Continuing Education

Volume 32 No. 10 Page 100

Minimally Invasive Cure

for Life-Long Discoloration
Authored by Frank J. Milnar, DDS

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Continuing Education

transmission properties of the tooth structure due to pulp

necrosis or variations in the dentin.2 As a result, the
permanent dentition is affected by turning a brown hue.3
Unfortunately, many more conditions that can create
permanent discoloration include dental fluorosis, plaque
calcifications, and the prenatal use of tetracycline.
Tooth discoloration can have psychological effects on
individuals. A study conducted by the US Air Force Dental
Corps identified what people thought characterized an
attractive smile. A total of 297 subjects viewed 8
photographs of female smiles, 8 photographs of male
smiles, and completed a questionnaire to rate the
attractiveness of each photograph. The study concluded that
in all cases, tooth shade was the most important factor in
determining an attractive smile. This is relevant because
science has already established that dentofacial
attractiveness greatly affects the psychosocial well-being of
an individual.4
Unfortunately, managing discolored teeth can be a
complex problem, and treatment usually requires a
combination of modalities for predictability. For cases in
which the discoloration is not extreme, dentist dispensed or
supervised at-home or in-office bleaching procedures may
be adequate to enhance tooth shade. Bleaching
procedures using hydrogen peroxide or carbamide
peroxide have been proven effective and safe, but there are
reports of adverse reactions such as cervical root
resorption5 and post-treatment sensitivity that can last from
a few hours up to several days.6 However, with brown
intrinsic staining, the discoloration is often more difficult to
address, and bleaching procedures alone will likely not be
sufficient to achieve the desired result.7
Porcelain veneers have been a preferred and effective
option for many patients to treat discolored teeth.8 The reasons
for this include the materials high strength, high aesthetics,
biocompatibility, and clinical longevity when proper adhesive
bonding protocol is followed.9 Some disadvantages of indirect
veneers are aggressive tooth preparation requirements and
technique-sensitive adhesive procedures that, if not performed
precisely, result in debonding or marginal leakage.9
All-ceramic crowns are another treatment option for
masking discolored teeth. These materials, such as lithium

Minimally Invasive Cure

for Life-Long Discoloration
Effective Date: 10/1/2013

Expiration Date: 10/1/2016

ABOUT THE AUTHOR

Dr. Milnar is a graduate from the
University of Minnesota, School of
Dentistry. He is an accredited member of
the American Academy of Cosmetic
Dentistry and a board examiner for
Accreditation. Dr. Milnar maintains a fulltime practice in St. Paul, Minn, emphasizing appearance
related dentistry. He has published numerous articles about
the direct placement of composites, shade selection, and
porcelain materials and is on editorial review boards for
dental journals. Dr. Milnar is cofounder of the Minnesota
Academy of Cosmetic Dentistry and has lectured
extensively within the US Armed Forces as well as
internationally on the subject of direct composite
restorations, shade selection and porcelain materials. He
has been voted Top Dentist for the last several years in the
Minneapolis/St. Paul Magazine. He has been named a
Leader in Continuing Education by Dentistry Today. He can
be reached at the Web site stpaulsmiles.com.
Disclosure: Dr. Milnar discloses that he received financial
support from Tokuyama Dental America.

INTRODUCTION
Often the first noticeable difference in varying dentition
between individuals is tooth color. Tooth discoloration is
caused in one of 2 ways.1 These causes can be extrinsic
when dietary colorants or other deposits attach to the tooth
surface or pellicle layer through tobacco use, coffee or tea
ingestion, poor oral hygiene, and use of chemical plaque
preventative agents.
The causes can also be intrinsic. The formation of
intrinsic discoloration occurs during tooth development (or
as a result of trauma) and produces altered light

