esthetic rehabilitation of

Tetracycline-Stained and Worn Teeth with

Porcelain laminate Veneers
Kazunori Matsumoto, RDT1

A
37-year-old female patient presented to the
dental clinic with a primary complaint of heav-
ily stained anterior teeth and misaligned denti-
tion. Clinical examination revealed heavy tetracycline
staining and attrition of anterior teeth (Fig 1).
Functional examination revealed protrusive move-
ment guided by the maxillary right second molar
and the mandibular right third molar and right lateral
movement guided by the maxillary right second mo-
lar and the mandibular right second molar. No ante-
1
Soejima Dental Clinic, Kumamoto City, Kumamoto, Japan.
Correspondence to: Kazunori Matsumoto, Soejima Dental Clinic,
7-7 Kyozukahonmachi, Kumamoto City, Kumamoto, Japan.
Published originally in the Japanese QDT (2009;34[May]:83–90).
rior guidance was found (Fig 2). The patient rejected
orthodontic treatment due to the duration and cost of
treatment.
TreaTmenT Plan
First, the mandibular right third molar was extracted
to eliminate the interference during protrusive move-
ment, thus establishing anterior guidance. A diagnos-
tic wax-up was fabricated after minimum occlusal ad-
justment on mounted study casts (Fig 3). Based on the
diagnostic wax-up, the treatment plan was to restore
the six maxillary and mandibular anterior teeth with
porcelain laminate veneers (PLVs), which are minimally
invasive.

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 esthetic rehabilitation of Tetracycline-Stained and Worn Teeth with Porcelain laminate Veneers

1a 1b 1c

1d 1e
Figs 1a to 1e Preoperative views. Heavy tetracycline stain-
ing and incisal abrasion are evident.

a b

Figs 2a and 2b Study casts mounted on the articulator. Interferences are found between the maxillary right second molar
and the mandibular right third molar at protrusive movement and the maxillary right second molar and the mandibular right
second molar at right lateral excursive movement. There was no anterior guidance.

a b c

Figs 3a to 3c Diagnostic wax-up. Interferences were eliminated on mounted casts. Crown length of maxillary and mandibu-
lar anterior teeth and the palatal surfaces of maxillary anterior teeth were improved.

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 MATSUMOTO

Figs 4a to 4d Tooth preparation.

A minimum but adequate amount of
reduction was carried out according to
the diagnostic wax-up.

Figs 5a to 5c Provisional restorations

were fabricated according to the diag-
nostic wax-up. Proper anterior guid-
ance, incisal line, and tooth shape were
established.
4a 4b

4c 4d

5a 5b 5c

TooTh PreParaTion and FabricaTion oF PlVS

ProViSional reSToraTion
In-office bleaching was performed prior to tooth
preparation. Abutments were minimally prepared ac-
cording to the diagnostic wax-up (Fig 4). A diagnostic
wax-up is an essential guide to control the amount of
tooth reduction so that uniform thickness of the final
restoration can be maintained.
A silicone index of the diagnostic wax-up was used
to fabricate a direct acrylic resin provisional restora-
tion. Tooth form was carefully adjusted to be in func-
tional and esthetic harmony with the patient’s lip and
smile line. Anterior guidance was established (Fig 5).
The provisional restoration was mechanically retained
with undercuts from the interproximal area without
spot etching.
Information obtained chairside from the provisional
restoration needs to be precisely transferred to the
laboratory. This information provides a clear goal for
the technician.
There are several techniques to fabricate PLVs (eg,
gold foil, refractory die, press ceramic), all of which
have advantages and disadvantages. Due to the pa-
tient’s high esthetic demands, feldspathic ceramic
with the refractory die technique was selected in this
case because it offers excellent reproducibility of
color and fit.

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 esthetic rehabilitation of Tetracycline-Stained and Worn Teeth with Porcelain laminate Veneers

6 7

8 9

Fig 6 Trimmed master dies and duplicated refractory dies. Antirotational grooves were provided.

Fig 7 Trimmed master dies were placed into the final impression and secured with wax, and then stone was poured.

Fig 8 Master cast without trimmed dies. The marginal soft tissue is well reproduced. Antirotational grooves are evident.

Fig 9 Maxillary and mandibular master casts mounted on the articulator. The emergence profile of the final restorations can
be predictably achieved with this technique.

