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In Vitro Color Change of Soft Tissues Caused by Restorative Materials

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251

In Vitro Color Changes of Soft Tissues

Caused by Restorative Materials

Ronald E. Jung, Dr Med Dent*/Irena Sailer, Dr Med Dent* In implant dentistry, a large variety of
Christoph H. F. Hämmerle, Prof Dr Med Dent** materials are available for restoring
Thomas Attin, Prof Dr Med Dent*** single or multiple implants. Decision
Patrick Schmidlin, PD Dr Med Dent**** making in implant prosthetics is often
A crucial factor influencing implant esthetics is the color of the peri-implant mucosa. This in based on the question of which
vitro study analyzed the effect of titanium and zirconia with and without veneering ceramic on restorative material will meet the
the color of mucosa of three different thicknesses. Ten pig maxillae were used, and the palatal physical and esthetic requirements of
area was chosen as the test region. To simulate different mucosa thicknesses, connective tis- a given patient situation. The most
sue grafts, 0.5 mm and 1.0 mm thick, were harvested from three additional jaws. Defined
frequently used abutment materials
mucosa thicknesses were created by placing the grafts under a palatal mucosa flap. Four dif-
for implant reconstructions include
ferent test specimens (titanium, titanium veneered with feldspathic ceramic, zirconia, and zir-
conia veneered with feldspathic ceramic) were placed under the mucosa, and the color of the gold, titanium, veneering ceramic,
tissue was evaluated with a spectrophotometer for three different soft tissue thicknesses (1.5, alumina (Al2O3), and zirconia (ZrO2).
2.0, and 3.0 mm). The color was compared to mucosa without test specimens, and the color The choice of material depends on a
difference (⌬E) was calculated. All restorative materials induced overall color changes (⌬E), number of criteria, including long-
which diminished with increases in soft tissue thickness. Titanium induced the most prominent
term stability, compatibility with oral
color change. Zirconia did not induce visible color changes in 2.0-mm-thick and 3.0-mm-thick
tissues, esthetics, and costs. Several
mucosa, regardless of whether it was veneered. However, with a mucosa thickness of 3.0 mm,
no change in color could be distinguished by the human eye on any specimen. Mucosa thick- clinical studies have documented
ness is a crucial factor in terms of discoloration caused by different restorative materials. In good long-term stability with titanium
patients with thinner mucosa, zirconia will show the least color change. (Int J Periodontics and zirconia abutments for the
Restorative Dent 2007;27:251–257.) restoration of single-tooth implants
for 3 to 5 years.1–3 In addition, exper-
imental studies have shown that both
*Senior Research Fellow, Clinic for Fixed and Removable Prosthodontics and Dental
Material Science, University of Zurich, Switzerland. titanium and zirconia have excellent
**Professor and Chairman, Clinic for Fixed and Removable Prosthodontics and Dental biocompatibility and are able to
Material Science, University of Zurich, Switzerland. establish a soft tissue attachment
***Professor and Chairman, Clinic for Preventive Dentistry, Periodontology and Cariology,
when used for transmucosal heal-
University of Zurich, Switzerland.
****Senior Research Fellow, Clinic for Preventive Dentistry, Periodontology and Cariology ing.4,5 Whereas zirconia and titanium
University of Zurich, Switzerland. have similar properties regarding
long-term stability and biocompati-
Correspondence to: Dr Ronald E. Jung, Clinic for Fixed and Removable Prosthodontics
and Dental Material Science, Dental School, University of Zurich, Plattenstrasse 11, CH-
bility, differences might be expected
8032 Zurich, Switzerland; fax: +41-44-634-43-05; e-mail: jung@zzmk.unizh.ch. with respect to esthetics.

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*
*

Fig 1 Mucoperiosteal flaps were raised in
the central region of the palate of 10
porcine jaws (white box). Connective tissue
grafts were taken from the lateral palatal
region of three additional jaws (black box
with asterisk).
Fig 2 To simulate different mucosal thick- Fig 3 Four different material samples were
nesses, connective tissue grafts (asterisk) prepared for the color evaluation (left to
were placed underneath the palatal mucosa right: titanium, veneered titanium, zirconia,
flap. and veneered zirconia).

Fig 4 Positioning of the titanium sample Figs 5a and 5b Spectrophotometric color evaluation of the mucosa and materials was done
underneath the raised palatal flap. by means of a spectrophotometer (SpectroShade). Shade was determined by positioning a
standardized circular measuring area over the area of interest. This resulted in CIE lab parame-
ters that were calculated for each measurement.

