Minocycline Treated with Crowns & Veneers
Jane is a very attractive 30-year old woman. I had treated Jane when she was a child but had not had the opportunity of seeing her for many years. She sought me out in my Vancouver office due to a very unfortunate series of events. Jane had been prescribed Minocycline by her physician for acne. She had been taking the medication for 5 years. Six months before I saw her, a family member had noticed that the sclera (white part) of her eyes was discoloured and her skin appeared to have a blue-gray cast. Upon a closer look, her teeth also were darkly discoloured with a blue-gray tone. Jane had sought the advice of a local dentist who recommended she have veneers placed on all the affected upper and lower teeth to cover the deep, intrinsic staining. The treatment was undertaken but Jane was not happy with the result for various reasons and requested that the dentist re-do them. This was undertaken several times but Jane was concerned when the results were not getting better. She felt that the color that had been chosen for her was too white, the shapes were not right and that the upper teeth would not match the lowers. She felt the over-all result would end up looking unnatural. She stopped treatment with her dentist and would not allow the upper replacement veneers to be completed.
When I first saw Jane regarding her concerns she was justifiably upset and highly anxious. Jane knew my practice was focused on esthetic and restorative dentistry and wanted me to treat her.
During Jane’s first visit to my office I listened to her story and then had a look at her teeth. She had twelve temporary veneers/crowns on her top teeth and twelve completed porcelain veneers on her lowers. There was a lot of luting cement stuck between the lower teeth preventing her from cleaning properly and she was unable to bite properly as her front teeth did not meet. I could see very dark intrinsic stain (meaning it can’t be removed from the surface, that it is actually inside the tooth structure) on the inside surfaces of many of her teeth – a result of the Minocycline. Although it would be big job to re-do everything, Jane decided that was what she wanted. I explained that in a situation such as this when the teeth have been treated multiple times, it was possible root canals might become necessary on one or more of her teeth. She was willing to accept the risk to get a healthy, functional and pretty smile. She was very clear how she wanted her teeth to look, what shade they should be and how they should be arranged; this information is always very helpful as it makes it easier to give someone what they want when they are clear about it!
We began with a comprehensive exam and full records – x-rays, photographs, bite registrations and mountings, perio charting etc. Unfortunately I was unable to photograph the initial condition of the stained teeth as by the time I saw Jane she already had veneers in place. The stain was clearly visible, however, on the lingual/palatal surfaces of the teeth. Jane then saw our hygienist to try and remove some of the cement that was stuck between her teeth so that the gums would be healthier when we started restorative treatment. Diagnostic wax-ups were created at my lab and Jane came in to see the wax-ups to ensure that she approved the shapes of the teeth. We were planning to treat all 24 teeth the same day – a challenging task but Jane was eager to get through the process as quickly as possible. Often it is easier to manage a case this way and control any necessary changes to the bite.
On the day of her appointment we got Jane settled; a warm blanket and NuCalm helped her relax. The upper temporary veneers were cut off in sections with care being taken to maintain the desired bite position. Underneath the temporary veneers and crowns the dark stain due to the Minocycline was clearly evident; all the upper teeth were affected. The challenge was going to be how to block out the dark stain and yet build some natural translucency on top so that the final result mimicked natural tooth structure and didn’t look too opaque. The tooth preparations were finalized and an impression obtained.
The lower porcelain veneers were then cut off, also in groups, and the bite registration re-lined each time. The lower teeth exhibited intrinsic stain also, but to a lesser degree than the uppers. The teeth were further prepared and a lower impression obtained of the final preps. Photographs were taken to record the underlying colours of the teeth so the lab knew what colour they were building upon. Registrations were also made that related the plane of the teeth to the horizontal.
Provisional restorations were then made from putty matrices that had been fabricated from the diagnostic wax-ups. The bite was checked and Jane was re-appointed a few days later so we could evaluate the esthetics and function of her provisionals when she was no longer numb and when she had had a chance to get to know her new smile. If necessary we could then make changes to the provisionals (length, shape, bite) and communicate these changes to the lab before the finalization of the veneers in porcelain. After a few minor adjustments at this follow-up appointment, photographs and impressions of the provisionals were obtained and sent to the lab with instructions to mimic the provisionals. This process of using the provisionals as a “trial run” allows both the patient and the dentist to preview the final result and ensures a predictable result.
About 2 weeks later, Jane came back to have the new porcelain veneers/crowns inserted. After numbing the teeth, the upper provisionals were carefully removed, the teeth cleaned and disinfected and each veneer tried in for fit. Once it was established that each one fitted well, they were all tried in together and evaluated again for fit and for esthetics. Jane was happy with the appearance so we proceeded to bond them into place. A rubber dam was placed to provide a dry field without any contamination from saliva and to prevent any of the materials we used from being swallowed or inhaled. The veneers were cleaned inside with ortho-phosphoric acid, silanated and primed with resin. The teeth were cleansed, disinfected, etched with ortho-phosphoric acid, primed and bonded. A light-cure luting resin was then used to bond the veneers to the teeth. They were all seated at once using the “rapid bonding technique”, excess resin cleaned away and then tacked into place with a curing light. The remaining excess resin was removed with care taken to ensure no resin remained between the teeth and the resin was then completely light-cured.
This process was repeated for all the lower teeth.
Once all the veneers were luted into place the bite was carefully checked and adjusted. A follow-up appointment was made to check the final result about one week later.
Both Jane and I were happy with how her teeth turned out. She was extremely pleased with the shape and shade she had chosen. It is not an easy task to block out a dark sub-structure and still create something that has natural translucency and appears life-like. The ceramists at my laboratory did an exemplary job.