CLINICAL
Aesthetic dentistry
Improvement of aesthetics in a patient with
tetracycline stains using the injectable composite resin
technique: case report with 24-month follow-up
Jorge Cortés-Bretón Brinkmann,*1 Maria Isabel Albanchez-González,2 Diana Marina Lobato Peña,3 Ignacio García Gil,2,4
Maria Jesús Suárez García5 and Jesus Peláez Rico6
Key points
Describes injectable composite resin technique
as an aesthetic treatment option for generalised
tetracycline dental stains.
Highlights the advantages and disadvantages
of this injectable flowable composite technique
compared with other more conventional
techniques.
Emphasises the importance of long-term
monitoring of the technique due to its unknown
longevity.
Abstract
This case report describes the conservative management of generalised tetracycline stains by means of the injectable
composite resin technique. This time-efficient technique obtained optimal and satisfactory aesthetic outcomes. Both
the patient and the clinician were very satisfied with the results. Composite veneers realised with injected flowable
resin composites are an effective treatment, with minimally invasive possibilities, providing the case selection protocol
is correct. In addition, it can be considered as a more economical treatment option.
Introduction
Tetracyclines are a broad-spectrum group of
antibiotics originally found in the products of
Streptomyces bacteria and used to treat many
common infections. This antibiotic is deposited
within the forming teeth and intrinsic staining
may result.1,2,3
Depending on the severity of the staining,
therapeutic options vary from simple
microabrasion to vital or non-vital bleaching,
ceramic veneers, full-coverage crowns,
Researcher/Assistant Professor, Department of Dental
Clinical Specialties, Faculty of Dentistry, Complutense
University of Madrid, Spain; 2Master Program in
Buccofacial Prostheses and Occlusion, Faculty of Dentistry,
Complutense University of Madrid, Spain; 3Master
Program in Orthodontics and Orthopaedics, Faculty of
Dentistry, Oviedo, Spain; 4Master Program in Advanced
Oral Implantology, European University of Madrid, Spain;
5
Full Professor of Oral Prosthodontics, Department of
Conservative Dentistry and Orofacial Prosthodontics,
Faculty of Dentistry, Complutense University of Madrid,
Spain; 6Assistant Professor, Department of Conservative
Dentistry and Orofacial Prosthodontics, Faculty of
Dentistry, Complutense University of Madrid, Spain.
*Correspondence to: Jorge Cortés-Bretón Brinkmann
Email address: brinkmann55@hotmail.com
1
Refereed Paper.
Accepted 13 July 2020
https://doi.org/10.1038/s41415-020-2405-x
774
or even a combination of several of these
techniques.2,3,4,5
In aesthetic dentistry, the predominant
trends are the minimally invasive treatments,
aiming to remove the least possible amount
of the dental structure, while obtaining
aesthetically satisfactory outcomes. Ceramic
veneers are indicated as a minimally invasive
treatment and are the first option because
of their mechanical properties and aesthetic
longevity. In addition, they have been
successfully used in tooth discolouration
cases.5 However, with the recent improvements
in composite resin properties, composite
veneers are increasing in popularity since
they show some advantages: they are easy to
lute and repair, have higher flexural modulus,
are cost-effective and are less abrasive to the
antagonistic teeth.6 The injectable composite
resin technique is a direct/indirect method
in which a transparent silicone index is used
to transfer the exact shape of the diagnostic
wax-up to create definitive composite
restorations as predictably as possible.
This technique can be used for definitive
restorations as well as temporary restorations
and even in cases with reduced vertical
dimensions.7,8,9,10 Flowable composites have
previously shown clinically acceptable
physical properties as filling materials,
similar to the conventional ones.11,12,13,14,15 The
present case report describes the use of the
injectable composite resin technique to treat a
52-year-old patient presenting compromised
aesthetics deriving from tetracycline dental
staining. As far as the authors are aware,
this is the first ever case report to describe
treatment of tetracycline staining with this
technique.
Case report
A 52-year-old woman, a non-smoker without
medical antecedents of interest (ASA I),
came to the dental clinic seeking treatment
to improve her smile aesthetics. The patient
was unhappy with: 1) tetracycline dental
staining; and 2) the shape, size and position
of the teeth. Clinical examination observed
grade II–III generalised tetracycline staining
(Boksman and Jordan classification, 1983)16
and slight dental malpositions (Fig 1). Having
completed a thorough examination of the
case, two treatment options were considered.
The first option was to place ceramic veneers
and the second to use composite veneers.
