Shortcuts in Esthetic Dentistry Compressed 1 - Part2

Chapter 1: Dental bleaching: concepts and bleaching substances 67
1.201e1.202: Ini tial case

presenting diastemas after
orthodontic treatment , and mi ld
discoloration of the teeth.
1.203: Note the presence of

composite resin residues from
of the material used to bond the
brackets. The bur H48L (Komet)
at low speed in a mu.Iti plier
contra - angle (T2 Revo /Sirona)
can be used for such removal.
1.204: Shade selection with the

Vita Classic shade guide prior to
dental bleaching.
1.205to1.207: Labial sunscreen

(lip balm spf 30, Discus Dental,
to fJ.lter UV-A rays) on the labial
commissure.
68 Shortcuts in Esthetic Dentistry a new look on TIPS
1.208and1.209: Placeme nt of
cheek and lip retractor with a
tongue protector.
I.210 to 1.212: Appli cation of

additional layer of sunscreen on
exposed regions of the lip.
I.213 to 1.216: Pos itioning of

gauzes on the upper and lower
lips. TI1ese are part of the
bleaching kit and cannot be
replaced by other products since
they are not effect ive in filtering
the light from the device.
I.217and1.218: Positioning of
facial shield around the borders
of the retractor.
I.219and1.220: One gauze is

wrapped lon g itudin~ly and
· illSerted in the upper and lower
bases of the vestibu le, below
t he retractor borders. A second
gauze is fo lded into a triangle and
placed on the corn ers to protect
the c heeks.
1.221to1.225: Application of the

gingival barrier (Liquidam) , with
a maximal thickness of 2 mm to
ensure complete polymerization.
It polymerizes with a sweeping
motion. Do not replace fo r
another gingival barrier sin ce the
Liquidam (Discus Dental) blocks
the transmission of UV ljght.
1he complete polymerization
of the gingival barrier should
be verified , and should also be
solid and rigid; with the help of a
mirror, the presence of possible
exposed gingival areas should be
identified .
1.226: Repeat the process on the

lower arch.
1.227 to 1.229: Application of a

pretreatment product based on
water and 5% potassium nitrate,
to keep the pH alkaline during
the entire process.
1.230: The automix tip is

attached on the syringe
containing the bleaching gel.
1.231and1.232: The gel is applied

on the labial surfaces. Note the
homogeneous thlckness of the
gel over the labial surfaces of the
teeth.
70 Shortcuts in Esthetic Dentistry: a new look on TIPS
1.233 and l.234: The light guide

is position ed according to the
smile line of the patient , over the
wings of the retractor.
1.235: Press start to initiate a

cycle of 15 minutes.
l.236 and I.237: ZOOM! 2

activated.
l.238 and l.239: The patient

should ho ld a note pad in case
he or she wants to pass some
informati on about any perceived
symptoms.
l.240: A light turns on at each

25 % of the procedure, emitting
three signals when e nding the
cycle, automati cally turning off
after three seconds,.
l.241and1.242: After each

bleaching application, a
desensitizer based on amorphous
calcium phosphate (ACP} can be
used (Relief ACP, Discus Dental}
for S minutes.
l.243: During the first session,

two 15-minute applications are
performed. A second session
was done after three days with
two additional applications
performed similarly.
I .244: Final shade se lection

with Vita Classic shade guide
immediately after the second
session.
1.245 and 1.246: Initial case and

hnal result (two weeks after the
last sess ion). Note that even after
bleaching, the tooth maintains an
enamel gloss with th e absence of a
milky appearance. Less recurrence
of the immediate effect and after two
weeks is observed when compared
to the traditional in- ofhce bleaching,
which is consistent with the study of
Matis et al. 49 •
1.247 and 1.248: Initial case and hnal

result.
1.249 and 1.250: Initial case and hnal

result.
1.251and1.252: Initial case and final

result
Bleaching with peroxide at

lower concentrations seems to
be a trend for in-office bleach-
ing products. The problem is
that reduced concentration also
decreases the action. The pho -
to-fenton process seems to be
the option for using bleaching
gels in lower concentrations
but with enhanced action.
The biggest advantage is not
brighter teeth, but a bleaching
that is less aggressive and more
biological.
1.253and1.254: Wax - up done on th e initial mode l, which

will gu.ide the cosmetic recontourig of teeth (Lab Studio
Dental I Curitiba - PR}.
1.255and1.256: Position of th e matrix should be ve rihed.

As it is desc ribed in the chapter about ante rior teeth, you
can fabricate a mock- up to help with diagnosis.
1.257and1.258: Typica lly, a modihed rubber dam

isolation (eight conn ected pe rfo rations} from premolar to
premolar is used.
1.259: The siLico ne guide is tested once again to ensure

that the isolation does not disturb the guide 's adaptation.
1.260 and 1.261: Roughening of t he enamel surface,

removing the superficial a pr ismatic enamel.
1.262 and 1.263 : Placement of the retraction cord (SilTrax

#7 , Pascal} without astringent treatment.
1.264: Note the retraction obtained.
1.265 to 1.267: Starting this case with the most fac ially
positioned central incisor.
1.268to1.273: Layering techn ique done with Opallis

system (FGM}.
1.274 and 1.275: The symmetry of the mirror area of

the central inc isors shou ld be emmulated, as well as
the actual width (which should be the same as in the
wax - up} .
1.276 and 1.277: Once th e central incisors are properly

treated, the cl inician should treat the lateral in cisors
similarly.
1.278: Occlusal check.
1.279 to 1.281: Using powder for ceramic

texture (Texture Marker/ Benzer) ,
the texture, primary, and secondary
anatomy can be observed. Modifications
are made on this reference obtained by
the use of the powder.
1.282 to 1.284: Finishing and polishing

with Jiffy rubber cup system (Ultradent).
1.285: Final polishing with Flexi-

buff (Cosmedent) and Enamelize
(Cosmedent) aluminum oxide paste.
1.286: Proximal polishing with finishing

strips (Oraltech) and polishing paste.
1.287 and 1.288: Before and after

cosmetic recontouring.
1.289 and 1.290: Before and after

cosmetic recontouring.
1.291: Final result with lips at rest,

exposing about 3.0 mm of central
incisors.
1.292to1.302: The sa me
sequence using the Zoom
system, but with four
applications in just one session as
an alternative.
The video with the bleaching tech-

nique using the Zoom 21 System (Dis-
cus Dental) can be viewed at the site:
www.shortcuts-book.com.
How long should you wait before placing the final restoration
once bleaching is completed?
The scientifi c literature reports a sign ificant decrease in bond
strength when a resin composite restoration is placed immedi-
ately after dental bleaching. 50 -54 Apart from this evident effect
--
the cause of this negative association is sti ll not completely un-
derstood. One poss ible explanation is the decrease of polymer-
ization of composite materials due to the presence of res idual
oxygen in the enamel pores and dentin immediately after dental
bleaching. 5556 Oxygen inhi bits the polymerization of composites 57
and it is possible that the oxygen fro m t he hydrogen peroxid e -

Restorative procedures absorbed by the enamel and dent in - is liberated slowly t hrough
slwulds be postponed for
two weeks due to the re- superficial diffusion, w hi ch can affect the enamel-composite resin
lease of remaining oxygen bond strength and interfere with th e infiltration of the ad hes ive
coming from the peroxide,
which can negatively affect into the dental tissues. 565 8
the bond strength between
the tooth and restoration.
This waiting period is Hence, it is safer t o restore the tooth only after a period of at least
necessary for color stabi-
two weeks from the day the bleaching treatment is complete 54·56
lization and rehydration of
bleached teeth. (Figs 1.303 to 1 308)
l.303: Clinical case post orthodontic treatment. Note that

the saturation increases during the orthodontic treatment.
1.304: For at-home bleaching with trays, teeth should be

splinted first, conditioning the proximal surfaces of the
teeth, applying adhesive, and using a flowable transparent
resin composite. This is need ed to avoid teeth movement
during the three or four weeks of treatment. Bleaching agent
containing 10% carbamide peroxide was used for three
weeks .
l.305: Two weeks after the end of the bleach.lng treatm ent ,
the esthetic restorations were done . A classic case of
cosmetic contouring.
l.306 to l.308: Step- by- step .

