Tooth color is determined by a combination of phenomena associated with optical properties and light. Essentially, tooth color is determined by the color of dentin and by intrinsic and extrinsic colorations. Intrinsic color is determined by the optical properties of enamel and dentin and their interaction with light. Extrinsic color depends on material absorption on the enamel surface. Any change in enamel, dentin, or coronal pulp structure can cause a change of the light-transmitting properties of the tooth – teeth discolouration.
Tooth discoloration varies in etiology, appearance, location, severity, and affinity to tooth structure. It can be classified as:
or a combination of both
according to its location and etiology.
The principal causes are chromogens (colour agent) derived from habitual intake of dietary sources, such as wine, coffee, tea, carrots, oranges, licorice, chocolate, or from tobacco, mouth rinses, or plaque on the tooth surface.
The most commonly used procedure to remove discoloration from a tooth surface is by using abrasives (such as prophylactic pastes) or a combination of abrasive and surface active agents such as toothpastes. These methods prevent stain accumulation and to a certain extent remove extrinsic stains; however, satisfactory stain removal depends on the type of discoloration. Unfortunately, the chemical interactions that determine the affinity of different types of materials that cause extrinsic dental stains are not well-understood.
Unlike extrinsic discolorations that occur on the surface, intrinsic discoloration is due to the presence of chromogenic (coloured) material within enamel or dentin, incorporated either during tooth developing (odontogenesis) or after eruption. This type of stain can be divided into 2 groups, preeruptive and posteruptive. The most common type of pre-eruptive staining is endemic fluorosis caused by excessive fluoride ingestion during tooth development. Post-eruptive stain usually associated with pulp problems such as pulp necrosis, or root canal material. Generally, intrinsic stain can be divided into:
Internal bleaching procedures are performed on devitalized (dead) teeth that have undergone root canal therapy (or RCT) but are discolored due to internal staining of the tooth structure by blood and other fluids that leached in. Unlike external bleaching, which brightens teeth from the outside in, internal bleaching brightens teeth from the inside out.
Bleaching the tooth internally involves drilling a hole to the pulp chamber, cleaning, sealing, and filling the root canal with a rubber-like substance, and placing a peroxide gel into the pulp chamber so the gel can work directly inside the tooth on the dentin layer.In this variation of whitening the peroxide is sealed within the tooth over a period of some days and replaced as needed, the so called “walking bleach” technique.
‘Walking bleach’ technique
Before treatment a radiograph would be made to check the quality of the root filling.
The quality and colour (shade) of any restoration present are assessed.
Tooth colour was evaluated and clinical photographs were taken at the beginning of and throughout the procedure.
Rubber dam should applied to isolate the treated tooth, to prevent reinfection of the root canal, and to protect the adjacent structures from the bleaching agent.
The restorative and the obutarating material was removed until below gum margin
A layer of cement was applied on top of the obturating material.
Bleaching agent: sodium perborate mixed with 30% hydrogen peroxide into paste form was be loaded into the pulp chamber of the tooth.
Finally, a temporary restoration was used to cover the cavity
The patient was rescheduled approximately 1 month later and the procedure was repeated 2 to three times.
External resorption – Internal bleaching occasionally induces external cervical root resorption. Chemicals combine with heat are likely cause necrosis of the cementum, inflammation of the periodontal ligament, and root resorption.
Crown (Coronal) fracture – Increased brittleness of the crown part of the tooth, particularly when heat is applied resulting in the tooth is more susceptible to fracture.
Chemical burn – 30% hydrogen peroxide is caustic and will cause chemical burns and sloughing of gingiva. Therefore, rubber dam is needed to protect the gum from chemical burn.
Even though internal bleaching can produce satisfactory result in most cases, no all will achieve the desirable result. Therefore, other options such as full porcelain crown, porcelain veneer will be the alternative to whiten non-vital tooth!!
Infection: Although rare, it does occur. The dentist may opt to prescribe antibiotics pre- and/or post-operatively if they determine the patient to be at risk.
