h Harvey Putter, D.D.S."
Four case studies are presented in which the concept that bleaching, porcelain veneer restorations, or a combination of both constitute a conservative treatment approach for discolored, malformed. malaligned, and worn dentition. These treatments can be used effectively not only for aging dentitions, but also for the very young, which makes them an attractive treatment modality.
T
he dramatic effects of fluorides in combination with patient education, improved home care, and other early preventativeprocedures havevirtually eliminated the disease of dental canes in the young population. Accordingly, the need for multiple quadrant "drill and fill" dentistry has ceased to exist. However, discolored, malaligned, worn, and malformed dentitions in all age groups are frequently encountered. In past years such problems called for the routine placement of full coverage restorations, which were very effective but extremely expensive in terms of sacrifice of sound tooth structure, chair time, and possible pulpal sequelae. Today, infmitely more conservativetreatment approaches in the form of bleaching and/or porcelain veneering are now possible. The following four cases serve to illustrate this important concept.
Figure LA. Anterior dentition of a 42-year-old patient with uneven, discolored teeth.
Case 1 A 42-year-old female patient presents with discolored, 'uneven" (her description) teeth (Fig. 1A). The combined effects of uneven wear and discoloration have resulted in a considerably less than esthetic appearance. In actual fact the discoloration consisted of white demineralized spots involving the maxillary central incisors in combination with yellow "aging"discoloration involving all of the maxillary anterior teeth. The white spots were removed in one appointment using enamel microabrasion. The incisal edges of the maxillary anterior teeth were then selectively recontoured using a fine diamond stone, and finally, a maxillary mouthguard was fabricated and the patient was properly instructed relative to the appropriate use of a carbamide peroxide home bleaching gel (Rembrandt Lighten, Den Mat Corp., Santa Maria, CAI .4.5 The denti-
pieare 1B. The same dentition(asin Fig. 1A)&er recontowing, enamel microabrasion, and Rembrandt Bleaching Gel (at 4 weeks).
tion is shown in Figure 1B after 3 to 4 weeks of home bleaching treatment. There was minimal sacrifice of tooth stnkture, absolutely no pain or discomfort, and the gingival tissue response to this conservative treatment was excellent.
'Prtvate Practice. Lindenhurst. New York. Address reprint requests to Harvey Putter, D.D.S.. 672 North Wellwood Avenue. Lindenhurst. NY 11757. 0 1992 Decker Perldcals Inc.
67
Figure 2A Anterior dentition of a 19-year-old patient with tetracycline discoloration.
Figure 3A. Discolored anterior dentition of a 72-year-old male
Figure 2B. The same dentition (as in Fig. 2A) 5 weeks after home bleaching of the maxillary dentition. Note the difference between the treated maxillary and the nontreated mandibular dentitions.
Hgurc 3B. The same dentition (as in Fig. 3A) after porcelain
Case 2
strated unsightly “blue line” cervical margins. Treatment consisted of porcelain veneers (CerinatePorcelain Veneers, Den-Mat)bonded with Tenurebond (Den-Mat) used in combination with Ultrabond (Den Mat), involving all of the maxillary anterior teeth and premolars. Home bleaching (Rembrandt Lighten) was used on the mandibular dentition. Postoperative results after porcelain veneer placement and 4 weeks of home bleaching (of the mandibular dentition) are shown in Figure 3B. Before fabrication of the porcelain veneers, full labial chamfer preparations6were made on all of the maxillary anterior teeth and premolars. Care was taken to ensure that the chamfer preparations on the maxillary lateral crown surfaces extended cervically to the “blue line” margins. Before bonding, the porcelain labial surfaces of the maxillary lateral incisor crownswere microetched (Microetcher. Dandle Engineering, Dandle, CA) and hydrofluoric acid etched using a dilute hydrofluoric acid gel etchant (Porcelok, Den-Mat). After phosphoric acid etching of the labial enamel surfaces of the maxil-
patient.
veneer placement (maxillary)and home bleaching of the mandibular dentition.
A 19-year-old orthodontic patient with moderate tetracycline discoloration (Fig. 2A).6 Treatment consisted of the fabrication of a maxillary mouthguard used in combination with home bleaching gel (Rembrandt Lighten) used for 3 hours a day for a 5-week period. Figure 2B shows the postoperative result. Treatment was totally noninvasive. No pain or discomfort was reported. The gingival tissue response was excellent.
