221 Chroma Meter, Minolta, Osaka, Japan).

 47

a b

Figure 10. Backgrounds and edge-loss control. a) Black and white background used for
translucency measurements. b) Drop of water was placed in between each
specimen and the background in order to reduce the edge-loss effect.

The contrast ratio (CR) values were calculated from the spectral reflectance of
light of the specimen (Y) over a black background (Yb) and over a white background
(Yw), in which CR = Yb/Yw.
The translucency parameters (TP) values were evaluated by calculating the color
difference of the specimens over black and white backgrounds by using the following
equation: TP= [(Lb* - Lw*)2 + (ab* - aw*)2 + (bb* - bw*)2 ]1/2, where letters “b” and “w”
refer to color coordinates over the black and white backgrounds, respectively.
The L* values of 0 to 100 represent a black and a reference white, respectively
(Paravina, 2004). This coordinate is a measure of lightness-darkness of the material. The
greater the L* is, the lighter the specimen. The a* and b* values represent the redness-
greenness and yellowness–blueness, respectively (Paravina, 2004). Positive a* relates to
the amount of redness and negative values relate to greenness of the specimen. b*
coordinate is a measure of the chroma along the yellow-blue axis. Positive b* values
relate to the amount of yellowness, while negative values relate to blueness of the
 48

specimen (Ozturk et al., 2008). ∆L*, ∆a* and ∆b* are the differences in the CIE color-
space parameters of two colors (Knispel, 1991), in this study they were considered as the
differences of the L*, a*, b* values of the specimens over the black and white
backgrounds.

Statistical Methods
Descriptive statistics were obtained for all variables. One-way ANOVA, followed
by post-hoc Tukey’s HSD (Honestly Significant Difference) test, were conducted to
determine whether there were significant differences between the types of materials
regarding Contrast Ratio (CR) and Translucency Parameter (∆E), ∆L*, ∆a*, and ∆b*.
The Shapiro-Wilk test was applied to verify normality of residuals (error distribution)
whenever ANOVA model was conducted.
When the assumption of normality was violated, the rank transformation was
conducted. Subsequently, one-way ANOVA based on rank-transformed data with the
post-hoc Bonferroni test was performed.
A two-sample t-test and a nonparametric Wilcoxon rank-sum test (when the
normality assumption was violated) were used to test for a significant difference between
two materials.

Finally, the correlation between CR and ∆E was assessed using Spearman’s rank
correlation test. The interpretation of the relationship strength between two variables,
based on the absolute value of the Spearman’s rank correlation coefficient, was depicted
according to the following guide: ±1= perfect correlation, ±0.8=strong correlation,
±0.5=moderate correlation, ±0.2=weak correlation, ±0.00=no correlation.
A p-value of less than 0.05 was used as a criterion for statistical significance. SAS
for Windows (v9.2, SAS Institute Inc, Cary, NC, USA) was used for the data analysis.
 49

CHAPTER III
RESULTS

The mean Contrast Ratios (CR), Translucency Parameters (TP), ∆L*, ∆a* and
∆b* values of the samples were calculated and the values for individual samples are
shown in Appendix A (RAW DATA). The descriptive statistics of contrast ratio and
translucency parameter for each material are presented in Tables 7 and 8, respectively.

Samples With Identical Thickness

It is already known that the material’s thickness will directly affect its
translucency; therefore the translucency measurement is considered inversely related to
thickness. To ensure consistency in the specimen thickness, sample thickness was
evaluated within the groups as well as compared between the groups. Each specimen’s
thickness was measured three times, and then the average of three measurements was
used for the evaluation and comparison within and between the groups. The only group
excluded from this analysis was the IPS e.maxPress 0.3mm, since this group was made
on purpose at a different thickness. The results of one-way ANOVA revealed no

significant difference in 0.7mm sample thickness among the groups (p=0.9204, Table 9)
and the mean thickness ranged from 0.70 to 0.71. The standard deviation of 0.01 for all
groups confirmed consistency in thickness within groups (Table 9).
The additional IPS e.maxPress group with the minimal clinically recommended
thickness of approximately 0.3mm was compared with its correspondent 0.7mm group.
Based on the two-sample t-test, the data showed that there was a significant difference in
the thickness between IPS e.maxPress 0.3mm and 0.7mm (p<0.0001) (Table 9).
 50

Table 7. Descriptive Statistics of Contrast Ratio (CR) by Materials.

Material n Mean SD Minimum Maximum Median

IPS InLine 5 0.25 0.01 0.24 0.27 0.25

IPS e.maxPress HT BL2 5 0.43 0.01 0.42 0.43 0.43

IPS e.maxPress HT BL4 5 0.37 0.01 0.36 0.38 0.37

IPS e.maxPress HT B1 5 0.32 0.01 0.31 0.33 0.32

IPS e.maxPress HT A1 5 0.37 0.02 0.35 0.40 0.36

IPS e.maxPress HT A1 5 0.13 0.00 0.13 0.14 0.13
0.3mm
IPS e.maxPress LT A1 5 0.47 0.01 0.46 0.49 0.47

IPS Empress Esthetic 5 0.34 0.01 0.33 0.34 0.34

Everest G-blank 5 0.26 0.01 0.25 0.27 0.26

Vita Mark II 5 0.24 0.00 0.23 0.24 0.24

Vita PM9 5 0.15 0.01 0.14 0.15 0.15

Lava Zirconia 5 0.73 0.00 0.72 0.73 0.73

 51

Table 8. Descriptive Statistics of Translucency Parameter (TP) by Materials.

