Whitening and direct composites: right choice for a bright smile

A clinical case by our Community member Dr. Nisha Deshpande

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.

Home bleaching and direct composite restorations are a great combination of treatment modalities for achieving a brighter smile for our patients. These days patients often request a brighter and whiter smile. Home bleaching is a safe and easy to perform procedure with quick long lasting results. When used in combination with direct composites, it can be minimally invasive yet provide appreciable outcomes which are beneficial to the patient and satisfying to the clinician. With the advent of fantastic materials like the Teeth Whitening gels by White Dental Beauty which come in a variety of concentrations to suit different patient needs, home bleaching has become predicable and with fantastic results. The patented NOVON technology used in these gels provides efficient results in lesser times making it a material of choice for a dentists bleaching needs. This article focuses on a case treated with a combination method of bleaching and direct composites to meet the expectations for a brighter smile for a young female patient.

styleitaliano style italiano smile before teeth bleaching

Fig.1
A beautiful young girl aged 24 walked into our office with a request for a brighter smile. She was also unhappy with the restorations on her front teeth and requested them to be changed. On examination, we noted the presence of composite restorations in the midline indicating a diastema closure with her central incisors as well a angle build up with 21. The restorations were done around 4 years ago. Since she specifically requested for a brighter smile, we decided on the following treatment plan for her:
1. Home Bleaching with 16% carbamide peroxide for 2 weeks
2. Removal of the old restorations and Direct Composite restorations for 11 and 21

styleitaliano style italiano color matching with shade guide

Fig.2
Pre operative photographic records were taken and the current shade was evaluated as 2M2 with the 3D Master Vita Shade Guide.

styleitaliano style italiano dental color comparison with shade guide

Fig.3
Pre operative photograph recording the shade against a black background. Alginate impressions were also recorded at this stage and trays were fabricated for Home Bleaching. The trays were 1mm thick, hard and scalloped around the gingival margins with reservoirs for the bleaching agent on the buccal surfaces.

styleitaliano style italiano white dental beauty carbamide peroxyde gel

Fig.4
The Home Bleaching agent selected for this case was 16% Carbamide Peroxide White Dental Beauty Teeth Whitening Gel (White Dental Beauty, UK). One syringe can be delivered to the patient at a time. The patient was instructed on how to use the whitening gel and was asked to follow up after a week. The home bleaching was carried out for both arches simultaneously for a period of two weeks. She did not report any sensitivity to the bleaching procedure.

style italiano styleitaliano white dental beauty teeth whitening gels
style italiano styleitaliano white dental beauty teeth whitening gels
styleitaliano style italiano dental color comparison with shade guide for whitening assessment

Fig.5
After 2 weeks, the final shade achieved was 1M1 with the same shade guide as before (3D Master Vita Shade Guide). The color change though subtle was appreciated by the patient. Note that the old composite now is visibly darker than the tooth color.

styleitaliano style italiano dental color comparison with shade guide for whitening assessment

Fig.6
The preoperative shade tab of 2M2 shade. The shade change is very well visible in this comparative photograph. The patient was asked to report back after 2 weeks for the replacement of the old composite restorations. It is imperative to wait minimum 10 days to 2 weeks to allow the nascent oxygen from the dentinal tubules to release so that it does not interfere with the adhesion of the bonding system. This wait period also allows the shade to stabilize before carrying out the final restorations.

styleitaliano style italiano rubber dam isolation for class 4 cavity

Fig.7
Proper rubber dam application is mandatory for all adhesive restorative procedures. It provides a good seal against moisture and makes the bonding more predictable. The old composite was carefully removed with a yellow point diamond bur and a sharp 12 no blade.A 2 mm wide bevel was placed on the 21 to achieve a seamless well blended restoration tooth interface.

styleitaliano style italiano acid etching for composite adhesion

Fig.8
Etching was done for 20 seconds with 37% Orthophosphoric Acid and rinsed well with water.

styleitaliano style italiano microbrush rubbing bonding agent on enamel

Fig.9
A bonding agent, Scotchbond Universal, 3M was applied in multiple coats, air thinned and photocured (Curing Pen, Eighteeth Medical).

styleitaliano style italiano transparent matrix for freehand palatal build up

Fig.10
A free hand palatal shell was created using a transparent mylar strip and finger pressure. The composite used was Si E White Dental Beauty Professional CompoSite System (White Dental Beauty, UK). A broad flat instrument , the LM Solo Anterior (LM Arte) was used to condense the material against the strip supported by finger pressure and cured.

style italiano styleitaliano white dental beauty composite system
style italiano styleitaliano white dental beauty composite system
style italiano styleitaliano lm arte solo instruments
style italiano styleitaliano lm arte solo instruments
styleitaliano style italiano layering of composite masses to build distal angle

Fig.11
Next, a layer of Dentin shade Si1 was applied and photocured. A final layer of Si E was used to complete the incisal restoration. The midline diastema was also closed using the front wing technique with 2 shades, Si 1 and Si E.

styleitaliano style italiano eighteeth curing pen for composite restorations

Fig.12
The Curing Pen (Eighteeth Medical) was used here to cure the final oxygen inhibited layer under a layer of water soluble gel.

curing pen light style italiano styleitaliano eighteeth
curing pen light style italiano styleitaliano eighteeth
styleitaliano style italiano finished restoration before final touches

Fig.13
Basic finishing was done with red ringed tapered diamond point on slow speed and rubber polishers from Shapeguard (Diatech).

styleitaliano style italiano result after bleaching and composite restoration

Fig.14
Immediate post-op after removal of rubber dam, and before final finishing and polishing.

styleitaliano style italiano check up of color match after rehydration of teeth

Fig.15
Final post-op after rehydration and polishing with Lucida polishing system.

style italiano styleitaliano diashine lucida
style italiano styleitaliano diashine lucida

Conclusions

Even though the patient did not have very discolored teeth to begin with, the starting shade being 2M2, we could still achieve a brighter smile as per her request. The comparison between the pre operative shade tab and the post operative one clearly shows the shade change that we achieved with a simple yet effective bleaching procedure with the White Dental Beauty Teeth Whitening Gels. The final result after changing the old composite restorations and replacing them with the specially designed composites catering to bleached or naturally white teeth (Professional CompoSite System, White Dental Beauty) was appreciated by the patient as it fulfilled her desire for a brighter smile while being minimally invasive. This combination method is a great choice of treatment in such cases and must definitely be considered an effective and efficient alternative to other more invasive options.

Bibliography

1. Manauta J, Salat A. Layers, An atlas of composite resin stratification. Quintessence Publishing Co; 2012.
2. 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 Meta-Analysis. Materials (Basel). 2022;15(2):468.
3. Akal N, Over H, Olmez A, Bodur H. Effects of carbamide peroxide containing bleaching agents on the morphology and subsurface hardness of enamel. J Clin Pediatr Dent. 2001;25(4):293-6.
4. Rim Bourgi www.styleitaliano.org/evolution-of-dental-bleaching-from-research-to-clinical/
5.Osama Shaalan www.styleitaliano.org/the-whiteology-approach-in-directveneering

style italiano styleitaliano Essential Dentistry kit online on demand course
style italiano styleitaliano Essential Dentistry kit online on demand course

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