Worn, Tetracycline-Stained Maxillary Teeth—Restored! An Elective Rehabilitation With a Minimally Invasive Approach

This case report describes an elective rehabilitation treatment approach to restore severely worn and stained anterior dentition.¹ The goal of the treatment was to restore the patient’s occlusion by correcting the severe wear, masking the tetracycline-stained dental abnormalities while delivering optimal aesthetics by using minimally invasive dental techniques.²

CASE REPORT
Diagnosis and Treatment Planning
A 56-year-old female presented with the following chief complaint: “I am unhappy with the color and shape of my teeth. I feel like my mouth is falling apart slowly and don’t like my smile. I would like a new smile.” Clinical intraoral examination (Figure 1) revealed severe anterior attrition, with vertical fracture lines on teeth Nos. 8 and 9.

Extraoral findings included tender muscles around the lateral border of the mandible upon palpitation, possibly due to clenching or nocturnal bruxism. The patient was in a generally healthy state, and she did not smoke and had no known allergies. The patient’s dental hygiene was not optimal. Therefore, a personalized oral hygiene regimen was given verbally and also demonstrated upon each dental visit.

Clinical evaluations and diagnoses were assessed during the treatment-planning phase, which included the following findings:

1. The patient presented with a small arch with corresponding small-sized teeth.
2. She had a deep bite with slight malocclusion due to crowding.
3. Her 2 maxillary central incisors (teeth Nos. 8 and 9) were inclined inward and presented with dentinal exposure.³
4. The patient also reported that she had been clenching for years, which would explain the moderate-to-severe attrition in the anterior dentition.
5. Her dental history also included mild tetracycline staining.

Preoperative Phase
Preliminary impressions of the patient’s maxillary and mandibular arches were taken for preliminary study casts. After a detailed occlusal analysis, an optimal treatment plan was discussed with the patient. The treatment would be phased in 3 subsequent visits that included 5 anterior lithium disilicate veneers (IPS e.max [Ivoclar Vivadent]) and 2 anterior porcelain-fused-to-metal (PFM) crowns. Additionally, a 15% at-home bleaching regimen was planned, along with the use of a long-term night guard.⁴

Due to the complexity of the bite and the desire for optimal results, a dental laboratory wax-up was requested and created to allow the patient to better visualize the proposed work before any treatment was begun.⁵ Once approved by the doctor and patient, the provisional restorations were fabricated by the laboratory team (Hi Tech Dental Ceramics in Fremont, Calif) with the desired shade selection before beginning treatment.  

Restorative Phase
Five maxillary anterior teeth (Nos. 5, 6, 7, 10, and 11) were prepared at a 0.55-mm enamel reduction with a chamfer proximo-incisal shoulder prep. Both maxillary centrals (teeth Nos. 8 and 9) were prepared at a 1.5-mm reduction to receive PFM crowns.

A retraction cord (#1 UltraPak [Ultradent Products]) was placed around each sulcus (teeth Nos. 5 to 11), and, after leaving in and removing per the manufacturer’s directions, a full-arch impression of the prepared teeth was taken using a light and heavy body vinyl polysiloxane (VPS) impression material (Imprint II [3M]). The one-piece provisional restoration was spot etched and cemented temporarily using a flowable composite (AeliteFlo, Shade A3 [BISCO Dental Products]). Then the excess cement was removed, the occlusion was checked, and the patient was dismissed.

Figure 1a. A pre-treatment photo of the patient in full smile.	Figure 1b. A pre-treatment photo of the patient in complete occlusion. The patient presented with a deep bite, several vertical fracture lines, and severe attrition in the anterior dentition.
Figure 1c. A pre-treatment side-view photo of the patient’s dentition.	Figure 1d. The initial pre-treatment occlusal-view photo of the maxillary dentition.

