Received: 6 December 2018 Revised: 31 May 2019 Accepted: 28 August 2019

DOI: 10.1111/jerd.12530

RESEARCH ARTICLE

A novel sample design for determining color compatibility

between layered resin composite and vita shade guides

Eman H. Ismail D.D.S., M.S., Ph.D.1,2 | Deborah V. Dawson M.Sc, Ph.D.3,4 |

Rodrigo R. Maia D.D.S., M.S., Ph.D.5

1
Oral Science Program, College of Dentistry,
The University of Iowa, Iowa City, Iowa
2
Restorative Dentistry Division, Department
of Clinical Dental Sciences, College of
Dentistry, Princess Nourah Bint Abdulrahman
University, Riyadh, Saudi Arabia
3
Department of Pediatric Dentistry and Iowa
Institute for Oral Health Research, College of
Dentistry, The University of Iowa, Iowa
City, Iowa
4
Department of Biostatistics, College of Public
Health, The University of Iowa, Iowa
City, Iowa
5
Department of Operative Dentistry, College
of Dentistry, The University of Iowa, Iowa
City, Iowa
Correspondence
Eman H. Ismail, Princess Nourah Bint
Abdulrahman University, King Khalid
International Airport, P.O. Box. 84428, Riyadh
11671, Kingdome of Saudi Arabia
Email: ehismail@pnu.edu.sa
Abstract
Objective: To compare the color of double-layered (DL) resin-composite
(RC) samples with variant enamel-thicknesses (ET) to their corresponding shade-tabs
from VITA classical (VC) and 3D-Master (V3DM).
Methods: A2-DL samples (N = 30) fabricated using three pairs of custom-made molds
with an ET of 0.5, 0.7, and 1.0 mm. Shades were selected according to the manufac-
turer's instructions of two RC brands: Clearfil-Majesty (CM), and Vita-l-essence (VL).
A spectrophotometer measured CIE L*a*b* color parameters. We used ΔE00 to cal-
culate color differences among DL samples, VC, and V3DM shade-tabs. The data
were analyzed using Spearman correlation coefficient, one-way ANOVA, and Tukey
test (/=0.05).
Results: ΔE00 between DL samples A2 and 2M2 shade tabs were all greater than the
predetermined 50:50% acceptability threshold (ΔE00 = 6.6-10.4). Depending on the
shade tabs compared, the ΔE00 among CM and VL ET subgroups were statistically
different (P < .001). ET and L* were negatively correlated for CM and VL. For CM,
ΔE00 and L* correlated on the A2 shade tab, whereas for VL, ΔE00, and ET correlated
on the 2M2 shade tab (P < .05).
Conclusions: The DL samples produced unacceptable color matches to their
corresponding shade. An enamel layer thickness of 0.7 mm corresponded to the low-
est ΔE00. The use of V3DM for RC shade selection should be investigated.
Clinical Significance: Understanding color interaction between RC layers is important
to achieve consistent results in esthetic clinical procedures. The thickness of the
enamel layer can critically alter the overall shade for a given RC shade and brand. This
variation is difficult for the clinician to predict and negatively impacts patient satisfac-
tion, increasing overall procedure costs, and decreasing efficiency. This color interac-
tion study aims to facilitate consistency in shade reproduction.

KEYWORDS
CIEDE2000, color difference, layering, operative dentistry, resin composite

34 © 2019 Wiley Periodicals, Inc. wileyonlinelibrary.com/journal/jerd J Esthet Restor Dent. 2020;32:34–42.