Material n Mean SD Minimum Maximum Median

IPS InLine 5 32.44 1.33 30.25 33.44 33.04

IPS e.maxPress HT BL2 5 22.70 0.51 21.84 23.10 22.88

IPS e.maxPress HT BL4 5 26.14 0.28 25.83 26.50 26.23

IPS e.maxPress HT B1 5 27.96 0.61 27.11 28.78 27.93

IPS e.maxPress HT A1 5 26.59 0.83 25.40 27.39 27.02

IPS e.maxPress HT A1 5 47.85 0.78 46.60 48.55 48.02
0.3mm
IPS e.maxPress LT A1 5 21.35 0.72 20.65 22.44 21.27

IPS Empress Esthetic 5 27.64 0.42 26.93 27.96 27.74

Everest G-blank 5 33.52 0.70 32.80 34.40 33.32

Vita Mark II 5 33.66 0.61 33.00 34.31 33.96

Vita PM9 5 40.34 0.52 39.65 40.91 40.30

Lava Zirconia 5 10.43 0.14 10.24 10.58 10.44

 52

Table 9. Comparisons of Thickness among Materials.

Materials Thickness Post-hoc Group Minimal thickness

Mean (SD) Comparisons* comparison***
IPS InLine 0.71 (0.00) A

IPS e.maxPress HT BL2 0.71 (0.00) A

IPS e.maxPress HT BL4 0.71 (0.01) A

IPS e.maxPress HT B1 0.71 (0.01) A

IPS e.maxPress HT A1 0.71 (0.01) A A

IPS e.maxPress HT A1 0.31 (0.00) ** B
0.3mm
IPS e.maxPress LT A1 0.71 (0.00) A

IPS Empress Esthetic 0.71 (0.01) A

Everest G-blank 0.71 (0.01) A

Vita Mark II 0.70 (0.00) A

Vita PM9 0.71 (0.01) A

Lava Zirconia 0.71 (0.00) A

*Column means with the same letter are not significantly different using ANOVA with
post-hoc Tukey’s HSD test (p > 0.05)
** Group excluded from comparisons

***Column means are significantly different (p < 0.0001, two-sample t-test)

 53

Contrast Ratio
Because CR was not normally or log-normally distributed when all materials were
included, rank transformation of CR data was required prior to analyses. Subsequently,
one-way ANOVA based on ranked data was performed.
Results of one-way ANOVA based on the ranked data revealed a significant
effect for the type of material on the CR (p<0.0001). Post-hoc Bonferroni test indicated
that the mean CR for Lava Zirconia was significantly greater than for other materials.
The mean CR values in decreasing order were: Lava Zirconia > IPS e.maxPress LT A1,
IPS e.maxPress HT BL2 > IPS e.maxPress HT BL4, IPS e.maxPress HT A1 > IPS
Empress Esthetic, IPS e.maxPress HT B1 > Everest G-blank, IPS InLine > Vita Mark II
> Vita PM9, IPS e.maxPress HT A1 0.3mm. The detailed results of multiple comparisons
from post-hoc Bonferroni test are showed in Table 10.
For the effect of different porcelain shades on CR values, one way ANOVA
showed that shades had a significant impact on the CR values (p<0.0001). The post-hoc
Tukey’s HSD test identified that CR for shade LT A1 was significantly greater than for
shades HT BL2, HT BL4, HT B1 and HT A1, while there was no significant difference
between shades HT BL4 and HT A1 (Table 10).
Based on the nonparametric Wilcoxon rank-sum test, the data showed that there

was a significant difference in the CR between IPS e.maxPress 0.3mm and 0.7mm
(p=0.0095). The mean CR observed in IPS e.maxPress 0.7mm (CR=0.37) was
significantly higher than that observed in IPS e.maxPress 0.3mm (CR=0.13) (Table 10).
 54

Table 10. Post-hot Multiple Comparisons of CR among Materials.

Selected Group
Materials CR All Groups Comparisons
Mean (SD) Comparisons*
Shade** Thickness***

Lava Zirconia 0.73 (0.00) A

IPS e.maxPress LT A1 0.47 (0.01) B A

IPS e.maxPress HT BL2 0.43 (0.01) B B

IPS e.maxPress HT BL4 0.37 (0.01) C C

IPS e.maxPress HT A1 0.37 (0.02) C C A

IPS Empress Esthetic 0.34 (0.01) D

IPS e.maxPress HT B1 0.32 (0.01) D D

Everest G-blank 0.26 (0.01) E

IPS InLine 0.25 (0.01) E

Vita Mark II 0.24 (0.00) F

Vita PM9 0.15 (0.01) G

IPS e.maxPress HT A1 0.13 (0.00) G B
0.3mm

*Column means with the same letter are not significantly different using ANOVA with
post-hoc Bonferroni test (p>0.05)

**Column means with the same letter are not significantly different using ANOVA with
post-hoc Tukey’s HSD test (p>0.05)
***Column means are significantly different (p=0.0095, Wilcoxon rank-sum test)
 55

Translucency Parameters
One-way ANOVA revealed a significant difference in TP, ∆L*, ∆a* and ∆b*
among materials (p<0.0001). The post-hoc Tukey’s HSD test indicated that the TP and
∆L* of IPS e.maxPress HT A1 0.3mm was significantly greater than that of the other
studied porcelains. The mean TP and mean ∆L* followed a similar decreasing order as
the CR: IPS e.maxPress HT A1 0.3mm > Vita PM9 > Vita Mark II, Everest G-blank, IPS
InLine > IPS e.maxPress HT B1, IPS Empress Esthetic ≥ IPS e.maxPress HT A1, IPS
e.maxPress HT BL4 > IPS e.maxPress HT BL2, IPS e.maxPress LT A1 > Lava Zirconia.
The detailed results of multiple comparisons from post-hoc Tukey’s HSD test are shown
in Tables 11 and 12.
The porcelain shade presented a significant influence on the TP values (p<0.0001
in each instance). The post-hoc Tukey’s HSD test identified significant differences in
mean TP values in the following decreasing order: IPS e.maxPress HT B1 > IPS
e.maxPress HT A1, IPS e.maxPress HT BL4 > IPS e.maxPress HT BL2 > IPS
e.maxPress LT A1 (Table 11).
When the effect of thickness in TP was addressed, the two-sample t-test revealed
a significant difference between 0.7mm and 0.3mm groups (p<0.0001). The mean TP
observed in the IPS e.maxPress HT A1 0.3mm group was significantly greater than that

