Fluorescence—Mimicking Nature for Ultimate Esthetics in Implant Dentistry

Iñaki Gamborena, DMD, MSD, FID1 Markus B. Blatz, DMD, PhD2

hade and translucency matching are fundamen- electron releases energy in the form of light (lumines- tal aspects in esthetic dentistry. The ultimate cence) when it falls back to a lower energy state. Fluo- Sgoal is to create tooth-like restorations; however, rescent substances absorb the UV light and the re-emit natural teeth also show fluorescence, which must be it almost instantaneously. Since some energy is lost in simulated to achieve ideal esthetic results. this process, the emitted light has a longer wavelength Fluorescence is defined as luminescence that oc- than the absorbed radiation, which makes this light curs when energy is supplied by electromagnetic ra- visible and causes the material to “glow.” diation, usually via ultraviolet (UV) light. The energy source transfers an electron of an atom from a lower energy state to a higher, “excited” energy state. The FLUORESCENCE OF NATURAL TEETH

1 1Clinical Assistant Professor, Department of Preventive and Re- In 1911, Stubel was the first to describe the fluores- storative Sciences, University of Pennsylvania School of Dental 2 cence of natural teeth under UV light (λmax = 450 nm). Medicine, Philadelphia, Pennsylvania, USA; Private Practice, San 3 Sebastian, Spain. In 1953, Hartles and Leaver further examined the flu- 2Professor and Chairman, Department of Preventive and Restor- orescence of different tooth structures and reported ative Sciences, University of Pennsylvania School of Dental Medi- that enamel exhibits “normal” fluorescence with a blu- cine, Philadelphia, Pennsylvania, USA. ish white appearance, occasionally tinged with yellow. 4 Correspondence to: Dr Iñaki Gamborena, Resureccion Mª de Azkue, They also confirmed findings by Benedict in 1928 that 6 20018 San Sebastian, Spain. Email: [email protected] dentin has much greater fluorescent properties than

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CASE 1

1 2 3

Fig 1 Preoperative view of the discolored maxillary left central incisor due to necrosis.

Fig 2 Intraoral preoperative view under UV light. The discolored tooth shows poor fluorescence.

Fig 3 Intraoral preoperative view under natural light. 4 5 Fig 4 Extraoral view after internal bleaching of the left central incisor.

Fig 5 Extraoral view after internal bleaching under UV light.

Fig 6 Final intraoral view.

enamel. This greater fluorescence is due to the higher When the organic structure of a tooth is affected by, organic content of dentin.3,5,6 Color is most intense in for example, caries or pulpal necrosis, the tooth loses the apical regions, particularly in immature teeth with its vitality under both natural and UV light and appears open apices.3 Cementum shows similar fluorescence dark brown. Therefore, less fluorescence correlates to dentin, but less intense. Carious enamel does not with lesser value. This effect, however, can be reversed provide fluorescence, and the carious areas appear in natural teeth using internal tooth bleaching (Case 1, black.7–9 Even the initial whitish patches will lose their Figs 1 to 6). fluorescence. Carious dentin also lacks fluorescence Due to the differences between sound and carious and appears black or dark brown under UV light.7,8 The tooth structures, fluorescence is increasingly used for fluorescent intensity of dentin increases with age. reliable and noninvasive caries detection.9–12 It even Fluorometric investigations revealed that a complex serves as a screening method for oral cancer since of cross-linked collagen with hydroxyapatite is a pos- abnormal oral mucosal lesions appear dark brown or sible fluorescing compound within the tooth tissue.2,6 black under UV light.13

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Fig 7 Cross sections of natural teeth viewed with a Fig 8 Tooth characteristics under various light condi- polarizing filter. tions.

Fig 9 Optical characteristics of different veneering porce- Fig 10 Fluorescence of different veneering porcelains. lains under transmitted light.

