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Authors: Dr. Manikya Shastri, Dr. Sunil Dhaded

ABSTRACT

Veneers are restorations which are envisioned to correct existing abnormalities , aesthetic deficiency and fluorosis discolorations. It may be processed in two different ways – direct or indirect : direct anterior composite restorations are inexpensive, minimally invasive restorations for fluorosis . it is a great alternative to full coverage crown in young patients and patients with healthy dentition and in cases of financially concerned patients. In conclusion direct composite veneer restorations may be a treatment option for problems of fluorosis and rotated laterals case reported here .
KEY WORDS : Direct composite veneers ,fluorosis, Minimally invasive technique.

INTRODUCTION

Modern dentistry provides us many techniques and materials in our armamentarium to create the aesthetically perfect smiles.1 Discoloration of teeth can be (a) extrinsic stains or (b) intrinsic stains. Intrinsic stains being more complicated to treat compared to extrinsic stains. The increased incidence of dental fluorosis in developing countries over the last few decades is considered to be largely due to the wide spread usage of fluoride. In many parts of the world where drinking water contains excessive amount of fluorine(3 to 5 mg /L), endemic fluorosis has been observed. Endemic fluorosis has been reported to be and important health issues in certain parts of India,example Andhra Pradesh(Nellore,nalgonda,andprakasam district),Punjab, Haryana,Karnataka,kerala,and tamilnadu.2 Discoloration due to fluorosis can affect both vital and non vital teeth. Vital teeth may be discoloured at the time the crown formation with causative factors including hereditary disorders. Aesthetics plays an important role in any individual’s life and discoloration of teeth can have a tremendous effect on overall quality of life.3Aesthetic dentistry involves harmonious integration of smile design, conception, and material selection. This is accomplished by a comprehensive knowledge of facial aesthetics, tooth morphology, available restoration techniques, and communication skills.4 It is a great alternative to full coverage crown in young patients, patients with healthy dentition and in cases of financial concern.

 
 Figure 1  Figure 2
Figure 1 Figure 2
 
 Figure 3  Figure 4
Figure 3 Figure 4


Case report

A 19 years old male patient,reported to the department of prosthodontics and Implantology with a chief complaint of discolouration of the anterior teeth and the rotation of the upper lateral incisors as well as unaesthetic canines(Figure 1). Examination revealed severe brown stained enamel surfaces in all teeth with a good periodontal status and no radiographic evidence of hard tissue disease. Temporo mandibular joint was asymptomatic with non contributing medical history. Dental caries was prognosed in relation to both the lower first molars. Final diagnosis of dental fluorosis classified as Dean’s severe type and rotation of upper laterals was reached. Treatment planning (based on the discussion with the patient ),resin composite veneering with minimal tooth preparation was planned.
 
 Figure 5
Figure 5


Procedure

Supragingival scaling followed by shade selection with vita classic shade guide was performed. Isolation of the operating area was achieved with cotton roles as the patient was experiencing gagging with rubber dam. Both maxillary central and lateral incisors were minimally prepared with a coarse diamond bur. A window preparation(Figure 2) was made to a depth roughly equivalent to half the width of the thickness of the facial enamel ranging from 0.5mm mid facially tapering down to a depth of about 0.2mm along the incisal edge.

A light chamfer finish gingival margin line was given and the preparation cleaned with pumice slurry , water washed and dried. The preparation was etched with 34% phosphoric acid for 30 seconds, rinsed with water and air dried. A single layer of bonding agent (Te – Econom bond) was applied according to the manufacturers direction and cured for 10 seconds in visible light source.

A thin layer of radiopaque hybrid composite ,A2-Ivoclair Te-Econom plus( Figure 3) was incrementally applied to the tooth surface and light cured for about 40 seconds. Finally finishing ,contouring and polishing was done with a super snap mini kit(Shofu)and polishing paste.at the end of the procedure clinical photographs were taken to evaluate the post operative smile design. (Figure 4 and Figure 5). Patient was recalled for post operative evaluation and check up after 1 week and after 4 months.

DISCUSSION

In this case we discuss the ability of a minimally invasive technique using a direct composite veneer to remove the fluorosis induced browns spots in an aesthetic and functional mannerIn cases of serve dental fluorosis the tooth enamel usually becomes porous and tooth whitening methods are not recommended as treatment. Treatment for severe cases of fluorosis requires covering the affected teeth with restoration, such as composite veneering / porcelain and full coverage are crowing.Direct composite veneers are becoming more popular in repairing cosmetic defects and to resurface teeth such as to make them appear straight and possess an aesthetically pleasing smile.5

Walls et al used resin composite laminate veneers for masking discoloration or hypoplasia of the anterior teeth of 68 patients clinical study showed that the gingival status of patients’ teeth improved significantly between the initial assessment visit and placement of the veneers. However, the veneer restorations showed a deleterious effect on the gingival health of the patients who were unable to maintain good oral hygiene.6

A light cured ,micro- hybrid composite, has excellent smoothness, strength, colour and is relatively easy to use. They require minimal removal of tooth structure and the colour and the blending of the restorative material can match almost any tooth colour and contour .7 Whereas ceramic veneers are more expensive as they involve custom impression in the dental office and custom fabrication by a dental laboratory technician. The patient very much appreciated the treatment as the discoloration of her dentition was quickly repaired with less cost. Patient was totally asymptomatic during the two month follow-up period and fully satisfied with the treatment provided.

CONCLUSION

Direct composite veneer restoration is a minimally invasive single visit technique in these conditions. And provides good esthetic result at the lesser cost.This minimally invasive technique is a better option in treatment of dental fluorosis compared to full crown,micro abrasion. however studies with larger sample size have to be performed on Indian population before it can become first choice of treatment.

REFERENCES
 
  1. Keri D, Direct resin veneers, a conservative research apporoach. Aesthet dentistry today 2009;33.
  2. Park’s text book of preventive and social medicine, 19th edition.
  3. AnjumS,Wadhwani K, Meena B. Treatment of generalized dental fluorosis with composite resin veneer using a minimally invasive technique: A case report and review.2012 Apr;1(1):40-3.
  4. Wahbi MA, Al Sharief HS, Tayeb H, Bokhari A. Minimally invasive use of coloured composite resin in aesthetic restoration of periodontially involved teeth: Case report. The Saudi Dental Journal. 2013 Apr 30;25(2):83-9.
  5. PincusCL,Building mouth personality, 1937.
  6. Walls AW, Murray JJ, McCabe JF. (1988) Composite laminate veneers: A clinical study. J Oral Rehabil 15: 439-454.
  7. Gordon J, Christensen. What is veneer? Resolving the confusing. Journal of American dentassociat 135(11): 1572-1576.

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