- Email: [email protected]
Noninvasive detection of microleakage in all-ceramic crowns using quantitative light-induced fluorescence technology
Journal Pre-proof Noninvasive detection of microleakage in all-ceramic crowns using quantitative light-induced fluorescence technology You-Jin Maeng, Hyung-Suk Lee, Eun-Song Lee, Hong-Cheol Yoon, Baek-Il Kim
PII:
S1572-1000(20)30025-9
DOI:
https://doi.org/10.1016/j.pdpdt.2020.101672
Reference:
PDPDT 101672
To appear in:
Photodiagnosis and Photodynamic Therapy
Received Date:
25 October 2019
Accepted Date:
21 January 2020
Please cite this article as: Maeng Y-Jin, Lee H-Suk, Lee E-Song, Yoon H-Cheol, Kim B-Il, Noninvasive detection of microleakage in all-ceramic crowns using quantitative light-induced fluorescence technology, Photodiagnosis and Photodynamic Therapy (2020), doi: https://doi.org/10.1016/j.pdpdt.2020.101672
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier.
Noninvasive detection of microleakage in all-ceramic crowns using quantitative light-induced fluorescence technology
Author names and affiliations: You-Jin Maeng1,2*, Hyung-Suk Lee1*, Eun-Song Lee1, Hong-Cheol Yoon3, Baek-Il Kim1 You-Jin Maeng and Hyung-Suk Lee contributed equally to this study.
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*
Department of Preventive Dentistry & Public Oral Health, BK21 PLUS Project, Yonsei University
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1
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Affiliations:
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College of Dentistry
Address: 03722, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea Department of Dental Hygiene, Shinsung University
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2
Address: 31801, 1 Daehak-ro, Jeongmi-myeon, Dangjin-si, Chungcheongnam-do, Republic of Korea BESTDEN Dental Clinic
ur
3
Jo
Address: 06232, 110 Teheran-ro 4F(Cambridge B/D), Gangnam-gu, Seoul, Republic of Korea
Corresponding author: Baek-Il Kim, D.D.S., Ph.D., Professor and Chair Department of Preventive Dentistry & Public Oral Health, BK21 PLUS Project, Oral Science 1
Research Institute, Yonsei University College of Dentistry Address: 03722, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea Tel: +82-2-2228-3070, Fax: +82-2-392-2926 E-mail: [email protected]
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Highlights
• The red fluorescence glow observed through the front wall of all-ceramic crown make it possible to
-p
decide the existence of bacteria-induced microleakage and carious lesions inside the crown.
• QLF examinations enables dentists to identify the presence of microleakage in an all-ceramic crown
re
noninvasively.
lP
• QLF technology can be effectively applied to provide subjective evidence for detecting
na
microleakage and diagnosing carious lesions inside an all-ceramic crown noninvasively.
Abstract
The early noninvasive detection of crown microleakage is very important for tooth maintenance and
ur
preservation. A crown margin in a subgingival position combined with the obscuring effect of a ceramic crown make it difficult to diagnose microleakage using traditional methods such as visual-tactile examinations and
Jo
radiography. The aim of this study was to determine the effectiveness of quantitative light-induced fluorescence (QLF) technology for diagnosing microleakage in an all-ceramic crown noninvasively. In this study the red fluorescence glow was detected through a crown wall using the Qraycam QLF device (AIOBIO, Seoul, Republic of Korea). No abnormalities were detected by a visual examination, whereas the Qraycam device revealed both strong red fluorescence and fluorescence loss in suspicious lesions, which were confirmed after crown removal. It was possible to determine that the carious lesions inside the crown were related to bacteriainduced microleakage. After performing caries removal and crown reattachment, the red fluorescence glow was no longer detected. QLF examinations made it easy to identify the presence of microleakage in an all-ceramic crown noninvasively based on red fluorescence. These findings indicate that QLF technology can be effectively 2
applied to provide objective evidence for detecting microleakage and diagnosing carious lesions inside an allceramic crown noninvasively.