Delivery of the Final Restorations
The die stone model of the prepared maxillary arch showed the marginal details of the preparations (Figure 2). A precementation radiograph was taken to confirm the fit of the restorations before the delivery commenced. PFM crowns for teeth Nos. 8 and 9 were first checked for fit. The bonding surface of each restoration was cleaned and air dried. Areas were then isolated with cotton rolls and gauze. A glass ionomer luting cement (Ketac Cem Plus Luting Cement [3M]) was mixed, and a thin layer was applied to the inside surface of each restoration prior to being seated with light pressure. This light pressure was maintained on the restorations to ensure proper positioning during the setting process. Then, after 2 minutes, excess cement was removed with explorer and scaler. After 5 minutes of placement (cement setting time), the PFM restorations were then finished, and the occlusion was evaluated and adjusted as needed.

Next, the IPS e.max veneers (teeth Nos. 5, 6, 7, 10, and 11, which were previously etched with hydrofluoric acid in the dental lab) were tried in and verified for proper fit. Each lithium disilicate veneer was then rinsed and dried with oil-free air. A universal primer (Monobond Plus [Ivoclar Vivadent]) was applied to the intaglio surfaces of the e.max restorations as directed. The interproximal contacts were then isolated using clear matrix bands. Next, the tooth surfaces were pumiced, acid-etched with 35% phosphoric acid, and rinsed, and then Multilink Primer A+B (Ivoclar Vivadent) was applied to the teeth using a micro brush. Multilink Automix (Ivoclar Vivadent) self-curing resin base (designed with a light curing option) was placed using a light wave technique (ie, lightly cured for about 2 seconds per tooth). Excess material was removed using explorer, and interproximal areas were flossed before all restorations were fully light cured (Figures 3 and 4). Occlusion was confirmed with articulation paper, and the patient was given both postoperative and oral hygiene instructions upon dismissal.

DISCUSSION
The advantages offered by the restoration of a patient’s anterior dentition include reestablishing the patient’s aesthetics and proper occlusal function.⁶ The decision for full-coverage crowns on teeth Nos. 8 and 9 was due to the severe pre-existing wear.^7,8 However, a more conservative and minimally invasive approach was taken to restore teeth Nos. 5, 6, 7, 10, and 11 with the placement of all-ceramic veneers.^9,10

Figure 3. A post-treatment photo of the patient in complete occlusion after receiving the delivery of the veneers (teeth Nos. 5, 6, 7, 10, and 11) and porcelain-fused-to-metal crowns (on teeth Nos. 8 and 9).	Figure 4. A post-treatment photo of the patient in full smile following the delivery of the maxillary restorations.

The decision to place porcelain veneers (IPS e.max) on discolored tetracycline teeth required additional preparation and the use of opacious porcelain to enhance the aesthetic properties of these restorations.¹¹ A night guard was also made and delivered at the cementation appointment. It was acknowledged that an ideal comprehensive treatment plan would also have included IPS e.max veneer restorations for the mandibular dentition; however, our patient opted to postpone that treatment. With this decision, the patient was informed that her smile might not achieve full cosmetic enhancement because, after completing the maxillary restorations, the mandibular teeth would then have a strong contrast in color. To correct and narrow this contrast, a bleaching protocol involving the lower anterior teeth was advised, accepted, and dispensed to the patient.4 Despite some abfraction lesions present in the anterior mandibular dentition, the patient reported no discomfort with the prescribed at-home bleaching regimen. The bleaching results were favorable, and the patient was satisfied with the final restorative outcome.

CLOSING COMMENTS
Minimally invasive approaches can be utilized to deliver an effective solution in correcting a misaligned, highly worn, and discolored dentition.¹² However, the success and longevity of all-ceramic veneers and crowns is multifactorial and dependent on proper clinical diagnoses and comprehensive assessments.¹³ For these reasons, proper treatment planning and selection of such cases should be individually assessed and not be considered as universal.¹⁴ If possible, clinical treatment should involve conservative preparations, proper selection of materials and tooth shade, and patient involvement in the treatment planning and approval process before delivery of the case.¹⁵ Upon delivery, proper post-op care should include routine dental maintenance that will optimize the longevity for the restorative work delivered.

