Direct approach on extremely dark teeth

Shadeguides - Bleaching - Direct anteriors
4 Oct 2017

Darkening of teeth is a pretty common phenomenon among endodontically treated teeth. In this case a patient, 40 years old female, had her four incisors with severe discromy and did not want a treatment to involve tooth preparation for crowns.

The endodontic treatment was evaluated and the retreatment of only one of them was indicated.

The bleaching of all teeth was proposed, including internal bleaching of the incisors combined with direct composite veneers, including the first premolars.

An important aspect of this kind of patient is the demand for a very good bleaching result.

Fig. 1

Img.1 – Frontal smile, initial situation.

Fig. 2

Img. 2 – Close-up of the incisors and premolars.

Fig. 3

Img. 3 – View with retractors, showing occlusion.

Fig. 4

Img. 4 – Right view of the smile.

Fig. 5

Img. 5 – Left view of the smile.

Fig. 6

Img. 6 – Access to the coronal chamber. In this step we create an internal protection with a glass ionomer cement and apply sodium perborate associated with hydrogen peroxide. Following restoration of the cavity with an adhesive system and composite resin was carried out and control was scheduled after 10 days. The patient was given a home bleaching product for external bleaching.

Fig. 7

Img. 7 – Aspect after 10 days of internal bleaching results, associated to home bleaching. In this appointment, the internal bleaching agent was renewed.

Fig. 8

Img. 8 – Aspect after 20 days of internal bleaching associated to home bleaching. In this appointment, the internal bleaching agent was renewed one more time.

Fig. 9

Img. 9 – Aspect after 30 days of internal bleaching associated to home bleaching. In this appointment, the internal bleaching agent was removed and a temporary restoration was done to facilitate the elimination of residual oxygen. The home bleaching was finished too.

Fig. 10

Img. 10 – After 3 weeks the present restorations were removed. 4 fiber post were cemented on incisors before this appointment.

Fig. 11

Img. 11 – The dental reconstruction based on previous wax-up was initiated using: Renamel OW (palatal shelf), Opaquer Renamel A1-B1-LO on the dark areas covered by layers of Herculite B2 – B1 on the deep dentin. A layer of Amelogen B1 shade was applied covering all the internal dentin and the opalescent effect was created with Supreme GT.

Fig. 12

Img. 12 – The adjacent incisors were treated with the same stratification, but customized with the necessity of each one. The enamel layer was reproduced with Renamell Microfill Body B2 on cervical third and Durafill B1 and Renamel IL microfill on the the medium and incisal third.

Fig. 13

Img. 13 – Initial aspect after primary polishing and the removal of retraction cords.

Fig. 14

Img. 14 – After 10 days the polishing and anatomy were refined.

Fig. 15

Img. 15 – Aspect after 21 days.

Fig. 16

Img. 16 – Aspect of the smile after 45 days.

Fig. 17

Img. 17 – Close-up view after 45 days.

Fig. 18

Img. 18 – Close-up lateral after 45 days.

Fig. 19

Img. 19 – Before and after in a leteral view.



With this clinical case, we can see the versatility of composite resins associated with other techniques to solve even the most difficult – and less esthetic – cases.


Dietschi D. Free-hand composite resin restorations: A key to anterior aesthetics. Pract Periodont Aesthet Dent 1995;7(7):15-25.
Magne P, Holz J. Stratification of composite restorations: Systematic and durable replication of natural aesthetics. Pract Periodont Aesthet Dent 1996;8(1):61-68.
Fahl N Jr. Achieving ultimate anterior esthetics with a new microhybrid composite. Compend Contin Educ Dent Suppl 2000;26:4-13.
Baratieri, Luiz N. Estética—Restaurações Adesivas Diretas em Dentes Anteriores Fraturados. 1st ed. São Paulo, Brazil: Quintessence Publishing; 1995.
Chiche GJ, Aoshima H. Smile Design: A Guide for Clinician,Ceramist, and Patient. Hanover Park, IL: Quintessence Publishing Co, Inc; 2004.
Fahl N Jr, Denehy GE, Jackson RD. Protocol for predictable restoration of anterior teeth with composite resins. Pract Periodont Aesthet Dent 1995;7(8):13-21.
Vargas MA, Lunn PS, Fortin D. Translucency of human enamel and dentin. J Dent Res 1994; AADR Abstracts(Abstract No.1747).
Muia PJ. Four Dimensional Color System. Chicago, IL:
Quintessence Publishing Co, Inc; 1993.
Dahl JE, Pallesen U. Tooth bleaching—A critical review of the biological aspects. Crit Rev Oral Biol Med 2003;14(4):292-304.
Reeh ES, Douglas WH, Messer HH. Stiffness of endodontically-treated teeth related to restoration technique. J Dent Res 1989;68(11):1540-1544.
Fahl N Jr. Trans-surgical restoration of extensive Class IV defects in the anterior dentition. Pract Periodontics Aesthet Dent 1997; 9(7):709-720.
Touati B. Defining form and function. Pract Periodont Aesthet Dent 1998;10(7):800-807.
Lombardi RE. The principles of visual perception and their clinical application to denture esthetics. J Prosthet Dent 1973;29: 358-382.
Feigenbaum NL. Aspects of aesthetic smile design. Pract Periodont Aesthet Dent 1991;3(3):9-13.
Goldstein RE. Composite resin bonding. In: Goldstein RE.Esthetics In Dentistry. 2nd ed. Hamilton, Ontario: BC Decker,
Terry DA. Contemporary composite resins. In: Terry DA. Natural Aesthetics With Composite Resin. Mahwah, NJ: Montage Media Corporation, 2004:20-37.
Greenwell L. Bleaching techniques in restorative dentistry: An Illustrated Guide. London, UK: Martin Dunitz, 2001:1
Terry DA, Leinfelder KF. An integration of composite resin with natural tooth structure: The class IV restoration. Pract Proced Aesthet Dent 2004;16(3):235-42.
Bichacho N. Direct composite resin restorations of the anterior single tooth: Clinical implications and practical applications. Compend Contin Educ Dent 1996;17(8):796-802.
Swift EJ Jr, Perdigão J, Heymann HO. Bonding to enamel and dentin: A brief history and state of the art, 1995. Quintessence Int 1995;26(2):95-110.