A clinical case by our Community member Dr. Rim Bourgi
This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.
In a society taken over by social media applications, people have been more conscious than ever regarding their physical look. The first aspect of the person anyone notices is the smile, and because of that, individuals are turning to dentists to achieve a picturesque smile that they can directly share with their friends. Tooth bleaching is the main approach that dentists follow to treat dental discoloration, being known for its effectiveness, safety, predictability, efficacy, longevity, and reduced side effects. Agents used in dental bleaching are mainly comprised of hydrogen peroxide (HP) which is used inside the clinic, or of carbamide peroxide (CP) for home applications. In this case, bleaching was done by an ideal concentration of whitening agent in the form of 16% CP (Teeth whitening gels, White Dental Beauty) for a duration of 2 weeks. The reasoning behind using White Dental Beauty products is their treatment safety, reduced tooth hypersensitivity, and absence of gingival irritation.
Moreover, the topography of the dental hard tissue will remain unchanged. In addition, for tooth shade improvement, the use of Optishade colorimeter (SmileLine, Switzerland) was suitable for bleaching tracking, leading to more accurate shade matching when compared to color shade tabs. Digital Single Lens Reflex (DSLR) is taken as a reference for photographic documentation, however, in dentistry, simplicity is key.
Since DSLR is expensive and heavy, as well as impossible to disinfect, and has a high learning curve, they are replaced with Smile Lite MDP (SmileLine, Switzerland) for obtaining better dental color references. MDP is simple, cost-effective, and can be used in treatment evolution, marketing, insurance, conferences and publications, plus artistic photography.
Further, it was previously demonstrated that the 5.3% and 6.5% HP gel strips which are applied for twice daily for 30 minutes whitened the teeth effectively and were well tolerated by patients due to their user friendliness without the need to visit a dentist. The use of Professional dissolving whitening Strips P3 (White Dental Beauty, UK) has been recently proposed as a viable option maintaining the tooth color after bleaching and the bright smile of the patient. These strips contain 6%HP along with two phosphates and HP, hence the addition of “P3” to the product’s name. How can a dentist succeed in providing patients with white teeth so they can smile with confidence?
The aim of this article is to shed light on the secrets behind the bleaching procedure. Also the documentation of the case by means of MDP2 (SmileLine, Switzerland), tracking the color change produced by a lower concentration of teeth-whitening gels using the Optishade colorimeter (SmileLine, Switzerland), and the assessment of the new professional whitening strips in maintaining the results of the bleaching.
Fig.1
A 38-year-old female visited the dental clinic and asked for a solution for her teeth discoloration problem, preferably without drilling. A picture is mandatory prior to the procedure to track the evolution of the teeth color before and after the bleaching treatment. This picture was taken with a device called Smile Lite MDP2 (Smile Line, Switzerland) at full power and the S22 Ultra smartphone. Six LEDs on each side of the lateral lights and eight LEDs on the central light were turned ON and covered with the white diffuser, thus softening the light and making the surface texture more prominent.
Fig.2
Dental cleaning is the first step, and an essential hygiene practice to remove all the dental plaque and stains from the surface of the enamel. It should be noted that professional dental cleaning is a crucial and accepted initial method to improve oral health and maintain a pretty smile.
Fig.3
The Smile Lite MDP2 (SmileLine, Switzerland) acts as a “mini photo studio”. Its design uniqueness provides the perfect lighting to capture impressive dental photographs. The novel Smile Lite MDP2 (SmileLine, Switzerland) was improved and works with any smartphone, in addition to having a convenient handle, simplifying dental photography for any operator. In this case, various pictures were taken with a Flexipalette contrastor (SmileLine, Switzerland), along with a lip retractor.
1. Central LEDs: The picture was taken with the central LEDs at full power ON (lateral LEDs OFF). The outcome was similar to the effect of a ring flash.
2. Image with diffuser: The picture was taken with the diffuser, the lateral LEDs and central LEDs were turned ON. The diffused light from all the sides of the device provides a softer light by scattering and spreading it. This effect is exclusive to Smile Lite MDP2 (Smile Line, Switzerland).
3. Image with lateral lights: The picture was taken with the lateral LEDs ON and central LEDs OFF. The final picture was similar to a dual flash effect.