observed in the IPS e.maxPress HT A1 0.7mm group (mean TP: 47.85 vs. 6.59,
respectively) (Table 11).
Negative values for Δa* and positive values for Δb* were observed, which
indicates a color shift towards the green and yellow in the CIELAB color space.
Significant differences for Δa* and Δb* values among materials are shown in Table 12.
 56

Table 11. Post-hoc Multiple Comparisons of TP among Materials.

Selected Group
Materials TP All Groups Comparisons
Mean (SD) Comparisons*
Shade** Thickness***
IPS e.maxPress HT A1 47.85 (0.78) A A
0.3mm
Vita PM9 40.34 (0.52) B

Vita Mark II 33.66 (0.61) C

Everest G-blank 33.52 (0.70) C

IPS InLine 32.44 (1.33) C

IPS e.maxPress HT B1 27.96 (0.61) D A

IPS Empress Esthetic 27.64 (0.42) D

IPS e.maxPress HT A1 26.59 (0.83) D, E B B

IPS e.maxPress HT BL4 26.14 (0.28) E B

IPS e.maxPress HT BL2 22.70 (0.51) F C

IPS e.maxPress LT A1 21.35 (0.72) F D

Lava Zirconia 10.43 (0.14) G

*Column means with the same letter are not significantly different using ANOVA with
post-hoc Tukey’s HSD test (p>0.05)

**Column means with the same letter are not significantly different using ANOVA with
post-hoc Tukey’s HSD test (p>0.05)
***Column means are significantly different (p<0.0001, two-sample t-test)
 57

Table 12. Comparison of ∆L*, ∆a*, and ∆b* among Materials.

Materials ∆L* ‡ ∆a* ‡ ∆b* ‡

Mean (SD) Mean (SD) Mean (SD)
IPS e.maxPress HT A1 46.92 (0.77) A -2.48 (0.05) G +9.04 (0.18) B
0.3mm
Vita PM9 39.65 (0.50)B -1.91 (0.09)F +7.18 (0.26)E

Vita Mark II 33.04 (0.59)C -1.85 (0.05)F +6.18 (0.17)F

Everest G-blank 31.46 (0.69)D -1.62 (0.12)E +11.47 (0.17)A

IPS InLine 31.27 (1.31)D -1.91 (0.09)F +8.45 (0.29)C

IPS e.maxPress HT B1 26.77 (0.59)E -1.35 (0.08)D +7.96 (0.17)D

IPS Empress Esthetic 26.64 (0.42)E -1.47 (0.06)D,E +7.22 (0.05)E

IPS e.maxPress HT A1 24.94 (0.81)F -1.10 (0.05)C +9.14 (0.21)B

IPS e.maxPress HT BL4 24.82 (0.26)F -0.85 (0.07)B +8.17 (0.09)C, D

IPS e.maxPress HT BL2 21.89 (0.50)G -0.82 (0.06)B +5.94 (0.15)F

IPS e.maxPress LT A1 19.37 (0.61)H -1.02 (0.11)C +8.94 (0.42)B

Lava Zirconia 9.97 (0.14)I -0.56 (0.04)A +3.00 (0.04)G

‡
Column means with the same letters are not significantly different (one-way ANOVA
with Post-hoc Tukey’s HSD test, p>0.05)

Assessment of Correlation between CR and TP

Based on Spearman’s rank correlation test, a significant correlation between CR
and TP was found when all samples were included (p<0.0001). The coefficient of -0.98
indicated that there was a strong decreasing relationship between the two variables,
considering the 0.00 to 1.00 scale, where 0.00 means no correlation and 1.00 perfect
correlation. When the correlation was assessed within each material, no significant
correlation was found between CR and TP (p>0.05 for each instance) (Figure 11).
 58

60  

50  

40  
TP  

30  

20  

10  

0  
0   0.1   0.2   0.3   0.4   0.5   0.6   0.7   0.8  
CR  

Figure 11. Correlation between the translucency parameters (TP) and contrast ratios (CR)
for all specimens.
 59

CHAPTER IV
DISCUSSION

Currently, a great range of porcelain materials indicated for the fabrication of

porcelain veneers is available in the market. These materials can be divided into three
main groups according to the fabrication technique: conventional feldspathic, pressable,
and machinable ceramics. The conventional feldspathic porcelains seem to be preferred
by most clinicians due to their great optical properties and their ability to create depth
notion and to nicely mimic tooth structure. On the other hand, pressable ceramics present
the advantages of superior marginal fit and reduction of intrinsic defects by the press
technique. Finally, clinicians have a growing interest for chairside porcelain systems due
to the possibility of having a one appointment procedure. Technology advancements have
also improved the quality of milling machines, which contributed to making the
machinable porcelains more popular. In this study, each group of ceramic indicated for
porcelain veneers (feldspathic, pressable and machinable) has been represented to
compare the translucency.