Which treatment is best: at-home or in-office?
Since dental bleaching with trays was introduced in 1989, numer-
ous products and techniques have been - and still are - being de-
veloped. As a result, a very common question arises: "Which tech-
nique works besf7" According to Heymann,24 nearly all techniques
work because bleaching is bleaching. If bleaching is done at home
using just 10% carbamide peroxide (which contains approximately
3% of hydrogen peroxide), or using over-the-counter whitening
strips with 6% of hydrogen peroxide, or in-office using 25-35%
hydrogen peroxide, the final result is potentially similar. This simi-
larity among results is possible because the bleaching mechanisms
are the same: oxidation of the organic pigments or chromophores
in the tooth. The difference from one technique to another is the
concentration of the bleaching agent and the treatment duration.
If the final results of different bleaching protocols are similar,
other factors might be important when selecting the treatment.
For example, if the patient has a lot of non-carious cervical lesions

with dentin exposure, in-office bleaching is most The combinat ion of bleaching trays and in-office
indicated because these areas can be protected bleaching can be interesting when is the patient
with light-cured gingival barrier. If the patient is The recurrence after can on ly to come to the practice once. In some
vital de11ta1 bleaching,
ab le to undergo bleaching for two to four weeks cases, the opposite can also be done, ie, initial
either at-home or
and does not mind to use trays at home, the best in-office, can occur bleaching with trays and finali zing the treatment
after two or three
method for him would be at-home bleaching at with an application in the office.
years at a rate of
night with carbam ide peroxide in low concen- around 30%. Mainte-
nance can be planned
trations (10-15%). This method provides a stable with the patient: if However, all techniques can be efficient when
bleaching result precisely because the oxidation home bleaching was bleaching, so the best is the one that fits the needs
done, a reapplication
process of the pigments is slower and progres- can be done after one and profile of the patient.
sive. 59 Meanwhile, if the patient needs to bleach and a half years, with
trays, during one
the teeth in a short period, often because of a fes- week. If the in-office
tive occasion in the near fut ure, the best option bleaching was done,
one or two clinical
is in-office bleaching using products with higher bleaching sessions
can be scheduled after
concentrations, so the result will be more visible
one and a halfyears.
initially. However, the initial and extremely white Remember that the
OTC systems ("over-
result is not stab le and can be lost quickly. Not
tl1e-counter") can
so much because of further discoloration, but to be an option for the
maintenance of the
the rehydration of the teeth, wh ich will dehydrate
bleaching treatment.
during the first 30-45 minutes of consu ltat ion.
Which are the techniques for non-vital tooth bleaching?
The discoloration of non -vital teeth can occur as the result of
various circumstances. For example, an hemorrhage in the pulp
chamber caused by a trauma, or pu lpal necrosis that allows the
penetration of erythrocytes in the dent inal tubu les. The he-
molysis of the red cells with the re lease of hemoglobin pro-
duces a brown-yellow disco loration caused by the release of
ferrous sulphates. 6° Clinical challenges during the endodont ic
treatment can also be responsible for discolorat ion of teeth . In-
adequate coronal access, insufficient irrigation, presence of de-
bris, or remnants of si lver and/or cements based on zinc oxide/
eugenol can also be etiological factors of discolored teeth. 61 ·62
The diagnosis of the discoloration plays an important role in
the success of any bleaching technique. When the discoloration
occurred due to decomposition byproducts of the pu lp in the
dent inal tubules, the prognosis is often very good. 63 Brown 64
reported that disco lorations induced by trauma or necros is can
be bleached in about 95% of the cases.

Different protocols have been proposed for bleach- gel68 may be favorable to ach ieve exce llent results
ing non-vital teeth. A technique that was used fre- in short period of time. 69
quently in the past was the thermocatalytic tech-
nique, w hich involves the placement of oxidizing It is fundamental to analyze the tooth t o be
chemicals in the pulp chamber, activated by dif- bleached in relat ion to the quantity of t he tooth
ferent heat sources, and for various durations. 41 Al- structure, since the effect of bleaching is on the
though satisfactory results could be obtained, this dentin, i.e., the tooth must have sufficient re main-
technique fell in disuse due to th e probable associ- ing dentin and should not be excessively doomed.
ation w ith external cervical resorptions caused by
excessive heat. 65 A bleaching technique t hat does

Keep in mind that
not employ heat is called walking bleach, and in- THE TECHNIQUE
recurrence af-
vo lves the use of an active ingredient such as car- ter bleaching of
non-vital teeth is
bamide peroxide at 37%, sod ium perborate, alone Tooth discoloration due to pulp necrosis (Figs.
very common after
or in combination with hydrogen peroxide at 5 to approximately three 1.309 and 1.310) was diagnosed by the presence of
years. With every
35%, directly inside the pulp chamber, fo llowed by attempt to bleach periapical lesion and absence of response to co ld
sealing of the cavity. 66 Th e bleaching occurs inside again, recurrence stimulus (Fig. 1.311). One week after the endodon-
occurs increasingly
t he tooth, whi le the bleaching agents are kept inside faster, this being the tic treatment is complete,65 the provisional restor-
t he pulp chamber. Satisfactory results in reducing main disadvantage of ative material must be removed (Fig. 1.312), and
the technique.
tooth discoloration should be observed after three tooth shade determined w ith a VITA shade guid e
to six procedures, 67 depending on the etiology of (Vita Zahnfabrik, Germany), sequenced accord ing
the discoloration. The latter has been traditionally to brightness. Then, about 3 mm of restorative ma-
used to treat discolored non-vital teeth, although terial must be removed in ap ical direction beyond
this procedure has the disadvantage of requiring the cementa enamel juncti on. Thi s can be eas ily
a long period of time t o complete the bleaching accomplished by measuring the clinical crown with
treatment. Th e combination of t his technique with a periodontal probe, and transfering this measure-
in-offi ce bleaching using 35% hydrogen peroxide ment using the probe to the pulp chamber.
Once this procedure is done, a cervical plug shou ld ionomer cement, compos ite resin cement, zinc
be placed to avoid contact of the bleaching agent phosphate cement, or fiowable composites. 67·71. 72 In
At proximal walls,
with the dentinal walls of the root canal, prevent- the case described: we used resin-modified glass
the cemento-enamel
ing penetration of hydrogen peroxide into the cer- junction is located ionomer (Vitremer, 3.M ESPE, St. Paul, MN, USA),
approximately 2 mm
vical and apical areas.65.7°.7 1 For this purpose, differ- inserted with a Centni1
x syringe (DFL) onto the gut-
coronally comparing
ent restorative materials can be used, such as glass to vestibular and ta-percha inside the root canal (Fig. 1.313).
palatal surfaces.
Therefore, the cervi-
cal plug must follow
this anatomy.
--
1.309 and 1.310: Tooth discolored

due to pulp necrosis.
1.311: A periapical lesion is

present.
1.312 and 1.313: Removing 3 mm

of material and placing cervica l
plug with resin - moctihed glass
ionomer (Vitremer, 3M ESPE).
It is hypoth es ized that th e hydrogen perox ide hydrogen perox ide (Lase Perox id e Sensi, DMC
can diffuse through the dentinal tubu les to th e Equ ipments). Usin g th e mi xin g too l from th e kit
ce rvical periodontal li gament 73 in the absence the peroxi de phase (Stage 1) must be mi xed w ith
of cervical sealing, 65·74 altering th ese structures the t hi ckener phase (Phase 2), usin g the propor-
and caus in g root resorpti on. 75 Experimental lab- t ion of t hree drop s of perox ide to one drop of
oratory stud ies have shown hi st ological signs of thickener (Figs. 1.316 to 1.318). Thi s is suffi cient
resorption just 3 months after internal bleac h- for the appl icat ion of a 2 mm th ick layer on the
ing with 30% hydrogen perox ide assoc iated buccal and palatal surfaces of the tooth, as we ll
w ith heat. 76·77 Other facto rs associated w ith root as to fill up the pulp chamber (Fi gs. 1.319 and
resor pti on are the app lication of 11eat (thermo- At each weekly 1.320). The material shoul d be kept on the teeth
catalyt ic met hod), and previous trauma. 73 Thus, appointment to for about 15 minutes to all ow its penetration into
reapply the internal
teeth that underwent root canal t reat ment as bleaching agent, the tooth stru cture (Figs. 1.321 and 1.322). Th en,
a result of t rauma should be carefu lly evaluated applications of 35% the gel is removed with suction (Fi gs. 1.323-
hydrogen perox-
prior to intracoronal bleac hin g. ide-based product 1.326), and it can be reapplied up to fo ur times
can be done in the per session.
practice to reduce the
Wi th th e help of a cheek and lip retractor, a 2-3 total bleaching time.
mm wide gin gival barrie r (Lase Protect DM C After the last applicat ion of ge l in the office,
Equipm ents) can be ap pli ed aro und th e contour teeth should be cleaned wit h air/water syringe,
of th e t ooth to be bl eac hed, and across the free and th e gingival barri er should be removed (Figs.
gin gival t issue, to prevent contact of the adja- 1.327 e 1. 328). Th en, a bleaching ge l w ith 37%
cent teeth and gingival tiss ues w ith the prod- carb amide perox ide (Whiteness Super Endo -
uct (Fi gs. 1.314 and 1.3 15). Th e gin gival barri er FGM) is ap pli ed in th e pulp chamb er (Figs . 1.329
must be li ght-cured fo r 20-30 seco nds and the and 1.330) to bleach internally using t he walking
disco lored t ooth bl eached in office w ith 35% bleach technique.

