Article_5_4_6
RESTORATIVE DENTISTRY
Case Report
MASKING POSTERIOR TOOTH DISCOLORATIONS
WITH COLOR MODIFIERS
Andreas Spaveras1a , Frantzeska Karkazi2b* , Maria Antoniadou1c
1
Department of Operative Dentistry, Dental School, National and Kapodistrian University of Athens, GR-11527 Athens, Greece
2
Department of Stomatology and Maxillofacial Surgery, Faculty of Medicine, Comenius University in Bratislava, SK- 81250 Bratislava, Slovakia
a
DMD, Postgraduate Student
b
MDDr
c
DDS, PhD, Assistant Professor
ABSTRACT DOI: 10.25241/stomaeduj.2018.5(4).art.6
Aim: The present article provides the clinician with a fundamental principle for achieving OPEN ACCESS This is an Open Ac-
cess article under the CC BY-NC 4.0 license.
success with direct application of resinous materials in cases of discolored posterior teeth, Peer-Reviewed Article
mainly due to amalgam corrosion of a previous restoration. The procedure, advantages,
and limitations of the technique are discussed. Citation: Spaveras A, Karkazi F, Antoniadou M.
Masking posterior tooth discolorations with color
Summary: A first upper right molar previously filled with amalgam was prepared for a modifiers. Stoma Edu J. 2018;5(4):256-262.
direct composite resin restoration, due to secondary caries. The discolored dentin on the Academic Editor: Dana Cristina Bodnar, DDS,
pulpal floor was treated with a white opaquer and a resinous corn color tint also applied PhD, Professor, “Carol Davila”University of Medicine
with a round painter’s brush. Dentin and enamel shade stratification was performed and Pharmacy Bucharest, Bucharest, Romania
according to the layering technique following the anatomical morphology of the tooth. Received: October 15, 2018
Revised: October 24, 2018
Finishing was performed with extra-fine diamond burs and aluminum oxide disks. Then Acccepted: November 07, 2018
a silicon-rubber polishing cups system was used with a 5 μm diamond polishing paste in Published: November 08, 2018
order to achieve high surface gloss. *Corresponding author:
Key learning points: The preparation of dentin should be kept in minimum in order to Dr. Frantzeska Karkazi, MDDr, Department of
Stomatology and Maxillofacial Surgery, Faculty
follow the principle of minimally invasive dentistry. The application of an opaquer over of Medicine, Comenius University in Bratislava,
the discolored dentin should be made in a very thin layer of 0.1 mm. The resinous color Heydukova 10, SK- 81250 Bratislava, Slovakia
Tel: +30 6976698009, Fax: +421 2/3224 9724,
modifiers should be applied and layered homogeneously. e-mail: fkarkazi@aol.com
Keywords: esthetic conservative direct restoration, posterior tooth, discolored dentin, Copyright: © 2018 the Editorial Council for
color modifiers, tints. the Stomatology Edu Journal.
1. Introduction single shade or layering shade technique (dentin
The aesthetic appearance of dentition is of concern /chromatic/achromatic enamel shades), as well
to a great percentage of the population. Natural as the use of opaquers and tints (color modifiers)
teeth demonstrate translucency, opalescence, and willingly. Single-shade restorations are simpler; less
fluorescence, all of which must be replicated by technique-sensitive and can reduce chair side time
restorative materials in order to achieve clinical for both the patient and the clinician. However, it is
success. Therefore, pursuing dental treatment not always easy to achieve a natural tooth structure
and respecting the natural color of the teeth is of by using a monochromatic technique, since teeth
particular cosmetic importance. Frequently, after are multichromatic with color variations. Layering
the removal of a previous amalgam restoration, shade technique is required in restorations of high
the exposed dentin commonly appears as a black aesthetical demand. The final restoration is usually
discoloration, which is attributed to the penetration more natural that single-shade technique, but it is
of corrosion products of amalgam into the dentin. technique sensitive and more time consuming. The
Composites are translucent by nature; even the proper knowledge of differences in translucency and
most opaque shades transmit nearly 60% of the the required thickness to mask dark background of
visible light [1]. As a result, composites require a the applied resin seems to be essential, though little
certain thickness to maintain their intended shade, information is available.
