R e s t o r a t i o n o f F l u o ro s i s Stained Teeth: A Case Study Barbara Slaska,
DDS
a
, Arnold I. Liebman,
DDS
b,
*, Diana Kukleris,
c DDS
KEYWORDS Fluorosis Golden proportion Teeth-whitening Porcelain veneer restorations KEY POINTS Dental fluorosis manifests itself by too much ingestion of fluoride resulting in disturbances in enamel mineralization. The result is an intrinsic discoloration in the maxillary and mandibular teeth with a poor esthetic appearance. In challenging cases, an esthetic result may be achieved only by a combination of techniques.
The patient was a 35-year-old African American man originally from Senegal, Africa who presented to New York University College of Dentistry with the chief complaint of discoloration of his anterior teeth and the desire to have white natural-looking and straight teeth (Figs. 1 and 2). His chief complaint: “I need cosmetic work.” MEDICAL HISTORY
There was no significant medical history. DENTAL HISTORY
A full mouth series of radiographs were taken that displayed no carious lesions. Diagnostic casts were made and the American Academy of Cosmetic Dentistry series of photographs were taken. Teeth #14, #19, and #30 were missing. A dental implant was proposed for future placement in the #30 position. The space was too narrow in the other positions. A class I malocclusion with bimaxillary protrusion was present.
The authors have nothing to disclose. a Department of Cariology and Comprehensive Care, New York University College of Dentistry, 77 East 12th Street, New York, NY 10016, USA; b Department of Cariology and Comprehensive Care, New York University College of Dentistry, 2280 East 71st Street, New York, NY 11234, USA; c Private Practice, 1248 Farm to Market 78, Schertz, TX 78154, USA * Corresponding author. E-mail address: [email protected] Dent Clin N Am - (2015) -–http://dx.doi.org/10.1016/j.cden.2015.03.003 dental.theclinics.com 0011-8532/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
2
Slaska et al
Fig. 1. Full-face view of severe anterior fluorosis case.
This condition is characterized by protrusive and proclined upper and lower incisors and an increased procumbency of the lips.1 A New York University College of Dentistry Smile Evaluation Form was completed. A clinical examination was performed and the basic restorative work subsequently completed. Periodontal examination revealed the need for scaling and root planing to achieve desired gingival health. The periodontal status showed local and generalized recession. Periodontal probing and charting revealed sulcus depth was within normal limits but mild gingivitis was present. TREATMENT PLAN AND SEQUENCING
The patient’s esthetic problem was caused by fluorosis. Treatment options included bleaching; microabrasion; direct or indirect composite resin; porcelain veneers; and all ceramic crowns, such as e.max (Ivoclar Vivadent, Amherst, NY) with some opacity to mask the discoloration but still allow an esthetic restoration by combining an opaque core with an esthetic veneer of feldspathic porcelain. The conservative treatment of bleaching in conjunction with feldspathic veneers was selected. PROGNOSIS
The depth of the staining could not be ascertained. Teeth bleaching was used to reduce the discoloration of the teeth before preparation and therefore the necessity for more opaque veneers. This would allow a more natural appearance of the final veneered teeth and allowing for an excellent prognosis.
Fig. 2. Retracted view of severe anterior fluorosis case.
