Case Study: Severe Drug Induced / Antibiotic Induced Discolouration and Crooked Teeth

This patient initially presented for improving severe drug/antibiotic induced discolouration, hence the aesthetic appearance of upper teeth. The lower teeth were of a lesser concern at this stage, however tooth whitening is also anticipated in the lower arch.

Before Severe Tetracycline Discolouration & Crooked Teeth


Following examination: x‐rays, photos, study models and composite mock up, we confirm the following:

1. Moderate to high smile line with upper teeth midline is in symmetry with upper lip. During full smile we have symmetrical exposure of gums. However the narrow upper arch gives the effect of dark lateral corridors combined with discolouration and chipped restorations. Teeth do affect aesthetic display of a smile. Patient commented ” I have forgotten how to smile”. Following composite mock up we agreed with the colour, level and arrangement of tooth display, improving the arch width, shape and teeth exposure and guiding the gum level recontouring.

2. The periodontal health is adequate. Teeth (14, 24, 35, 36 & 46 are missing) most back teeth are restored with amalgam and tooth coloured restorations. All teeth tested vital.

3. Normal range of craniomandibular (jaw) movements: function. Patient also tends to brux (grind) and clenches her teeth; which would have contributed to the chipping of upper restorations and teeth.

This patient initially presented for improving severe tetracycnine discolouration, hence the aesthetic apperance of upper teeth. The lower teeth were of a lesser concern at this stage, however tooth whitening is also anticipated in the lower arch.

Note the presence of severe & uneven teeth wear: affecting teeth display during static and dynamic tooth exposure.

Treatment should be directed to complementing patients dentofacial aesthetics and not simply white‐ straight teeth.

Generally patients with severe tetracycline discolouration wish to have very white teeth. This is simply a reaction to the discolouration problem. Therefore I consider very white mock up tooth coloured material to allow patients make their own decisions. It is usual after the mock up for the patient to sat, “yes Dr Nalbandian I agree this is too white, let’s look at natural tooth shades”

The composite mock up helps Dr Nalbandian and the patient to “test” the system: we test speech and smile dynamics and patient’s degree of habituation.

Treatment proposed as per composite mock confirmed amount of gum and tooth exposure required for improved aesthetics and lip support. Teeth: 13, 12,11,21,22 & 23 require porcelain veneers with minimal tooth intervention (since we are building the teeth outward) and teeth 15, 16, 25 & 26 composite veneers. This treatment plan would also reduce the cost of the procedure.

Following considerable discussion regarding various options of treatment including no treatment, composite veneers, orthodontics/orthognathic surgery, we decided to proceed with restorative treatment using porcelain veneers on teeth (13,12,11,21,22 & 23) and composite veneers on teeth (16, 15, 25 & 26) for improving overall tooth symmetry, arch form, tooth colour arrangement to improve function and aesthetics.

As always, following cosmetic dental procedures a habituation period of few days is anticipated. Any sensitivity, if present is usually transient.

Any bruxing/grinding habits will compromise the future longevity of your restorations and your dentitions as a whole. A night guard will be provided to control any bruxing.

The treatment fee is:

1. Porcelain veneers teeth: (13, 12, 11, 22 & 23). Composite veneers on teeth (16, 15,25 & 26) Fee is Items 583×6/583×4

2. Night guard will be provided. ‐ Item 965

3. Lower arch: tooth whitening only included in the treatment.

Dr Nalbandian has explained to our patient that extensive tooth invasion would lead to possible tooth sensitivity that may affect the tooth vitality and unnecessary future root canal treatment. Therefore minimal intervention is considered in both replacement of upper veneers and improvement in colour. It is also difficult to assess if there will be changes in the pulpal (tooth vitality status) before, during and after the completion of the proposed dental treatment. It is recognized in the international dental literature that there is a 10% chance of possible postoperative sensitivity that may require root canal therapy on teeth which have had extensive preparations. This may not be in this case per se, however due to difficulty in diagnosing future problems, should they arise and require treatment such as root canal therapy, unfortunately further fees may be incurred. The use of a night guard would be most advisable. This prevents nocturnal grinding and hence premature wear of teeth and chipping of veneers.

We pride ourselves with the quality of dentistry we provide however, there are always limitations placed on us by materials and oral environment. One can be reassured at the end of the treatment that all should be well, however if anything unexpected does show up or unusual symptoms occur within 3 years, please let me know. We are always here to look after you. Regular 6 monthly check‐up and maintenance visits help to enhance the longevity of the restorations and your oral health.

Note how we completed these aesthetic procedures and achieved the following:

1. Softening of the smile 2. Improved dentofacial aesthetics complementing patient’s facial beauty. 3. Creating symmetry, harmony and pleasant tooth display across the midline. 4. Improved tooth colour, form and shape. 5. Improved the smile from all angles; frontal oblique and lateral. Most importantly the patient agreed with Dr Nalbandian’s suggestions and underwent full treatment planning as per diagnostics, which complemented final aesthetics.

Special feldspathic porcelain Veneers were constructed by our master technicians.

Note how the upper smile is contained within the lower lip and how it complements this patient’s facial aesthetics. Final ultrathin veneers bonded to the tooth enamel. The whole procedure was accomplished in two visits and no injections, why? Because of careful planning, diagnostics such as composite mock up to assess the final smile line and aesthetics. We were able to determine the minimal amount of tooth intervention required to achieve optimal aesthetic and functional outcome for the patient. Please refer to diagnostics: direct composite mock up.

One Smile says it all!

All above procedures were performed by Dr Sarkis Nalbandian.

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