especially if the underlying substrate is particularly Miotti et al. [3] evaluated the ability of three resin
dark. Nevertheless, sometimes even relatively composite systems (IPS Empress Direct- Ivoclar
thick composite restorations might not be capable Vivadent, Charisma Diamond-Heraeus Kulzer
of covering discolored dentin. The dark pulpal and Filtek Z350 XT-3M, ESPE) to mask a severely
wall absorbs a significant part of light that would discolored background by the application of a
otherwise reflect towards the occlusal surface, and layering technique. Three groups presented clinically
the restoration, due to that phenomenon, appears a acceptable color difference values; however, the
non-vital monochromatic grayish color [2]. Filtek Z350 XT system was the only restoration system
Treatment options of direct posterior restorations capable of masking the C4 background. Moreover,
to minimize the effect of background color include Ikeda et al. [4] evaluated the translucency parameter
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MASKING POSTERIOR TOOTH DISCOLORATIONS
WITH COLOR MODIFIERS
Case Report
Figure 1. Preoperative occlusal view: insufficient amalgam restoration. Figure 2. Postoperative situation: examination of the dark discoloration.
and masking ability of three resin composites with and improve the aesthetics of restorations. Their
two shades (A3 and opaque A3) and in 1 and 2 mm application should be minimal and under the final
thicknesses. They concluded only 2 mm thickness composite layer. Shades such as honey, yellow,
of the opaque-shade materials could mask the dark light/dark brown, ocher and pink are frequently
background. However, Darabi et al. [5], compared the used in the restorations of posterior teeth [9]. It is
translucency parameter of five different opaque or suggested that clinicians should get familiarized with
dentin A2 shade resin composites Gradia (GC; Tokyo, different color modifiers in laboratory conditions
Japan), Herculite XRV (Kerr, Scafati, Salerno, Italy), before performing their clinical application. This
Vit-l-escence (Ultradent, South Jordan, UT, USA), would enhance their knowledge concerning color
Crystalline (Confi-dental, Louisville, KY, USA) and modifiers’ masking ability and optical characteristics.
Opallis (FGM, Joinville, Brazil) in different thicknesses Moreover, it enables the attainment of individualized
and evaluated their masking ability in black and customized composite restorations. The aim of
backgrounds. They concluded that in relatively thin this article is the presentation of a step-to-step direct
thicknesses, these opaque/dentin shade composite masking of the discolored dentin of a posterior tooth
resins could not mask the black background color. (#16) with the aid of color modifiers. Specific clinical
Color modifiers are used as base liners to tips and potential mistakes made by using such
counterbalance discolorations or to imitate the materials are also described thoroughly.
natural fissures of the occlusal wall. During the
restorative procedure, opaquers block out dark
colors, while tints bring the desired color back to the 2. Case Presentation
tooth. Opaquers are liquid dimethrycrylate resins A 35-year-old female patient requested the
(BIS-GMA), which are usually photopolymerised replacement of an insufficient old amalgam
and they contain potent pigments and high opacity restoration of the upper right first molar (#16), due to
percentages in different dentinal shades plus white secondary caries (Fig. 1).
and pink. They consist of 15% opaque metal oxides During the clinical inspection, the tooth did not react
(titanium, zirconium, barium etc.), which increase the sensitively in the cold test and showed no negative
opacity and thus the ability to mask dark discolorations reaction to the percussion test. The buccal and
[6]. Opaquers are available in a flowable viscocity, in palatal walls were measured and were greater than
base-catalyst paste form and powder/liquid one. The 1.5 mm in width; therefore a direct restoration could
main benefit of using color modifiers is that there is no be performed. Tooth shade selection was performed
need of extended removal of sound dentin, in order before field isolation to avoid color mismatching,
to perform a natural looking restoration [7]. When due to the dehydration of dental hard tissues during
opaquers are used, the protocol presupposes that the procedure. Since, successful composite resin
the discoloration should be covered approximately restorations are based on the bond formed between
at 70%. A lower percentage (<70%) will result in a the dental hard tissues and the composite, isolation
grayish restoration, while a higher one (>70%) will is an important part in direct restorations. It prevents
form an unnatural opaque final appearance. Their moisture contamination and ensures increased
application should be in meticulous layers [8]. In gingival retraction compared to other techniques.