Fluorosis Stained Teeth
TREATMENT SEQUENCING Periodontal Considerations
Scaling and root planing resulted in the resolution of the patient’s gingivitis. A healthy periodontium created the appropriate environment for the restorative phase of treatment. The gingival zeniths were determined to be in the correct position and no surgical intervention was required. Restorative Considerations
The initial phase requires in-office bleaching (Philips Zoom Light-Activated Whitening System [Philips Oral Healthcare, Stamford, CT]). An initial shade was taken to document the change (see Fig. 2; and Fig. 3). Three bleaching sessions were performed with 15-minute cycles in the same visit (Figs. 4 and 5). Feldspathic porcelain veneers on eight upper teeth were suggested subsequent to the bleaching. However, financial constraints permitted only teeth #6 to #11 to be treated. Bleaching was performed on the lower arch to improve their appearance and an acceptable result was accomplished. The concept of golden proportion without any spacing was used to guide the wax-up and mock-up before preparation for the porcelain veneers. The preparations were done with a diamond chamfer bur and guided with a preparation guide to have a controlled reduction (Fig. 6). The stains were taken out when prepared with a 0.5-mm facial reduction. In this case the staining was not deep, although unknown before preparation. If the staining was deeper, a deeper preparation would have been required. Final impressions were taken with Dentsply Reprosil polyvinyl siloxane (Dentsply Caulk, Milford, DE) and the resulting stone model was evaluated for adequate preparation. Provisionals were created from the wax-up using Luxatemp Shade A-1 (DMG America, Englewood, NJ), which was placed into a putty matrix. The laboratory was supplied with the study models of the wax-up. Feldspathic porcelain was used for the veneers to obtain the most esthetic result. Opaque porcelain was ordered to block-out the discoloration of the color of the teeth. When the case came back it was placed onto the model to check for accuracy before the patient’s appointment Fig. 7. The etched restorations were silanated with Bis-Silane (Bisco, Schaumburg, IL) (Fig. 8) and Bisco Choice 2 bonding agent was placed and light cured. Bisco Choice 2 resin cement shade translucent was used as the luting cement. This cement is a high
Fig. 3. Initial shade taken to document shade change.
3
4
Slaska et al
Fig. 4. Result of teeth bleaching.
compressive strength, light-cured luting cement designed specifically for cementation of porcelain and indirect composite veneers (Fig. 9). DISCUSSION
Dental fluorosis is caused by too much ingestion of fluoride resulting in disturbances in enamel mineralization. This results in an intrinsic discoloration in the upper and lower teeth causing a poor esthetic appearance. The extent of severity depends on the length, term, and quantity of fluoride overexposure. There exist a variety of additional factors that further influence the risk and susceptibility to developing dental fluorosis. Among these are age, growth, weight, and nutrition of the individual.2–5 The risk for developing fluorosis begins at 3 months and ends at 8 years of age. Once the tooth has erupted, it is no longer at risk for developing this condition. It is well known that the addition of artificial fluoride to drinking water has numerous benefits in dental caries prevention.6 Recent studies indicate overexposure to fluoride in some regions of the world, such as Africa, India, and China, where ongoing endemics of systemic fluorosis result from overexposure to naturally occurring fluoride ingested through water.7–9
Fig. 5. Retracted view of result of teeth bleaching.
Fluorosis Stained Teeth
Fig. 6. Veneer preparation showing stains removed.
To best assess the severity and treatment of dental fluorosis, one may refer to the Thylstrup and Fejerskov index.10 One may also use the fluorosis diagnosis index by Dean, largely known for determining the optimal fluoride concentration (1 ppm) in drinking water.11–13 Dean categorized mild fluorosis as small opaque areas or streaks covering less than 25% of the tooth surface, moderate as showing brown staining and wear on the occlusal surfaces, and severe as affecting all teeth causing mottling in addition to brown staining.14,15 Having dental fluorosis further affects the individual psychosocially. Such individuals report embarrassment to smile, have difficulties pursuing relationships, and lack self-esteem.16 Furthermore, having fluorosis is perceived as unesthetic and as having poor oral hygiene.16,17 Dental restorative procedures improve the overall esthetics and may result in increased psychosocial confidence in such individuals.
Fig. 7. (A–C) Veneers placed on model and checked for accuracy.
5
6
Slaska et al
Fig. 8. Veneers silanated with Bis-Silane.
It is important for the practicing dentist to be knowledgeable in the diagnosis and treatment of dental fluorosis. Depending on the extent of fluorosis severity, several options exist to minimize unesthetic effects. For mild cases, a conservative approach, such as enamel microabrasion, can be performed; hydrochloric acid or finishing bur can be used for this purpose. Additionally, tooth bleaching or combination of both has been successful at minimizing superficial enamel opacities.18–21 Composite resins are an option for moderate to severe cases, but may require knowledge of adhesive systems for optimum bonding strenghts.22,23 The finest and most durable restorative option for fluorotic teeth is the etched porcelain veneer restoration. For the patient discussed in this article, the use of bleaching followed by etched porcelain veneer restorations was used. Tooth whitening has become an integral aspect of esthetic dentistry. Significant research efforts during the last decade have resulted in various innovative products and new application technologies. Cumulative data demonstrate that when used properly, peroxide-based tooth whiteners are safe and effective.24–26 Since its introduction more than two decades ago, the etched porcelain veneer restoration has proved to be a durable esthetic modality of treatment.27,28 With the advent of high-strength porcelains, superior cements, and bonding agents, it is not unusual to provide a patient with maximum function and esthetics with minimal preparation using all-ceramic porcelain bonded restorations. The dental professional should have knowledge of smile design and proper selection and use of restorative materials. Proper dentofacial evaluation and treatment planning is required for optimal esthetics. The incisal edge position of the maxillary central incisors relative to the upper lip should be established at the onset. This
Fig. 9. Veneers cemented.
