Aesthetic considerations

• What causes tooth discolouration?

  Extrinsic / Intrinsic

  
  

  Enamel - local or systemic

  Dentine - local or systemic
• Extrinsic causes of staining ?

  • food beverages
  • Smoking
  • Poor OH
  • drugs
  • chromogenic bacteria
• Local intrinsic enamel staining causes?

  • caries
  • injury or infection of primary predecessor
  • Loss of vitality secondary to trauma or infection
  • internal resorption
  • idiopathic
• Systemic intrinsic enamel staining cause?

  • Amelogenesis imperfecta
  • MIH (molar-incisor hypoplasia)
  • Drugs
  • Fluorosis
  • Systemic illness during tooth formation (chronological)
  • Idiopathic 
• Aetiology of amelogenesis imperfecta?

  • hereditary enamel defect
  • single gene mutation
  • associated with a syndrome
• Classifications of amelogenesis imperfecta?

  • hypoplasia - enamel does not form correctly
  • hypocalcification - not enough calcium in matrix
  • hypomaturation - does not mature properly and complete dev

  Take account mode of inheritance
• Associated features of amelogenesis imperfecta?

  • anterior open bite
  • failure to erupt
  • absence of 3rd molars
  • on rads = taurodontism
• Prevalence of amelogenesis imperfecta 


  marked population differences
• What is taurodontism

  Taurodontism is a developmental disturbance of a tooth in which the body is enlarged at the expense of the roots
• Features of taurodontism

  • enlarged pulp chamber
  • apical displacement of the pulpal floor
  • lack of constriction at the cementoenamel junction
• Clinical appearance of taurodontism

  tooth's vertically enlarged pulp chamber that's almost three to four times larger than normal. below the gumline, the tooth appears to extend in a rectangular shape with stubby roots
• Molar incisor aetiology?

  Uknown, could be genetic or environmental
• Presentation of molar incisor hypoplasia

  Mineralisation defects of 1-4 of the first permanent molars and is freq associated with affected incisors
• Prevalence of molar incisor hypoplasia

  3.6 - 25%
• Tetracycline?

  • if taken during pregnancy and child hood as has to be present to be incorporated during tooth formation
  • distinctive blue or grey discolouration
  • chronological banded distribution
  • Will fluoresce
• Fluorosis aetiology?

  • Excessive fluoride intake
  • natural sources or over use of fluoride supplements or TP
• Presentation of fluorosis?

  • dose dependent
  • mild = opacity of enamel
  • severe = +++ opacity, areas of discolouration, pitting, +++ extensive hypoplastic defects
• Prevalence of fluorosis

  • higher in fluoridated areas
  • 35% kids in fluoridated area has fluorosis
  • higher socio economic class kids = more fluorosis
• 2-3 year olds swallow


  half the TP on their brush
• 3-4 year olds swallow

  1/3 of TP on the brush
• Maxillary incisors are most susceptible to fluorosis at

  22 - 26 months of age
• Systemic illnesses causing staining in utero ?

  • Endocrine disturbances (hypoparathyroidism)
  • Infections (rubella)
  • Drugs (thalidomide)
  • Nutritional deficiencies
  • Haematological and metabolic disorders (Rhesus compatibility)
• Neonatal ?

  • Pre-term infants - can be common as born before dev completed
  • Low birth weight
  • Use of intubation during neonatal period as can knock area (local effect) ?
• Childhood illnesses causing staining ?

  • chronic illness
  • Fevers caused by measles and other infections
• Intrinsic local staining causes of dentine ?

  • Caries
  • Internal resorption
  • Restorative materials
  • Necrotic pulp tissue (trauma/infection)
  • Root canal filling materials
• Systemic staining effects for dentine ?

  • Dentinogenesis imperfecta
  • Bilirubin (haemolytic disease of the new born)
  • Congenital porphyria
  • Drugs
• Dentinogenesis imperfecta aetiology?

  • Hereditary dentine defect
  • Autosomal dominant 
  • May be associated with a syndrome 
• What are the 2 main types of dentinogenesis imperfecta ?

  • Type I: associated with osteogenesis imperfecta
  • Type II: affecting teeth only 
• When Tx flourosis what do you need for full consent ?

  • inform that the very white marks will also go away as well as the brown marks
• Type 1 dentinogenesis imperfecta prevalence

  1 / 8000
• Presentation of Type 1 dentinogenesis imperfecta ?

  • Both dentitions affected but primary more
  • Teeth opalescent with a grey/brown hue
  • Loss of enamel
  • Marked attrition
  • Radiographically: bulbous crowns, short thin roots, large pulp chambers which become obliterated
• Drugs causing intrinsic staining ?

  • Tetracycline
  • Chemo-therapeutic agents eg cytotoxic drugs
• What is needed to diagnose?

  • thorough history taking
  • clinical exam
  • additional investigations
• What is needed to know for pt history

  • mother obstetric history / delivery
  • MH - Neonatal or early childhood illness, medicine
  • DH - infections of primary tooth
  • FH - discoloured or abnormal teeth
  • Fluoride - supplement, F area, type of TP, swallowing TP
• Examination ?

  • EO and IO
  • inc. presence or absence of primary and secondary teeth
  • distribution of discolouration
  • evident on eruption - where is it on the tooth
  • extent of staining - does it affect all teeth?
  • pattern
  • distribution
  • banded
• Additional investigations?

  • rads
  • sensibility test
  • histological sectioning of exfoliated or XLA teeth
• Bilirubin staining?


  • green
  • intrinsic (cant be polished off)
  • can be confused with chromogenic bacteria staining
• Tx options for staining

  • microabrasion
  • Bleaching - non vital or vital
  • Local composite restoration
  • composite resin veneers
  • Porcelain veneers
• what is microabrasion 


  a controlled method of removing the surface enamel to improve discoloured limited to the outer enamel. Involves abrasion and erosion.
• how much enamel should be removed during microabrasion

  no more than 100 micrometer of enamel