Keywords: crown microleakage, recurrent caries, cariogenic biofilm, quantitative light-induced fluorescence (QLF) technology
1. Introduction
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Microleakage is one of the main reasons for restoration replacement, and involves contamination of the marginal gap at the tooth–restoration interface. An infected marginal gap can allow the accumulation of oral debris and biofilm, leading to recurrent caries, periodontal disease, pulp necrosis, and aesthetic problems such as
-p
stains and margin discoloration[1].
Diagnostic methods for restoration microleakage such as visual-tactile examinations and radiographs are
re
limited by their dependence on the subjective decisions of dentists. Particularly in the case of all-ceramic crowned teeth, confirming the actual extent of microleakage is difficult because the color of the ceramic
lP
material is similar to natural teeth and the crown margin is placed subgingivally[2]. The radiopacity of ceramic materials also impairs the use of radiography for detecting contamination and lesions inside crown restorations caused by microleakage. Overcoming the aforementioned limitations requires the development of minimally
na
invasive diagnostic methods in order to avoid invasive crown removal and periodontal surgical procedures. Quantitative light-induced fluorescence (QLF) is a noninvasive method for detecting carious lesions based on
ur
filtering the autofluorescence emitted from teeth during illumination by visible blue light at 405 nm. This technology mainly evaluates two fluorescent characteristics: (1) the fluorescence reduction resulting from
Jo
mineral loss and (2) the red fluorescence emitted by bacterial deposits and bacteria-related lesion[3]. These characteristics of QLF can provide objective information for facilitating the early diagnosis of crown microleakage, which is difficult to detect using conventional diagnostic methods. The present study aimed to determine whether QLF technology is effective for diagnosing crown microleakage noninvasively.
2. Case report 3
A 62-year-old male patient visited the hospital complaining of discomfort and teeth hypersensitivity in his upper right incisors under crown restorations. The conventional diagnosis made it difficult to confirm not only the exact position of the problematic tooth but also the reason for the symptom (Figure 1A). Whereas red fluorescence inside the crown of tooth #13 was observable in the fluorescence image captured by Qraycam QLF device (AIOBIO, Seoul, Republic of Korea) (Figure 1A, yellow arrow). After removing the crown exhibiting microleakage and residual cement, nothing unusual was observed on the abutment tooth with the naked eye (Figure 1B). However, red fluorescence as well as fluorescence loss were
ro of
observed on smooth and interproximal tooth surfaces in a QLF examination, which confirmed the presence of demineralized lesions in the suspected areas (Figure 1B, yellow arrows). Closer inspections of the removed crown indicated strong red fluorescence covering the entire inside surface of the crown wall, providing clear evidence of the presence of bacteria-induced microleakage (Figure 1C).
-p
After first eliminating the red fluorescent substances inside the crown (Figure 2A), the carious lesions on smooth and interproximal surfaces were removed. During caries removal, demineralized tissues exhibiting
re
strong red fluorescence were peeled off (Figure 2B, yellow arrow). In addition to the red fluorescence, fluorescence loss was also identified clearly on the residual lesions (Figure 2C, yellow arrows). Lastly, the
lP
lesions were removed completely and the repaired crown was reattached. Thereafter, we confirmed that no further red fluorescence was observed on a fluorescence image (Figure 2D, yellow arrow). At follow-up visits
ur
3. Discussion
na
every 3 months after treatment, the tooth was healthy and well-functioning without any patient discomfort.