Prolonged bleeding: The dentist has a variety of means at their disposal to address bleeding; however, it is important to note that small amounts of blood mixed in the saliva after extractions are normal, even up to 72 hours after extraction. Usually, however, bleeding will almost completely stop within eight hours of the surgery, with only minuscule amounts of blood mixed with saliva coming from the wound. A gauze compress will significantly reduce bleeding over a period of a few hours.
Swelling: Often dictated by the amount of surgery performed to extract a tooth (e.g. surgical insult to the tissues both hard and soft surrounding a tooth). Generally, when a surgical flap must be elevated (i.e. and the periosteum covering the bone is thus injured), minor to moderate swelling will occur. A poorly-cut soft tissue flap, for instance, where the periosteum is torn off rather than cleanly elevated off the underlying bone, will often increase such swelling. Similarly, when bone must be removed using a drill, more swelling is likely to occur.
Sinus exposure and oral-antral communication: This can occur when extracting upper molars (and in some patients, upper premolars). The maxillary sinus sits right above the roots of maxillary molars and premolars. There is a bony floor of the sinus dividing the tooth socket from the sinus itself. This bone can range from thick to thin from tooth to tooth from patient to patient. In some cases it is absent and the root is in fact in the sinus. At other times, this bone may be removed with the tooth, or may be perforated during surgical extractions. The doctor typically mentions this risk to patients, based on evaluation of radiographs showing the relationship of the tooth to the sinus. It is important to note that the sinus cavity is lined with a membrane called the Sniderian membrane, which may or may not be perforated. If this membrane is exposed after an extraction, but remains intact, a “sinus exposed” has occurred. If the membrane is perforated, however, it is a “sinus communication”. These two conditions are treated differently. In the event of a sinus communication, the dentist may decide to let it heal on its own or may need to surgically obtain primary closure—depending on the size of the exposure as well as the likelihood of the patient to heal. In both cases, a resorbable material called “gelfoam” is typically placed in the extraction site to promote clotting and serve as a framework for granulation tissue to accumulate. Patients are typically provided with prescriptions for antibiotics that cover sinus bacterial flora, decongestants, as well as careful instructions to follow during the healing period.
Nerve injury: This is primarily an issue with extraction of third molars, but can occur with the extraction of any tooth should the nerve be close to the surgical site. Two nerves are typically of concern, and are found in duplicate (one left and one right): 1. the inferior alveolar nerve, which enters the mandible at the mandibular foramen and exits the mandible at the sides of the chin from the mental foramen. This nerve supplies sensation to the lower teeth on the right or left half of the dental arch, as well as sense of touch to the right or left half of the chin and lower lip. 2. The lingual nerve (one right and one left), which branches off the mandibular branches of the trigeminal nerve and courses just inside the jaw bone, entering the tongue and supplying sense of touch and taste to the right and left half of the anterior 2/3 of the tongue as well as the lingual gingiva (i.e. the gums on the inside surface of the dental arch). Such injuries can occur while lifting teeth (typically the inferior alveolar), but are most commonly caused by inadvertent damage with a surgical drill. Such injuries are rare and are usually temporary, but depending on the type of injury (i.e. Seddon classification: neuropraxia, axonotmesis, & neurotmesis), can be prolonged or even permanent.
Displacement of tooth or part of tooth into the maxillary sinus (upper teeth only). In such cases, almost always the tooth or tooth fragment must be retrieved. In some cases, the sinus cavity can be irrigated with saline (antral lavage) and the tooth fragment may be brought back to the site of the opening through which it entered the sinus, and may be retrievable. At other times, a window must be made into the sinus in the Canine fossa–a procedure referred to as “Caldwell luc”.
