Efficient, Uncomplicated and Minimally Invasive Aesthetics for Endodontically Treated Anterior Teeth.
Minimally invasive and aesthetic dentistry is becomingincreasingly important — especially in the anteriorregion. Healthy, white teeth play a key role in self-esteemand social acceptance of patients. Considering this, thediscoloration of one or more teeth in the anterior region becomesparticularly noticeable and may have a psychological impact on thepatient.
Endodontic treatment is primarily dedicated to the preservation ofteeth and their function. As a consequence, discoloration or darkeningmay occur due to numerous reasons which results in an aestheticimpairment. In the anterior region this becomes particularly important,therefore a holistic endodontic approach is the treatment of choice.This includes a state-of-the-art endodontic treatment/retreatment andan adequate restoration under consideration of function and aesthetics.The aesthetics of endodontically treated and discoloured teeth may berestored with veneers or crowns. These indirect restorations, however,require extensive preparations, which in turn result in loss of naturaltooth substance. Alternatively, a composite restoration combinedwith internal tooth whitening — also known as the "walking bleachmethod”— should be considered. This approach comprises theapplication of an oxygen-releasing whitening gel directly into thediscoloured coronal pulp chamber. An oxidation process is initiatedthat gradually splits the pigments resulting in a brighter appearance ofthe tooth substance.
This procedure is illustrated in the case of a 27-year-old female patient.Tooth 21 was non-vital and additionally diagnosed with a chronicapical periodontitis, which has been treated endodontically. As part ofthe root canal treatment the previously treating dentist had informedthe patient about the option of internal tooth whitening. Nevertheless,the patient declined at that time.
Pre-op: Endodontically treated, internal discolouredtooth 21
Being dissatisfied with the aesthetic outcome after all, she presented herselfto my practice several months later. Initially, the patient’s expectations wereassessed, and the procedure and possibilities of internal tooth whitening
were explained.
In preparation for the walking bleach method, a rubber dam was placed, andthe access cavity was re-opened. All restorative and root sealing materialwas removed from the coronal pulp chamber and 2 - 3 mm below the healthygingiva (a). The cavity was cleaned thoroughly in order not to compromisethe whitening result. After the cleaning procedure, the enamel was etchedcircumferentially around the access cavity with 37% phosphoric acid inorder to provide retention for the temporary fulling (b+c). Next, in order topromote an efficient cervical barrier, the canal obturation and surroundingdentin was etched. A bonding agentPeak™ Universal Bond adhesivewasapplied following the manufacturer instructions and a 2 mm thick layer offlowable composite was placed (d) and light cured with aVALO™ cordlessLED curing light.
Opalescence™ Endo, Ultradent Products, Inc., was applied into the coronal pulp chamber. (e)
Opalescence™ Endo whitening gel was expressed into the coronal pulpchamber, filling the open space up to 2/3 to accommodate the provisionalrestoration.
Opalescence Endo whitening gel contains 35% hydrogen peroxide and isavailable in convenient ready-to-use syringes. A suitableBlack Mini™tipor aMicro 20 ga tip, which is attached onto the syringe, allows for aquick and targeted application of the whitening gel. This results in greateraccuracy and reduces waste of material making its use very cost-effective.It is important to place a small cotton pellet over the whitening gel to makecertain that no whitening agent stays on the margins of the access cavity inorder to ensure a good temporary seal (f).
Also, users should leave enough space (1.0 - 1.5 mm) to accommodate the provisional restoration. Finally, the cavity was provisionally sealed with aflowable composite. Following the same protocol, this procedure should berepeated every 1 to 5 days until the desired shade change is achieved or nofurther benefit is noticed.In the present case, the desired whitening effect was achieved after eightdays. The provisional restorative material and the Opalescence Endowhitening gel were removed. After thorough rinsing and cleaning of theaccess cavity, a new temporary restoration was placed.
As whitening materials may interfere with bonding agents, we observed theresult for an additional seven days. This transition period also helped to see whether the tooth needed any further whitening. However, it turned out tobe unnecessary as the tooth shade remained stable. Thus, the permanentrestoration was created using Peak™ Universal Bond adhesive and Mosaic™universal composite A2/A3 — following a multi-layering technique. Therestoration was finally polymerized with the VALO™ Cordless LED curinglight (all products from Ultradent Products, Inc.).
During the two follow-up sessions — the first at seven days and the secondafter two months — a satisfying result was observed. The patient wasextremely happy to be able to laugh again.
In this case internal tooth whitening was better suited than a veneer or acrown while following a minimally invasive approach in order to preserveas much healthy tooth substance as possible.
Opalescence Endo whitening gel is viscous and dimensionally stable,which makes it easy to handle. Additionally, the use of syringes enables aprecise and uncomplicated application reducing the required chair time toa minimum.
Opalescence Endo whitening gel is mostly used for anterior teeth — caseselection, however, depends on the condition of the tooth in question. If thetooth to be treated was open over a long period or the discoloration is tooprominent, crowns or veneers might result in better aesthetics. In an effort tomimic nature, indirect restorations tend to be translucent to various degrees,which might constitute a problem if the prepared tooth is discoloured.Therefore, Opalescence Endo whitening gel may be used to whiten thestump before insertion of the final restorations.
In summary, internal tooth whitening with Opalescence Endo whiteninggel is a very simple, painless and cost-effective method to overcomecompromised esthetics associated with anterior endodontic treatment.
Before
After
About the Author
Jacques Nicolas Grebowiec, DDS
Dr. Jacques Nicolas Grebowiec has been working in Riga, Latvia since 2015. He is trained in endodontics and microscope-assisted endodontics.
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This article was originally published in the Clinical Life™ magazine: Winter 2022 edition
Clinical Life™ magazine is a premier periodical publication by Clinical Research Dental Supplies & Services Inc. Discover compelling clinical cases from Canadian and US dental professionals, cutting-edge techniques, product insights, and continuing education events.
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