1.314 and 1.315: Use of a gingival barrier (Lase

Protect /DMC).
1.316to1.318: Manipulation of the 35 %

hydrogen peroxide bleaching agent (Lase
Peroxide Sensi, DMC Equipment).
1.319and1.320: Application of the bleaching

agent inside the pulp chamber towards the
buccal surface.
1.321and1.322: Application of the bleachlng

agent on the internal and external surfaces.
1.323 to 1.326: Color change of the bleaching 1l 6

agent 15 minutes after application.
1.327 to 1.328: Removing the material used for

gingival protection.
1.329and1.330: Application of temporary sealer

material (Whiteness Super Endo , FGM).
Carbamide peroxide has re ce ntly been recom- cement (Cavit 3M ESPE) was used as tempo-
mended for intracoron al bleachin g. 78.7 9 Compar- rary restoration (Fig. 1.331). Occlusion shou ld be
in g to other bl eac hing age nts used for internal adjusted to prevent premature contact on that
bleaching, 35% carbamide peroxide gel is less tooth during the bl eaching period since the pu lp
ac idic and also shows low diffu sion of hydro- chamber is not fill ed w ith a permanent ad hesive
gen pero xide toward s the extracoronal environ- restorat ion and, thu s, the tooth is more suscepti-
ment.79 A recent study showed that 35% carba- ble to fracture during internal bleach ing.
mid e pero xide was as effective as 35% hyd rogen
peroxide to bleach artificially discolored teeth Bl each ing progress can be measured wee kly (F ig.
intracoronally, and both agents were sup erior to 1.332) and, if the des ired shade is not obtain ed,
sodium perborate. 79 the pulp chamber must be rinsed copiously and
the bleac hing agent should be replaced.
The bleaching agent should occupy almost the
entire space of the pulp chamber. Only a small A good bleach ing result can usually be observed
space is left for the temporary restoration on after the sixth cycle of internal bleaching (Figs.
the lingual access. In this case, an eugenol-free 1.333 to 1.335).
1.331: Temporary Lingual restoration

(Gavit , 3M ESPE) .
1.332: Immediately after the first in -

ofhce bleaching session.
The second in-office bleaching sess ion can be ob- Perfect FGM) Th e material is used at night for a
served in Figures 1.336 to 1.340. period of 8 hours.
After bleaching, the pulp chamber must be Preferab ly, rep lac ing ex isting re storat ions shou ld
cleaned and fil led w ith calcium hydroxide paste be done 14 days after the end of the bleaching.
and water fo r 7 days. Thi s procedu re aim s to neu- This also im proves the shade matc h in re lat ion
tralize and alkal inize the pH around the cervical to the bleached teeth (F igs. 1.341 to 1.343). The
area of the tooth, providing a suitable environ- lingual access must also be restored using the
ment to repa ir any possib le damage to the peri- same material.
odontal ligament, 80·81 and to increase ·adhes ion of
the composite to enamel. 82·83 After one year, the esthetic result was reevalu-
ated (F ig. 1 344), a rad iograph of t he tooth was
If necessary, at-home bleaching with trays can obtained (Fig. 1.345), and a slight recurrence of
be used to bleach the other teeth at the same discolorat ion was observed, but the fina l resu lt
time using 16% carbamide peroxide (Wh iteness remained sat isfactory.
1.333to1.335: Case after six changes of temporary sealer material.

88 Shortcuts in Est hetic Dentistry a new look on TIPS
1.336 to 1.340: Second in -office

session.
1.341to1.343: Replacement of
Class llJ restoration .
1.344to1.345: One year follow- up.

The immediate resu lts of non-vital teeth bleach- Another example ill ustrating the internal bleach-
ing has been considered excellent. On average, ing techn ique can be seen in Figures 1.346 to
immediate success rat e of 89.5% was reported 1.371. Disco lorat ion of the tooth caused by trau-
for non-vital teeth bleach ing techniques 84 . One of ma of the maxi llary right central in cisor. After the
the limitations of non-vital bleaching is the pos- diagnosis of pu lp necrosis, the toot h was treated
sibility of recu rrence of the discolorat ion, w hi ch endodont ically us in g a very co nse rvat ive access
means that the initial result may not be cons id- and the functi on was restored. Howeve r, t he
ered permanent. Many aut hors have evaluated esthetic appearance of the tooth was not sat-
Temporary sealing of
the incidence of color regress ion after 1 to 6 years isfactory to the patient. Two treatment opt ions
the cavity accom-
of follow-up, 2584 - 87 and different percentages of plished with flowable were presented to the patient: internal bleach-
composite over a
discoloration after internal bleac hing have been cotton pellet soaked ing, or restoration assoc iated w ith removal of
reported. Whi le Holmstrup et al. 84 and Brow n64 re- in pure adhesive sound t ooth stru cture. Internal bleaching was
("bond"). It takes
ported success rates of 80% and 75% after one less space and there chosen as the treatment plan since it is more
and five years, respective ly, Feiglin 86 reported a is no need to con- conservative and there is no need to remove
dense the material
success rate of only 45% after six years. It seems into the pulp cham- tooth structure. It was also explained to patient
that t he harder it is to obtain satisfactory res ults, ber as is done when that exte rn al root resorpt ion could occur as a re -
using other products
the greater the chances of suffering re currence 85. such as Cavit (3M sult of trauma or intern al bleaching and, si nce
ESPE) or Coltosol
The nature and origin of the pigment s involved it was a recent trauma, in case of resorpt ion, it
{COLTENE).
in recu rrence of discoloration are not yet fu lly would be diffi cult to identify if t he condition
known. It is possible t hat they are a res ult of the was originated from trauma or bleaching. Before
progressive transformation of the same organ ic proceeding with the bleaching treatment, the
material from the origi nal discoloration67. When pat ient was required to sign a consent for m, au-
recu rre nce of di sco lorati on occu rs, th e bleach in g thorizin g th e treatm ent and acknowledgin g th e
treatment can be repeated 25 . possible co mpli cations.

1.346 to 1.349: Initial case of

discoloration of tooth 11 after a
trauma .
1.350: Remov ing the restorati on

placed after endodontic
treatment.
1.351to1.358: Creating
the cervical plug: 1.351)
Measurement of the clinical
crown; 1.352) Intracoro nal
measurement after re mova l
of 2 mm of gutta percha;
1.353) Sealing of 4 mm from
the cervical area; 1. 354)
Measmement after sea ling;
1.355) Protection of th e palatal
gingival tissue with gingival
barrier and insertion of the
bleaching product - sodium
perborate; 1.356) Sealing of
the cavity with flowable resin
composite; 1.357 and 1.358)
Leaving the tooth out of
occlusion during protrusion.
1.359 to 1.361: Result after 5 days

of bleaching.
1.362 to 1.364: Result after

20 days without product
replacement.
1.365: Insertion of the calcium

hydroxide paste into the cavity,
for a period of 14 days between
the end of the bleaching
treatment and the permanent
restoration .
1.366 to 1.371: Reevalu ation

40 days after the end of the
treatment.
Is bleaching associated with adverse effects? What are the most important ones
and how can they be prevented?
TOOTH SENSITIVITY
ANSWER
Sensitivity during and after bleaching is a very common adverse

» The main adverse effect related to the
bleaching of vital teeth is the trans- and effect that may occur during the treatment of vital teeth. Typi-
postoperative sensitivity. There are several
cally, the occurrence of sensitivity is very low when bleaching is
ways to minimize them. Details can be found
below. carri ed out using trays, and it is more pronounced with in-office
bleaching, especially whe n light sources w ith em itting heat are

» In regards to non-vital bleaching, the major
adverse effect that may occur is the external used. The intensity of t he pain varies among patients and depends
cervical resorption, and ways to prevent it will
heavily on some factors such as the sensitivity t hres hold, t he size
also be subsequently described.
of the pu lp chamber, the presence of fracture lines or defective
restorations that can favor the penetration of peroxide into the
tooth. 8889 The sensitivity typically lasts around 2 days post at-
home bleaching, and 2 to 4 hours after in-office application.
The etiology of sensitivity post bleaching is not yet fully understood
but may be due to parts of hydrogen peroxide that trave l through
enamel and dentin. 88·89 This permeation of bleaching agents
through the hard tooth structure can result in pulp reactions, such
as a reversible pulpitis. 90 Although some laboratory and 2% sod ium fiuoride (Desensibilize l<F 2%, MGF),
studies have identified the presence of hydrogen prior to the application of 35% hydrogen peroxide
peroxide w it hin the pulp chamber, 91 measuring the bleaching gel, reduces post-bleaching sensitivity af-
concentration of peroxide in vivo is very difficult ter in-office bleaching treatment, when compared
and has not yet been done. Some in vivo studies to placebo.
suggests that there is no structural damage in the
pulp tissues of teeth bleached with 35% hydrogen When the treatment is conducted using trays, a
peroxide for 30 days. 25 gel with mild concentration (16% carbam ide per-
ox ide or 7.5% hydrogen peroxide) may be used
To treat or prevent the occurrence ·of sensitivity for the initial bleach ing. If sensit ivity occurs, the
associated w ith in-office bleaching, it is important ge l may be switched for one with lower concen-
to ident ify t he presence of many areas of gingi- trat ion. For example, 10% carbamide peroxide or
val recession, fracture lines in the enamel, areas of 3.5% hydrogen peroxide. Note that using a gel
tooth wear and/or defective restorations, which with lower concentration of bleaching agent w il l
should be protected with gingival barrier, as previ- also obtain the same result as the ones with higher
ously ment ioned. Since the sensitivity is transient, concentrations. However, longer treatment t imes
an anti-infiammatory such as Feldene (piroxicam) or periods are required. If the patient is already us-
20 mg SL can be admin istered 30-45 minutes pri- ing a gel w ith low concentration, and sensitivity is
or to the consultation for in-office application of still present, treatment days can be alternated, i. e.,
hydrogen peroxide gel. The medicine w ill help to the product is used every other day (or night). This
control the sensitivity, especially during the two protocol also increases the length of the treat-
hours post bleaching treatment, which is usually ment, but does not alter the effectiveness. If sen-
when the peak of the sensitivity occurs. sitivity persists, the pat ient may use toothpastes
containing potassium nitrate to decrease sensitiv-
In a recent study, Tay et al. 92 reported that the use of ity. However, their efficacy can be observed only
a desensitizer agent based on 5% potassium nitrate after two weeks of use. 93 Another, and faster, way
to decrease the sensitivity is to use a desensitizer bleaching, it is suggested that bleach ing agents
based on potassium nitrate or amorphous calcium reach periodontal t issues th rough t he dentinal tu-
phosphate (ACP) on t he bleaching tray. bules, from the pulp chamber out t ri ggering an
infl amm atory response at the extern al cervical
area. 95 Another theory suggest s t hat there is dif-
EXTERNAL CERVICAL RESORPTION f usion of peroxide through the dentinal tubu les,
denaturizin g the dent in. Th e immunologically al-
External root resorption is an inflammat ory re- tered ti ssue would not be recognized by th e body,
sponse that is usually asymptomatic diagnosed w hich would treat it as a fore ign body% These
with the help of periodic radiographs, and gener- Keep in mind that hypotheses hi gh li ght th e importance of th e cer-
the possibility of
ally located near the cementum-enamel junction external cervical vical plug described above in sealing t he cervi-
(Figs. 1.372 to 1.375). Various alterations of this resorption exists cal dentinal tubules, and preventin g peroxide to
ong; in situations
environment can induce th e onset of the resorp- of intra-coro- reach this extern al area of the root. Cases of ex-
nal bleaching of
tion process. Heithersay94 observed 257 teeth with ternal root resorption after endogenous bleaching
non-vital teeth. If the
external cervical resorption, and reported that the bleaching is applied are t ypi cally related to high concentrations of hy-
process was caused by orth odont ic t reatm ent in