Case 3 A 72-year-old male patient (Fig.3A) with discolored maxillary and mandibular anterior teeth. Treatment was complicated by the presence of cervical erosion/ abfraction7 lesions on the maxillary central incisors, canines, and the mandibular anterior teeth. In addition, off-shade porcelain fused to metal crowns were present on both maxillary lateral incisors, both of which demon-
68
Bleaching and/or Porcelain Veneers
plgnn 4A Anterior dentition of a 53-year-old patient (labial view).
Figure 4C. 'V" porcelain laminate restorations.
Figure 4B. Lingual view of Same dentition as in Fig. 4A.
Figure 4D. Labial view of bonded "Vlaminate restorations.
lary central incisors, canines, and premolors. Tenurebond was placed, and the porcelain veneers were luted into position using Ultra-bond. Despite the presence of cervical erosion/abfraction7 lesions on the mandibular anterior teeth. absolutely no discomfort or pain was reported in association with the home bleaching treatment. The mandibular mouthguard was used with the bleaching gel for approximately 3 hours a day for the 4week period. The gingival tissue response to the bleaching treatment was excellent. Occasionally tooth sensitivity may occur with home bleaching treatment particularly if cervical erosion/abfraction lesions are present. If such occurs it may be immediately eliminated by the placement of two to three layers of Tenurebond onto the affected areas.
ment involved the fabrication of "V" porcelain laminate restorations (Fig. 4C) covering both the labial and lingual surfaces of the maxillary anterior teeth bonded by means of Tenurebond used in combination with Ultrabond. Figure 4D shows a labial view of the "V" laminates 3 months after insertion. The lingual view is shown in Figure 4E. Should traditional cementation materials be used for such porcelain restorations, they would be highly prone to fracture and/or dislodgment because the cementation material simply fills in the space between the porcelain restorative material and tooth structure, but is bonded to neither. In this particular case, the internal surface of the "V" porcelain laminates were both microetched (Microetcher) and hydrofluoric acid etched (Porcelok): Tenurebond was applied to the tooth surfaces and the "V" laminates were luted using Ultra-Bond. The luting composite was accordingly micromechanically bonded both to the porcelain and to the tooth surfaces, thereby considerably enhancing both the strength and fracture resistance of the porcelain restorations in a similar fashion to dentin supported enamel, which is also highly fracture resistant.
Case 4 A 53-year-old male patient with discolored anterior teeth in association with a midline diastema space (Fig. 4A) complicated by severe lingual erosion/abrasion (Fig. 4B) involving the maxillary anterior teeth. Treat-
69
JOUKNiU. OF ESTtIETIC DEhTISTRY VOI,UME 4,NUMBER 3
May/.Junr 1992
and relatively conservative treatment approach for the discolored, malaligned. malformed, or worn dentition. The fact that such treatments can be effectively used for the very young a s well as the aging dentitions constitutes a particularly attractive treatment modality.
REFERENCES 1. CrollTP. Enamel color improvement: all things considered. Quintessence Int 1986; 17:271. 2. Croll TP. Cavanaugh RR. Enamel color modification by controlled hydrochloric acid-pumice surface abrasion. I. Techniques and examples. Quintessence Int 1986: 17:81. n Croll TP. Cavanaugh RR. Enamel color modification by a. controlled hydrochloric acid-pumice surface abrasion. 11. For further examples. Quintessence Int 1986: 17:157. 4. Haywood VB. Overview and status of mouthguard bleaching. J Esthet Dent 1991: 3(5):157-161. 5. Christensen GJ. Tooth bleaching, home-use products. CRA Newsletter 1989; 13: 1. 6. Jordan RE. Esthetic composite bonding, techniques and materials. Philadelphia: BC Decker. 1988. 7. Grippo JO. Abfractions: A new classification of hard tissue lesions of teeth. J Esthet Dent 1991: 3(1):14-19.
Figure 4E Lingual view of bonded ‘V” laminate restorations.
