CLINICAL REPORT

Gingival pigmentation by Ni-Cr-based metal ceramic crowns:

A clinical report
Min Tian, MD,a Sai Ma, DDS, PhD,b Lina Niu, DDS, PhD,c and Jihua Chen, DDS, PhDd

Metal ceramic prostheses are ABSTRACT

provided because they combine
This clinical report describes treatment of a patient with gingival pigmentation after the restoration
the strength of metal and the of the right maxillary canine and first premolar with Ni-Crebased metal ceramic crowns and
1
esthetics of porcelain. Nickel- investigation of mechanisms of gingival discoloration. Histopathological observation and energy
based alloys are commonly dispersive x-ray spectroscopy analysis of the retrieved pigmented gingiva revealed brown deposits
used for their substructure, both in the epithelial cells and along the basement membranes but no trace of Ni or Cr elements in
having been introduced as a the pigmented particles, indicating that the gingival pigmentation adjacent to the Ni-Crebased
replacement for noble alloys metal ceramic prosthesis may not be caused by direct deposition of the released ions. (J Prosthet
Dent 2016;115:1-4)
because of the increasing cost
2
of gold in the 1980s. Ni-based alloys possess the advan- elemental analysis of these pigments. In this clinical report,
tage of increased strength compared with gold, which al- gingival pigmentation adjacent to the Ni-Crebased metal
lows thinner crowns and, consequently, less tooth ceramic crowns is described. Histopathological observa-
structure removal during preparation.2 tion and energy dispersive x-ray (EDX) analysis were
Due to the complex oral environment, continuous performed to determine whether the penetration of Ni or
corrosion of alloys may occur. As a result, metal ions such Cr ions was the reason for gingival pigmentation.
as the nickel ion (Ni3+) may be released for a prolonged
time.3 Valentine-Thon et al4 reported that chronic low-
CLINICAL REPORT
level metal exposure might result in metal sensitization
and undesirable side effects, including chronic adverse A healthy 54-year-old woman visited the Department of
effects on the surrounding tissues and cells.5,6 Schmalz Prosthodontics, School of Stomatology of the Fourth
and Garhammer5 reported that metal ions could be Military Medical University with the chief complaint of
released from metal ceramic prostheses through the gingival pigmentation. The patient did not have a sig-
corrosion process and the released ions could sub- nificant medical history or allergy and was not using
sequently cause adverse reactions in the adjacent prescription medications. Intraoral examination showed
gingiva.5-7 The use of Ni-based alloys is of particular that the maxillary right canine and first premolar were
concern since Ni is the most allergenic of all metallic restored with Ni-Crebased metal ceramic crowns.
elements.8 One side effect of dental alloys, including Ni- Pigmentation of the buccal and palatal gingival margins
Cr alloys, is discoloration of the adjacent gingiva. His- adjacent to the metal ceramic crowns was observed. The
topathological analysis has indicated that discolored pigmented soft tissues showed a gray-black thread-like
gingiva may be related to the deposition of alloy micro- appearance (Fig. 1). The gingiva around other healthy
particles in gingival tissues.9 However, there has been no teeth showed a coral pink or salmon pink appearance.

Supported by Program No. IRT13051 for Changjiang Scholars and Innovative Research Team in University.
a
Resident, State Key Laboratory of Military Stomatology, Department of Prosthodontics, School of Stomatology, Fourth Military Medical University, Xi’an, China.
b
Resident, State Key Laboratory of Military Stomatology, Department of Prosthodontics, School of Stomatology, Fourth Military Medical University, Xi’an, China.
c
Resident, State Key Laboratory of Military Stomatology, Department of Prosthodontics, School of Stomatology, Fourth Military Medical University, Xi’an, China.
d
Professor, State Key Laboratory of Military Stomatology, Department of Prosthodontics, School of Stomatology, Fourth Military Medical University, Xi’an, China.

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Figure 1. Clinical appearance of pigmented gingiva. Maxillary right canine and first premolar restored with Ni-Crebased metal ceramic crowns.
Discolored gingival tissues showed gray-black thread-like appearance. A, Buccal view. B, Palatal view.

Figure 2. A, Metal ceramic crowns removed. B, Discolored gingiva resected under local anesthesia.