ISMAIL ET AL.
1 | I N T RO D UC T I O N
Restorative resin composite (RC) material is becoming the material of
choice for direct restorative treatments because it provides excellent
esthetics, with reasonable longevity, when compared to other tooth-
colored restorative materials such as ceramics.1,2 However, one of the
limitations of RC is the incompatibility of its shades to those they are
3
designated to match. A previous study evaluated the shade compati-
bility of five RC systems to their designated shades guides (A3.5, B2,
C1, C3, and D2) and found that none of the RC shades was an accept-
able match to those in the VITA classical (VC) shade guide (color dif-
ference Δ E = 3.9-22.8).4 Another study compared the A2, B2, and C2
shades of RC among six different composite brands and reported a
large difference in color for each shade (Δ E for A2 = 4.4, B2 = 7.3,
and C2 = 5.6), further demonstrating that RC shades are inconsistent
among different manufacturers of RC systems.5 Despite the fact that
the VC shade guide remains the gold standard in clinical practice and
is used by most dental education programs worldwide, it suffers from
many shortcomings, including its limited shade coverage for human
dentition.6 In contrast, the VITA 3D master (V3DM) shade guide is
superior in its coverage of natural tooth color and in shade-tab
arrangements.7-11 Additionally, using the V3DM for indirect restora-
tions, such as veneers and crowns, results in more closely matched
restorations that require less shade correction.12 Restorative materials
are named following the shades in the VC systems, and no correlation
has been made between restoration shades and those of the V3DM.
As such, the V3DM shade guide is not commonly used by the general
dentist for routine direct restorative procedures.
Manufacturers of RC have attempted to minimize this confusion
regarding the shade mismatch by developing a system-dependent
shade annotation system (refraining from naming their RC with VC
nomenclature). Such RC systems are classified as non-VITA-based
composite systems.13 Because non-VITA-based systems offer an array
of shades and tints with variable translucencies, they have been
marketed as being better suited for composite-layering techniques.13
Composite-layering techniques enable clinicians to emulate the bio-
logical appearance of natural teeth, producing more vital looking res-
torations. However, with the use of this technique, the shade for the
final layer of the restoration is rarely predictable, especially for young
clinicians who are eager to challenge their clinical skills to achieve bet-
ter esthetic outcomes.14
For marketing reasons, manufacturers usually provide recommen-
dations to clinicians to replicate a certain shade from the VC using
their non-VITA based products. This results in a repetitive cycle in
which only the VC shades, but not the V3DM shades, are referenced.
In addition, despite providing recommended shade combinations,
manufacturers fail to describe the optimal thickness of the final
enamel layer that is required to produce a certain shade. Maintaining
the proper combination of thicknesses in each layer is necessary to
achieve a desirable shade, as alterations in the thickness of each layer
can significantly alter the final shade of the restoration. In the litera-
ture, RC layering studies typically investigate either the translucency
35
parameters or the overall shade of layered RC. The studies that focus
on translucency parameters all conclude that the translucency of RC
decreases with increased thickness of the composite layer.15-17 Thus,
the thickness of the enamel layer can greatly impact the overall color
of RC, creating another obstacle that clinicians must overcome to
achieve the desired esthetic outcome.
In an effort to understand the impact of thickness, some studies
investigate the overall color difference of double-layered (DL) RC
samples, but varying methods yield varied results.14,18-21 Only two
studies were found in the literature that compared designated VC
shade tabs with flat, DL, disk-shape samples with varying degrees of
enamel layer thickness.19,20 One study concluded that the DL samples
did not improve the compatibility of the RC shade to the shade
guides.20 The other study concluded that increasing the thickness of
the enamel layer resulted in higher chroma and lower value when
compared to the VITA shade tabs; however, the overall color differ-
ences (ΔE) between the designated shade tabs and the DL samples
were not reported.19 Thus, in multiple settings, the thickness of the
enamel layer influences the overall shade of the RC; however, current
studies have only used flat surfaces, which are not representative of
surfaces in the oral cavity. A better model is needed to accurately rep-
resent DL RC restorations for in vitro studies.
In addition, the compatibility of direct restorative materials to the
V3DM shade guide has not yet been investigated. A better under-
standing of this would enable dentists to use the V3DM more fre-
quently and would help shift away from dependence on the use of
the VC shades, of which there are only a limited number. Thus, under-
standing how restorative materials match the V3DM shade guide
would ultimately result in better esthetic outcomes.
To fill these gaps, we set out to achieve the following: (a) to evalu-
ate the color compatibility of A2 DL samples of varying enamel thick-
ness (0.5, 0.7, and 1.0 mm) to their designated shade using two
different RC systems (VITA-based and non-VITA-based) and (b) to
make the analogous comparisons between DL RC samples and the
V3DM. These goals will be achieved by using a custom mold to repli-
cate VITA shade tabs. Our null hypotheses were (a) following the
manufacturer's instructions in shading concepts will result in an
acceptable color match to the designated shades within the VC and
its equivalent shade within the V3DM with at least one of the pro-
posed thicknesses of enamel, (b) that there will be no difference in the
overall color (ΔE) between VITA-based and non-VITA-based RC
systems.
2 | MATERIALS AND METHODS
Two RC systems were selected for this pilot study: Clearfil Majesty
(Kurary) representing a VITA-based RC, and Vita-l-essence (Ultradent)
representing a non-VITA-based RC. Our only criterion for including
RC is that the manufacturer provided a chart with recommendations
to replicate VC shade tabs using the two layering techniques
(Table 1).
36 ISMAIL ET AL.

