Pain, anxiety, and catastrophizing among pregnant women with dental pain, undergoing root canal treatment.

This prospective study aims to evaluate dental pain, anxiety, and catastrophizing levels in pregnant women undergoing root canal treatment. Sixty pregnant and non-pregnant women presenting dental pain and an indication for root canal treatment were included in the study. Dental anxiety and catastrophizing were investigated using validated questionnaires. The endodontic intervention was performed, and a numerical scale measured preoperative and postoperative dental pain. The results were analyzed using STATA software 12.0. Unadjusted analyses assessed the association between pregnancy and pain, anxiety, and catastrophizing levels. Multiple linear regression models using 'forward stepwise' entry procedures were used to assess the independent effects of variables on pain scores. The significance level was set at 0.05. Initially, most patients experienced intense dental pain. The levels of dental pain, dental anxiety, and catastrophizing did not differ between pregnant and non-pregnant women. Logistic regression showed that postoperative pain was associated with irreversible pulpitis diagnosis (OR = 4.78; 95%CI 1.55-13.55) and high catastrophizing levels (OR = 1.96; 95%CI 1.01-3.84). Preoperative and postoperative pain rates and anxiety and catastrophizing were similar between pregnant and non-pregnant patients. Postoperative pain was associated with irreversible pulpitis diagnosis and high catastrophizing levels. The similarity between pregnant and non-pregnant women regarding preoperative and postoperative dental pain and catastrophizing and anxiety levels supports the indication of root canal treatment during the gestational period whenever necessary.

Pain, anxiety, and catastrophizing among pregnant women with dental pain, undergoing root canal treatment

Abstract This prospective study aims to evaluate dental pain, anxiety, and catastrophizing levels in pregnant women undergoing root canal treatment. Sixty pregnant and non-pregnant women presenting dental pain and an indication for root canal treatment were included in the study. Dental anxiety and catastrophizing were investigated using validated questionnaires. The endodontic intervention was performed, and a numerical scale measured preoperative and postoperative dental pain. The results were analyzed using STATA software 12.0. Unadjusted analyses assessed the association between pregnancy and pain, anxiety, and catastrophizing levels. Multiple linear regression models using 'forward stepwise' entry procedures were used to assess the independent effects of variables on pain scores. The significance level was set at 0.05. Initially, most patients experienced intense dental pain. The levels of dental pain, dental anxiety, and catastrophizing did not differ between pregnant and non-pregnant women. Logistic regression showed that postoperative pain was associated with irreversible pulpitis diagnosis (OR = 4.78; 95%CI 1.55-13.55) and high catastrophizing levels (OR = 1.96; 95%CI 1.01-3.84). Preoperative and postoperative pain rates and anxiety and catastrophizing were similar between pregnant and non-pregnant patients. Postoperative pain was associated with irreversible pulpitis diagnosis and high catastrophizing levels. The similarity between pregnant and non-pregnant women regarding preoperative and postoperative dental pain and catastrophizing and anxiety levels supports the indication of root canal treatment during the gestational period whenever necessary.

Postoperative pain after endodontic reintervention: a randomized clinical trial

Resumo O objetivo deste ensaio clínico randomizado foi comparar a prevalência e a intensidade da dor pós-operatória em casos de retratamento endodôntico, utilizando instrumentos manuais ou reciprocantes (automatizados). O tempo necessário para desobturação e reinstrumentação do canal radicular também foi avaliado. Quarenta e oito indivíduos possuindo um dente unirradicular tratado endodonticamente e portador de periodontite apical assintomática foram incluídos no estudo. Os pacientes foram aleatoriamente distribuídos em dois grupos (n=24/grupo): retratamento com instrumentos manuais de aço inoxidável ou um sistema reciprocante de níquel-titânio (Reciproc; VDW, Munique, Alemanha). A reintervenção endodôntica foi realizada em duas consultas, sendo aplicada medicação intracanal à base de hidróxido de cálcio por 14 dias, antes da obturação. O tempo clínico gasto com os protocolos de desobturação e reinstrumentação do canal radicular foi registrado com um cronômetro digital. Após cada visita, a intensidade da dor pós-operatória foi avaliada em 12, 24, 48 horas e 7 dias por meio da escala de estimativa numérica (Numerical Rating Scale - NRS). Além do registro da dor, os pacientes foram questionados quanto ao uso de analgésicos. Os dados obtidos foram analisados por testes Qui-quadrado e Mann-Whitney (α=0.05). Não foi detectada diferença significativa entre os grupos quanto à prevalência e intensidade da dor ou uso de analgésicos em nenhum dos períodos avaliados. O tempo clínico foi significativamente menor no grupo reciprocante (18 versus 41 minutos). Pode-se concluir que os instrumentos manuais e reciprocantes foram equivalentes quanto à prevalência e intensidade de dor pós-operatória e uso de analgésicos, mas a desobturação e reinstrumentação do canal radicular foram duas vezes mais rápidas com o sistema reciprocante.