ong; externally, the drogen peroxide in co mbinat ion w ith: heat gen-
risk will be eliminat-
24.1% of the cases, dental trauma in 15.1 %, su r- ed, but the bleaching erated by a heated spatula or other heat sources,
will end up being
gery in 5.1%, and internal bleaching in only 3.9%. t eeth w here no cervical plug has been placed, in-
insufficient.
ternal bleac hing of teeth that have been traum a-
Th e combination of internal bleaching w ith one of t ized, bleaching right after endodontic treatment
the other causes accounted for 13.6% of the cases presence of structural defects on the cervical re-
(Figs. 1.376 to 1.382). gion - or cementum -enamel junction - that can
facilitate th e diffus ion of hydrogen pero xid e. 73
Despite many theories t o exp lai n the origin of ex- Hyd rogen perox ide at 30%, pure or co mbined
ternal cervical resorption, the tru e etiology of this with sodium perborate, is more to xic to ce ll s of
process is st ill unknown. When related to internal the peri odontal li gament than sodi um perborate
mixed with water. 97 Thus, the latter appears to of the periodontal tissues should be ver ifi ed
be a safer alternative for intracoronal bleaching, using periapical radiographs. Products such as
as wel l as the use of 35% carbamide peroxide. 98 calcium hydroxide powder can be used after
the internal bleach in g to in crease the pH of the
Appropr iate ways to prevent the occurrence of area and minimize the possible act ion of elastic
external cervical resorption are: always place a cells that are part of mineralized tissues. An-
cervical plug of approximately 4 mm in thick- other factor that should be cons id ered is the
ness and preferably with a less soluble material; detailed clinical history of the patient. If the
preference to sodium perborate with water or tooth to be bleached has been exposed to oth-
35% carbamide peroxide sho uld be given; heat er predisposing factors such as trauma, ortho-
should not be applied during any of the bleach- dontic treatment or previous internal bleaching
ing steps; presence of structural defects in the attempts w ith the use of heat another form of
cervical regions should be identified; integrity treatment should be preferred.

1.372to1.375: Tooth with ex ternal

cervical resorption.
1.376: Initial case. Est hetic

improveme nt of anteri or teeth.
Patient reported bleeding after use
of dental fl oss, assoc iated with the
right cent ral incisor. 111e tooth was
internally bleached ten years ago.
1.377: Radiograph showing advanced

external cervical resorption.
1.378: Central incisor right after

extraction. Note that the resorption
initiated cervically before spreading
it to other regions.
,-
1.379: Post- extraction site

preservation done for immediate
implant placement.
1.380: Implant placement (Nobel

Replace, Nobel Biocare).
1.381: Abutment made with the

Procera system (Nobel Biocare).
1.382: Final result with porcelain

veneers placed on teeth 21and12,
and porcelain crowns on 11 and 22
(DLT. Murilo Calgaro/ Studio dental;
Curitiba /PR).
Shortcuts in tooth bleaching: a simpler way
For quite some time, tooth bleaching has been one Protocol for in-office bleaching with 37% carba-
of the most requested treatments at the office, ei- mide peroxide: in bleaching trays in case of re-
ther as a preparatory step before restorative treat- treatment, under supervision of a dentist, for a
ment, or w ith the sole purpose of tooth whiten ing. 45-minute period in one cl inical session with oral
As a result, different techniques and commercial retractors and gingival barriers for the same pe-
brands are introduced to the dental community ev- riod, when the patient does not have trays (Figs.
ery day, which ends up comp licating and confusing 1.383 to 1.386).
professionals and patients about the best way to
perform the procedure. A simplification aims to an- For in-office bleaching with 35% hydrogen perox-
swer some questions, based on scientific evidence, ide, products with calcium in the composition are
regarding which one is the simplest and most ef- preferable; apply a desensitizer based on 5% po-
fective way to perform the procedure, t hinking of tass ium nitrate and 2% sodium fluoride for 10 min-
high effectiveness and low sensitivity. utes before applying the bleaching gel; apply one
time for 45 minutes if this wou ld be recommenda-
Therefore, an updated summary of the bleaching tion of the manufacturer; do not use a li ght source;
protocols w ith carbamide peroxide and hydrogen carry out 2 to 3 clinical sessions with an interval of
peroxide is now presented: two days in between (Figs. 1.387 to 1.400).

When bleaching with trays, the protocol to obtain
high effectiveness with low sensitivity is: bleach
using 10% carbamide peroxide or 7.5% hydrogen
peroxide for at least 1 hour, during the day or night,
over a period of 2 to 4 weeks (Figs. 1.401 to 1.407).
In case of unsupervised bleaching, products clas-
sifi ed as over-the-counter, spec ifi ca lly whitening
strips, can be eas ily found more in pharmacies
and may produce esthetic results and adverse
effects similar to those of the traditional bleach-
ing (F igs. 1.408 and 1.409). 99 However, patients

1.383: Patient presenting indication for bleaching retreatment.
may sti ll prefer to use trays, and irritation of the

1.384: Bleaching with carbarnide peroxide at 37% (Powerbleaching, BM4) , using cheek and lip retractors
gingival tissue may be clinically observed (Figs. and gingival barrier.
1.410 tO 1.413)WO-l0 2 1.385: Immediate res ult
1.386: Final result after two weeks.

1.387: Initial case. Smile before bleaching

treatment.
l.388to1.390: Intra- oral photographs

before in - office bleaching.
l.391: Application of desensitizer agent

based on 5% potassium nitrate and 2%
sodium fluoride (Dessensibilize 2%, FGM),
for 10 minutes, before application of the
bleaching gel.
1.392: Application of the bleac('.ling gel

under extensive protection of the soft
tissues. Note the use of cheek and lip
retractor, cotton rolls , and gingival
barriers.
1.393: Bleaching gel w ith 35% hydrogen

peroxide {Whiteness HP Blue 35% - FGM)
and calcium, applied on teeth for over 45
minutes.
1.394: Result after the first bleaching

session.
1.395: Result after the second bleaching

session.
1.395: Result after the third bleaching

session .
1.396 to 1.399: Final result two weeks after

the bleaching treatment was completed .
l.400: Final result.

1.401to1.403: Initial case

presenting indication for
bleaching treatment.
1.404: Bleaching done using

trays and 10% carbamide
peroxide.
1.405 to 1.407: Final result

fo ur weeks after the bleaching
treatmen t was completed.
1.408 and 1.409: Initial case