highly demanding cases, opaquers and tints could In this clinical case, the upper posterior teeth were
be mixed with composite resins of low viscosity to isolated with a medium weight rubber dam (Nictone,
enhance the opacity of the composites.Tints are MDC Dental, Mexico). Two wedges (wooden, orange,
resinous materials containing strong pigments, Polydentia, Switzerland) were inserted in the mesial
which increase hue and chroma. They transmit light, and distal interproximal spaces (pre-wedging
therefore they add translucency back to restorations technique) to overcome the close proximity with the
after the placement of the opaquer. They are also adjacent teeth to prevent removal of sound enamel.
used in order to reproduce anatomical characteristics The preparation of the cavity was performed mesially,
Stomatology Edu Journal 257
MASKING POSTERIOR TOOTH DISCOLORATIONS
WITH COLOR MODIFIERS
Case Report
Figure 3. Formation of the distal and mesial walls with enamel shade Figure 4. Pressing the sectional matrix towards the neighboring tooth
resin. to perform the appropriate contact point..
Figure 5. Occlusal view after polymerization of the proximal walls. Figure 6. Opaquer placement to the discolored pulpal wall.
occlusally and distally with a medium pear diamond 5). A small amount of the opaquer (Venus Color
(856, 0.16 mm, 10 mm, Comet Gebr., Brasseler) under White, Heraeus Kulzer GmbH, Hanau, Germany) was
water-cooling. applied uniformly in a very thin layer (0.1 mm) on the
After removing the amalgam and while conserving discolored pulpal wall with a round painter’s brush
the remaining dental hard tissues, a strong dark (Da Vinci, Series 373, Flat No. 2) (Fig. 6). Then, the
discoloration was observed on the pulpal wall (Fig. 2). yellow tint (Corn Inspiro, Edelweiss DR AG, Mercandor,
A 37.5 % phosphoric acid (Gel-Etchant, Kerr Switzerland) was applied again uniformly in a very
Corporation, Orange, CA, USA) was applied to thin layer (0.1 mm) over the previous opaque layer,
the prepared enamel and dentin for 30 and 15 in order to imitate the yellowish shade of dentin and
seconds, respectively. Dental tissues were rinsed add some translucency to the restoration (Fig. 7).
and nearly dried with a light air pressure spray (2 or Each layer was photopolymerized separately with
3 seconds). As soon as the etching was performed, a LED-curing device (TechnoGaz, Parma, Italy) for
sectional matrices (Palodent, Dentsply Sirona) with 20 seconds according to manufacturers’ directions
wedges (wooden, white and orange, Polydentia, of use (Fig. 8). After that, the layering of the dentin
Switzerland) were placed on the distal and mesial composite (Dentin A2, Filtek Supreme Ultimate,
walls respectively. An adhesive procedure was 3M ESPE) was performed, in order to achieve
performed with a three-step etch-and-rinse system better esthetic appearance of the restoration. The
(Optibond FL, Kerr Corporation, Orange, CA, USA) incremental technique was used, to ensure the
according to the manufacturer’s instructions of use. complete polymerization of all the underlying
Following the adhesion, the proximal walls were layers (Fig. 9). A thin layer of the appropriate
formed in order to transform the Class II cavity enamel shade of the same composite system
into a Class I cavity. An enamel shade (Enamel A2, (Enamel A2, Filtek Supreme Ultimate, 3M ESPE), was
Filtek Supreme Ultimate, 3M ESPE) was used (Fig. applied in relation to the morphology of the first upper
3) for the buildup of the proximal walls. During the molar and photopolymerized for 40 s, according
polymerization, the sectional matrix was pressed to the manufacturers’ directions of use (Fig. 10).
towards the adjacent tooth with a periodontal probe, Finally, the occlusal check was performed with an
in order to achieve the appropriate contact point articulating paper to confirm that the restoration
(Fig. 4). Following the interproximal walls conformed precisely to the patients pre-existing
construction, the dark discolored pulpal wall was occlusal scheme, in both the intercuspal position and
examined carefully, in order to estimate the proper all excursions (Fig. 11). Finishing for accomplishing
amount of opaquer, which should be used (Fig. contouring, shaping and smoothing of the restoration
258 Stoma Edu J. 2018;5(4): 256-262 http://www.stomaeduj.com
MASKING POSTERIOR TOOTH DISCOLORATIONS
WITH COLOR MODIFIERS
Case Report
Figure 7. Corn color placement with a small round painter’s brush. Figure 8. After the polymerization of the tint.