Abstract The present randomized clinical trial compared the prevalence and intensity of postoperative pain in cases of endodontic reintervention using manual or engine-driven reciprocating instruments. As secondary objectives, the analgesic intake and time required for the root canal filling removal and re-instrumentation were also evaluated. Forty-eight individuals with an endodontically treated single-rooted tooth diagnosed with asymptomatic apical periodontitis were included in the study. Patients were randomly assigned to two comparison groups (n=24/group): reintervention with stainless steel manual instruments or a nickel-titanium reciprocating system (Reciproc; VDW, Munich, Germany). The endodontic reintervention was performed in two sessions with a calcium hydroxide-based intracanal medication applied for 14 days before root canal obturation. Working time for the root canal filling removal and re-instrumentation was recorded with a digital stopwatch. After each visit, postoperative pain intensity was assessed at 12, 24, and 48 hours and seven days using the Numerical Rating Scale (NRS). The patients were also asked about analgesic intake. Data were analyzed using Pearson chi-square, T and Mann-Whitney U tests (α=0.05). No significant differences between groups were found regarding the prevalence and intensity of pain or the need for analgesic intake at any time point (P > 0.05). Working time was significantly shorter in the reciprocating group (18 versus 41 minutes). In conclusion, manual and reciprocating instruments achieved the same results in terms of prevalence and intensity of postoperative pain and analgesic intake. However, filling material removal and re-instrumentation of the root canals were more than twice as fast when using the reciprocating system.

Postoperative pain after endodontic reintervention: a randomized clinical trial.

The present randomized clinical trial compared the prevalence and intensity of postoperative pain in cases of endodontic reintervention using manual or engine-driven reciprocating instruments. As secondary objectives, the analgesic intake and time required for the root canal filling removal and re-instrumentation were also evaluated. Forty-eight individuals with an endodontically treated single-rooted tooth diagnosed with asymptomatic apical periodontitis were included in the study. Patients were randomly assigned to two comparison groups (n=24/group): reintervention with stainless steel manual instruments or a nickel-titanium reciprocating system (Reciproc; VDW, Munich, Germany). The endodontic reintervention was performed in two sessions with a calcium hydroxide-based intracanal medication applied for 14 days before root canal obturation. Working time for the root canal filling removal and re-instrumentation was recorded with a digital stopwatch. After each visit, postoperative pain intensity was assessed at 12, 24, and 48 hours and seven days using the Numerical Rating Scale (NRS). The patients were also asked about analgesic intake. Data were analyzed using Pearson chi-square, T and Mann-Whitney U tests (α=0.05). No significant differences between groups were found regarding the prevalence and intensity of pain or the need for analgesic intake at any time point (P > 0.05). Working time was significantly shorter in the reciprocating group (18 versus 41 minutes). In conclusion, manual and reciprocating instruments achieved the same results in terms of prevalence and intensity of postoperative pain and analgesic intake. However, filling material removal and re-instrumentation of the root canals were more than twice as fast when using the reciprocating system.

