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DOI: 10.1111/jerd.12553
RESEARCH ARTICLE
Wei-Hung He DDS., MS1 | Cheryl J. Park DDS., FACP2 | Sangho Byun DDS., FACP2 |
Daniel Tan BDS3 | Chih Y. Lin DDS4 | Winston Chee DDS, FACP5
1
Department of Dentistry, Division of
Prosthodontics and Operative Dentistry, Abstract
Chang Gung Memorial Hospital Kaohsiung Objectives: To understand (a) the effects of labial enamel on tooth color
Branch, Kaohsiung City, Taiwan, ROC
2 (b) relationship of color data taken by nonpolarized (NP), cross-polarization photogra-
Division of Restorative Sciences, Herman
Ostrow School of Dentistry, University of phy (CP), and spectrophotometry (SP).
Southern California, Los Angeles, California
Materials and methods: Fifty extracted human maxillary incisors were coated with
3
Advanced Prosthodontics Program, Herman
Ostrow School of Dentistry, University of resin on their palatal surfaces. Their color was measured with NP, CP, and SP and
Southern California, Los Angeles, California their dimensions were scanned by an intraoral scanner. The labial enamel was
4
Division of Endodontics, Department of
removed using a modified selective enamel demineralization technique. Tooth dimen-
Dentistry, Kaohsiung Chang Gung Memorial
Hospital, Kaohsiung City, Taiwan, ROC sions and color were recorded again. The differences in the labial enamel thickness
5
Division of Restorative Sciences, Herman (ΔT) and color (ΔE*00 and ΔL*, Δa*, Δb*) were statistically analyzed with the Pear-
Ostrow School of Dentistry, University of
son correlation coefficient and simple linear regression.
Southern California, Los Angeles, California,
Ralph and Jean Bleak Professor of Restorative Results: In CP and SP methods, ΔT and ΔE*00 were weakly to moderately positively
Dentistry, Director Advanced Prosthodontics
correlated (r = .38 and .27). In NP, CP, and SP methods, ΔT and Δb* are weakly posi-
Correspondence tively correlated (r = .27, .27 and .29). The color data of three measuring methods
Winston Chee, Ralph & Jean Bleak Professor
were highly positively correlated (r > .8). A linear relationship between ΔE*00 and ΔT
of Restorative Dentistry, Herman Ostrow
School of Dentistry, University of Southern were found (CP and SP groups).
California, Rm 4374, 925 W 34th St, Los
Conclusions: (a) Thicker labial enamel has a greater impact on tooth color.
Angeles, CA 90089.
Email: wchee@usc.edu (b) Reducing labial enamel thickness shifts the tooth color toward yellow. (c) Tooth
color measured from the three methods were highly correlated.
Clinical Significance: Knowing the relationship between enamel thickness and tooth
color, a clinician can better predict the stump shade before tooth preparation. Due to
the highly correlated measuring outcomes, it is reasonable to combine these three
methods during shade matching.
KEYWORDS
cross-polarization, enamel thickness, intraoral scanner, shade matching, spectrophotometer,
tooth color
scattering of light.5-7 Coops and ten Bosch5 compared the color of 1.3 | Objective
intact teeth and the color of the same teeth after removing the labial
This study attempts to measure the effect of altering the labial enamel
enamel and found that the colors were strongly correlated. Their
thickness on tooth color by utilizing three different color measure-
study confirmed that tooth color is determined mainly by the dentin,
ment methods (NP, CP, and SP). The data from these three measuring
while the enamel plays a minor role through scattering wavelengths in
methods will also be compared to understand how well they correlate
the blue range. Based on previous findings, there is still a need to
with each other.
understand how different enamel thicknesses could affect tooth color.
Therefore, this study was designed to investigate the relationship of
the enamel thickness to the overall tooth color. 1.4 | Hypotheses
The null hypotheses are as follows.
