Fluorosis and post-ortho lesions conservative treatment
After the enthusiastic adoption of resin infiltration, many colleagues around the world were dissapointed because it only works "sometimes". The indications of infiltration and the clinical action protocols are of extreme importance. Understanding as well that the combination of a bleaching therapy can improve importantly the outcome of the infiltration making these therapies easier and more successful.
Bleaching should not be considered a vanity procedure anymore, but a conservative tretament, as it has celar actions in the dissapearance of white and amber spots among many other benefits.
White spots are common lesions of different ethiology that have not been treated for ages, before the adhesive era, treatments of these were extremely destructive (i.e. crowns). After a while, more conservative treatments came to the rescue, as macro abrasion with bur, macroabrasion with acid and abrasives and composite resin restorations.
Recently, the ultraconservatie treatment with chemical erosion, bleaching and resin infiltration has open a window to the full treatment of these spots.
Fig 1.- The young patient presented bad oral hygiene during the orthodontic treatment, specially in the cervical area and after removing the appliances we found demineralisation of enamel caused by plaque accumulation. Labial white spots are frequently associated with fixed orthodontic treatment. White spot prevalence of 50%,1 60%2 or even 97%3 after bonded or banded. Postorthodontic spot not always follow the contour of the orthodontic appliances, but many times the appliance blocks a good higiene access to the proximal or cervical area while the peri-appliance area remains in good condition.
Fig 2.- There is a range of treatment options for such white spots. Enhancing remineralisation using fluoride or casein-phosphopeptide amorphous calcium phosphate has been shown to positively influence caries arrest. However, clinical studies could not show a cosmetic improvement 12,13. Microabrasion or restorative techniques with composite are effective options but the elective treatment was the resin infiltration technique as it is associated to minimal loss of dental hard tissue.
Fig 3.- Hiper contrast of the initial picture is obtained by decreasin brigthness and increasing contrast of the original picture, displays better the extent of the lesion helping us to determine the degree of the demineralisation. This method was described by Salat et. Al. 2011 (2).
Fig 4.- Isolation from first premolar to first premolar with well invaginated dental dam avoiding saliva infiltration. This field generally is more than enough, avoiding the use of clamps and ligatures.
Fig 5.- Superficial demineralization by application of a 15% solution of hydrochloric acid, this technique opens up access to the hypomineralized lesion; is mandatory to respect the time with a chronometer. Wash generously during at least 20 seconds and dry with air.
Fig 6.- Icon dry, which is 99,9% ethanol is placed in order to get a preview of the situation. Manufaturer instructions suggest to place it 30 seconds, we highly reccomend that if you want to have a real preview to leave abundant ethanol for 2 minutes to have a efficient penetration, then evaluate the aspect of thre teeth. After evaluation there are 2 roads, or make another round of acid attack or start the resin infiltration.In this case 2 rounds were made as the result at this stage was satisfactory.
Fig 7.- Resin infiltrantion (resin with low viscosity) penetrated into the lesion and occluded the porosities and masked the white lesions. Is necessary to place the low viscosity resin, make sure that ambient light (including the unit light) is not strong. Leave the infiltration resin during 2-3 minutes, a common mistake at this stage is to hurry, causing an incomplete resin penetration.
Fig 8.- Remove excess, and polymerize each tooth for 30 seconds. Apply glicerin and polymerize again. This step is completely optional, but what is not an option is to polymerize perfectly. We suggest 1 minute per tooth, at least.
Fig 9.- Interproximal resin was removed with a polishing strip and cervical resin (which must be avoided by removing the raw resin) with the Eccesso instrument.
Fig 10.- Finishing and poslishing steps are important for immediate appearence and for long term stability. Here in the picture, the goat brush is illustrated, but is mandatory to pass a polishing rubber appliance and then the brush with diamond paste. Generally only with this the gloss is excellent.