4. Image with polarizing filter: The picture was taken with the central LEDs at full power ON (lateral LEDs OFF) with a polarizing filter over the central part of the device. As a consequence, the resulting picture can be used to determine the color and the brightness of the teeth with precision, along with specific details.
Fig.4
In the polarized picture, the recorded color was D2 shade VITA Classical shade guide. The same starting color was also recorded with Optishade (SmileLine, Switzerland) colorimeter which is D2, and the most precise measurement was taken at the center of the image frame. With the picture now available, the dentist can explain the L*a*b numbers presented on the left side of the measured tooth to the patient. In this case, L*<70%, so, the teeth have a low value. Also, 2% of red and 10% of yellow indicate high chromaticity. The patient was then aware that the treatment could increase L* and decrease a*b*. This makes the Optishade (SmileLine, Switzerland) a rapid solution for daily dental practices.
Fig.5
The assessment and quantification of colorimetric variations became possible and objective using the Optishade (SmileLine, Switzerland). The Optishade linked to the Matisse software allows for an accurate reproduction of the color by the dental technician.
In addition, this device can aid in displaying the color difference according to the shade guide. Additionally, this device has a calibration cap that should be changed every month, however, in this picture, the cap was removed to display the inner part of the colorimeter.
Optishade (SmileLine, Switzerland) contains color readings aligned with a spectrophotometer to compare the readings with ready-made and common shade guides.
Fig.6
Home bleaching was used in this case. The patient was taught how to apply the bleaching agent. A 16% CP (White Dental Beauty, UK) was applied to a custom fit tray 2-4 hours per day for two weeks. The CP bleaching product was inserted in the amount of a drop per tooth (the size of half rice grain), and four gel syringes were delivered to the patient. Note that no sensitivity was reported due to Novon technology.
Fig.7
Beneficial effect after 14 days of at home dental bleaching with 16% CP (Teeth whitening gels, White Dental Beauty). The shade recorded was B1 which can be observed in the different photographs taken.
Fig.8
As a final result, after 14 days of bleaching, the shade was recorded as B1 according to the Vita Classical shade guide. This can be seen in the picture and is considered a visually and clinically pleasant result.
Fig.9
Using the polarization filter of the Smile Lite MDP2 device (SmileLine, Switzerland), a polarized photograph was captured to compare the shades without any reflection and to better frame the issue. Only the central light is ON in this picture.
Fig.10
Comparison between the initial (D2) and the final (B1) shade guide. The shade transformed from D2 to B1, and the patient was highly satisfied. Furthermore, the patient was given the opportunity to see the treatment evolution by observing the pictures taken using the MDP2 device (SmileLine, Switzerland).
Fig.11
The same measurement was taken by means of Optishade (SmileLine, Switzerland) colorimeter. L* increased, while a* and b* decreased. This is an objective and scientific way to assess and validate the bleaching treatment’s success.
Fig.12
In order to maintain the whitening process results, professional dissolving whitening strips P3 (White Dental Beauty, UK) were recently introduced.
P3 consists of a combination of 3 phosphates with three steps:
1- Peel from the corner and remove the strip.
2- Apply the strip to the teeth as shown in the picture. The strip was applied starting from the buccal side and flipped into the palatal side for the maxilla and the lingual side for the mandibula.
3- The strip should dissolve within 15 minutes. This time depends on the amount of contact with the moist surface.
Fig.13
Professional dissolving whitening strips P3 (White Dental Beauty, UK) include 28 strips with mint flavour.
Fig.14
These strips presented many advantages:
– Convenience (fast and simple application)
– A universal fit (Strips adapt to both upper and lower teeth)
– Easy application (There is no residue or plastic strips to remove)
– Invisible and dissolvable (These strips can be worn at anytime, leaving the mouth clean & refreshed)
– A triple action formula (Whitens the teeth from within and removes surface stains while freshening the breath)
– Hydrostatic action (Adheres to teeth on contact with moisture, allowing it to adapt to the surface of each tooth with optimum contact)
– Biocompatible (Mint flavour)
Fig.15
Same tooth was captured by the innovative colorimeter, and it demonstrated a maintenance in color after one week of strips applications (2 strips/day).