FLUORESCENCE OF DENTAL teristics are not only crucial for the restoration itself, but also to reduce the “shadowing effect” at the restor- MATERIALS ative-gingival interface and to provide a healthy-looking The goal of esthetic restorative dentistry is to mimic gingival architecture. In fact, the creation of an incon- the optical properties of natural teeth. However, the spicuous dental restoration starts with well-designed fluorescence of natural teeth is greatly overlooked in prosthetic contours and natural, healthy integration restorative dental materials. Fluorescence adds to the within the surrounding soft tissues. Feldspathic veneer- vitality of a restoration and minimizes the metameric ing porcelains typically contain particles that provide effect between teeth and restorative materials under fluorescence.17 It is important that all components of a various light conditions. porcelain system, including opaquers, dentin, enamel, Modern composite resins used for anterior tooth stains, and even glazing agents, are fluorescent. How- restorations contain fluorescent pigments to simulate ever, fluorescence is often not homogenous within the the lively expression of natural teeth in all types of same porcelain system or among different systems.17 light.14–16 Many modern composite resins have fluo- Various techniques and components have been sug- rescence wavelength peaks of 440 to 450 nm, which gested to achieve natural-looking fluorescence.18–20 is comparable to natural dentin.14,15 However, there is Proper positioning of varying degrees of fluores- still a considerable variation in fluorescence between cence on the tooth is crucial for natural esthetics. Roots different composite systems and between some com- and dentin reveal the strongest fluorescence, while posite resins and natural teeth. enamel shows the weakest. Figure 8 demonstrates Modern veneering porcelains and ceramic coping tooth characteristics under various light conditions. materials are intended to mimic the optical qualities of Veneering porcelain powders reveal different opaci- natural teeth (Fig 7): translucency, color (hue, chroma, ties, translucencies, and fluorescence under transmit- value), fluorescence, and opalescence. These charac- ted light (Fig 9) and UV light (Fig 10).

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CASE 2

11 12

13 14

Fig 11 Extraoral view of the central incisors restored with feldspathic porcelain.

Fig 12 Feldspathic porcelain restorations under UV light.

Fig 13 Periapical radiograph.

Fig 14 Ten-year follow-up view.

Porcelain Laminate Veneers an ideal situation, the abutment color already provides the total value of the final restoration, and only dif- Case 2 (Figs 11 to 14) depicts porcelain laminate ve- ferent chromatic dentin and incisal layers are needed. neers that were placed on two central incisors over Differences in opacity and translucency as well as the 10 years ago, exhibiting a favorable blend with the reduced degree of fluorescence among enamel, den- natural dentition under natural and UV light. In such tin, and shoulder porcelain are apparent.

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CASE 3

15 16 17

Fig 15 Preoperative intraoral view. Removal of the porcelain-fused-to- metal crown on the maxillary left central incisor revealed a severely discolored abutment tooth.

Fig 16 Alumina versus zirconia cop- ings with and without fluorescence: (a) alumina, (b) alumina with fluorescent internal staining, (c) zirconia, (d) zirconia infiltrated with fluorescence. 18 19

Fig 17 Try-in of the alumina coping.

Fig 18 Alumina versus zirconia cop- ings with and without fluorescence under UV light: (a) alumina, (b) alumina with fluorescent internal staining, (c) zirconia, (d) zirconia infiltrated with fluorescence.

Fig 19 Try-in of the alumina coping with a porcelain shoulder. Fig 20 Try-in of the alumina coping Fig 21 Alumina coping under UV under UV light. light at different stages of veneering porcelain application.