TABLE 1 Resin composite systems included in the study

Resin composite system Clearfil Majesty (CM) Vita-l-essence (VL)

Manufacturer Kurary Noritake Dental Inc., Okayama, Ultradent Products Inc., South Jordan, Utah
Japan.
Classification based on shading system VITA Non-VITA
Type based on fillers Nanocomposite Micro hybrid
Filler content (wt%) 78% 75%
Filler content (vol%) 40% 52%
Particle size range 0.37 to 1.5 μm 0.7 μm
Glass filler type Silanated barium glass filler Silanated strontium Alumina
Prepolymerized organic fillers Silicate Glass
Silanated silicon Dioxide
Matrix system Bis-GMA Bis-GMA
Hydrophobic aromatic dimethacrylate Diurethane Dimethacrylate
dl-Camphorquinone
Manufacturer instructions to replicate A2 A2E Pearl Neutral (PN)
shades Lot no. 270028 Lot no. BFL26
A2D A2
Lot no. 270018 Lot no. BFX5B
Light-cure time/depth for mid intensity 10 s 20 s
(1000-2000 mW/cm2) as per 2 mm 2 mm
instructions
Light energy delivered through the 14.7 J/cm2 29.4 J/cm2
transparent mold

One VITA shade tab was separated from its metal handle using a
hand-held, low-speed handpiece, Upower UP500 (Brasseler USA,
Savannah, Georgia), and a diamond disc. 3D scanning for the shade
tab was done using a GeoMagic Capture Scanner and GeoMagic
Design X software (3D Systems, Rock Hill, South Carolina). Designing
the 3D molds so the VITA shade tab would be embedded in a case
with variations in enamel thicknesses was done via Fusion 36 and 3ds
Max (Autodesk, San Rafael, California). The GrabCAD Print software
and Stratasys J750 Polyjet 3D printer (Stratasys, Eden Prairie,
Minnesota) were used to print the 3D molds. The printed molds were
made of VeroClear Acrylic Photo-Polymer (Stratasys), which is a trans-
parent photopolymer for clear acrylic simulation. Six iterations of the
3D mold design were made in the course of three months and
included several trials to achieve the desirable enamel layer thick- F I G U R E 1 Three pairs of molds replicating the VITA shade tab to
nesses and convenient mold design (Figure 1). produce samples with an enamel layer thickness of 0.5 mm (+E),
0.7 mm (++E), 1.0 mm (+++E) and their dentin analogue molds (+D,
++D, and +++D)
2.1 | Fabricating RC samples
One calibrated operator fabricated all the samples. The samples were bubbles. A scale was used (PG403-S DeltaRange, Mettler Toledo,
fabricated in pairs (dentin and enamel). The internal surface of the Columbus, Ohio) to measure the amount of composite placed in each
mold was finished and polished using Jiffy diamond impregnated rub- E mold to ensure that all enamel samples are within the desirable
ber points and cups (Green, yellow, and white, Ultradent Products thickness.
Inc., South Jordan, Utah). A silicon spray was used (Dentsply Trubyte, RC was placed inside the mold using a plastic instrument and con-
York, Pennsylvania) to prevent the samples from adhering to the mold. densed using an amalgam ball burnisher. The mold was closed,
RC was heated using CALSET (Model 201) (AdDent Inc. Danbury, pressed, and light cured from both sides using an LED light Paradigm
Connecticut) with a temperature of 98 F (37 C) for at least
! !
(3M, St. Paul, Minnesota). The LED-curing unit emits light at wave-
10 minutes to decrease resin viscosity and minimize entrapment of air lengths between 430 and 480 nm and a light intensity of 1550
ISMAIL ET AL.
mw/cm2, which was measured using the patient simulation, MARC,
by Blue Light Analytics (Halifax, NS, Canada). No significant reduction
in the light cure intensity was detected when subjected to RC through
the transparent mold, when assessed by MARC (1470 mw/cm2
through the mold) (Table 1).
Samples were removed from the mold, and the thickness of each
sample was verified using a stainless-steel handy gauge caliper
(0-10 mm) (Iwanson spring caliper for metal, Hu-Friedy Mfg. Co., LLC,
Chicago, Illinois). Only samples equal to the intended thickness
(or that differed by no less than 0.05 mm) were included.
Any excess RC was trimmed after curing, using a low-speed hand-
piece and Sof-Lex (3M) 1/2 M (light orange) discs. Samples were
00
rinsed and cleansed. Low-viscosity liquid polish (Biscover LV, Bisco,
Schaumburg, Illinois) was applied only on enamel layer samples using
a microbrush according to manufacturer's instructions and then light
2
cured for 30 seconds (44.1 J/cm ). Samples were randomly paired,
assigned to a group, and labeled according to their thicknesses, shade,
and brand of RC (Figure 2A). Samples were stored in a 37! incubator
(Queue stabil THERM series 300/3000, Surplus solutions LLC,
F I G U R E 2 A, Double-layered (DL) samples with VL and CM resin
composite with different enamel layer thickness. B, Color
measurement was done for the overall shade of the double-layered
samples and compared to A2 and 2M2 shade tabs
37
Woonsocket, Rhode Island) for 24 hours before color measurements
were taken.
2.2 | Shade-guide samples
Since there is a high consistency in color parameters among available
shade guides,22 only one shade guide from the VC system and one
from the V3DM (VITA Zahnfabrik, Bad Säckingen, Baden-
Württemberg, Germany), which were newly purchased, were included
in the study. The shade tabs were separated from their metal holders
using a hand-held low-speed handpiece Upower UP500 (Brasseler
USA) and a diamond disc. The back of the tabs was flattened using
wet silicon carbide papers (SCi 600/1200 grits) and a rotating tabletop
polishing wheel (Rotopol-V Polisher, Struers Inc., Cleveland, Ohio)
with a speed of 150 rpm with mild hand pressure for 30 seconds. The
shade-tabs samples were labeled and prepared for the color
measurement step.
2.3 | Color measurements
An optical contact gel, Cargille Optical gel (Cargille Laboratories,
Cedar Grove, New Jersey), with a refractive index of 1.5, was used to
make the dentin and enamel layers adhere transiently to each other.
The samples were mounted on a neutral gray background, Neutral
5 (L* = 50.9, a* = −0.15, b* = −0.27) X-Rite color checker (X-Rite,
Grand Rapids, Michigan). One calibrated examiner preceded all the
color measurement readings using an Easyshade V contact-type
spectrophotometer (VITA Zahnfabrik, Bad Säckingen, Baden-
Württemberg, Germany). This device has an integrated illumination
with built-in white LED light source (D65) with 2! standard observer,
and (45:0) optical geometry.23 The operating mode selected for mea-
surement was “averaged shade measurement,” and data were col-
lected in the CIE L*a*b* color space, where L* represents the
lightness and darkness values, a* represents values on the green-red
axes, and b* represents values on the blue-yellow axes.24 Calibration
of the spectrophotometer was done according to the manufacturer's
instructions. A jig was fabricated using Vinyl Polysiloxane impression
material (Exaflex, GC Corporation, Tokyo, Japan) to ensure a consis-
tent repositioning of the Easyshade tip at an angle of 90! in relation
to the shade tabs or RC specimens. Three color readings were
obtained with replacement, averaged, and recorded. Samples were
cleansed and stored in distilled water.
2.4 | Color difference calculations
The color difference was calculated between our DL samples and A2
and 2M2 shade tabs (Figure 2B) using the following CIELAB (ΔEab)
and CIED2000 (ΔE00) equations24:
rffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
" * #2 " #2 $ %2
ΔEab = L1 − L2* + a1* − a2* + b1* − b2*
38 ISMAIL ET AL.

sffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
& 0 '2 & ' & ' & 0 '& 0 ' requirements appeared to be met. Otherwise, an approach using rank
ΔL ΔC0ab 2 ΔH0ab 2 ΔC ab ΔH ab
ΔE00 = + + + RT transformations in the context of standard linear modeling was
K L SL K C SC K H SH K C SC K H SH
used.30,31
To assess whether better shade matches existed for the DL sam- Analyses were performed using SAS software for Windows (ver-
ples, the color difference was calculated between the DL samples and sion 9.4; SAS Institute, Cary, North Carolina). A 0.05 level of signifi-
the remaining 15 shades of the VC shade guide and the remaining cance was used unless otherwise specified.
28 shades of the V3DM shade guide. For each sample, the best shade
match was identified based on the lowest ΔEabvalues. The shade that
was most frequently identified for a given combination of material 3 | RESULTS
and thickness was further compared to all five samples using the
ΔE00. Descriptive statistics were generated for these values to charac- 3.1 | Description of color differences
terize the degree of matching (Table 4). The 50:50% acceptability
Descriptive statistics are shown in Table 2. Color difference values
threshold (AT) is used in dentistry to compare calculated CIE L*, a*, b*
color differences to actual visual color analysis. The AT is the point at generated by the two color-difference formulas ΔEab and ΔE00 were

which 50% of visual examiners would consider an object as an accept- clearly higher than the predetermined thresholds of AT. The ΔEab and

able match to another object. In this study, AT was used to interpret ΔE00 color differences were highly correlated whether the comparison

results and to determine clinical significance. The new established was being made to the A2 of the VC shade (r = 0.99, P < .0001) or to
thresholds in the field for the 50%:50% AT are 2.7 and 1.8 for the 2M2 of the V3DM (r = 0.98, P < .0001); thus, further discussion
ΔEaband ΔE00, respectively. 25,26 of results is confined to ΔE00 values.