Continuing Education

Minimally Invasive Cure for Life-Long Discoloration

disilicate and leucite-reinforced porcelains, exhibit
increased durability and aesthetics due to natural/high
translucency. This makes them an excellent option for
treating discoloration in the posterior region where high
strength is necessary and aesthetics are still a concern.
This treatment option should only be considered for teeth
with significant loss of anatomy or severe discoloration, as
all-ceramic crowns generally require more tooth preparation
as compared to other full-coverage options.10
Despite the multitude of options available, there are
several reasons why patients may decline these
recommended aesthetic dental treatments for correcting tooth
discoloration. These may include time constraints or financial
considerations that restrict the methods or materials chosen
by the dentist.11 A patients fear/anxiety level pertaining to
certain procedures like aggressive tooth preparation must
also be considered as a possible reason for refusing
treatment.12

reserved only for the most skillful clinicians, because the

careful layering technique, sculpting, and artistic coloration
were best performed by dentists who had mastered the
material.19 The 1970s brought about light-cured composites
with smaller filler particles that were more color stable than their
predecessors and demonstrated enhanced wear characteristics. A few years later, filler particle size decreased, load
increased, and subsequently the material strengths became
significantly higher, allowing for clinical longevity in the
posterior region. The next material advancement was in using
nanoparticles. These particles are very small, ranging in size
from one nm to 100 nm, increasing filler loading and thusly
enhancing the physical and mechanical properties of the
material.20
Todays composites are available as microfilled,
microhybrid, nanohybrid, and most recently suprananohybrid
materials. These composites range in viscosity from
packables that have handling characteristics similar to
amalgam,21 to flowables that can be syringed directly into
preparations. These advanced materials are important to
clinicians because they provide the ability to deliver
restorations that are aesthetic due to their light reflecting/refracting properties, bond well to dentin and enamel,
and they attain and maintain a good polish and gloss. Among
the composites to date that have addressed these requisites
are Estelite Sigma Quick (Tokuyama Dental America), Filtek
Supreme Ultra (3M ESPE), Tetric EvoCeram and IPS
Empress Direct (Ivoclar Vivadent), Venus Diamond and Venus
Pearl (Heraeus Kulzer), and Renamel Microfill (Cosmedent),
to name just a few.
The newest version of direct composite, suprananohybrids
(Estelite Sigma Quick), demonstrates the combination of
characteristics that dentists have desired from composites for
30 years. Suprananohybrid composite features exceptional
strength while also displaying enhanced optical properties.
Suprananohybrids also demonstrate chameleon shades that
allow for easy matching to natural tooth structure. This enables
dentists to reduce overhead and inventory while still
maintaining their ability to create highly aesthetic restorations
in all regions of the mouth. Additionally, there is almost no
variation in color or volume before and after light-curing, so
there is greater predictability when placing restorations.22

Considering Minimally Invasive Options

When minimally invasive preparation is ideal, dentistmonitored in-office and at-home bleaching procedures,
followed by carefully planned and placed direct composite
restorations, are an option that yields favorable results to
satisfy both patient and dentist aesthetic goals.13,14 Direct
composite is considered among clinicians to be the least
invasive and most conservative method to restore
aesthetically displeasing or diseased teeth to stable color,
form, and function.15 When paired with bleaching, this
combination of procedures achieves the desired appearance
with minimal discomfort, low cost, predictability, and excellent
success rates.16 There is also a very high rate of patient
satisfaction associated with these treatment methods.17
The first generation of dental composites was chemically
polymerized, very brittle, and only suitable for restoring anterior
teeth. These composites were usually quartz-filled, required
hand mixing of self-curing pastes that only came in 4 shades,
and were difficult to work with. Wear and fracture resistance
were low, the materials did not meet compressive and tensile
force requirements, were difficult to polish, and exhibited high
surface roughness.18
Even as they evolved, direct composites were, at first,