Dry socket (Alveolar osteitis) is a painful phenomenon that most commonly occurs a few days following the removal of mandibular (lower) wisdom teeth. It is commonly believed that it occurs because the blood clot within the healing tooth extraction site is disrupted. More likely,alveolar osteitis is a phenomenon of painful inflammation within the empty tooth socket because of the relatively poor blood supply to this area of the mandible (which explains why dry socket is usually not experienced in other parts of the jaws). Inflamed alveolar bone, unprotected and exposed to the oral environment after tooth extraction, can become packed with food and debris. A dry socket typically causes a sharp and sudden increase in pain commencing 2–5 days following the extraction of a mandibular molar, most commonly the third molar. This is often extremely unpleasant for the patient; the only symptom of dry socket is pain, which often radiates up and down the head and neck. A dry socket is not an infection, and is not directly associated with swelling because it occurs entirely within bone — it is a phenomenon of inflammation within the bony lining of an empty tooth socket. Because dry socket is not an infection, the use of antibiotics has no effect on its rate of occurrence. The risk factor for alveolar osteitis can dramatically increase with smoking after an extraction.
Bone fragments Particularly when extraction of molars is involved, it is not uncommon for the bones which formerly supported the tooth to shift and in some cases to erupt through the gums, presenting protruding sharp edges which can irritate the tongue and cause discomfort. This is distinguished from a similar phenomena where broken fragments of bone or tooth left over from the extraction can also protrude through the gums. In the latter case, the fragments will usually work their way out on their own. In the former case, the protrusions can either be snipped off by the dentist, or eventually the exposed bone will erode away on its own.
Bone graft is a material that used to replace missing bone or bone defect in the face and mouth region, particularly in jaw area for support of implant during implant placement. Bone graft can also be use support the cheek or the chin area for aesthetic reasons.
Usage of bone graft in dentistry:
Orthognathic (Corrective jaw surgery) Surgery
Alveolar Bone Grafting (ABG) procedure in cleft patient
Periodontal surgery (eg. Guided Bone Regeneration)
In implant dentistry, bone grafts are widely used in:
To preserve the socket after dental extraction of implant placement later
To repair defect after dental extraction
To cover exposed implant fixture during implant placement
Bone augmentation is a term that describes a variety of procedures used to “build” bone so that dental implants can be placed.
When do we use bone graft in implant surgery?
Bone graft is used when there is not enough of bone at the site where implant is intended to be placed. Usually, when the width or the height of the jaw bone is not enough to support the placement of implant.
Bone graft can be obtain from outside or from patient’s own bone (autologous bone). Autologous bone is the best bone to substitute missing bone due to its high survival rate and its capability of attract new bone formation.
Bone graft sources
Autograft (Autogenous Bone)
Autologous bone grafting involve taking bone graft from patient’s bone of the same individual who is receiving the graft. Bone can be harvested from intra-oral (in mouth) or extra-oral (outside the mouth); example iliac crest, rib, cavarium.
In oral and maxillofacial surgery, bones are harvested extra-oral under general anaesthesia to repair alveolus in cleft patient, reconstruct mandible or maxilla after tumor resection, condyle reconstruction etc.
In implant dentistry, the usual site in the mouth that used to get bone graft (Donor site) usually depends on surgeon preference, the quality and quantity required:
External oblique ridge (bone behind the lower last molar)
Tuberosity (bone behind the upper last molar)
Advantages of autograft:
Less rejection because graft originated from the patient’s own body
The graft doesn’t carry any disease
Using autograft bone as grafting material produce the highest successful outcome and predictability because the graft is a vital (living) bone which has the property of osteoinductive and osteogenic, as well as osteoconductive to regenerate new bone.
Additional surgical site is required (2 site surgery)
Post-operative pain and complications
Allograft bone, like autogenous bone, is derived from humans; the difference is that allograft is harvested from an individual other than the one receiving the graft. Allograft bone can be taken from cadavers that have donated their bone so that it can be used for living people who are in need of it.
There are three types of bone allograft available:
Fresh or fresh-frozen bone
Freeze-dried bone allograft (FDBA)
Demineralized freeze-dried bone allograft (DFDBA)
Allograft bone used in dentistry uses bone from cadaver that undergo process of removal of unwanted material such as fats, cells, antigens, and inactivates pathogens, while preserving the valuable minerals and collagen matrix. This material is than freeze-dried before package.
