John D. Da Silva

Clinical performance of a newly developed spectrophotometric system on tooth color reproduction

STATEMENT OF PROBLEM Matching a natural maxillary central incisor to a metal ceramic crown is one of the most difficult challenges in clinical dentistry due to the limitations of dental shade guides and the subjectivity of perceptual evaluation. PURPOSE The purpose of this study was to assess the clinical effectiveness of a spectrophotometric shade-matching system on tooth color reproduction. MATERIAL AND METHODS Two metal ceramic crowns were fabricated for a maxillary central incisor for 36 patients using 2 shade-matching techniques. The first technique was conventional visual matching using 3 shade guide systems, and the second was an instrument-based color-matching technique using a new spectrophotometric system. Color difference (DeltaE) values between the contralateral natural tooth and each of the 2 crowns were calculated in the cervical, middle, and incisal regions. The DeltaE values were compared using a Students t test (alpha=.05). Three calibrated examiners evaluated the color match by ranking it from 1 to 10 (10 = perfect match; 1 = no match; < or =8, accepted; > or =7, rejected). McNemars test was used to calculate the odds ratio of accepting restorations fabricated using a spectrophotometric system to conventional methods. RESULTS Results revealed that the mean DeltaE values of crowns matched with the spectrophotometer were significantly lower than those using a conventional technique (P<.001). The odds ratio of 12.5 was calculated, indicating that conventionally matched crowns were more likely to be rejected than those matched using the spectrophotometer (P<.001). CONCLUSIONS In this clinical study, crowns fabricated using a dedicated spectrophotometer had a significantly better color match and a lower rate of rejection due to shade mismatch compared to crowns fabricated with a conventional shade-matching method.

The optical effect of composite luting cement on all ceramic crowns.

PURPOSE To investigate the optical properties of resin-based composite cements and assess their effects on the color of all ceramic crowns. MATERIAL AND METHODS Optical properties of three cements (Variolink II, Esthetic, Nexus II) were analyzed using disk samples (100 microm and 1.0 mm diameter) based on CIELAB color coordinates L*a*b*C* and opacity index. Empress (Ivoclar) and Katana (Noritake) crowns were filled with four different shades of die material (IPS die material ST3, ST5, ST9 and Tetric Evo Ceram Bleach XL). The shade of the crowns was measured with each of three shades of composite cement (Chroma, Bleach and Opaque, Esthetic cement). ST3 and glycerin served as the control. Color differences were calculated in incisal, body and cervical regions. RESULTS In the cervical and body regions, the color change caused by the bleach abutment could not be altered by using different colored cements for the Empress and Katana crowns. In the cervical region, the color changes effected by the dark brown abutment could be reversed with the bleach luting cement; in the body region this was true only for the Empress crown. Neither different abutment colors nor different luting cement shades resulted in perceptible color changes in the incisal regions. Mean DeltaE* values in the three areas (incisal, body, cervical) were significantly different (p-value<0.01); in the cervical and body regions Empress mean DeltaE* was significantly larger (p<0.01). CONCLUSION The composite cements evaluated in this study created perceptible color differences with particular combinations of die material, cement and ceramic crown.

Spectrophotometric Analysis of Tooth Color Reproduction on Anterior All‐Ceramic Crowns: Part 2: Color Reproduction and Its Transfer from In Vitro to In Vivo