and final result. Bleaching
treatment done with
whitening strips (Whitestrips
- Oral B).
1.410: Initial case.
1.411: Bleaching treatment done with whitening strips {Whitestrips - Oral B).
1.412 and l.413: Final result with excellent whitening effect. However, gingival irritation is observed due to the contact of the hydrogen
peroxide with the soft tissue, mainly gingival papillae.
chapter 1: Dental bleaching: concepts and bleaching substances 103
What are the pathways of the science in dental bleaching?
Bleaching with low concentration of peroxide on effectiveness, there is already enough literature
trays for a few weeks has always been a safe and on bleaching to understand that the results ob-
efficient procedure, without causin'g much sen- tained with trays or in-office can be very sim-
sitivity. However, the need to speed up the pro- ilar immediately after the treatment and after
cess and save time led to the introduction of high 2 years of follow-up w 3 When choosing the best
,-
concentration products to the market with claims option (home or in-office), one should take into
of immediate bleaching and white teeth in one account what was described above in the an-
consultation. This created a huge demand from swer to question number 6.
patients, but served also to cause more intense
and persistent sensitivity as side effect because of In the office, vital teeth can be bleached with car-
t he excessive number of applications of high con- bamide peroxide or hydrogen peroxide, the lat-
centrations products, 103·104 combined with the use ter being the most used. Carbamide peroxide is a
of light sources such as lasers, LED, and halogen great option for retreatment cases after recurrence
lamps, among others w 5·106 of discoloration over the years. The concentration
of carbamide peroxide for in-office bleaching can
What we observe nowadays is that patients do range from 30 to 37%, the latter being the most
not desire immediate bleaching anymore. Not used. For hydrogen peroxide, the available concen-
even with laser. They prefer an effective and trations are between 15 and 38%, the concentra-
painless bleaching. Thus, thinking about the tion of 35% being more often used.
104 Shortcuts in Esthetic Denti stry a new look on TIPS
The techn ique for the use of peroxide carbamide app li cation, and contain desen sit izin g age nts in
suggests using th e product from 15 to 45 minutes its composition .
on a tray, under the supervision of a dent ist, 100.107·108
or w ith the aid of cheek and lip retractors and gin- Hydrogen peroxide is alkaline, but it decomposes
gival barriers. Although this technique is not new, very easi ly. To maintain the stability of the ge l,
there are few clinical trials with new products. manufacturers turn t he mi xtures more acid ic. 109·11 0
However, due to the low final concentrat ion (car- However, the effectiveness of alkaline gels is far
bamide peroxide between 30 and 37% wou ld be superior to that of the acidic gels, 111 and th is has
equ ivalent to hydrogen peroxide of 1O to 12%) and led to a pH change of current gels. Th e pH in-
slow re lease 'due to the presence of carbopol or crease (p H 8-9) led to a very interesting change
sim ilar thickeners, the degree of sensit ivity shou ld from a pract ical point of view: the gels can now
be low and, therefore, they have also been recom- be applied in one time of 40-50 min. This can be
mended for application on trays without the need understood in t he light of the last gene'rat ion of
for gingival protection.100·107·108 ge ls, that maintain a stable pH fo r a longer period .
Even if a small drop occurs, the pH wou ld st ill not
When using hydrogen peroxide gels, they should be ac idi c and, therefore, they lead to fewer prob-
only be used w ith cheek and lip retract ors and gin- lems w ith the tooth structure surface. 112·113
gival barriers. In particular w hen ge ls containing
high concentrations are used (final concentration Generally, products in which the pH is stable are ap-
of 20-38% hydrogen peroxide, two to three times plied once for 45 minutes, in contrast to the older
more w hen compared the carbam ide peroxide gels gels that would be appl ied for three times of 15 min-
mentioned before). utes in a single consultation. In fact the latter could
be applied in one t ime of 45 minutes, because they
However, clini cians shoul d se lect the latest gen- maintain their effectiveness; however, t hey gener-
eration of hydrogen peroxide ge ls, which are ate more sensitivity, 114 possibly because it lacks the
hi gh ly alkaline, prese nt stable pH during the characteristic of maintaining the pHm ·113 Thus, for
chapter 1: Dental bleaching: concepts and bleaching substances 105
convenience, the technique of a single gel applica- be decreased to only 2 days due to the low per-
tion can be used, as indicated by the manufacturer. centage and low sensitivity degrees of intensity
when compared to the traditional indication of 7
When these alkaline gels interact with the tooth days between each clinical session. A recent clinical
structure, different radicals are formed when com- study showed no differences in the risk and inten-
paring to the more acidic gels, and this should have sity of the dental sensitivity when these two time
an impact in reducing tooth sensitivity when these periods were compared to bleaching with 35% hy-
new materials are clinically evaluated. However, in drogen peroxide. 119
general, these gels contain in its compositions de-
sensitizing agents, such as calcium, and derivatives In order to perform a more active desensitization,
of calcium, potassium nitrate, and sodium fluoride. particularly for patients at risk or with a history of
hypersensitivity, the use of therapeutic activator
The use of alkaline bleaching products with calci- sources, oral, and topical medication have been
um in their composition, for example, can reduce evaluated. According to a recent meta-analysis
the penetration of hydrogen peroxide into the of the literature, the application of desensitizing
pulp chamber, 115 and can reduce tooth sensitivity based on 5% potassium nitrate and 2% sodium flu-
during bleaching without altering the effective- oride, for 10 minutes before the application of the
ness,116 maintaining the sensitivity degree as low bleaching gel, is the most evaluated and effective
as those for 20% hydrogen peroxide gel. 117 In an- in reducing the sensitivity120 in patients with sound
other randomized trial, the use of an alkaline gel teeth, 92 and especially in patients who have resto-
containing potassium nitrate and fluoride gener- rations on anterior teeth, 121which are more likely to
ated lower degrees of sensitivity when compared feel sensitivity during in-office bleaching.122
to another acidic ge1ns
For patients with a history of hypersensitivity,
When products such as those mentioned above preventive drug prescription (ibuprofen 400-600
are applied, the interval between the sessions can mg) 1 hour before the treatment can decrease
106 Shortcuts in Esthetic Dent istry: a new look on TIPS
the intensity of pain in the first hour after The use of these act ivators sources (LED/ Laser)
bl eac hing. 123 124 only as a therapeutic so urce for the prevention
of sens itivity was not con firm ed by a recent clin-
As already mentioned, a way of trying to reduce ical study. 127
post-operative sensitivity is to decrease the con-
centration of hydrogen peroxide in the gel; how- Th e number of consultati ons required should be
ever, to avo id loss of efficacy of the bleaching informed to t he patient before starting the treat-
gel, products with semiconducting nanoparticles ment with the 37% carbamide peroxide be ing of-
as photocatalysts for devices with a visible light ten used on ly once for re-treatments. For bleach-
source have been introduced to the market. In a ing w ith 35% hydrogen peroxide, a cl inical study
randomized cl ini cal trial, 125 it was observed that t he demonstrated that 2 to 3 sess ions provide satis-
use of 15% hydrogen peroxide containing titani- factory results fo r 88% and 90% of the average
,-
um oxide nanoparticles (Lase Peroxide Lite, DMC pat ient respectively.46
Sao Carlos, Brazi l) photocatalyzed by a LED/Laser
li ght source (Whitening Lase II, DMC) resulted in Bleaching using trays can be done at home by
lower sensitivity and higher efficiency compared the patient w ith products based on 10-22% car-
to the conventional technique of 35% hydrogen bam ide peroxide, or 3.5-10% hydrogen peroxide.
peroxide without activation. Accord ing to Sakai As stated earlier, high concentrations may result
et al. (2007), 126 incorporating these nanoparticles in faster bleaching but t heir efficacy is the same.
in hydrogen peroxide enables a reduction in the Moreover, they present a higher risk for sensitivity.
req uired concentration of t he latter, thereby pre- An exampl e is the clinical study by Basting et al., 118
venting t he postoperative sensitivity and irradia- in wh ich it was shown that using two times the
tion by a suitab le light source that generat es hi gh concentration of carbamide peroxide (20%) did
concentrations of free radicals and other react ive not increase the effectiveness of bleaching, but
oxygen kind s necessary to break the molecular doubled the number of patients with sensitivity
bonds of pigments within t he tooth structure. when compared to 10% carbamide peroxide.
Hence, lower concentrations such as 10% carbam- between 1-2h, and this should be considered the
ide peroxide and 3.5% or 7.5% hydrogen peroxide ideal appli cation t ime.29·129 This same trend can be
are most often used. observed for the hydrogen perox ide, but for even
less time, since the rate of hydrogen peroxide re-
Theoretically, based on the reaction speed of the lease to provide 50% of the act ive concentration
product hydrogen peroxide is recommended for would be between 15 and 20 minutes. 29·130
daytime use and carbamide peroxide for night use.
In general, simil ar tim es have been used for car-
However, there is a tendency towarads daytime use, bam ide peroxide and hydrogen peroxide when
not only because of better control by the patient app li ed during the day, as shown in Alonso de
but mainly because the increase in contact time la Pena's randomized clinical study 131 in which a
w ith peroxides has been associated w ith higher lev- simil ar degree of bleaching was achieved with
,-
els of sensitivity. Thi s could be clearly observed in a 10% and 15% carbamide perox ide and 7.5% and
randomized clinical trial wh ich the efficacy of 10% 9.5% hydrogen peroxide, when used for two
carbamide peroxide was evaluated when used dif- weeks during one hour per day. Moreover, no
ferent times during the day and it was concluded sign ifi cant differences were observed with re-
that the use of the gel for 1 hour presented a tooth gard to dental sensitivityrn
bleaching speed closest to the 8-hour use, but with
less sensitivity, provided that it was used for at least A clear trend is the use of home bleaching mate-
two weeks.128 rials that have desens itizing agents in their com-
position, accord ing to clinical studies, 132·133 and the
So what wou ld be the ideal t ime to apply? The combination of potassium nitrate and fl uoride is
shortest possible time in wh ich we can achieve the most establ ished, as already mentioned. For-
a satisfactory cl inical result. Taking into account tunately, many commercial brands contain these
the release rate of carbamide peroxide, general- desensitizing agents in their composition, w hich
ly we have on ly 50% of the active concentration greatly facil itates the selection by dentists.
CONCLUSION
Tooth bleaching treatment can be wide ly used
if properly indicated, and the technique is judi-
ciously chosen.
This chapter discussed the techniques for bleach-
ing vital and non-vital teeth, address ing al l top-
ics involving these procedures, from indi cations,
techniques, and risks, to the technical details of
procedures and bleaching products.

