CLINICAL RESEARCH

The non-vital discolored central

incisor dilemma
Luís Henrique Schlichting, DDS, MS, PhD
Clinical Assistant Professor, Department of General Dentistry, School of Dental Medicine,
East Carolina University, Greenville, North Carolina, USA

Kyle Stanley, DDS

Adjunct Faculty, Division of Restorative Sciences, Ostrow School of Dentistry of USC,
Los Angeles, California, USA

Michel Magne, MDT, BS

Oral Design Beverly Hills, Beverly Hills, California, USA

Pascal Magne, DMD, MS, PhD

Associate Professor, The Don and Sybil Harrington Professor of Esthetic Dentistry,
Division of Restorative Sciences, Ostrow School of Dentistry of USC, Los Angeles,
California, USA

Correspondence to: Luís Henrique Schlichting

Department of General Dentistry, East Carolina University, School of Dental Medicine, 1851 MacGregor Downs Road, Mail Stop #701,

Greenville, NC 27834; E-mail: luishschlichting@gmail.com

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Abstract recover the original biomechanics of

the intact tooth, allow an optimal mask-
The restoration of anterior teeth is fre- ing of the substrate, remain stable, and
quently a demanding mission. Patients have a reasonable biological cost when
generally have high expectations for the compared to full-coverage crowns. This
anterior region, which makes the emo- strategy is explained in this article and
tional side of treatment especially im- documented with a clinical case. We de-
portant. When this involves discolored scribe treatment planning based on the
endodontically treated teeth, consen- biomimetic concept, taking into consid-
sus can hardly ever be found as to the eration what is possible with current ma-
chosen approach. Bleaching with direct terials and techniques when combined
composites is undoubtedly the most with the patient’s particular needs, in-
conservative choice for these cases. cluding the introduction of an innovative
However, this may require more mainte- step during dentin sealing – the micro-
nance (touch-up bleaching and repairs) suction. The laboratory work was totally
in the long term, which is an important accomplished by ‘teledentistry’, with no
issue for adult patients. On the other direct contact between the dental tech-
hand, bonded porcelain veneers repre- nologist and the patient.
sent a more ‘high-end’ option, as they (Int J Esthet Dent 2015;10:548–562)

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Watch nature… Choosing the treatment

the timeless reference approach – thinking
‘biomimetically’
One of the most difficult challenges
for any dental professional is restoring Nowadays, making an appropriate
a single central incisor and naturally choice in certain clinical situations might
matching the contralateral intact inci- be more difficult than it was 20 to 30 years
sor. This dilemma is further heightened ago.2 Over the past decades, several
when the patient has a high lip line, de- ultraconservative treatment strategies
mands a natural esthetic outcome, and have been introduced, and the most
presents a discolored endodontically conservative one – in-office bleaching –
treated tooth due to a history of dental has enjoyed a resurgence.4 For didactic
trauma (Fig 1). The solution in this sce- reasons, the invasive modalities will be
nario often constitutes a controversial discussed first.
therapeutic and academic debate. As Some doctrines from traditional pros-
described in a previous article,1 op- thodontics continue to influence many
tions can swing from more aggressive decisions in the modern dental prac-
to highly conservative approaches, of- tice. A preconception still exists that an-
ten driven by esthetic outcomes, con- terior pulpless teeth, because of either
venience (favorite technique) or specific their endodontic access or their darker
products available on the market. What shades, should be prepared with cor-
is the best position to adopt regarding onal coverage, posts, and cores; that
this decision-making pendulum? We porcelain should overlap any preexist-
should remember that our timeless refer- ent resin restoration; and that longevity
ence is the intact tooth.2,3 Therefore, the will be dependent on 360-degree prep-
treatment options should be evidence- arations. It is known that full-coverage
based protocols that maintain or recover crowns sacrifice almost three times the
the physiological balance between the amount of sound structure as do non-
parameters of biology, mechanics, func- retentive partial preparations (68.2% vs
tion, and esthetics.2 We need to know the 23.5%).5 The latter therefore promotes a
tooth and look deeply at it because it is better preservation of natural tissues be-
our craft. This means not only mastering cause the ‘principle of combined action’
shape and color, but also understanding is maintained,6,7 in that two extremely
how teeth structures behave under nor- distinct tissues – enamel and den-
mal function, in overloading situations, tin – engineer a structure (intact tooth)
and in trauma. Combining this skill and with a better combination of properties
understanding with the fact that dental (compliant to stresses, lifetime wear re-
materials can be synergistically used sistant). The resultant super-stiff crown
to mimic enamel, dentin, and the den- makes the underlying dentin hypofunc-
tinoenamel junction (DEJ) results in the tional,8 ignoring its role in stress dissipa-
conceptual basis of biomimetics. How to tion, as well as hyperstressed in cases
apply biomimetics in daily practice is the of extreme loading, when non-restorable
central challenge of this article. failures are more likely to occur.