2.5 | Statistical analysis

3.2 | Correlations among L*, enamel thickness, and
Spearman rank correlations were used to assess the relationships color difference
among enamel thickness, lightness (L*), and the two measures of color
difference. The method for two independent samples based on the A negative correlation was found between L* and enamel layer thick-

Fisher z transformation was used to assess whether the correlation ness, regardless of the RC brand or the shade-tab comparison being

characterizing each of these relationships differed significantly considered. However, there was no statistically significant difference

between the two brands of RC.27-29 in this regard between the two resin brands (P = .85).
A one-way analysis of variance (ANOVA) was used to compare The effect of change in enamel thickness for the VITA-based RC
the six groups defined by RC brand and enamel thickness with respect (CM) showed a moderate direct correlation with ΔE00 when compared
to ΔE00 color difference relative to a particular shade tab. Adjustment to A2 shade tab of the VC shade guide (r = 0.63, P = .012). In contrast,
for all pairwise multiple comparisons among the six groups was made the effect of change in enamel thickness for the non-VITA-based RC
using the Tukey method in conjunction with an overall 0.05 level of (VL) had a strong inverse correlation with ΔE00 when compared to
statistical significance. Validity of model assumptions of normality and 2M2 shade tab of the V3DM shade guide (r = −0.84, P < .0001).
variance homogeneity was assessed using the Shapiro-Wilk and Lightness (L*) and color change ΔE00 were negatively correlated
Levene procedure, respectively. for CM when compared to the A2 shade tab (r = −0.98, P < .0001)
Linear regression modeling was used to assess the effects of RC and were positively correlated for VL when compared to 2M2 shade
brand and ET on lightness and color change, where model tab (r = 0.64, P = .0095).

TABLE 2 Descriptive statistics of color differences between double-layered (DL) samples DC and VITA A2, 2 M2 and 1 M1 shade tabs

