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Consultant/Senior Clinical Lecturer in Restorative Dentistry, Bristol University Dental Hospital and School, University Hospitals Bristol NHS Foundation Trust, Lower Maudlin Street, Bristol BS1 2LY, UK
This is the second article of a two part series covering the aetiology, prevention and broad range of management options for the single discoloured tooth. The article covers situations where masking and simulation techniques with direct composite are required. Direct composite, indirect composite and ceramic veneers are then considered, as well as full coverage crowns. The option of extraction of the affected tooth and its prosthodontic replacement will also be considered. Clinical cases are used to illustrate various scenarios.
Clinical Relevance: The single discoloured tooth is a commonly encountered clinical problem in general dental practice. A wide variety of management options exist and it is recommended that general dental practitioners consider adopting minimally invasive techniques in the first instance before moving on to more invasive therapies.
Article
This is the second article of a two part series on management of the single discoloured tooth. It considers direct restorative options as well as indirect restorative options that involve teamwork with a suitable dental laboratory. It is assumed that the minimally invasive restorative techniques considered in part one have been exhausted, have not been successful or are judged to be unsuitable for the particular case. As described in part one, the logical approach suggested is a ‘crescendo’1 with less invasive techniques being considered first before moving towards techniques that are more destructive of tooth tissue. The overall hierarchy of treatment options is demonstrated in Figure 1. The aim of this article is to outline the final four restorative options in the hierarchy and consider their relative indications and contra-indications.
This is the direct application of a thin film of composite over the entire labial aspect of a tooth in order to modify the contour and/or shade. As for megabrasion,2 a preliminary single tooth bleaching treatment may be indicated to raise the value of the tooth shade so that a thinner layer of composite may be applied to mask the discoloration and reduce the likelihood of the tooth appearing over-contoured. For worn teeth or teeth with areas of hypoplastic or pitted discoloured enamel, the technique has the advantage of managing the deficient contours as well as the shade. It is particularly applicable for young patients with teeth which are minimally or unrestored since it preserves tooth tissue. Direct composite veneers can be placed with no or minimal tooth preparation in a single appointment, often with no local anaesthetic. The final labial contour is best placed in one increment to avoid voids3 and the interface between increments attracting stains and becoming visible. With experience and using a stratified technique4 composite veneers can be highly aesthetic. Nalbandian and Millar5 found, in a survey of patients who received maxillary anterior veneers, that the choice of material (direct composite resin versus porcelain) did not significantly affect the patient's perception of cosmetic improvement. A Cochrane review6 found that there is no reliable evidence to show a benefit of one type of veneer restoration (direct or indirect) over the other with regard to the longevity of the restoration.
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