Variables Affecting Translucency

Various factors related to the material itself, the specimen, or the measurement
procedure can affect the translucency: specimen thickness, amount of crystals within the
porcelain matrix, surface texture, material’s batch, degree of porosity, illuminant,
observer degree and edge-loss.
The literature has shown that thickness indirectly affects the transmission of light
through dental porcelains. The greater the material thickness, the lower its translucency
(Brodbelt et al., 1980; O’Keefe et al. 1991; Heffernan et al., 2002 Part I; Shokry et al.,
2006; Ozturk et al., 2008; Yu et al., 2009; Terzioglu et al., 2009). For this reason, the
 60

thickness of each sample in this study was measured three times and the means were
compared among groups. There was no statistical difference among groups and the low
standard deviations confirmed the low variability within groups, which guaranteed the
consistency in thickness among the specimens. Rigorous thickness control ensured that
the differences in translucencies between materials were not due to variable specimen
thickness. The results of the present study are in accordance with the literature in respect
to how thickness affects porcelain translucency (Brodbelt et al., 1980; O’Keefe et al.
1991; Heffernan et al., 2002 Part I; Shokry et al., 2006; Ozturk et al., 2008; Yu et al.,
2009; Terzioglu et al., 2009). Statistically significant differences were measured when
lithium disilicate 0.3mm and 0.7mm groups were compared.
Out of concern for clinical relevance, the specimens were fabricated at 0.7mm
thickness since it is the minimal thickness recommended by manufacturers in the middle
third of a tooth receiving a porcelain veneer. An extra group was fabricated for the
lithium disilicate porcelain (EP), because this was the only material studied for which the
manufacturer claimed that it was possible to fabricate thin veneers up to 0.3mm thickness
without compromising the material’s strength. Although it is known that cementation
with resin cements strengthens ceramic restorations (Magne & Douglas, 1999) and that
thinner veneers can also be fabricated with feldspathic porcelains (Piemjai &

Arksornnukit, 2007), the thickness of 0.7mm was chosen for all other materials since this
was the minimal thickness recommended by the manufacturers in the middle third of a
tooth receiving a porcelain veneer.
The materials evaluated in the present study are basically formed by a glass
matrix, in which filler particles are added to control optical effects and improve
mechanical properties (Kelly, 2008). The exception is Lava Zirconia, which is a
polycrystalline ceramic with no glass content. The glass ceramics studied can be
classified as predominantly glass ceramic, high glass content (IL, VPM, VMII, EG, EE),
or particle-filled glass ceramic, low glass content (EP) (Kelly, 2008).
 61

According to Heffernan (2002), the amount of light that is absorbed, reflected and
transmitted will depend on the amount of crystals within the matrix, their chemical nature
and the size of particles compared to the incident light’s wavelength. The results of this
study are in accordance with Heffernan’s statement, since Lava Zirconia was considered
to be the least translucent, followed by lithium disilicate, and then all other high glass
content ceramics. Likewise, it can be stated that porcelain translucency decreases as the
amount and size of particles increases in its composition. Among the low glass content
ceramics, IPS e.maxPress presents 70% lithium disilicate crystals in its composition
(Kelly, 2008). The manufacturer claims that the addition of lithium disilicate crystals will
promote not only higher strength, but also better esthetics by diffusing light similarly to
natural teeth to make restorations blend seamlessly (Ivoclar website). However, in the
present study, this type of ceramic showed lower translucency values than high glass
content ceramics. This finding confirmed that the addition of particles in the glass matrix
would somehow compromise the porcelain translucency, when materials are compared at
the same thickness. The advantage of lithium disilicate porcelain is the possibility of
fabricating thinner veneers without compromising the strength (Ivoclar Vivadent
Instructions for use, 2009), which allows for more translucent restorations.
Surface texture is another variable shown to influence the translucency of

porcelains. O’Brien (1985) stated that surface gloss would interfere with the correct
identification of tooth and porcelain color due to specular reflection. Also, Kingery et al.
(1976) affirmed that a very smooth surface, or surface gloss, would cause reflectance of
light at the same angle as incidence, resulting in specular reflection. This variable
probably did not interfere with our results since the comparisons were made among
relative values of translucency and also because a standard polishing process was
established leading to a consistent surface appearance for all groups.
The specular reflection is more dependent on the illumination properties than the
material optical properties; therefore, diffuse illumination would be preferred for color
 62

matching (O’Brien, 1985). According to Heffernan (2000), the use of 0o illumination and
diffuse viewing geometry of the integrate sphere would exclude the specular component
allowing a measurement of the subsurface opacity of the samples even when they were
glazed. In the present study, 0o illumination angle and 0o viewing angle were used to
measure the translucency.
Heffernan et al. (2002 Part I) had all specimens air abraded with 50µm aluminum
oxide at 3 bar to create a similar matte surface finish. Since the manufacturer of IPS
e.maxPress did not recommend this procedure, none of the porcelains evaluated in this
study were sandblasted in order to have homogeneity among groups.
In the present study, it was also decided not to proceed with the glazing process
because it could affect the porcelain translucency. Moreover, it would have been difficult
to control the amount of glazing material in each specimen, which could have lead to a
higher variability within groups. Heffernan et al. (2002 Part II) found significant
differences in CR between glazed and nonglazed specimens. It their study, Vitadur Alpha
(0.71), IPS Empress (0.75), In-Ceram Spinell (0.76), and Procera (0.80) glazed specimens
were significantly more translucent than their corresponding air-abraded specimens, 0.73,
0.78, 0.78, 0.83, respectively. Although the differences in translucency were statistically
significant, they were lower than 0.06, then probably not perceived clinically (Liu et al.,

2010). Heffernan et al. (2002 Part II) also pointed out that, visually, the degree of glazing
was not the same for all the specimens, which may have affected the rank of
translucency.
O’Brien et al. (1991) measured differences in color with different batches of the
same porcelain system. The differences in color ranged from 0.55 to 3.38, which is
considered not clinically perceivable, when 3.7 is taken as the color perception threshold
(Johnston & Kao, 1989). Therefore, in the present study, specimens from the same group
were fabricated with ceramic materials from the same batch. Other studies also evaluated
differences in color of the same designated shade of porcelain among different brands
 63

