Improved Esthetics Using Single-Tooth Bleaching
An effective retreatment of a dark maxillary central incisor
In the challenging clinical situation of a single discolored tooth, as in all bleaching cases, the cause of tooth discoloration must be understood before developing a treatment plan. Not only will this approach help dental practitioners achieve the best possible esthetic outcome in the least invasive way possible, but it will also assist in the management of patient expectations.
It is widely acknowledged that bleaching should precede restorative intervention for the correction of tooth discoloration; not only is this a less invasive approach, but also restorative treatment may be unnecessary after bleaching.1-3 Unfortunately, a minimally invasive approach is not always taken, as in the following case, which illustrates a patient who presented to the authors with an endodontically treated dark maxillary central incisor that was veneered without bleaching.
A healthy 45-year-old male patient presented with the following chief complaint: “My front tooth looks fat and has a purple color.” He related that his maxillary central incisor had darkened and lost vitality following a sports injury. Subsequent to endodontic therapy, the tooth received resin composite access closure and veneer restorations. The patient could recall no attempt to lighten the tooth color through bleaching, although he could recall the facial surface being prepared prior to restoration.
Clinical examination revealed a very light shade of resin composite veneer on tooth No. 9, which was over-contoured but did not effectively conceal dark reddish discoloration beneath the restoration (Figure 1).
Radiographic examination revealed an extremely large access opening restored with a resin composite (Figure 2). Although reopening the access and bleaching internally or performing external bleaching from the lingual would be considered the optimal treatments for this situation,4 these were not attempted due to concern about the risk of further weakening the tooth and because a lingually applied bleaching agent would be unlikely to reach facial dentin.
After being informed of alternate treatments and associated risks, the patient agreed to removal of the veneer and single-tooth bleaching. Cautious removal of the resin composite veneer revealed dark red-violet discoloration of the dentin due to extravasation of blood into the dentinal tubules (Figure 3).
Unfortunately, enamel had been removed from the cervical third of the facial surface, which typically makes discoloration more prominent5 and requires re-restoration on a less-than-optimal dentin substrate.
Following veneer removal, the patient was provided with a single-tooth bleaching tray,2 and instructed to apply 10% carbamide whitening agent (Opalesence® PF; Ultradent Products, Inc., www.ultradent.com) at night for approximately 20 repetitions.
The patient complied over approximately 2 months and afterward demonstrated nearly normal dentin coloration (Figure 4). It is expected that the tooth will only slowly regress in shade over time, making the need for additional retreatment unlikely.6
Two weeks after cessation of bleaching, the tooth was restored with a fourth-generation dentin adhesive (Optibond FL®; Kerr Corporation, www.kerrdental.com) and a microhybrid resin composite (Premise™; Kerr Corporation). The resin composite restoration included a minor non-carious cervical lesion and extended over approximately the gingival half of the facial surface. The patient was highly satisfied with the esthetic improvement in his maxillary incisors (Figure 5).
Nightguard bleaching with carbamide peroxide is customarily used to lighten the entire dentition or at least one arch. However, the technique can be used to lighten a single discolored tooth.7-9 At-home application by the patient allows extended treatment times without additional office visits or fees. Also, the potential side effects of bleaching with carbamide peroxide are much less severe than complications associated with in-office use of concentrated hydrogen peroxide, such as internal resorption.10
The preceding case effectively illustrates that bleaching should precede restoration, or may even eliminate the need for it, in the esthetic treatment of such teeth. Although the patient is of low caries risk, the lack of enamel beneath the present restoration may invite margin staining and cause restoration replacement to become necessary.
About the authors
Martha G. Brackett, DDS, MSD
Associate Professor, Department of Oral Rehabilitation
Georgia Regents University
Yosvany Vento, DDS
William W. Brackett, DDS, MSD<
Professor, Department of Oral Rehabilitation
Georgia Regents University
For more information, contact:
Ultradent Products, Inc.
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