Influence of Colour of Cement, Ceramic Thickness
and Try-in pastes on the Colour of Ceramic
Restorations. Mapping of the Literature
Author: Ronja Andersson, Hero Amiri
Tutor: Berit Ardlin
ABSTRACT
Today it is possible to create veneers that are aesthetically and functionally satisfying, but there are some factors that may compromise the aesthetic results. The aim of this study was to investigate influence of cement shades and ceramic thickness on the colour of ceramic veneers, but also to study how well try-in pastes match with their corresponding cements. PubMed was used to search for papers using MeSH-terms and keywords. 144 titles and abstracts were read, 29 full texts were read and 24 papers were used in the analysis. All of the studies were in vitro.
In 20 studies, it was found that the cement shade influences the colour of the ceramic veneer. Two studies reported that the cement shade had no influence on the colour of ceramic
veneers, and two did not draw any conclusions regarding the influence of cement shade. Twelve studies compared different thicknesses of the veneers; all of them found that the thicknesses had an influence on the colour of the veneers.
Two out of four studies found no compatibility between try-in pastes and their corresponding cements, while two studies found compatibility for some try-in pastes.
The shades of cement and thicknesses of ceramic veneers can influence the colour of the ceramics. The colour of try-in pastes does not always show a similarity with their
INTRODUCTION
History of ceramics in dentistry
In the year of 1774 Alexis Duchateau made the first porcelain denture to replace ivory. Year 1885, Logan started using platinum posts, which he fused porcelain to and made a Richmond crown. In 1886, Land introduced the first fused feltspathic porcelain inlays and this was an aesthetically preferable but weak material. In the 1950s leucite was added to porcelain materials to modify the thermal expansion. This made it easier to fuse porcelain on gold alloys, forming metal-ceramic systems that were strong and aesthetic. The all-porcelain system was not particularly popular at this time. Despite being aesthetically superior to other systems, it lacked strength (Kelly et al., 1996). In 1965 McLean and Hughes introduced a dental core ceramic consisting of glass matrix with 40-50% Al2O3 added. This improved the
fracture resistance of porcelain crowns (Anusavice et al., 2013).
“Shrink-free” all-ceramics were introduced in the year of 1980 and the popularity of these systems increased. There was a significant increase in the number of papers published about ceramics in the Journal of Prosthetic Dentistry between the years of 1981 and 1993, but few of these papers addressed the aesthetical properties. The majority of the research involved the mechanical properties of ceramics. This indicates that the aesthetics was not of concern regarding ceramics; it was taken for granted that porcelain ceramics rarely fail to achieve aesthetical satisfaction. The issue was rather the mechanical properties of porcelain ceramics – the strength of the material (Kelly et al., 1996).
Since 1970, the very strong yttrium-stabilized zirconia with aluminium oxide particles has been used as hip replacement material. By stabilizing zirconia with yttrium, a strong material that is flexural and tensile resistant was formed. Those properties made it convenient to use zirconia in dental restorations. In 2004 the first crowns and bridge constructions were made out of zirconia (Anusavice et al., 2013).
Other factors affecting the aesthetics
Today we can achieve ceramic constructions that are mostly both aesthetical and functionally satisfying. But there are also other factors that research has revealed could jeopardize the aesthetics of ceramic veneers. Among these there are several clinical factors affecting the
aesthetics such as colour scale, light source during colour evaluation, characteristic of core material, colour of supporting tooth, presence of root post, and choice of cement. There are also factors at the dental laboratories including technique for ceramic condensation, thickness, temperature and number of firing of cycles that has an influence on the aesthetics. The all-ceramic veneers aesthetics and durability has also been shown to be dependent on the integration with the periodontal tissue that surrounds it (Barão et al., 2010).
These days, coloured cements are used to improve the aesthetics of ceramic constructions. Earlier studies have shown divergent results as to how much the colour of the cement influences the final colour of ceramic veneers (ALGhazali et al., 2010; Xing et al., 2010; Xu., et al., 2014).
Some studies have compared resin cements with their corresponding try-in pastes. Try-in pastes are solutions that come in the same shades and consistency as resin cements, and are therefore used to determine which shade should be used before cementation. It is put on the prepared tooth and then the veneer is placed over it. If the try-in paste was a correct colour match, resin cement in the same shade can be selected. The try-in paste has to be removed before cementation (Rigoni et al., 2012).