Fluorosis Stained Teeth
assessment is made with the patient’s upper lip at rest using a millimeter ruler or a periodontal probe. The position of the maxillary central incisor can be either acceptable or unacceptable. An acceptable amount of incisal edge display at rest depends on the patient’s age and sex. Establishment of the maxillary dental midline is determined relative to the facial midline.29 The golden proportion is used as a guideline to determine a pleasing esthetic appearance of the upper anterior teeth.30,31 The golden proportion theory seems to be applicable to relate the successive widths of the maxillary anterior teeth if percentages are adjusted. A clinical examination was performed and the basic restorative work completed. The periodontal examination revealed the need for scaling and root planing to achieve gingival health. After scaling and root planing and healing phase were completed the patient’s periodontal condition was re-evaluated. The result was a healthy periodontal status now ready for restorative dentistry. The depth of the staining could not be determined. Teeth bleaching was introduced to reduce the discoloration and the necessity for more opaque veneers, thus creating a more natural appearance. However, it is generally not recommended that bonded restoration treatment be carried out immediately after bleaching treatment because the bleaching affects bond strength. The use of 10% sodium ascorbate gel (an antioxidant) can help the clinician to perform bonding procedures immediately after bleaching treatments.32 SUMMARY
This article discusses how to use a multistep process to conservatively achieve a successful esthetic result in a patient with severe dental fluorosis. Bleaching and porcelain veneers were used in this case to successfully address the needs of this patient. A combination of bleaching and porcelain veneer restoration can provide the patient maximum function and esthetics. Patient teeth have been treated with bleaching and/or microabrasion with some degree of success. However, predictable longterm results for stained discolored teeth can be achieved with resin bonded porcelain veneers (Fig. 10).
Fig. 10. One-year recall.
7
8
Slaska et al
REFERENCES
1. Chu YM, Bergeron L, Chen YR. Bimaxillary protrusion: an overview of the surgical-orthodontic treatment. Semin Plast Surg 2009;23:32–9. lar S, C 2. Bag ¸ olak H, Hamidi MM. Evaluation of novel microabrasion paste as a dental bleaching material and effects on enamel surface. J Esthet Restor Dent 2014. [Epub ahead of print]. 3. Den Besten PK. Dental fluorosis: its use as a biomarker. Adv Dent Res 1994;8: 105–10. 4. Akosu TJ, Zoakah AI. Risk factors associated with dental fluorosis in Central Plateau State, Nigeria. Community Dent Oral Epidemiol 2008;36:144–8. 5. Yoder KM, Mabelya L, Robison VA, et al. Severe dental fluorosis in a Tanzanian population consuming water with negligible fluoride concentration. Community Dent Oral Epidemiol 1998;26:382–93. 6. Porcar C, Bronsoms J, Lopez-Bonet E, et al. Fluorosis, osteomalacia and pseudohyperparathyroidism in a patient with renal failure. Nephron 1998;79:234–5. 7. Dean HT, Arnold FA, Elvone E. Domestic water and dental caries. V. Additional studies of the relation of fluoride domestic waters to dental caries experience in 4425 white children aged 12 to 14 years of 13 cities in 4 states. Public Health Rep 1942;57:1155. 8. Rango T, Vengosh A, Jeuland M, et al. Fluoride exposure from groundwater as reflected by urinary fluoride and children’s dental fluorosis in the Main Ethiopian Rift Valley. Sci Total Environ 2014;496:188–97. 