TOWNIE CLINICAL: Bonding of Severe Tetracycline Stained Teeth By: Dory H. Stutman, DDS

There are paradigms in dentistry that are hard and fast. Certain techniques have become the gold standard for many situations. Many dentists are unwilling to break out of the box and try new, or innovative procedures. Sometimes dentists cannot perform the ideal procedure in a situation. They often pass on cases that would have been very rewarding to them and their patient. I hope the following case can illustrate an example of trying an alternative when you think you're stuck at a dead end.

This attractive thirtyish woman came to my office desperately seeking a makeover for an important function by the end of the week! She had a pretty face, but severely tetracycline stained dentition. There was also some slight crowding and rotations she wanted to correct. Her teeth detracted terribly from an otherwise very pleasant smile. She had no decay and excellent oral hygiene but she is a bruxer! Ideally, some type of porcelain restoration would have been the best treatment but I didn’t have that luxury. Time constraints, and the patient’s request for the most conservative type of treatment left few options. Cosmetic bonding quickly became the treatment of choice for this dire predicament.

		Patient’s before full-face shot. Close-up and retracted photos below show deep dark tetracycline stain, and slight crowding. Teeth #5 and #12 are congenitally missing
		Before close-up
		Retracted before
		Close-up after using Renamel Restorative System
		Retracted after
		After Close-Up: 1 week later I decided not to lengthen the patient’s teeth due to her bruxing. Preparation included only the facial surface.
		There was no incisal wrap over to the lingual. Preparation was like a typical veneer, .5mm in depth with a chamfer. The preparation and impression for resin bonded inlay bridges were performed at the first visit. The touch-up and final polish were completed on the second visit.
		After Close-Up: 1 week later The shot above shows the final restoration after insertion of resin-bonded inlay bridges for teeth numbers 5 & 12 with internalized metal substructure for extra strength. An impression for a bite guard was taken at this appointment. All in all, one VERY happy patient!

I decided not to lengthen the patient's teeth due to her bruxing. Preparation included only the facial surface. I used Cosmedent’s Renamel Restorative System that includes microfills, hybrids, opaquers and tints, all integrated to each other and the vita shade guide.

There was no incisal wrap over to the lingual. Preparation was like a typical veneer .5mm in depth with a chamfer. The prep and impression for resin bonded inlay bridges were performed at the first visit.

The touch-up and final polish was completed on the second visit.

When presented with this type of challenge, you should consider bonding as a conservative option to treat severely tetracycline stained teeth. Yes, I agree crowns or veneers might have been a better option. This patient had no decay in the past and has only virgin enamel. She felt very concerned about even the slightest alteration of her teeth. I did the best I could and got a happy patient. Actually, the results were even better than expected!

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Dory H. Stutman received his dental degree from Case Western Reserve University School of Graduate Dentistry in 1990, followed by a General Practice Residency in 1991. He is the owner of South Shore Dental Care, a private group practice, established in 1996.

Dr. Stutman can be reached for questions by phone: 516-798-3808 or by email at: smilesofstyle@yahoo.com.

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Townie Comments
From the DentalTown.com online Case Presentation

larryhibbard 11/19/2002 10:19 pm		What a nice service for this patient! It is almost a situation that any help at all is a great step forward with this patient. I just started a case with 10 upper porcelain veneers on a patient that I had bonded twice over the last 14 years. Just the provisionals were a huge help to my patient.
cavitfil 11/19/2002 9:24pm		Nice work! I especially like the facial indentations. Did you consider giving them some translucencies at the incisal edges?
stutman 11/19/2002 10:28 pm		Thanks for the comments. I would like to have imparted a translucent component to the incisal edge but there would have been brown show through from the underlying tooth.
doctored 11/20/2002 12:18pm		Nice job! Looks like you are very talented with direct resin. I'll bet she loves you. How long did it take and how much did you charge for this service? Bet you worked your buns off!!
stutman 11/20/2002 10:28 pm		Thanks for the compliment. I do lots of these cases so they don't take as long as they used to—2-2.5 hrs for 6 teeth including pictures, and anesthesia with 15-20 minutes for a 2nd visit final polish & any adjustments. I charge $500-600/tooth depending on the case. This case took only 2hrs...the first time! After we finished she decided that B1 was not light enough, so I reveneered a 2nd layer of bleached shade. I really earned my money on this case, but it was worth it. She was so happy that she signed on for more than $10,000 of more work immediatly after fixing it!
kleinfelder 11/21/2002 6:20 pm		What did you do to block out the dark tetracycline staining? Did you use a white opaquer or did you use a partial opaquing agent?
stutman 11/22/2002 10:28 pm		Actually I didn’t use an opaquer, but I prepped about .5mm deep with chamfer and tried to stay in enamel. Luckily I was able to add at least 1mm of composite to the restoration without it looking too bulky. I used Renamel sb1 (bleached shade) microfill as the final layer, over b1 hybrid .The sb1 bleached blocked out the tetracycline shade very niceley without making the restoration look too opaque.
garzadds 11/22/2002 9:21 pm		Excellent job. Did you break any contacts? It looks like you would see some darkening interproximally otherwise. Good point if you look hard you can see some darkening interproximally.
stutman 11/22/2002 9:27 pm		I probably could have prepped deeper interproximally to block that out. At conversational distance it is not noticeable though. I did not break contact or wrap over incisal because patient is somewhat of a bruxer.