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Aesthetic dentistry
The latter offered the advantages of more
conservative dental preparation possibilities
and lower economic cost for the patient. 4
Moreover, composite restorations make any
alterations, readjustments or repairs much
simpler.
As the case would involve the anterior
region and first premolars in both mandible
and maxilla, with the patient’s agreement it
was decided to opt for the injectable composite
resin technique, since this offered, as the patient
requested, the fastest, more conservative and
more economical option. The patient accepted
this technique, mindful that it was a new and
little documented option, especially for cases
like hers. Consequently, we highlighted the
paramount importance of periodic follow-ups.
At the first appointment, photographs were
taken to help design the patient’s smile. All the
information needed to fix patient dental casts
in a semi-adjustable articulator was recorded:
dental impressions of heavy and light body
polyvinyl siloxane (3M Express, 3M Espe,
3M, Saint Paul, Minnesota, USA), facebow
and maximum intercuspation wax bite
registration. The maximum intercuspation
relation was used since the patient’s occlusion
was stable and it was not planned to modify
her occlusal pattern. The Vita Classical
A1–D4 shade guide (Vita Zahnfabrik, Bad
Säckingen, Germany) was used to select
the correct shade: A1 shade for incisors and
premolars, and A2 for canines.
After detailed analysis of these registers, a
diagnostic wax-up was made for 16 composite
vestibular veneers, located in the upper and
lower anterior sectors (teeth 14, 13, 12, 11,
21, 22, 23, 24 and 34, 33, 32, 31, 41, 42, 43,
44), making sure they were consistent with
functional movements in the articulator,
and following the established parameters
and principles of smile aesthetics.17,18 The
restoration margins were planned in juxtagingival position.
To check aesthetic and occlusal parameters
before fabricating the definitive restorations, a
mock-up (Fig. 2) was created, transferring the
wax-up to the mouth using a silicone index
made from heavy and light body polyvinyl
siloxane (3M Express, 3M Espe, 3M, Saint Paul,
Minnesota, USA) and A1 shade self-curing
resin for provisional restorations (3M Protemp
4, 3M Espe, 3M, Saint Paul, Minnesota, USA).
At this point, the mock-up was examined to
ensure that, with this shade, the tetracycline
stains would be adequately masked, as well
as to confirm the choice of selected shades
CLINICAL
Fig. 1 Intraoral front view of patient before treatment
Fig. 2 Diagnostic wax-up of the maxillary teeth
Fig. 3 Definitive maxillary veneers using the injectable resin composite technique – frontal
view (close-up)
Fig. 4 Definitive upper veneers – lateral view (close-up)
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CLINICAL
Aesthetic dentistry
Fig. 5 Silicone index of the lower teeth made with transparent silicone
Fig. 6 Vestibular preparation of the lower anterior sector – frontal view (close-up)
Fig. 7 Definitive upper veneers and vestibular preparation of the lower anterior sector
for the definitive veneers. At the same time,
the length and shape of the teeth, lateral
movements, protrusion movement, maximum
intercuspation and thickness of the veneers
were checked.
776
As soon as the clinician and patient were
satisfied with all parameters, the definitive
veneers were fabricated using the injectable
composite resin technique (Figures 3 and
4). A silicone index of the diagnostic wax-up
was made with transparent silicone (Exaclear,
GC Corporation, Tokyo, Japan), loaded in a
Rim-Lock non-perforated metal impression
tray (Fig. 5). The flowable composite injection
holes were drilled with a fine chamfer diamond
bur, positioning them level with the incisal
edges. Before creating the veneers, vestibular
preparation of 1.5 mm was performed in the
lower anterior sector (teeth 34, 33, 32, 31,
41, 42, 43, 44) to obtain the correct veneer
thickness in this area (Figures 6 and 7). In the
upper anterior sector (teeth 14, 13, 12, 11, 21,
22, 23, 24), preparation was performed with
a reduction of only 0.2 mm – no more was
considered necessary due to the position of
the upper teeth. After etching the enamel with
38% orthophosphoric acid for 30 seconds and
rinsing, each individual tooth to be injected
with composite was isolated from the adjacent
teeth with a strip of polytetrafluoroethylene,
which had a thickness of 0.075 mm and a
density of 0.35 g/cm3. These strips were placed
at the interproximal level, both mesially and
distally, so that they completely covered
the adjacent teeth, meaning they avoided
contact with both adhesive and composite
resin. Then, adhesive was applied (G-Premio
Bond, GC Corporation, Tokyo, Japan). After
applying air to the adhesive and curing for
20 seconds, the silicone index was placed
in position and the flowable composite was
injected (G-ænial Universal Injectable, GC
Corporation, Tokyo, Japan) through the hole
at the incisor edge, filling the space between
the tooth and the silicone index from the
cervical area to the incisal edge (Fig. 8). When
the space was completely filled, it was lightcured with an LED curing light for 40 seconds.