9. Majumdar KK. Health impact of supplying safe drinking water containing fluoride below permissible level on fluorosis patients in a fluoride-endemic rural area of West Bengal. Indian J Public Health 2011;55:303–8. 10. Zhi C, Sun J. The quantitative epidemiologic study of endemic fluorosis. Chinese Journal of Control of Endemic Disease 1989;1:007. 11. Thylstrup A, Fejerskov O. Clinical appearance of dental fluorosis in permanent teeth in relation to histologic changes. Community Dent Oral Epidemiol 1978;6: 315–28. 12. Subcommittee on Health Effects of Ingested Fluoride (National Research Council). Health effects of ingested fluoride. Washington, DC: National Academy of Sciences; 1993. 13. Dean HT. Fluorine in the control of dental caries. J Am Dent Assoc 1956;52:1–8. 14. Dean HT. Endemic fluorosis and its relation to dental caries: 1938. Public Health Rep 2006;121(Suppl 1):213–9 [discussion: 212]. 15. Harris NO, Garcia-Godoy F. Primary preventive dentistry. 5th edition. Stamford (CT): Appleton and Lange; 1999. p. 658. 16. de Castilho LS, e Ferreira EF, Perini E. Perceptions of adolescents and young people regarding endemic dental fluorosis in a rural area of Brazil: psychosocial suffering. Health Soc Care Community 2009;17(6):557–63. 17. Fantaye W, Anne A, Asgeir B, et al. Perception of dental fluorosis among adolescents living in urban areas of Ethiopia. Ethiop Med J 2003;41(1):35–44. 18. Riordan PJ. Perceptions of dental fluorosis. J Dent Res 1993;72(9):1268–74. 19. Pontes DG, Correa KM, Cohen-Carneiro F. Re-establishing esthetics of fluorosisstained teeth using enamel microabrasion and dental bleaching techniques. Eur J Esthet Dent 2012;7:130–7. 20. Celik E, Tildiz G, Yazkan B. Comparison of enamel microabrasion with a combined approach to the esthetic management of fluorosed teeth. Oper Dent 2013;38(5):E134–43.
Fluorosis Stained Teeth
21. Loguercio AD, Correia LD, Zago C, et al. Clinical effectiveness of two microabrasion materials for the removal of enamel fluorosis stains. Oper Dent 2007;32: 531–8. 22. Knosel M, Attin R, Becker K, et al. A randomized CIE lab evaluation of external bleaching therapy effects on fluorotic enamel stains. Quintessence Int 2008;39: 391–9. rul F, Tu¨rku¨n M, Tu¨rku¨n LS, et al. Bond strength of different dentin bonding 23. Ertug systems to fluorotic enamel. J Adhes Dent 2009;11(4):299–303. 24. Torres-Gallegos I, A Martinez-Castan˜on G, Loyola-Rodriguez JP, et al. Effectiveness of bonding resin-based composite to healthy and fluorotic enamel using total-etch and two self-etch adhesive systems. Dent Mater J 2012;31(6):1021–7. 25. Heymann HO, Swift EJ Jr, Bayne SC, et al. Clinical evaluation of two carbamide peroxide tooth-whitening agents. Compend Contin Educ Dent 1998;19(4): 359–62, 364–6, 369. 26. Li Y. Peroxide-containing tooth whiteners: an update on safety. Compend Contin Educ Dent 2000;21(Suppl 28):4–9. 27. Maggio B, Gallagher A, Bowman J, et al. Evaluation of a whitening gel designed to accelerate whitening. Compend Contin Educ Dent 2003;24(7):519–20, 523–6, 528,536. 28. Calamia JR. The current status of etched porcelain veneer restorations. J Indiana Dent Assoc 1993;72(5):10–5. 29. Calamia JR, Calamia CS. Porcelain laminate veneers: reasons for 25 years of success. Dent Clin North Am 2007;51(2):399–417, ix. 30. Spear FM, Kokich VG, Mathews DP. Interdisciplinary management of anterior dental esthetics. J Am Dent Assoc 2006;137(2):160–9. 31. Snow SR. Esthetic smile analysis of maxillary anterior tooth width: the golden percentage. J Esthet Dent 1999;11(4):177–84. 32. Garcia EJ, Mena-Serrano A, de Andrade AM, et al. Immediate bonding to bleached enamel treated with 10% sodium ascorbate gel: a case report with one-year follow-up. Eur J Esthet Dent 2012;7(2):154–62.