Full-Coverage Crowns ceramics, and internal stains, which were applied in the gingival area to support light distribution and optimal Case 3 (Figs 15 to 30) demonstrates the use of den- integration with the highly fluorescent dentin tooth tal ceramics for full-coverage restorations. Selection of structure (Fig 24). The importance of the shoulder loca- the coping material was the first step because even tion in the gingival area is obvious under UV light (Fig different metal-oxide ceramics (eg, alumina and zirco- 25). Light is distributed to the surrounding structures nia) provide considerably different optical properties and soft tissues, such as marginal gingiva and papillae. (Figs 21 and 23). Alumina (Procera, Nobel Biocare, Dentin ceramic masses were applied in different chro- Gothenburg, Sweden) was ultimately selected as the mas and saturations toward the incisal aspect of the coping material due to its favorable esthetic properties. tooth. The incisal third of a natural tooth features the Fluorescence was controlled through liners, shoulder highest degree of translucency. The actual tooth shade

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22 23

24 25

Fig 22 Intraoperative view of the bleached abutment tooth during crown preparation.

Fig 23 Fluorescence of the bleached abutment tooth under UV light.

Fig 24 Definitive alumina-based crown after cementation.

Fig 25 The crown exhibits the same fluorescence as the neighboring natural teeth under UV light.

is achieved through the colors at the center of the tooth between the enamel and the transparent layers. The to simulate the natural core dentin. After a full-contour final shape is typically completed using a few translu- build up, cutback was performed in an irregular manner cent characteristics or transparent enamel powders to to enhance internal effects. Enamel mixtures with bluish provide the impression of depth. Translucent materi- opalescent translucent powders were applied to pro- als should always receive minimal firing to protect the vide a more vivid restoration. Some teeth have distinct characteristics of a natural-looking restoration. Surface mamelons, which are typically located underneath the texture and luster intensity may affect reflective features natural enamel and are more opaque than normal den- of the restoration and should ultimately be the respon- tin and highly fluorescent. Mamelons should be placed sibility of the clinician.

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Fig 26 Preoperative view of porcelain-fused-to- metal crown.

Fig 27 Preoperative periapical radiograph.

26 27

Fig 28 Extraoral view of the alumina crown.

Fig 29 Postoperative periapical radiograph.

Fig 30 Intraoral view of the definitive crown.

28 29

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CASE 4

31 32

33 34

Fig 31 Smile view after implant-crown restoration of the mandibular right central and lateral incisors.

Fig 32 Intraoral view of implant-supported crown restorations under natural light.

Fig 33 Fluorescent properties of the crowns and neighboring natural teeth.

Fig 34 Black-and-white photograph of the implant-supported crowns.

Single-Implant Restorations Cases 4 through 6 demonstrate the optical properties, selection, and fabrication of fluorescent zirconia Zirconia has gained tremendous popularity as an im- abutments. plant abutment material in the esthetic zone because Case 4 (Figs 31 to 45), in which the mandibular right it prevents the grayish appearance of the surrounding central and lateral incisors were replaced with implant- soft tissues often seen with titanium or other metal- supported single crowns, demonstrates the difficulty alloy abutments. The availability of colored zirconia of perfectly matching all optical properties of the natu- abutments in different shades further improves esthet- ral teeth and soft tissues with conventional materials ic outcomes over the conventional, white zirconia. In and techniques. The central incisor crown was sup- thin soft tissue situations, however, fluorescence may ported by a titanium abutment, and the lateral incisor actually play a greater role than color. Fluorescence crown was supported by a zirconia abutment (Figs 42 provides natural illumination and light transmission of and 43). While the definitive crowns blended favorably the soft tissue at the implant-restorative interface and with the remaining dentition in some light conditions, eliminates the shadowing effect that may appear when the use of UV light, transmitted light, and postopera- tooth-colored abutments are used. tive photographs revealed esthetic deficiencies, espe-

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35 36

37 38

Fig 35 Intraoral view of the zirconia and titanium abutments.

Fig 36 Periapical radiograph of the definitive implant crowns.

Fig 37 Optical behavior of crowns on a zirconia versus a titanium abutment under transmitted light.

