TREATMENT OF DISCOLORED ANTERIOR TEETH

Introduction
One of the most frequent reasons for seeking dental treatment or care is
discolored anterior teeth. Even persons having teeth with normal color often
request to have them more whiter. Treatment options include removal of
surface stains, bleaching, microabrasion or macroabrasion, veneering and
placement of porcelain crowns. Many dentists recommend porcelain crowns as
the best solutions for badly discolored teeth. If crowns are properly done with
the highly esthetic ceramic materials presently available, they have great
potential for being esthetic and long lasting. On the other hand, there are
increasing number of patients who do not want their teeth cut down! for
crowns and are electing an alternative, conservative approach such as veneers,
that preserves as much of the natural tooth as possible. Their treatment is
performed with the understanding that the conservative measures may be less
permanent!.
Discolorations maybe classified as
"# E$trinsic stains% E$trinsic stains are located on the outer surfaces of the
teeth.
&# Intrinsic stains% Intrinsic stains are those which are internal or present
with in the tooth structures.
Discoloration Cause
' (hite )luorosis
' *ight yellow )luorosis, aging, Tetracycline +Type
I#
' ,ark yellow +moderate stain# -ging, Tetracycline +Type II#
' .rown +dark stain# )luorosis, Tetracycline +Type I / II#
or endodontic therapy
' .luish gray +severe stain# Tetracycline stain or endodontic
therapy
' .lack 0aries, fluorosis, or amalgam stain
"
Extrinsic Discolorations:
Metallic Non-metallic
' Occupational e$posure to
metallic salts and with a
number of medicines
containing metal salts.
0haracteristics black staining
of teeth in people using iron
supplements.
0u causes a green stain in
mouth rinses containing 0u
salts.
-g1O
2
salt used causes a grey
colour.
3tannous fluoride causes a
golden brown discoloration.
' -re adsorped onto tooth
surface deposits such as
plaque 4 acquired pellicle.
' -etiological agents include
,iet.
.everages.
Tobacco.
Mouth rinses.
Other medicaments.
' 3taining effect due to
prolonged rinses with
chlore$hidine.
Originally the mechanism was thought to be breakdown of
chlorhe$idine, the oral cavity to a# form parachloraniline and b# it decreases
the bacterial activity such that partly metalised sugars were broken down and
degraded over time to produce brown'coloured compounds. 5ecently 2
mechanisms%
a# 1on'en6ymatic browning reaction decreased +Maillaro reaction#.
0hlorhe$idine accelerates the formation of the acquired pellicle +the
proteins and carbohydrates in the acquired pellicle could undergo a
series of condensation and polymeri6ation reaction leading to
discoloration of the acquired pellicle#.
b# The formation of pigmented sulphides of iron
&
tin

this suggests that chlorhe$idine denatures the acquired pellicle to e$pose

sulphur radicals

which then react with the metal ions to form metal sulphide.
increased level of iron are found in chlorehe$idine.
c# 7recipitation of dietary chromogens by chlorhe$idine

plaque inhibition is dependent upon absorption of chlore$idine onto the tooth

surface.
' *ocally adsorped chlorhe$idine comple$ed with ions from the oral
environment and bind dietary chromogens to surfaces to produce
staining.
Etiology:
In young patients stains of almost any color can be found and are
usually more prominent in the cervical areas of the teeth. These stains may be
related to remnants of 1asmyth8s membrane, poor oral hygiene, e$isting
restorations, bleeding gums, plaque accumulation, eating habits or the
presence of chromogenic bacteria or fungi.
In older patients stains on the surfaces of the teeth are more likely to be
brown, black, a gray and occur on areas ad9acent to the gingival tissues. 7oor
oral hygiene is a contributing factor, but coffee, tea and certain types of food
or medications can produce stains even on plaque free surfaces. Tobacco
stains also are observed frequently. E$isting restorations may be discolored for
the same reasons.
2
E$otic decoration of anterior teeth by etching with citrus fruit 9uice and
applying black pigment In southeast -sia, some women traditionally dye
their teeth with beetle nut 9uice to match their hair and eyes as a sign of
beauty. 3lices of lemon are held in contact with the teeth before applying, the
beetle nut 9uice, to make the staining process more effective. This e$ample
was probably one of the first applications of the acid etch technique. - weak
acid such as that found in citrus fruits is known to cause rapid decalcification
of the enamel.
Treatment%
' Mostly by routine oral prophylactic procedures.
' 3ome superficial discolorations on the tooth colored restorations
and decalcified areas on the teeth which cannot be removed by
prophylactic procedures, may be accomplished by mild
microabrasion or by surfacing the thin outer discolored layer with
flame : shaped carbide finishing bur or diamond instrument
+macroabrasion# followed by polishing with abrasive discs or
points to obtain an acceptable result.
Intrinsic discolorations:
-re caused by deeper internal stains. Teeth with vital 4 non vital pulps
can be affected as well as root canal treated teeth.
Etiology:
;ital teeth%
' ,uring crown formation
' <ereditary disorders
' Medications +Tetracycline preparations#
' E$cess fluoride in9ection
' E$anthamatous fever
' Trauma
=
3taining may be located in enamel 4 dentin. ,iscoloration restricted to
dentin may still show through enamel.
Tetraccline stains: !Co"en#
' Teeth are most susceptible to tetracycline discoloration during
formation, beginning in the &
nd
trimester in utero and continuing to
roughly > years. Tetracycline particles get incorporated into the
dentin during calcification of teeth, three chelation with calcium
and forms tetracycline orthophosphate.
' The discoloration itself results from e$posure of the teeth to
sunlight, which is why the labial surfaces of the incisors tend to
darken more quickly and intensely while the protected molars
remain yellow longer.
' Tetracycline staining is variable in its e$tent, color intensity and
location, since the severity of stains depends on the time and
duration of drug administration.
$ ma%or cate&ories 'ro'osed ( )ordan and *o+sman:
I
st
degree : tetracycline staining, a light yellow or light gray stain, uniformly
distributed in local areas, highly amenable to bleaching.