Figure 9. Stratification of the composite resin of dentin shade. Figure 10. Enamel shade composite placement of the same system.
were performed with an extra-fine diamond bur and discoloration might be not beneficial.
aluminum oxide disks (Sof-Lex, 3M ESPE AG, Seefeld, Furthermore, a scanning electron microscope
Germany), in order to give the proper anatomical (SEM) study of Harnirattisai et al. [13] shows that
morphology and simultaneously to remove all excess the majority of the dentinal tubules in cases of
at the tooth restoration interfaces. For the polishing, discolored dentin were open, but plasma proteins
a two-step silicon-rubber polishing cups system inside the dentinal fluid may reduce the permeability
(Flexi Cups, Cosmedent, Chicago, IL, USA) and a 5 of dentin and interfere with the ability of the resin
μm diamond-polishing paste (Diamond Polish Mint, monomer to infiltrate. As a result, discolored dentin
Ultradent Products Inc, South Jordan) were used for could be considered as a different substrate during
30 seconds, to achieve a higher surface gloss. The clinical procedures, which is able to decrease the
final restoration and the neighboring teeth were bond strength. However, on the basis of an in vitro
photo-documented at the end of the restoration (Fig. study, there are no benefits in extending the cavity
12). walls of the preparation, when replacing amalgam
restorations [14]. The application of dental liners,
bases and cavity varnishes results in reducing micro-
3. Discussion leakage that may cause sensitivity, discolorations
Many amalgam restorations have to be replaced due and bacterial invasion, due to the fact that these
to micro-leakage, recurrent caries, bulk amalgam materials are able to seal the dentinal tubules.
fracture and sometimes the aesthetic demands of the Discolorations of posterior teeth should be restored
patient [10]. Amalgam corrosion products penetrate primarily with the least invasive techniques. In
deeply into the dentinal walls and cause dark more detail, dental bleaching can be used as an
discolorations [11]. The penetration of black pigments alternative or the first treatment step before a
in dentin underneath both high-Cu and low-Cu direct restoration or to treat a stained arrested
amalgams in demineralized specimens are unevenly caries lesions [15]. Apart from bleaching and the
distributed and observed predominantly in dentin well-established restorative options, a restoration
near to pulp horns. Discoloration in the majority of that covers both buccal and cuspal areas can
cases is not limited to the outer demineralized dentin be used, the so called “vonlay”. Generally, they
but extended beyond this zone. An evenly distributed are monolithic structure fabricated from lithium
bluish-green discoloration is frequently observed disilicate, a vonlay is a hybrid of an onlay with an
underneath all high-Cu amalgam specimens extended buccal veneer surface for use in bicuspid
independent of demineralization [12]. Therefore, the regions where there is mostly enamel to bond to [16].
extension of the cavity preparation to ameliorate the Even if extra tooth structure is removed, the problem
Stomatology Edu Journal 259
MASKING POSTERIOR TOOTH DISCOLORATIONS
WITH COLOR MODIFIERS
Case Report
Figure 11. Checking occlusion. Figure 12. Final occlusal view.
of obtaining an optimal result can be more difficult suggested in presenting the “lege artis” of direct
due to the effect of the underlying resin cement. The posterior restorations.
tooth shade can also vary somewhat after placing Clinical tips of how to apply correctly the color
the specific restorations because of a color shift in modifiers in the posterior restorations will be
the polymerized resin cement. On the contrary, the mentioned below. Color modifiers should be
shade of direct composite restorations can be easily applied homogeneously in very thin layers (0.1–0.5
modified in order to obtain the optimal result. mm each) with a small round brush. Moreover,
It is recommended that general dental practitioners they should be selected carefully. Some of them
consider adopting minimally invasive techniques in are highly pigmented, therefore only a single thin
the first instance before moving on to more invasive layer is needed to obtain an adequate coverage
treatment plans. Indirect restorations require more of a discoloration; whereas others may require the
tooth preparation and more than one appointment application of two or more layers of color modifiers
to be completed [17–20]. Metal ceramic restorations [30]. The clinician has to prepare and preserve an
though they have shown long-term success due to adequate space (minimum 1.5 mm); to be filled with
good mechanical properties [21], achieving a natural resin composite [2,31]. Masking of the opaque layer is
appearance is more challenging with a metal-ceramic also an esthetic necessity. Monochromatic or layering
restoration than an all-ceramic restoration due to the techniques can be either used. However, aesthetics
fact that metal copings prevent light transmission in these situations is usually of high importance, the
[22]. Additionally, since porcelain is the main material layering shade technique (enamel-dentin shades) is
of choice in the aforementioned treatment plans, preferred by many clinicians.