Fig 38 Postoperative intraoral view. Note the unfavorable soft tissue color especially around the titanium abutment, but also around the zirconia abutment.

cially in the surrounding soft tissues (Figs 44 and 45). the sinter furnace. Sixteen coloring liquids for zirconia These deficiencies were due to the abutment materi- (Zirkonzahn) are also infiltrated during the sintering als (titanium) and, even for the zirconia abutment, to process. Figures 42 and 43 show conventional versus the lack of fluorescence at the abutment-restoration colored zirconia abutments after applying fluores- interface. cence under natural and UV light. Recently, colorants and fluorescent modifiers have The creation of natural esthetics with implant-sup- been developed that can be applied to zirconia abut- ported restorations requires highly fluorescent proper- ments even after milling and finishing. Figures 39 and ties at the implant-restorative interface and the gingival 40 show the optical properties of conventional versus third of the restoration (Figs 44 and 45). Fluorescence colored zirconia abutments under natural and UV light. and color can be added to zirconia to a certain degree. Fluorescence is achieved by dipping the abutment or It is still difficult to create a dark shade (eg, C3 or C4) framework into a fluorescent coloring liquid before with a high degree of fluorescence since the dark color sintering (Colour Liquid Fluoreszenz, Zirkonzahn, Gais, pigments may overshadow the fluorescent properties. Italy). The abutment is blow dried after the dipping Therefore, strong fluorescence of the implant abut- process to remove excess and placed under a drying ment may actually be more important for overall and lamp to prevent damage to the heating elements of especially gingival esthetics than the shade itself.

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39 40

Fig 39 Conventional zirconia versus colored zirconia abutments under natural light.

Fig 40 Conventional zirconia versus colored zirconia abutments under UV light.

Fig 41 Fluorescence is added by infiltrat- ing the zirconia with fluorescent colorants. The abutment is dipped into the colorant and fully sintered or sintered again. 41

Fig 42 Zirconia abutments after application of Fig 43 Zirconia abutments after application of fluorescence (Zr + Fl) under natural light. In ad- fluorescence (Zr + Fl) and colorants (A1, B1, C1, dition to fluorescence, shade-modifying colo- D2) under UV light. Note the negative effect of rants were applied (A1, B1, C1, D2). coloring pigments on the degree of fluorescence.

Fig 44 Regular zirconia abutment (Zr) versus a Fig 45 Regular zirconia abutment (Zr) versus a natural tooth and fluorescent zirconia abutment natural tooth and fluorescent zirconia abutment (Zr + Fl) under natural light. (Zr + Fl) under UV light.

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CASE 5

46 47

48 49

Fig 46 Provisional crown restoration at the maxillary left central incisor site.

Fig 47 Fluorescent zirconia (Zr + Fl) versus regular zirconia abutment (Zr) under UV and natural light.

Fig 48 Fluorescent zirconia (Zr + Fl) versus regular zirconia abutment (Zr) under UV and natural light.

Fig 49 Fluorescent zirconia abutment under UV light showing the favorable fluorescent properties.

In case 5 (Figs 46 to 56) a provisional implant crown for the definitive crown on the zirconia abutment. Fig- was placed at the maxillary left central incisor site to ures 50 to 56 show the preoperative and postopera- condition the soft tissue morphology after implant tive situation after implant placement and fabrication placement (Fig 46). The provisional restoration re- of an implant-supported restoration with natural fluo- mained in place for 6 weeks until the position of the rescence. The integration of a high degree of fluores- soft tissue was stabilized. The optical differences be- cence is especially important in patients with a high tween a conventional and a fluorescent zirconia abut- smile line, as presented here, to reduce the so-called ment are evident under different light conditions (Figs umbrella shadowing effect. 47 to 49). Alumina was selected as the coping material

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50 51

Fig 50 Preoperative situation.

Fig 51 Definitive alumina crown on the fluorescent zirconia abutment under UV light showing natural fluorescence.

Fig 52 Postoperative view of the definitive alumina crown on the fluorescent zirconia abutment.

52 Fig 53 Preoperative periapical radiograph.

Fig 54 Preoperative smile.

Fig 55 Postoperative periapical radiograph.

Fig 56 Definitive implant crown.