(Rosensteil and Johnston, 1988; O’Brien et al, 1991; Seghi et al., 1986). In our study, it
was attempted to use all ceramic groups with corresponding A1 shade; however, this was
difficult to control. Some of the manufacturers do not offer enamel A1 shade; they either
have an incisal shade or light and dark enamel. We chose to compare enamel shades only,
simulating clinical situations where only enamel structure would be replaced. However,
those discrepancies in shade may have affected the range of translucency.
Likewise, the degree of porosity can affect the translucency of ceramic materials
(Yamamoto, 1985; Heffernan 2000), especially when voids are incorporated during
porcelain manipulation and not eliminated during condensation process. In our study, for
the fabrication of the conventional feldspathic specimens, the porcelain was mixed with a
flexible metal spatula on a glass slab with an effort to minimize incorporation of air in the
mix. The slurry was added in the silicone matrix and condensed, and the excess of
moisture was then removed with light pressure of paper tissue in order to compact the
porcelain particles prior to vacuum firing. For the fabrication of pressed specimens, the
incorporation of voids was controlled during the resin patterns fabrication. The resin
patterns were immersed in water into a pressure pan during the polymerization process to
form an acrylic cylinder free of voids.
The literature has shown that the color of an object can be strongly influenced by

illumination (O’Brien, 1985; Ahn & Lee, 2008). The CIE has selected incandescent (A)
lamplight and daylight (D65) as standard illuminants, representing the most common
illuminating lights in daily life (Ohta et al., 2006). The most important illuminant is D65
with a correlated temperature of 6500K (Russel et al., 2001). Ahn & Lee (2008)
evaluated the differences in TP of all-ceramic core, veneer and layered specimens relative
to the CIE standard illuminant D65, A and F2. TP values were influenced by the type of
ceramic, its thickness, and the illuminant. In daylight condition (D65), translucency of all-
ceramic materials was lower than that in incandescent (A) or fluorescent light (F2).
 64

Therefore, in the present study, daylight condition (D65) was chosen to make the
measurements.
Finally, it is known that the edge loss phenomenon that occurs whenever the light
within the sample is scattered near the edges without being absorbed (Bolt et al., 1994;
Yu et al., 2009) can lead to a loss of accuracy in color measurements (Ragain &
Johnston, 2001). To minimize the edge loss, the observation port should be at least two to
three times larger than the beam size (Hsia, 1976) and the specimen should be in optical
contact with the backing (Johnston et al., 1996; Davis et al., 1994; Ragain & Johnston,
2001). To seal the air between specimen and backing, studies have used index-matching
liquids, such as a sucrose solution (Johnston et al., 1996; Davis et al., 1994; Ragain &
Johnston, 2001), optical fluid (Ahn & Lee, 2008; Segui et al., 1989), glycerol and water
solution (Molenaar et al., 1999; Wayne & McAree, 1985), or immersion oil (Liu, 2008)
whose refractive index of approximately 1.5 would match that of the backings. In the
present study, a colorimeter with 3mm diameter window was used to measure the
translucency of 13mm diameter specimens, meeting the requirements found in the
literature. In addition, to control for edge loss, a drop of water was used to seal the air
between the specimen and its backing.
In summary, numerous efforts were made in order to control for all the variables

that could affect the measurement of CR and TP. This can be considered as strengths in
the present study, and the small standard deviations observed in all groups confirmed
consistency in the specimens’ fabrication and control over variables.

Relative translucency of ceramic systems

Since there are several variables that can affect the translucency of ceramic
systems, it is difficult to compare translucency in terms of absolute values. Therefore, the
relative translucency was used and comparisons among different studies were made
 65

considering translucency ranks. The results of the present study showed that different
porcelains present different translucencies, which is in agreement with previous studies
that compared various all-ceramic systems (Brodbelt et al., 1980; O’Keefe et al. 1991;
Heffernan et al., 2002 Part I; Heffernan et al., 2002 Part II; Barath et al., 2003; Shokry et
al., 2006; Chu et al., 2007; Ozturk et al., 2008; Yu et al., 2009; Li et al., 2009).
Heffernan et al. (2002 Part I) compared the translucency of 6 all-ceramic systems
core materials: IPS Empress dentin; IPS Empress 2; In-Ceram Alumina; In-Ceram
Spinell; In-Ceram Zirconia and Procera AllCeram. In their study, the specimens were
0.5mm thick and two additional groups, IPS Empress dentin and IPS Empress 2, were
0.8mm thick. All specimens were fabricated in a corresponding shade to Vita Lumin A2.
Even though the shade and specimen thickness were different from our study, the
comparison of translucency ranking among materials is still possible.
Heffernan et al. (2002 Part I) found a significant range of translucency among
groups, ranking from most translucent to least (CR) as: Vitadur Alpha (0.60) > Empress
(0.64) > In-Ceram Spinell (0.67), Empress 2 (0.68) > Procera (0.72) > In-Ceram Alumina
(0.87) > In-Ceram Zirconia (1.00), SF52 alloy (1.00). Differences in thickness resulted in
significant differences in opacity when comparing Empress and Empress 2. Even though
the difference in CR between Vitadur Alpha (conventional feldspathic porcelain) and

Empress (pressable feldspathic porcelain) was statistically significant, this difference

would not be clinically perceived considering that the perceptibility threshold is a CR
difference of 0.06 or more (Liu et al., 2010). In the present study, the conventional
feldspathic porcelain (IL) presented statistically significant and clinically perceptible
differences when it was compared to the pressable feldspathic porcelain (EE), since the
difference between their CR means was greater than 0.06.
We found in our study a statistically significant range of translucency among
groups, ranking from most translucent to least (CR) as: VPM (0.15) > VMII (0.24), IL
(0.25), KEG (0.26) > EP HTB1 (0.32), EE (0.34) > EP HTA1 (0.37), EP HTBL4 (0.37) >
 66