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a b

c d

Fig 1 Initial aspect of an endodontically treated tooth of a 35-year-old female patient (a to d).

Naturally, the opposite standpoint ever, a significant incidence of discol-

would be the ultraconservative ap- oration relapse has been reported,11-13
proach, which combines chemical treat- ranging from 10% to 40% after 2 years
ments (bleaching) with freehand com- and 8 years of follow-up, respectively.
posites. This should always be the first In light of this evidence, the predict-
option, since progression toward more ability of this technique is limited, and
complex treatments is possible anytime, this must be discussed with patients. In
albeit irreversible2 – the so-called pro- cases where a discoloration relapse has
gressive approach concept.9 Bleaching already occurred, it is highly probable
can be considered the most ultracon- that new bleaching will be a non-perma-
servative modality for the treatment of nent treatment, and restorative solutions
endodontically discolored teeth, as it should be proposed as more predictable
preserves the biomechanical potential treatments for adult teeth.10 Regarding
of the restored teeth10 with virtually no the large direct composites that are fre-
sacrifice of intact tooth structure. How- quently associated with the restoration

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of traumatized anterior teeth, the follow- launched that, thanks to the greater
ing aspects should be observed: The stiffness of its composite fuselage, can
mechanical properties of contemporary be pressurized at a higher level, which
dental composites are adequate due to simulates a maximum cabin altitude
significant improvements in filler tech- of 6,000 ft (as opposed to the 7,500
nology, which makes them eligible for to 8,000 ft of typical airplanes) and re-
both anterior and posterior use.14 How- sults in greater comfort for passengers.
ever, concerns still exist regarding wear Coming ‘back to earth’, a healthy tooth
and fracture (chipping of surfaces and can last for 100 years (even more), as
margins)15 when the materials are uti- is witnessed in many octogenarian and
lized under extreme conditions, for ex- nonagenarian patients seen in clinical
ample in high-stress situations, for large practice. The longevity of teeth is direct-
preparations, in the case of cuspal re- ly related to crown stiffness. Stiffness, in
placement or for the restoration of the turn, is based on the physical proper-
full quadrant.16 In a 3-year follow-up ties of the tissues (enamel and dentin),
clinical study,17 composite veneers pre- loading configuration, and geometry.19
sented surface quality changes (slightly The enamel shell determines the stress
rough) 6 times more frequently than was distribution over the crown.8 During
observed for porcelain ones. This phe- functional protrusive movements, in the
nomenon could simply be unnoticed by maxillary incisors for example, the facial
patients – and even by dentists – in the enamel blade will be mostly subjected
posterior region, but not in the anterior to compressive stresses, while tensile
region, where mirror symmetry between stresses will concentrate in the palatal
central incisors is unconsciously expect- fossa.20 This mechanism can provide
ed. In another 3-year clinical study,18 reciprocal protection during millions of
where 170 anterior restorations were masticatory cycles, yet any threat to
placed by undergraduate dental stu- this balance can shorten the lifespan
dents, class IV restorations showed the of this sophisticated structure. Several
highest prevalence of failure (deficient studies19-22 have demonstrated the im-
marginal adaptation and loss of restor- pact of restorative procedures on crown
ation). This is consistent with another rigidity. When enamel is replaced by a
important property, the fracture tough- more flexible material like a microhybrid
ness, which even in current composites composite (elastic modulus ≈ 16 GPa),
is bellow 2.0 MPa m½ (3 times less than only 76% to 88% of its original rigidity is
reinforced ceramics).14 recovered after the placement of com-
Finally, our presented approach is dis- posite restorations21 and composite ve-
tinguished from those discussed above neers,22 respectively. On the other hand,
in that it relies on the recovery of the a study showed that 97% of the crown
original stiffness of the crown: traditional stiffness is recovered when feldspathic
porcelain veneers. Stiffness plays a key porcelain (elastic modulus ≈ 70 GPa)
role in the performance of any complex is used as an enamel substitute.20 It is
structure, mainly for those subjected to worth noting that there is no evidence to
cyclic loads. Recently, an airplane was show that extra intrinsic strength such

