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Recently when presenting in Minneapolis at the Star of The North a conversation came up about managing a single dark tooth during the restorative process. If the tooth has had endodontic therapy one approach is internal bleaching to lighten the stump shade. Often though these teeth have not been treated endodontically, and there is some evidence of increased risk of internal resorption following internal or walking bleach. A friend and excellent dentist that I know joined the conversation and shared a fantastic tip. He explained that if the tooth is treatment planned for a full coverage restoration he uses the provisional as a bleaching tray. Since then I have used this technique numerous times with great success.
I have the patient in for the initial prep and provisional. Most of the time I capture a final impression at this appointment, bite records and whatever other lab records we need and make sure the lab knows we are holding the case for final shade information and photographs. The provisional is relieved internally on all surfaces other than the last millimeter at the margins. We leave the provisional uncemented and send the patient home with several tubes of tray bleach and instructions. The patient is to remove the provisional 3-4 times per day, rinse it out and put the bleach inside the crown. The patient then puts the provisional on the tooth and wipes off any excess. The bisacryl crown acts as a single tooth bleaching tray.
Two Weeks of Bleaching
So you may be thinking, how does this work? An uncemented provisional? Isn’t it sensitive? I had all of these same questions and now having done it for months I have some answers. The effect of the bleaching gel is equal to what you get with any tray application. It is incremental every day, but cumulatively you can get as light as you want based on having the patience to keep up with the process. As bothersome as patients find it when a provisional comes uncemented unexpectedly, they don’t mind at all when it is done with intention, and they learn very quickly how to take it off and on. I have only done this with anterior teeth, and we coach the patient about eating and incising food during the process. As to sensitivity I have had none, not a single patient who even mentioned this as an issue. True a good portion of the teeth have had endo therapy, but the ones that haven’t are also comfortable.
My patients have been very engaged in the process of optimizing the final esthetics, and many want to continue whitening even after I think we have adequate change for color control. Ideally I aim to get within the two shade rule between the prep color and the final shade of the restoration, and the time frame is variable. The photos show a single crown prep on an upper right central incisor. The tooth had previous endo and a core. the day we did the prep, the stump shade was a dark brown, off the shade guide. The patient had a previous porcelain fused to metal crown, disliked the dark shadow at the margin and wanted a better esthetic outcome. The next photo was taken after two weeks of bleaching with Venus Max 22% (Heraeus) using the provisional twice daily. The stump shade is now an A 3.5, and the patient presented telling me ” I need to keep bleaching another few weeks.”
It is an interesting technique that may be a nice tool for certain occasions. Would you say you are able to change the restorative material for this patient?
For dark teeth – I think cored materials are the most predictable type of long term solution. While whitening is a great conservative option, I have had patients I have whitened their teeth, then wait 4-6 weeks for color modification and then restored. And 6 months later, they have not used their trays for maintenance and color can be noticeably different.
Who’s to say what this will look like in a few months after the permanent restoration has been cemented. I would be leary of using a monolithic type of restoration – Lithium Disilicate or Empress. You may be able to get away with Feldspathic but most predictable would be a metal ceramic or a zr type of restoration. Thoughts?
Aly Sergie DDS
Aly,
In this case we are going to continue the bleaching for two more weeks, and then yes I do think it will change what I chose for a restorative material. the root and tooth were so dark it was causing a discoloration of the gingival tissues at the margin, and we have reduced this. You are correct that the tooth can discolor again. I very rarely use monolithic materials int he anterior when I am doing full coverage. The original tooth color was leaning me toward porcelain fused to metal with subgingival margins, the patient wants all ceramic. With the bleaching I think we can go lithium disilicate as a core in an opaque shade with .5mm of layering porcelain for color and effects.
Lee
You mentioned the tooth can discolored agin
Why ?
After replacing the crown ?
its very nice…