II
nd
degree III
rd
degree
' Triangular but with darker
or more e$tensive yellow
or gray stains.
' 5equire more bleaching or
' - combination of in'office
4 home matri$.
' Most intense often dark
grey or blue in colour.
' Most distinctive aspect is
banding.
' ;eneering technique with
opaquers to provide
satisfactory esthetic
results.
?
IV
th
degree : Tetracycline stains that are simply too dark to attempt vital
bleaching and for which bonding or laminating is a more appropriate place to
begin.
Minoccline:
The recent sudden appearance of ring like stains on the teeth of adolescents
and adults could be due to a semisynthetic derivative of tetracycline,
minocycline, given in routine prescription for acne.
Minocycline is absorbed from the @IT and combines poorly with calcium.
Instead, it chelates with iron and forms insoluble comple$es.
Minocycline pigment produced in tissues is same or very similar to that
produced by ultra'violet radiation.
Tetraccline stains: Is a most distracting generali6ed type of intrinsic
discoloration. The severity depends on the dosage, duration of e$posure, the
type of tetracycline analog used. 0olor varies from yellow'orange to dark
blue'gray.
Fluorosis % 0onsuming e$cess fluoride in drinking water at the time of teeth
forming. .ecause of the high fluoride content in the enamel, fluorosed teeth
may be difficult to treat with acid etching and resin bonding.
H'o'lastic de,ects:
' ,ue to enamel and dentin malformation.
' 7oor oral hygiene following tooth eruption
' 7oor oral hygiene during orthodontic treatment
-"ite s'ots % are the locali6ed areas of demineralisation or failure of enamel to
calcify properly resulting in decalcified white spots.
Ot"er causes % of intrinsic discolorations are caries, metallic restorations,
corroded pins, and leakage or secondary caries around e$isting restorations.
.ello/er teet"% -ging wear of the enamel thinner enamel
underlying dentin becomes transparent. ,ue to this permeability of the teeth,
A
usually organic pigments from foods, drinks, tobacco products etc. can be
seen.
Non-0ital teet"% infected or degeneration of pulp due to trauma, deep caries,
or irritation from the restorative procedures.
.ello/in& o, teet" : Trauma resulting in calcific metamorphosis :
calcification of pulp chamber and 4 or root canals.
Treatment:
' Bustification of treatment : 7atient educationC Motivation.
' 0onservative methods like bleaching 4 microabrasion 4
macroabrasion4 veneering techniques can be used.
' Mild discolorations are best left untreated, bleached or treated
conservatively with microabrasion or macroabrasion as no
restorative material is as good as the natural, healthy tooth
structure.
' 0orrection of intrinsic discoloration caused by failing restorative
entails replacement of the faulty position or the entire restoration.
' 0orrection of discolorations due to carious lesions requires
appropriate restorative treatment.
Dental conditions t"at cause discoloration
' 0aries is a primary cause of pigmentation, appearing as opaque,
white halo or gray discoloration.
' .acterial degradation of food debris in areas of tooth decay or
decomposing filling can cause even deeper brown to black
discolorations.
' ,egraded tooth'colored restorations such as acrylics, glass
ionomer, or composites can cause teeth to look gray and
discolored.
' 5estorations with metal amalgams, even silver and gold ones, may
reflect shadows through the enamel, even when there has been no
D
breakdown in the material. 5eplacing these restorations with less
visible materials such as composite resin often changes the
appearance of the tooth enough to satisfy the patients without
bleaching.
' The most troublesome staining from dental treatments are those
from oils, iodines, nitrates, root canal sealers, pins and other
materials that have penetrated the dentinal tubules. The length of
the time, the stain has been present determines the residual
discoloration and can affect the eventual success of bleaching
efforts.
A Rationale For Tec"ni1ue Selection and Material C"oice ,or Anterior
Restorations
' 7eriod
ontal health
' 0aries
incidence
' Occlus
ion
0ase selection
-nd
Treatment 7lanning
' Orthodonti
cs
' Esthetic
evaluation
' Economic
s
.leaching 1on'.leaching
' In
office
;s
' -t
home
' Original
shade O.E.
' Economics
' Other
+3moker,
7regnancy#
0osmetic
contouring
.onding : 7artial
coverage
)ull labial
coverage
)ull coverage
.onded
>
' 0lass III, I;, ;
' 7artial veneer
' ,irect resin
veneers
' Indirect resin
veneers
' 7orcelain
veneers
' -ll 7orcelain
bonded
' 5esin to metal
' 7orcelain to
metal
*leac"in& treatment:
The lightening of the color of a tooth through the application of a
chemical agent to o$idi6e the organic pigmentation in the tooth is referred to
as bleaching.
T'es:
;ital teeth bleaching in office bleaching
1on vital teeth bleacing <ome bleaching
+night guard bleaching matri$#
Contraindications o, *leac"in&:
' Too much sensitivity because of severe erosion of the enamel,
e$tremely large pulps, e$posed root surfaces, the transient
hyperemia associated with orthodontic tooth movement, or the
patient8s report of sensitivity.
' Teeth with white or opaque spots. )urthermore, many patients
report the difference between the spots varies during the cource of
the day, depending on a host of factors ranging from how dry the
mouth is to the use of alcohol. - preferable treatment would be
attempting to remove the white spot with microabrasion.
' E$tremely dark strains, especially those with banding or with
uneven distribution.
F
' Teeth that have been bonded, laminated or have e$tensive
restorations.
1o, one, bleaching technique is effective in every solution, and success
is not equals. Often with vital bleaching, a combination of the in'office
technique and the dentist prescribed home applied technique will have better
results than either techniques used alone.
2ital (leac"in&: .leaching of vital teeth in'office was first reported in ">A>.
-lthough, there are reports of a 2G ether'pero$ide mouthwash used for
bleaching in ">F2, the dentist'prescribed home'applied! +night guard vital
bleaching# began around "FA>.
Indications:
"# Intrinsically discolored teeth from aging 4 drug ingestion.
&# Trauma.
2# -s an alternative treatment for failed non'vital walking bleach.