Continuing Education

Minimally Invasive Cure for Life-Long Discoloration

In fact, several studies were
conducted to identify the amount
of volumetric shrinkage suprananohybrid composites undergo
due to polymerization, and the
results illustrate that the rate of
volumetric shrinkage is statistically low (ie, about 1.3% to
Figure 2. Close-up view, following in-office tooth
2%).23,24 These composites also Figure 1. Preoperative view exhibiting the severe
whitening.
tooth discoloration.
bond well to all tooth surfaces. In
a study testing microtensile bond
strength of an experimental
adhesive between dentin and
different restorative materials,
the suprananohybrid performed
well, demonstrating a good microtensile bond to dentin with
strength of 51.0 MPa.25
Figure 4. The proposed enamel composite shades
Aesthetically, due to the Figure 3. The proposed dentin composite shades
were previewed.
were previewed.
submicron particle size of the filler,
these composites can be polished very quickly to a high gloss
would have allowed for the subsequent opportunity to
that is maintained for years and enhanced using a systematic
consider prosthodontic treatments in the future. The patient
finishing and polishing kit (eg, Shofu Dental).
indicated that she wanted to pursue a minimally invasive
option and wanted to understand what could be possible.
CASE REPORT
During the aesthetic evaluation, it was noted that the
A female patient in her 40s presented for a consultation to
patient displayed a full smile. However, it was determined that
discuss treatment options for correcting the appearance of
her aesthetic concerns could be addressed with a
her severely discolored teeth (Figure 1). A comprehensive
combination of in-office whitening (eg, BriteSmile) and direct
examination was performed that included an aesthetic
composite restorations (Estelite Sigma Quick) in a minimally
evaluation.
invasive, reversible, and repairable way. Her dental condition
She had been afflicted with such discoloration and
was good, so she was scheduled for a hygiene appointment
aesthetic dilemma since age 13 years that affected her
and for tooth whitening.
psychologically. However, despite the social stigma she
endured due to the tooth discoloration, she was reluctant to
Clinical Treatment
undergo the more aggressive treatments (eg, all-ceramic
Fourteen days after completing the tooth whitening
crowns, veneers) that previous dentists had recommended.
procedure (Figure 2), the patients tooth color could be
As she described the prosthodontic solutions that had
managed in the labial enamel, with minimal tooth preparation
been suggested to her, it was clear that her previous
required. The composite selected for the case was a
consultations did not include discussion about tooth structure
suprananohybrid (Estelite Sigma Quick), since this material
removal or tooth shade. Additionally, it was apparent that there
would provide the simplified shade selection necessary to
was a lack of clarity within the profession regarding minimally
cover the tooth space using one or 2 shades, making it ideal
invasive alternatives for enhancing her smile at this time that
for this type of everyday dentistry.22 Yet, it would enable

Continuing Education

Minimally Invasive Cure for Life-Long Discoloration

Figure 5. Areas of color concerns and zones

of high chroma areas were outlined.

Figure 6. A minimally invasive preparation

was undertaken using a No. 331-0913
diamond (Shofu Dental).

Figure 7. Bevels were placed using a No.

7903-0939 diamond (Shofu Dental).

Figure 8. A selective-etch technique was

used.

Figure 9. A dentin bonding agent was

placed according to the manufacturers
instructions (Bond Force [Tokuyama Dental
America]).

Figure 10. The initial dentin composite layer

in shade A1 was applied and sculpted onto
tooth No. 8 (Estelite Sigma Quick [Tokuyama
Dental America]).

Figure 11. The A1 dentin composite was

then placed on tooth No. 9.

Figure 12. The final shade CE composite

enamel layer was placed on tooth No. 8.

Figure 13. Pencil lines were drawn to

identify necessary line angles.

effective shade matching with the adjacent natural dentition,

maximization of the selected shades for recreating the tooths
inherent hue, chroma and value, and therefore realization of
aesthetic principles.
During the restorative appointment, the proposed dentin
composite shades (eg, B1 on the left, A1 on the right) were
previewed on the unprepared teeth (Figure 3). Shade A1
was selected. Then proposed enamel composite shades
(eg, WE on the left, CE on right) were previewed (Figure 4),
and shade CE was selected.
Teeth Nos. 8 and 9 were evaluated to outline areas of
concern regarding color and zones of high chroma areas
(Figure 5), after which a minimally invasive preparation was

begun using a No. 331-0913 diamond (Shofu Dental)

(Figure 6). Initially, the preparation demonstrated areas of
high chroma. Bevels were placed using a No. 7903-0939
diamond (Shofu Dental) to complete the preparation
(Figure 7).
Because a small area of the preparation extended into
dentin, a selective-etch technique was used (Figure 8). The
etchant was then rinsed thoroughly, and the teeth were dried.
Next, a dentin bonding agent (Bond Force [Tokuyama Dental
America]) was placed according to the manufacturers
instructions (Figure 9) and light-cured.
Using freehand direct composite artistry, the initial
dentin composite layer (Estelite Sigma Quick) in shade A1

Continuing Education

Minimally Invasive Cure for Life-Long Discoloration

Figure 14. The line angles were modified

with a disc.