F I G U R E 1 This flowchart shows the main procedures. 50 specimens were photo recorded and 3D shape scanned, and then proceeded acid-
dissection. After acid-dissection (48 specimens left), specimens were photo recorded and 3D shape scanned again. Color and shape measuring
data were aligned and measured, followed by statistical calculations
2.2 | Modified selective enamel demineralization twin flash cold shoes was made (Figure 3). This equipment allowed
for consistent repositioning of the samples at the same distance
A technique to remove the enamel and preserve the dentin was modi-
on the camera's optical axis.
fied from Bazos and Magne's method.21
2. A full-frame camera (D810, Nikon Corporation, Tokyo, Japan) with
a 105 mm macro-lens (105 mm f/2.8G ED-IF AF-S VR Micro
1. The palatal resin-coated specimens were submerged in 10% HCl
NIKKOR Lens, Nikon Corporation, Tokyo, Japan) and a twin flash
for 15 minutes to remove the labial enamel layer.
(Twin Lite MT-24EX Speedlite Flash, Canon Inc., Tokyo, Japan)
2. Excess acid was then removed from the samples by washing under
was used to capture the digital photographs. An external flash bat-
flowing water for 30 minutes. After washing, samples were stored
tery pack (PROPAC PB960 Lithium-Ion Flash Power Pack,
in water.
GODOX Photo Equipment Co., Ltd., Shenzhen, China) was used
3. The samples were placed back onto the mounting stand, and post-
operative measurements were carried out, including color mea- ensure a consistent twin flash output.
surements with the three methods described above and 3D 3. Camera settings. The camera was set in manual mode (ISO
scanning. 100, shutter speed 1/100, aperture f13, flash output 1/8). The
optical viewfinder was closed to prevent light leakage, and all
images were captured in RAW format.
2.3 | Color testing method NP: Regular twin flash 4. Image recording. Samples were photographed before and after
photography, no cross polarization modified selective enamel demineralization. To avoid color
1. A custom-made dark box (25 × 32 × 24 cm) including a fixed changes due to dehydration, photographs were taken within
mounting seat for the tooth samples, a camera adaptor, and two 20 seconds of removing the samples from water.
94 HE ET AL.
5. Exposure calibration. All image files were processed with Adobe Photoshop CC 2017 (Adobe Systems Inc.). The white point was
Lightroom CC 2015 (Adobe Systems Inc., San Jose, California) and set as D65.
were calibrated in grayscale mode to obtain the same exact
exposure.
6. Color and white balance calibration. Camera color profiles and
2.4 | Color testing method CP: Cross polarization
white balance were calibrated using the X-Rite ColorChecker extra
mini Chart and Adobe Lightroom CC 2015 with the X-rite Col- 1. Cross-polarized filters were attached in front of the camera lens
orChecker Passport plugin (Figure 2). and twin flashes (Figures 3 and 4).
7. Color space and measurements. All color measurements were 2. The camera was set in manual mode (ISO 100, shutter
recorded in International Commission on Illumination color space speed 1/100, aperture f11, flash output 1/1). All other
(CIELAB) values in a ProPhoto RGB color space with Adobe steps were exactly the same as those described for the NP
method.
F I G U R E 3 A, Photography
set-up. A custom-made dark box
(BO) with fixed adaptors for a
camera (CA) and a twinflash (F). A
flash battery pack (P) was used
for providing stable power
output. A set of crossed polarized
filters (CP1 and CP2) was used
while taking cross-polarization
photos, attached in front of the
camera lens (CP1) and the twin
flash (CP2), respectively. B, The
actual photography set-up. The
cover on top of the box was
removed for showing the internal
structure
HE ET AL. 95
2. A custom stand (Figure 5) was used to maintain the position of 3. To avoid color changes due to dehydration, color measurements
the spectrophotometer in relation to the tooth specimen. The stand were made within 20 seconds of removing the samples from the
also provided shading to eliminate the influence of ambient light. water.
4. Measurements were taken before and after modified selective
enamel demineralization (Figure 6).
