DR. DENNIS HARTLIEB
Blocking out the dark tooth
Blocking out the dark tooth
Ok, in your head, name the hardest things to do in cosmetic dentistry. Closing diastemas? Tough, but not the hardest. Prepping tooth #15 in the small mouth patient with the big cheeks and fat tongue? No fun…but not the hardest. Taking accurate final impression of crowns and veneers on an entire arch? Stressful and difficult, but not the worst.
What do I think is the most challenging treatment in cosmetic dentistry? One of three things:
1. Matching the single central incisor with an indirect restoration
2. Replacing the missing anterior tooth, especially when there are bone and soft tissue compromises.
3. Blocking out the dark anterior tooth!
In today’s blog, we are going to limit our conversation to just this one overly stressful dental procedure – blocking out the dark tooth.
The dark tooth comes in several varieties and forms: the traumatized tooth with endodontic treatment, the traumatized tooth that is vital, and the tetracycline stained teeth. When a tooth has been endodontically treated, intracoronal bleaching – i.e. walking bleach, can be utilized with varying degrees of success. However, there are times when the tooth is restored with a post and core build-up restoration and it may be dangerous to remove the post and restorative material in fear of damaging the tooth or fracturing the root. In other cases where the teeth are vital, intracoronal bleaching is not an option. Whitening techniques, such as Kor (in the US) or Enlighten (UK), can lighten tetracycline stained teeth for some individuals, but the timeframe to get to a satisfactory level is extended, and it may be difficult for patients to stay motivated to perform the home bleaching aspect of the treatment.
What do I think is the most challenging treatment in cosmetic dentistry? One of three things:
1. Matching the single central incisor with an indirect restoration
2. Replacing the missing anterior tooth, especially when there are bone and soft tissue compromises.
3. Blocking out the dark anterior tooth!
In today’s blog, we are going to limit our conversation to just this one overly stressful dental procedure – blocking out the dark tooth.
The dark tooth comes in several varieties and forms: the traumatized tooth with endodontic treatment, the traumatized tooth that is vital, and the tetracycline stained teeth. When a tooth has been endodontically treated, intracoronal bleaching – i.e. walking bleach, can be utilized with varying degrees of success. However, there are times when the tooth is restored with a post and core build-up restoration and it may be dangerous to remove the post and restorative material in fear of damaging the tooth or fracturing the root. In other cases where the teeth are vital, intracoronal bleaching is not an option. Whitening techniques, such as Kor (in the US) or Enlighten (UK), can lighten tetracycline stained teeth for some individuals, but the timeframe to get to a satisfactory level is extended, and it may be difficult for patients to stay motivated to perform the home bleaching aspect of the treatment.
If we look at restorative treatment options, things are challenging. Here are today’s options:
1. Full coverage restorations using either zirconia-based crowns or porcelain-fused-to-metal restorations
2. Veneering with a highly opaque porcelain substrate, such as Zirconia
3. Direct resin bonding with composite
Related course: Masking the Dark Tooth with Direct Resin
All three of these options have their advantages and disadvantages. Obviously, full coverage restorations are our least conservative treatment option. Properly executed full crown preparations allow the dental ceramist adequate space to block out the underlying tooth color and still have space for layering porcelain. This is especially true with the more highly opaque zirconia materials that will block out the discoloration leaving enough space for the ceramist to create natural characteristics in the veneering porcelain. Unfortunately, so many of the patients that I have seen with tetracycline staining, have otherwise incredibly healthy teeth free of dental restorations, and they are looking for a treatment option that is not so damaging to their teeth.
Recently, zirconia veneers have been introduced to dentistry. I have yet to place a zirconia veneer (though I have cemented/bonded) many full zirconia crowns and a number of anterior zirconia resin bonded bridges (think single winged Maryland bridge without the metal). The restorations have maintained well, so it is likely that given the proper adhesive protocol and techniques, zirconia veneer restorations should be equally similar in their success rate. But as of now, there is no research that I am familiar with that demonstrates long-term success bonding zirconia veneers.
