Esthetic Dentistry for Tots and Teens Featured article #1

1. Esthetic restoration of
discolored primary incisors
Fred S. Margolis, DDS
RESTORING PRIMARY TEETH CAN BE A STRENUOUS TASK FOR MANY DENTISTS WHO WOULD LIKE TO
HAVE AN ESTHETIC, EASY-TO-USE AND RELATIVELY QUICK RESTORATION FOR CHILDREN. BUT, THE
RESTORATION OF CARIOUS, FRACTURED OR DISCOLORED PRIMARY INCISORS GIVES THE DENTIST THE SAT-
ISFACTION OF KNOWING THAT HE/SHE HAS RESTORED THE SMILE AND SELF-CONFIDENCE OF A GROW-
ING CHILD. THIS ARTICLE DESCRIBES A TECHNIQUE WHICH IS RELATIVELY EASY AND PRODUCES A BEAUTI-
FUL OUTCOME IN A RELATIVELY SHORT TIME. THE AUTHOR HAS USED THE TECHNIQUE IN HUNDREDS OF
CHILDREN FOR OVER TWENTY-FIVE YEARS. MODIFICATIONS IN THE TECHNIQUE HAVE BEEN MADE AS
NEWER MATERIALS AND TECHNIQUES HAVE EVOLVED.
M
any children have one or more discol- that during the course of the injury, the iron-containing
ored primary teeth resulting from pigment of the red blood cells, heme, was released. Will
enamel hypocalcification, enamel this discolored tooth return to its normal color? Will this
hypoplasia, amelogenesis and dentino- discolored tooth remain dark or become darker?
genesis imperfecta, or traumatic A yellow primary tooth may indicate calcific degenera-
injuries. These teeth can be of various tion or calcific metamorphosis of the pulp of the tooth.
colors: yellowish, reddish, brown, grey or even black. This can be confirmed with a radiograph, which would
Most parents want their child’s teeth to be white in show the calcification of the pulp chamber. Because of
appearance to match the adjacent teeth. Having nice the color of the dentin underlying the thin enamel of pri-
looking teeth is important to these children so that they mary teeth, the tooth appears yellow.
will have a positive self image and not be introverted due A primary tooth appearing reddish could be the result
to shame or embarassment caused by their discolored of a ruptured blood vessel in the pulp or a tooth with
teeth and unsightly smile. internal resorption. A radiograph would aid in the diag-
Fortunately, there are cosmetic techniques that allow nosis of the latter.
us to lighten discolored teeth, including composite Enamel hypocalcification and hypoplasia, which cause
veneers, porcelain veneers and bleaching. Whether these irregularity in the surface of the enamel, can also cause
teeth have pulpal involvement or not, we have the mate- discoloration of this surface.3 According to Soares, et al:
rials and techniques to esthetically restore these discol- “Alterations during tooth structure formation, mainly on
ored teeth. When I attended dental school 30 years ago, I anterior teeth, are known to severely compromise esthet-
was told that bonding could not be accomplished with ics.”4 In a study reported by Slayton, et al, 698 children
primary teeth because of the aprismatic layer of enamel.1 were examined at four and five years of age. Six percent
Today, we have the techniques available to remove this of these healthy children had one or more teeth with
thin layer of non-prismatic enamel to allow bonding to enamel hypoplasia.5 In another study, Aine and co-work-
occur. ers found that the prevalence of enamel defects was
A discolored primary incisor does not necessarily indi- “clearly higher” in both primary and permanent teeth
cate that the tooth has pulpal injury. Holan and Fuks when the child had been born prematurely.6
state: “The diagnostic value of dark-gray discoloration of The purpose of this article is to give the reader a
the crown of primary incisors following traumatic injury method by which discolored primary teeth can be
as a predictor of pulp vitality is controversial.”2 In the restored to their natural tooth color.
case of a dark primary incisor, this discoloration indicates
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2. CASE HISTORY 1
Figure 1A Figure 1B Figure 1C
Figure 1D Figure 1E Figure 1F
Figure 1G Figure 1H Figure 1I
Madeline, a 3-year-old girl, came to my office for her first dental visit. Upon FIGURE 1D: The enamel was etched with a 35% phosphoric acid gel for 15
oral examination I noticed the gray color of the maxillary left central incisor. seconds. The etching gel was thoroughly rinsed off the surface and the sur-
The mother reported that the child had fallen three weeks prior to this dental face dryed with the air syringe.
visit. The tooth has remained asymptomatic. The gingiva was normal in
appearance and the tooth was not mobile. FIGURE 1E: Due to the dark grey color of this tooth, a thin layer of opaquer
was placed on the labial surface. The opaquer was cured with a bonding light.