FabricaTion oF maSTer caSTS ceramicS and color

The refractory die technique was used to fabricate
master casts (Figs 6 to 8). Soft tissue casts with silicone
rubber often cause discrepancies. In cases of multiple
adjacent restorations, such discrepancies could criti-
cally affect the form of restorations.
A solid stone tissue cast is highly accurate, allowing
for the emergence profile of the final restorations to
be formed in a predictable manner.
Duplicate casts of provisional restorations and mas-
ter casts were cross-mounted (Fig 9). The silicone in-
dex of the provisional restorations was used to provide
information for the final restorations.
In cases that require a natural-looking white shade,
simple masking with opaque ceramics is not sufficient
to utilize the light-transmission properties of the abut-
ment. Abutment shade after preparation is an impor-
tant factor to determine the layering of ceramics. In
this case, the cervical areas of the maxillary anterior
teeth were not severely discolored. It was determined
that a masking procedure was unnecessary. Wash-
bake and transparent ceramics were built up to utilize
the lens effect.
Value was controlled by using opaque dentin ce-
ramics at the incisal areas and heavily discolored ar-

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 MATSUMOTO

10 11

12 13

Fig 10 Wash-bake and opaque dentin ceramics must be layered carefully to control light reflection from the abutment (Cre-
ation: H51 + CL-O (1:1) for wash-bake and ODA1 for ODA1 for opaque ceramics).

Fig 11 Dentin layer buildup. Dentin ceramic is built up in full contour according to the provisional restorations (Creation:
AD1, DA1, and DA2).

Fig 12 Less than the usual amount of dentin ceramic was cut back due to the strong color of the abutments. At the incisal
edges, the mamelons were shaped to control to the transparency of the Creation system.

Fig 13 Enamel layer buildup. It is important not to overbuild ceramics when fabricating PLVs.

eas (Fig 10). Mandibular anterior teeth usually have a
slightly higher value than maxillary anterior teeth, so if
ceramics are layered exactly the same way in regions,
it may result in discrepancies in chroma after cemen-
tation. Therefore, ceramics with slightly lower chroma
were chosen for the mandibular restorations than those
used for the maxillary restorations. The choice of resin
cement is also important to compensate for the color
discrepancy. In the incisal areas, ceramics were built up
to achieve gradual light reflection (Creation Porcelain
System, Jensen Dental, North Haven, CT, USA).
Layering of dentin ceramics has a great influence
on the value and chroma of final restorations. Extra at-
tention was paid to the thickness of the dentin layer
(Fig 11). During the cut-back procedure, more than the
usual amount of the dentin layer was left untouched
to obtain the desired color, considering the shade of
the mandibular abutments (Fig 12). Staining (Creation)
was applied to heavily discolored portions of the inci-
sal area to prevent a monotone color.
For enamel ceramics buildup, ceramics with lower
chroma were chosen for mandibular restorations than
those for maxillary restorations to compensate for the
color discrepancy between maxillary and mandibular
abutments (Fig 13).

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 esthetic rehabilitation of Tetracycline-Stained and Worn Teeth with Porcelain laminate Veneers

a b

c d

Figs 14a to 14d Postoperative views.

Thus, ceramic buildup for PLVs is influenced not only
by the color of the abutment, but also by the design
of the preparation and amount of reduction. The usual
amount of reduction at the cervical area is 0.5 mm with
a right chamfer margin, unless drastic color modifica-
tion is indicated. If this area is overprepared, transpar-
ent ceramics, which can lower the value of restorations
due to excessive light transmission, should be used
minimally. Body ceramics, which have low light trans-
mission, are required according to the amount of re-
duction.
age the restoration during removal of this material.
The final adjustment is performed on the master cast
under microscope. The characterized surface must be
mechanically polished before self-glazing. The author
performs self-glazing at about 10°C lower than the fir-
ing temperature of body ceramics and for a slightly
longer time (with different glazing times for anterior
and posterior teeth).
In some cases, surfaces in interproximal and cervical
areas are porous, making the area difficult to polish.
Glazing powder (Creation Make Up Instant) is an ef-
fective solution to achieve smooth surfaces in those
situations.

oTher laboraTory
conSideraTionS
Final reSulTS
The disadvantage of the refractory die technique is the
difficulty in adjusting shape and color after removing The patient was very satisfied with the esthetics of the
the refractory material. Care must be taken not to dam- final restorations (Figs 14 to 16). Smooth mandibular

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 MATSUMOTO

Figs 15a and 15b Pre- (a) and postop-

erative (b) mounted casts.

Figs 16a and 16b Pre- (a) and postop-

erative (b) extraoral views.

15a 15b

16a 16b

excursive movement was established by providing bibliograPhy

anterior guidance. The patient, who had been coping
with the appearance of her anterior teeth for a long
time, is undergoing smile training.
acknoWledgmenTS
The author would like to thank Dr Masakazu Soejima, owner of
the Soejima Dental Clinic, for his guidance, as well as Ms Miyoko
Uemura, dental hygienist, and all staff members of Soejima Dental
Clinic for their help organizing the clinical information.
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