The other issue, and this where things get really tough when we are dealing with dark teeth, is that the more that we prep the tooth for the restoration, the darker the tooth becomes! That’s right – the enamel is filtering the darkened dentin underneath, and as we remove the enamel to gain restorative space, we make it harder on ourselves to block out the discoloration.
So now that we are prepping deeper to gain space for our restorative material, the more likely we are to having to rely on dentin as our bonding substrate, rather than enamel. In this case, if I am relying on my bond to dentin instead of enamel, my choice of restorative material will always be composite. Why, you ask? For two reasons. Reason #1 – porcelain, especially zirconia, is a very stiff substrate whereas the dentin of the tooth has more flex, especially under function. Composite, in my experience, is better able to ‘bend’ and flex with the tooth structure and I find that the margins maintain better than when I have bonded porcelain to teeth with reduced enamel. The second issue, and this is critical, we must realize that regardless of the material chosen, over time, there will likely be breakdown of the restorative margin interface.
A major advantage of composite over porcelain or zirconia, is its reparability. In cases of margin breakdown, or recession, I can roughen the existing composite and tooth structure, and following proper adhesion procedures, bond new composite to the existing composite covering over the failed margin or the exposed, dark tooth structure. It is my opinion that using composite to veneer dark teeth allows me to manage the inherent challenges of maintaining the restorations long term.
Recently, zirconia veneers have been introduced to dentistry. I have yet to place a zirconia veneer (though I have cemented/bonded) many full zirconia crowns and a number of anterior zirconia resin bonded bridges (think single winged Maryland bridge without the metal). The restorations have maintained well, so it is likely that given the proper adhesive protocol and techniques, zirconia veneer restorations should be equally similar in their success rate. But as of now, there is no research that I am familiar with that demonstrates long-term success bonding zirconia veneers.
The other issue, and this where things get really tough when we are dealing with dark teeth, is that the more that we prep the tooth for the restoration, the darker the tooth becomes! That’s right – the enamel is filtering the darkened dentin underneath, and as we remove the enamel to gain restorative space, we make it harder on ourselves to block out the discoloration.
So now that we are prepping deeper to gain space for our restorative material, the more likely we are to having to rely on dentin as our bonding substrate, rather than enamel. In this case, if I am relying on my bond to dentin instead of enamel, my choice of restorative material will always be composite. Why, you ask? For two reasons. Reason #1 – porcelain, especially zirconia, is a very stiff substrate whereas the dentin of the tooth has more flex, especially under function. Composite, in my experience, is better able to ‘bend’ and flex with the tooth structure and I find that the margins maintain better than when I have bonded porcelain to teeth with reduced enamel. The second issue, and this is critical, we must realize that regardless of the material chosen, over time, there will likely be breakdown of the restorative margin interface.
A major advantage of composite over porcelain or zirconia, is its reparability. In cases of margin breakdown, or recession, I can roughen the existing composite and tooth structure, and following proper adhesion procedures, bond new composite to the existing composite covering over the failed margin or the exposed, dark tooth structure. It is my opinion that using composite to veneer dark teeth allows me to manage the inherent challenges of maintaining the restorations long term.
Read also: Blocking out the dark tooth with pink opaque
The other advantage of composite is that it is inherently more opaque than porcelain. We can use this to our advantage when we are working with dark teeth. But it is important to understand the step-by-step workflow when using composite. The first key when blocking out dark teeth is to use a pink opaquer as the first layer of material, after the adhesion technique. Pink opaquer is used to neutralize the dark under color. For clinicians that have tried to use white opaquers, they probably have found that when the white opaquer is used in a thin layer, the value (brightness) is low and the white becomes grey.