Acknowledgment
Dr. Charlie would like to thank the expert dental laboratory team at Hi Tech Dental Ceramics (Fremont, Calif) for their work on this case.

References

1. Castelnuovo J, Tjan AH, Phillips K, et al. Fracture load and mode of failure of ceramic veneers with different preparations. J Prosthet Dent. 2000;83:171-180.
2. Garber DA. Rational tooth preparation for porcelain laminate veneers. Compendium. 1991;12:316-320.
3. Burke FJ. Survival rates for porcelain laminate veneers with special reference to the effect of preparation in dentin: a literature review. J Esthet Restor Dent. 2012;24:257-265.
4. Haywood VB. Overview and status of mouthguard bleaching. J Esthet Dent. 1991;3:157-161.
5. Mizrahi B. Visualization before finalization: a predictable procedure for porcelain laminate veneers. Pract Proced Aesthet Dent. 2005;17:513-518.
6. Morley J. Smile design—specific considerations. J Calif Dent Assoc. 1997;25:633-637.
7. Rouse JS. Full veneer versus traditional veneer preparation: a discussion of interproximal extension. J Prosthet Dent. 1997;78:545-549.
8. El-Badrawy W, El-Mowafy O. Comparison of porcelain veneers and crowns for resolving esthetic problems: two case reports. J Can Dent Assoc. 2009;75:701-704.
9. Chu FC, Chow TW, Chai J. Contrast ratios and masking ability of three types of ceramic veneers. J Prosthet Dent. 2007;98:359-364.
10. Katoh Y, Takagi Y, Hasegawa K, et al. Esthetic improvement of teeth discolored by the side effects of antibiotic tetracycline using porcelain laminate veneer and castable glass ceramics crown. J Esthet Dent. 1993;6:33-39.
11. Jun SK, Wilson S. Restoration of severely discolored maxillary anterior teeth with porcelain laminate veneers. Pract Proced Aesthet Dent. 2008;20:285-287.
12. Katoh Y. Laminate veneer restorations on discolored teeth: porcelain laminate veneer technique. In: Haga M, Ishikawa T, eds. Dental Forum. Tokyo, Japan; 1990:115-124.
13. Dunne SM, Millar BJ. A longitudinal study of the clinical performance of porcelain veneers. Br Dent J. 1993;175:317-321.
14. Touati B. Bonded ceramic restorations: achieving predictability. Pract Periodontics Aesthet Dent. 1995;7:33-37.
15. Johnston WM, Kao EC. Assessment of appearance match by visual observation and clinical colorimetry. J Dent Res. 1989;68:819-822.

Dr. Charlie received her bachelor’s degree from the University of California, Irvine. She received her DDS from Meharry Medical College in Nashville and completed her residency training in Advanced Education in General Dentistry (AEGD) from the University of California, San Francisco (UCSF). Dr. Charlie is an active member of the AGD, the American Academy of Cosmetic Dentistry, the American Academy of Implant Dentistry, the ADA, and the California Dental Association. She can be reached via email at sanna.charlie@ucsf.edu.

Dr. Nanjapa completed his initial dental training in India. He received his master’s degree in Dental Biomaterials at the University of Alabama at Birmingham. In 2003, he received both a DDS license and a Certificate in Advanced Prosthodontics from the University of Illinois at Chicago. Dr. Nanjapa is in private practice in San Mateo, Calif. He continues to maintain a faculty position at UCSF. He can be reached via email at samir.nanjapa@ucsf.edu.

Dr. Vaderhobli is a full-time faculty member at the UCSF School of Dentistry, where he moved after completing his AEGD residency training at the Eastman Institute of Oral Health at the University of Rochester. He is the dental director for the Advanced Education in General Dentistry residency program, as well as the Clinical Director for the CAD/CAM program. His practice is based on the application of a conservative, evidence-based preventive-treatment approach. He can be reached via email at ram.vaderhobli@ucsf.edu.

Disclosure: The authors report no disclosures.

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