Anterior Aesthetics for the Child and Adolescence

Created by

Eleanor Jubb

Cards (57)

Aetiology of tooth discolouration in young people:
Extrinsic/intrinsic
Systemic/local
Enamel/dentine
Congenital/acquired
Extrinsic staining:
Food/drink (coffee, red wine, tomato sauces, etc)
Smoking
Poor oral hygiene (e.g. chromogenic flora can produce grey-green plaque)
Drugs (e.g. ferrous iron [particularly in liquid form], minocycline)
Intrinsic enamel staining - local:
Primary trauma (primary tooth may have been luxated - thus disordered the development of the permanent successor tooth)
Idiopathic
Caries
Internal resorption
Intrinsic enamel staining - systemic:
Amelogenesis imperfecta (inherited condition - defect in formation of enamel)
Fluorosis (excessive fluoride ingestion)
Systemic illness (linear marks can form on teeth because during systemic illness the ameloblasts will stop working)
Idiopathic
This image shows systemic enamel discolouration - example of amelogenesis imperfecta.
Mix of primary and permanent teeth
Primary teeth are fractured, with exposed dentine - therefore enamel must be weak/weak enamel-dentine bond
Permanent teeth - good/normal shape - intrinsic brown marks in enamel and white opacities too - large mammelons present too
Teeth may wear and chip as time goes on
The image shows an example of local problems with enamel:
Primary central incisor was intruded and the root of it disturbed the development of the permanent successor tooth
Chromogenic staining present - extrinsic stain
Intrinsic stain + lack of enamel where localised trauma was
Intrinsic dentine staining - local:
Necrotic pulp
Root canal filling materials - used to be silver, so metal ions would leak out into surrounding dentine
Caries
Internal resorption
Intrinsic dentine staining - systemic:
Dentinogenesis imperfecta (inherited condition - defect in formation of dentine)
Tetracycline drug (if given during tooth development, the dentine will be stained dark)
Congenital porphyria
Bilirubin
Example of dentine staining shining through the enamel:
The tooth is non-vital - had trauma and was thus root-filled, as well as having had an apicectomy (scar visible on picture)
Some intrinsic dentine staining still visible
Inside-outside bleaching would have to be done here to match the tooth colour to that of the neighbouring one
Image shows a partly restored anterior dentition from a child with dentinogenesis imperfecta:
Poor plaque control + gingivitis
Composite work has been done on central incisors but there is a shine-through
As the permanent teeth age they will get darker and darker and more problematic - enamel can chip away from dentine
These teeth can also form cysts without us realising from chronic inflammation when there's no caries present, just from the poor connection between enamel and dentine
Image shows dentition of child born with a sick liver - teeth that formed during the time whilst the liver was sick are stained with bilirubin - teeth that formed post liver transplant look relatively normal (although they still have extrinsic staining).