O objetivo deste ensaio clínico randomizado foi comparar a prevalência e a intensidade da dor pós-operatória em casos de retratamento endodôntico, utilizando instrumentos manuais ou reciprocantes (automatizados). O tempo necessário para desobturação e reinstrumentação do canal radicular também foi avaliado. Quarenta e oito indivíduos possuindo um dente unirradicular tratado endodonticamente e portador de periodontite apical assintomática foram incluídos no estudo. Os pacientes foram aleatoriamente distribuídos em dois grupos (n=24/grupo): retratamento com instrumentos manuais de aço inoxidável ou um sistema reciprocante de níquel-titânio (Reciproc; VDW, Munique, Alemanha). A reintervenção endodôntica foi realizada em duas consultas, sendo aplicada medicação intracanal à base de hidróxido de cálcio por 14 dias, antes da obturação. O tempo clínico gasto com os protocolos de desobturação e reinstrumentação do canal radicular foi registrado com um cronômetro digital. Após cada visita, a intensidade da dor pós-operatória foi avaliada em 12, 24, 48 horas e 7 dias por meio da escala de estimativa numérica (Numerical Rating Scale - NRS). Além do registro da dor, os pacientes foram questionados quanto ao uso de analgésicos. Os dados obtidos foram analisados por testes Qui-quadrado e Mann-Whitney (α=0.05). Não foi detectada diferença significativa entre os grupos quanto à prevalência e intensidade da dor ou uso de analgésicos em nenhum dos períodos avaliados. O tempo clínico foi significativamente menor no grupo reciprocante (18 versus 41 minutos). Pode-se concluir que os instrumentos manuais e reciprocantes foram equivalentes quanto à prevalência e intensidade de dor pós-operatória e uso de analgésicos, mas a desobturação e reinstrumentação do canal radicular foram duas vezes mais rápidas com o sistema reciprocante.

Endodontic treatment during pregnancy: case series and literature review / Tratamento endodôntico na gestação: série de casos e revisão da literatura

ABSTRACT The aim of this paper is to provide a scientific basis for conducting safe root canal treatment in pregnant women, illustrating with case reports treated in the extension project Maternal-Child Dental Care at the Federal University of Pelotas. The scientific bases address the main doubts of professionals when performing prenatal dental care: use of radiographic examination, local anesthetics, prescription of medications, among other essential factors in the care of pregnant women. The assisted pregnant women sought care with dental pain. In two cases symptomatic irreversible pulpitis was diagnosed, while a third was experiencing acute apical periodontitis. Endodontic procedures were performed under controlled and standardized conditions. The root canals were prepared in a single session, using mechanical instrumentation with reciprocating kinematics (Wave One® Gold Primary - Dentsply Sirona), and the root canal length was determined by an electronic apex locator FinePex (Schuster). Root canal filling was performed by the single cone technique with Wave One® gutta-percha points. After endodontic treatment, coronal sealing was performed with composite resin A2 Z350 XT (3M ESPE). The care related to the gestational condition is highlighted, and the patients remain under monitoring. It is concluded that the use of apical locators and mechanical instrumentation, using reciprocating files associated with the single cone obturation technique with a standardized cone for each system, represents advances for the accomplishment of endodontic treatment in pregnant patients due to the shorter clinical time and greater comfort of the procedure.

RESUMO O objetivo deste trabalho é fornecer embasamento científico para condução do tratamento endodôntico em gestantes através de uma revisão de literatura e série de casos clínicos conduzidos em sessão única no projeto de extensão Atenção Odontológica Materno-infantil da Faculdade de Odontologia da Universidade Federal de Pelotas. As bases científicas abordam as principais dúvidas do profissional na condução do pré-natal odontológico: uso do exame radiográfico, anestésico local, prescrição de medicamentos, entre outros fatores essenciais no atendimento da gestante. As gestantes assistidas procuraram atendimento apresentando dor de origem dentária. Em dois casos foi diagnosticado pulpite irreversível sintomática, enquanto um terceiro se travava de periodontite apical aguda. Os procedimentos endodônticos foram realizados sob condições controladas e padronizadas, sob supervisão de um professor de Endodontia. O preparo dos canais radiculares foi realizado em sessão única, através de instrumentação mecanizada de cinemática reciprocante (Wave One® Gold Primary (Dentsply Sirona), sendo o comprimento dos canais determinado por meio de localizador foraminal FinePex (Schuster). A obturação dos canais foi realizada pela técnica do cone único com cones do sistema Wave One®. Após o tratamento endodôntico foi realizada blindagem coronária com resina composta cor A2 Z350 XT (3M ESPE). Os cuidados relacionados à condição gestacional estão destacados, sendo que as pacientes permanecem em acompanhamento no projeto. Conclui-se que o uso de localizadores foraminais e da instrumentação mecanizada, utilizando limas reciprocantes associadas à técnica de obturação com cone único padronizado para cada sistema representam avanços para a realização do tratamento endodôntico em pacientes gestantes devido ao menor tempo clínico e maior conforto do procedimento.

