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UK. He graduated from
Leeds University Dental School in 1976. In etracycline broad-spectrum antibiotics calcium ions and to be incorporated into teeth,
1986 he joined Hong Kong University where were introduced in 1948 for use in the cartilage and bone, to form a tetracycline-cal-
he is currently an Associate Professor. He treatment of many common infections cium orthophosphate complex (Eisenberg
holds the Fellowship in Dental Surgery and found in both children and adults. All tetracy- 1975) resulting in discoloration and enamel
Membership in Restorative Dentistry from cline compounds consist of four fused cyclic hypoplasia of both the primary and permanent
the Royal College of Surgeons of Edinburgh rings, hence the name tetracyclines. They have dentitions if administered during the period of
as well as an MBA, with Distinction, from
been found to have a number of systemic side tooth development. The ability of tetracycline
the University of Warwick Business School
effects – for example, pregnant women are par- to intrinsically stain teeth during odontogen-
and a PhD from The University of Bradford
Management Centre. He has written four ticularly susceptible to tetracycline-induced esis has been well-known for almost five dec-
dental textbooks and he maintains a thriving hepatic damage (Madison 1963). These drugs ades (Schwachman 1956; Davies 1962).
private practice focusing primarily on aes- also cross the placenta and can have toxic ef- The severity of the discolouration is consid-
thetic dentistry and is particularly interested fects on the developing foetus, and are there- ered to be related to dose, frequency, duration
in the current ethical debate over the use of fore contraindicated during pregnancy. There of therapy and critically the stage of odon-
porcelain veneers to Œtransform¹ smiles. has been a resurgence of interest in the tetracy- togenesis. The calcification of deciduous teeth
cline group of drugs since their recommenda- begins at approximately the end of the fourth
Linda Greenwall BDS
tion for use in combination therapy for bone month of gestation and ends at approximately
MGDS MRD MSc
metastasis (Saikali 2003) and in the treatment 11–14 months of age. Permanent teeth begin
FFGDP is a specialist
in Prosthodontics and and prophylaxis of tubercuosis, anthrax and calcifying after birth and are not affected by
Restorative Dentistry malaria. Tetracycline antibiotics are still com- exposure to tetracycline during the prenatal
and runs a multi disci- monly used in the treatment of acne in adoles- period. The calcification of permanent teeth is
plinary private practice cents and young adults. This long term used of completed at seven to eight years of age with
in Hampstead, London. tetracycline in particular Minocyline (Minocin) the exception of the third molars (Jackson
She is editor in chief of which is a semi synthetic tetracycline deriva- 1979; Mello 1967). Therefore, the administra-
Aesthetic Dentistry Today tive can also cause staining of the adult teeth tion of tetracycline to pregnant women must
magazine and has written a book called
(Cheek and Heymann 1999). be avoided during the second or third trimes-
ŒBleaching Techniques in Restorative
ter of gestation and to children up to eight
Dentistry an Illustrated Guide which was
awarded Best New Dental Book of the Year Effects of tetracyclines on teeth years of age because it may result in discolora-
2001. Linda lectures all over the world on One of the most obvious and well-docu- tion and enamel hypoplasia (Conchie 1970).