The treatment plan was discussed with the patient,
who consented to resection of the discolored gingiva,
removal of metal ceramic crowns, and restoration with
ceramic crowns. The patient authorized biopsy and EDX
analysis of the removed gingiva. The 2 crowns were
removed with a diamond rotary instrument, and the
discolored gingiva was resected under local 2% lidocaine
anesthesia (Fig. 2). A specimen (10×3 mm) obtained from
the discolored gingiva was fixed in 2.5% glutaraldehyde
for 24 hours and sectioned into 2 parts for light micro-
scopy and EDX analysis. For light microscopy examina-
tion, the specimen was dehydrated in ascending
concentrations of alcohol, cleared in xylene, embedded in
paraffin, and finally cut into sections of 4- to 5-mm
thickness. Sections were then stained with hematoxylin-
eosin. For EDX analysis, the specimen was dehydrated,
embedded in an epoxy resin (EPON 812, TAAB Labora-
tories Equipment, Ltd) without postfixation and prepared
as for ultrathin sections. These sections were mounted on
stainless steel grids and examined using an energy
dispersive x-ray microanalyzer (model 7000; Kevex) at
5 kV and 20 kV accelerating voltage after carbon coating.
A large quantity of fine yellowish brown or brown
deposits was found in the discolored gingival tissues.
Most of the deposits were located either in the epithelial
cells or along the basement membrane (Fig. 3A). Infil-
trated inflammatory cells were also found in the dis-
colored gingival tissues. Desmosomes connecting the
epithelial cells were missing in some cells and separated
cells could be identified (Fig. 3B). There were increased
local vessels with thickened vascular walls and swelling
endothelial cells (Fig. 3C). Gingiva showed fibrosis,
degeneration, and local infiltration of basophils. Fibrous
tissues showed scattering of brown particles (Fig. 3D).
For the EDX analysis, an incident 20.0-kV electron
beam passed through an electron microscope vacuum
column to a 5-mm-thick, deparaffinized, unstained tissue
section mounted on a carbon stub. Tissues were identi-
fied by secondary electron images, and the location of
metals was observed by back-scattered electron images.
X-ray emissions from the specimen were detected over
variable times ranging up to 60 seconds, over a range of
0 to 10 keV. Pigmented particles showed peaks for C, O,
Ca, and Na (Fig. 4) but not Ni, Cr, or other metal

THE JOURNAL OF PROSTHETIC DENTISTRY Tian et al

January 2016 3

Figure 3. A, Microscopically, pigmentation located mainly in epithelial cells and along basement membrane (small arrows); ×225 magnification. B, Des-
mosomes connecting epithelial cells were missing in some cells, and separated cells can be seen. C, Increased local vessels with thickened vascular walls and
swelling endothelial cells. D, Gingiva showed fibrosis, degeneration, and local infiltration of basophils. Fibrous tissues were scattered with brown particles.

O Spectrum 2 Table 1. Results of energy dispersive x-ray spectroscopy analysis

Element Weight, % Atomic, %
Ca
C 61.00 69.63
c
O 30.24 25.91
Na 4.85 2.89
P 0.54 0.24
S 0.91 0.39
O
Na Cl Cl 2.22 0.86
S Ca 0.24 0.08
P Ca Total 100.00 100.00

0 2 4 6 8 10 12 14 16
Full Scale 1582 cts Cursor: 0.000
Figure 4. C, O, and Na were discovered in deposited microparticles.
Small amounts of Cl, S, P, and Ca also were discovered.
elements. Results of EDX analysis are summarized in
Table 1. The main elements of the deposited particles
were C and O. Small amounts of Na, P, Cl, S, and Ca
were also identified. However, no trace of Ni or Cr was
found in the deposits. Finally, the 2 affected teeth were
restored with ceramic crowns (Fig. 5). During the 5-year
follow-up, no relapse was noticed.
18 20 DISCUSSION
keV The occurrence of blue-gray pigmentation in the soft
tissues adjacent to metallic restorations represents a
challenging problem for dentists. Although much effort
has been made, the exact underlying mechanism is still
largely unknown. It is generally accepted that such
pigmentation is caused by mechanical penetration of the
metallic materials.10 Yamada and Sato11 reported the
presence of silver-containing stains in the vicinity of a
gold alloy based crown. The presence of silver, gold,
copper, and palladium in the tissues adjacent to dental
alloys has also been reported by Garhammer et al.12

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Figure 5. Lateral view shows restoration with ceramic crowns.
A patient with gingival discoloration around the Ni-
Crebased metal ceramic crowns is described. A biopsy
from the pigmented tissues was histopathologically
examined. Large amounts of pigmented deposits were
found along the basement membranes, which is similar to
a previous study of amalgam tattoos.13 When EDX was
used to analyze the elements in the deposited pigments,
C, O, and Na were identified (Fig. 4), but no trace of Ni or
Cr was discovered. This finding contradicts previous re-
ports. It has been reported that metal ions such as Ni3+
and Cr3+ released from cast alloys can alter gingival
fibroblast behavior, including proliferation and meta-
bolism, and enhance the level of inflammatory mediators
such as Interleukin 6 (IL-6), IL-1b, and tumor necrosis
factor-alpha (TNF-a).14 Cytotoxicity tests have also shown
that ions released from cast alloys could result in changes
in DNA, RNA, and protein syntheses, promoting oxidative
DNA damage and ultimately inducing apoptosis.15
Further investigation is needed to clarify whether this
patient’s discoloration was caused by apoptosis.
SUMMARY
This clinical report describes a patient with gingival
pigmentation near the Ni-Crebased metal ceramic crowns.
A specimen from the pigmented gingiva was examined
THE JOURNAL OF PROSTHETIC DENTISTRY
with histopathological microscopy and EDX. Results indi-
cated that the discoloration was not caused by the direct
deposition of the Ni and Cr ions, because the gray-black
gingiva did not contain Ni and Cr.
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Corresponding author:
Dr Jihua Chen
State Key Laboratory of Military Stomatology
Department of Prosthodontics
School of Stomatology
Fourth Military Medical University
No.145, Changlexi Rd
Xi’an
CHINA
Email: jhchen@fmmu.edu.cn
Copyright © 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.
Tian et al