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as that of reinforced ceramics would be her central incisors to ensure good color
needed. As for the natural tooth, which is matching. The tooth had first been trau-
made of extremely brittle enamel, it is the matized in 1985 when, at the age of 9, the
synergistic combination of the materials patient fell and fractured the distoincisal
(ceramic shell and luting agent), as well third of the tooth. She was treated with
as the bonding quality, that defines the a direct class IV composite restoration
performance of the restored tooth. Sev- on surfaces MIDBL. In 1989, she devel-
eral treatment modalities may usually be oped an acute periapical abscess. At
associated with endodontically treated this point, root canal therapy was carried
teeth (eg, class III composite restorations out. The patient was not satisfied with
due to previous caries, or class IV com- the esthetic result, and in 1997 internal
posite restorations related to previous bleaching was performed, along with a
trauma). It has been demonstrated that new class IV composite restoration. Four
successive restorative procedures per- years later, the tooth was again internally
formed on the same tooth significantly bleached with hydrogen peroxide 35%
influences crown flexure.19 Only 88% of gel, and a fiber post was placed, fol-
the original crown stiffness is recovered lowed by external bleaching in 2003,
when class III cavities and endodon- which was done with a laser. When the
tic access are restored with composite patient presented in 2010, she insisted
resin (as the endodontic access is lo- that, regardless of the advantages of tis-
cated in a critical area, its contribution sue conservation,24 she did not want to
to crown rigidity is higher). If this tooth try bleaching again since she was wor-
had been endodontically treated at an ried about the risk of root resorption;
earlier stage (childhood/adolescence; instead, she would choose either a di-
Fig 1b), this percentage would be even rect or indirect restorative solution. The
lower. Therefore, any additional replace- patient was esthetically minded, having
ment of sound enamel by composite is even undergone surgery in 2009 to de-
not recommended in these cases. With crease her gummy smile.
survival rates of 96%23 after 10 years, The case illustrates a biomimetic ap-
porcelain veneers are the only restora- proach with ceramics, where a porce-
tive treatment with no additional effect lain veneer preparation completed for
on crown compliance. a combined indication (types IB and
IIIA)25 allowed for the solving of the
problem of the remaining staining of a
Case presentation pulpless tooth and the restoration of an
extensive coronal fracture. The palatal
A 35-year-old female dentist present- endodontic access was treated before
ed as a new patient to a private dental the veneer preparation, to both improve
practice in Florianópolis, Brazil, in 2010 the biomechanics through a more ana-
requesting a full-coverage crown restor- tomical cingulum/palatal fossa and en-
ation on her maxillary right central incisor sure proper bonding through a proven
(Fig 1). The patient was willing to receive protocol (fourth generation bonding
full-coverage crown restorations on both system). The large palatal endodontic

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a b c

d e f

g h i

Fig 2 The existing class IV composite is completely removed from the distofacial–incisal angle with a
tapered diamond bur, unveiling the type IIIA indication (extensive coronal fracture) (a). After the placement
of a deflection cord (eg, Ultrapak #000, Ultradent), facial depth grooves are prepared (recommended bur:
6850.016, Brasseler) (b and c), followed by gross reduction (6850.023, Brasseler) (d and e). In the ab-
sence of oscillating instruments, a thin bur should be used to create the proximal margins (eg, 6850.014,
Brasseler) (f). Control with the facial silicon index (a uniform space is generated) (g). The large proximal
contact demands stripping to prevent deep interdental penetration (h). Regardless of the dark shade, a
paragingival margin is chosen (i).