=# .efore and after restorations to harmoni6e shades of the restorative
materials with natural teeth.
?# 3ingle teeth which have darkened from trauma, but are still vital or
have a poor endodontic prognosis due to absence of a relatively visible
canal.
T'es :
In office technique or power bleaching! +calcific
metamorphosis#.
Out side the office technique or night guard vital bleaching!.
These technique may be used separately or in combination with one
another.
Ad0anta&es: !in &eneral#
"# 3afer.
"H
&# 1o effect on e$isting restorative materials because <
&
O
&
has such a low
molecular weight, it easily passes through the enamel and dentin.
2# Mild tooth sensitivity occasionally e$perienced during treatment.
<owever, this effect is transient, and no long'term harm to the pulp has
been noted.
Ad0anta&es o, t"e in-o,,ice 0ital (leac"in& techniques are that%
"# (hile using very caustic chemicals, it is totally under the dentists
control.
&# The soft tissue is generally protected from the process.
2# It has the potential for bleaching teeth more rapidly.
Disad0anta&es primarily related to the%
"# The cost.
&# The unpredictable outcome.
2# The unknown duration of the treatment. The features that warrant
concern and caution include.
=# The potential for soft tissue damage to patient and provider.
?# The discomfort of a rubber dam.
A# The potential for post treatment sensitivity.
Non-0ital (leac"in& 'rocedures:
.leaching of non'vital teeth was first reported in ">=>. The primary
indication for non'vital bleaching is to lighten teeth which have undergone
root canal therapy. This discoloration may be a result of%
"# .leeding into the dentin from trauma prior to root canal therapy.
&# ,egradation of pulp tissue left in the chamber after such therapy.
2# 3taining from restorative materials and cements placed in the tooth as a
part of the root canal treatment. Most posterior teeth which have
""
received 50T require cast restorations which encompass the tooth to
prevent subsequent fracture. <owever, anterior teeth needing
restorative treatment and, which are largely intact may be restored with
composite rather than with partial or full coverage restorations without
significantly compromising the strength of the tooth. This knowledge
has created a resurgence in the utili6ation of non'vital bleaching
techniques.
Tec"ni1ue o, non-0ital (leac"in&:
In office thermocatalytic technique.
Out of the office technique +walking bleach#.
0ombination of these two.
-lthough non'vital bleaching in quite effective, there is a potential
+I"G# for a most deleterious side effect termed cervical resorption. This
sequela requires prompt and aggressive treatment. On animal models, cervical
resorption has been observed most often when using the thermocatalytic
technique. Therefore, the walking bleach technique or an in office technique
which does not require the use of heat are preferred for non'vital bleaching. To
reduce the possibility of resorption,
"# Immediately after bleaching a paste of calciumhydro$ide powder, and
sterile water is placed in the operated pulp chamber as described later.
&# -lso, sodiumperborate alone, rather than in con9unction with
hydrogenpero$ide, may be used as the primary bleaching agent.
-lthough sodium perborate may bleach slowly, it is safer and less
offensive to the tooth. 7eriodic radiographs should be made post'
bleaching to screen for cervical resorption, which generally has its
onset in "'D years.
Other treatment options for cervical resorption are%
' )orced orthodontic e$trusion
' 3urgery
' E$traction
"&
' 3ubmersion of the root
In o,,ice non-0ital (leac"in& tec"ni1ue:
In office non'vital bleaching for non'vital teeth is historically a
thermocatalytic technique involving the placement of 2HG <
&
O
&
into the
debrided pulp chamber and activation of the o$idation process by placement
of a heating instrument into the pulp chamber. The diffusion of <
&
O
&
, through
the patent dentinal tubules into the cervical 7,*, may initiate a local
inflammatory reaction. - more recent technique utili6e a light activated
bleaching preparation of 2HG <
&
O
&
that requires no heat. This technique in
frequently the preferred in'office technique for bleaching non'vital teeth. In
both techniques it is imperative that a sealing cement +polycarbo$ylate# or
light cured glass ionomer cement is to be placed over the e$posed root canal
filling prior to application of the bleaching agent.
-al+in& (leac" tec"ni1ue:
"# Evaluate the potential for occlusal contact on the area of the root canal
access opening.
&# 5ubber dam isolation of the tooth to be bleached.
2# 5emove all materials in the coronal portion of the tooth +access
opening#.
=# 5emove gutta percha to J&mm apical of the clinical crown.
?# Enlarge the endodontic access opening sufficiently to ensure complete
debridement of the pulp chamber.
A# 7lace a polycarbo$ylate cement or light cured @I0 to seal the e$posed
gutta percha to prevent the percolation of the bleaching agent into the
root canal.
D# Trim the e$cess material once it sets so as to e$pose the discolored
peripheral dentin.
># Ksing a cement spatula with heavy pressure on a glass slab, blend one
drop of 2HG hydrogenpero$ide with enough sodium perborate to form
a creamy paste +3upero$al solution#.
"2
F# Kse a spoon e$cavator or similar instrument to fill the pulp chamber to
within &mm of the cavosurface margin with the bleaching mi$ture,
avoiding contact with the enamel cavosurface margin of the access
opening.
"H# Kse a cotton pallet to blot the mi$ture to place.
""# 1ow place a temporary sealing material such as I5M or cavit to seal
the access opening.
"&# The area should remain isolated for ? minutes after closure to evaluate
the adequacy of sealing.
The bleaching mi$ture is very active for &= hours, after which little
potential for harm to tissue e$ists. The mi$ture may be changed every 2 to ?
days and usually "'2 treatments are required. If sodium perborate is used
alone, it should be changed bi'weekly.
1a perborate 1a metaborate L <
&
O
&
/ release O
L
(hen mi$ed with supero$ol
1a metaborate L <
&
O L O
L
+active O
&
# This o$idi6es and discolors the
stain slowly.
To overcome the disadvantage of cervical root resorption associated
with the walking bleach technique, 3passer suggested the use of
Recent Ad0ances
a# Sodium perborate and H
2
O
The procedure for the technique is same
The reaction is
1a perborate L <
&
O
decompose
1a Metaborate L <
&
O
&
<
&
O
&
<
&
O L O
&
-ctive o$ygen which starts the bleaching process.
