Article dark primary incisor -cds review

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28 | CDS REVIEW | JANUARY/FEBRUARY 2005 M any children have one or more discol- ored primary teeth resulting from enamel hypocalcification, enamel hypoplasia, amelogenesis and dentino- genesis imperfecta, or traumatic injuries. These teeth can be of various colors: yellowish, reddish, brown, grey or even black. Most parents want their child’s teeth to be white in appearance to match the adjacent teeth. Having nice looking teeth is important to these children so that they will have a positive self image and not be introverted due to shame or embarassment caused by their discolored teeth and unsightly smile. Fortunately, there are cosmetic techniques that allow us to lighten discolored teeth, including composite veneers, porcelain veneers and bleaching. Whether these teeth have pulpal involvement or not, we have the mate- rials and techniques to esthetically restore these discol- ored teeth. When I attended dental school 30 years ago, I was told that bonding could not be accomplished with primary teeth because of the aprismatic layer of enamel. 1 Today, we have the techniques available to remove this thin layer of non-prismatic enamel to allow bonding to occur. A discolored primary incisor does not necessarily indi- cate that the tooth has pulpal injury. Holan and Fuks state: “The diagnostic value of dark-gray discoloration of the crown of primary incisors following traumatic injury as a predictor of pulp vitality is controversial.” 2 In the case of a dark primary incisor, this discoloration indicates that during the course of the injury, the iron-containing pigment of the red blood cells, heme, was released. Will this discolored tooth return to its normal color? Will this discolored tooth remain dark or become darker? A yellow primary tooth may indicate calcific degenera- tion or calcific metamorphosis of the pulp of the tooth. This can be confirmed with a radiograph, which would show the calcification of the pulp chamber. Because of the color of the dentin underlying the thin enamel of pri- mary teeth, the tooth appears yellow. A primary tooth appearing reddish could be the result of a ruptured blood vessel in the pulp or a tooth with internal resorption. A radiograph would aid in the diag- nosis of the latter. Enamel hypocalcification and hypoplasia, which cause irregularity in the surface of the enamel, can also cause discoloration of this surface. 3 According to Soares, et al: “Alterations during tooth structure formation, mainly on anterior teeth, are known to severely compromise esthet- ics.” 4 In a study reported by Slayton, et al, 698 children were examined at four and five years of age. Six percent of these healthy children had one or more teeth with enamel hypoplasia. 5 In another study, Aine and co-work- ers found that the prevalence of enamel defects was “clearly higher” in both primary and permanent teeth when the child had been born prematurely. 6 The purpose of this article is to give the reader a method by which discolored primary teeth can be restored to their natural tooth color. 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.

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Transcript of Article dark primary incisor -cds review

Page 1: Article   dark primary incisor -cds review

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Many children have one or more discol-ored primary teeth resulting fromenamel hypocalcification, enamelhypoplasia, amelogenesis and dentino-genesis imperfecta, or traumaticinjuries. These teeth can be of various

colors: yellowish, reddish, brown, grey or even black.Most parents want their child’s teeth to be white inappearance to match the adjacent teeth. Having nicelooking teeth is important to these children so that theywill have a positive self image and not be introverted dueto shame or embarassment caused by their discoloredteeth and unsightly smile.

Fortunately, there are cosmetic techniques that allowus to lighten discolored teeth, including compositeveneers, porcelain veneers and bleaching. Whether theseteeth have pulpal involvement or not, we have the mate-rials and techniques to esthetically restore these discol-ored teeth. When I attended dental school 30 years ago, Iwas told that bonding could not be accomplished withprimary teeth because of the aprismatic layer of enamel.1

Today, we have the techniques available to remove thisthin layer of non-prismatic enamel to allow bonding tooccur.

A discolored primary incisor does not necessarily indi-cate that the tooth has pulpal injury. Holan and Fuksstate: “The diagnostic value of dark-gray discoloration ofthe crown of primary incisors following traumatic injuryas a predictor of pulp vitality is controversial.”2 In thecase of a dark primary incisor, this discoloration indicates

that during the course of the injury, the iron-containingpigment of the red blood cells, heme, was released. Willthis discolored tooth return to its normal color? Will thisdiscolored tooth remain dark or become darker?

A yellow primary tooth may indicate calcific degenera-tion or calcific metamorphosis of the pulp of the tooth.This can be confirmed with a radiograph, which wouldshow the calcification of the pulp chamber. Because ofthe color of the dentin underlying the thin enamel of pri-mary teeth, the tooth appears yellow.

A primary tooth appearing reddish could be the resultof a ruptured blood vessel in the pulp or a tooth withinternal resorption. A radiograph would aid in the diag-nosis of the latter.