F I G U R E 6 A, The noncrossed-polarized (NP) images from one of the testing specimen before and after acid-dissection. The little squares
indicate the color measuring areas. Several specular reflections on the line angle areas can be noticed. B, The crossed-polarized (CP) images from
the same testing specimen before and after acid-dissection. There is almost no specular reflection. The overall color is slightly different from the
images of NP method even though exposure and camera profile were calibrated. C, Spectrophotometer Images from the same testing specimen
before and after acid-dissection. The overall color is also slightly different from the images of NP and CP method
96 HE ET AL.
the midpoint of each horizontal section, as previously described 3. The dimensional differences obtained before and after modified
(ie, incisal, middle, and cervical). selective enamel demineralization were measured in the direction
3. Screen-overlapping software (Ghost-it! 1.04, Matthew T. Pandina) of the camera's optical axis using a 3D engineering software
was used to locate the measurement points via the different soft- (Geomagic Control, 3D Systems, Rock Hill, South Carolina). This
ware packages for the digital photographs, 3D files, and spectro- allowed the change in enamel thickness to be quantified.
photometer images.
F I G U R E 8 Three dimensional (3D) digital comparison. Superimposed two 3D files (original and after acid-dissection) the thickness of
removed structure (ΔT) was measured on those defined color measuring points
HE ET AL. 97
2. The Pearson correlation coefficient (r) and a simple regression positive correlation, with correlation coefficients of 0.38 and 0.27,
analysis were used to calculate the differences in the enamel respectively. There was no significant correlation between the
thickness (ΔT) and color (ΔE*ab and ΔE*00). changes in the enamel thickness and color of the NP measurements
3. The Pearson correlation coefficient (r) was also used to calculate of ΔE*00NP. (Table 2).
the differences in the enamel thickness (ΔT) and color in ΔL*, Δa*, In all three testing methods, ΔT and the color differences present
and Δb*. in Δb* showed a weak positive correlation, with correlation coeffi-
4. All the statistical calculations were conducted by JMP Pro 13 soft- cients of 0.27 (NP), 0.27 (CP), and 0.29 (SM).
ware (SAS Institute, Cary, North Carolina). There was no significant correlation between the enamel thick-
ness and color differences present in ΔL* and Δa* in all three
methods (Table 3).
3 | RESULTS
T A B L E 2 Pearson correlation coefficient (r) between the enamel
During the process, two samples were damaged and removed from thickness (ΔT) and color difference (ΔE)
this study. All color differences were calculated in the CIEDE2000
Pearson
system as a standard. To allow a comparison with previous studies, correlation
the data calculated in CIELAB ΔE* are also provided. coefficient (r) P value Correlation
ΔT and ΔE*00NP .08 .3475 Very weak
ΔT and ΔE*00CP .38 <.0001* Moderate
3.1 | Correlation coefficients among all
ΔT and ΔE*00SP .27 .0011* Weak
measurements
ΔT and ΔE*ab NP
.06 .4880 Very weak
In the CP and SP methods, the enamel thickness (ΔT) changes and the ΔT and ΔE*ab CP .31 .0002* Weak
color differences ΔE*00CP and ΔE*00SP showed a weak-to-moderate ΔT and ΔE*ab SP .25 .0027* Weak
Pearson
correlation
coefficient (r) P value Correlation
ΔT and ΔL*NP −.06 0.4787 Very weak
ΔT and ΔL* CP
.08 0.3376 Very weak
ΔT and ΔL*SP −.07 0.3882 Very weak
ΔT and Δa* NP
.16 0.0589 Very weak
ΔT and Δa*CP .07 0.3946 Very weak
ΔT and Δa* SP
.13 0.1161 Very weak
ΔT and Δb*NP .27 0.0012* Weak
ΔT and Δb* CP
.27 0.0011* Weak
F I G U R E 9 The palatal surface (P) was used for overlapping and
aligning the three dimensional files before and after acid-dissection. ΔT and Δb*SP .29 0.0004* Weak
The arrow shows the measuring direction, equal to the camera
*P < .05. Values with a superscript asterisk indicates a statistically
optical axis
significance.