In one earlier study try-in pastes and their corresponding composite cements influence on the final colour of ceramic veneers was compared for five different shades. Instead of veneers they used ceromers with the thickness of 1 mm, 0.8 mm and 0.5 mm. Composite discs were fabricated to imitate the teeth. The cements and try-in pastes were applied on the composite discs and then the ceromers were placed over the cements or try-in pastes. The colours were registered for the try-in pastes and the cement was polymerized by light before colour measurements. The conclusion was that the colour of try-in pastes and their corresponding composite cements did not always match, especially not for the darker colours (Xing et al., 2010).
One study had resin teeth in nine different dentin colours that had been prepared. Ceramic veneers with a thickness of 0.6 mm and seven different colours of resin cements were used. The goal was to achieve the colour of A1. Totally 63 different combinations of cement and resin teeth with five samples in each were used. After the preparation of the resin teeth, the veneers were cemented and the colour differences were measured. The result of the study
showed that none of the seven cements had any significant effect on the final colour of the veneers (Dozic et al., 2010).
In one study, 10 extracted molars were abraded on the buccal and lingual surfaces and sliced into two halves. Ceramic discs were fabricated in 0.8 mm thick samples. The ceramic discs were cemented with the shades A1 and A3on the flat surfaces of the teeth. The colours were measured. The colour changes after cementation were not clinically perceptible
(Karaagaclioglu and Yilmaz, 2008).
Colour measurements
To measure colour, spectrophotometers can be used. When measuring colour with
spectrophotometers the colour is defined as three different values. The L* value represent the lightness. The a* value represent red as a positive value and green as a negative value. The b* value represent yellow as a positive value and blue as a negative value. By comparing all those values between two objects the total colour difference defined as a ΔE-value is achieved. The ΔE value is calculated with the following formula: ΔE(L,a,b) = [(L1-L2)2+(a1
-a2)2+(b1-b2)2]½ (Karaagaclioglu and Yilmaz, 2008).
The choice of an acceptable ΔE-threshold can vary. There are perceptible colour changes that are hard for some observers to see but still can be measured, and it is therefore hard to set boundaries for relevant colour mismatches. Conclusions that ΔE 2.72 is the value for clinically unacceptable colour mismatch have been made (Ragain and Johnston, 2000).
Aim of this study
The aim of this study was to conduct a mapping of literature of quantitative studies regarding colour changes of ceramic veneers of different thicknesses caused by coloured resin cements and try-in pastes.
The clinical question this study aim to answer is: “Does the colour of resin cement and thickness of ceramic influence the colour of the ceramic veneer? And does the try-in pastes match with their corresponding resin cements?”.
MATERIALS & METHODS
Inclusion and exclusion criteria
The information required for the inclusion in the analysis is shortened PICOS. Papers were included only if they matched with PICOS. The PICOS used in this study were:
- P (population): Ceramic veneers, crowns or discs
- I (intervention): Cementation of ceramic restoration with resin cement or try-in pastes. - C (comparison): Ceramic thickness, cement shade and compatibility between try-in
pastes and corresponding resin cement. - O (outcome): Colour difference. - S (study type): In vivo and in vitro.
Papers that were not available in English were also excluded.
Database search
Scientific papers were searched for on the database PubMed using MeSH-terms and key words, Fig 1. The search was done on December the 7th. 2016.
The MeSH-terms that were found were: “color”, “ceramics”, “resin cement”, “dental cement” and “dental porcelain”. The MeSH-terms were used in different combinations during searches in PubMed. Combinations used were:
- Color AND ceramics AND resin cement, 105 papers - Color AND ceramics AND dental cement, 129 papers
- Color AND dental porcelain AND dental cement, 107 papers - Color AND dental porcelain AND resin cement, 92 papers Those combinations gave 433 papers.
“Try-in paste” was a keyword that was related to our topic. Another search with that keyword was made, not combined with the MeSH-terms. The keyword search identified 11 papers for a total of 444 papers. No manual search was done. After excluding duplicates, there were 143 papers.
Two dental students, independent of each other, read the titles and abstracts of those 143 papers. 114 were then excluded according to PICOS (Table 1) after a consensus was achieved between the dental studies. 29 full texts papers were read. Of those 29 papers, 24 were used in the analysis and 5 were excluded (Table 2)
Filters that were used in both searches were “last 10 years”.