Treatment of discoloured anterior teeth:
Enamel microabrasion
Tooth whitening (vital or non-vital)
Veneers
Composite - used more than porcelain; easier to add to - important because children always growing
Porcelain
Crowns
Indications for enamel microabrasion:
It is applicable for many white and brown intrinsic blemishes in the outer layer of the enamel - hard to know how deep blemish goes though
Turner teeth (enamel hypoplasia)
Fluorosis
Idiopathic speckling
Post-ortho demineralisation
Prior to veneers (so that veneering process is easier; discolouration is made smaller + lighter so the veneer doesn't have to work as hard to cover it)
Contraindications for enamel microabrasion:
The technique is not suitable for non-vital teeth and those stained with tetracycline - because this type of staining is in the dentine, so removing surface enamel isn't going to do anything
Enamel microabrasion technique:
Phosphoric acid etch tends to be used nowadays instead of hydrochloric acid; used to get nasty burns
First clean teeth with pumice & water
Apply rubber dam
Seal edge of dam with copalite varnish
Sodium bicarbonate + water paste placed on rubber dam around teeth
Protective glasses - pt, operator, nurse
Apply phosphoric acid etch + pumice slurry to buccal surfaces - 5 secs
After 5 secs, wash thoroughly
Repeat - maximum 10x for each tooth
Non-acidulated F- gel for 3 mins
Polish for 1 min with F- prophyl paste
Final lustre with soflex discs
Pre-op photo for enamel microabrasion:
Fluorosis evident - generalised white opacities on multiple teeth - central incisors have white opacities and brown sub-surface staining that takes up around half the labial tooth surface - speckles of white on other half of enamel though
White marks tend to be deeper into surface of the tooth than brown marks
Brown marks removed better by acid-pumice microabrasion
Rubber dam left on tooth surface - sealed with Copalite
Bicarb + water placed around teeth to buffer & de-acidify the acid + pumice
Wooden stick applying pumice slurry to the tooth surface
Fizzing at contact because bicarb + water neutralising the acid
Leave on for 5 seconds, wash, dry, then have a look - do one tooth at a time
Keep applying the bicarb + water because it will get washed away each time
Flurodide being applied to remineralise the surface
Brown marks all gone - some of the white ones have too
Soflex disc used to add a final lustre to the teeth
Tell pt not to have highly-coloured food for 24 hours too; teeth act like sponges
Before and after images of enamel microabrasion:
Patient was happy with background-whiteness - just wanted to get rid of brown marks
Need to be careful at incisal edge of tooth though; it's the thinnest part & microabrasion removes tooth tissue
Another case example of enamel microabrasion:
Fluorosis evident again - note speckling on permanent dentition
Central incisors show most white and brown marks though - mostly concentrated towards thinnest part of the tooth again, therefore need to be careful with how much tooth tissue we remove
Acid pumice microabrasion was done but there is some shine-through due to how thin the enamel has become
Ideal correction of enamel discolouration:
Give permanent results (acid pumice microabrasion is permanent)
Cause insignificant loss of tooth structure (if not careful, acid pumice microabrasion can remove a lot of tooth tissue)
Cause no damage to dental pulp or associated periodontal tissues (if you use rubber dam and are careful, as well as using phosphoric acid instead of HCl then damage shouldn't be done with acid pumice microabrasion)
Require a minimum of treatment time (microabrasion requires no lab work)
Easy for pt to tolerate and for dentist to perform
Microabrasion - depth of enamel removed:
5x5 sec application - 45μm
10x5 sec application - 74μm
15x5 sec application - 100μm
Quite a significant amount, particularly at incisal edge where tooth is already thin.
Dental treatments and enamel loss:
5-10μm - Prophy with prophy/toothpaste
5-50μm - Prophy with pumice
5-50μm - Ortho bracket bonding and debonding
10μm - Etching
100μm - 10x5 secs HCl-pumice microabrasion
Microabrasion didn't get rid of the white marks on the central incisors, so the enamel defects were drilled away with a round bur, just into sound enamel - only about 0.5mm, and then composite was placed in the cavity left behind.
Vital tooth whitening: tray-based is a gentler approach to in-surgery treatments; the teeth are being whitened over a longer period of time with no catalysts like heat/light.
Vital tooth whitening - indications:
Severe extrinsic staining
Age-related discolouration
Calcified pulp - if the tooth experiences trauma the root canal can calcify
Fluorosis
Mild tetracycline
Vital tooth whitening - contraindications:
Large pulps
During orthodontics
Hypersensitive teeth
Severe enamel loss
Extensive restoration - because the restoration won't whiten
Pregnancy/nursing
Whitening - how it works - not completely understood:
Oxidation - key to remember that it's oxidation that causes it
Photo-oxidation - light can catalyse the reaction
Ion exchange - likely to involve ion exchange, but main focus is on oxidation
Whitening - oxidation:
Darkly pigmented carbon ring structures are broken down into carbon-ring structures, which are then broken down into lightly pigmented unsaturated structures, which are then broken down into completely bleached stains.
If you do it for too long, you can cause enamel breakdown and loss of enamel matrix.