9
DDS
a
, Arnold I. Liebman,
DDS
b,
*, Diana Kukleris,
c DDS
KEYWORDS Fluorosis Golden proportion Teeth-whitening Porcelain veneer restorations KEY POINTS Dental fluorosis manifests itself by too much ingestion of fluoride resulting in disturbances in enamel mineralization. The result is an intrinsic discoloration in the maxillary and mandibular teeth with a poor esthetic appearance. In challenging cases, an esthetic result may be achieved only by a combination of techniques.
The patient was a 35-year-old African American man originally from Senegal, Africa who presented to New York University College of Dentistry with the chief complaint of discoloration of his anterior teeth and the desire to have white natural-looking and straight teeth (Figs. 1 and 2). His chief complaint: “I need cosmetic work.” MEDICAL HISTORY
There was no significant medical history. DENTAL HISTORY
A full mouth series of radiographs were taken that displayed no carious lesions. Diagnostic casts were made and the American Academy of Cosmetic Dentistry series of photographs were taken. Teeth #14, #19, and #30 were missing. A dental implant was proposed for future placement in the #30 position. The space was too narrow in the other positions. A class I malocclusion with bimaxillary protrusion was present.
The authors have nothing to disclose. a Department of Cariology and Comprehensive Care, New York University College of Dentistry, 77 East 12th Street, New York, NY 10016, USA; b Department of Cariology and Comprehensive Care, New York University College of Dentistry, 2280 East 71st Street, New York, NY 11234, USA; c Private Practice, 1248 Farm to Market 78, Schertz, TX 78154, USA * Corresponding author. E-mail address: [email protected] Dent Clin N Am - (2015) -–http://dx.doi.org/10.1016/j.cden.2015.03.003 dental.theclinics.com 0011-8532/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
2
Slaska et al
Fig. 1. Full-face view of severe anterior fluorosis case.
This condition is characterized by protrusive and proclined upper and lower incisors and an increased procumbency of the lips.1 A New York University College of Dentistry Smile Evaluation Form was completed. A clinical examination was performed and the basic restorative work subsequently completed. Periodontal examination revealed the need for scaling and root planing to achieve desired gingival health. The periodontal status showed local and generalized recession. Periodontal probing and charting revealed sulcus depth was within normal limits but mild gingivitis was present. TREATMENT PLAN AND SEQUENCING
The patient’s esthetic problem was caused by fluorosis. Treatment options included bleaching; microabrasion; direct or indirect composite resin; porcelain veneers; and all ceramic crowns, such as e.max (Ivoclar Vivadent, Amherst, NY) with some opacity to mask the discoloration but still allow an esthetic restoration by combining an opaque core with an esthetic veneer of feldspathic porcelain. The conservative treatment of bleaching in conjunction with feldspathic veneers was selected. PROGNOSIS
The depth of the staining could not be ascertained. Teeth bleaching was used to reduce the discoloration of the teeth before preparation and therefore the necessity for more opaque veneers. This would allow a more natural appearance of the final veneered teeth and allowing for an excellent prognosis.
Fig. 2. Retracted view of severe anterior fluorosis case.
