Dental bleaching and spot removal: goals and mistakes

28 Jun 2018 - 14024

Tooth bleaching and spot removal are frequent requests of our patients, or situations we bump into and want to solve for our patients’ aesthetic satisfaction. Moreover, bleaching procedures shouldn’t be considered as an isolated treatment, but as a minimally invasive part of a more extensive treatment plan.

Starting from whiter teeth facilitates all of our rehabilitation procedures whether they are very complex or simple cases.

Fig. 1

This 27-year-old patient wanted to improve his smile, in particular, he asked to get whiter and more harmonious teeth.

As a protocol,  we start treating the upper arch.

Fig. 2

We started by temporarily covering the brown spots on teeth 22 and 23, and building new canine guides; it is better to do it in the beginning so you can adjust them during the following appointments and verify function.

 
Fig. 3

On the central incisors were white spots that he wanted to eliminate, as well as the abraded canines that were described by the patient as “short”.

Fig. 4

Dark spots tend to be more superficial than white ones.

Fig. 5

Furthermore, these composites together with the elements of the lower jaw will serve as a chromatic reference for bleaching

Fig. 6

A polarized picture of teeth 22 and 23 with remarkable brown spot discolorations.

Fig. 7

Polarized picture of teeth 11 and 12.

Fig. 8

Polarized picture of the central incisors.

Fig. 9

Abrasion on tooth 23.

Fig. 10

Abrasion on tooth 13.

Fig. 11

Restoration on tooth 13.

Fig. 12

Restoration on teeth 22 and 23.

Fig. 13

Baseline color before bleaching.

Fig. 14

Delivery of the upper soft tray, with carbamide peroxide 16% White Dental Beauty.

Fig. 15

1 week control.

Fig. 16

After one week we can already see the difference between the bleached upper teeth and the composite restorations, and the lower arch which was not bleached yet.

Fig. 17

2 weeks control

Fig. 18

20 days after infiltration and new restorations 

Fig. 19

Icon Etching

Fig. 20

Sandblasting. The white spots on the central incisor was too deep, and even with different etchant applications, I did not get the desired result, so I decided to sandblast with 27 microns aluminum dioxide.

Fig. 21

Post-sandblasting etch.

Fig. 22

Rinsing with the specific alcohol dedicated to pre-visualize the result.

Fig. 23

Teeth covered with alcohol.

Fig. 24

I removed the superficial layer of the restorations I wanted to replace.

Fig. 25

After etching.

Fig. 26

ICON infiltration.

Fig. 27

Immediate post operative picture.

In this phase there was actually a mistake; as many of you might have thought, having performed microabrasion, I should have filled the defect with some composite in addition to the ICON resin.

Fig. 28

In fact, this defect in I will fill with a following restoration.

Fig. 29

Lateral view.

Fig. 30

The difference in color between upper and lower teeth.

The defect on the surface of tooth 11.

Fig. 31

MDP picture with diffusers.

 

Fig. 32

MDP image: the deference between bleached and non-bleached teeth is even clearer.

Fig. 33

Post-operative: composite addition on tooth 11.

Fig. 34

Polarized view.

Fig. 35

Lateral views to highlight the difference between upper arch bleached and lower arch not bleached.

Fig. 36
 

Conclusions

Diagnosis is the key point to manage bleaching and resin infiltration.

The proper selection of the case and the patient always makes the difference: even though we can  sometimes make up for mistakes thanks to our skills, it is always better avoiding problems than finding a solution!

Remember, bleach before you infiltrate, because afterwards, it’ll be too late. When you infiltrate, if you need to remove enamel even if just a little bit by sandblasting , remember to add composite to the resin.

Combining bleaching and resin infiltration is a great simple conservative, non-expensive  and predictable solution for many cases of  dyschromic anterior teeth.

 

 

Bibliography

Loguercio AD, Servat F, Stanislawczuk R, Mena-Serrano A, Rezende M, Prieto MV, Cereño V, Rojas MF, Ortega K, Fernandez E, Reis A. Effect of acidity of in-office bleaching gels on tooth sensitivity and whitenings: a two-center double-blind randomized clinical trial. Clin Oral Investig. 2017 Dec;21(9):2811-2818.

Attal JP, Atlan A, Denis M, Vennat E, Tirlet G. White spots on enamel: treatment protocol by superficial or deep infiltration (part 2). Int Orthod. 2014 Mar;12(1):1-31

Salat A. Post orthodontic white spots. Style Italiano.