Incisor dyschromia: endo & resto

Shadeguides - Bleaching - Direct anteriors
4 Apr 2016

Treating dark teeth in anterior region can be easy if the approach is planned accordingly to the type of dyschromia suffered by the patient.

The patient is a 20 years old girl complaining about a fractured dyschromic central incisor; she reports the tooth was endodontically treated about 7 years ago, without using the rubber dam, and it soon became darker. It was also restored with a direct composite that was lost after a couple of years. This type of teeth problems are often related to a filtration phenomena or gutta-percha staining. Dark yellow and brown hues are related to filtration and blood, while dark grey is related to Gutta-percha, this second often not being a good candidate for bleaching.

Fig. 1

Img. 1 – Initial situation: assessment of discoloration degree, together with the class IV cavity of tooth 2.1.

Fig. 2

Img. 2 – Pre-operative X-ray shows an incomplete root canal filling: an endodontic retreatment is necessary.

Fig. 3

Img. 3 – Rubber dam must be used during endodontic treatment.

Fig. 4

Img. 4 – Intra-operative X-ray.

Fig. 5

Img. 5 – Post-operative X-ray: a self-etching adhesive and a thin layer of flowable composite were applied over the gutta-percha in order to seal the root canal system. This is really important before putting bleaching agents into the pulp chamber to prevent root resorption.

Fig. 6

Img. 6 – Situation after walking bleaching with hydrogen peroxide (White Dental Beauty); the discoloration of 2.1 completely disappeared.

Fig. 7

Img. 7 – 20 days with no usage of bleaching agents are necessary for all of the oxygen to be removed so that it cannot interfere with adhesion procedures. A new appointment was scheduled and a DIY wax-up was made using composite resin (no adhesive), and a silicone key was made directly in the patient’s mouth.

Fig. 8

Img. 8 – Rubber dam is mandatory when performing adhesive procedures.n

Fig. 9

Img. 9 – The dowel space was prepared, paying attention to avoid any unnecessary tooth structure removal.

Fig. 10

Img. 10 – A short bevel was created on the buccal aspect of the fracture line.

Fig. 11

Img. 11 – Tooth preparation is now complete.

Fig. 12

Img. 12 – The dowel space was rinsed in order to clean it from gutta-percha and endodontic cement debris.

Fig. 13

Img. 13 – The correct post was chosen and the proper length is measured.

Fig. 14

Img. 14 – The post was cut in order to keep it completely inside the restoration.

Fig. 15

Img. 15 – The silicone key is very helpful to control the correct length of the post.

Fig. 16

Img. 16 – A self-adhesive cement (Rely-X Unicem) was applied into the dowel space.

Fig. 17

Img. 17 – The fiber post was put in place with a forcep.

Fig. 18

Img. 18 – After light curing the post is ready.

Fig. 19

Img. 19 -Whilst adhesive procedures are not necessary to cement the post with a self adhesive cement, they are mandatory for restoration build up.

Fig. 20

Img. 20 – In order to simplify the procedure, a single shade layering technique was chosen. A thin layer of A2B (Filtek Supreme XTE) was applied directly on the silicone key and cured.

Fig. 21

Img. 21 – The first palatal shell.

Fig. 22

Img. 22 – A posterior sectional matrix is very useful to build the interproximal wall up in anterior direct restorations, as it carries the correct curvature for the composite.

Fig. 23

Img. 23 – The shell is complete; with a single layering technique it’s really easy to complete the restoration, just filling all the frame with one composite.

Fig. 24

Img. 24 – The restoration was easily completed.

Fig. 25

Img. 25 – Finishing and polishing procedures are extremely important to achieve a correct aesthetic integration.

Fig. 26

Img. 26 – The restoration immediately after rubber dam removal.

Fig. 27

Img. 27 – 3 weeks control picture: the patient is very satisfied with the restoration.