access was removed until natural tissue ite (Miris, Coltène Whaledent). The final
was reached, leaving only the existing layer was completed with the aid of a
fiber post untouched. In order to sim- transparent index, based on a previous
plify the procedures, the post was not re- wax-up (Transil, Ivoclar Vivadent).
moved, since the mechanical principles The axial reduction for veneers should
on which veneer preparation are based be agreed upon by both the clinician
are not dependent on intraradicular re- and the laboratory technician (Fig 2).
tention.26 The pulp chamber was sealed The depth of the preparation will be de-
with the total-etch bonding technique termined by the thickness of the bond-
(OptiBond FL, Kerr), followed by incre- ing layer, the masking agent, and the
mentally placed microhybrid compos- porcelain itself. Although non-discolor-

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a b c

d e

f g

Fig 3 When using a 3-step etch-and-rinse system, the procedure starts by etching the freshly cut dentin
with a 35% phosphoric acid (eg, Ultra-etch, Ultradent) (a), followed by rinsing, and the evacuation of ex-
cess water by microsuction (eg, Black Mini Tip, Ultradent) (b and c). A hydrophilic monomer (Optibond
FL, Bottle no. 1, Kerr) is applied with a gentle brushing motion and the excess solvent is suctioned (d).
A thin coat of filled adhesive resin is then applied (Optibond FL, Bottle no. 2, Kerr) (e). In cases where
the adhesive surpasses the dentin/enamel margins, an applicator tip can be used to remove most of the
excess with pinpoint accuracy by microsuction. No air blowing should be needed, and direct contact with
the dentin should be avoided (f). The adhesive is then light-polymerized for 20 s, with an additional 10 s
under an air-blocking barrier (eg, K-Y Jelly, Johnson & Johnson) to reduce the oxygen-inhibition layer (g).

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ed teeth can be restored with 0.5 mm or dentin margins in veneer preparations.

less in the gingival third, this particular The use of a periodontal probe has been
case required more space for the den- proposed for the more accurate and
tal technologist to properly mask and careful placement of the adhesive when
match for the desired shade (Fig 2g). dentin exposure encroaches on the mar-
For this case, this space amounted to gins.30 However, it is quite common for
0.7 mm in the gingival third, with 0.9 mm the excess adhesive to flow beyond the
at the mid-facial reduction. The chances margins (mainly when it is being applied
of dentin exposure at this depth, includ- under motion with a microbrush), which
ing the sacrifice of the DEJ, is quite high, could jeopardize the procedure by con-
mainly in the cervical third, which could founding margin visualization (Fig 3e).
jeopardize the chances of success in the Microsuction is an innovative step that
long term.27 Hence, the freshly cut den- has been developed to eliminate any
tin surfaces were immediately sealed type of liquid (water, primer, adhesive)
with a dentin bonding agent (DBA) fol- during dental procedures with pinpoint
lowing preparation (Fig 3), before the precision (Figs 3b, 3c, and 3f). The pro-
impression was taken. This enhances cedure is quite simple. Blunt-end appli-
the potential for adhesion and for recre- cator tips (Fig 4a) are connected to a
ating the DEJ.20,28,29 saliva aspirator (either regular or high-
Immediate dentin sealing (IDS) has speed; Fig 4b), which is applied where
many known practical and technical the excess is located (eg, into the gin-
advantages, including increased bond gival sulcus along the preparation mar-
strength, less gap formation, decreased gin). Microsuction therefore reduces the
sensitivity, and decreased bacterial leak- need for the extensive use of oscillating
age during the provisional stage.30 How- (interdentally) or rotary instruments (cer-
ever, IDS can be technique-sensitive for vically) when finalizing the preparation
many practitioners when it comes to margin (Fig 5).

a b

Fig 4 Cannulae tips (from left to right: Black Mini Tip, Blue Micro Tip, Black Micro Tip; Ultradent) (a).
A cannulae tip connected to a saliva ejector valve (b).

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The laboratory work, performed by

MM, included the challenge of not see-
ing the patient in person. All the com-
munication between the dentist and the
dental technician was accomplished by
teledentistry (Fig 6). The shade docu-
mentation was not performed in the
preparation session but in the follow-
ing visit, to allow full tooth rehydration.