Nonpolarized twin flash L*NP, a*NP, b*NP ΔL*NP, Δa*NP, Δb*NP ΔE*ab NP ΔE*00NP
photography
Cross-polarization L*CP, a*CP, b*CP ΔL*CP, Δa*CP, Δb*CP ΔE*ab CP ΔE*00CP
photography
Spectrophotometry L*SP, a*SP, b*SP ΔL*SP, Δa*SP, Δb*SP ΔE*ab SP ΔE*00SP
98 HE ET AL.
T A B L E 4 Pearson correlation
CIELAB Measuring methods Pearson correlation coefficient (r) P value Correlation
coefficient (r) between the color
L* NP and CP .93 <.0001* Very strong measuring values (CIELAB) from three
NP and SP .93 <.0001* Very strong different testing methods (NP, CP, SP)
CP and SP .88 <.0001* Very strong
a* NP and CP .93 <.0001* Very strong
NP and SP .92 <.0001* Very strong
CP and SP .95 <.0001* Very strong
b* NP and CP .93 <.0001* Very strong
NP and SP .82 <.0001* Very strong
CP and SP .84 <.0001* Very strong
F I G U R E 1 0 A, The simple regression analysis shows that ΔE00CP is positively related to ΔT with an intercept (arrow), for example,
ΔE00CP = 1.2 + 2.4 ΔT (mm). B, The simple regression analysis shows that ΔE00SP is positively related to ΔT with an intercept (arrow), for example,
ΔE00SP = 1.7 + 1.7 ΔT (mm)
F I G U R E 1 1 A, The simple regression analysis shows that Δb*NP is positively related to ΔT, Δb*NP = −3.0 + 4.9 ΔT (mm). B, The simple
regression analysis shows that Δb*CP is positively related to ΔT, Δb*CP = −0.8 + 4.0 ΔT (mm). C, The simple regression analysis shows that Δb*SP
is positively related to ΔT, Δb*SP = 0.4 + 4.1 ΔT (mm)
The correlation coefficients among the three measuring methods The simple regression analysis shows the linear relationships
are higher than 0.8, showing that the color measuring outcomes of all between the differences in the enamel thicknesses (ΔT) and color:
three methods are strongly correlated (Table 4). ΔE*00CP = 1.2 + 2.4ΔT (mm) (Figure 10a).
HE ET AL. 99
ΔE*00SP = 1.7 + 1.7ΔT (mm) (Figure 10b). For the present study, the labial enamel needed to be removed
ΔE*abCP = 2.1 + 3.1ΔT (mm). without damaging the underlying dentin or the palatal enamel. A mod-
ΔE*abSP = 2.7 + 2.7ΔT (mm). ified selective enamel demineralization technique was developed. We
Δb*NP = −3.0 + 4.9ΔT (mm) (Figure 11a). coated a thin layer of liquid resin (Optibond FL) with an enamel bond-
Δb*CP = −0.8 + 4.0ΔT (mm) (Figure 11b). ing technique onto the palatal surface of each tooth specimen prior to
Δb*SP = 0.4 + 4.1ΔT (mm) (Figure 11c). any color and dimensional measurements. When performing enamel
The statistical results show that the color differences (ΔE*ab and demineralization, this coating protected the palatal enamel and kept it
ΔE*00 and Δb*) are weakly to moderately correlated with the differ- intact. According to our pilot study, tooth acid treatment with 10%
ent enamel thicknesses (ΔT). Linear relationships are found between
HCl for 15 minutes is the most suitable protocol for enamel removal
ΔE and ΔT (the CP and SP methods). Additionally, linear relationships
for our purposes.
are found between Δb* and ΔT. This result means that changing
enamel thickness leads to a color change. For example, reducing the
enamel thickness makes the tooth color appear more yellow. Hence, 4.3 | Intraoral scanner
the first null hypothesis is rejected.
