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Two-Year Clinical Evaluation of Nonvital Tooth Whitening and Resin Composite Restorations

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Two-Year Clinical Evaluation of Nonvital Tooth Whitening and Resin Composite Restorations Two-Year Clinical Evaluation of Nonvital Tooth Whitening and Resin Composite Restorations SIMONE DELIPERI, DDS* DAVID N. BARDWELL, DDS, MS† ABSTRACT Background: Adhesive systems, resin composites, and light curing systems underwent continuous improvement in the past decade. The number of patients asking for ultraconservative treatments is increasing; clinicians are starting to reevaluate the dogma of traditional restorative dentistry and look for alternative methods to build up severely destroyed teeth. Purpose: The purpose of this study was to evaluate the efficacy of nonvital tooth whitening and the clinical performance of direct composite restorations used to reconstruct extensive restora- tions on endodontically bleached teeth. Materials and Methods: Twenty-one patients 18 years or older were included in this clinical trial, and 26 endodontically treated and bleached maxillary and mandibular teeth were restored using a microhybrid resin composite. Patients with severe internal (tetracycline stains) and external dis- coloration (fluorosis), smokers, and pregnant and nursing women were excluded from the study. Only patients with A3 or darker shades were included. Teeth having endodontic access opening only to be restored were excluded; conversely, teeth having a combination of endodontic access and Class III/IV cavities were included in the study. A Vita shade guide (Vita Zahnfabrik, Bad Säckingen, Germany) arranged by value order was used to record the shade for each patient. Temporary or existing restorations were removed, along with a 1 mm gutta-percha below the cementoenamel junction (CEJ), and a resin-modified glass ionomer barrier was placed at the CEJ. Bleaching treatment was performed using a combination of in-office (OpalescenceXtra, Ultradent Products, South Jordan, UT, USA) and at-home (Opalescence 10% PF, Ultradent Prod- ucts) applications. Two weeks after completion of the bleaching, the teeth were restored using a combination of PQ1 adhesive system and Vit-l-escence microhybrid resin composite (Ultradent Products). Wedge-shaped increments were placed and cured using the VIP Light (Bisco, Inc Schaumburg, IL, USA) through a combination of pulse and progressive curing techniques. Results: All but one restoration were evaluated by two independent evaluators every 6 months during a 2-year period using modified US Public Health Service criteria. No restoration failed and “alpha” scores were recorded for all parameters but color stability, which was scored “bravo.” Analysis of variance showed a significant shade change between baseline (mean = 14.4 ± 1.9) versus 2 weeks (mean = 1.6 ± 0.7) and 2 years (mean = 2.8 ± 1.7) (p < .0001). Although a significant shade change was observed between 2 weeks and the 2-year follow-up (p = .008), no significant difference was reported between the baseline and 2 weeks (12.9 ± 2) versus baseline and 2 years (11.9 ± 2.3). *Visiting instructor and research associate, Tufts University School of Dental Medicine, Boston, MA, USA, and private practice, Cagliari, Italy †Associate clinical professor of Restorative Dentistry and former director Postgraduate Esthetic Dentistry, Tufts University School of Dental Medicine, Boston, MA, USA VOLUME 17, NUMBER 6, 2005 369 TWO-YEAR CLINICAL EVALUATION OF NONVITAL TOOTH WHITENING AND RESIN COMPOSITE RESTORATIONS Conclusions: Significant tooth lightening was reported after the completion of whitening therapy on devitalized teeth; shade rebound was reported in less than 50% of the treated teeth and was limited to a maximum of four shades. A microhybrid resin composite demonstrated excellent clinical performance in the restoration of all endodontically treated and bleached teeth after a 2-year evaluation period. CLINICAL SIGNIFICANCE Nonvital tooth whitening is responsible for a significant change in color of endodontically stained teeth. Successful nonvital tooth-whitening therapy allows for conservative tooth prepara- tion, preserving and reinforcing sound tooth structure. The proper use of modern adhesive sys- tems along with resin composite restorations precludes the use of more extensive restorative treatment, delaying expensive crown and bridge procedures. (J Esthet Restor Dent 17:369 –379, 2005) ver the past decade, the This is considered paramount for a when placed in severely destroyed Orestoration of endodontically successful outcome. Some labora- vital or nonvital teeth.15,16 How- treated teeth has been associated tory studies have demonstrated that ever, the mechanism of dentin with a combination of prefabri- modern adhesive systems in combi- bonding to endodontically treated cated or custom-made metallic nation