Effect of number of uses and sterilization on the instrumented area and resistance of reciprocating instruments.

OBJECTIVES: This study evaluated the effect of repeated uses and autoclaving in the instrumented area, fracture resistance, and time of instrumentation of thermally treated nickel-titanium reciprocating systems. MATERIALS AND METHODS: Two hundred simulated canals were instrumented using Reciproc Blue and WaveOne Gold. Each file was used up to 10 times or until fracture. The instrumented area was measured in pre- and post-operative images, using ImageJ software. Kaplan-Meier survival analysis evaluated the number of uses of instruments before fracture. Instrumented area and time of instrumentation were analyzed by Mann-Whitney U test and Kruskal-Wallis. Correlations among the number of uses and instrumented area were measured. The level of statistical significance was set at p < 0.05. RESULTS: Reciproc Blue presented a higher estimated number of uses in comparison with WaveOne Gold (p = 0.026), but autoclaving did not affect the resistance to fracture of instruments (p > 0.05). The instrumented area was different among the evaluated groups (p = 0.039), and the instrumented area along the uses of both tested instruments was reduced. With the time of instrumentation, there was also a significant difference among the evaluated groups; the groups without sterilization cycles were faster, in comparison to those submitted to autoclaving (p = 0.010). CONCLUSIONS: Reciproc Blue was more resistant than WaveOne Gold, suffering later fracture. Additionally, the sterilization cycles did not influence the estimated number of uses of thermally treated reciprocating instruments, but the instrumented area of root canals was reduced along with the repeated uses of both instruments.

Fatores preditivos do sucesso en dodôntico em tratamentos realizados por alunos de graduação§ / Predictive factors of endodontic success in treatments performed by undergraduate / Factores predictivos del éxito endodontico en tratamientos realizados por un estudiante

Resumo Introdução e objetivo: Ainda são escassos os estudos que avaliam com exatidão o sucesso do tratamento e retratamento endodônticos e quais as falhas que realmente impactam no desfecho dos mesmos. Determinar o índice e os fatores preditivos para o sucesso de tratamentos e retratamentos endodônticos, realizados por alunos de graduação com o mesmo nível de aprendizado. Materiais e métodos: Foram verificados os registros de proservação, com pelo menos 12 meses, dos tratamentos endodônticos realizados na Faculdade de Odontologia de Pelotas, analisando o sucesso ou o fracasso endodôntico, de acordo com critérios clínicos e radiográficos. As variáveis preditivas no resultado do sucesso do tratamento foram: dente, número de canais, coroa dentária, sintomas, diagnóstico da polpa e índice periapical radiográfico. As variáveis relacionadas ao tratamento foram: técnica de instrumentação, número de sessões e limite de instrumentação apical. Resultados: 136 tratamentos endodônticos foram realizados com um acompanhamento de, pelo menos, 12 meses. A avaliação mostrou que o sucesso endodôntico foi influenciado pelo número de sessões (P = 0,015), diagnóstico inicial e grupo dentário (P= 0.014). Também foi possível observar que, quanto maior o índice periapical radiográfico inicial, pior o prognóstico endodôntico (P < 0.001). Conclusão: O índice de sucesso do tratamento endodôntico foi de 96.7% para casos de polpa vital, 87.5% para os casos de necrose pulpar e 92.9% em retratamentos. Estes índices foram influenciados pelo dente tratado, diagnóstico inicial, índice periapical radiográfico inicial e pelo número de sessões utilizadas no tratamento.

Abstract Introduction and objective: There are still few studies that accurately address endodontic success and which failures actually impact the endodontic treatment outcome. Determine success rate and predictive factors for successful endodontic treatment and retreatment by undergraduate students of the same learning level. Materials and methods: The preservation records (12 months) of the endodontic treatments performed in the Faculty of Dentistry of Pelotas were verified, indicating the success or failure of the treatment. Predictive variables in the outcome of successful endodontic treatment or retreatment were: tooth, number of channels, dental crown, symptoms, pulp diagnosis, radiographic periapical index. The treatmentrelated variables were: instrumentation technique, number of sessions and apical instrumentation limit. Results: 136 endodontic treatments were performed with a follow-up of at least 12 months. The evaluation showed that endodontic success was influenced by the number of sessions (P = 0.015), initial diagnosis and dental group (P = 0.014). It was also observed that the higher the initial radiographic periapical index, the worse the endodontic prognosis (P < 0.001). Conclusion: The success rate of endodontic treatment was 96.7% for cases of vital pulp, 87.5% for cases of pulp necrosis and 92.9% for retreatments. These indices were influenced by type tooth, initial diagnosis, initial radiographic periapical index and the number of visits used in the treatment.