FIGURE 1A: Note the gray appearance of the maxillary left central incisor.
FIGURE 1F: A bonding agent was next placed and light cured.
FIGURE 1B: A radiograph was taken which showed no apparent abnormal-
ity. The mother reported that the tooth discolored to its present gray color FIGURE 1G: A thin layer of composite was placed over the labial surface.
and shade within two weeks of the injury. The author informed the mother
that if the tooth remained grey it could be lightened. The technique suggest- FIGURE 1H: The composite was sculpted with a composite placement instru-
ed was to provide a composite veneer on the labial surface of the maxillary ment and then cured with a bonding light. Finishing and polishing were
left primary incisor. At the subsequent appointment, informed consent was then completed with carbide finishing burs and polishing discs.
obtained. No anesthetic was required.
FIGURE 1I: The completed restoration.
FIGURE 1C: The aprismatic layer of enamel was removed with an
Erbium:YAG laser. If the laser had not been used a fine tapered diamond See the technique described in Case History 2
would have been used to remove the non-prismatic layer of enamel.
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3. CASE HISTORY 2
Figure 2A Figure 2B Figure 2C
Figure 2D Figure 2E Figure 2F
Matthew, age 3, has enamel hypoplasia on the maxillary right primary central incisor.
FIGURE 2A: Matthew’s mother reported no trauma that she could recall. Tooth eruption occurred with-
in normal limits. Her pregnancy was unremarkable. Informed consent was given for the cosmetic
restoration of Matthew’s tooth. No anesthetic was required to restore Matthew’s tooth.
FIGURE 2B: The Erbium:YAG laser was used to remove caries and remove the aprismatic layer of
enamel. An alternative technique is to use a fine diamond bur and swipe it gently across the enamel
surface to remove the aprismatic layer of enamel.
Figure 2G
FIGURE 2C: A 35% phosphoric acid gel is placed for 15 seconds and then thoroughly rinsed and
dryed.
FIGURE 2D: A white opaquer was placed with a paint brush to obtain a thin, even surface on the area of
hypoplastic enamel. A bonding agent was then placed over the entire enamel surface and light cured.
FIGURE 2E: A layer of composite was then placed over the entire labial surface and set with the curing
light.
FIGURE 2F: The composite was then finished and polished. Contouring and polishing were completed
with sandpaper discs.
FIGURE 2G: The completed restoration. ■
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4. Dr. Fred Margolis received his BS and DDS from Ohio State University and REFERENCES
his certificate in pediatric dentistry from the University of Illinois College of 1. Whittaker DK: Structural variations in the surface zone of human
Dentistry. Dr. Margolis is a clinical instructor at Loyola University’s Oral tooth enamel observe by scanning electron microscopy. Arch Oral Biol
Health Center. He is a fellow of the Pierre Fauchard Academy, International 27:383-392, 1982
College of Dentists, American College of Dentists and the Odontographic 2. Holan G, Fuks AB: The diagnostic value of coronal dark-gray discol-
Society. He is the author of a course manual, Beautiful Smiles for Special oration in primary teeth following traumatic injuries. Pediatr Dent 18:224-
People, and has written articles for both lay and professional publications. 227, 1996
He is a product evaluator for several dental manufacturers. 3. Kimoto S, Suga H,et al: Hypoplasia of primary and permanent teeth
following osteitis and the implications of delayed diagnosis of a neonatal
Dr. Margolis is director of the Institute for Advanced Dental Education and maxillary primary molar. Int J Paediatr Dent 13:35-40, 2003
has lectured both nationally and internationally. He is a consultant to the 4. Soares CJ, Fonseca RB, et al: Esthetic rehabilitation of anterior teeth
ADA Council on Dental Practice and an ADA seminar series lecturer. Dr. affected by enamel hypoplasia: a case report. J Esthet Restor Dent 14:340-
Margolis maintains a full-time private pediatric dental practice in Buffalo 348, 2002
Grove. Dr. Margolis can be reached at his office at (847)537-7695 or by 5. Slayton RL, Warren JJ, et al: Prevalence of enamel hypoplasia and
e-mail at kidzdr@comcast.net. isolated opacities in the primary dentition. Pediatr Dent 23:32-36; 2001
6. Aine L, Backstrom MC,et al: Enamel defects in primary and perma-
nent teeth of children born prematurely. J Oral Pathol Med 29:403-409,
2000
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