Color reproduction of an anterior tooth requires advanced laboratory techniques, talent, and artistic skills. Color matching in a laboratory requires the successful transfer from in vivo with careful considerations. The purpose of this study was to monitor and verify the color reproduction process for an anterior all-ceramic crown in a laboratory through spectrophotometric measurements. Furthermore, a crown insertion process using composite luting cements was assessed, and the final color match was measured and confirmed. An all-ceramic crown with a zirconia ceramic coping for the maxillary right central incisor was fabricated. There was a significant color difference between the prepared tooth and the die material. The die material selected was the closest match available. The ceramic coping filled with die material indicated a large color difference from the target tooth in both lightness and chromaticity. During the first bake, three different approaches were intentionally used corresponding with three different tooth regions (cervical, body, and incisal). The first bake created the fundamental color of the crown that allowed some color shifts in the enamel layer, which was added later. The color of the completed crown demonstrated an excellent color match, with Delta E 1.27 in the incisal and 1.71 in the body. In the cervical area, color match with Delta E 2.37 was fabricated with the expectation of a color effect from the underlying prepared tooth. The optimal use of composite luting cement adjusted the effect from the underlying prepared tooth color, and the color match fabricated at a laboratory was successfully transferred to the clinical setting. The precise color measurement system leads to an accurate verification of color reproduction and its transfer. CLINICAL SIGNIFICANCE The use of a dedicated dental spectrophotometer during the fabrication of an all-ceramic crown allows the dentist and the laboratory technician to accurately communicate important information to one another about the shade of the tooth preparation, the shade of the contralateral target tooth, and the influence of luting cement on the final restoration, thereby allowing the technician better control over the outcome of their tooth color matching efforts and the final color match of an all-ceramic restoration.

Outcomes of implants and restorations placed in general dental practices: A retrospective study by the Practitioners Engaged in Applied Research and Learning (PEARL) Network

OBJECTIVES The authors conducted a study to determine the types, outcomes, risk factors and esthetic assessment of implants and their restorations placed in the general practices of a practice-based research network. METHODS All patients who visited network practices three to five years previously and underwent placement of an implant and restoration within the practice were invited to enroll. Practitioner-investigators (P-Is) recorded the status of the implant and restoration, characteristics of the implant site and restoration, presence of peri-implant pathology and an esthetic assessment by the P-I and patient. The P-Is classified implants as failures if the original implant was missing or had been replaced, the implant was mobile or elicited pain on percussion, there was overt clinical or radiographic evidence of pathology or excessive bone loss (> 0.2 millimeter per year after an initial bone loss of 2 mm). They classified restorations as failures if they had been replaced or if there was abutment or restoration fracture. RESULTS The authors enrolled 922 implants and patients from 87 practices, with a mean (standard deviation) follow-up of 4.2 (0.6) years. Of the 920 implants for which complete data records were available, 64 (7.0 percent) were classified as failures when excessive bone loss was excluded from the analysis. When excessive bone loss was included, 172 implants (18.7 percent) were classified as failures. According to the results of univariate analysis, a history of severe periodontitis, sites with preexisting inflammation or type IV bone, cases of immediate implant placement and placement in the incisor or canine region were associated with implant failure. According to the results of multivariate analysis, sites with preexisting inflammation (odds ratio [OR] = 2.17; 95 percent confidence interval [CI], 1.41-3.34]) or type IV bone (OR = 1.99; 95 percent CI, 1.12-3.55) were associated with a greater risk of implant failure. Of the 908 surviving implants, 20 (2.2 percent) had restorations replaced or judged as needing to be replaced. The majority of P-Is and patients were satisfied with the esthetic outcomes for both the implant and restoration. CONCLUSIONS These results suggest that implant survival and success rates in general dental practices may be lower than those reported in studies conducted in academic or specialty settings. PRACTICAL IMPLICATIONS The results of this study, generated in the private general practice setting, add to the evidence base to facilitate implant treatment planning.

Assessment of a prototype computer colour matching system to reproduce natural tooth colour on ceramic restorations

OBJECTIVES The aim of this study was to assess the accuracy of a prototype computer colour matching (CCM) system for dental ceramics targeting the colour of natural maxillary central incisors employing a dental spectrophotometer and the Kubelka-Munk theory. METHODS Seventeen human volunteers with natural intact maxillary central incisors were selected to participate in this study. One central incisor from each subject was measured in the body region by a spectrophotometer and the reflectance values were used by the CCM system in order to generate a prescription for a ceramic mixture to reproduce the target tooths colour. Ceramic discs were fabricated based on these prescriptions and layered on a zirconia ceramic core material of a specified colour. The colour match of each two-layered specimen to the target natural tooth was assessed by CIELAB colour coordinates (ΔE(*), ΔL(*), Δa(*) and Δb(*)). RESULTS The average colour difference ΔE(*) value was 2.58±84 for the ceramic specimen-natural tooth (CS-NT) pairs. ΔL(*) values ranged from 0.17 to 2.71, Δa(*) values ranged from -1.70 to 0.61, and Δb(*) values ranged from -1.48 to 3.81. There was a moderate inverse correlation (R=-0.44, p-value=0.0721) between L(*) values for natural target teeth and ΔE(*) values; no such correlation was found for a(*) and b(*) values. CONCLUSION The newly developed prototype CCM system has the potential to be used as an efficient tool in the reproduction of natural tooth colour.