Enamel hypocalcification and hypoplasia, which causeirregularity in the surface of the enamel, can also causediscoloration of this surface.3 According to Soares, et al:“Alterations during tooth structure formation, mainly onanterior teeth, are known to severely compromise esthet-ics.”4 In a study reported by Slayton, et al, 698 childrenwere examined at four and five years of age. Six percentof these healthy children had one or more teeth withenamel hypoplasia.5 In another study, Aine and co-work-ers found that the prevalence of enamel defects was“clearly higher” in both primary and permanent teethwhen the child had been born prematurely.6

The purpose of this article is to give the reader amethod by which discolored primary teeth can berestored to their natural tooth color.

Esthetic restoration of discolored primary incisorsFred 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.

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Madeline, a 3-year-old girl, came to my office for her first dental visit. Uponoral examination I noticed the gray color of the maxillary left central incisor.The mother reported that the child had fallen three weeks prior to this dentalvisit. The tooth has remained asymptomatic. The gingiva was normal inappearance and the tooth was not mobile.

FIGURE 1A: Note the gray appearance of the maxillary left central incisor.

FIGURE 1B: A radiograph was taken which showed no apparent abnormal-ity. The mother reported that the tooth discolored to its present gray colorand shade within two weeks of the injury. The author informed the motherthat if the tooth remained grey it could be lightened. The technique suggest-ed was to provide a composite veneer on the labial surface of the maxillaryleft primary incisor. At the subsequent appointment, informed consent wasobtained. No anesthetic was required.

FIGURE 1C: The aprismatic layer of enamel was removed with anErbium:YAG laser. If the laser had not been used a fine tapered diamondwould have been used to remove the non-prismatic layer of enamel.

FIGURE 1D: The enamel was etched with a 35% phosphoric acid gel for 15seconds. The etching gel was thoroughly rinsed off the surface and the sur-face dryed with the air syringe.

FIGURE 1E: Due to the dark grey color of this tooth, a thin layer of opaquerwas placed on the labial surface. The opaquer was cured with a bonding light.

FIGURE 1F: A bonding agent was next placed and light cured.

FIGURE 1G: A thin layer of composite was placed over the labial surface.

FIGURE 1H: The composite was sculpted with a composite placement instru-ment and then cured with a bonding light. Finishing and polishing werethen completed with carbide finishing burs and polishing discs.

FIGURE 1I: The completed restoration.

See the technique described in Case History 2

Figure 1A Figure 1B Figure 1C

Figure 1D Figure 1E Figure 1F

Figure 1G Figure 1H Figure 1I

CASE HISTORY 1

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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 cosmeticrestoration 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 ofenamel. An alternative technique is to use a fine diamond bur and swipe it gently across the enamelsurface to remove the aprismatic layer of enamel.

FIGURE 2C: A 35% phosphoric acid gel is placed for 15 seconds and then thoroughly rinsed anddryed.

FIGURE 2D: A white opaquer was placed with a paint brush to obtain a thin, even surface on the area ofhypoplastic 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 curinglight.

FIGURE 2F: The composite was then finished and polished. Contouring and polishing were completedwith sandpaper discs.

FIGURE 2G: The completed restoration. ■

Figure 2A Figure 2B Figure 2C

Figure 2D Figure 2E Figure 2F

Figure 2G

CASE HISTORY 2

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Dr. Fred Margolis received his BS and DDS from Ohio State University andhis certificate in pediatric dentistry from the University of Illinois College ofDentistry. Dr. Margolis is a clinical instructor at Loyola University’s OralHealth Center. He is a fellow of the Pierre Fauchard Academy, InternationalCollege of Dentists, American College of Dentists and the OdontographicSociety. He is the author of a course manual, Beautiful Smiles for SpecialPeople, and has written articles for both lay and professional publications.He is a product evaluator for several dental manufacturers.

Dr. Margolis is director of the Institute for Advanced Dental Education andhas lectured both nationally and internationally. He is a consultant to theADA Council on Dental Practice and an ADA seminar series lecturer. Dr.Margolis maintains a full-time private pediatric dental practice in BuffaloGrove. Dr. Margolis can be reached at his office at (847)537-7695 or bye-mail at [email protected].

REFERENCES1. Whittaker DK: Structural variations in the surface zone of human

tooth enamel observe by scanning electron microscopy. Arch Oral Biol27:383-392, 1982

2. Holan G, Fuks AB: The diagnostic value of coronal dark-gray discol-oration in primary teeth following traumatic injuries. Pediatr Dent 18:224-227, 1996

3. Kimoto S, Suga H,et al: Hypoplasia of primary and permanent teethfollowing osteitis and the implications of delayed diagnosis of a neonatalmaxillary primary molar. Int J Paediatr Dent 13:35-40, 2003

4. Soares CJ, Fonseca RB, et al: Esthetic rehabilitation of anterior teethaffected by enamel hypoplasia: a case report. J Esthet Restor Dent 14:340-348, 2002

5. Slayton RL, Warren JJ, et al: Prevalence of enamel hypoplasia andisolated 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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