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Color-Matching Strategies for Non-Vital Discolored Teeth: Part 1. Laboratory

Ceramic Veneer Fabrication Solutions

Article  in  Journal of Esthetic and Restorative Dentistry · August 2014

DOI: 10.1111/jerd.12111

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 CLINICAL ARTICLE

Color-Matching Strategies for Non-Vital Discolored Teeth:

Part 1. Laboratory Ceramic Veneer Fabrication Solutions
STEPHEN J. CHU, DMD, MSD, CDT*, ADAM J. MIELESZKO, CDT†

ABSTRACT

The following is a case report exemplifying the restorative and esthetic correction of a discolored stump shade of a
non-vital tooth maxillary left central incisor tooth. Treatment options are non-vital bleaching of the root canal-treated
tooth or esthetic restoration through an understanding of color and layered ceramics, where the latter was employed.
Proper shade communication as well as additional facial tooth preparation and reduction are key clinical requirements
in order to allow the ceramist adequate room to affect a color change without sacrificing translucency or vitality of the
definitive restorations.

CLINICAL SIGNIFICANCE
Esthetic restorative correction of a discolored stump tooth shade can be managed with an understanding of color,
shade communication, proper tooth preparation, and ceramic layering techniques.
(J Esthet Restor Dent 26:240–246, 2014)

INTRODUCTION remove slightly more tooth structure, i.e., increase

Another color-matching challenge is managing the
discolored stump shade of a non-vital tooth. Ceramic
veneers tend to be more translucent and easier to
match if the stump shade is not discolored. The
reasoning being that the non-discolored stump shade
can be used as the correct colored “canvas” for
predictable shade matching.1 However, when the stump
shade is discolored due to deposition of ferric sulfide
into the dentinal tubules of a non-vital tooth,2 then
what options can be performed from a laboratory
restorative standpoint to mask the discoloration while
maintaining vitality of the restoration?
The ceramist must be conscious of the delicate balance
between opacity and translucency in such situations,
where the latter would be detrimental to the effect of
vitality and translucency. One of the clinical keys is to
tooth reduction, in facial-palatal preparation as per
Sulikowski and Yoshida.3 This allows greater restorative
space for the ceramist to create not only the proper
colored canvas but also the correct chroma, brightness,
and fluorescence of the restoration.
CLINICAL CASE REPORT (NON-VITAL
DISCOLORED STUMP OF TOOTH #9)
A 48-year-old Caucasian man with existing veneer
restorations on teeth #7–10 placed more than a decade
ago was looking for replacement because of gingival
recession and exposure of the restorative margins,
which were becoming stained (Figure 1). The patient
had undergone recontouring of the gingival tissues
through gingivectomy involving teeth #7 and 8 to level
the periodontal architecture with teeth #9 and 10 and

*Clinical Associate Professor, Ashman Department of Periodontology and Implant Dentistry, Department of Prosthodontics, New York University College of Dentistry,
New York, NY, USA
†
Head Ceramist, Specialized Dentistry of New York, New York, NY, USA