Fig 5 Any excess adhesive on enamel and dentin

margins should be carefully removed with diamond
burs. Note that the accurate removal of excess ad-
hesive by microsuction leaves minimal or no excess
to be cleaned by rotary instruments.

a b c

d e f

Fig 6 Pumice is used to remove the residual unpolymerized layer of adhesive to obtain defect-free im-
pressions (a). New deflection cords are positioned in the gingival sulcus, allowing the margin to be visible
(b). A double-mix/one-step impression is used to capture the margin without tears or defects (c). In the
follow-up visit (2-3 weeks later, to allow for rehydration) the shade guides are viewed in the same plane in
order to aid the stump shade match for the final restoration (d and e). A strict photographic protocol, in-
cluding polarized pictures (eg, Polar_eyes) (f) is always recommended. It was particularly necessary in this
challenging case, where the technician and the patient did not meet because they live in different countries.

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a b

c d e

f g

Fig 7 Porcelain veneer (Creation CC, Klema) on an optical verification die (alveolar delta die).31,32 Only
one veneer was fabricated, and after the first try-in, a minor correction was performed in the incisal halo re-
gion using low-fusion porcelain (a). Field isolation with rubber dam allows full access to the margins, which
is the standard for luting procedures of porcelain veneers (clamp 212) (b). Tooth preparation is treated with
airborne-particle abrasion and etched for 30 s with 37.5% phosphoric acid (Gel etchant, Kerr) (c and d),
rinsed, and dried. Fitting surfaces, restoration, and tooth were coated with adhesive resin (Optibond FL,
Bottle no. 2, Kerr) and left unpolymerized until the application of the luting material (Variolink Veneer High
Value +1, Ivoclar Vivadent) to the restoration, which was then digitally seated. Before light polymerization,
the gross excess luting material is removed with an explorer (e). Microbrushes should be avoided because
their fine bristles could extract the luting agent from the margin joint.2 Still under rubber dam, excess adhe-
sive and luting material are best removed with hand instruments (no. 12 surgical blade) (f and g).

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The veneer was fabricated using the

refractory die technique (Fig 7a). This
option still provides unmatched effects
of color and translucency through a full-
thickness layering technique,2 which in-
cludes the unique possibility of intrinsic
selective masking. Based on intraoral
photographic documentation (Fig 6e)
and the subsequent masking map, the
ceramist will sequentially apply very
a
thin, opaque layers on the refractory die
to block the undesired discolored areas.
Optionally, the technician can improve
predictability by first trying the effects of
masking on customized porcelain tabs
that are fabricated with a similar color
to that of the tooth substrate – the so-
called parallel stratification masking
technique.32 The discolored preparation
can also be directly masked by the den-
tist in the mouth using opaque resins
b
(eg, Kolor + Plus, Kerr); however, this will
result in a decrease in bond strength.33
The veneer was delivered following the
classical bonding protocol (field isola-
tion with rubber dam, porcelain etching,
post-etching cleaning, silane/heat dry-
ing, bonding agent, light-curing com-
posite resin; Figs 7b to g). Figures 8 and
9 show the excellent results achieved
with tissue and facial integration.
c

Fig 8 Final restoration after healing (a). Note the

periodontal health and matching gingival appear-
ance despite the previously discolored tooth (b).
Final radiograph (c).

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a b

Fig 9 Smile (a). Under natural light, close to sunset (b). The patient was satisfied with the integration of
the restoration (c).

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Conclusion ceramist. Microsuction is one innovative

technique that can help clinicians to ob-
Porcelain veneers bonded through im- tain the precision they require in bond-
proved protocols provide predictable ing. Its technical advantages could also
and reliable treatment for vital, pulpless, be implemented for direct techniques.
and unresponsive discolored teeth. This Additional studies are needed to inves-
approach has the principles of biomimet- tigate its influence in bonding effective-
ics at its core, which strives to replace ness to dentin.
damaged dental tissues with human-
made materials that mimic those found
in nature in a conservative way that re-
Acknowledgments
establishes the biologic crown stiffness
and allows for functional stress to pass The authors would like to express their gratitude
through the tooth naturally. It must be to Dr Saulo Fortkamp and Mr Geraldo Coelho for
their support with the portrait photography, and to
emphasized that the success of this
Dr Camila Madruga and Mr Herbert Mendes (Ivo-
procedure would not have been possi- clar Vivadent, São Paulo, Brazil) for providing the
ble without the outstanding skills of the Variolink Veneer.

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