with direct resin composites teeth, and the longevity of this posts and cores and full crowns1; can adequately reinforce remaining bond, has yet to be explored. Simi- a considerable amount of coronal tooth structure.13,14 These findings larly, research has not provided and radicular tooth structure was have encouraged clinicians to long-term data regarding the clini- sacrificed, increasing the risk of restore nonvital teeth by replacing cal performance of modern adhe- root perforation and fracture.2,3 only missing tooth structure in a sive systems with previously Moreover, patient acceptance is minimally invasive manner. Patient bleached teeth. costly and time consuming for demands for esthetic restorations, the patient.4 coupled with their desire to save Conversely, it has become clear in remaining sound tooth structure, literature reviews that metal posts Lately, there has been an expansion are pushing dentists to stretch pre- do not strengthen endodontically in cosmetic dentistry owing to the sent-day clinical indications for treated teeth. Their use is justified introduction of nightguard vital direct RBC restorations.15,16 This only for retention of the coronal bleaching,5,6 the continued situation may be further influenced restoration.17,18 Post preparation development of total-etch adhesive by a patient’s inability to afford the may be responsible for the destruc- systems,7–10 and the improvement ideal indirect restoration in large tion of sound tooth structure, and of resin-bonded composite (RBC) posterior or anterior applications. tooth perforation can occur during physical and mechanical instrumentation. Teeth with properties.11,12 Nonvital teeth have As a consequence, clinical indica- remaining coronal structure may become primary benefactors of tions for anterior and posterior not require the cementation of a these new developments. The com- RBC restorations have progres- post if correct adhesive techniques bination of tooth whitening and sively expanded; practitioners are are used.19,20 modern adhesive dentistry has looking for new materials and tech- allowed clinicians to preserve niques to further enhance the clini- The purpose of this study was to remaining sound tooth structure. cal performance of direct RBCs evaluate the clinical performance of 370 JOURNAL OF ESTHETIC AND RESTORATIVE DENTISTRY DELIPERI AND BARDWELL direct composite restorations when included in the study. Sixteen of 25 Prior to the start of in-office bleach- a microhybrid resin composite is teeth had a combination of proxi- ing, teeth were pumiced and gingi- used to reconstruct previous mal surface and incisal edge (Class val tissue isolation was performed endodontically treated and III plus Class IV) restorations with using a light-cured resin dam bleached anterior teeth. The endodontic access; the remaining (OpalDam, Ultradent Products). hypothesis of our study was three- teeth had at least a Class III restora- A 35% hydrogen peroxide gel fold; we hypothesized that there tion, along with endodontic access, (OpalescenceXtra, Ultradent Prod- would be (1) tooth color modifica- to be restored. All subjects received ucts) was applied into the pulp tion greater than five shades on the a dental prophylaxis 2 weeks prior chamber and on the facial enamel Vita shade guide (Vita Zahnfabrik, to the start of bleaching. for 30 minutes. The in-office Bad Säckingen, Germany) arranged bleaching treatment was main- in value order, (2) rebound not A Vita shade guide arranged by tained and reinforced using a 10% greater than two shades at each value order (lightest to darkest) was carbamide peroxide at-home annual recall, and (3) a 100% resin used to record the shade for each bleaching agent (Opalescence 10% composite retention rate at the patient. PF, Ultradent Products) according 6-month recall. to the inside/outside bleaching tech- An alginate impression of the max- nique.21 Shades were recorded MATERIALS AND METHODS illary or mandibular arch was 14 days after the completion of the Twenty-one patients 18 years or taken, poured with dental stone, home-bleaching treatment and older were included in this clinical and the resultant casts were 1 week after the restoration was trial to bleach and restore endodon- trimmed and prepared for a custom completed. The endodontic access tically treated maxillary and stent; a light-cured resin blockout was not sealed during the tooth- mandibular anterior teeth. Patients material (LC Block-out Resin, whitening procedures and the 2- with severe internal and external Ultradent Products, South Jordan, week waiting period following the discoloration (tetracycline stains, UT, USA) was placed on the facial completion of nonvital bleaching. fluorosis), smokers, and pregnant aspect 1 mm from the gingival area. and nursing women were excluded Trays were fabricated with a A rubber dam was placed and cavity from the study. Teeth having
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