Esthetic Dentistry

Esthetic treatment of severe tetracycline staining with orthodontics andveneers: A case reportMichael S, Cooke* / Stephen H. Y, Wei**

This case history describes and ilhtstrate.'i the excellent esthetic results now clinicallypossible when fixed appliance orthodontic therapy is combined with porcelain veneers totreat severe tetracydine staining and crowding. Because the patient also presented witha himaxillary protrusion and a displaced maxillary inidline, the treatment options alsoillustrate the dilemma between ideal, but prolonged, treatment options and quicker, butcompromised, alternatives. The excellent final result accepted the initial protrusion butcorrected the midtine. A long-span bonded inultistrand wire functioned as semiperma-nent retention. (Quintessence Int ¡994:25:161-165.)

Introduction

The clinical use of veneers, and especially of porcelainveneers, has drarnatically itiiproved the cosmetic im-provements now possible for patients presenting withtetracycline staining.' •' The case to be presented com-bined the twin challenges of severe tetracycline stain-ing with the added esthetic problems of crowding,rotations, and midline shift of the maxillary incisors.

Case report

A 24-year-old Chinese woman presented complainingof the iinesthetic appearance of her teeth. This com-plaint was addressed mainly at the discoloration ofthe teeth but also at their irregular dental alignment(Fig 1).

Physically she was small statured. Her face wasrounded and symmetric with protrusive lips, Intra-orally the teeth all had the characteristic discoloration

Senior Lecturer, Department of Children's Dentistry and Or-thodotltics. University of Hong Kong. Faculty of Dentistry,Prince Phihp Dental Hospital, 34 Hospitai Road, Hong Kong,Professor and Head, Departmetit of Children's Dentistry andOrthodontics, and Dean, Factiity of Dentistry, University ofHong Kong.

and translucency of severe tetracycline staining, andthe history confirmed this diagnosis. The oral hygienewas excellent and the dentition was caries free. Allpermanent teeth were erupted with the exception ofthe permanent mandibular third molars, both ofwhich were mesioangularly impacted.

Cephalometric and cast analyses resulted in adiagnosis of bimaxillary protrusion on mild skeletalClass II dental bases (point A-nasion-point B angleof 5.5 degrees) complicated by maxillary arch crowd-ing (5 mm) with the maxillary left lateral incisor (tooth22) in crossbite. A slight forward mandibular dis-placement was detected following an initial contacton tooth 22. The maxillary midline was displaced4 mm to the left and the central incisor (tooth 21) wasdistohuccally rotated. The first molar occlusion wasClass I on the left and half-unit Class II on the right.Very mild crowding was present in the mandibulararch.

Tooth 22 was wider mesiodistally than was tooth12 and was somewhat triangular in shape, A partialexplanation may be that, because tooth 22 had beenlingually displaced since its eruption, it had not heensubjected to the attrition that had occurred continu-ously to the contact points of the other teeth in thearch.

From the cephalometric study, the clinical protru-sion of the incisors was confirmed.''' The maxillaryincisors were at 126 degrees to the maxillary plane(compared to the population average of 118 degrees)

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Esthetic Dentistry

Figs la to Ic initial appearance ol 24-year-old Chinesewoman complaining ot severe tetracycline staining andmaxiliary arch crowding. The maxiliary midline is displacedto the left, and a bimaxiilary dentai protrusion was con-tirmed by t;ephalometric analysis.

Fig 1c

and the mandibular incisors were at 105 degrees tothe mandibular plane (compared to the southernChinese average of 9B.5 degrees). The mandibular in-cisor tips were 9 mm in front of the point A-porionreference line (compared to the average of +5 mmfor this population group). Despite these findings, theupper and lower lips were normally related to theesthetic plane. This confirmed the clinical assessmentthat the proHle was acceptable despite the slightly in-competent resting lip posture.

Treatment plan

The overall treatment plan was to align the teeth withfixed orthodontic appliances and then to place por-celain veneers on ihe maxillary incisor and canineteeth. The third molars were to be extracted beforethe orthodontic phase and the triangular tooth 22 wasto be narrowed tnesiodistally during the orthodonticstages through interdental stripping with abrasivestrips and disks.*' The aim was to match the size and.'ihape of tooth 22 with those of tooth 12. Finally,before the fabrication of the veneers, tooth 22 was tobe pericised (supracrestal fiberotomy) and a bondedpalatal retainer was to be placed as semipermanentretention. Initial post-active treatment removable re-tainers were also planned to retain the closed extrac-tion spaces while the alveolar and periodontal tissuereorganization consolidated,

Exiraaion options

The following options were considered:

1. Extract the four first premolars and eliminate thedental protrusion in addition to correcting thecrowding and the midlines. This ideai plan wouldinvolve placing mandibular and maxillary fixed ap-pliances, but this was rejected by the patient.

