permanent results may not be realistic in the young patient; however, significant
improvements are achievable which do not compromise the teeth in the long term.
The approach to treatment for all forms of discolouration should be cautious, with the
emphasis on minimal tooth preparation. For example, in a case of fluorosis the
microabrasion technique may produce some improvement but the patient/parent may
still be dissatisfied. Composite veneers can then be placed, although if the child
requires subsequent fixed appliance treatment these may be damaged and require
replacement before placing porcelain veneers as the definitive restoration in the late
teenage years.
Discolouration originating in the dentine is often difficult to treat. The single, non-
vital dark incisor presents particular problems. In the young patient, the apex may be
immature, root canal therapy incomplete, and non-vital bleaching therefore precluded.
A composite veneer can improve the aesthetics but may fail to adequately disguise the
discolouration even with the use of opaqueing agents. Ultimately, a jacket crown may
be the best option in the older patient. Similarly, moderate-to- severe tetracycline
discolouration, which fortunately is less common today, is very difficult to treat in the
young patient. Long-term full crowns or porcelain veneers often provide definitive
treatment, but composite veneers can be acceptable in the adolescent without
completely masking the underlying discolouration (556HFig. 10.13 (a)-(c)). Indirect
composite veneers, placed with minimal tooth preparation, may be useful in the
management of this problem but this technique has yet to be evaluated.
Key Points
- Microabrasion should be the first line of treatment in all cases of enamel opacities.
- Composite should be used in preference to porcelain in children.
Finally, it is very important to bear in mind the expectations of the patient and, often
more importantly, the parent. An unrealistically high expectation of brilliant white
'film star' teeth will result in postoperative disappointment. For instance, in fluorosis
cases it is the excessively white, mottled areas which will be removed by the
microabrasion technique resulting in a uniform colour that is the same as the original
background colour, but some patients will feel their treated teeth are 'too yellow'.
Adequate preoperative explanation, preferably with photographic examples, may help
to minimize this problem. Nevertheless, there will remain a group of dissatisfied
patients and for medico-legal reasons careful documentation of all cases of cosmetic
treatment should be kept.
557H
Fig. 10.13 (a) Severe tetracycline discolouration in a 14 year old. (b) Composite
veneers placed under opaqueing agents to mask the discoloration. (c) Porcelain jacket
crowns were provided at 20 years of age.