240 Vol 26 • No 4 • 240–246 • 2014 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12111 © 2014 Wiley Periodicals, Inc.
 COLOR-MATCHING FOR NON-VITAL DISCOLORED TEETH Chu and Mieleszko
FIGURE 1. Preoperative intraoral view of patients dentition
in maximum intercuspal position. Note the discrepancies in
gingival levels and existing ceramic laminate veneers on teeth
#7–10.
FIGURE 3. The periapical radiograph of the maxillary central
incisors reveals prior root canal therapy on tooth #9.
restore individual esthetic tooth proportion
(Figure 2).4–6 After removal of the veneer restorations,
the true stump color of endodontically treated tooth #9
was revealed (Figures 3 and 4). It is not uncommon that
discoloration of the remaining tooth structure after root
canal therapy is present because ferric sulfide is a
by-product of oxidation of ferric ions in the
© 2014 Wiley Periodicals, Inc. DOI 10.1111/jerd.12111
FIGURE 2. Excessive pseudo-pocketing was recorded
through sulcular periodontal probing and the free gingiva was
excised to restore the proper individual tooth proportion
(75–85%) as well as re-establish the gingival architecture.
FIGURE 4. Following removal of the existing veneers, it
became obvious that the darker stump of tooth #9 would
need to be addressed and managed in regard to color
matching the non-discolored adjacent teeth and stump shades.
hemoglobin of blood. Even though non-vital bleaching
of the tooth structure to remove the ferric sulfide ions
is a treatment option, some authors have reported
rebound of color post-non-vital bleaching techniques.7,8
In this clinical situation, non-vital bleaching of the
tooth stump was not elected. A kaolin-based hemostatic
material (Expasyl, Kerr, Cary, NC, USA) was used
(Figure 5) prior to impression making with a
polyvinylsiloxane material (Flexitime, Heraeus, South
Bend, IN, USA). A gypsum cast was poured to create a
master die cast (Figure 6). A silicone matrix key was
made reflective of the labial contours of the definitive
restorations and used in tooth preparation. Note that
the tooth preparation of tooth #9 has greater labial
reduction than that of tooth #8 (Figure 7). The stump
shade of the non-discolored and discolored teeth was
Journal of Esthetic and Restorative Dentistry Vol 26 • No 4 • 240–246 • 2014 241
 COLOR-MATCHING FOR NON-VITAL DISCOLORED TEETH Chu and Mieleszko

FIGURE 5. Definitive impression making to expand the FIGURE 6. A master die cast was created in the laboratory
gingival sulcus was performed using retraction cord followed using gypsum stone.
by a kaolin-based hemostatic material.

FIGURE 7. A silicone facial matrix or key was used as a

preparation guide intraorally. The same guide shows greater
facial reduction of tooth #9 to allow the technician to manage
the discolored stump shade during the ceramic build up of the
restoration.
FIGURE 8. The stump shade was taken with the dental
laboratory ceramic powder shade guide (Heraceram).

made with the laboratory ceramic shade tabs

(HeraCeram, Heraeus, South Bend, IN, USA; Figure 8)
as well as the clinical shade guide (Vita Classic, Vident,
Brea, CA, USA; Figure 9).

A custom ceramic shade tab was made of the

discolored stump with opacious dentin (Figure 10).
The clinical shade tab was compared (Figure 11) to the
custom stump shade to visualize in the laboratory how
much opacity and brightness change would be required
with the correction ceramic. A custom blend of
opacious and fluorescent dentin powders (Figure 12)
was used as a thin coating of ceramic to mask the shade FIGURE 9. The shade of the stump was also taken with the
of the custom shade tab representative of the discolored clinical tooth shade guide (Vita 3D Master).
tooth stump shade (Figure 13), yet maintaining
brightness and vitality to match that of the shade guide
tab (Figure 14).

242 Vol 26 • No 4 • 240–246 • 2014 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12111 © 2014 Wiley Periodicals, Inc.
 COLOR-MATCHING FOR NON-VITAL DISCOLORED TEETH Chu and Mieleszko

FIGURE 10. A custom shade tab was made of opacious FIGURE 11. The custom stump shade tab is compared to
dentin to match the shade of the discolored stump. the desired tooth shade of the definitive restoration.

FIGURE 13. The fired opacious and fluorescent powder

fired onto the custom stump shade tab. Note the thin
thickness of the correction ceramic layer. The two shades that
are layered and sandwiched together formulate the final stump
shade of the adjacent vital teeth.
FIGURE 12. A blend of opacious and fluorescent dentin
powders was used as a thin coating of ceramic to mask the
shade of the custom shade tab.