Nowadays, the esthetic aspects
of implant reconstructions are of
increasing importance. Natural-look-
ing peri-implant soft tissue is charac-
terized by healthy conditions and by
appropriate volume, color, and con-
tours that are in harmony with the
healthy surrounding tissues.6 One fac-
tor that plays a crucial role in soft tissue
esthetics is the color of the peri-implant
mucosa. Although it has often been
reported that titanium abutments can
cause a grayish appearance of the
mucosa,7 this has never been evalu-
ated objectively. In addition, clinicians
have recommended augmentation of
the peri-implant soft tissue thickness in
the esthetic area to better cover the
underlying restorative materials for
improved esthetics and to create a nat-
ural soft tissue contour.8 However, the
influence of abutment material and
soft tissue thickness on the color of
the peri-implant mucosa has never
been investigated.
The aim of the present in vitro
study was to analyze the effect of tita-
nium and zirconia with and without
veneering ceramics on the color of
mucosa of three different thicknesses.
Method and materials
In vitro model
For the present in vitro study, 10 pig
maxillae were used. The in vitro tests
started no longer than 2 hours follow-
ing the death of the pigs. These pigs
were raised for food production accord-
ing to the Swiss standards for animal
care. Therefore, this investigation was
not classified as an animal study and the
institutional ethics committee had no
objections to the protocol.

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Jung.qxd 5/7/07 10:24 AM Page 253
To minimize artifacts, the jaws
were stored in a humidity chamber
until use. Palatal pig mucosa exhibits
similarities to the keratinized mucosa of
humans with respect to color and tex-
ture. Hence, this area was chosen as
the test area. To simulate different
palatal mucosa thicknesses, connec-
tive tissue grafts with a thickness of 0.5
or 1.0 mm were harvested from the
palatal mucosa of three other jaws (Fig
1). To provide grafts of uniform thick-
ness, a Mucotome instrument (GB270,
Aesculap) was used for the harvesting
process. By adjusting the oscillating
blades of this instrument, the operator
can preset the thickness of the yielded
grafts. Accuracy of the resulting
mucosal thickness was verified by care-
ful measurement with a caliper. Thicker
mucosa layers were prepared by plac-
ing the different grafts underneath the
palatal mucosal flap (Fig 2). Thus,
mucosa layers with a thickness of 1.5,
2.0, or 3.0 mm resulted. The 1.5-mm
mucosa thickness was achieved by
placing a 0.5-mm-thick graft under the
mucosa, the 2.0-mm mucosa thickness
was created by placing a 1.0-mm-thick
graft under the mucosa, and the 3.0-
mm mucosa thickness was created
with two 1-mm-thick grafts. To avoid air
trapping, glycerin gel was applied
between the grafts and the host tissue.
Test specimens
To test a variety of clinical situations,
different abutment and crown materi-
als were evaluated. The following test
specimens were prepared in dimen-
sions of 5 ⫻ 5 mm and a thickness of
1 mm (Fig 3):
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1. Titanium
2. Titanium veneered with veneering
ceramic (color A3) (Triceram,
Dentaurum)
3. Zirconia (Cercon, DeguDent)
4. Zirconia veneered with a veneering
ceramic (color A3) (Triceram,
Dentaurum)
Mucosa without an underlying test
specimen served as control.
Spectrophotometric setup
In the present study, a reflectance
spectrophotometer (SpectroShade,
No. LUA005, Medical High Technolo-
gies; software version 2.5, MHT) was
used to evaluate the color of the
mucosa in an objective manner. The
spectrophotometer works with two
basic optic systems to standardize
angles of illumination and observation.
The camera disposes a D65 light source
(6,500 K), which is transformed into
monochromatic light (␭ 400 to 720 nm)
using a grate. With the standard lens,
the light is split to illuminate the object
simultaneously from two sides at a 45-
degree angle. The reflected light is
directed at 0 degrees onto the system
detector area (18 ⫻ 13 mm) for the
measuring process. One detector area
was a color charge-coupled distributor
(CCD) chip responsible for the gener-
ation of the colored video image. A
black and white CCD detector area
recorded the spectrophotometric
data. Prior to every measurement, the
camera was calibrated to the white
and green ceramic tiles supplied by the
manufacturer. The data of each mea-
surement were calculated and dis-
253
played based on the parameters of
the Commission Internationale de
l’Eclaire (CIE), with L = lightness, a =
chroma along red-green axis, and b =
chroma along yellow-blue axis.9
Spectophotometric assessment
of mucosa color
For each of the 10 pig jaws, the color
assessment was performed for three
different soft tissue thicknesses (1.5,
2.0, and 3.0 mm). After a mucoperi-
osteal flap was elevated in the area of
interest, each of the different soft tissue
thicknesses was measured with a
caliper. The baseline spectrophoto-
metric measurements were then taken
from the mucosa region with no test
specimen in place. Subsequently, the
four test specimens were placed one
at a time underneath the mucosa (Fig
4), and spectrophotometric measure-
ments were taken again of the same
mucosa area.
To obtain measurements, the
adapter of the spectrophotometer
standard lens was positioned perpen-
dicular to the mucosa, allowing a stan-
dardized distance to the mucosa. An
image was captured when the result-
ing video image of the defined area
was centered in the measuring square,
as depicted on the computer screen
(Figs 5a and 5b). Three consecutive
images were captured to be used for
data analysis. Thus, three images were
acquired of each mucosa thickness
(1.5, 2.0, and 3.0 mm) in all five test
groups (mucosa alone, titanium, tita-
nium veneered, zirconia, and zirconia
veneered).
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Table 1 Mean ⌬E values and 95% confidence intervals (95% CI) of the evaluated materials at
different mucosa thicknesses
Mean ⌬E (95% CI)
Mucosa
thickness Ti Ti-C ZrO2 ZrO2-C
1.5 mm 5.06 (3.34, 6.70) 4.04 (2.32, 5.77) 3.87 (1.86, 5.88) 3.99 (2.22, 5.76)
2.0 mm 4.32 (2.52, 6.12) 3.85 (1.19, 6.51) 3.17 (1.53, 4.82) 3.07 (1.25, 4.89)
3.0 mm 2.14 (1.54, 2.75) 2.18 (1.45, 2.90) 2.47 (1.57, 3.37) 1.83 (–0.94, 2.71)
Ti = titanium;Ti-C = veneered titanium; ZrO2 = zirconia; ZrO2-C = veneered zirconia; ⌬E = overall color difference.