Ethic analysis
In the studies that were analysed only three involved human teeth, but there was no
information regarding the patients used in the studies and the teeth were already extracted. The rest of the studies used artificial material in their experiments. Therefore no patients were harmed, and no sensitive patient information was exposed.
Prosthetic treatments are relatively costly and there are high expectations on the aesthetic results. Therefore this study is important to ensure that high aesthetic quality is achieved. This study had minimal harm for patients but the results that can be reported can be of great use in the clinical work.
RESULTS
Out of 144 papers, 24 were included in this literature mapping (Table 3). 120 papers were excluded (Table 1; Table 2).
In 20 of the 24 studies it was found that the resin cement does influence the colour of the ceramic veneers (ALGhazali et al., 2010; Alqahtani et al., 2012; Azer et al., 2011; de Azevedo Cubas et al., 2011; Begum et al., 2014; Calgaro et al., 2014; Chaiyabutr et al., 2011; Chang et al., 2009; Dede et al., 2016; Jankar et al., 2015; Kampouropoulos et al., 2014; Kürklü et al., 2013; Niu et al., 2014; Omar et al., 2010; Terzioğlu et al., 2009; Turgut and Bagis, 2011; Turgut and Bagis, 2013; Turgut and Bagis, 2014; Xu et al., 2014; Öztürk et al., 2013). In the remaining four studies, no conclusions could be made in one of the studies regarding if the resin cement shade influenced the colour of the ceramic veneer (Rigoni et al., 2012). One study only drew the conclusion that the presence of cement influences the colour of the ceramic veneers (Pires, et al., 2016). Two of the studies showed that the shade of the resin cement did not influence the final colour of the ceramic veneer (Karaagaclioglu and Yilmaz, 2008; Dozic et al., 2010).
In the twelve studies that compared different ceramic thicknesses, the thickness of the ceramic veneers influenced the colour of the veneers (Alqahtani et al., 2012; de Azevedo Cubas et al., 2011; Begum et al., 2014; Calgaro et al., 2014; Chaiyabutr et al., 2011; Kürklü et al., 2013; Niu et al., 2014; Omar et al., 2010; Pires et al., 2016; Turgut and Bagis, 2013; Turgut and Bagis, 2014; Xu et al., 2014).
Try-in pastes were tested in four studies. Two studies considered it to be colour differences between all try-in pastes and their corresponding cement shades (ALGhazali et al., 2010; Kampouropoulos et al., 2014). Two of the studies found that the colour match was satisfying for some of the try-in pastes, but not for others (Rigoni et al., 2012; Xu et al., 2014).
The studies all had similar designs. The biggest difference was the materials that were used to achieve dentin-like background. Three studies used human teeth (Jankar et al., 2015;
Karaagaclioglu and Yilmaz, 2008; Omar et al., 2010) and another used bovine teeth
(ALGhazali et al., 2010). Six studies had no dentine-like background (Kampouropoulos et al., 2014; Kürklü et al., 2013; Terzioğlu et al., 2009; Turgut and Bagis, 2011; Turgut and Bagis, 2013; Öztürk et al., 2013). The other studies used some kind of resin backgrounds (Alqahtani et al., 2012; Azer et al., 2011; de Azevedo Cubas et al., 2011; Begum et al., 2014; Calgaro et al., 2014; Chaiyabutr et al., 2011; Chang et al., 2009; Dede et al., 2016; Dozic et al., 2010; Kampouropoulos et al., 2014; Niu et al., 2014; Omar et al., 2010; Pires et al., 2016; Rigoni et al., 2012; Turgut and Bagis, 2014; Xu et al., 2014).
Different brands and shades of cements were used in the studies. Types and brands of ceramic material also varied between the studies.
The colour measurements were done with a spectrophotometer and colour differences were expressed as ΔE. A ΔE-threshold was used to determine whether the colour difference was clinically acceptable. This threshold varied between the studies. Many studies compared this value with another value that was considered as a perceptible colour difference.