The master gypsum cast was duplicated in a refractory

material (Figure 15) and sectioned accordingly to create
individual dies. The custom-blended masking ceramic
was layered to coat the refractory die creating the
thinnest of layers prior to firing (Figure 16). Once the
masking ceramic was fired and properly covered the die
FIGURE 14. The shade is corrected to match that of the
preparation representing the discolored tooth stump final shade tab (left) versus the discolored stump shade (right).
shade (Figure 17), the veneering ceramic material was
layered uniformly on the refractory dies with the
appropriate dentin, enamel, and effect powders difference is seen in regard to hue, chroma, and
(Figures 18 and 19). After three build-up firing cycles, translucency between the two central incisor
the restorations were contoured, textured, glazed, and restorations (Figure 21). Even with the masking
polished (Figure 20). After devesting of the refractory fluorescent opacious dentin layer, there is light
die material from the veneer restorations, a noticeable transmission through the veneer restoration of tooth #9

© 2014 Wiley Periodicals, Inc. DOI 10.1111/jerd.12111 Journal of Esthetic and Restorative Dentistry Vol 26 • No 4 • 240–246 • 2014 243
 COLOR-MATCHING FOR NON-VITAL DISCOLORED TEETH Chu and Mieleszko

FIGURE 15. The master cast was duplicated in a refractory FIGURE 16. The opacious dentin powder blend was applied
material for veneer fabrication. to the refractory die of tooth #9, which was discolored.

FIGURE 17. Refractory die tooth #9 after firing and FIGURE 18. The same ceramic layering can be performed
sintering of the custom-blended ceramic. and applied to all the refractory dies equally since the stump
shade of tooth #9 was corrected prior. Dentin and effect
powders were added first.

FIGURE 19. Enamel and incisal effect powders were FIGURE 20. The definitive restorations was contoured,
layered. glazed, and polished on the refractory dies.

(Figure 22). The proximal contacts of the final veneer (Variolink, Ivoclar-Vivadent, Amherst, NY, USA) and
restorations were fitted and seated on the master Figures 24–26 represent 2-week post-healing of the soft
gypsum cast (Figure 23). The final restorations were tissues showing integration and harmony with all
cemented with a clear resin light-cured luting agent veneer restorations. The hue, chroma, opacity, and

244 Vol 26 • No 4 • 240–246 • 2014 Journal of Esthetic and Restorative Dentistry DOI 10.1111/jerd.12111 © 2014 Wiley Periodicals, Inc.
 COLOR-MATCHING FOR NON-VITAL DISCOLORED TEETH Chu and Mieleszko
FIGURE 21. The definitive restorations after devesting.
No-prep additive veneers were made in indirect laboratory
composite material (Gradia, GC America) to restore cuspid
guidance to teeth #6 and 11.
FIGURE 23. The final restoration seated on the master cast.
The master cast is used to adjust all proximal contacts. Notice
that tooth #9 veneer does not match because the color of
the gypsum cast is not representative of the actual stump
shade of tooth #9.
FIGURE 25. Right maximum intercuspal position intraoral
view of the restorations showing the incisal edge increase and
overbite of the right cuspid tooth #6.
© 2014 Wiley Periodicals, Inc. DOI 10.1111/jerd.12111
FIGURE 22. The shade difference between the maxillary
central veneers is noticeable yet even with the opacious
correction layered applied, the restorations allow light
transmission.
FIGURE 24. The definitive veneer restorations seated and
luted 1-week post-cementation. Note the seamless integration
of shade between the original discolored tooth #9 and the
adjacent restorations without sacrificing translucency and
vitality.
FIGURE 26. Left maximum intercuspal position intraoral
view of the restorations showing the incisal edge increase and
overbite of the right cuspid tooth #11.
Journal of Esthetic and Restorative Dentistry Vol 26 • No 4 • 240–246 • 2014 245
 COLOR-MATCHING FOR NON-VITAL DISCOLORED TEETH Chu and Mieleszko
brightness of the veneer restoration tooth #9 are
compatible matches to tooth #8 in all regard of esthetic
assimilation.
DISCLOSURE STATEMENT
The authors do not have any financial interest in the
companies whose materials are included in
this article.
REFERENCES
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sodium perborate preparations used for intracoronal
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246 Vol 26 • No 4 • 240–246 • 2014 Journal of Esthetic and Restorative Dentistry
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Reprint requests: Stephen J. Chu, DMD, MSD, CDT, NYCSD, 150 East
58th Street, Suite 3200, New York, NY 10155, USA; Tel.: 212-752-7937;
Fax: 212-754-6753; email: schudmd@gmail.com
DOI 10.1111/jerd.12111 © 2014 Wiley Periodicals, Inc.