Incisor dyschromia: endo&resto

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.

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Fig.1
Initial situation: assessment of discoloration degree, together with the class IV cavity of tooth 21.

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

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Fig.3
Rubber dam must be used during endodontic treatment.

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Fig.4
Intra-operative X-ray.

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Fig.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.

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Fig.6
Situation after walking bleaching with hydrogen peroxide (White Dental Beauty Teeth Whitening gels); the discoloration of 21 completely disappeared.

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Fig.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.

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Fig.8
Rubber dam is mandatory when performing adhesive procedures.

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Fig.9
The post space was prepared, paying attention to avoid any unnecessary tooth structure removal.

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

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Fig.11
Tooth preparation is now complete.

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Fig.12
The post space was rinsed in order to clean it from gutta-percha and endodontic cement debris.

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

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

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

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

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

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Fig.18
After light curing the post is ready.

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

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Fig.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.

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Fig.21
The first palatal shell.

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Fig.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.

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Fig.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.

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Fig.24
The restoration was easily completed.

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

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Fig.26
The restoration immediately after rubber dam removal.

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

Conclusions

Modern materials such as composites, adhesives and bleaching agents allow dental practitioners to achieve excellent, predictable results with less tooth structure sacrifice.

Bibliography

1. Grandini S, Chieffi N, Cagidiaco MC, Goracci C, Ferrari M. Fatigue resistance and structural integrity of different types of fiber posts. Dent Mater J. 2008 Sep;27(5):687-94.
2. Grandini S, Goracci C, Tay FR, Grandini R, Ferrari M. Clinical evaluation of the use of fiber posts and direct resin restorations for endodontically treated teeth. Int J Prosthodont. 2005 Sep-Oct;18(5):399-404.
3. 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.
4. 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.

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