Resumen Introducción y objetivo: Todavía hay pocos estudios que aborden con precisión el éxito endodóntico y cuáles fracasos realmente impactan el resultado del tratamiento endodóntico. Determinar la tasa de éxito y los factores predictivos para el tratamiento y el retratamiento exitoso de endodoncia por estudiantes universitarios del mismo nivel de aprendizaje. Materiales y métodos: Se verificaron los registros de conservación (12 meses) de los tratamientos de endodoncia realizados en la Facultad de Odontología de Pelotas, lo que indica el éxito o el fracaso del tratamiento. Las variables predictivas en el resultado de un tratamiento o retratamiento endodóntico exitoso fueron: diente, número de canales, corona dental, síntomas, diagnóstico pulpar, índice periapical radiográfico. Las variables relacionadas con el tratamiento fueron: técnica de instrumentación, número de sesiones y límite de instrumentación apical. Resultados: se realizaron 136 tratamientos de endodoncia con un seguimiento de al menos 12 meses. La evaluación mostró que el éxito endodóntico estaba influenciado por el número de sesiones (P = 0.015), el diagnóstico inicial y el grupo dental (P = 0.014). También se observó que cuanto mayor es el índice periapical radiográfico inicial, peor es el pronóstico endodóntico (P <0.001). Conclusión: La tasa de éxito del tratamiento endodóntico fue del 96.7% para casos de pulpa vital, 87.5% para casos de necrosis pulpar y 92.9% para retratamientos. Estos índices fueron influenciados por el tipo de diente, el diagnóstico inicial, el índice periapical radiográfico inicial y el número de visitas utilizadas en el tratamiento.

Dor pós-operatória em dentes tratados endodonticamente por estudantes de Odontologia, utilizando técnicas manual e reciprocante / Postoperative pain in teeth endodontically treated by dental students, using manual and reciprocating techniques

O objetivo do presente estudo foi determinar a frequênciae/ou intensidadede dor pós-operatória e os fatores associados a esta ocorrência em tratamentos e retratamentos endodônticos realizados pelas técnicas de instrumentação manual e reciprocante, por estudantesde graduação em Odontologia da Universidade Federal de Pelotas. Para tal, utilizou-se informações dos prontuários de pacientes atendidos por estudantesdo último ano de graduação, no período compreendido entrejaneiro de 2017 ejulho de 2019, totalizando 182 tratamentos. A dor foi registrada por meiodaEscala de Avaliação Numérica da Dor (EAND). Considerou-se como variáveis preditivas no desfecho de dor pós-operatória: dente, número de canais, sintomas, coroa dentária, tratamento indicadoe índice periapical radiográfico. Como variáveis relativas aos tratamentos, técnica de instrumentação, número de sessões e limite apical de instrumentação. Havia relato de dor no momento do tratamento em 28% dos prontuários, enquanto 11,5% não reportaram dor prévia. Em 149 casos (81,9%) incluídos neste estudo não foi relatada a ocorrência de dor pós-operatória, enquanto dor leve foi relatada em 17 casos (9,3%), moderada em 6(3,3%)e intensa em 10(5,5%). Em 67,4% dos casos dos dentes foram tratados até a marcação 0 do localizador apical,enquanto em 32,6% o comprimento foi estabelecido a 1mm desta marcação. Não houve associação entre o tipo de tratamento realizado e a ocorrência de dor pós-operatória (p=0,206). Conclui-se que, entreos fatores avaliados, apenas a sintomatologia prévia apresentou associação com a maior frequência de dor pós operatória (AU).