Advantages of allograft:
Less antigenic rejection because allogaft bone originated from the same species
No need additional surgical site is required (2 site surgery)
The success of grafting using allograft will be lesser than autograft as the material used is basically a dead tissues
However, this material still carry property of osteoinductive and osteoconductive to regenerate new bone
Allograft bone might carry certain unknown diseases that resist the cleaning process during preparation of the graft
The graft usually resorb faster than xenograft material
Additional cost to the surgery
Xenograft bone substitute has its origin from a species other than human, such as bovine bone (or recently porcine bone) which can be freeze dried or demineralized and deproteinized. This material still has the property of osteoinductive and osteoconductive to regenerate new bone.
Advantages of xenograft:
No need additional surgical site is required (2 site surgery)
This material still carry bone regeneration property of osteoinductive and osteoconductive.
However, success of grafting using xenograft will be lesser than autograft as the material used is basically a dead tissues
Xenograft material last longer in the mouth therefore, it with maintain the bone thickness for years
Just like allograft, xenograft material might carry certain unknown diseases that resist the cleaning process during preparation of the graft
Additional cost to the surgery
Alloplastic grafts may be made from hydroxylapatite, a naturally occurring mineral that is also the main mineral component of bone. They may be made from bioactive glass. Hydroxylapatite is a Synthetic Bone Graft, which is the most used now among other synthetic due to its osteoconduction, hardness and acceptability by bone.
Some synthetic bone graft are made of calcium carbonate, which start to decrease in usagebecause it is completely resorbable in short time which make the bone easy to break again.
Tricalcium phosphate which now used in combination with hydroxylapatite thus give both effect osteoconduction and resorbability.
Polymers such as some microporous grades of PMMA and various other acrylates (such as polyhydroxylethylmethacrylate aka PHEMA), coated with calcium hydroxide for adhesion, are also used as alloplastic grafts for their inhibition of infection and their mechanical resilience and biocompatibility. Calcifying marine algae such as Corallina officinalis have a fluorohydroxyapatitic composition whose structure is similar to human bone and offers gradual resorption, thus it is treated and standardized as “FHA (Fluoro-hydroxy-apatitic) biomaterial” alloplastic bone grafts.
Properties of various types of bone graft sources.
Bone grafting is possible because bone tissue, unlike most other tissues, has the ability to regenerate completely if provided the space into which to grow. As native bone grows, it will generally replace the graft material completely, resulting in a fully integrated region of new bone. The biologic mechanisms that provide a rationale for bone grafting are osteoconduction, osteoinduction and osteogenesis.
Osteoconduction occurs when the bone graft material serves as a scaffold for new bone growth that is perpetuated by the native bone. Osteoblasts from the margin of the defect that is being grafted utilize the bone graft material as a framework upon which to spread and generate new bone. In the very least, a bone graft material should be osteoconductive.
Osteoinduction involves the stimulation of osteoprogenitor cells to differentiate into osteoblasts that then begin new bone formation. The most widely studied type of osteoinductive cell mediators are bone morphogenetic proteins (BMPs). A bone graft material that is osteoconductive and osteoinductive will not only serve as a scaffold for currently existing osteoblasts but will also trigger the formation of new osteoblasts, theoretically promoting faster integration of the graft.
Osteopromotion involves the enhancement of osteoinduction without the possession of osteoinductive properties. For example, enamel matrix derivative has been shown to enhance the osteoinductive effect of demineralized freeze dried bone allograft (DFDBA), but will not stimulate de novo bone growth alone.
Osteogenesis occurs when vital osteoblasts originating from the bone graft material contribute to new bone growth along with bone growth generated via the other two mechanisms.
Air polishing is an alternative, non-contact, method of polishing teeth using a polishing cup and paste after teeth scaling. It requires a special ultrasonic unit (e.g. Air Flow from EMS) that allows use of this insert in the handpiece.
Air polishing uses medical-grade sodium bicarbonate and water in a jet of compressed air to “sandblast” the surface of the enamel smooth. Examples include the Prophy-Jet® and Cavitron Jet® (Dentsply Ltd.). The nozzle is held 3 to 5 mm from the tooth, centred on the middle third of the tooth. Use at 60° to the long axis of the root. Do not direct into the gingival sulcus.