After removing the index, excess material was
removed with a 12D scalpel blade and a dental
probe (Fig. 9). Afterwards, definitive light
curing of the vestibular surfaces was carried
out for 20 seconds, applying a glycerin gel to
prevent the formation of an oxygen-inhibited
layer.19,20 After repeating this process for each
of the teeth, all restorations were polished
with a fine diamond bur, polishing discs,
interproximal strips, rubber polishers and
diamond polishing paste to prevent plaque
accumulation and staining.
Lastly, occlusion was tested with
12- and 8-μm articulating paper, checking
for the absence of premature contacts, a
correct anterior guidance supported by the
four incisors and a stable canine guidance.
Interproximal contacts were checked with
dental floss. Registers were taken to fabricate
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CLINICAL
Aesthetic dentistry
a Michigan stabilisation splint for night-time
wear. The patient was recalled for check-ups at
15 days, one month and thereafter every three
months (Fig. 10). After 24 months’ follow-up,
no gingival inflammation, bleeding on probing
or significant wear of the restorations were
detected (Fig. 11). The patient expressed her
satisfaction with the treatment both in terms
of function and aesthetics.
Discussion
This clinical report describes a case of
generalised dental staining caused by
tetracyclines, which was treated successfully
by means of veneers placed using the injectable
composite resin technique. Compared with
the more conventional techniques described
for treating this type of case,2,3,4,5 injectable
resin composite is a more conservative and
economical option that requires a shorter
clinical treatment time. Moreover, providing
the case selection protocol is followed correctly,
it can be used as a purely additive treatment,
being completely reversible.10 In this case, due
to the position of the teeth in relation to the
position planned in the diagnostic wax-up,
a minimally invasive preparation of 0.2 mm
was only possible in the upper teeth, while in
the lower teeth, a more invasive preparation of
1.5 mm was required.
The aesthetic outcomes may be poorer than
ceramic veneers due to resin composite staining
over time.21 Nevertheless, this technique can be
very useful in cases such as the present one,
in which the patient wished to improve her
smile aesthetics but rejected more invasive
and expensive treatments. The mechanical
and aesthetic properties of composites have
improved considerably in recent years, and
they can be polished and shined to provide a
good finish.11,12
Due to their consistency, flowable composites
are preferable to conventional composites for
this technique;10 they have the advantage of
adapting to the shape of the transparent silicone
index and so to the diagnostic wax-up, without
any need for external pressure. In previous
studies using conventional composites, it was
necessary to apply external pressure (in order
to reproduce anatomy exactly) and to cut the
index in segments for each tooth, both of
which compromise stability and precision.9,22
The latest generations of flowable composites
come in different colours and levels of opacity/
translucency, which allow treatments to
provide optimal aesthetics.2,3,4,5
Fig. 8 Flowable composite injection through the hole at the incisor edge of the silicone index
Fig. 9 Trimming of excess material with a 12D scalpel blade
Fig. 10 Three-month review – frontal view
As far as the authors are aware, this is the
first case report that describes the use of
this technique to treat tetracycline staining.
As this report describes a single clinical
case, it is not possible to reach definitive
conclusions about the longevity of this
type of restoration. The literature lacks
information and evidence regarding this
technique. Long-term follow-ups are also
lacking as this is a relatively new technique.
Nevertheless, the present case has shown
that satisfactory results can be achieved over
a 24-month follow-up, providing the case
selection protocol is followed correctly, and
treatment planning and workflow are carried
out efficiently.
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CLINICAL
Aesthetic dentistry
7.
8.
9.
10.
11.
12.
13.
14.
15.
Fig. 11 24-month review – frontal view
References
Conclusions
1.
Composite veneers applied with the injectable
flowable composite technique are an effective,
economic and satisfactory treatment; moreover,
this technique may offer a more conservative
option than ceramic veneers, providing the case
selection protocol is adequate. However, more
studies are necessary, with correct protocols,
adequate sample sizes and follow-up periods,
which would provide clear and reliable results
in the medium-to-long term.
Conflict of interest
The authors declare that there are no conflicts of
interest in this case report.
778
2.
3.
4.
5.
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