Internal Bleaching - A step-by-step guide

A Couple of weeks ago, I got the chance to do Internal Bleaching on a patient who was very self concious of her smile and is really motivated to regain her smile back .  Tooth #8 has had a Hx of trauma.  It was avulsed as a result of a sport injury, and was subsequently fixated with a wire.  The tooth underwent Root Canal Therapy (RCT) and internal bleaching roughly four years after the day of trauma.  The tooth has discolored since then.
The following are the steps followed in Internal Bleaching:
Step 1: Get your basic Armamentarium ready, as you would for a RCT case.

Step 2:  A photo of the tooth with the appropriate shade guide is taken for future reference.  In this case the shade for the discolored tooth was A35 while the surrounding dentition has a shade of A1. 

Step 3:  Anesthetize the gingiva surrounding the tooth and place a rubber dam with a clamp.  Then, access the tooth from the lingual using a round bur with a high speed drill.  In this case a lingual composite had been placed on top of a cotton ball which had been left in the pulp chamber.  Note that it is not recommended to leave a cotton in the chamber.  The cotton appeared discolored upon removal.

Step 3: Anesthetize the gingiva surrounding the tooth and place a rubber dam with a clamp.  Then, access the tooth from the lingual using a round bur with a high speed drill.  In this case a lingual composite had been placed on top of a cotton ball which had been left in the pulp chamber.  Note that it is not recommended to leave a cotton in the chamber.  The cotton appeared discolored upon removal.

Step 4: After removing the entire composite restoration, irrigate the tooth chamber and the canal using Chlorohexidine.  This is an important step because it removes any contaminants from the pulp chamber.  DO NOT use Sodium Hypochlorite for irrigation as it will interfere with the subsequent bonding step.

Step 5: Follow the following diagram to place composite seal at the cervical end of the canal to prevent the bleaching material from entering the dental structure below the CEJ.

Step 6: Very accurate measurements are necessary in order to put the composite plug.  First measure the the distance from the incisal edge to the CEJ at the outer surface of the tooth, then remove enough Gutta Percha from the coronal end of the canal to get the measured distance + 3 mm. 

Step 7:  One you have removed 3 mm  of Gutta Percha below CEJ, acid etch the canal walls for 10-15 seconds and rinse with water for 20 seconds.  Dry the canal using a cotton swab.  DO NOT over dry! 

Step 8: The use of a flowable composite with its compatible bonding system is the easiest way to place the composite plug.  So, use the bonding system, followed by 3 mm of flowable composite. 

 

Step 9:  Use a condenser instrument to condense the composite to the CEJ level. Note that the placement of composite in increments is necessary.

Step 10: Light Cure according to the manufacturer's instructions.  Usually forty seconds to get full curing.

Step 11: Mix Sodium Perborate with 18% Hydrogen peroxide on a glass slab.

Step 12: Make sure you mix enough Sodium perborate powder with 18% H2O2 liquid to get a mushy consistency

Step 13: Condense the mixture into the tooth chamber, and allow ~3 mm space from the orafice.

Step 14: Here a fugi temporary material, readily used at the endodontics clinic, was used to seal the tooth.  Pt was given post op instructions and asked to immediately call back if the temporary material fell out.  Pt placed on one week recall.

Visit 2: At the second visit, there was a considerable improvement in the shade of the tooth.  The shade went from a shade of A35 to Shade A1.  However, improving the shade even further is recommended since the tooth might revert to a darker shade after the bleaching material is removed and replaced with a restorative material. 

Step 1: Pt did not want any anesthesia, so only topical benzocaine used to anesthetize the gingiva surrounding the tooth for the purpose of RD and clamp placement. Temporary restoration and Na Perborate/ 18% H2O2 mixture removed.  The chamber rinsed with water.

Step 2: Sodium perborate granules mixed with water to get a mushy consistency.  Condensed the mixture in the chamber, leaving 3 mm space for temporary material.

Step 3: Fugi temporary restoraton placed to seal the tooth.  Pt placed on one week recall.

Third visit: Ideal shade acquired. Pt very satisfied.  Topical 20% benzocaine on surrounding gingiva, RD placed as shown below.  Temporary restoration and Na Perborate removed. 

Step 1: The chamber was acid etched with 37% phosphoric acid for 10 seconds, rinsed with water for 25 seconds, dried using a cotton swab.  Optibond bonding agent used and light cured for 25 seconds.  Condensed A1 composite in VERY, VERY SMALL increments and light cured.  The entire chamber filled with composite.  The middle tooth in the image below shows the restoration. 

Tooth #8 Final results after bleaching!  Very successful, and a very satisfied Pt.

Supervising Faculty: Dr. KOSUKE
Student Dentist: SEYAR BAQI
Blue Hen Dental
Dentist in Smyrna, DE 19977
BlueHenDental.com
231 S. DuPont BLVD
Smyrna, DE 19977
302-314-3077