The content of 1ascent O
L
depends on the type of 1a perborate used%
"=
1a perborate monohydrate release "AG O
&
Trihydrate releases "".>G O
&
Tetrahydrate releases "H.H=G O
&
To diminish the risk of cervical root resorption, use of 1a perborate
trihydrate or tetrahydrate with water has been recommended.
b# 5ecently, a modified walking bleach technique using "HG carbamide
pero$ide has been described. This is known as inside 4 outside bleaching
technique. +It consists of administration by the patient of the bleaching agent
within and outside the tooth simultaneously#.
Ad0anta&es%
Time needed to complete the treatment +2'= days#. The use of catalase
to eliminate the residual O
&
from the tooth structure, contributes to the rapid
treatment.
In-o,,ice 0ital (leac"in& tec"ni1ue:
3re'arin& t"e teet" ,or *leac"in&
"# 7lace ;aseline or cocoa butter on the lips and gingival tissues prior to
the application of the rubber dam.
&# Isolate the anterior teeth and sometimes the first premolars as well,
with a heavy rubber dam to provide ma$imum retraction of tissue and
an optimal seal around the teeth.
2# 7lace a 2?G <
&
O
&
soaked gau6e or a gel form of <
&
O
&
on the teeth.
1ote% the patient is instructed to note any sensation of burning of the
lips or gingiva, which would indicate a leaking dam and the need to
terminate treatment.
=# The o$idation reaction of the <
&
O
&
can be accelerated by applying heat
with either a heating instrument +& min per tooth# set at the ma$imum
tolerance of the patient, or with an intense light +2H min per arch#.
?# Kpon completion of the treatment, rinse the teeth, remove the rubber
and caution the patient about post operative sensitivity.
"?
.leaching treatments are generally rendered weekly for &'A treatments
with each treatment lasting for 2H'=? minutes. 7atients may e$perience
transient sensitivity of teeth between appointments, but again, no long term
adverse pulpal effects have been reported.
Originally the thermocatalytic technique of vital bleaching was is used
"2 inches away from the teeth to be bleached temperature : ""?'"=HM.
- bleaching light is used in this at a temperature less than "HHM0 so as
not to damage the pulp.
The patient and the operator should be protected from the bleaching
light.
' The bleaching light could be a photoflood lamp that focuses its
rays on the labial surface, providing light as well as heat.
' Or a polymeri6ation light to accelerate the bleaching process.
' <odosh and colleagues introduced a rheostat controlled solid state
heating device with specially designed tips that allow the dentist to
provide pin'point bleaching and heating in grooves, depressions
and in smaller areas.
Ad0anta&es:
' 5equire less time.
' Illuminator : a state of the art bleaching instrument that combines
an activation light and activation want for bleaching procedures on
both vital and pulpless teeth.
' Then, came into use, the combination of
+" part# +? parts# +? parts#
ether L <0l L <
&
O +Old Mc Eein8s solution#
+H.&ml# 2AG +" ml# 2HG +" ml# ' p< =.A
to bleach the teeth -ccording to @rossman
"A
The disadvantage with this type of technique is that it abrades the
enamel surface more readily, resulting in over contouring or flattening of the
crown.
To overcome this, <0l was replaced with 1aO< to neutrali6e the
acidic environment +as it creates an alkaline environment#. This was termed as
the 1ew McEein8s solution : p< F.
Ether 5emoval of surface debris.
<0l Initial etching 4 entry.
<
&
O
&
+discovered by -bbot# O$idi6es removes the stains.
1aO< decreases the amount of decalcification produced by <
&
O
&
and creates an alkaline environment at p< of F compared to p< of =.A. 5ecent
studies have demonstrated that this p< 4 alkalinity enhances the bleaching
mechanism.
Controversy exists as to whether to:
Etc" (e,ore (leac"in& No to etc"
' If your case suggests the
need to enhance the
penetrability of the
bleaching solution, you
can etch lightly using 2?'
2DG buffered phosphoric
acid for ? seconds.
' Increased stain reduction
has been noted.
' )alkenstein reports that the
combination increased
penetration on the calcium
phosphate tetracycline
molecule to reach upto ?'
DN into the surface which
' "HN of enamel are lost
during acid etching in
addition to the &?N of
enamel that are etched.
)urthermore, if it is
etched, it must be polished
after every appointments.
' <aywood points out to
not etch! preserves the
enamel, retaining the
fluoride rich surface layer
of enamel, as well as
shortening of the
appointment time.
"D
is very high.
' .egin treatment on the most discolored teeth, proceeding to the
lesser ones.

' Oellow 4 yellow brown stains are easier to remove than grey.

' Incisal halves of teeth respond to bleach more quickly than cervical
halves, due to thinner dentin.
T"e ad0anta&es of the dentist 'rescri(ed 4 "ome a''lied tec"ni1ue +night
guard vital bleaching# are%
"# The use of a lower concentration of pero$ide +generally "HG'"?G
carbomide pero$ide#.
&# The ease of application.
2# Minimal side effects.
=# *ower cost due to the reduced chair time required for treatment.
T"e disad0anta&es are%
"# The reliance on patient compliances.
&# The longer treatment time.
2# The +unknown# potential for soft tissue changes with e$cessively
e$tended use.
This uses an athletic style vacuum formed soft mouthguard and
currently available "HG carbamide pero$ide : containing materials to bleach
the teeth.
">
There are & basic regimens for the application of the whitening
solution.
a# 3leeping with the nightguard filled with the bleaching
material each night.
b# (earing the loaded nightguard during the day while
changing the solution every "P ' & hrs.
Treatment time is ='A weeks for nighttime bleaching and "'2 wks for
the daytime regimen of multiple applications.
Dentist 'rescri(ed-"ome a''lied tec"ni1ue: Ni&"t &uard 5 Matrix
(leac"in&6
"# -n alginate impression of the arch to be treated is made free of bubbles
and poured in cast stone.