DISCUSSION
In 20 of the 24 studies it was found that the shade of the cement influenced the final colour of the ceramic veneer (ALGhazali et al., 2010; Alqahtani et al., 2012; Azer et al., 2011; de Azevedo Cubas et al., 2011; Begum et al., 2014; Calgaro et al., 2014; Chaiyabutr et al., 2011; Chang et al., 2009; Dede et al., 2016; Jankar et al., 2015; Kampouropoulos et al., 2014;
Kürklü et al., 2013; Niu et al., 2014; Omar et al., 2010; Terzioğlu et al., 2009; Turgut and Bagis, 2011; Turgut and Bagis, 2013; Turgut and Bagis, 2014; Xu et al., 2014; Öztürk et al., 2013). In one of the studies, no conclusions was made regarding influence of cement shades and conclusions could only be made regarding try-in pastes (Rigoni et al., 2012). One study only drew the conclusion that presence of cement influences the colour of the ceramic veneers (Pires et al., 2016). Only two out of 24 studies came to the conclusion that cement shade had no influence on the final colour of the ceramic veneer (Karaagaclioglu and Yilmaz, 2008; Dozic et al., 2010).
Earlier studies have found that the thickness of ceramic veneers influences the final colour (Son et al., 2010; Barão et al., 2010; Ozturk et al., 2008). It is therefore not surprising that all the studies found that the thickness of ceramic veneers influenced the colour of the veneers (Alqahtani et al., 2012; de Azevedo Cubas et al., 2011; Begum et al., 2014; Calgaro et al., 2014; Chaiyabutr et al., 2011; Kürklü et al., 2013; Niu et al., 2014; Omar et al., 2010; Pires et al., 2016; Turgut and Bagis, 2013; Turgut and Bagis, 2014; Xu et al., 2014). The answer to the clinical question whether the colour of cement and thickness of ceramic influence the colour of the ceramic veneer is likely yes, because a majority of the studies came to this conclusion.
Colour agreement between try-in pastes and their corresponding composite cements were diverse in the four studies that investigated the compatibility. Two showed similar results (Rigoni et al., 2012; Xu et al., 2014); that some try-in pastes and their corresponding cement had high agreement but others did not. The other two found no agreement between try-in pastes and corresponding cement (ALGhazali et al 2010; Kampouropoulos et al., 2014). Because of the divergent results from the studies regarding try-in pastes the clinical question whether the try-in pastes match with their corresponding cements cannot be answered. More studies regarding this topic are needed.
The recommended ΔE-threshold differed between almost all studies - the value for what was considered a perceptible colour change and the value that was considered clinically
unacceptable colour change - varied. This could have a great impact whether the studies found the colour difference on the ceramic as significant or not. The determination of an appropriate ΔE-threshold for clinically significant colour change has been a hard task, although according to one study, the ΔE-value of 2-2.5 has been shown to represent a value which is perceptible for all people and not only for trained or skilled persons (ALGhazali et al., 2010). According
to another study the value of 5.5 has been concluded to be the threshold for clinically
unacceptable colour change (Douglas et al., 2007). However, some of the studies have chosen other values. The value ΔE >3-3.5 was used in many of the studies (Alqahtani et al., 2012; Dozic et al., 2010; Kampouropoulos et al., 2014; Kürklü et al., 2013; Turgut and Bagis, 2011; Turgut and Bagis, 2013; Turgut and Bagis, 2014).
All the studies that were used had statistical calculations with a pre-determined p-value considered as statistically significant. The conclusions drawn in the studies were therefore statistically significant. In some studies some of the results were not formulated as
“statistically significant”, which led to uncertainty concerning the findings. However, when the authors did not write if a statement was statistically significant or not, it was because they instead wrote if the colour differences were perceptible and/or clinical unacceptable
(ALGhazali et al., 2010; Alqahtani et al., 2012; Karaagaclioglu and Yilmaz 2008; Kürklü et al., 2013; Turgut and Bagis, 2013; Xing et al., 2010).
Different brands and shades of cement were used in the studies. The number of different brands and shades also varied widely between the studies. It is possible that in some studies the chosen shades were too much alike to get a significant colour change on the ceramic. A lot of the studies also had few samples for each shade, which leaves place for errors.
The findings from this study that the colour of the cement can have an influence on the colour of the ceramic veneer is of value in the clinical work when it is of importance to achieve high aesthetics, such as in the anterior region of the dental arch. The choice of cement shade is of great importance. Therefore a reliable tool for choosing cement shade would be of clinical value, but try-in pastes are not optimal for choosing cement shade. None of the studies used in this literature mapping involved real patients. The oral environment is unique and could affect the colour result. Also none of the studies have investigated the patients’ opinions on the aesthetic result. Future studies should focus on in vivo studies and patients’ perspectives.
