1.1. Objective: Describe, with a case report, the treatment of a vestibular white spot lesion due to traumatic hypomineralization in a maxillary incisor, through the combined use of microabrasion and resin infiltration.
1.2. Data: For this paper, the research were based on the scientific data bases PubMed. Sources: No one’s involvement.
1.3. Study selection: The selection criteria used for the clinical case were patients that presented white spot lesions on the anterior teeth.
1.4. Conclusion: Findings of this case suggest that significant improvement in esthetics may be achieved by using these two combined clinical strategies to effectively mask deep white lesions resulting from development defects on enamel.
1.5. Clinical Significance: This approach provides a minimally invasive treatment which leads to a significative esthetic improvement. The final result represents a clinically and esthetically satisfactory outcome.
2. Key wordsNoncavitated lesion; Minimal invasive dentistry; Resin infiltration; White spot; Enamel
3. IntroductionWhite spot lesions in anterior teeth are often the cause of discomfort for patients and reason for treatment. Since esthetic goals have become highly relevant in recent years, patients’ demands for a natural look through minimal invasive applications have increased [1]. In white spot lesions, the hypomineralization, confined to enamel, occurs due change in the chemical composition as a result of mineral loss and its substitution by organic fluids. As a consequence, the optical characteristics of the affected enamel are altered [2]. The whitish appearance stems from a high difference in Refractive Indexes (IR) between the enamel crystals and the medium inside the porosities, resulting from the modification of the spaces between crystals filled with either air (IR 1.00) or watery medium (IR 1.33). The difference of refractive indexes inside the porosities causes light scattering, showing the typical white and opaque appearance [3] (Table 1). An infiltration resin showing good penetration characteristics was recently developed at Charitè University Hospital in Berlin and made available on the market under the brand name Icon® (DMG, Hamburg, Germany) [4]. Designed to bridge the gap between prevention and restoration with a minimally invasive technique, Icon® can produce a positive esthetic effect by filling the pore system induced by hypomineralization, thus mimicking the existing healthy enamel by means of a lightcurable resin with a refractive index (IR 1.52) that is roughly similar to hydroxyapatite (IR 1.62) [4, 7]. The use of this technique sometimes leads to an inconsistent result due to the topographical characteristics of the lesions. Treatment should be carried out with due caution, analyzing the type of injury and looking for protocol modifications to improve efficacy. In cases where lesions, despite the superficial origin, develop in depth, the potential of infiltration is rapidly reached and only a small part of the lesion is infiltrated, with the consequence of an insufficient disguise of the lesion [2, 8]. The primary aims of the present study is to demonstrate the esthetic result in a deep white lesion treated firstly with a more invasive preliminary preparation of the enamel surface, such as microabrasion to ensure that infiltration can indeed reach the entire lesion, and then with resin infiltration technique.
4. Case ReportA 24 years old male requested a treatment to correct the appearance of a white spot on the maxillary left central incisor and blend it in with the surrounding enamel (Figure 1). Anamnesis and clinical assessment were performed to determine the etiology of discoloration. This case was classified as hypomineralized spot resulting from injury to the permanent incisor as a consequence of trauma to the primary tooth. After visual examination, thickness and depth were evaluated also using a curing light source positioned on the palatal surface of the tooth (Figure 2). Taking into consideration the type of lesion, the treatment decision was based on minimal intervention dentistry, combining the resin infiltration with Icon® (DMG, Hamburg, Germany) and microabrasion technique with Opalustre® (Ultradent, St. Louis, MO, USA). Patient signed an informed consent authorizing the treatment and use of images. Small composite-buttons were applied on the incisal third of the contralateral tooth (without bonding agent) and light cured. In this way the enamel shade closest to the one of the natural tooth could be determined (Figure 3). A rubber dam with ligatures was used in order to protect the oral soft tissues and provide a clean and dry working field. Thereafter the lesion was circumscribed with a resinous gingival barrier, the liquid rubber dam OpalDam® (Ultradent Product, Inc.) (Table 1) in order to protect the surrounding enamel during the procedure of microabrasion (Figure 5). Enamel microabrasion involves the use of acidic and abrasive agents, such as 6.6% hydrochloric acid and silicon carbide micro particles in a watersoluble paste, applied to the enamel surface with mechanical pressure of a low-rotation micromotor [9]. The spot was therefore treated with two applications of Opalustre®, using the rubber cup at a slow RPM with medium pressure (Table 1). Each cycle was interspersed with Icon-Dry® for a visual check. Once the microabrasion was complete, it was time to switch to the Icon® procedures (Table 1). The technique requires pre-conditioning of surface with 15% hydrochloric acid, which removes approximately 40 μm of enamel surface7,10.