Table 2 Means and 95% confidence intervals (95% CI) of ⌬L, ⌬a, and ⌬b values at different
mucosa thicknesses
Value/ Mean ⌬E (95% CI)
mucosa
thickness Ti Ti-C ZrO2 ZrO2-C
⌬L
1.5 mm –2.6** (–3.48, –1.72) –2.88** (–4.65, –1.10) –0.65 (–1.71, 0.41) –2.08** (–3.33, –0.82)
2.0 mm –2.06* (–3.84, –0.28) –1.5 (–3.69, 0.69) –0.51 (–2.50, 1.48) –1.96(–4.35, 0.47)
3.0 mm –0.55 (–1.28, 0.18) –0.61 (–2.13, 0.90) –0.39 (–1.68, 0.90) –0.43 (–1.72, 0.87)
⌬a
1.5 mm 2.73** (1.43, 4.02) –0.41 (–1.90, 0.08) –1.39* (–2.71, –0.07) –0.71 (–2.58, 1.15)
2.0 mm 2.23** (1.48, 2.97) 0.9* (0.12, 1.68) 0.03 (–0.86, 0.95) 0.46 (–0.58, 1.50)
3.0 mm 1.55** (0.78, 2.31) 0.95** (0.39, 1.51) –0.59 (–1.62, 0.44) 0.68 (–0.18, 1.53)
⌬b
1.5 mm 1.66 (–1.02, 4.34) –1.56* (–2.97, –0.15) –2.74* (–5.04, –0.44) –1.1 (–3.49, 1.29)
2.0 mm 0.1 (–2.56, 2.76) –0.71 (–3.98, 2.56) –0.99 (–3.23, 1.25) 0.16 (–0.36, 0.69)
3.0 mm 0.24 (–0.60, 1.08) 0.5 (–0.19, 1.19) 0.21 (–1.81, 1.38) 0.23 (–0.47, 0.92)
Ti = titanium;Ti-C = veneered titanium; ZrO2 = zirconia; ZrO2-C = veneered zirconia; L = lightness; a = chroma along red-green axis; b = chroma along
yellow-blue axis.
*P < .05; **P < .01.