This study determined the frequency and/or intensity of postoperative pain and factors associated with such occurrence in endodontic treatments and retreatments performed by manual and reciprocating techniques, by undergraduate dental students at the Federal University of Pelotas. For that purpose, data were collected from the records of patients treated by last-term undergraduate students, in the period between January 2017 and July 2019, adding up to 182 treatments. Pain was recorded by the Numerical Pain Rating Scale (NPRS). The following predictive variables were considered in the outcome of postoperative pain: tooth, number of canals, symptoms, dental crown, indicated treatment and radiographic periapical index. The variables related to the treatments included the instrumentation techniques, number of sessions and apical limit of instrumentation. There was report of pain during treatment in 28% of records, while 11.5% did not report previous pain. In 149 cases (81.9%) included in this study there were no reports of postoperative pain, while mild pain was reported in 17 cases (9.3%), moderate in 6(3.3%)and intensive in 10(5.5%). In 67.4% of cases, the teeth were treated up to mark "0"of the apex locator, while in 32.6% the length was established at 1mm from this mark.There was no association between the type of treatment performed and the occurrence of postoperative pain (p=0.206). It was concluded that, among the evaluated factors, only the previous symptomatology was associated with higher frequency of postoperative pain (AU).

Bovine Tooth Discoloration Induced by Endodontic Filling Materials for Primary Teeth.

Objective. This study evaluated the discoloration potential of endodontic materials used in primary teeth. Material and Methods. Dentine-enamel blocks were prepared from 75 bovine teeth, assorted in five experimental groups (n = 15). The tested materials included an MTA-based material; zinc oxide and eugenol cement (ZOE); Vitapex; and calcium hydroxide thickened with zinc oxide (Calen + ZO). The color measurements were performed using a spectrophotometer at the following intervals: prior to (T0) and after placement of the filling (T1) and after 1 week (T2), 1 month (T3), 3 months (T4), 6 months (T5), and 9 months (T6). Data were submitted to ANOVA with repeated measures and Tukey's test. Results. The time had a significant effect on the color variation (ΔE00⁎) (p < 0.0001). The effect of the materials on the color variation (ΔE00⁎) was statistically significant (p = 0.004). Interactions between time and materials demonstrated a significant effect on the values (ΔE00⁎) (p < 0.0001). The ZOE cement showed the highest darkening effect (p = 0.018). Conclusion. The MTA-based material showed the smallest discoloration during the experimental time; however, it was similar to the other materials and to the control group. Zinc oxide and eugenol showed higher discoloration.

Restabelecimento da estética dentária por meio da combinação de clareamento de consultório e caseiro / Reestablishment of dental aesthetics by combination of in-office and at-home dental bleaching

O objetivo deste trabalho é descrever o tratamento clareador em dentes vitalizados empregando a combinação das técnicas de consultório e caseiro supervisionado. A técnica clareadora de consultório foi realizada em uma sessão clínica, com a realização de três aplicações e, consecutivamente, a técnica de clareamento caseiro foi realizada durante duas semanas. Aplicou-se gel a base de peróxido de hidrogénio a 35% para o clareamento de consultório associado ao peróxido de carbamida a 10% para o procedimento caseiro. Concluímos que a associação de técnicas clareadoras mostrou-se uma excelente opção estética para dentes que foram alterados cromaticamente...

The aim of this study is to describe the vital teeth bleaching combining both in-office and at-home techniques. The office bleaching technique was performed in a one clinical session, with the completion of three applications and consecutively the home bleaching technique was performed for two weeks. Hydrogen peroxide gel at 35% for office bleaching was applied associated with carbamide peroxide at 10% for the home procedure. We conclude that the association of bleaching techniques proved to be an excellent aesthetic choice for teeth that have changed chromatically...

Alternativa estética em dente cromaticamente alterado através do esvaziamento dentinário / Aesthetic alternative for discolored tooth through dentin removal

O objetivo deste trabalho é descrever o tratamento estético em um dente escurecido empregando a técnica de esvaziamento dentinário. Após a substituição de parte da dentina coronária escurecida por uma resina composta, verificou-se mudança cromática do dente. Concluímos que o esvaziamento coronário é uma opção estética para a manutenção do aspecto natural do esmalte sem a utilização de facetas diretas ou coroas protéticas em dentes cromaticamente alterados.

The aim of this paper is to describe the treatment of a darkened tooth using the removal dentin technique. After, the replacement of the discolored dentin by composite resin, a dramatic improvement of the tooth shade was verified. We conclude that the removal of dentin is an aesthetic option for maintaining the natural appearance of enamel without the use of direct veneers or prosthetic crowns in chromatically changed teeth.