Figure 15. A CTF yellow Robot carbide

finisher (Shofu Dental) was used to create
the secondary anatomy.

Figure 16. To create the tertiary anatomy, a

Dura-Green Stone No. 1211252 (Shofu
Dental) was used.

Figure 17. An initial polish was applied to

the restorations using One Gloss (Shofu
Dental).

Figure 18. A buffing disc (Super Snap

Buff Disc [Shofu Dental]) moistened with
water was used to continue polishing the
restorations.

Figure 19. The restorations achieved their

final luster using a buffing disc and polishing
paste (Direct Dia [Shofu Dental]).

was applied and sculpted onto tooth No. 8, then light-cured

(Figure 10). The A1 dentin composite was then placed on
tooth No. 9 (Figure 11) in a similar manner and light-cured. A
matrix (Omni Band [Ultradent Products]) was placed, after
which the final CE shade composite enamel layer was placed
on tooth No. 8 and light-cured (Figure 12). The CE composite
enamel layer was then applied to tooth No. 9 and light-cured.
Pencil lines were drawn to identify necessary line angles
and facilitate construction of primary anatomy (Figure 13).
These line angles were then modified in the restorations using
a disc (Super Snap [Shofu Dental]) (Figure 14). Next, a CTF
yellow Robot carbide finisher (Shofu Dental) was used to
create the secondary anatomy (Figure 15). Subsequently, a
Dura-Green Stone No. 1211252 (Shofu Dental) was used to
create the tertiary anatomy (Figure 16).
The restorations were initially polished using One Gloss
(Shofu Dental) (Figure 17). A buffing disc (Super Snap Buff
Disc [Shofu Dental]) moistened with water continued the
polishing sequence to create a prelustered surface (Figure 18).
The restorations achieved their final luster through the use
of a buffing disc (Super Snap Buff Disc) and polishing paste
(Direct Dia [Shofu Dental]) (Figure 19).

Figure 20. Final close-up

postoperative view of the
patients direct composite
restorations. Note the
dramatically enhanced
appearance of her smile,
accomplished with a
minimally invasive
protocol.

The handling, physical, and visual properties

demonstrated in the selected composite (Estelite Sigma
Quick) represent the evolution of direct composites to their
currently advanced state, which enabled the use of only 2
ideal dentin and enamel shades for creating the chameleon
effect necessary for the restorations to appear naturally
aesthetic (Figure 20).

IN SUMMARY
The in-office whitening and suprananohybrid composite,
combined with the dentists full understanding of the
transformational possibilities of responsible aesthetics,
essentially cured this patients discolored smile, with
which she had been afflicted all her life.

Continuing Education

Minimally Invasive Cure for Life-Long Discoloration

14. LeSage BP. Are you treating planned cases or treating
teeth to stay busy? Dent Today. 2012;31:76-78.
15. LeSage BP. Aesthetic anterior composite restorations:
a guide to direct placement. Dent Clin North Am.
2007;51:359-378, viii.
16. Dietschi D. Optimizing smile composition and esthetics
with resin composites and other conservative esthetic
procedures. Eur J Esthet Dent. 2008;3:14-29.
17. Kelleher MG, Djemal S, Al-Khayatt AS, et al. Bleaching
and bonding for the older patient. Dent Update.
2011;38:294-303.
18. Small BW. Direct resin composites for 2002 and
beyond. Gen Dent. 2002;50:30-33.
19. Milnar FJ. The evolution of direct composites.
Compendium. 2011;32:79-81.
20. Margeas R. Composite materials: advances lead to
ease of use, better performance. Compendium.
2013;34:370.
21. Suzuki S. Does the wear resistance of packable
composite equal that of dental amalgam? J Esthet
Restor Dent. 2004;16:355-365.
22. Tokuyama Estelite Sigma Quick.
www.dentalaegis.com/id/2012/08/tokuyama-estelitesigma-quick. Accessed July 12, 2013.
23. Kaga S, Fusejima F, Kumagai T, et al. Polymerization
shrinkage ratio of various resin composites. J Dent
Res. 2009;88(special issue A). Abstract 2441.
24. Beck P, Lindsey M, Michelson C, et al. Polymerization
shrinkage of nine highly-filled composite materials. J
Dent Res. 2011;90(special issue A). Abstract 606.
25. Hirata K, Armstrong S, Qian F. Material compatibility of
self-etching self-cure 1-step adhesive when dentin
bonding. J Dent Res. 2012;91(special issue A).
Abstract 225.