Color effects of gingiva on cervical regions of all-ceramic crowns.

STATEMENT OF PROBLEM The final color of all-ceramic crowns is influenced by the color of both the remaining tooth structure and the surrounding gingival tissue. The optical effects of gingival tissue on an all-ceramic crown have never been fully studied. PURPOSE The purpose of this study is to investigate the effects of gingival color on ceramic crowns in the cervical region. materials and methods: Thirty-one all-ceramic crowns of differing shades were included in this study. Using a spectrophotometer, the color values of each crown were measured on a typodont in the absence of an artificial gingiva (control group) and in the presence of an artificial gingiva (test group). CIELAB color coordinates (L*, a*, b*) were collected from three regions of the cervical area in descending order from the gingival margin (upper region, middle region, and lower region). Color difference values (ΔE*) were calculated for each cervical region between the test and control groups. ΔE* between the test and control groups from the upper to lower cervical regions was also compared with each other. The statistical analysis was performed using the student t-test and one-way analysis of variance (ANOVA) test. RESULTS The mean ΔE* values between the test group and control group at the upper, middle, and lower cervical regions were 5.8, 2.8, and 1.8, respectively. Significant color differences between the test and control group were detected in all three incremental regions (p < 0.001 at ΔE* = 1.6 threshold), with all color coordinates (L*, a*, and b*) contributing significantly to the color differences in these regions (p < 0.001). The color variations in the cervical area also varied significantly from the upper region to the lower region, with L* and a* contributing most to the differences. CONCLUSIONS The presence of artificial gingiva is a critical factor in precise color matching and color reproduction for all-ceramic crowns. CLINICAL SIGNIFICANCE Gingival tissue has significant optical effects on the color of all-ceramic crowns at the cervical areas; therefore, it is suggested that artificial gingiva be used by both dentists and ceramists while matching and replicating tooth color with ceramic restorations. (J Esthet Restor Dent ••:••-••, 2012).

Establishment of Epithelial Attachment on Titanium Surface Coated with Platelet Activating Peptide.

The aim of this study was to produce epithelial attachment on a typical implant abutment surface of smooth titanium. A challenging complication that hinders the success of dental implants is peri-implantitis. A common cause of peri-implantitis may results from the lack of epithelial sealing at the peri-implant collar. Histologically, epithelial sealing is recognized as the attachment of the basement membrane (BM). BM-attachment is promoted by activated platelet aggregates at surgical wound sites. On the other hand, platelets did not aggregate on smooth titanium, the surface typical of the implant abutment. We then hypothesized that epithelial BM-attachment was produced when titanium surface was modified to allow platelet aggregation. Titanium surfaces were coated with a protease activated receptor 4-activating peptide (PAR4-AP). PAR4-AP coating yielded rapid aggregation of platelets on the titanium surface. Platelet aggregates released robust amount of epithelial chemoattractants (IGF-I, TGF-β) and growth factors (EGF, VEGF) on the titanium surface. Human gingival epithelial cells, when they were co-cultured on the platelet aggregates, successfully attached to the PAR4-AP coated titanium surface with spread laminin5 positive BM and consecutive staining of the epithelial tight junction component ZO1, indicating the formation of complete epithelial sheet. These in-vitro results indicate the establishment of epithelial BM-attachment to the titanium surface.