Note% -fter appropriate infection control procedures, rinse the impression
vigorously, and then pour with cast stone. In complete rinsing of the
impression may cause a softened surface on the stone, which may result in a
guard which is slightly too small and irritates tissue.
&# Trim the resultant cast around the periphery to eliminate the vestibule
and thin the base of the cast.
2# -llow the cast to dry, and block out any significant undercuts.
=# The night guard is formed on the cast using a heat 4 vacuum forming
machine. -fter the machine has warmed up for "H mintues, a sheet of
H.&Q : H.2?Q might guard material is inserted and allowed to soften by
heat until it sags by "Q. Then close the top position of the machine
slowly and gently, and allow the vacuum to form the heat softened
material around the cast.
?# Kse a no. "" surgical blade in a bard'parker handle to trim in a smooth
straight cut about 2'? mm from the most apical portion of the gingival
crest of the teeth facially and lingually. This e$cess material is
removed first. Then remove the horseshoe shaped night guard from the
cast.
"F
A# Trim the edges of the night guard to a smooth te$ture using a sharp,
curved scissor until only about & mm of tissue +apically of gingival
crest# is covered, being sure the night guard does not engage tissue
undercuts. The night guard is completed and ready for delivery to the
patient.
D# Insert the night guard into the patients mouth and evaluate it for
adaptation, rough edges or blanching of tissue.
># )urther shortening +trimming# may be indicated in problem areas.
F# Evaluate the occlusion on the night guard with the patient in ma$imum
intercuspation. If the patient is unable to obtain a comfortable
occlusion due to premature posterior tooth contact, trim the night guard
to e$clude coverage of the terminal posterior teeth, as needed to allow
optimal tooth contact in ma$imum intercuspation.
"H# - "HG ' "?G carbamide pero$ide bleaching material is generally
recommended for this bleaching technique. "HG carbamide pero$ide
degrades into 2G <
&
O
&
and DG urea. .leaching materials containing
carbopol are recommended because it thickens the bleaching solution
and e$tends the o$idation process. To prolong the +carbopel
carbamide pero$ide#, hydro$y gel is now added.
""# Instruct the patient in the application of the bleaching solution into the
night guard. & or 2 drops of bleaching solution are placed onto the area
of each tooth to be bleached in the night guard.
If either of two primary side effects occur is sensitivity of the teeth or
irritated gingiva, the patient should reduce or discontinue treatment
immediately, and contact the dentist so the cause of the problem can be
determined.
It is recommended that only one arch should be bleached at a time,
beginning with the ma$illary arch. .leaching the ma$illary arch first allows
the untreated mandibular arch to serve as a constant standard for comparison.
Moreover, restricting the bleaching to one arch at a time reduces the potential
for occlusal problems which could potentially occur if the thickness of two
mouth guards were interposed simultaneously.
&H
,ue to the difficulty in bleaching tetracycline'stained teeth, some
clinicians advocated intentional 50T, with the use of a non'vital bleaching
technique in order to overcome this problem. (hile the esthetic result appears
much better than that obtained from e$ternal bleaching, this approach involves
all the inherent risks otherwise associated with 50T.
Microa(rasion and Macroa(rasion:
Microabrasion and macroabrasion represent conservative alternatives
for the reduction or elimination of superficial disolorations. -s the terms
imply, the stained areas or defects are abraded away. These techniques do
result in the physical removal of tooth structure and therefore are indicated
only for stains or enamel defects that do not e$tend beyond a few tenths of a
millimeter in depth. If the defect or discoloration still remains after treatment
with microabrasion or macroabrasion, a restorative alternative is indicated.
Microa(rasion:
In "F>=, Mc0loskey reported the use of ">G hydrochloric acid on
teeth for the removal of superficial fluorosis stains and white spots where
bleaching is not effective. 3ubsequently, in "F>A, 0roll modified the technique
to include the use of pumice with <0l to form a paste applied with a tongue
blade. This technique was called microabrasion! and involved the surface
dissolution of the enamel by the acid along with the abrasions of the pumice to
remove superficial stains or defects. 3ince that time, 0roll further modified the
technique, reducing the concentration of the acid to ""G along with increasing
the abrasiveness of the paste by using silicon carbide particles +in a water
soluble gel paste# instead of pumice. This product is marketed as 7rema!
compound +"FFH#.
' -ctually removes &&'&DNm of enamel 4 application.
It should be emphasi6ed that this technique involves the physical
removal of tooth structure and does not remove stains or defects through any
bleaching phenomenon.
"# Incipient caries is reversible if treated immediately. If however, the
carious lesion has progressed to have a slightly roughened surface,
microabrasion coupled with a reminerali6ation program is an initial
option, which if unsuccessful, can be followed by a restoration.
&"
&# The developmental discolored +opaque white 4 light brown# spot'
microabrasion is successful if the defect is superficial +or H.& : H.2
mm# if greater restoration is the treatment of choice.
3urface discoloration due to fluorosis also can be removed by
microabrasion if the discoloration is within the H.& : H.2 mm removal
depth limit.
3rocedure:
"# -pply rubber dam, protective glasses should be given to the patient to
shield the eyes from any splatter.
&# The 7rema paste in applied to the defective area of the tooth with a
special rubber cup which has fluted edges.
2# )or small locali6ed idiopathic white or light brown areas, a hand
application device is also available for use with the 7rema compound.
=# 7eriodically, the paste is rinsed away to assess defect removal.
?# The treatment areas are polished with a fluoride containing
prophypaste to restore surface lusture.
A# Immediately following treatment, a topical fluoride is applied to the
teeth to enhance reminerali6ation.
Macroa(rasion:
-n alternative technique for the removal of locali6ed superficial white
spots and other surface stains or defects is called macroabrasion!. It simply
utili6es a "& fluted composite finishing bur or micron finishing diamond in a
high'speed handpiece to remove the defect. 0are must be taken to use light
intermittent pressure and to carefully monitor removal of tooth structure in
order to avoid irreversible damage to the tooth.