Alternatively, when the white is used in a thicker layer, the white will become too opaque in an effort to block out the underlying dark tooth structure, and masking the white with the composite becomes impossible, resulting in an opaque, unnatural restoration. The pink opaque in contrast, when placed in thin layers, raises the value of the restorative surface without over opaquing the tooth. Utilizing pink opaquer as an undersurface allows the dentist to layer traditional composites to create a natural and esthetic final restoration.
Alternatively, when the white is used in a thicker layer, the white will become too opaque in an effort to block out the underlying dark tooth structure, and masking the white with the composite becomes impossible, resulting in an opaque, unnatural restoration. The pink opaque in contrast, when placed in thin layers, raises the value of the restorative surface without over opaquing the tooth. Utilizing pink opaquer as an undersurface allows the dentist to layer traditional composites to create a natural and esthetic final restoration.
I hope that the information on pink opaquer was helpful in understanding its use in pre-opaquing to raise the value of the dark tooth.
Yours for better dentistry,
Yours for better dentistry,
Dennis Hartlieb, DDS, AAACD
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Meet Dr. Dennis Hartlieb
Dr. Dennis Hartlieb owns his own practice in Chicago,IL and has been teaching dentistry for over 30 years. Dr. Hartlieb is the CEO and the main instructor at Dental Online Training. He is an active member in the American Academy of Cosmetic Dentistry where he’s both an Accredited Member and Examiner for Accreditation.
Dr. Hartlieb is also the President of the Chicago Academy of Interdisciplinary Dentofacial Therapy, and a member of the prestigious American Academy of Restorative Dentistry.
Dr. Hartlieb is also the President of the Chicago Academy of Interdisciplinary Dentofacial Therapy, and a member of the prestigious American Academy of Restorative Dentistry.
Meet Dr. Angela Luek
Dr. Angela M. Lueck is a Wisconsin native and was the youngest female in her class from Marquette University in 1998. Since completing her residency she has consistently taken more than 100 hours a year of continuing education to keep current on the latest trends, techniques, and materials available in dentistry.
She volunteers her time to teach at Marquette University providing the students additional training with anterior and posterior bonding techniques as well as dental photography. She is also the co-chair of the mentorship program at the University. Dr. Lueck has been voted as one of Milwaukee’s top dentists multiple times by Milwaukee Magazine.
She volunteers her time to teach at Marquette University providing the students additional training with anterior and posterior bonding techniques as well as dental photography. She is also the co-chair of the mentorship program at the University. Dr. Lueck has been voted as one of Milwaukee’s top dentists multiple times by Milwaukee Magazine.
Meet Clare O'Neill
Clare O’Neill is the Director of Operations at Dental Online Training and has a professional background in digital marketing. Clare has certifications in content marketing and digital advertising. Clare has expertise in social media marketing, email marketing, content marketing, website management, and project management. Clare has been using Canva for over 5 years and is a self-proclaimed Canva Queen.
Clare graduated from Georgia State University with a Bachelor’s degree is Sociology. Clare wanted you to know that she is a dog person, loves the colors emerald green and periwinkle, and would eat french fries at every meal if she could!
Clare graduated from Georgia State University with a Bachelor’s degree is Sociology. Clare wanted you to know that she is a dog person, loves the colors emerald green and periwinkle, and would eat french fries at every meal if she could!
Meet Dr. Jim Mckee
Dr. McKee is a member of the Spear Resident Faculty. He has maintained a private practice since 1984 in Downers Grove, Illinois where he treats a wide variety of cases with a focus on predictable restorative dentistry. He is a member of the American Academy of Restorative Dentistry and former president of the American Equilibration Society.
He has lectured both nationally and internationally for over 25 years and directs several study clubs. Dr. McKee graduated from the University of Notre Dame in 1980 and earned his dental degree from the University of Illinois College of Dentistry in 1984.
He has lectured both nationally and internationally for over 25 years and directs several study clubs. Dr. McKee graduated from the University of Notre Dame in 1980 and earned his dental degree from the University of Illinois College of Dentistry in 1984.