The present case report has confirmed that fluorescence images obtained using QLF technology can provide
Jo
objective evidence for the noninvasive diagnosis of microleakage in an all-ceramic crown. The red fluorescence glow observed inside the crown prior to crown removal clearly suggested that the all-ceramic crown exhibited bacteria-induced microleakage. According to previous studies, the red fluorescence detected by QLF originates from bacterial metabolites such as porphyrin, and the associated mature and pathogenic biofilm emits strong red fluorescence[4]. Red fluorescence under a crown restoration derives from bacteria, which penetrate into the crown via a marginal gap and form a biofilm and carious lesions internally. In the present case we were easily able to identify the fluorescence loss (an indicator of carious lesions) as well as the red fluorescence together on 4
the abutment tooth. The confined space of internal crown provided optimal culture conditions for anaerobic bacteria, leading to strong fluorescence reactions of biofilm. These observations confirmed the presence of crown microleakage that had led to bacterial growth. The crown restoration in the present case was the IPS e-max® system constructed from lithium disilicate glass ceramic. An e-max® crown has a natural-looking tooth color due to its excellent translucency, and so is widely used for aesthetic restorations. This optical characteristic of an e-max® crown allows the ultraviolet light of a QLF device to pass through the crown and hence also visualization of the red fluorescence produced by any
ro of
pathogenic biofilm present on the inner surface of the restoration[5]. QLF technology facilitates evaluations of the microleakage in all-ceramic crowns, but its limitations in detecting opaque gold and metal crowns mean that further studies are needed into detecting internal lesions of ceramic crowns constructed from other types of material.
-p
QLF technology provides objective information about lesions at a leakage site without requiring crown removal, and can also be effectively used to confirm the presence and extent of lesions during treatment
re
procedures. In the present case, since the crown exhibiting microleakage had a margin located below the gingival margin, there was not only a high probability of not detecting the microleakage if the patient did not
lP
experience discomfort, but also the impossibility of diagnosing the microleakage using conventional methods. Crown microleakage is mainly diagnosed based on the presence of discoloration or a gap in the margin, but a
na
standard consensus does not yet exist. This situation makes it difficult for dental clinicians to decide whether to remove a crown in order to diagnose crown microleakage when strong evidence is not present. In contrast, the application of QLF technology can lead to accurate diagnoses based on clear evidence and successful treatment
ur
outcomes, because it demonstrates cariogenic discoloration resulting from the red fluorescence produced by
Jo
bacteria penetrating the crown margin[6]. In conclusion, QLF technology can be effectively applied to provide objective evidence for detecting
microleakage and diagnosing carious lesions inside all-ceramic crown noninvasively.
Conflict of interest The authors declare that they have no conflict of interest. 5
6
ro of
-p
re
lP
na
ur
Jo
References [1]
Gu XH, Kern M. Marginal discrepancies and leakage of all-ceramic crowns: influence of luting agents and aging conditions. Int J Prosthodont 2003;16:109-16.
[2]
Zoellner A, Heuermann M, Weber HP, Gaengler P. Secondary caries in crowned teeth: correlation of clinical and radiographic findings. J Prosthet Dent 2002;88:314-9.
[3]
Volgenant CM, van der Veen MH, de Soet JJ, ten Cate JM. Effect of metalloporphyrins on red autofluorescence from oral bacteria. Eur J Oral Sci 2013;121:156-61. Lee ES, Kang SM, Ko HY, Kwon HK, Kim BI. Association between the cariogenicity of a dental
ro of
[4]
microcosm biofilm and its red fluorescence detected by Quantitative Light-induced FluorescenceDigital (QLF-D). J Dent 2013;41:1264-70. [5]
Rafael CF, Guth JF, Kauling AEC, Cesar PF, Volpato CAM, Liebermann A. Impact of background on
[6]
-p
color, transmittance, and fluorescence of leucite based ceramics. Dent Mater J 2017;36:394-401.
Lee HS, Kim SK, Park SW, de Josselin de Jong E, Kwon HK, Jeong SH, et al. Caries detection and
re
quantification around stained pits and fissures in occlusal tooth surfaces with fluorescence. J Biomed
Jo
ur
na
lP
Opt 2018;23:1-7.
7
Figure legends
Fig. 1. Images of all-ceramic crown microleakage before (A) and after (B) crown removal, and vertical images of the inside surface of the crown restoration (C). White-light images (upper) and fluorescent images
na
lP
re
-p
ro of
(lower) were obtained using the Qraycam device. Yellow arrows indicate the suspicious lesion areas.
Fig. 2. Qraycam images obtained at the different treatment stages: elimination of luting cement that remained
ur
inside the crown restoration (A), removal of red fluorescent tissues (B), confirmation of demineralized lesions (C), and reattachment of the repaired crown after removing carious lesions (D). Yellow arrows indicate the
Jo
suspicious lesion areas.