EP HTBL2 (0.43), EP LTA1 (0.47) > LZ (0.73). Most of the statistically significant
differences were also clinically relevant (difference in CR > 0.06). The exception was for
the groups EP HTB1 and EE, which presented statistically significant lower CR than that
of groups EP HTA1 and EP HTBL4, but the difference of CR among those groups could
not be clinically perceived.
When the porcelain translucencies were compared through TP means, the range
was similar to the one measured with CR. The only distinction was that there was no
statistical difference between EP HTA1 and EE groups. The TP means in order of
decreasing translucency were: VPM (40.34) > VMII (33.66), KEG (33.52), IL (32.44) >
EP HTB1 (27.96), EE (27.64) > EP HTA1 (26.59), EP HTBL4 (26.14) > EP HTBL2
(22.70), EP LTA1 (21.35) > LZ (10.43). According to the findings of Johnston & Kao
(1989) who defined a difference in color greater than 3.7 as clinically unacceptable, all
the statistically significant differences in TP found in the present study would be
clinically perceptible. The exception is only for the difference between TP of groups EP
HTB1 and EE that would not be clinically perceived when compared with groups EP
HTA1 and EP HTBL4.
The present results showed that porcelain shade significantly affects the
translucency of lithium disilicate porcelain. When the CR and TP values of different

shades of IPS e.max Press were compared, the shade LT A1 presented the highest CR
mean and the lowest TP value, as expected, since this was the only low translucency
shade evaluated. However, even if this difference in translucency was statistically
different from all other shades, it was not clinically relevant when LT A1 (21.35 ± 0.72)
was compared with HT BL2 (22.70 ± 0.51), since the color difference between those two
shades was less than 3.7 (Johnston & Kao, 1989).
 67

Human Perception
When color differences are compared, it is not enough to identify statistically
significant differences. The clinical relevance of the data should also be addressed, by
looking into differences that could be detected by the human eyes. (Johnston & Kao,
1989; Ruyter et al., 1987; Ishikawa-Nagai et al., 2009; Liu et al., 2010). The perception
of color by an observer is very subjective, resulting in varied and unpredictable
differences in color evaluation and matching among clinicians (Ishikawa-Nagai et al.,
2009). Previous studies evaluated the relationship between visual criteria and
instrumental colorimetry for color measurement and came up with a minimal ∆E value in
which color differences are detectable clinically.
Johnston & Kao (1989) measured an average CIELAB color difference (∆E) of
ratings judged as matching by the visual criteria equal to 3.7. Likewise, Ruyter et al.
(1987) found that 50% of the observers considered that sample pairs were unacceptable
when the color difference ∆E*ab was approximately 3.3. Furthermore, Ishikawa-Nagai et
al. (2009) performed a clinical evaluation of perceptibility of color differences by
experienced experts in color science. The authors found ∆E = 1.6 to be a color difference
that could not be detected by human eye. This last standard for color difference was set
for ideal esthetic color matching but was not a perceptibility threshold that could be

generalized for all clinicians. For this study, it was considered more reasonable to define
clinically detectable differences as ∆E higher than 3.7.
Moreover, Liu et al. (2010) evaluated the capability of human subjects to detect
differences in the translucency of ceramic materials determined by a spectrophotometer.
Contrary to previous studies, Liu et al. (2010) used CR means as a reference of
translucency measurements instead of using ∆E. They named the Translucency
Perception Threshold (TPT) the perceptibility of translucency differences according to
the training experience (freshman dental students, prosthodontic residents, and senior
faculties). The mean TPT was significantly different among observers’ groups. The
 68

authors concluded that differences in CR greater than 0.06 between ceramic restorations
and natural teeth may be perceived by 50% of the population. The present study followed
this parameter to analyze the translucency differences found among groups, considering
differences in CR greater than 0.06 as clinically relevant.

Correlation between TP and CR

Yu et al. (2009) found a negative correlation between TP and CR with the
translucency of human tooth enamel and dentin. These authors observed an increase of
TP values in direct proportion with wavelength and inverse proportion to thickness; CR
values of enamel and dentin decreased when the wavelength increased. Their findings are
in agreement with the present study, in which a strong negative correlation was found
between TP and CR among all porcelain groups. Thus, the greater the TP, the smaller the
CR. The porcelain translucency rankings according to TP and CR were very similar,
except for EP HTA1 and EE groups, which presented a statistically significant difference
when translucency was compared through CR, but not when it was compared through TP.

Clinical implications

Translucency is not always desirable. Depending upon the clinical situation, a

different need between greater translucency and masking ability will be identified
according to the remaining tooth structure shade or core build up material. For this
reason, it is important to be familiar with the translucency of different porcelain systems.
The most appropriate porcelain system can be identified only according to a specific
clinical situation.
In this regard, Chu et al. (2007) compared the contrast ratios (CR) and masking
abilities (∆E) of three types of porcelain veneers. The CR were significantly different
among the materials as follow: Procera (0.50 ± 0.02) > Empress 2 (0.46 ± 0.05) > Vitadur
 69