Materials for in-surgery tooth whitening:
PPE
Rubber dam, gauze strips (needed to cover metal clamps if they're being used)
Orabase/vaseline over the gingiva
Topical anaesthesia for gingivae
Pumice & water - clean teeth with these first
37% phosphoric acid - once enamel has been opened up, etch it with this
6% hydrogen peroxide solution - apply to areas you wish to whiten
Light source
Fluoride drops/solution - to be applied afterwards
Polishing discs
Vital whitening example: extrinsic staining has been removed but has lightened the background of the teeth as well. This treatment will need topping up every 1-2 years though.
Tray-based whitening:
Syringes of carbamide peroxide gel 10% (urea hydrogen peroxide)
Polyvinyl tray made that's designed to sit over the teeth w/ labial reservoirs built in so the bleach doesn't seep out of the tray and that it's held on the labial surface of the tooth.
Mechanism of action:
10% carbamide peroxide -> 3% hydrogen peroxide + 7% urea
The 3% hydrogen peroxide that is produced is what causes the whitening
Good results after a few weeks, but will need to be topped up every 1-2 years.
Typically only done on maxillary dentition -> causes mismatch with mandibular dentition.
Effects of vital whitening on teeth:
Mild sensitivity to temperature changes
Cellular pulp changes
Damage to enamel
pH of solution
Bond strength to composite resin - because lots of oxygen produced due to oxidation reaction and teeth sensitive - wait a few weeks after bleaching before doing a composite restoration
Junctional epithelium may be permeable to carbamide peroxide. This would lead to exposure of a number of cell types including vascular epithelium.
No significant intrinsic colour change of restorative materials
Vital whitening for young pts (<18 years):
If you're >18, it's legal to do vital tooth-whitening, if <18 it's not
Larger pulp chambers
Little secondary dentine
Poorer plaque control - may be the case for some, but not all
Increased potential for pulpal hyperaemia (sensitivity)
Heat should not be used
GDC statement: use for therapeutic reasons, not cosmetic
Vital whitening for pts >18:
From October 2012 - amendment to the UK Cosmetics directive 2011/84/EU
Material for vital whitening (carbamide peroxide) thought of as a cosmetic, rather than a medicine, therefore under UK Cosmetics directive
<6% hydrogen peroxide can be supplied to patients by a dentist
GDC reinforced that tooth whitening is in the practice of dentistry
Recent GDC statement for children/young adults
Prescribed by the dentist and delivered or supervised by the dentist
Appropriate fully informed consent must be gained
Non-vital tooth whitening is when the tooth that is being whitened is non-vital - i.e. root filled. Non-vital teeth can look dark because the dentine is typically stained with blood products from the time of the trauma that caused the tooth to become non-vital.
Non-vital tooth whitening - advantages:
Simple
Tooth conserving - conserves tooth tissue; not putting a veneer on the tooth instead
Conserves original morphology
Kind to gingival tissues
Adolescents can cope with it
No laboratory assistance
Non-vital tooth whitening - materials and methods:
Thermocatalytic
Source, light or probe, used to release O₂ from the bleaching agent
Walking bleach
Oxidising process allowed to proceed gradually over days - repeat visits need to be done for this though
Inside/outside bleaching
Newer approach: uses bleaching tray and an open access cavity
Ideal tooth for doing non-vital whitening:
Although the GP does extend way into the access cavity, so GP must be taken down to CEJ/dento-gingival junction, otherwise it'll stop the dentine from whitening
Want anterior teeth without large restorations
Don't really want teeth with staining caused by restorative materials (amalgam not amenable) - because that won't bleach
Fluorosis or tetracycline - inappropriate; we would want to maintain the vitality of those teeth, not devitalise them
Non-vital whitening technique:
Walking bleach - seal the carbamide peroxide gel in for a week repeatedly. Takes several visits.
Inside/outside - produce a bleaching tray, prepare the access cavity and supply the patient with syringe of whitening gel (up to 15% carbamide peroxide). May only take two visits - depends on how dark the tooth is though.