Shade determination was finally
executed by positioning a standard-
ized circular measuring area, 2 mm in
diameter, over the area of interest. This
resulted in the CIE lab parameters cal-
culated for each measurement. The
differences (⌬L, ⌬a, and ⌬b) were then
calculated by subtracting the baseline
measurements from the measure-
ments with the specimens. To estimate
the overall color difference between
one of the test specimens and the
baseline measurement, the following
equation was used: ⌬E = [(Ls – Lb )2 +
(as – ab )2 + (bs – bb )2]1/2, where s =
specimen and b = baseline.
Data presentation and
statistical analysis
Differences were calculated between
the colorimetric values of tissues with
and without test specimen interposi-
tion for each material group. The ⌬L,
⌬a, ⌬b, and ⌬E values of the three
measurements were averaged, and
this value was used for further analy-
sis. For the description of these data,
mean values and corresponding 95%
confidence intervals (95% CI) were
given. The ⌬E values were compared
to the critical ⌬E threshold of 3.7 for
intraoral color distinction as perceived
by the naked eye.10 For statistical
analysis of the differences between

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255

Fig 6 Bar chart illustrating the ⌬E values for the different materials Mucosa thickness
evaluated under different mucosa thicknesses. The line at the ⌬E 1.5 mm
value of 3.7 represents the critical ⌬E threshold for intraoral color 6 2.0 mm
distinction as perceived by the naked eye.10 Ti = titanium; Ti-C = 3.0 mm
5
veneered titanium; ZrO2 = zirconia; ZrO2-C = veneered zirconia. YES
4 Visible color

⌬E
3 change
NO
2
1
0
Ti Ti-C ZrO2 ZrO2-C

the ⌬L, ⌬a, and ⌬b values, the one-
sample t test was used. The null
hypothesis was that no visible
changes occurred.
Results
Descriptive statistics revealed that all
tested restorative materials induced
an overall color change (⌬E values) in
the covering mucosa (Table 1). A
decrease in the overall color change
was observed with increasing mucosa
thicknesses (Fig 6). With a mucosa
thickness of 1.5 mm, all specimens
demonstrated mean ⌬E values that
were above the critical ⌬E threshold of
3.7 for intraoral color distinction by the
naked eye. However, the titanium
specimens caused the most promi-
nent color change. Zirconia with and
without veneering ceramics did not
induce a visible overall color change
for mucosa thicknesses of 2.0 and 3.0
mm. With a mucosa thickness of 3.0
mm, all tested specimens showed an
overall color change that could not be
distinguished by the human eye.
Statistical analysis of the ⌬L, ⌬a,
and ⌬b values is presented in Table 2.
Significant changes in lightness (⌬L)
were noted for the titanium specimens
placed under mucosa with thicknesses
of 1.5 and 2.0 mm and for the
veneered titanium as well as the
veneered zirconia disks at 1.5 mm. For
soft tissue thicknesses of 2.0 and 3.0
mm, no changes in lightness were
detectable for the veneered zirconia.
Zirconia specimens showed no signif-
icant changes in ⌬L values, regardless
of soft tissue thickness. Significant
changes in ⌬a values were noted for
the titanium disks, even at mucosa cov-
erage of 3.0 mm, whereas zirconia
samples showed no changes at 2.0
and 3.0 mm.
The only significant alterations in
⌬b values were observed for veneered
titanium and nonveneered zirconia
samples at 1.5-mm mucosal thickness.
All other materials showed no changes
in ⌬b values at different mucosal thick-
nesses.
Discussion
The present in vitro study demon-
strated that the tested restorative
materials had a significant influence
on soft tissue color appearance. This
diminished with increasing mucosa
thickness.
Clinicians face decisions daily
about which restorative material should
be chosen for a specific clinical situa-
tion. The restorative materials tested in
the present study are widely used,
either as abutment materials for
cemented implant reconstructions or
as crown materials for screw-retained
reconstructions.1,2 Esthetic appear-
ance—especially the color of peri-
implant mucosa—is of great impor-
tance in implant dentistry, and data in
this field are very scarce. In a recent clin-
ical study, the color match of autoge-
nous soft tissue grafts was compared to
the color of the surrounding soft tissue
at prospective implant sites.11 The
results demonstrated a color match
below visually detectable levels.
Nevertheless, soft tissue discoloration
caused by different abutment and
crown materials has never been the
subject of scientific analysis. However,
a clinical study was performed to eval-
uate the effect of gingival discoloration
by artificial crowns on natural teeth.12
Spectrophotometric measurements of
15 patients receiving artificial crowns
documented a more “noticeable” (⌬E
= 3.26 to 6.51) or even a “very notice-