8
9
ro of
-p
re
lP
na
ur
Jo
PII:
S1572-1000(20)30025-9
DOI:
https://doi.org/10.1016/j.pdpdt.2020.101672
Reference:
PDPDT 101672
To appear in:
Photodiagnosis and Photodynamic Therapy
Received Date:
25 October 2019
Accepted Date:
21 January 2020
Please cite this article as: Maeng Y-Jin, Lee H-Suk, Lee E-Song, Yoon H-Cheol, Kim B-Il, Noninvasive detection of microleakage in all-ceramic crowns using quantitative light-induced fluorescence technology, Photodiagnosis and Photodynamic Therapy (2020), doi: https://doi.org/10.1016/j.pdpdt.2020.101672
This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier.
Noninvasive detection of microleakage in all-ceramic crowns using quantitative light-induced fluorescence technology
Author names and affiliations: You-Jin Maeng1,2*, Hyung-Suk Lee1*, Eun-Song Lee1, Hong-Cheol Yoon3, Baek-Il Kim1 You-Jin Maeng and Hyung-Suk Lee contributed equally to this study.
ro of
*
Department of Preventive Dentistry & Public Oral Health, BK21 PLUS Project, Yonsei University
re
1
-p
Affiliations:
lP
College of Dentistry
Address: 03722, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea Department of Dental Hygiene, Shinsung University
na
2
Address: 31801, 1 Daehak-ro, Jeongmi-myeon, Dangjin-si, Chungcheongnam-do, Republic of Korea BESTDEN Dental Clinic
ur
3
Jo
Address: 06232, 110 Teheran-ro 4F(Cambridge B/D), Gangnam-gu, Seoul, Republic of Korea
Corresponding author: Baek-Il Kim, D.D.S., Ph.D., Professor and Chair Department of Preventive Dentistry & Public Oral Health, BK21 PLUS Project, Oral Science 1
Research Institute, Yonsei University College of Dentistry Address: 03722, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea Tel: +82-2-2228-3070, Fax: +82-2-392-2926 E-mail: [email protected]
ro of
Highlights
• The red fluorescence glow observed through the front wall of all-ceramic crown make it possible to
-p
decide the existence of bacteria-induced microleakage and carious lesions inside the crown.
• QLF examinations enables dentists to identify the presence of microleakage in an all-ceramic crown
re
noninvasively.
lP
• QLF technology can be effectively applied to provide subjective evidence for detecting
na
microleakage and diagnosing carious lesions inside an all-ceramic crown noninvasively.
Abstract
The early noninvasive detection of crown microleakage is very important for tooth maintenance and
ur
preservation. A crown margin in a subgingival position combined with the obscuring effect of a ceramic crown make it difficult to diagnose microleakage using traditional methods such as visual-tactile examinations and
Jo
radiography. The aim of this study was to determine the effectiveness of quantitative light-induced fluorescence (QLF) technology for diagnosing microleakage in an all-ceramic crown noninvasively. In this study the red fluorescence glow was detected through a crown wall using the Qraycam QLF device (AIOBIO, Seoul, Republic of Korea). No abnormalities were detected by a visual examination, whereas the Qraycam device revealed both strong red fluorescence and fluorescence loss in suspicious lesions, which were confirmed after crown removal. It was possible to determine that the carious lesions inside the crown were related to bacteriainduced microleakage. After performing caries removal and crown reattachment, the red fluorescence glow was no longer detected. QLF examinations made it easy to identify the presence of microleakage in an all-ceramic crown noninvasively based on red fluorescence. These findings indicate that QLF technology can be effectively 2
applied to provide objective evidence for detecting microleakage and diagnosing carious lesions inside an allceramic crown noninvasively.
Keywords: crown microleakage, recurrent caries, cariogenic biofilm, quantitative light-induced fluorescence (QLF) technology
1. Introduction
ro of
Microleakage is one of the main reasons for restoration replacement, and involves contamination of the marginal gap at the tooth–restoration interface. An infected marginal gap can allow the accumulation of oral debris and biofilm, leading to recurrent caries, periodontal disease, pulp necrosis, and aesthetic problems such as
-p
stains and margin discoloration[1].