)ollowing removal of the defect or upon termination of any further
removal of tooth structure, a 2H fluted composite finishing bur is used to
remove any factor or striations created by the previous instruments. )inal
polishing is accomplished with an abrasive rubber point.
&&
Microa(rasion Macroa(rasion
' Ensures better control of
the removal of tooth structure
' 5ecommended over
macroabrasion for the treatment
of superficial defects
' <igh speed
instrumentation.
' Is technique : sensitive
to operator ability.
' Is faster and does not
require the use of a rubber dam
' ,efect removal is easier
Cosmetic recontourin& !DCNA7 899$#
' 0an be used to reshape enamel, smooth incisal edges, round incisal
edges, open embrasures, reduce prominent surfaces or change line
angles.
' It is easily accomplished by lightly reducing enamel at moderate
speed with a small flame : shaped medium diamond followed by
an > or "& fluted carbide bur.
2eneers:
- veneer is a layer of tooth colored material that is applied to a tooth
for esthetically restoring locali6ed or generali6ed defects or intrinsic
discolorations.
Indications ,or 0eneers
' Tetracycline discoloration
' )lurosis discoloration
' Teeth darkened by age
' Irregular tooth positioning in the arch
' Malformed teeth
' Teeth discolored by endodontic procedures
&2
' Teeth with numerous visible cracks
' Teeth with numerous unsightly restorations
' Teeth denuded of superficial structure by acid deminerali6ation.
Contraindications ,or 0eneers
' <eavy occlusion
' Teeth in severe labial version +buck teeth!#
' Mouth breathers
' 7oor oral hygiene
' ,enuded dentin
' <igh fluoridated +fluorosed# teeth
Typically veneers are made of :
' 0hairside composite,
' 7rocessed composite
' 7orcelain
' 0ast ceramic materials.
-ccording to ,01-, "F>?, the current generation of materials and
concepts for veneers to teeth can be divided into three categories
"# )ree hand placed, composite or microfill
&# *aminate pre'formed
2# *aboratory formed, acrylic resin, microfill resin or porcelain
T'es:
' 7artial
' 0omplete
&=
artial veneers are indicated for the restoration of locali6ed defects
areas of intrinsic discolorations.
!ull veneers are indicated for the restorations of generali6ed defects or
areas of intensive staining involving the ma9ority of the facial surface of the
tooth.
<owever, several important factors including patient age, teeth
position and alignment, occlusion, tissue health, and oral hygiene must be
evaluated prior to pursuing full veneers. )urthermore, if full veneers are done,
care must be taken to provide proper physiological contours, particularly in the
gingival area, to favor good gingival health.
Full 0eneers
' ,irect technique
' Indirect technique
Direct tec"ni1ue% done when a small number of teeth are involved or
when the entire facial surface is not faulty +partial veneers#. ,irectly applied
composite veneers can be completed for the patient in one appointment with
chairside composite. 7lacing direct composite full veneers is very time
consuming and labor intensive. <owever, for cases involving young children,
a single discolored teeth or where economics or patient time are limited
precluding a laboratory fabricated veneer, the direct technique is a viable
option.
Indire"t veneers require two appointment but offer more advantages
over directly placed full veneers.
a# )irst, indirectly placed veneers are much less technique sensitive to
operator ability. 0onsiderable artistic e$pertise and attention to detail
are required to consistently achieve esthetic and physiologically sound
direct veneers. Indirect veneers are made by lab technician and are
typically more esthetic.
b# 3econd, if multiple teeth are to be veneered, indirect veneers usually
can be placed much more e$peditiously.
&?
c# Third, indirect veneers typically will last much longer than a direct
veneer, especially if made of porcelain or cast ceramic.
#ire"t: 3ome controversy e$ists regarding the e$tent of tooth preparation that
is necessary and the amount of coverage for veneers. 3ome operators prefer to
etch the e$isting enamel and apply the veneer over the entire e$isting facial
surface without any tooth preparation. The perceived advantage of this method
is that in case of failure or in the event the patient does not like the veneer, it
can be removed, thus being reversible. <owever, several significant problems
e$ist with this approach. In order to achieve an esthetic results the facial
surface of such a restoration must be overcontoured, thus appearing and
feeling unnatural. -n overcontoured veneer frequently results in gingival
irritation with accompanying hyperemia and bleeding due to bulbous and
impinging gingival contours. The veneers is more likely to be dislodged when
no tooth structure is removed before etching and bonding procedures. If the
veneer is lost it can be replaced, but the patient may live in constant fear that it
will happen again, possibly creating a embarrassing situation. The reversibility
of these veneers may seem desirable and appealing to patients from a
psychological standpoint, however, few patients who had to have veneers wish
to return to the original condition. -lso, removing full veneers with no damage
to the underlying unprepared teeth is e$ceedingly difficult if not impossible.
To consistently achieve esthetic and physiologically sound results, an intra
enamel preparation is almost always indicated. The only e$ception is in cases
where the facial aspect of the tooth is significantly under contoured due to
severe abrasion or erosion. In these cases more roughening of the involved
enamel and defining of the peripheral margins are indicated.
Intraenamel preparation +or the roughening of the surface in under
contoured areas# before placing a veneer is strongly recommended for the
following reasons%
"# To provide space for opaque, tinting, bonding and 4 or veneering
materials for ma$imal esthetics without overcontounting
&# To remove the outer fluoride'rich layer of enamel which may be more
resistant to acid etching.
2# To create a rough surface for improved bonding.
=# To establish a definite finish line.
&A
-nother controversy involves the location of the gingival margin of the
veneer. 3hould it terminate short of the free gingival crest, at the level of the
gingival crest, or apical to the gingival crestR
The answer depends on the individual situation. If the defect or
discoloration does not e$tend subgingivally, then the margin of the veneer
should not e$tend subgingivally.
The only logical reason for e$tending the margin subgingivally, is if
the area is carious or defective, warranting restoration, or if the area involves
significantly dark discoloration that presents a difficult esthetic problem.
5ecall that no restorative material is as good as normal tooth structure, and the
gingival tissue is never as healthy when it is in contact with an artificial
material.