all aspects of combining Bleaching with mented side-effects of tetracycline use is it’s Enamel hypoplasia may, of course, be also the
Aesthetic and Restorative Dentistry. She is incorporation as a fluorescent pigment into result of childhood disease, hereditary defects
also the President of the British Bleaching tissues that are calcifying at the time of admin- in enamel formation or prematurity of the
Society. istration (Figure 1). It has the ability to chelate child; all of which are known to cause enamel
Figure 6d Figure 6e
Figure 6a-e: Direct composite has been placed, unsuccessfully, at some point in the past to try and mask tetracycline Figure 7: An occlusal view showing the huge difference
discolouration. E.max press veneers using opaque ingots combined with a covering layer of more aesthetic porcelain in colour between ceramic veneers and the underlying
were placed to produce a much more satisfactory result. Note the dark colour of the prepared teeth tetracycline-affected teeth. It is important that such
transitions are kept out of sight as much as possible
els of discolouration and increasingly, their create more space for the ceramic, thus allow- Alumina (Nobel Biocare) are better placed to
use is combined with tooth-whitening con- ing the technician to maximise the aesthetic mask out dark underlying hues. While zir-
ducted over a considerable period of time (as possibilities provided by modern porcelain conium-based polycrystalline ceramics such
described above) prior to tooth preparation. materials. The difficulty with this approach as 3M’s Lava and Dentsply’s Cercon are to-
Should bleaching be carried out is important is that dentine provides a weaker bond and tally opaque they cannot be etched to provide
to leave a period of at least two weeks between there is a greater risk of failure. Another sig- a micromechanical bond and so are not used
the final bleaching and bonding otherwise nificant issue is that as one cuts further into in laminate veneers. It is beyond the scope of
the bond strength will likely be compromised tetracycline-affected dentine the darker it usu- this paper to give a detailed account of veneer
(Titley 1988). It is now generally accepted that ally becomes (Figure 8). Attempts have been preparation but whichever ceramic system is
the highest levels of retention occur when a made to overcome these difficulties by cutting chosen the normal principles of veneer prepa-
veneer is bonded to a predominantly enamel a standard veneer preparation and then ei- ration should be followed (Newsome (b&c)
substrate (Friedman 1998). While this is usu- ther bleaching the tooth prior to cementation 2008) paying particular attention to the fol-
ally no problem and perfectly manageable in (Sadan 1998) or carrying out what is referred lowing:
‘normal-coloured’ teeth, in tetracycline-af- to as sub-opaquing i.e. the selective removal
fected teeth, however, there is considerable of the darkest bands of dentine and replace- • Preparation margins should be placed slight-
risk that the dark shade of the underlying ment with a lighter composite (Nixon 1996). ly sub-gingivally and interproximally to hide
preparation will shine through the relatively The latter can be done either at the tooth the transition between veneer and dark tooth.
translucent porcelain. Ways around this in- preparation phase or, as has been advocated • If using a material such as Procera, which
clude using more opaque ceramics and luting recently, at the cementation phase, in order to requires the model to be scanned, make sure
agents, cutting deeper into the tooth to allow a) prevent the provisional veneers adhering to that all margins are very clear, that the cham-
a greater thickness of overlaying ceramic or the composite restoration and b) enhance the fer does not become a weak ‘J’ margin with
manipulation of the prepared tooth to lighten bond strength achieved by removing the need unsupported enamel that the scanner cannot
its shade. Each one of these is not without to etch and silanate the freshly-placed com- register. Similarly, it is usually advisable to
problems. Thus, opaque porcelains and luting posite (Lowe 2005). break the contact points so that the scanner
agents can, without care, appear rather lifeless Should veneers be the treatment of choice can detect the margins fully. This also helps to
and any visible transition between veneer and then the question arises as to which ceramic hide the interproximal margins.
underlying tooth can be extremely noticeable system is the most appropriate (Newsome (a) • The shade of the prepared tooth (if possible
(Figure 7). Many patients however, are just 2008). Clearly, in most cases, highly translu- together with photographs) should be sent to
relieved to free of the stigma of dark teeth, re- cent ceramics are not recommended and for the laboratory to help them achieve the best
lieved simply to have ‘white teeth’ at last and this reason moderately filled glasses materi- possible result.
often do not comment negatively about such als such as IPS Empress I (now branded as • At the bonding stage it is vital to use a selec-
lack of characterisation. In other words, our Empress Esthetic) are unsuitable as they allow tion of different water-soluble try-in pastes to
expectations as professionals may differ from too much of the underlying discolouration to determine the most appropriate shade of lut-
those of our patients. The second alternative shine through. More opaque systems such ing cement. The more translucent the veneer
is to cut deeper into tooth tissue in order to as IPS Empress 2 (E.max Press) and Procera the more critical this step becomes.