DENTAL BLEACHING
Superficial extrinsic staining Intrinsic staining

Diagnosis of type of stain
Intrinsic staining
Microabrasion Bleaching of the non-vital tooth
Association of t echniques Associ ation of t echniques
Bleaching of the vital tooth
Carbamide peroxide or sodium perborate
Walking Bleach technique
Association of techniques Association of te chniques
Supervised at-home bleaching method Over-the-Counter Method In-office method --
Hydrogen peroxide Carbamide peroxide Carbamide peroxide 30-37% Hydrogen peroxide 25-38%
Daytime use Night-time use In trays With soft tissue protection
Toothpastes Brushes
With light With light
~
Mouthwashes Whitening strips
Chewing gums
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73. Smith JJ. Cunningham CJ. Montgomery S. Cervical canal leakage after internal bleaching procedures. J Endod. 106. He LB. Shao MY. Tan K Xu X. Li JY. The effects of light on bleaching and tooth sensitivity during in-ofAce vital
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techniques. Oper Dent. 2010; 35(1):3-10.
Composite resins ana adhesive
systems: ttlle material
Alessandro Oourado Loguercio

/l.,;ti - Composite resins
What is the basic composition of composite resins?
Vinicius Di Hipolito · Ronalda Hirata · Bruna Marin Franza · Marcelo Giannini
Compos ite resins (also known as resin compos ites or resin-based

ANSWER composites) are one of the numerous varieties of synthet ic res-
ins appl ied in dentistry, to w hich inert filler particles are added
» Main monomers of the polymeric structure:
to increase its strength and to reduce the adverse' effects of
Bis-GMA (bisphenol-A glycidylmethacrylate),
UDMA (urethane dimethacrylate), Bis-EMA po lymer ization shrinkage. Resins are used as an organ ic matri x
(bisphenol A ethoxylated dimethacrylate) etc. for the insertion of filler particles, which increase the strength
» Diluent monomers: MMA (methylmethacrylate), of the material.

EDMA (ethylene glycol dimethacrylate) or
TEGDMA (triethylene glycol dimethacrylate).
Their first compos ite resins contained polymethyl methacry-
» Filler particles: quartz, coloidal silica, zirconia-
late (PMMA), in which the filler particles cou ld not be incorpo-
silica, ytterbium fluoride, borosilicate,
aluminosilicate, bariumsilicate, strontium and rated properly, causing structural defects and disintegrat ion of
zirconium glass. the material.
» Coupling agent between resin matrix and filler
particles: -metacryloxypropyltrimetoxyl silane.
In 1962, Bowen 1 produced a new type of resin composite, upon
» Activation system/initiator: benzoylperoxide,
developing the bis-GMA monomer (bi sphenol-A glycidyl) and a
camphorquinone/amines.
» Inhibitor: butylated hydroxytoluene. bonding agent an organic si lane, able to incorporate the particles
efficient ly. After th is development composite resins contained

Chapter 2: Composite resins and adhesive systems: the material 115
three main components: organic matrix, inorgan- Alternative monomers to bis-GMA were developed
ic particles and the coupling agent (Drawing 2.1). in order to improve the properties of compos ite
resins. As an example, the substitution of the pen-
The majority of composites that are available dant hydroxyl group (OH) of the bis-GMA molecule
at the moment contain bis-GMA as their organ- Organic matrix by methyl groups (CH 3 bis-GMA), resulted in a more
ic matrix. Alternatively, ot her monomers such as • Inorgan ic matrix hydrophob ic monomer; composites such as Filtek
UDMA or their chemical derivatives can also be Q Silane

Z250 (3M ESPE) contain this monomer. This new
used . UDMA in creases the mechanical strength composition, called bis-EMA, has higher molecular
Drawing 2.1: Basic
composition of a composite
of the resin, but can induce color change; an ex- weight than their predecessors. The absence of
resin.
amp le was the lsosit composite (lvoclar Vivadent). - Organic matrix hydroxyl groups allows slidi ng between the mol-
- Inorganic matrix
To avo id this undesirable effect the add ition of - Silane ecules, w hich gives the material a lower viscos ity
this monomer in the composition of compos ites and therefore require lower amounts of monomer
is currently limited. diluents. Th ese characteristics reduce the polym-
erizat ion shrinkage and water sorption, provid ing
The high molecular weight of the base monomers more stability to the material w hen used in the
provides the composite properties that minimize challenging oral environment 2-s (Fig. 2.1).
the undesirable effects of po lymerization shrink-
age, w hich preserves the bonding interface with
the substrate and reduces the formation of mar-
ginal gaps. Another feature of these monomers is Many indirect resin

the high viscosity, which compromises handling of systems still present
large amounts of
the material. To adjust the level of viscosity, diluent UDMA in the organic
monomers of low molecular weight and low vis- matrix, which makes
Bis EMA
them more mechan- TEGDMA BisGMA
(Bowen-Monomtrl
cosity are added, such as MMA EDMA or TEGDMA. icaUy resistant;
They are called diluents. however, they show 2.1
signiftcant color
change over time. 2.1: Examples of monomers and diluents (Photo: Mauricio Watanabe).
Activators and initiator systems that are present Other compounds of the organic matrix are mol-
together with resin monomers in the organic ecules call ed inhibitors such as butylated hy-
Currently a bis-GMA
matrix are responsible for triggering the polym- alternative is being droxytoluene . In small amounts (about 0.01% by
sought that is more
erization of the composite. The molecules that we ight), they prevent spontaneous polymerization
hydrophobic, forming
make up these systems are specific and vary ac- stable and longer of the composite when it is briefly exposed to
polymer chains,
cording to the type of polymerizat ion reaction, mainly by decreasing light which prolongs their durability. Composites
which can be activated chemical ly or by visible the sorption property that are sculptable use these inhibitors to provide
of the material, re -
li ght (Chart 2.1; Fig. 2.2). sulting in increased more clinical working time, avoiding premature
longevity of the light polymerization from the operatory light.
restoration.
Chart 2.1: Basic composition of composite resins. Modified from De
Goes, M.F.
Various types of fi ll er particles are incorporated
Composite resin in composites to improve their propert ies. The

(basic compos1t1on)
most widely used particles are co ll oidal silica,
. :·
zirconia-silica partic les or glasses and ceram-
ics that contain heavy metals such as barium,
stro ntium and zirconium. In accordance with th e

- Diluent monomers: UDMA. DEGMA, TUDMA and TEGMA;
- Initiator: benzoylperoxide. cam phorquinone; category of the composite resin, particles show
- Activator: tertiary amine, visible light;
characteristic dimensions and distribution, be in g
- Inhibitor: hydroquinone;
- Radiopacifier: barium and strontium. fundamenta l in determ inin g its properties (as
described in item 3). Generally, the presence of
inorganic content in the composites reduces the
polymerization shrinkage and thermal expans ion
coefficient, increases the hardness and improves
the mechanical properties . Clinically, handling

2.2: Camphorquinone
initiator, which has an also benefit from their addit ion (Fig. 2.3).
intense yellow color (Photo:
Mauricio Watanabe).
Maintaining the cohesiveness of compos ite res-
ins mainly depends on the effective coupling of
the organ ic matrix to the inorganic portion. This
junction is done by treating the surface of inor-
ganic particles with a coup ling agent commonly
silane ( -methacryloxy propyl silane). Silane is a bi-

2.3: Examples of filler particles {Photo: Mauricio Watanabe) .
funct ional molecule capable of forming a covalent
bond w ith the si li con present in the particles at
one of its ends while the other end remain s avail-
able for copo lymerization with the organic matrix.
Deficiency in this interaction implies a non-uni-
form distribution of the forces app li ed to the ma-

--
terial during chewing activity. This flaw allows for 2.4: Continuous loss of the flJJ er
particles from the organic matrix
water penetration into the filler-resin interface m ass.
and monomeric leach ing, compromising the clini-
cal perform ance of the restoration (Fig. 2.4).

Why do composite resins have good clinical performance?
For decades, restorative dentistry was founded on the con-
cepts advocated by G. V. Black, where the strength (or lack
th ereof) of the re storat ive materi al was valu ed at the expe nse
of healt hy tooth stru cture. Cavity preparation s were extend ed
beyond car ies (e xten sion for preve nt ion) and had to provid e
retentive geometric configu rat ions, sin ce the materials used at
th e tim e, espec ially metals, had no potent ial to ad here to the
tooth (Figs. 2.5 and 2.6).
2.5 and 2.6: Conventional cavity prepared for a Class I amalgam restoration. Minimum
thickness of 2.5 mm and a width of at least 2.0 mm were necessary for the strength and
retention of the restorations. Note fracture of the distobuccal cusp after removal of the
amalgam material in Figure 2.6.
Restorative procedures involving metal all oys
often expose the remaining tooth structure to
a condit ion of increased suscept ibility to frac-
ture. When a healthy, virgin tooth is subjected to
masticatory forces, the cusp s are inflected as a
mechanism helpin g in the dissipation of the gen-
erated stresses. In case of loss of tooth structure

2. 7 to 2. 9: Partial crack present in the base of the distolingual cusp.
and restoration with metal all oy materials, the
rema inin g structure is unprotected and tends to
suffer higher degree of bending in ·their cusps.
In this cond iti on, repetitive occlusal stresses are
ab le to generate and propagate cracks in regions
close to the base of the cusp s, mainly in pre-
molars and molars restored with si lver amalgam,
leading to tooth fracture fatigue. 6·7 In other cas-
es where dentin is more compromised, fracture s
may occur in the pulpal floor, leading to loss of

2.IO and 2.11: Note the presence of the partial crack after caries removal. In this case, reinforcement
the tooth (Figs. 2. 7 to 2.12). of the dental structure is necessary to prevent crack propagation, which could lead to cusp fracture;
adhesive procedures and resin composite were used, without employing any liner or base.
2.12: Restored case (Vitalescence /Ultradent).