Meet Kirk Behrendt
Kirk Behrendt is a renowned consultant and speaker in the dental industry, known for his expertise in helping dentists create better practices and better lives.
With over 25 years of experience in the field, Kirk has dedicated his professional life to optimizing the best systems and practices in dentistry.
Kirk Behrendt is the founder of ACT Dental, and his vision is driven by the commitment to provide highly personalized care to the dental profession. By creating a talented team of experts, Kirk and his team continue to positively impact the practice of dentistry on practice at a time. Kirk lectures all over the world to help individuals take control of their own lives.
With over 25 years of experience in the field, Kirk has dedicated his professional life to optimizing the best systems and practices in dentistry.
Kirk Behrendt is the founder of ACT Dental, and his vision is driven by the commitment to provide highly personalized care to the dental profession. By creating a talented team of experts, Kirk and his team continue to positively impact the practice of dentistry on practice at a time. Kirk lectures all over the world to help individuals take control of their own lives.
Meet Dr. Melissa Seibert
Melissa Seibert is a comprehensive dentist proudly serving in the Air Force. She holds a dual faculty appointment at Uniformed Services University and Creighton Dental School. She serves on the editorial board for Inside Dentistry.
Her current research projects involve investigating ceramic overlays, zirconia and salivary contamination of universal adhesives. Dr. Seibert is the creator and host of the top dental podcast, Dental Digest. She lectures to national and international audiences.
Her current research projects involve investigating ceramic overlays, zirconia and salivary contamination of universal adhesives. Dr. Seibert is the creator and host of the top dental podcast, Dental Digest. She lectures to national and international audiences.
Meet Olivia Wisden
Olivia Wisden is the founder & CEO of TwoLips Creative. What started as an events discovery app pivoted into a creative agency that specializes in working with startups, small businesses, and organizations who are looking for bold, impactful designs and strategies.
She has worked with dozens of brands over the years ranging from the City of Madison to product launches and beyond.
She has worked with dozens of brands over the years ranging from the City of Madison to product launches and beyond.
Meet Dr. Sofya Kats
Dr. Sofya Kats is local to Milwaukee, WI. She grew up in Bayside and attended Nicolet HS, UW-Milwaukee and Marquette University School of Dentistry. Dr. Kats is a member of the Greater Milwaukee Dental Association, Wisconsin Dental Association, American Dental Association, and The Forum Study Club (oldest Dental Study Club in the United States).
Dr. Kats loves the art of dentistry, and healing it can bring to her patients. She volunteers her time by going on international dental mission trips and local events, such as the Mission of Mercy (free dental care sponsored by the Wisconsin Dental Association).
Dr. Kats loves the art of dentistry, and healing it can bring to her patients. She volunteers her time by going on international dental mission trips and local events, such as the Mission of Mercy (free dental care sponsored by the Wisconsin Dental Association).
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Day 1 (8 - 4 pm CST)
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Erosion and wear – the why and the how
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Adding length to teeth – when is it safe
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Opening VDO to compensate for lost tooth structure – where to begin
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Records visit and key points you need to understand before you start
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The smile – the 7 strategic points to consider when evaluating the smile
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Anterior tooth shape, morphology
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Clinical case review
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Upper Putty matrix construction
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Build lingual incisal wall with putty matrix #6 - #11/ Upper anteriors
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Full contour build-up #6, #7, #8, #9, #10, #11, shape and polish/ Upper anteriors
Day 2 (8 - 2 pm CST)
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Who – which patients are candidates
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Why – explaining to patients the value of the prototype
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How – step-by-step techniques to maximize predictability, efficiency and success
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Getting to Yes: conversations with patients about esthetic and reconstructive dentistry
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The ‘Smile Preview’ – techniques to show the possibilities
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Lower Putty matrix construction
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Build lingual incisal wall with putty matrix #22 - #27 / lower anteriors
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Build-up #22 - #27, shape and polish / lower anteriors
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Build-up lower occlusal posteriors
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Demonstration of Smile Preview