CONCLUSION Four cases have been presented that illustrate the concept that bleaching, porcelain veneer restorations, or a combination ofboth constitute an effective, reliable,
70
Four case studies are presented in which the concept that bleaching, porcelain veneer restorations, or a combination of both constitute a conservative treatment approach for discolored, malformed. malaligned, and worn dentition. These treatments can be used effectively not only for aging dentitions, but also for the very young, which makes them an attractive treatment modality.
T
he dramatic effects of fluorides in combination with patient education, improved home care, and other early preventativeprocedures havevirtually eliminated the disease of dental canes in the young population. Accordingly, the need for multiple quadrant "drill and fill" dentistry has ceased to exist. However, discolored, malaligned, worn, and malformed dentitions in all age groups are frequently encountered. In past years such problems called for the routine placement of full coverage restorations, which were very effective but extremely expensive in terms of sacrifice of sound tooth structure, chair time, and possible pulpal sequelae. Today, infmitely more conservativetreatment approaches in the form of bleaching and/or porcelain veneering are now possible. The following four cases serve to illustrate this important concept.
Figure LA. Anterior dentition of a 42-year-old patient with uneven, discolored teeth.
Case 1 A 42-year-old female patient presents with discolored, 'uneven" (her description) teeth (Fig. 1A). The combined effects of uneven wear and discoloration have resulted in a considerably less than esthetic appearance. In actual fact the discoloration consisted of white demineralized spots involving the maxillary central incisors in combination with yellow "aging"discoloration involving all of the maxillary anterior teeth. The white spots were removed in one appointment using enamel microabrasion. The incisal edges of the maxillary anterior teeth were then selectively recontoured using a fine diamond stone, and finally, a maxillary mouthguard was fabricated and the patient was properly instructed relative to the appropriate use of a carbamide peroxide home bleaching gel (Rembrandt Lighten, Den Mat Corp., Santa Maria, CAI .4.5 The denti-
pieare 1B. The same dentition(asin Fig. 1A)&er recontowing, enamel microabrasion, and Rembrandt Bleaching Gel (at 4 weeks).
tion is shown in Figure 1B after 3 to 4 weeks of home bleaching treatment. There was minimal sacrifice of tooth stnkture, absolutely no pain or discomfort, and the gingival tissue response to this conservative treatment was excellent.
'Prtvate Practice. Lindenhurst. New York. Address reprint requests to Harvey Putter, D.D.S.. 672 North Wellwood Avenue. Lindenhurst. NY 11757. 0 1992 Decker Perldcals Inc.
67
Figure 2A Anterior dentition of a 19-year-old patient with tetracycline discoloration.
Figure 3A. Discolored anterior dentition of a 72-year-old male
Figure 2B. The same dentition (as in Fig. 2A) 5 weeks after home bleaching of the maxillary dentition. Note the difference between the treated maxillary and the nontreated mandibular dentitions.
Hgurc 3B. The same dentition (as in Fig. 3A) after porcelain
Case 2
strated unsightly “blue line” cervical margins. Treatment consisted of porcelain veneers (CerinatePorcelain Veneers, Den-Mat)bonded with Tenurebond (Den-Mat) used in combination with Ultrabond (Den Mat), involving all of the maxillary anterior teeth and premolars. Home bleaching (Rembrandt Lighten) was used on the mandibular dentition. Postoperative results after porcelain veneer placement and 4 weeks of home bleaching (of the mandibular dentition) are shown in Figure 3B. Before fabrication of the porcelain veneers, full labial chamfer preparations6were made on all of the maxillary anterior teeth and premolars. Care was taken to ensure that the chamfer preparations on the maxillary lateral crown surfaces extended cervically to the “blue line” margins. Before bonding, the porcelain labial surfaces of the maxillary lateral incisor crownswere microetched (Microetcher. Dandle Engineering, Dandle, CA) and hydrofluoric acid etched using a dilute hydrofluoric acid gel etchant (Porcelok, Den-Mat). After phosphoric acid etching of the labial enamel surfaces of the maxil-
patient.
veneer placement (maxillary)and home bleaching of the mandibular dentition.
A 19-year-old orthodontic patient with moderate tetracycline discoloration (Fig. 2A).6 Treatment consisted of the fabrication of a maxillary mouthguard used in combination with home bleaching gel (Rembrandt Lighten) used for 3 hours a day for a 5-week period. Figure 2B shows the postoperative result. Treatment was totally noninvasive. No pain or discomfort was reported. The gingival tissue response was excellent.