Fig.16
Before and after dental bleaching (extraoral pictures).
Fig.17
To obtain a white smile with confidence, the following recipe should be taken into consideration:
1- MDP2: Secret for dental documentation.
2- Optishade colorimeter: Secret for color comparisons.
3- Teeth whitening gels, White Dental Beauty: Secret for at-home dental bleaching.
4- Whitening Strips “P3”: Secret for dental bleaching maintenance.
Fig.18
The patient was satisfied and happy with the result. Some tips were given to the patient to preserve the bleaching effects.
Conclusions
To achieve success in any dental restoration, a certain recipe are required. This recipe involves several tools throughout the treatment steps. The steps and tools include capturing a photograph using Smile Lite MDP2 (SmileLine, Switzerland), tracking the color change before and after bleaching by means of the Optishade colorimeter (SmileLine, Switzerland), and bleaching at a low concentration of CP (White Dental Beauty products). After the treatment was completed, the results should be maintained by the newly introduced professional dissolving whitening strips P3 (White Dental Beauty, UK). Following the steps and tools described above will lead to a predictable and satisfying outcome.
Bibliography
1. Hardan LS. Protocols for Mobile Dental Photography with Auxiliary Lighting. Quintessence Publishing Co; 2020.
2. Manauta J, Salat A. Layers, An atlas of composite resin stratification. Quintessence Publishing Co; 2012.
3. Hardan LS, Moussa C. Mobile dental photography: a simple technique for documentation and communication. Quintessence Int. 2020;51(6):510-518.
4. https://www.styleitaliano.org/optishade/#1624532105384-c1050905-db29
5. https://www.styleitaliano.org/optishade-for-bleaching/
6. Orilisi G, Tosco V, Monterubbianesi R, et al. ATR-FTIR, EDS and SEM evaluations of enamel structure after treatment with hydrogen peroxide bleaching agents loaded with nano-hydroxyapatite particles. PeerJ. 2021;9:e10606.
7. Hardan L, Bourgi R, Cuevas-Suárez CE, Lukomska-Szymanska M, MonjarásÁvila AJ, Zarow M, Jakubowicz N, Jorquera G, Ashi T, Mancino D, Kharouf N, Haikel Y. Novel Trends in Dental Color Match Using Different Shade Selection Methods: A Systematic Review and MetaAnalysis. Materials (Basel). 2022;15(2):468.
8. Ghaleb M, Orsini G, Putignano A, Dabbagh S, Haber G, Hardan L. The Effect of Different Bleaching Protocols, Used with and without Sodium Ascorbate, on Bond Strength between Composite and Enamel. Materials (Basel). 2020;13(12):2710.
9. Hardan, L. Mobile dental photography (MDP): A new era in dental documentation. Int Arab J Dent. 2017;8(3):6.
10. Sampaio CS, Atria PJ, Hirata R, Jorquera G. Variability of color matching with different digital photography techniques and a gray reference card. J Prosthet Dent. 2019;121(2):333-339.
11. Moussa C, Hardan L, Kassis C, Bourgi R, Devoto W, Jorquera G, Panda S, Abou Fadel R, Cuevas-Suárez CE, Lukomska-Szymanska M. Accuracy of Dental Photography: Professional vs. Smartphone’s Camera. Biomed Res Int. 2021;2021:3910291.
12. Paolone G, Orsini G, Manauta J, Devoto W, Putignano A. Composite shade guides and color matching. Int J Esthet Dent. 2014;9(2):164-182.
13. Mounika A, Mandava J, Roopesh B, Karri G. Clinical evaluation of color change and tooth sensitivity with inoffice and home bleaching treatments. Indian J Dent Res. 2018;29(4):423-427. 14. Mailart MC, Sakassegawa PA, Santos KC, Torres CRG, Palo RM, Borges AB. One-year follow-up comparing at-home bleaching systems outcomes and the impact on patient’s satisfaction: Randomized clinical trial. J Esthet Restor Dent. 2021;33(8):1175-1185.
15. de Geus JL, Wambier LM, Boing TF, Loguercio AD, Reis A. At-home Bleaching With 10% vs More Concentrated Carbamide Peroxide Gels: A Systematic Review and Meta-analysis. Oper Dent. 2018;43(4):210-222