The Zoom! ™ In-Office Whitening System is a revolutionary tooth whitening procedure. It’s safe, effective and fast, very fast. In just over an hour, your teeth will be dramatically whiter. Zoom!™ Whitening is ideal for anyone looking for immediate results. The convenience of Zoom!™ in comparison to days of wearing trays and gradual whitening makes it the perfect choice for the busy individual.
Get ready to Zoom!
The Zoom! ™ Whitening procedure is simple and painless. It begins with a short preparation to isolate your lips and gums. The Zoom! ™ clinician then applies the proprietary Zoom!™ Whitening Gel, which is activated by a specially designed light. Teeth typically become at least six to ten shades whiter, sometimes more. A fiveminute fluoride treatment completes the procedure. You’ll be amazed with the results. In most cases, teeth get even whiter the first few days after the procedure.
How Zoom! works
The Zoom!™ light activated gel was developed after years of research by Discus Dental, the leaders in professional take-home tooth whitening. The gel is a scientifically formulated, pH balanced Hydrogen Peroxide that, when activated by the Zoom!™ light, gently penetrates the teeth to remove deep stains and discoloration. With proper care and an occasional touch-up at home, your whiter smile will sparkle for years.
Zoom! Teeth Whitening procedure
The Zoom! Whitening procedure is simple. It begins with a short preparation to isolate your lips and gums.
The accredited and trained dentist then applies the proprietary Zoom Whitening Gel, which is activated by a specially designed light.
Teeth typically become at least six to twelve shades whiter, sometimes more. A fluoride treatment for a few minutes completes the procedure. You’ll be amazed with the results. In most cases, teeth get even whiter the first few days after the procedure. We recommend a consultation and a thorough clean around one or two weeks before the Zoom! Teeth Whitening procedure if you have tartar or superficial stains.
Tune in to Zoom!
Ask your dental professional how the Zoom!™ In-office Whitening System will work for you. Take your first step to feeling good, looking great and making a memorable impression every time you smile. You owe it to yourself!
Frequent Asked Questions
Q. What is Zoom!™ tooth whitening?
A. Zoom!™ is a bleaching process that lightens discoloration of enamel and dentin.
Q. What causes tooth discoloration?
A. There are many causes. The most common include aging and consumption of staining substances such as coffee, tea, colas, tobacco, red wine, etc. During tooth formation, consumption of tetracycline, certain antibiotics or excessive fluoride may also cause tooth discoloration.
Q. Who may benefit from tooth whitening?
A. Almost anyone. However, treatment may not be as effective for some as it is for others. Your dental professional can determine if you are a viable candidate for this procedure through a thorough oral exam, including a shade assessment.
Q. Do many people whiten their teeth?
A. More people than you might imagine. A bright, sparkling smile can make a big difference for everyone. The Zoom!™ Whitening System makes it easier and faster than ever before.
Q. Is whitening safe?
A. Yes, extensive research and clinical studies indicate that whitening teeth under the supervision of a dentist is safe. In fact, many dentists consider whitening the safest cosmetic dental procedure available. As with any tooth whitening product, Zoom!™ is not recommended for children under 13 years of age and pregnant or lactating women.
Q. How does Zoom!™ work?
A. The Zoom!™ light-activated whitening gel’s active ingredient is Hydrogen Peroxide. As the Hydrogen Peroxide gel is broken down, oxygen enters the enamel and dentin bleaching colored substances, while the structure of the tooth is unchanged.
Q. What does a patient experience during the Zoom!™ procedure?
A. During the procedure, patients may comfortably watch television or listen to music. Many actually fall asleep. Individuals with a strong gag reflex or anxiety may have difficulty undergoing the entire procedure.
