Dyschromia in anterior teeth, a direct approach. Trouble, challenge or what else?

Shadeguides - Bleaching - Direct anteriors
1 Dec 2017

Endodontically treated anterior teeth always represent a challenge for all dentists. The Author focuses on the topic showing the possibility to restore both from a functional and aesthetic point of view, even when a tooth is affected by dyschromia. The use of bleaching combined with adhesive techniques allows to save considerable tooth structure achieving an excellent and long lasting aesthetic outcome especially in young patients, where is crucial to operate conservatively, according to the concept of minimally invasive treatments.

Fig. 1

Female patient, 23 years old, comes to the office with the main desire of receiving a prosthetic treatment with crowns, highly unsatisfied with her smile 

 

Fig. 2
Fig. 3

Due to the failed existing direct restorations, showing marginal infiltration and composite overcontour which causes marginal gingivitis

Fig. 4

Afterwards a radiographic examination was made: this put under evidence asymptomatical periapical lesions in both elements, even though insufficient cleaning, shaping and obturation are clear. On the other hand, the radiograph shows carious infiltration in both teeth.

Fig. 5

The treatment plan proposed to the patient consisted in a thorough cavity cleaning, followed by a bleaching technique (which in that moment makes her very curious) and direct restorative dentistry with the following periodic maintenance controls and evaluation over time before going for more aggressive treatments, specially when factors as the age of the patient are involved.

Fig. 6

After isolating the field with rubber dam, cavity cleaning is performed thoroughly, using magnification.

Fig. 7

Margins were done with a chamfer in the buccal and a butt-joint in the proximal and palatal.

Fig. 8

The transparent silicone index done previously, allows to do a simple buccal stamp of the composite material.

Fig. 9

Using a limited amount of enamel composite that will be preserved for the final restorations.

Fig. 10

On the other hand, the use of anatomical posterior matrices will give an adequate proximal anatomy and shape, without overhangs, done with the dentin chosen during the color matching stage.

Fig. 11

The temporary composite fillings are thoroughly finished and polished 

Fig. 12

Before starting the endodontic therapy, to turn this stage much more agile.

Fig. 13

When a correct endodontic therapy was carried out, the gutta-percha was located 2mm below the buccal bone ridge, before starting to do a walking bleach technique, a sealer was placed above the gutta-percha in order to avoid external root resorptions due to the hydrogen peroxide infiltration by the dentinal tubules complex to the periodontal ligament

Fig. 14
Fig. 15

After the endodontic sealing and its depth control, White Dental Beauty in ists 6% Hydrogen Peroxide was selected

Fig. 16

On purpose due to its stability and high viscosity characteristics.

Fig. 17

After applying the bleaching gel in the pulp chamber a temporary material as reinforced Zinc Oxyde was placed to obtain a good seal, the patient leaves the office with an appointment for the following days.

Fig. 18

The control after 5 days shows the complete disappearance of dischromia and an excellent integration of the previous build-up

Fig. 19

After the temporary filling material and the remaining bleaching gel removal, a thorough cleaning of the coronal portion of the cavity was done, in order to proceed to the bonding stage with a universal adhesive, a reverse stratification technique was done, filling from the palatal to the buccal with the chosen dentin shade, reproducing the mamelons.

Fig. 20

In the free incisal space, between the mamelons and the incisal halo done during the transparent silicone stage, a blue stain was added in order to enhance the incisal translucency 

Fig. 21

Before closing the restorations palatally with a thin layer of enamel.

Fig. 22

Immediately after finishing and polishing stage is performed with spiral wheels and low speed, leaving intact the buccal shape done during the transparent silicone index stage.

Fig. 23

The check-up shows a nice integration and an excellent aesthetic situation.

Fig. 24

Similarly, the radiographic exam shows a very nice root canal and coronal filling.

Fig. 25

Patient came to the check-up appointment showing a completely different smile, regardless of using a very conservative and non invasive technique that in the near future may be the base of a more complex prosthodontic approach with partial restorations with ceramics.

Fig. 26
Fig. 27
 

Bibliography

Paolone G, Saracinelli M, Devoto W, Putignano A. Esthetic direct restorations in endodontically treated anterior teeth. Eur J Esthet Dent 2013 Spring;8(1):44-67.

Tsujimoto A, Barkmeier WW, Takamizawa T, Latta MA, Miyazaki M. Influence of the Oxygen-inhibited Layer on Bonding Performance of Dental Adhesive Systems: Surface Free Energy Perspectives. J. Adhesive Dent. 2016; 18(1):51-8.

Vichi A et al. Influence of thickness on color in multi-layering technique. Dent Mater 2007 Dec 23(12);1584-9.

Devoto W, Saracinelli M, Manauta J. Composite in every day practice: How to choose the right material and simplify techniques in the anterior teeth. Eur J Esthet Dent 2010 Spring;5(1):102-24.