Modern restorative dentistry is focused on con- what occurs naturally at the dentinoenamel junc-
cepts involving the preservation of tooth structure tion (Fig. 2.16). Hence, it is poss ible to return to the
and the choice of materials and restorative tech- restored tooth biomechanical performance simi lar
niques capable of producing similar behavior to to the intact tooth during mastication.
that of natural teeth. Composites have mechanical Modulus of elasticit.Y

refers to the rigidit.Y
properties close to those of dentin, among which Another feature of this material is the color diver-
of the material: the
we can highlight the modulus of elasticity (stiffness) higher the modu- sity that allows to reproduce the dental polychro-
lus, the greater its
and resilien ce. These properties enable this mate- matism, giving excellent esthetic characteristics to
rigidit,Y; the lower
rial to respond to deformation absorbing mastica- the modulus, the less the restorations. These are the main features that
rigid the material is.
tory forces in a simi lar manner as the lost dentin 8·9 explain the clinical success of the adhesive restor-
(Fig. 2.13 to 2.15). Moreover, it is able to effectively ative treatment model with composite resins, ca-
adhere to the dental tissues, by means of adhesive pable of combining biological and esthetic aspects
systems and hybrid layer formation, comparable to (Figs. 2.17 and 2.18).
2.13 to 2.15: Extensive palatal destruction due to caries and endodontic treatment . Reco nstruction with Filtek Supreme Ultra system (3M).
2.16: Scanning electron microscopy image (s.ooox) showing the dentinoenamel

junction , dentin at th e top of the image (D) and enamel (E) at the bottom of the image.
In dentin, it is possibl e to see the ope nings of the tubules and coll agen fibrils in the
tubule walls. In ename l, the structures of the prism cores and the extraprismatic area
can be seen (Carlos J. Soares & Marcelo Giannini).
2.17: Init ial case showing the need to replace and esthetically modify the restorations
because of poor harmony.
2.18: After restoration replacement and anterior cosmetic recontouring (4 Seasons

restorative system/ Ivoclar Vivadent).
122 Shortcuts in Esthet ic Dentistry: a new look on TIPS
How can the composite resins be classified?
An intensive transformation in the characteristics of the inorganic

ANSWER
portion of composite resins has been occurring in recent years,
» Macrofilled. due to techno logical improvements in the production of the filler
» Microfilled. particles, w ith new grinding methods and chemical process of the
» Traditional hybrids (small particles). sol-gel precipitation . This has allowed developing new types of
» Micro-hybrids (modern hybrids). composite resins with specific properties, w ith improved clini cal
» Nanofilled. performance and durability.
» Low-shrinkage composites.
To group the various composite resins, a class ification system
based on average filler particles size and their size distribution as
the parameters has been created.
The division into classes also shows the evo lution of composite
resins over the years, incl uding composites that were used in t he
past and are no longer commercially available today.

3.1 MACROFILLED COMPOSITE RESINS
In chronological order, the first composite resins,
called traditional, conventional or macrofilled,
emerged in the 1970s. These composites had
amorphous silica fillers or quartz with a size gener-
ally being between 8 and 12 µm, but could contain
particles of up to 50 µm occupying 60 to 70% of
t heir volume (Fig. 2.19).
The incorporation of inorganic particles in the resin
composition marked the beginning of a new gen-
eration of composites, which has been updated

2.19: Photomicrograph of the macroftlled composite Concise (3M ESPE) (Di Hipolito, V.; De Goes, M.F.).
over the years, along with other technological ad-
2.20: Clinical picture of an old Adaptic (Johnson & Johnson) restoration .
vancements.
2.21and2.22: Photomicrograph I SEM (scanning electron microscopy) of an epoxy resin replica of the
same restoration (Di Hipolito , V.; De Goes , M.F.). Note the loss of structure of the composite due to the
Although macrofilled composites had better re- detachment of filler particles.
sults than acrylic resins, in some aspects they were
also ineffective in clinical performance. The rigidity
of their particles did not allow a good surface fin-
ish. Clinical follow-up showed wear of the organic
matrix that, along with the tooth brush attrition,
exposed the filler particles, making the surface
even more rough (Figs. 2.20 to 2.22). This condition
makes the surface highly prone to staining that in- Man.JJ of the resins of this class left the
market or are often used now to adhere
duce color changes in the restoration. orthodontic brackets.
Another di sadvantage of macrofill ed composites chemi ca l properties, bein g equal or superior to
is their radiolucency. Both quartz and sili ca do trad iti onal compos ites .
not provide radiopacity similar to or greater than
that of ename l to the composite. Hence, radio- Thi s new category of restorat ive composite was
graphs are of littl e use w hen marginal gaps are called small-particle composite. Amorphous sili-
suspected and in the diagnos is of recu rrent or ca can be prese nt along w ith glasses contain in g
secondary cari es. heavy metal s (barium, strontium and zirconium),
w hich predominate in the in organic phase of the
Some co mposite res ins pertaining to this group material (Fig. 2.23).
0
we re Adaptic (Johnson &. Johnson) and Concise (3M
ESPE). Although they were superior t o the res ults The metal gives the composite the desirable radi-
already achieved, th e search for solutions for the opacity in the radiograph ic examination. Some rep-
improvement of composites was intensif ied. resentatives of this category contain only synthetic
zirconium-silica fill er part icles, fo r example, Filtek
Thi s compos ite group was only che mical ly activat- ZlOO (3M ESPE) , Filtek Z250 (3M ESPE) and P60
ed. Among th e restorat ive composite resins, th ese (3M ESPE) 10 (Fi g. 2.24).
are t he on ly ones w ith thi s characteristic, w hose
technological value was surpassed by more mod-
ern systems.
3.2 HYBRID COMPOSITES (TRADITIONAL
COMPOSITES WITH SMALL PARTICLES)
To improve the surface sm oothn ess of the res-
toration, the filler part icles were reduce d in 2.23: SEM photomicrograph of the composite ZlOO (3M ESPE) (Di Hipolito , V.; De Goes, M.F.).
size w ithout co m pro mi sin g the physical and 2.24: SEM photomicrograph of the compos ite Filtek Z250 (3M ESPE) (Di Hipolito , V.; De Goes, M. F. ).
As we shall see later on, composites containing
particles of two or more sizes are class ified as hy-
brid. From th is point of view, many small-particle
composites could also be called hybrid composites.
The organic matrix of small-particle compos ites is
similar to traditional resins. However, the inorgan-
ic particles undergo a milling process until they
reach sizes of approx im ate ly 0.5 to 3 µm. With
the reduction of particle size, it was possib le to
distribute them in order to obtain better packing
and to increase the inorganic content (65 to 77%
by volum e). This new arrangement increased the
strength of the material, making it better able to
withstand the mastication stresses and related
wear, such as, for example, in Class IV and posteri-
or restorations. Another advantage of the small er 2.25 to 2.30: Example of an occlusal restoration in which the hybrid composite resin Tetric
Ceram (lvoclar Vivadent) was used.
particle size is the possibil ity to obtain a better
surface gloss (Fig. 2.25 to 2.30).

2.31
With the increased filler load and the reduced
amount of organic matri x, it was possible to obtain
reduced polymerization shrinkage wh ich generates
stresses in the tooth-restoration interface, where
cracks and other technical imperfections may occur.
Desp ite the advantages presented, clini ca l as-
sessments show that small-particle compos ites
(hybrid) do not maintain the surface gloss over
time due to th e still relatively lar'ge parti cle size,
as we ll as their distribution and irregular shape
(Fig. 2.31 to 2.36).
Some examples of this t ype of small-particle hybrid
composites are on the site:
www.shortcuts-book.com .
2.31: SEM photomicrograph of the composite resin TPH Spectrum

(Dentsply CauU<) (Di Hipolito, V; De Goes, M. F.).
2.32: Ve neering with smaU- particle hybrid composites.
2.33 and 2.34: Clinical case two yea rs later. Note the loss in surface
gloss.
2.35: Clinical case seven years later. The surface now remains stable
due to frequent repolishing.
2.36: Clinical case twelve years later.

3.3 M ICROFILLED COMPOSITES fill er part icles. Thi s invo lves t he add it ion of 60
to 70% by weight of co ll oidal sil ica treated w it h
With the cont inu ed development of improved the si lane monomer t o form a paste t hat is po-
composites, new compos ites were deve loped so lyme ri zed. At t he end of this process, t he res in
as to address defi ciencies t hat were still present. is grin ded, generat ing partic les w it h dimensions
To improve surface po li shabili ty and increase Besides the small close to th ose in traditi onal res ins (5-5 0 µm.) In
particle size, the high
trans lucency of tradit ional and small - parti cle a second ste p, th e prepo lymeri zed part icles are
degree of polishabil-
compos ites, research and deve lopment sought ity, which tends to added to t hese parti cles of col loidal si lica treat ed
increase with the
to further red uce t he size of t he fil ler parti cles, w ith silane and m ixed w ith the monomer. Final-
abrasive action of
creat in g microfilled composite resi ns. the tooth-paste and ly, the compos ite w ill have a filler load of about
frictional movements
of the toothbrush 50% by we ight.
Co lloidal sili ca parti cles were re duced to dim en- (Figs. 2.37 to 2.40),
is also related to the ,-
sions of t he ord er of 0.04 µm (40 nm). With th ese presence of large

dimens ions, t he co lloidal si li ca generates electro- amounts organic
matrix, which is
static fo rces, groupi ng them toget her (Fig. 2.37). highly polishable.
2.37
Dependi ng on t he co mposit ion of t he agglomer- Try to seal the sur-
f ace of a temporary
ates, structures are fo rm ed from 0.04 t o 0.4 µm . restoration with a
pure adhesive (pure
Wit h th e re du cti on in fill er size, t he su rface area
organic matrix) and
increases consid erably. As a consequence, a great - polish this polym-
erized layer, and
er amou nt of monomer, w hic h is not desi rable, is
you will notice that
necessary to wet t he inorgan ic portion. it will be highly
polished.
Two ste ps were use d t o increase th e in organi c
phase and co unteract th e undes irabl e in crease in