Fluorosis Stained Teeth
TREATMENT SEQUENCING Periodontal Considerations
Scaling and root planing resulted in the resolution of the patient’s gingivitis. A healthy periodontium created the appropriate environment for the restorative phase of treatment. The gingival zeniths were determined to be in the correct position and no surgical intervention was required. Restorative Considerations
The initial phase requires in-office bleaching (Philips Zoom Light-Activated Whitening System [Philips Oral Healthcare, Stamford, CT]). An initial shade was taken to document the change (see Fig. 2; and Fig. 3). Three bleaching sessions were performed with 15-minute cycles in the same visit (Figs. 4 and 5). Feldspathic porcelain veneers on eight upper teeth were suggested subsequent to the bleaching. However, financial constraints permitted only teeth #6 to #11 to be treated. Bleaching was performed on the lower arch to improve their appearance and an acceptable result was accomplished. The concept of golden proportion without any spacing was used to guide the wax-up and mock-up before preparation for the porcelain veneers. The preparations were done with a diamond chamfer bur and guided with a preparation guide to have a controlled reduction (Fig. 6). The stains were taken out when prepared with a 0.5-mm facial reduction. In this case the staining was not deep, although unknown before preparation. If the staining was deeper, a deeper preparation would have been required. Final impressions were taken with Dentsply Reprosil polyvinyl siloxane (Dentsply Caulk, Milford, DE) and the resulting stone model was evaluated for adequate preparation. Provisionals were created from the wax-up using Luxatemp Shade A-1 (DMG America, Englewood, NJ), which was placed into a putty matrix. The laboratory was supplied with the study models of the wax-up. Feldspathic porcelain was used for the veneers to obtain the most esthetic result. Opaque porcelain was ordered to block-out the discoloration of the color of the teeth. When the case came back it was placed onto the model to check for accuracy before the patient’s appointment Fig. 7. The etched restorations were silanated with Bis-Silane (Bisco, Schaumburg, IL) (Fig. 8) and Bisco Choice 2 bonding agent was placed and light cured. Bisco Choice 2 resin cement shade translucent was used as the luting cement. This cement is a high
Fig. 3. Initial shade taken to document shade change.
3
4
Slaska et al
Fig. 4. Result of teeth bleaching.
compressive strength, light-cured luting cement designed specifically for cementation of porcelain and indirect composite veneers (Fig. 9). DISCUSSION
Dental fluorosis is caused by too much ingestion of fluoride resulting in disturbances in enamel mineralization. This results in an intrinsic discoloration in the upper and lower teeth causing a poor esthetic appearance. The extent of severity depends on the length, term, and quantity of fluoride overexposure. There exist a variety of additional factors that further influence the risk and susceptibility to developing dental fluorosis. Among these are age, growth, weight, and nutrition of the individual.2–5 The risk for developing fluorosis begins at 3 months and ends at 8 years of age. Once the tooth has erupted, it is no longer at risk for developing this condition. It is well known that the addition of artificial fluoride to drinking water has numerous benefits in dental caries prevention.6 Recent studies indicate overexposure to fluoride in some regions of the world, such as Africa, India, and China, where ongoing endemics of systemic fluorosis result from overexposure to naturally occurring fluoride ingested through water.7–9
Fig. 5. Retracted view of result of teeth bleaching.
Fluorosis Stained Teeth
Fig. 6. Veneer preparation showing stains removed.
To best assess the severity and treatment of dental fluorosis, one may refer to the Thylstrup and Fejerskov index.10 One may also use the fluorosis diagnosis index by Dean, largely known for determining the optimal fluoride concentration (1 ppm) in drinking water.11–13 Dean categorized mild fluorosis as small opaque areas or streaks covering less than 25% of the tooth surface, moderate as showing brown staining and wear on the occlusal surfaces, and severe as affecting all teeth causing mottling in addition to brown staining.14,15 Having dental fluorosis further affects the individual psychosocially. Such individuals report embarrassment to smile, have difficulties pursuing relationships, and lack self-esteem.16 Furthermore, having fluorosis is perceived as unesthetic and as having poor oral hygiene.16,17 Dental restorative procedures improve the overall esthetics and may result in increased psychosocial confidence in such individuals.
Fig. 7. (A–C) Veneers placed on model and checked for accuracy.
5
6
Slaska et al
Fig. 8. Veneers silanated with Bis-Silane.
It is important for the practicing dentist to be knowledgeable in the diagnosis and treatment of dental fluorosis. Depending on the extent of fluorosis severity, several options exist to minimize unesthetic effects. For mild cases, a conservative approach, such as enamel microabrasion, can be performed; hydrochloric acid or finishing bur can be used for this purpose. Additionally, tooth bleaching or combination of both has been successful at minimizing superficial enamel opacities.18–21 Composite resins are an option for moderate to severe cases, but may require knowledge of adhesive systems for optimum bonding strenghts.22,23 The finest and most durable restorative option for fluorotic teeth is the etched porcelain veneer restoration. For the patient discussed in this article, the use of bleaching followed by etched porcelain veneer restorations was used. Tooth whitening has become an integral aspect of esthetic dentistry. Significant research efforts during the last decade have resulted in various innovative products and new application technologies. Cumulative data demonstrate that when used properly, peroxide-based tooth whiteners are safe and effective.24–26 Since its introduction more than two decades ago, the etched porcelain veneer restoration has proved to be a durable esthetic modality of treatment.27,28 With the advent of high-strength porcelains, superior cements, and bonding agents, it is not unusual to provide a patient with maximum function and esthetics with minimal preparation using all-ceramic porcelain bonded restorations. The dental professional should have knowledge of smile design and proper selection and use of restorative materials. Proper dentofacial evaluation and treatment planning is required for optimal esthetics. The incisal edge position of the maxillary central incisors relative to the upper lip should be established at the onset. This
Fig. 9. Veneers cemented.