Case 3 A 72-year-old male patient (Fig.3A) with discolored maxillary and mandibular anterior teeth. Treatment was complicated by the presence of cervical erosion/ abfraction7 lesions on the maxillary central incisors, canines, and the mandibular anterior teeth. In addition, off-shade porcelain fused to metal crowns were present on both maxillary lateral incisors, both of which demon-
68
Bleaching and/or Porcelain Veneers
plgnn 4A Anterior dentition of a 53-year-old patient (labial view).
Figure 4C. 'V" porcelain laminate restorations.
Figure 4B. Lingual view of Same dentition as in Fig. 4A.
Figure 4D. Labial view of bonded "Vlaminate restorations.
lary central incisors, canines, and premolors. Tenurebond was placed, and the porcelain veneers were luted into position using Ultra-bond. Despite the presence of cervical erosion/abfraction7 lesions on the mandibular anterior teeth. absolutely no discomfort or pain was reported in association with the home bleaching treatment. The mandibular mouthguard was used with the bleaching gel for approximately 3 hours a day for the 4week period. The gingival tissue response to the bleaching treatment was excellent. Occasionally tooth sensitivity may occur with home bleaching treatment particularly if cervical erosion/abfraction lesions are present. If such occurs it may be immediately eliminated by the placement of two to three layers of Tenurebond onto the affected areas.
ment involved the fabrication of "V" porcelain laminate restorations (Fig. 4C) covering both the labial and lingual surfaces of the maxillary anterior teeth bonded by means of Tenurebond used in combination with Ultrabond. Figure 4D shows a labial view of the "V" laminates 3 months after insertion. The lingual view is shown in Figure 4E. Should traditional cementation materials be used for such porcelain restorations, they would be highly prone to fracture and/or dislodgment because the cementation material simply fills in the space between the porcelain restorative material and tooth structure, but is bonded to neither. In this particular case, the internal surface of the "V" porcelain laminates were both microetched (Microetcher) and hydrofluoric acid etched (Porcelok): Tenurebond was applied to the tooth surfaces and the "V" laminates were luted using Ultra-Bond. The luting composite was accordingly micromechanically bonded both to the porcelain and to the tooth surfaces, thereby considerably enhancing both the strength and fracture resistance of the porcelain restorations in a similar fashion to dentin supported enamel, which is also highly fracture resistant.
Case 4 A 53-year-old male patient with discolored anterior teeth in association with a midline diastema space (Fig. 4A) complicated by severe lingual erosion/abrasion (Fig. 4B) involving the maxillary anterior teeth. Treat-
69
JOUKNiU. OF ESTtIETIC DEhTISTRY VOI,UME 4,NUMBER 3
May/.Junr 1992
and relatively conservative treatment approach for the discolored, malaligned. malformed, or worn dentition. The fact that such treatments can be effectively used for the very young a s well as the aging dentitions constitutes a particularly attractive treatment modality.
REFERENCES 1. CrollTP. Enamel color improvement: all things considered. Quintessence Int 1986; 17:271. 2. Croll TP. Cavanaugh RR. Enamel color modification by controlled hydrochloric acid-pumice surface abrasion. I. Techniques and examples. Quintessence Int 1986: 17:81. n Croll TP. Cavanaugh RR. Enamel color modification by a. controlled hydrochloric acid-pumice surface abrasion. 11. For further examples. Quintessence Int 1986: 17:157. 4. Haywood VB. Overview and status of mouthguard bleaching. J Esthet Dent 1991: 3(5):157-161. 5. Christensen GJ. Tooth bleaching, home-use products. CRA Newsletter 1989; 13: 1. 6. Jordan RE. Esthetic composite bonding, techniques and materials. Philadelphia: BC Decker. 1988. 7. Grippo JO. Abfractions: A new classification of hard tissue lesions of teeth. J Esthet Dent 1991: 3(1):14-19.
Figure 4E Lingual view of bonded ‘V” laminate restorations.
CONCLUSION Four cases have been presented that illustrate the concept that bleaching, porcelain veneer restorations, or a combination ofboth constitute an effective, reliable,
70