53 54

55 56

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Fig 57 Fluorescent zirconia abut- Fig 58 Fluorescent zirconia abutment (Zr+Fl) versus a natural tooth ment (Zr+Fl) versus a natural tooth as well as a fluorescent and trans- and a fluorescent and translucent lucent zirconia abutment (Tr+Fl) zirconia abutment (Tr + Fl) under under natural light. UV light. Note the reduced fluorescence of the Tr + Fl abutment.

CASE 6

Fig 59 Shade selection of the natural abutment tooth, ie, the stump shade (C3).

Fig 60 Digital shade selection of the natural abutment tooth.

Some challenging cases may require shaded or with an implant-supported crown. To achieve an opti- more translucent types of zirconia (Prettau Zircona mal match between the two restorations, the color of “translucent,” Zirkonzahn) or further coloring of the the severely destructed maxillary left central abutment implant abutment to achieve ideal esthetics. The de- tooth must be taken into consideration. In addition to gree of translucency, however, translates to a lower conventional shade tabs (Fig 59), a digital spectropho- value and influences the ultimate degree of fluores- tometer (Spectroshade, MHT Optical Research, Nie- cence (Figs 57 and 58). derhasli, Switzerland) was used to select the stump In case 6 (Figs 59 to 76), the maxillary right cen- shade of the abutment tooth (VITA shade C3, VITA tral incisor was restored with a full-coverage crown, Zahnfrabrik, Bad Säckingen, Germany). At first, it was while the maxillary left central incisor was replaced attempted to match the shade of the implant abut-

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Fig 61 Translucent zirconia abutment modified with colorant (shade C1) and fluorescence (Tr + C1 + Fl).

Fig 62 Translucent zirconia abutment modified with colorant (shade C1) and fluorescence under UV light (Tr + C1 + Fl). Note the unfavorable fluorescent properties.

61 62

Fig 63 Zirconia abutment modified with fluorescence (Zr + Fl).

Fig 64 Zirconia abutment modified with fluorescence (Zr + Fl) under UV light. Note the matching fluorescent properties.

63 64

Fig 65 Translucent zirconia abutment modified with colorant (shade C3) and fluorescence (Tr + C3 + Fl).

Fig 66 Translucent zirconia abutment modified with colorant (shade C3) and fluorescence under UV light (Tr + C3 + Fl). While the shade and translucency were favorable, the fluorescent properties did not match the natural teeth. 65 66

Fig 67 Provisional restorations on the central incisors.

Fig 68 Intraoral view of the natural abutment tooth (shade C3) versus the fluorescent zirconia abutment (Zr + Fl) under UV light.

67 68

Fig 69 Intraoral view of the abutment tooth (shade C3) versus the fluorescent zirconia abutment (Zr + Fl) under natural light.

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70 71

72 73

Fig 70 Preoperative intraoral situation.

Fig 71 Preoperative periapical radiograph.

Fig 72 Postoperative intraoral view of the definitive zirconia crowns under UV light, depict- ing favorable fluorescent properties.

Fig 73 Postoperative periapical radiograph.

Fig 74 Postoperative intraoral view of the definitive zirconia crowns. 74

ment with that of the natural abutment tooth. Howev- natural abutment tooth. Therefore, in such situations, er, Figs 61 to 66 depict the negative effect of the high fluorescence/value matching takes priority over trans- translucency/low value on the fluorescence. A prefer- lucency/shade matching. able soft tissue appearance with new provisional res- The importance of mimicking natural fluorescence torations (Fig 67) was achieved with an uncolored but to achieve optimal esthetics in implant dentistry is ex- fluorescent zirconia abutment (Figs 68 and 69), which emplified in Figs 70 to 76, which compare the initial matched the fluorescence and value but not necessar- and postoperative situations. ily the shade (chroma and hue) and translucency of the

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Fig 75 Preoperative smile.

Fig 76 Postoperative smile.

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CRITERIA FOR ZIRCONIA IMPLANT REFERENCES

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