Assessing the accuracy of computer color matching with a new dental porcelain shade system

STATEMENT OF PROBLEM In a previous study, a novel computer color matching system for dental ceramic restoration was developed, and 21 new shades were established. Theoretically, a natural tooth color can be accurately reproduced by combining 2 or 3 ceramic mixtures from the database of 21 new shades. PURPOSE The purpose of this study was to test the use of these shades in conjunction with the computer color matching system to determine their ability to accurately reproduce the body color of 29 shade tabs from a shade guide (VITAPAN 3D-Master). MATERIAL AND METHODS Disks of 21 reference shades were prepared with porcelain (Cerabien CZR) and polished to 1.0 mm thickness. A spectrophotometer was used to measure the reflectance values from 380 to 780 nm for each disk; the scattering coefficient and absorption coefficient were determined. By using the reflectance values and the scattering and absorption coefficients, the computer color matching program generated porcelain prescriptions incorporating proportions from the 21 reference shades to reproduce the shade tabs. Disks were fabricated from the prescriptions, polished to 1.0 mm thickness, then placed over a zirconia core plate and measured with the spectrophotometer. The color differences (ΔE*) between the shade tabs and the corresponding ceramic disks were calculated. Statistical analysis was performed with the 1-sample t test. RESULTS The ΔE* values between computer color matching specimens and the target shade tabs varied from 0.5 to 1.9, with an average ΔE* of 1.3, which was significantly less than the clinically detectable ΔE* threshold of 1.6 (P<.001). CONCLUSIONS The computer color matching system with the established 21 new shades is accurate and effective for reproducing tooth shades.

Developing a custom dental porcelain shade system for computer color matching

OBJECTIVES This study aims to update the computer color matching method by generating a new ceramic shade system that covers the entire spectrum of natural tooth color and has an efficient design. METHODS First, the color map of 176 maxillary natural incisors and two commercially available and commonly used shade guide systems (Vitapan classic and 3D master) were drawn. Then, 15 shades of layered disks (NW-0: neutral white-0, A1, A2, A3, A4, B1, B4, C4, and D4, and six modifiers; white, pink, grey, blue, cervical-1 and cervical-2, Cerabien ZR) were plotted on the tooth color distribution map. Ultimately, 12 target shades were selected around the perimeter of the natural tooth color space, and nine different shades were selected within the cluster. By trial and error informed by known formulations published previously, the formulations of Cerabien ZR porcelain powders necessary to achieve these 21 target shades in thickness of 1.0mm layered on zirconia substrate were then determined and ceramic disks were fabricated. RESULTS Color distribution L*-C* and a*-b* maps showed that new 21 shade system covers a slightly broader range than the natural tooth distribution, and its distribution is larger than the 3D Master shades range. CONCLUSIONS In the present study, a 21 custom dental porcelain shade system was developed with a 1.0mm porcelain thickness overlying a zirconia substrate, which can be incorporated into the computer color matching system. This new shade system has homogeneity with 3D Master, and has a slightly wider color distribution than that of natural teeth.

Optical effects of different colors of artificial gingiva on ceramic crowns

OBJECTIVES The interaction between gingival color and the shade of ceramic restorations has never been fully studied. The purpose of this study is to investigate the optical effects of altering artificial gingival color on the ceramic crown shade in the cervical area. METHODS Thirty-one all-ceramic crowns of different shades were used in this study with six different artificial gingival colors. Using a spectrophotometer (Crystaleye(®) Olympus, Japan), we measured the shade of crowns in cervical areas with each of six different artificial gingiva. The crown color measured in the presence of pink artificial gingiva (control) was compared with the crown color with five other artificial gingiva. color difference values ΔE* were calculated and compared between the control group and test groups and the correlation of the artificial gingival color with the crown color was also assessed. RESULTS Significant differences were found in the mean L* and a* values of all-ceramic crowns at the cervical regions in all six gingival color groups (p<0.001) and significant Pearson correlations were also found for the mean L* (r=0.987, p<0.001) and a* (r=0.856, p=0.03) values between the artificial gingiva and the ceramic crowns. The mean ΔE* values between the control group and each of the five other gingival groups were all significantly larger than the clinical perceptual threshold of ΔE* 1.6 (p<0.001). CONCLUSIONS Different colors of artificial gingiva generated clinically detectable shade differences in the cervical region of ceramic crowns.