A2 VITA classical 2M2 VITA 3D master 1M1 VITA 3D master

(n=) Mean (SD) L* Mean (SD) ΔEab Mean (SD) ΔE00 Mean (SD) ΔEab Mean (SD) ΔE00 Mean (SD) ΔEab Mean (SD) ΔE00
Vita-l-essence (VL)
0.5 5 81.2 (4.1) 9.4 (0.6) 6.9 (0.5) 15.2 (1.3) 10.4 (0.9) 8.4 (1.7) 5.8 (1.2)
0.7 5 77.8 (3.2) 9.1 (1.9) 6.6 (1.3) 13.0 (1.5) 8.7 (1.2) 9.7 (2.9) 6.6 (2.0)
1.0 5 75.8 (1.3) 9.6 (0.9) 6.7 (0.6) 12.1 (0.8) 7.9 (0.7) 11.2 (1.1) 7.6 (0.9)
Clearfil Majesty (CM)
0.5 5 73.0 (1.0) 11.4 (0.6) 7.9 (0.6) 11.7 (0.6) 7.3 (0.4) 14.0 (1.0) 9.9 (0.9)
0.7 5 71.5 (0.4) 12.1 (0.4) 8.8 (0.3) 10.6 (0.5) 6.7 (0.4) 15.4 (0.4) 11.2 (0.3)
1.0 5 71.1 (1.0) 12.8 (0.9) 9.0 (0.7) 11.5 (0.7) 7.4 (0.5) 16.7 (1.0) 11.3 (0.8)
ISMAIL ET AL.
3.3 | Effects of RC brand and enamel thickness on
color difference
Due to non-normality, rank regression methods were used to assess
the effect of RC brand and enamel thickness on color difference
(ΔE00) relative to A2 shade tab of the VC shade guide, which was sig-
nificantly lower when the VL RC was used (P < .0001). The inconsis-
tency of the effect of enamel thickness previously described was also
observed, with a strong correlation between enamel thickness and
color difference for CM samples that was not present in the VL
samples.
Color difference ΔE00 relative to the 2M2 V3DM shade tab was
significantly lower when the CM RC was used (P < .0001). There was
evidence of an interaction between the RC brand and enamel thick-
ness (P = .0025), reflecting the inconsistency of the effect of enamel
thickness. In addition, a strong correlation between enamel thickness
and color change in VL samples was observed that was not present in
CM samples.
3.4 | Pairwise comparisons of six subgroups
The results from all possible pairwise multiple comparisons among the
six groups defined by RC brand and enamel thickness are presented in
Table 3. There was strong evidence that the mean color differences
varied among these six groups (P < .0001).
For the CM RC tested with the A2 shade tab, the Tukey adjust-
ment for multiple comparisons revealed no difference in mean color
(ΔE00) among the enamel thickness subgroups (Table 3, Column 1).
However, when the CM RC was compared to the VL, the mean color
difference of the CM groups (0.7 mm and 1.0 mm thickness) was sig-
nificantly higher than the means of all three VL groups. Mean color
change did not differ significantly among this set of four groups: the
0.5 mm CM group and the three VL groups (0.5, 0.7, and 1.0 mm
T A B L E 3 Multiple pairwise comparisons of mean color difference among the six groups defined by resin composite brand and enamel
thickness with respect to comparisons with A2 and 2 M2 shade tabs
Color difference ΔE00 compared to A2 shade tab
Tukey grouping Mean n Group
A 9.0 5 CM_1.0
A
A 8.7 5 CM_0.7
A B
B A 7.9 5 CM_0.5
B C
B 6.9 5 VL_0.5
B C
B 6.7 5 VL_1.0
B C
B 6.7 5 VL_0.7
Note: Means with the same letter are not significantly different.
39
enamel thicknesses). The smallest mean color change (ΔE00 = 6.56)
was associated with the VL RC and enamel thickness of 0.7 mm.
When the mean color differences relative to the 2M2 shade tab
were compared using the same methodology (Table 3, Column 2),
mean color change was significantly greater in the 0.5 mm VL group
than in any other group. Mean color differences did not differ among
the three groups corresponding to the 0.7 and 1.0 mm thicknesses of
VL and the 1.0 mm thickness of CM, which had intermediate mean
values. Finally, the four groups with the lowest means did not differ
from each other; these included the 1.0 mm VL group and the three
CM groups (0.5, 0.7, and 1.0 mm thicknesses). The smallest mean
color change (ΔE00 = 6.70) was associated with the CM RC and
enamel thickness of 0.7 mm.
4 | DISCUSSION
Knowledge of different RC materials is critical for dentists to develop
the skills needed to meet the increasing demand for esthetically pleas-
ing restorations. However, clinicians are often hesitant to use mate-
rials that could produce better results due to the risk of unsatisfactory
or unpredictable outcomes. Certain conditions require that dentists
use trial and error, which can result in an unacceptable color match
that requires the procedure to be redone at the cost of the dentist's
chair time. Collecting data about the performance of different RC
materials will help develop more efficient protocols that can reliably
predict the outcome of restorative procedures in a reasonable time
frame, thus leading to improved esthetic outcomes and patient
satisfaction.
In the current study, we assessed the shade compatibility of DL
tooth-like samples composed of different thicknesses of enamel with
their designated shades within the VC shade guide. Additionally, we
set out to determine if a corresponding shade to the VC shade guide
exists within the V3DM shade guide. Using the two formulas ΔEab
Color difference ΔE00 compared to 2M2 shade tab
Tukey grouping Mean n Group
A 10.4 5 VL_0.5
B 8.7 5 VL_0.7
C B 7.9 5 VL_1.0
B
C B 7.4 5 CM_1.0
C 7.3 5 CM_0.5
C 6.7 5 CM_0.7
40
and ΔE00 for all samples, our data showed that the color difference
values, regardless of enamel layer thickness, were higher from the
visual acceptability threshold (50:50% AT) when compared to the A2
and 2M2 shades (Table 2). Therefore, our null hypotheses were
rejected. The variability in correlations between RC brand, enamel
thickness, and color difference underscores a need to understand the
relationships among these factors. Specific combinations of RC brand
and enamel thickness are critical to achieving close color matches and
must be accounted for to achieve optimal esthetic results. Pairwise
comparison results show that CM DL samples were a closer match to
the A2 shade tab, whereas VL DL samples were closer matches to
2M2, indicating that an equivalent shade combination to 2M2 of the
V3DM could be established (Table 3). More work is needed to estab-