there is a high probability of excessive wear of the In addition, potential problems regarding the tone
opposing restoration or the natural tooth, due to the of the restorations will be discussed below. Grey
friction between the two [23]. Direct resin composite restorations may result due to the inefficacy of the
materials exhibit a promising long-term clinical opaquer to mask the discoloration or insufficient
performance when rehabilitation of posterior teeth amount of opaquer applied. A matte restoration may
is needed [24]. Therefore, they may be used as an be the result of one of the following: (a) too strong
equivalent alternative to glass-rich-ceramic inlays opacification ability of the opaquer, (b) excessive
regarding mechanical performance [25]. As a result, amount of the opaquer and (c) close proximity of the
a direct composite restoration may be the preferable opaquer to the occlusal surface (less than 1.5 mm).
choice, especially if there is adequate tooth structure Spotted restorations are mainly the result of uneven
and the patient is a perfectionist. layering of color modifiers [32].
In addition, the new generation of composites The knowledge and the correct use of color modifiers,
(nanohybrid composites) has been improved in as well as, the skills and the aesthetic perception of
respect of shade, wear and fracture resistance [26,27]. the dentist are the key factors in establishing a natural
Nanohybrid resin composites are able to imitate result [33,34], particularly when the restoration
ceramic materials in functional and optical aspects relates to a single discolored tooth. Therefore, the
[28,29]. Even dischromatic posterior areas could be ability to accurately perceive and differentiate
covered with great effectiveness. However, because the color characteristics of natural dentition is a
of their low opacification ability, they sometimes fail major prerequisite for a successful restoration. The
to cover very dark discolored pulpal walls of previous aesthetic success of the restoration depends mainly
amalgam restorations. on the correct choice of the shade of the composite
In these demanding cases opaquers and tints and the total opacification ability of the opaquer and
should be used to counterbalance even the the composite materials used. The importance of
darkest discolorations and simultaneously follow a the specific technique is that even the most difficult
minimally invasive approach. Therefore, the correct and dark pulpal wall discolorations can be covered
and moderate use of opaquers and tints should be by simultaneously following the minimally invasive
260 Stoma Edu J. 2018;5(4): 256-262 http://www.stomaeduj.com
MASKING POSTERIOR TOOTH DISCOLORATIONS
WITH COLOR MODIFIERS
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Andreas SPAVERAS
DMD, Postgraduate Student
Department of Operative Dentistry Dental School,
National and Kapodistrian University of Athens,
GR-11527 Athens, Greece
CV
Dr. Andreas Spaveras received his degree in dentistry (DMD) in 2013 from the Semmelweis University of Budapest, Hungary.
Currently, he is finishing his postgraduate studies (MSc) at the Restorative Dentistry Department, Dental School of the National
and Kapodistrian University of Athens, Greece. He has published several scientific articles in the field of restorative dentistry.
Questions
1. Color Modifiers promote:
qa. Non-invasive procedures;
qb. Minimally invasive indirect restorations;
qc. Minimally invasive direct restorations;
qd. Invasive restorations.
2. Color modifiers should be applied:
qa. In very thin layers (0.1-0.5 mm each);
qb. In thin layers (0.5-0.7 mm each);
qc. In moderate layers (0.7-1.2 mm each);
qd. In thick layers (1.2-1.5 mm each).
3. Opaquers and Tints should be applied homogeneously with:
qa. A probe;
qb. A micro-brush;
qc. A small round painter’s brush;
qd. A flat painter’s brush.
4. The clinician has to prepare and preserve:
qa. A minimum 1.0 mm space to be filled with resin composite;
qb. A minimum 1.5 mm space to be filled with resin composite;
qc. A minimum 2.0 mm space to be filled with resin composite;
qd. A minimum 3 mm space to be filled with resin composite.
262 Stoma Edu J. 2018;5(4): 256-262 http://www.stomaeduj.com