Two basic preparation designs e$ists for full veneers
"# - Window! preparation and &# an incisal overlapping! preparation.
(indow preparation is recommended for most direct and
indirect composite veneer. This intraenamel preparation design
preserves the functional lingual and incisal surfaces of the
ma$illary anterior teeth, protecting the veneers from
significantly occlusal stress.
.y using a window! preparation, the functional surfaces are
better preserved in enamel. Their design reduces the potential
for accelerated wear of the opposing tooth.
Incisal lapping% preparation is indicated when the tooth being
veneered needs lengthening or when an incisal defect warrents
restoration. -dditionally, the incisal lapping design is
frequently used with porcelain veneers, because it not only
facilitates accurate seating of the veneer upon cementation, but
also allows for improved esthetics along the incisal edge.
Direct 0eneer tec"ni1ues:
7artial
)ull
&D
"# #ire"t partial veneers: 3mall locali6ed intrinsic defects or
discolorations are ideally treated with direct partial veneers.
Ste's%
"# 0leaning, shade selection and isolation with cotton rolls or rubber dam.
&# The outline is dictated solely by the e$tent of the defect and should
include all the discolored area.
2# Kse a coarse elliptical or round diamond instrument with air water
coolant to prepare the cavity generally to a depth of about H.? : H.D?
mm.
=# Ksually it is not necessary to remove all the discolored enamel in a
pulpal direction, however, the preparation must be e$tended
peripherally to sound, unaffected enamel.
?# Kse an opaquing agent for masking dark stain.
A# If the entire defect or stain is removal then a microfill composite is
recommended for restoring the cavity.
If a residual lightly stained area or white spot remains in enamel, an
intensively less translucent composite can be used rather than e$tending the
preparation into dentin to eliminate the defect.
Ste's%
The window! preparation is typically made to a depth roughly
equivalent to half the thickness of the facial enamel ranging from J H.? : H.D?
mm midfacially and tapering down to a depth of about H.& : H.? mm along the
gingival margin, depending on the thickness of enamel.
The preparation for a direct veneer normally is terminated 9ust facial to
the pro$imal contact e$cept in the area of a diastema. To correct the diastema,
the preparations are e$tended from the facial and the mesial surfaces,
terminating at the mesiolingual line angles. If the discoloration are not
involving the incisal edges, then it is not involved in the preparation. -lso,
preservation of the incisal edges better protects the veneers from heavy
functional forces as noted earlier for window! preparations.
&>
The teeth should be restored one at a time. -fter etching rinsing and
drying procedures apply and polymeri6e the resin bonding agent. 7lace the
composite on the tooth in increments, especially along the gingival margin to
reduce the effects of polymeri6ation shrinkage. -fter the first veneer is
finished, restore the second tooth in a similar manner. ,uring a second
appointment the remaining four anterior teeth are restored with direct
composite veneers.
In case of dark tetracycline stained teeth with the discoloration
e$tending subgingivally, the finish line is placed subgingivally.
Indirect 0eneer tec"ni1ue:
#rawba"$s o% dire"t veneering
"# 7reparation, insertion and finishing of several direct veneers at one
time is too difficult, fatiguing and time consuming. 3ome patients
become uncomfortable and restless during long appointments.
&# ;eneer shades and contour can be better controlled when made outside
+Indirect# of the mouth on a cast than direct technique.
Indire"t veneers in"lude those made o%:
"# 7rocessed composite
&# )eldspathic porcelain
2# 0ast ceramic
.ecause of superior strength, durability and esthetics, feldspathic
porcelain is by far the most popular material for indirect veneering techniques
used by dentist. 0ast ceramic veneers offer comparable qualities, but require
e$acting laboratory technique and allow only limited chairside finishing and
alteration of contourC however e$cellent laboratory support and the superb
marginal fit of these veneers can minimi6e or eliminate this disadvantage.
-lthough & appointments are required for indirect veneers, chair time is saved
because much of the work is done in the laboratory. E$cellent result can be
obtained when proper clinical evaluation and careful operating procedures are
followed. Indirect veneers are attached to the enamel by acid etching and
bonding with either a self cured, light cured or dual cured resin bonding
material.
&F
8# 3rocessed com'osite 0eneers:
0omposite veneers are processed in a lab to achieve superior
properties, using intense light, heat, vacuum, pressure or a combination of
these. 0ured composite can be produced which possess improved physical and
mechanical properties compared to traditional chairside composites.
-dditionally, indirectly fabricated composite veneers offer superior shading.
.ecause their composition is similar to chairside composite, indirect
composite veneer are capable of being bonded to the tooth with a resin
bonding medium.
-fter acid etching, a bonding agent is applied to the etched enamel as
with any composite restoration. - fluid resin bonding medium then is used to
bond the veneer in place.
- newly developed processed composite of the hybrid type, filled with
barium glass and colloidal silica, offers a significant increase in bond strength.
.ecause barium glass is a relatively soft radiopaque filler, it can be
sandblasted and etched in the lab with F : "HG of hydrofluoric acid to produce
numerous areas of microscopic undercuts, similar to the phenomenon that
occurs when enamel is etched.
Etched composite veneers.
7rocessed composite veneers are easily finished and polished. They
also can be replaced and repaired easily with chairside composite. ;eneers are
often recommended for placement in children and adolescents as interim
restorations until the teeth have fully erupted and achieved their complete
clinical crown length.
Indirect processed composite veneers are indicated for placement in
patient who e$hibit significant wear of their anterior teeth due to occlusal
stress. There offer esthetic affordable alternative to more costly porcelain or
castable ceramic types when economics is the primary consideration.
Etc"ed 'orcelain 0eneers:
The most frequently used indirect veneer type is the etched porcelain
+feldspathic# veneer. 7orcelain veneers etched with hydrofluoric acid are
2H
capable of achieving high bond strength to the etched enamel via a resin
bonding medium.
Ad0anta&es:
The etched porcelain veneers are
' <ighly esthetic
' 3tain resistant
' 7eriodontally compatible
' -ppear to significantly outlast composite veneers.