lish equivalent shade combinations for other shades.
Only two studies were found in the literature that compared DL
samples to the VC shade tabs.19,20 A study studied the compatibility
of flat, DL samples of three RC systems, employing one enamel thick-
ness of 1.0 mm and one dentin layer thickness of 1.5 mm. Their DL
samples were compared to shades A1, A2, B1, and B2 of the VC
shade guide.20 In that study, the ΔEab exceeded their study-defined
50:50% AT value of 3.3, which is in agreement with our findings.20
Similarly, another study compared the chroma (C*) of DL samples to
the VC shade tabs. The study concluded that increasing the enamel
layer thickness increased the C* and reduced the L* values for the DL
19
samples, suggesting a color mismatch. In our current study, the C*
was not one of our primary outcomes since only one dentin shade
was used per RC system, however, this could be addressed in future
studies.
One study used similar method to the ones used in the present
study to evaluate shade compatibility of readily available dual-
laminate shade tabs of Miris 2RC system (Colten, Whalednet Inc. Cuy-
ahoga, Falls, Ohio) to customized RC shade tab with a predetermined
thickness and to A1-A3 VC shade tabs.32 The researchers tested air,
glycerin, and water in between the dual-laminate layers of the tabs.
They concluded that water or glycerin both produced acceptable color
matches to VITA shade tabs.32 We took this into account for our
study and initially used water in our feasibility (pilot) study. Since our
tooth models are convex, the water would not stay in place. Instead,
we applied a very thin layer of optical contact gel as a temporary
adhesive media between the enamel and dentin layers. The gel has
the same refractive index of glycerin and RC, so it minimized the light
diffraction that occurs when air is present in the space between the
two layers.
Another facet of previous studies of layering RC is the use of flat
samples.14,18-21 As flat surfaces are rarely observed in the oral cavity,
it is difficult to translate these findings. A curved sample design, like
the one introduced in this study, is more representative of the natural
shape of teeth. The novel use of the transparent molds that were fab-
ricated specifically for this study enable us to produce an exact geo-
metric replicate of VITA shade tabs. Furthermore, since enamel
thickness varies, the thickness of the dentin layer compensated for
the remaining space, so the total thicknesses of all samples were equal
to the thickness of the VITA shade tab. The different thicknesses of
ISMAIL ET AL.
the enamel layer that were chosen for this study were 0.5, 07, and
1.0 mm. These measurements represent the average thickness of the
enamel layer in natural teeth in three different anatomical locations;
cervical, middle, and incisal, respectively.
Our custom-designed molds, and the enamel thicknesses that are
replicated by these molds (0.5, 0.7, and 1.0 mm), can be translated
into clinical practice with the aid of an instrument recently released
on the market (LM-Arte-Misura, LM-instrument Oy, Parainen, Fin-
land). This instrument is designed specifically for RC layering. The
molds also replicate clinical situations where increasing the enamel
thickness gives little room for the dentin layer, and vice versa, a factor
that all of the previous studies failed to include. Lastly, the molds can
continue to be used to generate more data to study the performance
of RC layering and are easily modified to replicate more complex lay-
ering techniques.
The RC systems included in this study were chosen to represent
VITA and non-VITA-based resin systems based on Dietschi and Fahl's
classification.13 The fundamental difference between the VITA and
non-VITA-based systems is the shade of the enamel layer. In the non-
VITA-based shading concepts, the enamel shade is typically offered in
three shades of very high translucency: (a) universal or neutral shade,
representing the enamel of general population; (b) bleached or high
value, representing the shade of young enamel or whitened teeth;
(c) dark or low value, representing the shade of old enamel.13 Addi-
tionally, the VITA-based systems enamel shades have the same
chroma as the VC shades but are more translucent.
It is worth mentioning that other studies have also investigated
the overall change in color (ΔE) of DL RC samples. However, the color
difference comparisons in those studies were made against a control
sample of a specific thickness or against the thinner combinations
from the same samples.14,18,21 As the studies did not evaluate VC
shade tabs, they were not included in our discussion. Previous litera-
ture concerning RC color utilized five sample replicates. For this rea-
son, we used 30 double-layered samples (n = 5 per enamel
thickness/RC brand subgroup) in this study. Our procedure in
selecting the shade combinations to reproduce shade A2 was stan-
dardized since we followed the manufacturers’ suggestions.
4.1 | Alternative better shade matches
The calculations for ΔE00 of our DL RC samples varied between thick-
nesses and shades. For example, with respect to the VC and V3DM
shade guides, using CM with an enamel layer thickness of 0.7 mm
would optimally match the C3 shade tab, whereas using a thickness of
1.0 mm would optimally match the 4M1 shade tab. Additionally, if the
thickness exceeded 0.5 mm, the overall shade would shift two values
darker according to the VC shade guide. The VL matching had the
same layer of specificity in regard to the thickness and shades. For VL,
an enamel layer thickness of 0.5 mm would match the 1M1 shade tab,
whereas a thickness of 1.0 mm would match the C1 shade tab
(Table 4). If the thickness exceeded 0.7 mm, the overall shade of the
DL restoration would be two values darker according to the V3DM
shade guide, revealing variations with respect to how the thickness,
ISMAIL ET AL. 41

