When Less Is More

A clinical case by our Community member Dr. Lisa Fernandes Gonçalves

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.

The aesthetic appearance of teeth has a major role in the overall physical attractiveness of a person. Tooth discoloration is considered to be more challenging to overcome than restoring the normal alignment of teeth. A single tooth discoloration can be a critical aesthetic setback to the patient wellbeing, while also proving to be a very meticulous aesthetic challenge.
Regardless of the etiology and its specific characteristics – which are key to correct treatment planning – tooth discoloration can be defined either as being extrinsic or intrinsic. In all cases, the selected treatment option should be the one with the least biological costs.
External bleaching can be a treatment option of endodontically treated teeth, and is considered the least invasive of all approaches. It might be a complement to internal bleaching, if the results are not satisfactory. There is a deficiency of evidence-based science in the literature that addresses the prognosis of bleached non-vital teeth and also their follow-up, which makes awareness of the possible drawbacks and risks associated with internal bleaching, fundamental.
Sometimes less is more, and the ability to provide treatment with minimal biological side effects continues to make bleaching a first line choice in cases presenting a single discoloured tooth.

single discolored tooth styleitaliano style italiano community clinical case

Fig.1
First appointment. 22 Years old woman wants to improve the aesthetic in her central anterior teeth.

discolored and fractured central incisor styleitaliano style italiano community clinical case

Fig.2
A discolored central incisor with a previous root canal treatment and a horizontal crown fracture due to trauma.
After discussing different treatment options with the patient, and our final decision was to follow a conservative approach. Upon radiographic examination no sign of periapical lesion above the existing RCT was found, so we decided to proceed to restoration.

shade matching of discolored incisor styleitaliano style italiano community clinical case

Fig.3
Initial color shade selection with VITA Classical shade guide (A3).

application of carbamide peroxide gel on bleaching tray styleitaliano style italiano community clinical case

Fig.4
In order to improve the color of the other teeth we decided to start with external bleaching. In this case we began with a custom bleaching tray that was given to the patient, who was instructed to apply the gel (16% carbamide peroxide).

style italiano styleitaliano community clinical case color check of discolored tooth after external bleaching

Fig.5
Color check with Vita Classical shade guide after external bleaching. Overall, teeth were identical to A1, while tooth 21 was matched with an A2.

open pulp chamber for internal bleaching styleitaliano style italiano community clinical case

Fig.6
After waiting for color stabilization we decided to do internal bleaching in order to achieve a better color of tooth 21. The coronal restoration and endodontic filling were removed from the pulp chamber creating a “pocket” allowing penetration of the bleaching material inside the dentin.

measuring of incisor crown styleitaliano style italiano community clinical case

Fig.7
It’s important to make sure that the apical portion is correctly filled and sealed, this way preventing the possibility of external resorption. The root filling should be reduced by 2-3 mm bellow the CEJ.

measuring internal bleaching space with periodontal probe styleitaliano style italiano community clinical case

Fig.8
A periodontal probe was used to ensure the whole length of the bleaching “pocket” is free of guttapercha, up to 2-3 mm bellow the CEJ. The bleaching 16% carbamide peroxide gel was replaced 3 times, once every 5 days.
Furthermore, photo-activated temporary resin material (Flow composite) was used to seal the chamber.

final shade matching after internal and external bleaching styleitaliano style italiano community clinical case

Fig.9
After internal bleaching, tooth 21 matched the A1 VITA Classical shade.

button try of composite masses before restoration styleitaliano style italiano community clinical case

Fig.10
Color selection was done with an HRI Enamel composite button try-in.

bleached enamel before applying bonding styleitaliano style italiano community clinical case

Fig.11
Optibond Fl was applied after etching the enamel surface. It was gently air-blown and light-cured.

layers composite veneer before finishing and polishing styleitaliano style italiano community clinical case

Fig.12
By applying a layer of composite a convex anatomy was necessary in order to try to hide the fracture line.
Polishing was done after removing the rubber dam.

polshed composite veneer on upper left incisor styleitaliano style italiano community clinical case

Fig.13
Since the patient didn’t want to refine her incisal edge on the tooth 11, copying its anatomy on the tooth 21 was mandatory for natural symmetry.

smile of patient after esthetic smile restoration styleitaliano style italiano community clinical case

Fig.14
Final outcome.

Conclusions

The single discoloured tooth is an aesthetic challenge. Although management can be complex, through appropriate diagnosis, treatment planning and protocols, a predictable result can be achieved. Bleaching and a direct restoration provide a successful minimally invasive treatment.

Bibliography

1. Hattab FN, Qudeimat MA, AL-Rimawi HS, Dental discoloration: an overview. J Esthet Restor Dent 1999;11(6): 291-310.
2.Plotino G, Buono L, Grande NM, et al. Nonvital tooth bleaching: a review of the literature and clinical procedures. J Endod 2008;34(4):394–404.
3. Deliperi S. Clinical evaluation of nonvital tooth whitening and composite resin restorations: five-year results. Eur J Esthet Dent 2008;3(2):148–59.
4. Burrows S. A review of the efficacy of tooth bleaching. Dent Update 2009;36:537–51.
5.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.
6.Dietschi D. Nonvital bleaching: general considerations and report of two failure cases. Eur J Esthet Dent. 2006 Apr;1(1):52-61.

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