Alpha (0.39 ± 0.02). Likewise, the color difference (∆E) of the three materials was as
follow: Vitadur Alpha > Procera = Empress 2. The Vitadur Alpha was found to be the
most translucent material, but had the weakest masking ability. Although Procera and
Empress 2 presented higher CR and ∆E, their clinical application may still be limited
when tooth discoloration is too intense.
Moreover, Li et al. (2009) found statistically significant and clinically relevant
(∆E > 3.7) differences in the translucency of IPS Empress 2, In-Ceram Alumina and
Vitablocks Mark II according to various core build-up shades. The authors concluded that
the final color of all-ceramic restoration was the blend of ceramic and composite core
shades. Barath et al. (2003) also investigated the effect of background color and luting
agents on the final color of IPS Empress 2 and VITA In-Ceram Alumina. The authors
verified that IPS Empress 2 was more translucent than In-Ceram Alumina and that luting
agents in combination with the background shade influenced the final restoration color.
On the other hand, Terzioglu et al. (2009) found no significant difference when different
cement shades (A1, A3) were compared, although they also identified a color shift (∆E >
3.7) for all specimens between baseline and postcementation.
In order to be able to create natural looking restorations, the translucencies of
ceramics for porcelain veneers need to be similar to that of enamel and dentin. In the

literature, there are not many studies comparing the translucency of enamel and different
materials, mainly because of the difficulty in obtaining specimens of pure enamel at
adequate size and shape to provide accurate translucency measurements (Ryan et al.,
2010). Moreover, translucency of enamel varies substantially with individual age, gender
and tooth shade (Yu, B. et al., 2009).
Lee (2007) compared the translucency of a feldspathic porcelain (IPS d.SIGN)
with three different composite resins according to three different illuminants. He verified
that color difference by illuminant was correlated with translucency difference by
illuminant; however, the correlation was negative for ceramic and positive for composite
 70

resin. This difference in translucency may increase the potential shade mismatch between
porcelain and composite resins, thus should be considered in shade selection for porcelain
repair with composite resins. Besides Lee (2007) study, no other study was found in the
literature ranking the translucency of composite resins and ceramics.
As discussed previously in this chapter, there are many variables that will affect
translucency regarding sample preparation and translucency measurement. Therefore, it
is difficult to compare absolute enamel translucency values among different studies. An
example of this are the studies from Ryan et al. (2010) and Li et al. (2010), which both
compared translucency of enamel with different composite resins but obtained very
different enamel TP values of 11.6 ± 0.3 and 28.45 ± 2.2, respectively. An enamel group
was not part of the present study, and the current data from the literature cannot be used
to compare our results because of the differences in methodology.
Another important clinical consideration is the need for strength. Depending upon
the clinical case, a decision will have to be made between a stronger or a more
translucent material. It has been shown in the literature that ceramics with high strength
tend to be more opaque (Chen et al., 2008; Spear & Holloway, 2008). It occurs because
the dispersion of reinforcement particles into the glass matrix is the most prevalent
method to strengthen ceramics, and some filler particles are exceptionally opaque

(Holloway and Miller, 1997; Kelly, 2008).

According to Chen et al. (2008), the relative translucencies of all-ceramic core
materials decrease as their flexural strengths increase. They identified a range from the
most to the least translucent as follow: IPS Empress 2 dentin (0.78 ± 0.03) > In-Ceram
Alumina (0.94 ± 0.01) > In-Ceram Zirconia (1.00 ± 0.01) = Cercon Base (1.00 ± 0.01).
Likewise, biaxial flexural strength (MPa) means from the strongest to the weakest
material followed the range: Cercon Base (910.5 ± 95.3) > In-Ceram Zirconia (592.4 ±
84.7) = In-Ceram Alumina (514.0 ± 49.5) > IPS Empress 2 dentin (355.1 ± 25.7). The
IPS Empress 2 was considered the most translucent but also the weakest material.
 71

Study Limitations
The use of different measurement equipments, edge loss control, manufacturing
process and discrepancies in shade can affect the porcelain translucency. Comparisons
between values obtained in our study and in other studies can be unreliable because of
differences in methodology. Only ranks among materials can be compared.
In the present study, the pressable ceramic (VPM) was more translucent than the
conventional feldspathic (IL), whereas the translucency of conventional feldspathic
porcelain (IL) was similar of that of machinable porcelains (VMII; EG). Clinically, the
conventional feldspathic could result in a restoration with more natural appearance, when
layering and staining techniques are considered. However, the objective of this study was
to compare the relative translucency among porcelains, disregarding fabrication
technique, which can also affect the final appearance of the restoration.
Since it was an in-vitro study, and in order to reduce the variables in the
specimens’ preparation, the glazing process was not done even though it is always done
in a clinical situation. It was decided not to proceed with glazing because of the difficulty
to control for the same amount of glazing material on each specimen, which could have
affected the consistency among specimens’ thickness.
Moreover, it was not possible to reproduce a layering technique although it is

known that a combination of different shades and translucencies would usually be used
for conventional feldspathic porcelain to obtain a final esthetic result. Also, for pressable
ceramics, a cut-back technique can be used to layer feldspathic porcelain on top of
pressable ceramics to achieve better esthetic results. In this study, a single shade of
porcelain was used for feldspathic and pressable systems, without any layering.
Finally, another limitation of this study was ceramic shade selection. Since there
is no universal nomenclature of ceramic shades among manufacturers, it was difficult to
select matching shades from different brands. Even with the same denomination,
differences in shade could be observed.
 72

Suggestions for future research

From the results of the present study, further research can be considered in the
following areas:
1. Effect of glazing process on the translucency of ceramic systems indicated for
porcelain veneers.
2. Effect of layering and staining techniques on the porcelain translucency.
3. Comparison of translucency measurements from various instruments (colorimeter,
spectrophotometer, spectroradiometer).
4. Correlation among CIELAB and CIEDE 2000 values.
5. Confirm manufacturer claim of higher translucency with new ceramic materials
(IPS e.max Press Impulse).
6. Comparison of instrument translucency measurements with human perception.
7. Comparison of human enamel translucency with different ceramic systems.
8. Comparison of ceramic and composite resin translucency.
 73

CONCLUSION

This study compared the relative translucency of different types of ceramic

systems indicated for porcelain veneers, with various shades and opacities. According to
the results of the present study:
• There was a difference in the relative translucency among conventional
feldspathic porcelain and the other ceramics investigated. Therefore, the Null
Hypothesis (1) was rejected.
• There was a difference in the relative translucency between different shades of the
lithium disilicate ceramic. Therefore, the Null Hypothesis (2) was rejected.
• There was a difference in the relative translucency between different thicknesses
of the lithium disilicate ceramic. Therefore, the Null Hypothesis (3) was rejected.
• There was a correlation between contrast ratio and translucency parameter values
of ceramic systems evaluated. Therefore, the Null Hypothesis (4) was rejected.