T A B L E 4 Alternative shade match

VITA classical VITA 3D master
from VITA classical and 3D Master
shades with the recommended enamel Shade ΔE00 (SD) Median Shade ΔE00 (SD) Median
layer thickness (ΔE00)
Vita-l-essence (VL)
A2 + PN
0.5 mm C1 5.7 (1.2) 5.4 1M1 5.8 (1.2) 5.9
0.7 mm C1 4.4 (1.0) 4.5 1M1 6.7 (2.1) 6.5
1.0 mm C1 3.8 (0.6) 3.7 3M1 6.7 (0.8) 6.5
Clearfil Majesty (CM)
A2D + A2E
0.5 mm C1 4.9 (0.6) 4.7 4M1 4.9 (1.0) 4.9
0.7 mm C3 3.3 (0.3) 3.2 4M1 2.9 (0.2) 2.9
1.0 mm C3 4.0 (0.6) 4.2 4M1 3.8 (0.8) 3.8

shades, and brands compare to the shade guides (Table 4). It is impor- practice. Within the limitations of this in vitro study, we can con-
tant to use a shade guide that is able to detect the change in color clude that:
produced by different restorations. We expect enamel layer thickness
to be inversely proportional to L*, so if thickness increases, the shade • Following the manufacturer's instructions for shade selection of
will be darker. Our data suggest that the VC shade guide is more sen- RCs generated using the DL technique did not produce acceptable
sitive to thickness-dependent color change with VITA-based compos- shade matches to the A2 shade tab, nor to the 2M2 shade tab
ite, whereas the V3DM shade guide was more sensitive to this color when enamel thickness was confined to 0.5, 0.7, or 1.0 mm.
change with non-VITA-based RC. • The application of the 0.7 mm enamel layer of RC tested produced
Finally, the ΔEab and ΔE00 between the chosen shade tabs must the closest color matches to the shade tabs.
be addressed. Our experiment calculated a ΔEab and ΔE00 between • Further studies are required to evaluate the applicability of using
A2 and 2M2 of 8.2 and 5.6, respectively, which was higher than the the V3DM shade guide for RC shade selection.
reported shade-tab color difference.6 Consequently, we calculated
the ΔEab of all the V3DM shade guide shade tabs to determine if there
was a shade tab that was a better color match to A2. We found that ACKNOWLEDG MENTS
the shade tab with the lowest ΔE was 1M1 (ΔEab = 4.5 and ΔE00 = 3.5).
The authors extend their gratitude to Kuraray America Inc. and
It is possible that our results may have been different, if we compared
Ultradent Products Inc. for their generous donations of materials used
the DL samples of A2 and 1M1 (Table 2, Column 3). VL might have
in this study and to VITA North America for donating the color mea-
consistently achieved the lowest ΔE00 for both shade tabs. However,
surement device. The authors also thank MERG ProtoStudio at The
since this study's goal was to compare shade guides, we compared
University of Iowa for their help in fabricating the 3D molds. Lastly,
our samples to the closest shade tab recommended by the VITA man-
authors acknowledge the contribution of Dr. Rade Paravina and his
ufacturers (2M2).
team for providing their data calculation resources that were used in
It is possible that the discrepancy with the reported shade-tab
this study.
color difference could be due to the use of a different color measure-
ment instrument to obtain the CIE L*a*b values. Our study used the
VITA Easyshade V spectrophotometer, a device designed for clinical
DISCLOS URE OF I NTE RE ST S
color communication and verification among dental personnel. This
method has some limitations. Easyshade V does not measure the The authors do not have any financial interest in the companies
absolute color L*a*b color parameters. The device measures color whose materials are included in this article.
only in light reflectance mode, which makes the light more prone to
edge loss. Since our goal was to compare shade guides, not to mea-
sure absolutes, Easyshade V was sufficient for our research purposes. OR CID

Eman H. Ismail https://orcid.org/0000-0003-1539-798X

5 | CO NC LUSIO NS
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How to cite this article: Ismail EH, Dawson DV, Maia RR. A
novel sample design for determining color compatibility
between layered resin composite and vita shade guides.
J Esthet Restor Dent. 2020;32:34–42. https://doi.org/10.
1111/jerd.12530