2.37: SEM photomicrograph of the composite Durahll VS (Heraeus
t he organi c mat eri al. Th e first st ep was the prepa- Kulzer) (Di Hip6lito , V.; De Goes, M.F. ). The white arrow points to a
colloidal silica particle. Note the presence of large pre- polymerized
rat ion of a compos ite res in w ith prepo lymerized particles, but the size of the silica particles has been reduced.
128 Shortcuts in Esthetic Dentistry a new look on TI PS
The micrometer features of the fillers provide
extreme ly smoot h surfaces to the composite
that remain over t im en Thi s particular quali-
ty of microfilled co mposites made it a material
of choice in the est hetic treatment of anterior
teeth (Figs. 2.38 to 2.51).
As a result of the large quantity of organic ma-
trix (40 to 80% by vo lum e ), the microfilled res-
in composites absorb more water, have a higher
coefficient of thermal expans ion and lower mod-
ulus (st iffness). Another disadvantage is t he frag-
ile coupling between t he parti cles of pre-polym-
eri zed fillers and the organ ic matrix. In a clinical
examp le, chipping of the composit e can be see n,
particularly in areas subjected to large stresses

2.38: Initial case of Class III restoration on tooth
(Figs. 2.52 to 2.57). #lO with need fo r replacement . The Class III and V
restorations on tooth .,9 will also be replaced.
2.39: Cavity prepared for the restoration.

Some commercial examples of microfilled com-
posite resins can be found at the site: 2.40: Tooth #10 restored with the microhlled
composite Durahll VS (Heraeus Kulzer).
www.shortcuts- book.com.
2.41: Initial photo of the restoration of tooth #9.
2.42: Finished Class Ill and V cavities in toot h #9.
2.43: Restorati on in progress.
2.44: Final aspect of tooth " 9 also restored with

microhlled composite resin (Durahll VS, Heraeus
Kulzer).
2.45 : Clinical follow - up of 12 years. Note that the surface is more

polished than immediately after restoring.
2.46: Despite the high degree of polishing, some clinical problems

can be observed, such as marginal staining , chipping and small
marginal fractures, and surface wear.
2.47: Note the restoration margin in relation to the original bevel

termination , showing that wear has occurred.
2.48 and 2.49 : SEM photomicrograph of teeth #9 and #10 (Di Hip6lito ,
V.; De Goes, M.F.) .
2. 50 and 2.51: Clinical follow - up of 18 years.

2.52: Initial case with restorations

made from macrofilled com posites
(Adaptic/ johnson & Johnson).
2.53: Finished case with micro filled

composites (Duralill VS/ Heraeus
Kulzer) .
2.54: Case three years later.
2.55: Case ten years later. A high

degree of marginal staining fractures
of edges and incisal area and surface
wear can be observed.
2.56 and 2.57: Common problems

related to micro filled composites:
Staining of thin margins, small
chipping and fractures of the margins
or loaded areas .
,-
Clinical problems occurring

with microftlled resins are:
- high degree of marginal
staining (due to water
sorption);
- small chippings and fractures
(due to the low ft Iler load).
chapter 2: Composite resins and adhesive systems: the material 131
3.4 MICRO-HYBRID COMPOSITES (MODERN
HYBRIDS) Although the im-

proved polishability
has been clinically
Considering how important the inorganic phase demonstrated, some
of a composite resin is relative to its surface qual- brands are lacking in
surface gloss quality
ity, another class of composites with two types and retention. There
of filler was ,developed, called modern hybrid or is a wide variation
in clinical outcome
micro-hybrid composite resins. from brand to brand,
although all of them
are classified in the
Most modern composite resins in' this group same group.
contain colloidal silica (10 to 20% by weight) and
glass containing heavy metals in sizes of 0.4 to
1.0 µm, counting for 75 to 80% of the compos-
ite' s weight. In Figs. 2.58 to 2.60, their smaller
particle size is evident when compared to tradi-
tional and small-particle composites. This modi-

2.58: SEM photomicrograph
of the composite 4 Seasons
fication was made in part because surface gloss
(lvoclar Vivadent) (Di Hip6lito ,
retention was still insufficient with small-particle V.; De Goes, M. F.).
hybrid composites systems. 2.59: SEM photomicrograph of

the composite Opallis (FGM) (Di
Hip6lito , V.; De Goes, M.F.).
In addition to the decreased particle size, the dis-

2.60: Photomicrograph of the
tri bution curve in the particle size in modern hybrid composite Esthet -X (Dentsply
Caulk) (Di Hip6lito , V.; De Goes,
res ins was also modified. These new models con- M.F. ).
tained greater amount of smaller particles, render-
ing those better packed and more densely distrib-
uted, as seen in Figs. 2.58 to 2.60.

Similarly to what occurs with microfi ll ed com-
posites, increased inorganic su rface area hinders
the in corporation of filler particles. With lower
filler content, the material's phys ical and me-
chanical properties vary between those of tradi -
tional and small -part icle composites. St ill, these
properties remain higher than those of th e mi-
crofilled compos ites . This group of re sins can be
used in all clini cal situations, in posterior teeth,
where strength is a key factor, as well as in ante-
rior teeth (Figs. 2.61 to 2.68).
Commercial examples of moder hybrid or mi-
cro-hybrid composites can be found at the site:
www.shortcuts-book.com.
2.61: Initial case of substitution of amalgam for a composite resin restoration.
Modern hybrid or micro- hybrid composites exhibit satis- 2.62 to 2.64: Restoration sequence with the hybrid composite Rename! Hybrid (Cosmedent).
factory clinical results. However, they will hardly provide
the quality of polishing of a microftlled resin which has a 2.65: Clinical case after nine years. With hybrid composites, a slight loss in surface gloss can
high amount of organic matrix and reduced particle size. still be seen, not always accompanied by intense staining.
On the other hand, micro-hybrid composites have higher

2.66: Clinical case after 12 years. A tendency of stabilization of the surface can be perceived .
ftller content than microftlled resins, rendering them less
susceptible to water sorption and with improved mechani- 2.67: Radiograph of the restoration 15 years later.
cal properties.
2.68: Clinical follow - up at 18 years .

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Chapter 1: Dental bleaching: concepts and bleaching substances 67

1.201e1.202: Ini tial case

1.203: Note the presence of

1.204: Shade selection with the

1.205to1.207: Labial sunscreen

I.210 to 1.212: Appli cation of

I.213 to 1.216: Pos itioning of

I.219and1.220: One gauze is

1.221to1.225: Application of the

1.226: Repeat the process on the

1.227 to 1.229: Application of a

1.230: The automix tip is

1.231and1.232: The gel is applied

1.233 and l.234: The light guide

1.235: Press start to initiate a

l.236 and I.237: ZOOM! 2

l.238 and l.239: The patient

l.240: A light turns on at each

l.241and1.242: After each

l.243: During the first session,

I .244: Final shade se lection

1.245 and 1.246: Initial case and

1.247 and 1.248: Initial case and hnal

1.249 and 1.250: Initial case and hnal

1.251and1.252: Initial case and final

Bleaching with peroxide at

1.253and1.254: Wax - up done on th e initial mode l, which

1.255and1.256: Position of th e matrix should be ve rihed.

1.257and1.258: Typica lly, a modihed rubber dam

1.259: The siLico ne guide is tested once again to ensure

1.260 and 1.261: Roughening of t he enamel surface,

1.262 and 1.263 : Placement of the retraction cord (SilTrax

1.264: Note the retraction obtained.

1.268to1.273: Layering techn ique done with Opallis

1.274 and 1.275: The symmetry of the mirror area of

1.276 and 1.277: Once th e central incisors are properly

1.278: Occlusal check.

1.279 to 1.281: Using powder for ceramic

1.282 to 1.284: Finishing and polishing

1.285: Final polishing with Flexi-

1.286: Proximal polishing with finishing

1.287 and 1.288: Before and after

1.289 and 1.290: Before and after

1.291: Final result with lips at rest,

The video with the bleaching tech-

The scientifi c literature reports a sign ificant decrease in bond

strength when a resin composite restoration is placed immedi-

derstood. One poss ible explanation is the decrease of polymer-

ization of composite materials due to the presence of res idual

oxygen in the enamel pores and dentin immediately after dental

bleaching. 5556 Oxygen inhi bits the polymerization of composites 57

and it is possible that the oxygen fro m t he hydrogen peroxid e -

l.303: Clinical case post orthodontic treatment. Note that

1.304: For at-home bleaching with trays, teeth should be

l.306 to l.308: Step- by- step .

Which treatment is best: at-home or in-office?

Since dental bleaching with trays was introduced in 1989, numer-

veloped. As a result, a very common question arises: "Which tech-

nique works besf7" According to Heymann,24 nearly all techniques

work because bleaching is bleaching. If bleaching is done at home

using just 10% carbamide peroxide (which contains approximately

3% of hydrogen peroxide), or using over-the-counter whitening

strips with 6% of hydrogen peroxide, or in-office using 25-35%