2. Extract the maxillary left premolar (tooth 24) andalign the teeth along the existing lme of the dentalarch with a maxillary fixed appliance. This planhad the advantage of offering a quick result, butthe maxiliary midhnc would have become even fur-ther displaced to the left.

3. Extract the maxillary right first premolar (tooth14) and align the teeth along the existing line ofthe dental arch with fixed appliances. This opfionhad the advantage of enabling the maxillary mid-line to be fully corrected and of idealizing the finalesthetics. On the other hand, the teeth would have

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Esthetic Dentistry

aS l ianc ÏwL i'̂ P^^^^ °* treatrrient. After the extraction of tooth 14, an edgewise (0.018-inch¡ preadjustedbecau.p1. w . l H ^^^"1^ 1 " ' " " ' ^ '^^"^ ""^ ' ° ^^^ " ' '^^ " ^ ' ^ ' i " ^ - Toot" 22 was reshaped during this phase (Fig 2b)because it was wider mesiodistally than tooth 12 and was triangular. ^ ^ \ y i

Fig 2c Fig2d

to be moved, one at a time, to the right side andsome extra anchorage support would be needed topartially hold back the maxillary right first molar.Treatment time would be longer than for the pre-vious options.

After careful discussion with the patient it was de-cided to follow the third option and to aim for goodesthetics within the patient's choice of maxillary archtreatment only. The patient agreed to bedtime wearof extraoral headgear. The theoretical option of non-extraction treatment with interproximal reductionwas not considered realistic, in view of the markedmaxillary crowding and the displaced midline.

Onhodontk treatment

A maxillary edgewise preadjiLsted (0,Û18-inch) appli-ance was placed after the extraction of tooth 14 andail the third molars. A Kloehn bow headgear andcervical neck strap were fitted with 300 g (total) offorce for bedtime wear. Treatment progressed fromround Ü.016-inch nitinol wire, through round Ü.0I8-inch stainless steel wire, to 0.017 x 0.025-inch rect-angular wire for final space closure (Fig 2). The fixedappliance was removed after 15 months.

At the end of the active orthodontic treatment, themaxillary midline was coincident with the mandibularmidline and with the midface. Tooth 22 had beenreshaped and tooth 16 had been slipped forward intoa Class II occlusal relationship. All the orthodonticgoals had been achieved.

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Esthetic Dentistry

Figs 3a to 3c After bonding of the porcelain veneers tothe labial surfaces of the six maxiiiary anterior teeth. Aflexible (0 015-inch] wire was bonded as a retainer to thepalatal surfaces.

Fig 3c

Indirect resit! vcitccrs

Because the patient could not afford the time, andwas initially not interested in having porcelain veneersconstructed, the flrst set of veneers consisted of in-direct resin veneers. The esthetic results of Dentaeolor(Kulzer) resin veneers were an improvernent over theseverely tetracyclinc-stained dentition and served asan intermediate esthetic improvement. The patientsubsequently agreed to return for porcelain veneers.

Porcelain veneers

Porcelain veneers were finally constructed approxi-mately 18 months following the placement of the Den-taeolor resin veneers. To prepare the maxillary ante-rior teeth, the resin veneers were removed.

The porcelain veneers were custom fabricated withthe refractory die cast method. The dental technicianwas included in the chairside consultation in deter-mining the shade, shape, and special considerationsof color and characterization, and Vitadur porcelainwas used.

After the veneers were ready for bonding, the innersurfaces were etched with hydrofluoric acid gel to cre-ate increased surface roughness and areas for hond-ing. Ccrinate Primer (Den-Mat), a sllane couplingagent that bonds to the porcelain and enamel, wasthen applied to the veneers. The honding procedurewas facihtated by the use of the Advanced PorcelainRestoration Kit (Den-Mat), This kit has the advan-tage of having a try-in paste that does not set andallows maximal color matching to the Vita color guide(Vita ZahnfabrikI prior to final bonding. After try-inwith the appropriate shade of bonding resin, the ve-neers were removed and the try-in paste was carefullyremoved. The final bonding was achieved using Ultra-bond, a dual-curing resin jDen-Mat), The veneerswere plaeed on the labial surface with light fingerpressure, and the excess resin was removed at the gin-gival and incisai margins with a brush slightly moist-ened with the bonding agent.

