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2 Dental Fluorosis Treated with At-Home Whitening and Porcelain Veneers

2 Dental Fluorosis Treated with At-Home Whitening and Porcelain Veneers

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260



E. Araújo and J. Perdigão



a



b



Fig. 15.5 (a) Clinical aspect immediately after bonding the ceramic restorations with a two-step

etch-and-rinse adhesive (Adper Single Bond Plus, 3M ESPE) and a dual-cured resin-based luting

composite material (RelyX ARC, 3M ESPE). (b) Patient’s smile 2 days after the restorations were

bonded



a



b



c



Fig. 15.6 (a) Nonretracted frontal view showing the wide yellowish discoloration on teeth #8

(FDI 1.1) and #9 (FDI 2.1) and white spot areas in other teeth. Some teeth display single pitted

enamel areas. (b) Retracted view. The lower incisors also have yellowish discolorations along the

perikymata. (c) Close-up view of the maxillary incisors



conditions and no history in her family related to alterations in the appearance of

teeth. The clinical exam revealed that the periodontal condition was excellent.

Radiographically, there were no structural areas of concern in the periodontal and

periapical areas.

Similar to the patient shown in Sect. 15.1, this patient had lived in the same rural

area. Other children in the same community had discolored teeth, including some of

her family members.



15  Restorative Options for Discolored Teeth



261



Fig. 15.7  Preparation of

maxillary teeth for

porcelain veneers. Patient

was not anesthetized

because the preparation

was limited to enamel



a



b



c



Fig. 15.8 (a) Porcelain veneers fabricated with IPS e.max Press (Ivoclar Vivadent) lithium disilicate. (b, c) The thickness of the veneers ranged from 0.2 mm to 0.3 mm



The diagnosis for this clinical case was dental fluorosis. This patient’s fluorosis

level would fall into TSIF score of 4 (Horowitz et al. 1984) and a TF index score of

4 (Thylstrup and Fejerskov 1978). The treatment plan proposed to the patient was

at-home whitening with 10% carbamide peroxide gel in a custom-fitted tray for one

month and possibly every month thereafter up to 5–6 months, depending on the

outcome after the first month. In case at-home whitening did not result in “whiter”

teeth, we would try enamel microbrasion (Chap. 9) or a more invasive restorative

procedure, such as direct or indirect veneers. Patient was informed that microabrasion is usually less conservative than at-home whitening. Patient accepted this initial treatment plan.



262



E. Araújo and J. Perdigão



a



b



c



Fig. 15.9  The veneers were cemented with a two-step etch-and-rinse adhesive system (Adper

Single Bond Plus, 3M ESPE) and a light-cure resin-based luting composite material (RelyX

Veneer, 3M ESPE) (a–c). One week after the luting procedure, the integration of the porcelain

restorations with the gingival tissue was excellent

Fig. 15.10  Patient’s smile

1 week after the veneers

were bonded



Patient returned to the dental office after 5 weeks. No visible changes had

occurred with the color of her teeth. Patient’s compliance might have been responsible for the apparently unsuccessful whitening regimen, as patient mentioned that

she forgot to wear the trays for a few days. At this point we asked patient if she

wanted to start the enamel microabrasion procedure, which she declined. She

wanted a “more permanent solution.”

After presenting the restorative treatment options to the patient, which

included direct resin-based composite veneers or porcelain veneers, she returned

2 weeks later to start the clinical procedure for 8 thin porcelain veneers in her

maxillary teeth.



15  Restorative Options for Discolored Teeth



263



15.3 E

 namel Idiopathic Hypomineralization Treated

with Direct Resin-based Composite

As mentioned in Chap. 6, at-home whitening may highlight the enamel hypomineralized areas and make them more pronounced in case they are located deep in the

enamel. The photograph shown in Fig. 15.11a is that of a 19-year-old female patient

who had bleached her teeth a few months earlier with 10% carbamide peroxide in a

custom-fitted tray for 3 weeks. All the patients’ anterior teeth were vital without any

clinical or radiographic signs of pathology, except for the enamel hypomineralized

area on tooth #10 (FDI 2.2).

According to the patient’s description, the white enamel area of tooth #10 (FDI

2.2) became wider and more opaque with the whitening treatment (as shown in

Chap. 6, Figs. 6.14a, b). Clinically, the white opaque enamel area exhibited a concavity in the central area of the lesion, denoting loss of enamel (Fig. 15.11).

Transillumination confirmed that the center of the lesion had a thinner area of tooth

structure compared to the periphery (Fig. 15.12). The increased opacity of the tooth

structure surrounding the more translucent zone suggested that the defect was deep

inside the tooth and therefore not amenable to enamel microabrasion.

The treatment plan was removal of the hypomineralized area (Fig. 15.13), etching with 35% phosphoric acid for 15 s, and restoration with a two-step etch-and-­

rinse adhesive (Adper Single Bond Plus, 3M ESPE) followed by a resin-based

composite (Filtek Supreme Ultra, 3M ESPE). After inserting and light curing the

resin-based composite, the restoration was finished with Sof-Lex XT disks (3M

a



b



c



Fig. 15.11 (a) Smile of a 19-year-old female patient who had bleached her teeth a few months

earlier with 10% carbamide peroxide in a custom-fitted tray for 3 weeks. (b, c) Tooth #10 (FDI 2.2)

displayed an enamel hypomineralized area with a concavity in the central area of the lesion denoting loss of enamel



264



E. Araújo and J. Perdigão



Fig. 15.12 Transillumination

confirmed that the center of the

hypomineralized area had a

thinner area of tooth structure

compared to the periphery



a



b



c



Fig. 15.13  The porous enamel was removed with a diamond bur



ESPE) (Fig. 15.14a) followed by characterization of the secondary anatomy

(Fig. 15.14b) with a composite finishing bur. A felt disk (Diamond Flex, FGM) and

a fine diamond paste (Diamond Excel, FGM) and used for the final polishing step

(Fig. 15.14c). Figure 15.15 is a close-up photograph of the final aspect of restored

tooth #10 (FDI 2.2) showing an optimal esthetic integration with the other anterior

teeth. Figure 15.16 portrays the patient’s new smile.



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