Recently I received photos of a beautiful anterior esthetic case where discoloration was occurring. Since seating this case of all porcelain crowns on the upper anterior teeth, one lateral on the upper right began to get darker and darker, ultimately almost a light brown in the photos I was sent. Photos taken at a week post operatively showed that the crown matched perfectly at the time of cementation.
The patient reports that the crown seemed to get darker and darker until it reached it’s current color. The dentist who placed the restorations was already in the process of replacing the one crown, and had photos of the prep from the day of the seat and the day he cut the crown off to replace it. The prep itself had turned a dark brown color in an unusual pattern on the labial. I’m familiar with discoloration of the resin cement when it is contaminated during the seating, but this was the actual tooth. So I went in search of an answer and learned something about the interaction of iron based hemostatic agents and preps. Iron has a very high affinity for hard tissue and is attracted to the cut surface of the tooth. This attraction in combination with the etching of the dentin surface because of the acidic nature of the gingival retraction fluid can result in iron particles being absorbed into the porous dentin. This absorbed iron can react with bacteria that produce hydrogen sulfide, and the final resulting insoluble iron compound is trapped in the dentin structure. It takes a certain set of circumstances for this to happen, but once I started looking found lots of reports from dentists of this same phenomenon. There are lots of astringents, hemostatic agents, and impregnated retraction cords available on the market. One way to prevent this problem is avoid things that contain iron, or don’t result in an acidic fluid environment.
I had a few cases of this years ago. Had to redo the cases. :(
I switched to using aluminum chloride for all aesthetic work, including the prep stage. No problems since then.
Joe, thanks for sharing this. I use a double cord technique, and I guess have been fortunate not to have this happen as I don’t often use one that is impregnated or add astringents. For folks who are sounds like they can look for products containing aluminum chloride and feel confident this will not be an issue.
a few questions:
when you redid the cases, did you have to switch materials to mask the staining?
did the staining return under the new permanent veneers?
did the stain wipe away with hydrogen peroxide?
thanks for the insight!
It will depend on the color of the prep once the restorations are removed.
I too now only use aluminum chloride on anterior cases. I use to see this problem more with temporaries than on the final restorations.
Hans,
Were you ever able to get rid of the color once this happened. I was thinking superoxyl might work, but haven’t had a chance to try it.
Hey Lee,
Love these posts! Yep, I’m an Viscostat Clear guy only from the bicuspids forward. If you have more bleeding than aluminum chloride can handle, you shouldn’t be impressing that day! Hope to sit next to you again soon!
Couldn’t agree more about tissue management. Aren’t we in Atlanta together tomorrow for the Cerec Discovery? I was planning to listen to your presentation!
there was a huge settlement in texas years ago over 12 veneers discoloring. good to get the word out
Armen,
Was this the cause of the discoloration in that case?
Lee,
Great thread. I agree with all of the above. I try and utilize expasyl and even have the patient rinse with chlorhexidine for two weeks prior to anterior cases to really get that tissue healthy. Tissue management is vital!!
Greg,
The chlorhexidine is a great idea, I used to do that and stopped for some reason, I’ll have to try it out again. I just had a patient in to seat her veneers, and she had been afraid to brush or floss in the provisionals, so you can imagine. She and I talked, we went over OH, and never even took the temps off, but had her spend an hour with my hygienist and then rescheduled her to come back in two weeks. Your comment has me wondering do you do Chlorhexidine while they are in provisionals also? Does it cause stain, maybe you have them dilute it?
Hi Lee Ann,
I don’t use any iron sulfate astringents (tissue staining and prep staining issues), have found that aluminum chloride 25% isn’t adequate at times, but do use Superoxyl and Expasyl as needed. Add in a touch of diode laser too for spot hemorrhaging.
.
I use the following regimen and modify it as needed based on the case. Can’t emphasize enough excellent tissue health as insertion!
o Continue to drink plenty of fluids
o Take three (3) Advil tablets every 6 hours for 3-5 days
o 1000 mg Vitamin C daily for three weeks
o Keep yourself comfortable using medications as prescribed
o Follow all post operative instructions as written
• Sonicare: 2xs per day for full 2 minutes
• Warm saltwater rinses: 1tsp table salt in 6 oz warm water, continue for 2-3 days 2-3xs per day. Peroxide (household 3% H2O2) irrigation using a 3cc syringe and black brush tipped applicator daily until 3 days before insert-then switch to the chlorhexidine below.
• Interdental cleaning w/ Piksters (Nexadental) size 0 or 1; Flossing: 2xs per day as shown
Use floss threader-
• Rubber tip stimulation: 2-3xs per day into the gum sulcus especially if I lasered the tissue.
• Chlorhexidine: starting 3 days before impression date (if final impressions were not taken at prep date) or 3 days before final placement date-2xs per day, 30 seconds
I have to thank my good friends and mentors David Hornbrook, John Nosti and Mark Montgomery for their guidance!
Roger D Urlaub DDS
Thanks for posting this, it is great!
No brushing during her provisionals?! Yikes. Staining seems to be a mixed bag for me with temps. Usually due to patient compliance. I also only have them rinse once a day. Overall, staining hasn’t been too much if an issue. I just really stress to the patient that the most important thing is the long term look of the veneers, and the cementation appointment is the determining step. Reminds me of one of my favorite quotes, “the main thing is to keep the main thing the main thing.”:)
Fab posting Dr Urlaub!!! Great !!!
Thanks for this article! I’m a lab technician and i’ve seen this a few times. As I’m sure you know, veneers add a lot more work to us techs; small, thin and fragile, no retention to die while working them, etc. How do you and the other doctors here expect a remake cost to be handled in this situation? Half charge from the lab? no charge? Full charge? I stand at full charge as the shade is a match and accepted by doctor and patient at the seating and it’s not the crown material that is changing. I find that most doctors expect free or deeply discounted.
Those are individual decisions. In my office if the discoloration occurs quickly after seat, i believe it is something that occurred based on the procedure, we redo the restorations at no charge and I do not expect the lab to absorb that.
Thank you for sharing this. I met with a patient who was suffering from the same issue yesturday and would like to find more info to work out a treatment plan. Your article is very good reference.
I am not sure what type of information you are looking for, You can find articles on pubmed about the science described but that will not help with treatment planning. You will need to get the restorations off, see the color of the preps, and then if you can bleach the preps, or you need to mask with restorative materials.
Hello, I’m just curious, I recently had a porcelain crown put on one of my back, lower teeth. Maybe 4-5 months ago. He had some left over cement that, unfortunately he had to get out. Every since then, my gums around the tooth are sensitive and I see a slight discoloration between my gum line and the crown. Is this normal, what should I do? And if he has to redo it, do I have to pay for another crown? Thank you
Also, is it true, what I read about all porcelain crowns. Are they not as strong as those lined with metal. Cause I have a few of them and am afraid they will need work again in the future. I have had such crap luck with dentists and owe so much money. It would be a real shame if some crowns would lead to infection or future root canal…maybe even extraction. I really can’t afford that…any suggetsions.