The excess set resin at all margins was removed withcarbon-tipped sharp hand instruments and very fine-pointed diamond finishers, such as LVS-5 and LVS-6 and LVS-7, The lingual excess was removed by theuse of the flne diamond LVS-S, which is a football-shaped diamond. The interproximal contacts of excessresin were broken with a Cerisaw (Den-Mat) wherenecessary, and the interproximal surfaces were fin-ished with finishing strips. Exposed margins were fur-

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Esthetic Dentistry

ther finished with Sof-Lex XT (3M Denial) polishingdisks followed by fubber wheels irtipregnaled with adtatnond polishing paste to repolish Ihe porcelainmargins.

Figure 3 shows Ihe completed porcelain veneers andthe improved esthetic appearance of the same patientreflecting a much happier stnilc and positive person-ality.

Retention

A bonded retainer was fitted to the palatal surfacesof teeth 13 to 23 with a light wire composite resinbonding system {Durafill VS. Kulzer). The retainerwas tnade from 0.015-inch twistfiex wire (Dentaflex,Dentaurum) that had been carefully contoured on aworking cast to follow the marked marginal ridgespresent on this patient's incisors. The retainer wasinitially held in posttion, during the bonding proce-dures, with a "locating jig" systetn.^'^The use of flex-ible wire permits rtormal phy.siologic movement ofthebonded teeth during function, and this may be ben-eficial to long-term periodontal health."

The patient did not wear the maxillary removableretainer, which had been planned for 6 tnonlhs ofwear, and she also refused to have the percision ontooth 22. It came as no surprise to find that a spaceopened after 6 months between teeth 15 and 13. Themaxillary bonded retainer should have been extendeddistally to include teeth on both sides ofthe extractionsite. The patient accepted this minor change and didnot wish to have any further treatment. The bondedretainer has been in place for 2.5 years.

Acknowledgments

Thanks to the Dental Illtjstration Unit at the Universily uf HungKong atid to Ms Connie Che for the secretariiil iissistaiice.

References

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2. Berlolotti RL, Lacy AM. Treatment of discolored vital teeth:Bleaching and laminate veneers, in: Wei SHY (ed). PaediatriLDentistry: Total Patient Care. Philadelphia: Lea & Febiger.19BR49401^03

3. Nasedkin JN. Current perspectives on esthetic restorative den-tistry. Pan I. Porcelain laminates. J Can Dent Assoc19S8;50:24g-255.

4. Wei SHY, Tang LKE, King NM. Aesthetic anterior icstora-tions for children and yotine adults. Ann Ac ad Med1989; 18:573-584.

5. Wei SHY, Tang E, Laminate veneers for the aesthetic resto-ration of anterior teeth. Ann Royal Aust Coll Dent Surg1989; 10:148-159.

6. Cooke MS, Cephalomctric Analyses Based on Natural HeadPosture of Chinese Children in Hong Kong [thesis]. Universityof Hong Kong, 19M6:IS5-258,

7. Cooke MS, Wei SHY, Cephaiometric "standards" for theSouthern Chinese. Eur J Orthod 1988; 10:264-272,

8. Zachrisson BU, On excellence in finishing. Part I, J Clin Orthod9

9, Becker A, Goultschin J. The mullistrand retainer and splint.Am J Orthod I<)84;85:470-474.

10. Becker A. Periodontal splinting with tnultistrand wire followingorthodontic reahgnmenl of migrated teeth: Report of 38 cases.Int J Adult Orlhod Orthognath Surg 1987:2:99-109,

11, Zachrisson BU. Clinical experience with direct-bonded ortho-dontic retainers. Am J Orthod 1977;71:441)-448. D

24th International Meetingon Dental Implants and Transplants

Bologna (Italy), June 3-5,1994

Information: G.I.S.I. c/o Prof. G. Muratori1, Via S. Gervasio. 40121 Bologna (Italy), Tel. 51 /22 75 05-23 75 16, Fax 51/26 00 31

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