Fluorosis Stained Teeth
assessment is made with the patient’s upper lip at rest using a millimeter ruler or a periodontal probe. The position of the maxillary central incisor can be either acceptable or unacceptable. An acceptable amount of incisal edge display at rest depends on the patient’s age and sex. Establishment of the maxillary dental midline is determined relative to the facial midline.29 The golden proportion is used as a guideline to determine a pleasing esthetic appearance of the upper anterior teeth.30,31 The golden proportion theory seems to be applicable to relate the successive widths of the maxillary anterior teeth if percentages are adjusted. A clinical examination was performed and the basic restorative work completed. The periodontal examination revealed the need for scaling and root planing to achieve gingival health. After scaling and root planing and healing phase were completed the patient’s periodontal condition was re-evaluated. The result was a healthy periodontal status now ready for restorative dentistry. The depth of the staining could not be determined. Teeth bleaching was introduced to reduce the discoloration and the necessity for more opaque veneers, thus creating a more natural appearance. However, it is generally not recommended that bonded restoration treatment be carried out immediately after bleaching treatment because the bleaching affects bond strength. The use of 10% sodium ascorbate gel (an antioxidant) can help the clinician to perform bonding procedures immediately after bleaching treatments.32 SUMMARY
This article discusses how to use a multistep process to conservatively achieve a successful esthetic result in a patient with severe dental fluorosis. Bleaching and porcelain veneers were used in this case to successfully address the needs of this patient. A combination of bleaching and porcelain veneer restoration can provide the patient maximum function and esthetics. Patient teeth have been treated with bleaching and/or microabrasion with some degree of success. However, predictable longterm results for stained discolored teeth can be achieved with resin bonded porcelain veneers (Fig. 10).
Fig. 10. One-year recall.
7
8
Slaska et al
REFERENCES
1. Chu YM, Bergeron L, Chen YR. Bimaxillary protrusion: an overview of the surgical-orthodontic treatment. Semin Plast Surg 2009;23:32–9. lar S, C 2. Bag ¸ olak H, Hamidi MM. Evaluation of novel microabrasion paste as a dental bleaching material and effects on enamel surface. J Esthet Restor Dent 2014. [Epub ahead of print]. 3. Den Besten PK. Dental fluorosis: its use as a biomarker. Adv Dent Res 1994;8: 105–10. 4. Akosu TJ, Zoakah AI. Risk factors associated with dental fluorosis in Central Plateau State, Nigeria. Community Dent Oral Epidemiol 2008;36:144–8. 5. Yoder KM, Mabelya L, Robison VA, et al. Severe dental fluorosis in a Tanzanian population consuming water with negligible fluoride concentration. Community Dent Oral Epidemiol 1998;26:382–93. 6. Porcar C, Bronsoms J, Lopez-Bonet E, et al. Fluorosis, osteomalacia and pseudohyperparathyroidism in a patient with renal failure. Nephron 1998;79:234–5. 7. Dean HT, Arnold FA, Elvone E. Domestic water and dental caries. V. Additional studies of the relation of fluoride domestic waters to dental caries experience in 4425 white children aged 12 to 14 years of 13 cities in 4 states. Public Health Rep 1942;57:1155. 8. Rango T, Vengosh A, Jeuland M, et al. Fluoride exposure from groundwater as reflected by urinary fluoride and children’s dental fluorosis in the Main Ethiopian Rift Valley. Sci Total Environ 2014;496:188–97. 