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256
able” color difference (⌬E = 6.52 to
13.04) in the marginal gingiva of teeth
restored with artificial crowns com-
pared to unrestored natural teeth. In
the present study, the color difference
reached only a “noticeable” appear-
ance (⌬E = 3.87 to 5.06) for all materi-
als with a mucosa thickness of 1.5 mm.
Zirconia specimens with and without
veneering ceramic did not cause a
“noticeable” color difference with
mucosa thicknesses of 2.0 and 3.0 mm.
This level of “noticeable” color differ-
ence is in accordance with a study that
assessed appearance match by visual
observation and clinical colorimetry.10
The investigators showed that, in the
oral cavity, a difference in tooth color
of 3.7 ⌬E units was still classified as a
match by human evaluators.
Analysis of the gingival color
around teeth with artificial crowns
revealed a shift toward red-purple.12
Similar to these clinical results, the pres-
ent study showed a shift of the chroma
along the red-green axis when titanium
specimens with and without ceramic
veneering were tested. The literature
provides no explanation for the slight
shift of the chroma along the yellow-
blue axis for the zirconia specimens
with mucosa thickness of 1.5 mm.
Although differences in CIE parameters
represent changes in color and appear-
ance, the ⌬E value represents the over-
all color change and is the commonly
used parameter for clinical purposes.
Determination of color by visual
means is considered highly subjective.
General variables such as external light
conditions, experience, age, and
fatigue of the human eye lead to incon-
sistencies.13,14 Computerized col-
orimetry or spectrophotometry based
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on the CIE color system allows for
mathematical comparison of colors.15
Nonetheless, computerized data col-
lection is still subject to errors.16 A
recent study evaluating the same spec-
trophotometric device as was used in
the present experiment revealed that
spectrophotometric tooth shade analy-
sis was more accurate and repro-
ducible than human visual shade
assessment.9 The high accuracy and
reproducibility of spectrophotometric
measurements may help to increase
objectivity in evaluating soft tissue
esthetics. Thus, a clinician could be
provided with objective criteria for the
choices of abutment and crown mate-
rials in implant dentistry.
It might be difficult to compare
the colors of the present study with
those in a clinical situation. In the pres-
ent study, the palatal mucosa of pigs,
not of humans, was used. The pig
model was chosen for the present
investigation since different studies
have documented the similarity of
human and pig oral mucosa regarding
a variety of parameters such as per-
meability, mechanical resistance, and
tissue composition.17–20 However, a
direct comparison of the color of pig
and human mucosa has never been
performed. This lack of a direct com-
parison is not of significance for the
interpretation of the results in the pres-
ent study, since no absolute values but
rather color changes under different
conditions were assessed.
The present study demonstrated
that thickness of the mucosa plays an
important role in terms of the discol-
oration and esthetic appearance
caused by different restorative materi-
als. The various mucosa thicknesses
tested correspond well with the data of
a clinical study evaluating the thickness
of the peri-implant mucosa.6 The aver-
age thickness of the facial mucosa of
maxillary anterior implants assessed at
a level corresponding to the bottom of
probeable pockets was 2.0 ± 0.7 mm.
In that study, the peri-implant mucosa
was approximately 1 mm thicker than
the gingiva around contralateral natural
teeth (1.1 ± 0.3 mm). From the results
of the present study, it can be specu-
lated that in a clinical situation with a
mucosa thickness of 2 mm, a titanium
abutment in contrast to zirconia abut-
ments may cause a change in color
appearance of the peri-implant
mucosa. Hence, measurement of the
thickness of the peri-implant mucosa
may help clinicians to decide which
abutment material is indicated in a
given clinical situation. A recent clinical
study evaluated soft tissue esthetics
around single-tooth implant crowns.21
It was reported that the color of the
peri-implant mucosa matched that of
the reference mucosa in no more than
one third of the cases. Although the
investigators stated that tooth-colored
abutments may play an important role
in terms of mucosa discoloration, no
correlation between abutment type
(titanium versus ceramic) and mucosa
color was performed in their study.
It can be concluded from the pres-
ent in vitro study that the type of abut-
ment or crown material and the
mucosa thickness have significant influ-
ences on color changes of the mucosa.
Zirconia induces the least noticeable
color changes to the mucosa. Further
clinical research is needed and is ongo-
ing to complement these in vitro
results with clinical data.
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