Diagnostic methods for restoration microleakage such as visual-tactile examinations and radiographs are
re
limited by their dependence on the subjective decisions of dentists. Particularly in the case of all-ceramic crowned teeth, confirming the actual extent of microleakage is difficult because the color of the ceramic
lP
material is similar to natural teeth and the crown margin is placed subgingivally[2]. The radiopacity of ceramic materials also impairs the use of radiography for detecting contamination and lesions inside crown restorations caused by microleakage. Overcoming the aforementioned limitations requires the development of minimally
na
invasive diagnostic methods in order to avoid invasive crown removal and periodontal surgical procedures. Quantitative light-induced fluorescence (QLF) is a noninvasive method for detecting carious lesions based on
ur
filtering the autofluorescence emitted from teeth during illumination by visible blue light at 405 nm. This technology mainly evaluates two fluorescent characteristics: (1) the fluorescence reduction resulting from
Jo
mineral loss and (2) the red fluorescence emitted by bacterial deposits and bacteria-related lesion[3]. These characteristics of QLF can provide objective information for facilitating the early diagnosis of crown microleakage, which is difficult to detect using conventional diagnostic methods. The present study aimed to determine whether QLF technology is effective for diagnosing crown microleakage noninvasively.
2. Case report 3
A 62-year-old male patient visited the hospital complaining of discomfort and teeth hypersensitivity in his upper right incisors under crown restorations. The conventional diagnosis made it difficult to confirm not only the exact position of the problematic tooth but also the reason for the symptom (Figure 1A). Whereas red fluorescence inside the crown of tooth #13 was observable in the fluorescence image captured by Qraycam QLF device (AIOBIO, Seoul, Republic of Korea) (Figure 1A, yellow arrow). After removing the crown exhibiting microleakage and residual cement, nothing unusual was observed on the abutment tooth with the naked eye (Figure 1B). However, red fluorescence as well as fluorescence loss were
ro of
observed on smooth and interproximal tooth surfaces in a QLF examination, which confirmed the presence of demineralized lesions in the suspected areas (Figure 1B, yellow arrows). Closer inspections of the removed crown indicated strong red fluorescence covering the entire inside surface of the crown wall, providing clear evidence of the presence of bacteria-induced microleakage (Figure 1C).
-p
After first eliminating the red fluorescent substances inside the crown (Figure 2A), the carious lesions on smooth and interproximal surfaces were removed. During caries removal, demineralized tissues exhibiting
re
strong red fluorescence were peeled off (Figure 2B, yellow arrow). In addition to the red fluorescence, fluorescence loss was also identified clearly on the residual lesions (Figure 2C, yellow arrows). Lastly, the
lP
lesions were removed completely and the repaired crown was reattached. Thereafter, we confirmed that no further red fluorescence was observed on a fluorescence image (Figure 2D, yellow arrow). At follow-up visits
ur
3. Discussion
na
every 3 months after treatment, the tooth was healthy and well-functioning without any patient discomfort.
The present case report has confirmed that fluorescence images obtained using QLF technology can provide
Jo
objective evidence for the noninvasive diagnosis of microleakage in an all-ceramic crown. The red fluorescence glow observed inside the crown prior to crown removal clearly suggested that the all-ceramic crown exhibited bacteria-induced microleakage. According to previous studies, the red fluorescence detected by QLF originates from bacterial metabolites such as porphyrin, and the associated mature and pathogenic biofilm emits strong red fluorescence[4]. Red fluorescence under a crown restoration derives from bacteria, which penetrate into the crown via a marginal gap and form a biofilm and carious lesions internally. In the present case we were easily able to identify the fluorescence loss (an indicator of carious lesions) as well as the red fluorescence together on 4
the abutment tooth. The confined space of internal crown provided optimal culture conditions for anaerobic bacteria, leading to strong fluorescence reactions of biofilm. These observations confirmed the presence of crown microleakage that had led to bacterial growth. The crown restoration in the present case was the IPS e-max® system constructed from lithium disilicate glass ceramic. An e-max® crown has a natural-looking tooth color due to its excellent translucency, and so is widely used for aesthetic restorations. This optical characteristic of an e-max® crown allows the ultraviolet light of a QLF device to pass through the crown and hence also visualization of the red fluorescence produced by any
ro of
pathogenic biofilm present on the inner surface of the restoration[5]. QLF technology facilitates evaluations of the microleakage in all-ceramic crowns, but its limitations in detecting opaque gold and metal crowns mean that further studies are needed into detecting internal lesions of ceramic crowns constructed from other types of material.
