Fig.1
Pre-operative pictures are very important to select the proper shade and to evaluate bleaching treatment.

Fig.2
Root canal treatment of 21 and re-treatment of 11 were performed, obviously after rubber dam isolation.

Fig.3
We need to properly seal the canal, to avoid any bleaching agent to go beyond the clinical crown causing root resorption. A probe is useful to evaluate the position of the point to be sealed.

Fig.4
Canals are sealed using a self-etching adhesive and a drop of flowable composite.  Then the bleaching agent (35% hydrogen peroxide) was applied and the cavities were filled with a temporary restoration.

Fig.5
The bleaching agent was replaced once a week. After 4 weeks the discoloration of 21 had completely reverted, but tooth 11 still had a dark shade.

Fig.6
Considering the young age of the patient, we decided to try with a simple direct composite restoration, in order to be as conservative as possible, and to limit the cost of the treatment. To obtain enough thickness to cover the discoloration without removing sound structure, we thought we could exploit the slight palatal tipping of 11. In this picture we can also appreciate that gingival margins are not visually at the same level.

Fig.7
Rubber dam isolation is mandatory to perform adhesive procedures.

Fig.8
The old restoration was removed and the buccal surface of 11 was polished with a red ring flame diamond bur. A small bevel was created on the buccal margin.

Fig.9
After adhesive procedures (Universal Bond, Tokuyama) a thin layer of opaque stain (Estelite Color MCO, Tokuyama) was applied to cover the discoloration. This is very important to reduce the required thickness.

Fig.10
A specific instrument (Gengiva, LM) was used as a matrix to create a new cemento-enamel junction in a more apical position. This step was necessary to level the gingival margins of the two central incisors.

Fig.11
The new emergence profile is now sustaining the rubber dam.

Fig.12
It’s so easy to make a mistake about opacity and translucency. Having translucent composite in the wrong place will lead to a low value (grey) of the restoration. This is why we decided to create most of the palatal wall with a body mass (Asteria A2B, Tokuyama).

Fig.13
Just the incisal third of the palatal shell was made with enamel (Asteria NE, Tokuyama).

Fig.14
A posterior metal matrix can be perfect to easily restore the proximal wall.

Fig.15
Once the shell is complete, we just need to fill it.

Fig.16
We always try to reduce as much as we can the number of different composite used. In this case just a body mass (Asteria A2B, Tokuyama) was used to restore the dentinal body. The same composite was applied in the incisal edge to reproduce an opaque halo.

Fig.17
A translucent mass (Estelite Color Clear, Tokuyama) was used to enhance the differences between the mamelons, then the incisal third was covered with a layer of enamel (Asteria NE, Tokuyama). With this composite, just the translucent areas need to be covered by enamel; the middle third was just made with a body shade.

Fig.18
A simple pencil is a great help for contouring.

Fig.19
After finishing and polishing procedures, the rubber dam was removed.

Fig.20
After one week a pencil was used once again to plan a new contouring of the restoration.

Fig.21
The situation after the second contouring.

Fig.22
The situation after the second contouring.

Fig.23
A polarized picture taken with MDP.

Fig.24
Before and after. In this picture it’s easy to see how the gingival margins have changed.

Fig.25
Final picture with MDP.

Fig.26
5-month check-up.

Fig.27

Conclusions

Being conservative is always really important, from any point of view. We should also keep in mind that we only have one right diagnosis, but there might be more than one correct treatment plan. So it’s mandatory to look at the whole picture and consider every aspect of the situation.
It’s not just about the tooth, the arch, the mouth. It’s about the patient, his age, his attitude, his compliance, his financial situation and a lot of other factors.
Bleaching should always be performed (or at least attempted) in cases like this.

Bibliography

1. Devoto W, Saracinelli M, Manauta J. Composite in everyday practice: how to choose the right material and simplify application techniques in the anterior teeth.Eur J Esthet Dent. 2010 Spring;5(1):102-24.
2. Paolone G, Orsini G, Manauta J, Devoto W, Putignano A. Composite shade guides and color matching.Int J Esthet Dent. 2014 Summer;9(2):164-82.
3. Zarow, Maciej. EndoProsthodontics. A Guide for Practicing Dentists. 2017