REFERENCES
1. Hattab FN, Qudeimat MA, al-Rimawi HS. Dental
discoloration: an overview. J Esthet Dent.
1999;11:291-310.
2. Sulieman M. An overview of tooth discoloration:
extrinsic, intrinsic and internalized stains. Dent Update.
2005;32:463-471.
3. Watts A, Addy M. Tooth discolouration and staining: a
review of the literature. Br Dent J. 2001;190:309-316.
4. Dunn WJ, Murchison DF, Broome JC. Esthetics:
patients perceptions of dental attractiveness. J
Prosthodont. 1996;5:166-171.
5. Friedman S, Rotstein I, Libfeld H, et al. Incidence of
external root resorption and esthetic results in 58
bleached pulpless teeth. Endod Dent Traumatol.
1988;4:23-26.
6. Tam L. The safety of home bleaching techniques. J
Can Dent Assoc. 1999;65:453-455.
7. Setien VJ, Roshan S, Nelson PW. Clinical
management of discolored teeth. Gen Dent.
2008;56:294-300.
8. Taleghani M, Wathen WF. Porcelain laminate veneers
in the adult dentition. Tex Dent J. 2006;123:928-936.
9. Ibarra G, Johnson GH, Geurtsen W, et al. Microleakage
of porcelain veneer restorations bonded to enamel and
dentin with a new self-adhesive resin-based dental
cement. Dent Mater. 2007;23:218-225.
10. Sadowsky SJ. An overview of treatment considerations
for esthetic restorations: a review of the literature. J
Prosthet Dent. 2006;96:433-442.
11. Feigenbaum N. The challenge of cost restrictions in
smile design. Pract Periodontics Aesthet Dent.
1991;3:41-44.
12. Cohen SM, Fiske J, Newton JT. The impact of dental
anxiety on daily living. Br Dent J. 2000;189:385-390.
13. Milnar FJ. Incorporating flowable composites into the
minimally invasive treatment sequence for aesthetic
enhancement. Pract Proced Aesthet Dent. 2006;18:65-70.

Continuing Education

Minimally Invasive Cure for Life-Long Discoloration

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1. Conditions that can often cause permanent

discoloration include dental fluorosis, plaque
calcifications, and the prenatal use of tetracycline.
a. True

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b. False

2. Science has already established that dentofacial

attractiveness rarely affects the psychosocial well
being of an individual.
a. True

b. False

3. Bleaching procedures using hydrogen peroxide or

carbamide peroxide have been proven effective and
safe, but there are reports of adverse reactions such
as cervical root resorption and post-treatment
sensitivity that can last from a few hours up to
several days.

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a. True

b. False

4. Porcelain veneers have been a preferred and

effective option for many patients to treat discolored
teeth.
a. True

b. False

5. All-ceramic crowns are another treatment option for

masking discolored teeth.
a. True

b. False

6. A patients fear/anxiety level pertaining to certain

procedures like aggressive tooth preparation should
not be considered as a reason for refusing treatment.

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a. True

b. False

7. Direct composite is considered among clinicians to

be the least invasive and most conservative method
to restore aesthetically displeasing or diseased teeth
to stable color, form, and function.

This CE activity was not developed in accordance with

AGD PACE or ADA CERP Standards.
CEUs for this activity will not be accepted by the AGD
for MAGD/FAGD credit.

a. True

b. False

8. The newest version of direct composite, suprananohybrids demonstrate the combination of

characteristics that dentists have desired from
composites for 30 years.
a. True

b. False

Continuing Education

Minimally Invasive Cure for Life-Long Discoloration

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