Conclusion
The shades of cement and thicknesses of ceramic veneers can influence the colour of the ceramics. The colour of try-in pastes does not always show a similarity with their
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Paper Reason for
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C
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Not available in English
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C
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C
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Not available in full text
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Not available in English
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Not available in English
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Not available in English
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Not available in English
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Table 2. Papers excluded after reading full text
Paper Reason for
exclusion
Hernandes DK, Arrais CA, Lima Ed, Cesar PF, Rodrigues JA. Influence of resin cement shade on the color and translucency of ceramic veneers. J Appl Oral Sci. 2016 24(4):391-6
O
Kilinc E, Antonson SA, Hardigan PC, Kesercioglu A. Resin cement color stability and its influence on the final shade of all-ceramics. J Dent. 2011 39 Suppl 1:e30-6.
C
Kucukesmen HC, Usumez A, Ozturk N, Eroglu E. Change of shade by light polymerization in a resin cement polymerized beneath a ceramic restoration. J Dent. 2008 36(3):219-23.
C
Shadman N, Kandi SG, Ebrahimi SF, Shoul MA. The minimum thickness of a multilayer porcelain restoration required for masking severe tooth
discoloration. Dent Res J (Isfahan). 2015 12(6):562-8.
O
Xing W, Jiang T, Ma X, Liang S, Wang Z, Sa Y, Wang Y. Evaluation of the esthetic effect of resin cements and try-in pastes on ceromer veneers. J Dent. 2010 38 Suppl 2:e87-94.
Authors and publishing years Samples (n) Ceramic thickness Cement thickness ΔE-threshold
Results and conclusions
ALGhazali et al., 2010 135 bovine teeth. 15 in each group 1.0 mm No information
>5.5 There was a statistical significant colour difference of the veneers depending on cement shades. There were also statistically
significant colour differences on the veneers between different try-in pastes. The colour of the try-in pastes differed from the corresponding luting cements with a ΔE-value of 1.05-3.34.
Alqahtani et al., 2012 30 ceramic discs, 2 in each group 0.5 mm, 0.7 mm
0.1 mm >3.3 Ceramic material, ceramic thickness and cement shades have a statistically significant effect on the colour of the veneers. Three of the cement shades made the veneers darker and two cement shades made the veneers lighter than the control group.
Azer et al., 2011 40 ceramic discs, 5 in each group
0.3-1 mm No
information
>2.6 The cement shades that were used had a statistically significant influence on the colour of the ceramic veneers.
de Azevedo Cubas et al., 2011 15 ceramic discs, 5 in each group 1.0 mm, 1.5 mm, 2.0 mm
0.2 mm >2 There was a statistically significant influence of the cement shade and ceramic thickness on the colour of the ceramics.
Begum et al., 2014 15 ceramic discs, 5 in each group 0.5 mm, 1.0 mm, 1.5 mm
0.02 mm >3.7 The thickness of the ceramic has a statistically significant influence on the colour of the ceramic. The colour of the cement has a statistically significant influence on the colour of the veneers. Opaque cement has greater ability to mask underlying colour. Calgaro et al., 2014 120 ceramic discs, 40 in each group 0.5 mm, 0.7 mm, 1.0 mm
2 mm >3.7 There was a statistically significant influence of the cement and ceramic thickness on the colour of the ceramics.
Chaiyabutr et al., 2011 20 ceramic crowns, 5 in each group 1.0 mm, 1.5 mm, 2.0 mm, 2.5 mm
0.3 mm >3.7 Cement color and ceramic thickness had a statistically significant influence on the color of the ceramic crowns.
Chang et al., 2009 42 ceramic crowns, 3 in each group Different thickness in different regions of the crowns
0.1 mm >2 The shades of the cements had a statistically significant influence on the colour of both the zirconia crowns and lithium disilicate glass-ceramic crowns, but had a statistically significant greater effect on the glass-ceramic.
Dede et al., 2016 20 ceramic discs, no information regarding samples in
1.5 mm 0.2 mm >2.25 The shade of resin cement significantly influenced the final color of the ceramic veneers. The opaque cement had a significant greater influence on the colour of the veneers.
each group.
Dozic et al., 2010 315 ceramic veneers, 5 in each group
0.6 mm No
information
>3.3 The shades of the resin cements had no statistically significant influence on the colour of the ceramic veneers.