Just after polishing the resin. Unpolished resin has a fair appearance in the immediate postoperative, but the resin in the surface remains raw due to the inhibited oxygen layer and it is extremely sensitive to the oral enviroment and pigments. In a nutshell, is contraindicated to leave infiltration resins unpolished as they will deteriorate in matter of weeks. Fig 11.- Mechanical polishing will act partially in the resin and in the superficial portion of the enamel prisms, making it a hybrid surface wich is very stable and performant shine.
Fig 12.- White spots were transformed into -Type 2 M- intensive features (3), both patient and clinician were very satisfied with only 2 rounds of erosion, minimising chair time and potential damage due to erosion. Remeber that more than 4 rounds there is a risk of stucture loss due to the acid erosion and the logical use of composite to restore that damage.
Fig 13.- An extension of the indications of the resin infiltration technique was proposed (Tirlet) to include fluorosis and traumatic lesions since, in these cases, as in early-stage caries, the lesion involves the external third of the enamel [Denis]. When the white spot involve deep enamel lesions Molar Incisor Hypomineralization (MIH) or certain types of hypomineralization of traumatic origin, or severe cases of fluorosis, resin infiltration is not effective. In the present case we can see a mild-moderate fluorosis camouflage of white spots.
Fig 14.- Intraoral situation, the upper teeth are the most affected by the fluorosis spots.
Fig 15.- Spots are aesthetically unpleasant, patient came to our attention searching for the especifical non invasive treatment. MAIN TIP OF THE ARTICLE: The strategy consists in a mandatory stage of bleaching with 10% Carbamide Peroxide (White Dental Beauty) at home during 15 days. This might sound as a paradox, but many of the spots change, color of the substrate whitens and the contrast between spot and tooth becomes less evident. Spots are wasier to infiltrate after bleaching abnd the reason is still ot clear.
Fig 16.- Vita shade guide before treatment to have an approximate shade of the healthy tooth. and evaluate the shade before and after bleaching.
Fig 17.- Vita shade guide after bleaching treatment. Note how many spots have drastically changed especially on tooth 21-22 that are more evident.
Fig 18.- After bleaching we appreciate an increase in the overall luminosity. White spots were dissimulated but as we predicted additional treatment is required.
Fig 19.- Intraoral situation before acid erosion.
Fig 20.- Polarized image before, this kind of illumination gives us a clear view of each and every spot. Is the best method to evaluate the infiltration therapy.
Fig 21.- Icon etch application during 2 minutes.
Fig 22.- Icon dry application
Fig 23.- Product is applied generously for 2 minutes to have a real preview as described in the previous case.
Fig 24.- Low density resin is applied as well for 2-3 minutes without heavy ambience light sources. Note that an incomplete infiltration (insufficient time) may mean the failure of the infiltration therapy.
Fig 25.- Teeth after infiltration therapy show none unpleasant white spots.
Fig 26.- Mild fluorosis indication is generally very predictable with this kind of approach.
Fig 27.- Patient is happy with the new smile, brighter and without spots
Fig 28.- Polarized image before.
Fig 29.- Polarized image after treatment, showing how succesful this therapy was.
Fig 30.- Digital composition to show the dramatic effect of the before and after.
Post-orthodontic white spots eliminated with resin infiltration technique is an effective treatment option in a large number of cases. A first clinical study demonstrated successful masking of post-orthodontic lesions (61% completely and 33% incompletely masked lesions) with infiltration treatment (Kim S. et al). In our experience even in the incompletely masked lesion the patients are satisfied with the results. After the success of the resin infiltration technique masking post-orthodontic white spots we decided to propose the technique to different origin white spots. So in our serie of clinical cases (see bibliografhy) it is seen that the resin infiltration makes it possible to treat the superficial enamel lesions effectively, whatever their etiology.
The role of whitening is very important since it helps vanishing effectively white spots and amber spots, making them more attackable by the resin infiltration technique.
First case performed by Dr. Elisa Oneto. Second case by Dr. Elisa Oneto and Dr. Anna Salat. Thanks to Dr. Elisa Oneto with whom it is always a pleasure to collaborate for an interdisciplinary approach.