9. Majumdar KK. Health impact of supplying safe drinking water containing fluoride below permissible level on fluorosis patients in a fluoride-endemic rural area of West Bengal. Indian J Public Health 2011;55:303–8. 10. Zhi C, Sun J. The quantitative epidemiologic study of endemic fluorosis. Chinese Journal of Control of Endemic Disease 1989;1:007. 11. Thylstrup A, Fejerskov O. Clinical appearance of dental fluorosis in permanent teeth in relation to histologic changes. Community Dent Oral Epidemiol 1978;6: 315–28. 12. Subcommittee on Health Effects of Ingested Fluoride (National Research Council). Health effects of ingested fluoride. Washington, DC: National Academy of Sciences; 1993. 13. Dean HT. Fluorine in the control of dental caries. J Am Dent Assoc 1956;52:1–8. 14. Dean HT. Endemic fluorosis and its relation to dental caries: 1938. Public Health Rep 2006;121(Suppl 1):213–9 [discussion: 212]. 15. Harris NO, Garcia-Godoy F. Primary preventive dentistry. 5th edition. Stamford (CT): Appleton and Lange; 1999. p. 658. 16. de Castilho LS, e Ferreira EF, Perini E. Perceptions of adolescents and young people regarding endemic dental fluorosis in a rural area of Brazil: psychosocial suffering. Health Soc Care Community 2009;17(6):557–63. 17. Fantaye W, Anne A, Asgeir B, et al. Perception of dental fluorosis among adolescents living in urban areas of Ethiopia. Ethiop Med J 2003;41(1):35–44. 18. Riordan PJ. Perceptions of dental fluorosis. J Dent Res 1993;72(9):1268–74. 19. Pontes DG, Correa KM, Cohen-Carneiro F. Re-establishing esthetics of fluorosisstained teeth using enamel microabrasion and dental bleaching techniques. Eur J Esthet Dent 2012;7:130–7. 20. Celik E, Tildiz G, Yazkan B. Comparison of enamel microabrasion with a combined approach to the esthetic management of fluorosed teeth. Oper Dent 2013;38(5):E134–43.
Fluorosis Stained Teeth
21. Loguercio AD, Correia LD, Zago C, et al. Clinical effectiveness of two microabrasion materials for the removal of enamel fluorosis stains. Oper Dent 2007;32: 531–8. 22. Knosel M, Attin R, Becker K, et al. A randomized CIE lab evaluation of external bleaching therapy effects on fluorotic enamel stains. Quintessence Int 2008;39: 391–9. rul F, Tu¨rku¨n M, Tu¨rku¨n LS, et al. Bond strength of different dentin bonding 23. Ertug systems to fluorotic enamel. J Adhes Dent 2009;11(4):299–303. 24. Torres-Gallegos I, A Martinez-Castan˜on G, Loyola-Rodriguez JP, et al. Effectiveness of bonding resin-based composite to healthy and fluorotic enamel using total-etch and two self-etch adhesive systems. Dent Mater J 2012;31(6):1021–7. 25. Heymann HO, Swift EJ Jr, Bayne SC, et al. Clinical evaluation of two carbamide peroxide tooth-whitening agents. Compend Contin Educ Dent 1998;19(4): 359–62, 364–6, 369. 26. Li Y. Peroxide-containing tooth whiteners: an update on safety. Compend Contin Educ Dent 2000;21(Suppl 28):4–9. 27. Maggio B, Gallagher A, Bowman J, et al. Evaluation of a whitening gel designed to accelerate whitening. Compend Contin Educ Dent 2003;24(7):519–20, 523–6, 528,536. 28. Calamia JR. The current status of etched porcelain veneer restorations. J Indiana Dent Assoc 1993;72(5):10–5. 29. Calamia JR, Calamia CS. Porcelain laminate veneers: reasons for 25 years of success. Dent Clin North Am 2007;51(2):399–417, ix. 30. Spear FM, Kokich VG, Mathews DP. Interdisciplinary management of anterior dental esthetics. J Am Dent Assoc 2006;137(2):160–9. 31. Snow SR. Esthetic smile analysis of maxillary anterior tooth width: the golden percentage. J Esthet Dent 1999;11(4):177–84. 32. Garcia EJ, Mena-Serrano A, de Andrade AM, et al. Immediate bonding to bleached enamel treated with 10% sodium ascorbate gel: a case report with one-year follow-up. Eur J Esthet Dent 2012;7(2):154–62.
9