5. DiscussionUnlike the systemic factors, reflected on all developing teeth, local factors such as a traumatic injury involve only teeth around the area of damage. A root of the primary tooth exerting force on the bud of the permanent tooth during morphogenesis can disturb the ameloblast layer. This type of trauma most frequently involves the incisors. However also an infection present on a deciduous tooth that propagates to the subsequent tooth during its morphogenesis can cause an abnormality in the latter [2]. The lesion appears as a white spot since the interprismatic spacing in a hypomineralized enamel scatters more light than sound ename [13, 12]. This type of lesions can present a wide variety of clinical expressions differing in shape, outline, localization and even color. They are generally punctiform, located on the incisal third of tooth crowns, often limited to one tooth and asymmetrical with respect to the corresponding contralateral tooth. The diagnosis of traumatic hypomineralization is essentially by exclusion [2]. There is a range of treatment options to improve the appearance of these white spot lesions. Infiltration technique is a recent concept that allows esthetic and functional properties improvement by sealing the microporosities through a lightcuring resin with low viscosity [4]. A fundamental aspect is to choose the most appropriate treatment starting from a correct diagnosis and a clinical evaluation of the depth of the lesion [2, 13, 14]. In cases where the defect develops in depth, just a small part is infiltrated, with the consequence of insufficient masking. For this reason Attal et al. introduced the concept of deep infiltration, that involves paying a price in the form of mild mutilation of the enamel to ensure that the infiltration can indeed reach the “ceiling” of the lesion [13]. Enamel microabrasion, where both chemical and mechanical abrasion simultaneously take place, can be a choice to remove that superficial layer of hypermineralized enamel. Dental treatment has changed dramatically in recent years, providing alternatives to the more invasive restorations. A more conservative approach with the concept of minimal intervention is gaining popularity in modern dentistry [15]. Resin infiltration, proposed in the context of camouflage, represents an intermediary treatment even in cases where white spots spread deeply in the enamel. Through this technique the infiltrated lesion gains new mechanical and esthetic characteristics that are similar to healthy ename [12, 13, 16, 17].
6. ConclusionMicroabrasion and infiltration technique showed to be two complementary techniques. Their application must always be assessed on the basis of diagnosis and topographical position of the enamel defect.
References1. Bahadır HS, Karadağ G, Bayraktar Y. Minimally Invasive Approach for Improving Anterior Dental Aesthetics: Case Report with 1-Year Follow-Up. Case Rep Dent. 2018 Sep 6; 2018: 1-5.
2. Denis M, Atlan A, Vennat E, Tirlet G, Attal J-P. White defects on enamel: Diagnosis and anatomopathology: Two essential factors for proper treatment (part 1). Int Orthod. 2013 Jun; 11(2): 139-65.
3. Paris S, Schwendicke F, Keltsch J, Dörfer C, Meyer-Lueckel H. Masking of white spot lesions by resin infiltration in vitro. J Dent. 2013 Nov; 41: 28-34.
4. Borges AB, Caneppele TMF, Masterson D, Maia LC. Is resin infiltration an effective esthetic treatment for enamel development defects and white spot lesions? A systematic review. J Dent. 2017 Jan; 56: 11-8.
5. Meyer-Lueckel H, Paris S. Improved Resin Infiltration of Natural Caries Lesions. J Dent Res. 2008 Dec; 87(12): 1112-6.
6. Meyer-Lueckel H, Paris S, Kielbassa AM. Surface Layer Erosion of Natural Caries Lesions with Phosphoric and Hydrochloric Acid Gels in Preparation for Resin Infiltration. Caries Res. 2007; 41(3): 223-30.
7. Paris S, Meyer-Lueckel H. Masking of labial enamel white spot lesions by resin infiltration - A clinical report. Quintessence Int. 2009 Oct; 40(9): 713-8.
8. Giannetti L, Murri Dello Diago A, Silingardi G, Spinas E. Superficial infiltration to treat white hypomineralized defects of enamel: clinical trial with 12-month follow-up. J Biol Regul Homeost Agents. 2018 Oct; 32(5): 1335-8.
9. Pini NIP, Sundfeld-Neto D, Aguiar FHB, Sundfeld RH, Martins LRM, Lovadino JR, et al. Enamel microabrasion: An overview of clinical and scientific considerations. World J Clin Cases. 2015 Jan 16; 3(1): 34-41.
10. Tirlet G, Chabouis HF, Attal J-P. Infiltration, a new therapy for masking enamel white spots: a 19-month follow-up case series. Eur J Esthet Dent. 2013; 8(2): 178-88.
11. Park HH, Lee IB. Effect of glycerin on the surface hardness of composites after curing. J Korean Acad Conserv Dent. 2011 Jan 1; 36: 483.
12. Abbas BA, Marzouk ES, Zaher AR. Treatment of various degrees of white spot lesions using resin infiltration-in vitro study. Prog Orthod. 2018 Aug; 19(1): 27.
13. Attal J-P, Atlan A, Denis M, Vennat E, Tirlet G. White spots on enamel: Treatment protocol by superficial or deep infiltration (part 2). Int Orthod. 2014 Mar; 12(1): 1-31.
14. Torres C, Borges A. Color masking of developmental enamel defects: a case series. Oper Dent. 2015 Aug; 40(1): 25-33.
15. Dalli M, Çolak H, Mustafa Hamidi M. Minimal intervention concept: a new paradigm for operative dentistry. J Investig Clin Dent. 2012 Aug; 3(3): 167-75.
16. Giannetti L, Murri Dello Diago A, Corciolani E, Spinas E. Deep infiltration for the treatment of hypomineralized enamel lesions in a patient with molar incisor hypomineralization: a clinical case. J Biol Regul Homeost Agents. 2018 Jun; 32(3): 751-4.
17. Mazur M, Westland S, Guerra F, Corridore D, Vichi M, Maruotti A, et al. Objective and subjective aesthetic performance of icon(R) treatment for enamel hypomineralization lesions in young adolescents: a retrospective single center study. J Dent. 2018 Jan; 68: 104-8.
Orlanda T. Microabrasion Combined with Resin Infiltration to Treat a white Spot Lesion: A Clinical Case. Annals of Clinical and Medical Case Reports 2020