Q. How is exposure to the Zoom!™ light controlled?
A. The Zoom!™ procedure requires that all soft tissue in and around the mouth be protected. The clinician is required to monitor the procedure to insure any exposed skin or tissue is isolated and protected. Protective eyewear is required during the procedure. Light sensitive individuals including those undergoing PUVA therapy (Psoralen+UV Radiation) or other photochemotherapy, as well as patients with melanoma, should not undergo the Zoom!™ in-office procedure. Also, patients taking any light sensitive drugs or substances, whether over-the-counter, prescription or homeopathic, should consult their primary physician prior to procedure.
Q. How long does Zoom!™ Whitening take?
A. The complete procedure takes just over an hour. The procedure begins with a preparation period followed by one hour of bleaching. A five minute fluoride treatment completes the procedure. (A cleaning is recommended prior to the actual Zoom!™ Whitening session)
Q. Are there any side effects?
A. Sensitivity during the treatment may occur with some patients. The Zoom!™ light generates minimal heat which is the usual source for discomfort. On rare occasions, minor tingling sensations are experienced immediately after the procedure but always dissipate.
Q. How white will my teeth become ?
A. The results are spectacular. Clinical studies have shown that the Zoom teeth whitening treatment achieves up to 12 shades lighter with the average being 8 shades (On Vita-Shade guide). Individual results may vary and will depend upon your age, type of stain, initial tooth colour and any visible restorations (White fillings, crowns etc). Please ask our qualified dental staff how much whiter your teeth can be and we will show you what is possible on a tooth shade guide as shown below.To boost your results we recommend using custom made whitening trays for only 30 minutes a day for 5 to 10 days.
Some whitening clinics will only recommend either surgery whitening or home whitening. We have found that combining both methods is the best way to get the most dramatic results and keep them for life.
Q. How long do the results last?
A. By following the Zoom!™ Post Whitening Care Instructions, your teeth will always be lighter than they were prior to the procedure. The Zoom!™ whitening procedure includes a take-home touch-up kit and trays that can be used whenever discoloration is noticed. Most often a touch-up once a year will maintain a whiter smile that sparkles for years.
A Note of Assurance
Tooth whitening is a well-established procedure in cosmetic dentistry. Hydrogen Peroxide, the active agent in Zoom!,™ has also been safely used for many years in the treatment of gums and other oral soft tissue. The whitening process is effective on most discolored teeth. Darker stains, such as those caused by antibiotics, are more difficult to whiten. The degree of whiteness will vary from patient to patient, depending on the structure of the teeth. If you have any questions, please ask your dental professional who is there to help maximize your smile using the Zoom!™ Whitening System.
Electrosurgery is the application of a high-frequency electric current to biological tissue as a means to cut, coagulate, desiccate, or fulgurate tissue. (These terms are used in specific ways for this methodology—see below). Its benefits include the ability to make precise cuts with limited blood loss. Electrosurgical devices are frequently used during surgical operations helping to prevent blood loss in hospital operating rooms or in outpatient procedures.
In electrosurgical procedures, the tissue is heated by an electric current. Although electrical devices may be used for the cauterization of tissue in some applications, electrosurgery is usually used to refer to a quite different method than electrocautery. The latter uses heat conduction from a probe heated to a glowing temperature by a direct current (much in the manner of a soldering iron). This may be accomplished by direct current from dry-cells in a penlight-type device. Electrosurgery, by contrast, uses alternating current to directly heat the tissue itself. When this results in destruction of small blood vessels and halting of bleeding, it is technically a process of electrocoagulation, although “electrocautery” is sometimes loosely and nontechnically used to describe it. (Source from Wiakipidia)
Using electrosurgery in oral surgery procedures
Electrocautery is a very useful tool to make a cut or excise soft tissue just like a scaple blade does. While a cut is made; at the same time, electrosurgery coagulate the surrounding blood vessels make surgery bloodless. This will improve visibility during surgery and less blood loss. More over, healing of a wound with electrosurgery is proven to be faster that wound made by scaple blade.
Dental procedure which can be done with
Excision of lesions (eg. cysts, tumors)
Coagulating the gum area before impression taking during tooth preparation for crowns/bridges
Advantages of using electrocautery
Can be use to control bleeding
Wound heal faster with electrosurgery than using scaple blade