-p
QLF technology provides objective information about lesions at a leakage site without requiring crown removal, and can also be effectively used to confirm the presence and extent of lesions during treatment
re
procedures. In the present case, since the crown exhibiting microleakage had a margin located below the gingival margin, there was not only a high probability of not detecting the microleakage if the patient did not
lP
experience discomfort, but also the impossibility of diagnosing the microleakage using conventional methods. Crown microleakage is mainly diagnosed based on the presence of discoloration or a gap in the margin, but a
na
standard consensus does not yet exist. This situation makes it difficult for dental clinicians to decide whether to remove a crown in order to diagnose crown microleakage when strong evidence is not present. In contrast, the application of QLF technology can lead to accurate diagnoses based on clear evidence and successful treatment
ur
outcomes, because it demonstrates cariogenic discoloration resulting from the red fluorescence produced by
Jo
bacteria penetrating the crown margin[6]. In conclusion, QLF technology can be effectively applied to provide objective evidence for detecting
microleakage and diagnosing carious lesions inside all-ceramic crown noninvasively.
Conflict of interest The authors declare that they have no conflict of interest. 5
6
ro of
-p
re
lP
na
ur
Jo
References [1]
Gu XH, Kern M. Marginal discrepancies and leakage of all-ceramic crowns: influence of luting agents and aging conditions. Int J Prosthodont 2003;16:109-16.
[2]
Zoellner A, Heuermann M, Weber HP, Gaengler P. Secondary caries in crowned teeth: correlation of clinical and radiographic findings. J Prosthet Dent 2002;88:314-9.
[3]
Volgenant CM, van der Veen MH, de Soet JJ, ten Cate JM. Effect of metalloporphyrins on red autofluorescence from oral bacteria. Eur J Oral Sci 2013;121:156-61. Lee ES, Kang SM, Ko HY, Kwon HK, Kim BI. Association between the cariogenicity of a dental
ro of
[4]
microcosm biofilm and its red fluorescence detected by Quantitative Light-induced FluorescenceDigital (QLF-D). J Dent 2013;41:1264-70. [5]
Rafael CF, Guth JF, Kauling AEC, Cesar PF, Volpato CAM, Liebermann A. Impact of background on
[6]
-p
color, transmittance, and fluorescence of leucite based ceramics. Dent Mater J 2017;36:394-401.
Lee HS, Kim SK, Park SW, de Josselin de Jong E, Kwon HK, Jeong SH, et al. Caries detection and
re
quantification around stained pits and fissures in occlusal tooth surfaces with fluorescence. J Biomed
Jo
ur
na
lP
Opt 2018;23:1-7.
7
Figure legends
Fig. 1. Images of all-ceramic crown microleakage before (A) and after (B) crown removal, and vertical images of the inside surface of the crown restoration (C). White-light images (upper) and fluorescent images
na
lP
re
-p
ro of
(lower) were obtained using the Qraycam device. Yellow arrows indicate the suspicious lesion areas.
Fig. 2. Qraycam images obtained at the different treatment stages: elimination of luting cement that remained
ur
inside the crown restoration (A), removal of red fluorescent tissues (B), confirmation of demineralized lesions (C), and reattachment of the repaired crown after removing carious lesions (D). Yellow arrows indicate the
Jo
suspicious lesion areas.
8
9
ro of
-p
re
lP
na
ur
Jo