Jankar et al., 2015 25 human incisor teeth, different nimber in different groups 0.5 mm No information
>3.7 The cement had statistically significant influence on the colour of the ceramic veneers.
Kampouropoulos et al., 2014
64 ceramic discs, 8 in each group.
0.8 mm 0.8mm >3.3 The cement had a statistically significant influence on the colour of the ceramic veneers. Try-in pastes did not match with their corresponding resin cements.
Karaagaclioglu and Yilmaz, 2008 20 human teeth halves, 10 in each group 0.8 mm No information
>3.7 The colour changes on the veneers after cementation were within a clinical acceptance level. There were no statistically significant colour differences on the veneers after cementations between the different cement shades.
Kürklü, et al., 2013 36 porcelain discs, 6 in each group 0.5 mm, 1.0 mm
0.2 mm 3.5 In porcelain thicknesses between 0.5-1.0 mm, neutral cement will not give clinically unacceptable colour changes. Using the same thicknesses, it will do so if using chromatic and opaque white cements. All shades gave a colour difference that is statistically significant perceptible on the veneer, but not clinically
Niu et al., 2014 15 ceramic discs, 15 in each group (samples reused) 1.5 mm 50 μm, 100 μm, 300 μm
>5.5 The colour of the ceramic discs was statistically significantly affected by both the color and the thickness of resin cements.
Omar et al., 2010 200 human molar teeth, 20 in each group 0.3 mm, 0.5 mm, 0.7 mm No information
>2.8 The thickness of the veneers and the colour of the resin cements had a statistically significant influence on the colour of the ceramic veneers.
Pires et al., 2016 40 ceramic discs, 10 in each group
1.0 mm, 1.5 mm, 2.0 mm
0.1 mm >5.5 Thicknesses of ceramic veneers and the presence of cement significantly influenced the color of the ceramic veneers.
Rigoni et al., 2012 30 resin discs, 10 in each group 0.5 mm 3.0 mm No information
Statistically significant colour compatibility was shown between two brands of try-in pastes and their corresponding resin cements. The other brand showed no similarity.
Terzioğlu et al., 2009 40 ceramic discs, 10 in each group 0.5 mm, 1.0 mm, 2.0 mm, 3.0 mm
0.3 mm >3.7 The colour of the resin cement had a statistically significant influence on the colour of the ceramic veneers.
Turgut and Bagis, 2014 224ceramic discs, 7 in 0.5 mm, 1.0 mm No information
>3.5 The colour of the ceramic veneers was statistically significantly affected by the ceramic thickness and resin cement shade.
each group
Turgut and Bagis, 2013 392 ceramic discs, 7 in each group 0.5 mm, 1.0 mm
0.1 mm >3.5 Four of the thirteen shades of cement had a statistically significant effect on the colour of laminate veneers. For the 0.5 mm
thickness, the colour change is clinically unacceptable, but for the 1.0 mm thickness it was clinical acceptable.
Turgut and Bagis, 2011
392 ceramic discs, 7 in each group
0.5 mm 0.1 mm >3.5 Statistically significant colour changes on the ceramic veneers occurred for four out of 16 of the cement shades.
Xu et al., 2014 50 ceramic discs, 10 in each group 1.0 mm, 0.7 mm, 0.5 mm No information
>1 The colour differences for 1.0 mm thick ceramic discs were statistically significantly less than the colour difference for the 0.7 and 0.5 mm thick ceramics after cementation, and were not perceptible. Statistically significant colour changes could be seen when using different cement shades on the 0.7 and 0.5 mm thick ceramics. The agreement of try-in pastes was statistically
significant better for the 0.5 mm thick ceramic than for the 0.7 mm thick ceramic. There was statistically significant less agreement between the luting cements and corresponding try-in pastes for the more darker and opaque cements.
Öztürk et al., 2013 80 ceramic discs, 10 in each group 1.0 mm No information No information
The resin shades had a statistically significant effect on the opacity of the ceramic veneers.
Figure 1. Schematic figure of literature search
433 papers were identified from the MeSH term search. 11 papers were identified from keywords from a total of 444.
301 papers removed because of duplicates
143 titles and abstracts read.
114 papers excluded based on PICOS or not available in English or not available in full text
29 full text papers were read.
5 papers excluded based on PICOS
24 papers used in the analysis.
Umeå University Department of Odontology
SE-901 87 Umeå, Sweden www.odont.umu.se
