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Case Study
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Minimally Invasive Treatment to Correct Stained Anterior Dentition

 

Learning objectives:

This study discusses the use of bleaching and flowable composites for correcting tooth discoloration in the anterior maxilla.  Upon reviewing this study, the viewer should:

  • Understand the importance of utilizing minimally invasive techniques to achieve patients’ aesthetic goals.
  • Recognize that a treatment sequence incorporating tooth bleaching and direct composites can be successful for whitening stained teeth.

 

Whether utilized for the replacement of worn or cavitated enamel or dentin, or the correction of aesthetically displeasing form or color, restorative procedures are now guided by principles of minimal intervention that dictate the manner in which treatments are planned and restorative materials are selected and placed. Aesthetic enhancement of intrinsically stained anterior dentition—in which no other disease is present—represents a treatment situation that can be approached with minimally invasive techniques. 

Intrinsic staining of the dentition manifests following naturally occurring processes (eg, aging, disease, trauma). Dentition with intrinsic stains have responded favorably to whitening treatments of varying durations with peroxide agents. Alternative approaches to correct the appearance of stained dentition include placement of all-ceramic veneers or full-coverage crown restorations, in addition to placement of direct composite resins. Bleaching teeth prior to the placement of porcelain laminate veneers has also been advocated. Based on minimally invasive techniques, air-abrasion has also been promoted in literature as a useful alternative for the removal of extrinsic stains.  

Conservative correction of stained anterior dentition would be well suited to minimally invasive techniques that first incorporate in-office, light-activated bleaching and take-home, dentist-monitored tray bleaching. Then, if insufficient to achieve the patient’s anticipated result, the next most conservative approach in the sequence protocol would be the placement of direct composite restoratives, including recently introduced flowable varieties. These flowable composite materials—with improved physical properties, handling characteristics, and aesthetics—can contribute to a clinician’s ability to more precisely and predictably place them in order to reproduce the optical properties of natural tooth structure. 

Principles of minimal intervention are increasingly dictating the manner in which restorative procedures are scheduled and their related materials placed as part of an elective aesthetic protocol. In this case presentation, the patient’s aesthetic expectations were achieved through a planned sequence of conservative approaches to address the discoloration of her anterior maxillary dentition. The combined use of in-office and take-home bleaching systems designed to enhance whitening efficiency and patient comfort was implemented initially to produce the desired effects. Had the bleaching process not uncovered the underlying hypocalcifications, no further restorative treatment would have been undertaken. Since unforeseen hypocalcifications were present, however, it was necessary to proceed with the placement of a flowable composite and a microhybrid composite resin in a minimally invasive manner using micropreparations in order to achieve the patient’s aesthetic goals. When conservative preparation designs are used, it behooves clinicians to consider the incorporation of flowable composites into the restorative protocol that are well suited to such indications.

 

*Private practice, St. Paul, MN.

  

Related Reading:

  1. Staehle HJ. Minimally invasive restorative treatment. J Adhes Dent 1999;1(3):267-284.
  2. Gerlach RW. Whitening paradigms 1 year later: Introduction of a novel professional tooth-bleaching system. Compend Contin Educ Dent 2002;23(1A):4-8.
  3. Watts A, Addy M. Tooth discoloration and staining: A review of the literature. Br Dent J 2001;190(6):309-316.
  4. Lowe E, Rego N, Rego J. A delayed subopaquing technique for treatment of stained dentition: Clinical protocol. Pract Proced Aesthet Dent 2005;17(1):41-48.
  5. Marshall MV, Cancro LP, Fischman SL. Hydrogen peroxide: A review of its use in dentistry. J Periodontol 1995;66(9):786-796.
  6. Haywood VB, Heymann HO. Nightguard vital bleaching. Quint Int 1989;20(3):173-176.
  7. Haywood VB, Leonard RH, Nelson CF, et al. Effectiveness, side effects and long-term status of nightguard vital bleaching. J Am Dent Assoc 1994;125(9):1219-1226.
  8. Sadan A, Lemon RR. Combining modalities for tetracycline-discolored teeth. Int J Periodont Rest Dent 1998;18(6):564-571.
  9. Rainey JT. Air abrasion: An emerging standard of care in conservative operative dentistry. Dent Clin North Am 2002;46(2):185-209.
  10. Terry DA, Leinfelder KF. An integration of composite resin with natural tooth structure: The Class IV restorations. Pract Proced Aesthet Dent 2004;16(3):235-242.
  11. Tavares M, Stultz J, Newman M, et al. Light augments tooth whitening with peroxide. J Am Dent Assoc 2003;134(2):167-75.
  12. Nathanson D. Vital tooth bleaching: Sensitivity and pulpal considerations. J Am Dent Assoc 1997;128(Suppl):S41-S44.
  13. Viscio D, Gaffar A, Fakhry-Smith S, Xu T. Present and future technologies of tooth whitening. Compend Contin Educ Dent 2000;(28):S36-S43.
  14. Luk K, Tam L, Hubert M. Effect of light energy on peroxide tooth bleaching. J Am Dent Assoc 2004;135(2):194-201.
  15. Chafaie A. Minimally invasive aesthetic treatment for discolored and fractured teeth in adolescents: A case report. Pract Proced Aesthet Dent 2004;16(4):319-324.
  16. Cavalli V, Reis AF, Giannini M, Ambrosano GM. The effect of elapsed time following bleaching on enamel bond strength of resin composite. Oper Dent 2001;26(6):597-602.
  17. Bonilla ED, Yashur M, Caputo AA. Fracture toughness of nine flowable composites. J Prosthet Dent 2003;89(3):261-267.
  18. Lee IB, Son HH, Um CM. Rheologic properties of flowable, conventional hybrid, and condensable composite resins. Dent Mater 2003;19(4):298-307.
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