Indication:
@enerali6ed discoloration of the anterior teeth along with facial and
incisal hypoplastic defectsC a midline diastema will be closed as well when
porcelain veneer are replaced.
Incisal lapping preparation design is generally used for porcelain
veneers, especially if incisal defects warrant inclusion or the teeth need
lengthening.
The only difference in the procedure of bonding is the need to
condition the internal surface of each veneer with a silane primer 9ust prior to
applying the resin bonding agent. The silane acts as a coupling agent enabling
a chemical bond to occur between the porcelain and the resin. It also improves
wettability of the porcelain. The primary source of retention still remains the
etched porcelain surface. Only a modest increase in bond strength results from
silani6ation of the porcelain but is nonetheless recommended.
,arkly discolored teeth are more difficult to treat with porcelain
veneers.
<owever, several modifications in the veneering technique can be used
to enhance the final esthetic result.
a# Opaque porcelain is incorporated in the fabrication of the veneers
in order to induce more inherent masking +?'"?G opaque
porcelain#.
2"
b# - slightly deeper cavity preparation can be used to allow greater
veneer thickness. <owever, the preparation should always be
restricted to enamel to ensure optimal bonding of the veneer of
the tooth.
Casta(le ceramic 0eneers:
-nother esthetic alternative for veneering teeth is the use of castable
ceramics such as ,icor. Knlike etched porcelain veneers which are fabricated
by stacking and firing feldspathic porcelain, castable ceramic veneers are
literally cast using a lost wa$ technique. The castable ,icor veneer material
itself is grayish in shade and very translucent.
*ow fusing feldspathic shading porcelain fired onto the surface of the
veneer provide the final coloration. E$cellent esthetics and possible resin
castable ceramic materials for most cases involving mild to moderate
discoloration. <owever, due to the limited amount of intrinsic opaquing
possible with castable ceramic veneers, dark discoloration are best treated with
porcelain veneers.
The margins of castable ceramic veneers cannot be contoured and
finished with rotary instrumentation.
3ince shading of castable ceramic veneers is accomplished by surface
coloration, the use of rotary instrumentation on the veneer surface would result
in loss of their coloration revealing an unesthetic grayish appearance.
2eneers ,or existin& metal restorations:
Occasionally the facial portion of an e$isting metal restoration
+amalgam and gold# is 9udged to be distracting. - careful e$amination
including a radiograph is required to determine that the e$isting restoration is
sound before an esthetic correlation is made. The si6e of the offensive area
determines the e$tent of the preparation.
- no. & carbide bur rotating at high speed with air water coolant is
used to remove the metal and starting at a point midway between the gingival
and occlusal margins. The preparation is made perpendicular to the surface "
mm deep at a minimum leaving a butt 9oint at the cavosurface margins. The
"mm depth and a but 9oint should be maintained as the preparation is e$tended
occlusally. -ll the metal along the facial enamel is removed and the
2&
preparation is e$tended into the facial and occlusal embrasures 9ust enough for
the veneer to hide the metal. The contact areas on the pro$imal or occlusal
surface must not be included in the preparation. To complete the outline from,
the preparation is e$tended gingivally "mm past the mark indicating the
clinical level of the gingival tissue.
-fter it is etched, rinsed and dried, the cavity preparation is complete.
1ew adhesive resin liners containing a chemical called ='MET- capable
of bonding composite to metal, also may be used but are quite technique
sensitive. Manufacturer8s instructions should be followed e$plicitly to ensure
optimal results with these materials. The composite material is inserted and
finished in the usual manner.
Re'air o, 2eneers
)ailures of esthetic veneers occur because of breakage, discoloration or
wear. 0onsideration should be given to conservative repair of veneers if
e$amination reveals that the remaining tooth and restoration are sound. It is
not always necessary to remove all of the old restoration. The material most
commonly used for making repairs is light'cured composite.
2eneers on toot" structure
3mall chipped areas on veneers can often be corrected by recontouring
and polishing. (hen a si6able area is brokenC it can usually be repaired if the
remaining portion is sound.
)or direct composite veneers repair ideally should be made with the
same material that was used originally. The operator should roughen the
damaged surface of the veneer and 4 or tooth to a cavosurface margin. )or
more positive retention mechanical locks may be placed in the remaining
composite material with a small round bur. -n etching solution is applied to
clean the prepared area which is then rinsed and dried. - resin bonding agent
is applied to the preparation and polymeri6ed. 0hairside composite material is
then added, cured and finished in the usual manner.
Indirect processed composite veneers are repaired in a similar manner.
<owever, in order to repair porcelain veneers, a mild hydrofluoric acid
preparation, suitable for intraoral use, must be used to etch the fractured
porcelain, acid is applied washed and dried. - slightly frosted appearance,
similar to that of etched enamel should be seen if the porcelain has been
22
properly etched. - silane coupling agent may be applied to the etched
porcelain surface prior to the application of the resin bonding agent. 0hairside
composite material is then added, cured, and finished in the usual manner.
*arge fractures are best treated by replacing the entire porcelain veneers.
Conclusion:
Many a times, discoloration of the anterior teeth is the prime reason
that brings the patient to dental clinic for aesthetic correction. Ksing the above
mentioned techniques, we can do the needful for the patient. .ut these
techniques are not able to achieve the natural tooth esthetic qualities. 3o
patient should be informed about this prior to the treatment itself. Every effort
should be made to learn and deliver proper esthetic techniques for discolored
anterior teeth cases.
Re,erences
' 3turdevant.
' @rossman +S
th
and 4 SI
th
Edition#.
' 0ohen +A
th
Edition#.
' (eine.
2=
TREATMENT OF DISCOLORED TEETH
CONTENTS
Introduction
Types of 3tains
' Intrinsic
' E$trinsic
Treatment
' .leaching
o ;ital
o 1on vital
' Microabrasion
' Macroabrasion
' ;eneers
7artial
)ull
' 7reparation
' ,irect and Indirect techniques
' Etched porcelain veneers
' 0astable ceramic veneers
' ;eneers for metal restoration
' 5epair of veneers
0onclusion
5eference
2?