In this study, we chose an intraoral scanner that did not require the
The statistical results also show that the color data of the three
use of powder. This approach removed any concern regarding the
measuring methods are highly positively correlated, indicating that all
alteration of the tooth surface and reduced the measuring time; thus,
three methods measure color in a very similar manner.
the tooth was able to remain hydrated. By comparing the 3D scanning
data before and after selective enamel demineralization, the amount
4 | DISCUSSION of labial enamel removed from each specific area was known. This
quantity was previously difficult to measure without the risk of dam-
4.1 | Calibration aging or altering the specimens. After superimposing the two dimen-
Since the color information recorded by digital devices is device sional color mapping data onto the 3D measurement data, we
dependent, proper calibration of all digital equipment is necessary obtained the relationship between the differences in the labial enamel
To accurately observe how labial enamel affects tooth color, the pala- and ΔT are only weakly to moderately correlated. This outcome might
tal enamel needs to be preserved. Coops and ten Bosch grounded 5 indicate that the enamel layer is not homogeneous.
away enamel with a special tool to maintain the parallelism with the
anatomical surface to assess the effect of enamel on tooth color. 4.4.3 | Effect of labial enamel on tooth color
However, it is technically challenging to remove enamel without dam-
aging the dentin structure. In a previous study, Coops and ten Bosch5 measured the influence of
Selective enamel demineralization was used by Bazos and the enamel layer on the color. These researchers confirmed that tooth
21 color is determined mainly by dentin, with enamel playing only a
Magne for observing enamel and dentin patterns. Their technique
uses acid treatment to selectively remove the enamel and maintain minor role in the blue range. In the present study, similar findings
the dentin. However, this method cannot preserve the palatal were observed. ΔT and Δb* (the color difference on the blue-yellow
enamel. axis in the CIELAB color space) are positively correlated. When more
100 HE ET AL.
labial enamel was removed, the tooth appeared more yellowish. All 5 | C O N CL U S I O N S
three testing methods reveal the same findings.
Coops and ten Bosch5 also found that the color of a labial enamel- 1. With the CP and SP testing methods, there is a weak-to-moderate
removed tooth correlated strongly with the color of the complete positive correlation between the varying labial enamel thickness
tooth. By adding one more factor, the enamel thickness, the present and the tooth color difference. A thicker labial enamel has a
study shows that color differences (ΔE*ab and ΔE*00 and Δb*) are greater impact on the tooth color.
weakly to moderately correlated with the variation in the enamel 2. With all three testing methods, the change in the labial enamel
thickness (ΔT). thickness (ΔT) and color differences present in Δb* showed a
weak positive correlation. Reducing the labial enamel thickness
shifts the tooth color appearance toward yellow.
4.4.4 | Applying the results in a clinical situation
3. The measurement results of NP, CP, and SP are highly correlated,
To interpret the simple linear regression analysis, we used the out- which suggests that clinicians and technicians can combine all
come of the cross-polarization method as an example. Simple linear three different methods for shade matching.
regression analysis gives two formulas: ΔE*00CP = 1.2 + 2.4ΔT(mm;
Figure 10a) and Δb*CP = −0.8 + 4.0ΔT(mm; Figure 11b).
In a clinical situation, ΔT can be the labial enamel reduction in a 6 | CLINICAL IMPLICATIONS
veneer preparation.
If a veneer preparation removes 0.5 mm of the labial enamel 1. This study establishes the relationship between varying labial
(ΔT = 0.5), then the color difference (ΔE*00CP) will be 2.4. With 1 mm enamel thickness and differences in tooth color. The greater the
labial enamel removal (ΔT = 1), the color difference will be 3.6. With thickness of the removed labial enamel is, the more yellowish the
0.5 and 1 mm labial enamel removal, the Δb* is 1.2 and 3.2, respec- tooth color is. This basic rule could be helpful to clinicians when
tively. This result means that when more labial enamel is removed, the preparing veneers.
tooth color becomes more yellowish. 2. It is reasonable to combine NP, CP, and SP for shade matching;
According to these formulas, a clinician can roughly estimate the however, further research is still needed.
stump shade even before preparing the tooth.
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