Within the limitations of the present study, the following conclusions can be
drawn:
• Various ceramics systems designed for porcelain veneers present various degrees

of translucencies.
• Either Contrast Ratio or Translucency Parameter can be used to evaluate the
relative translucency of ceramic systems.
 74

APPENDIX

RAW DATA OF TRANSLUCENCY AND THICKNESS

Material CR TP (∆E) ∆L* ∆a* ∆b* Thickness

1 0.24 33.04 31.88 -1.98 8.46 0.705

1 0.25 33.37 32.14 -1.89 8.78 0.712
1 0.27 33.44 32.26 -1.94 8.57 0.709
1 0.25 32.12 30.93 -1.92 8.43 0.71
1 0.25 30.25 29.12 -1.84 8 0.71
2 0.43 22.63 21.78 -0.81 6.08 0.716
2 0.43 23.04 22.24 -0.86 5.96 0.713
2 0.42 21.84 21.08 -0.72 5.68 0.715
2 0.42 22.88 22.06 -0.86 6.01 0.708
2 0.43 23.1 22.3 -0.84 5.95 0.708
3 0.36 25.9 24.57 -0.93 8.13 0.704
3 0.38 25.83 24.54 -0.73 8.03 0.704
3 0.36 26.25 24.92 -0.87 8.2 0.706
3 0.37 26.23 24.89 -0.87 8.24 0.716
3 0.37 26.5 25.17 -0.85 8.25 0.703
4 0.31 28.78 27.55 -1.48 8.18 0.712
4 0.33 27.93 26.71 -1.34 8.04 0.709
4 0.32 28.23 27.03 -1.37 8.01 0.706
4 0.32 27.77 26.61 -1.28 7.84 0.693
4 0.33 27.11 25.95 -1.28 7.75 0.718
5 0.35 27.39 25.74 -1.15 9.29 0.696
5 0.36 25.4 23.8 -1.04 8.8 0.711
5 0.37 27.02 25.37 -1.14 9.24 0.708
5 0.4 26.06 24.4 -1.04 9.08 0.709
5 0.36 27.06 25.39 -1.11 9.3 0.72
 75

CONTINUED
6 0.13 47.68 46.77 -2.48 8.93 0.31
6 0.13 48.41 47.45 -2.51 9.25 0.307
6 0.14 46.6 45.66 -2.4 8.98 0.308
6 0.13 48.02 47.13 -2.51 8.83 0.301
6 0.13 48.55 47.6 -2.49 9.21 0.3
7 0.46 22.44 20.22 -1.18 9.67 0.706
7 0.46 20.8 18.85 -0.9 8.75 0.702
7 0.49 21.27 19.38 -1.03 8.7 0.707
7 0.48 20.65 18.72 -0.96 8.66 0.707
7 0.47 21.61 19.66 -1.05 8.9 0.714
8 0.34 27.96 26.97 -1.45 7.24 0.705
8 0.34 27.93 26.92 -1.55 7.27 0.702
8 0.33 27.65 26.65 -1.51 7.22 0.707
8 0.34 27.74 26.74 -1.46 7.22 0.715
8 0.33 26.93 25.93 -1.39 7.13 0.717
9 0.25 34.12 32.02 -1.68 11.67 0.716
9 0.26 33.32 31.23 -1.61 11.5 0.709
9 0.25 34.4 32.35 -1.69 11.57 0.688
9 0.27 32.98 30.93 -1.69 11.32 0.713
9 0.26 32.8 30.77 -1.41 11.28 0.711
10 0.24 34.02 33.39 -1.83 6.27 0.7
10 0.24 33.96 33.31 -1.92 6.31 0.71
10 0.23 34.31 33.67 -1.88 6.33 0.7
10 0.24 33 32.41 -1.79 5.97 0.708
10 0.24 33.03 32.42 -1.85 6.03 0.705
11 0.14 39.65 39.03 -1.82 6.75 0.718
11 0.15 40.05 39.31 -1.89 7.42 0.706
11 0.14 40.91 40.23 -1.91 7.15 0.7
11 0.15 40.77 40.06 -2.06 7.31 0.702
 76

CONTINUED
11 0.15 40.3 39.6 -1.87 7.26 0.707
12 0.73 10.44 9.99 -0.59 2.99 0.712
12 0.73 10.53 10.07 -0.58 3.03 0.713
12 0.73 10.35 9.88 -0.5 3.04 0.71
12 0.72 10.58 10.14 -0.59 2.96 0.703
12 0.73 10.24 9.79 -0.54 2.96 0.709

material 1 = IPS InLine

material 2 = IPS e.maxPress HT BL2
material 3 = IPS e.maxPress HT BL4
material 4 = IPS e.maxPress HT B1
material 5 = IPS e.maxPress HT A1
material 6 = IPS e.maxPress HT A1 0.3mm
material 7 = IPS e.maxPress LT A1
material 8 = IPS Empress Esthetic
material 9 = Everest G-blank
material 10 = Vita Mark II
material 11 = Vita PM9
material 12 = Lava Zirconia
 77

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