Bleach, infiltrate and restore

The Infiltration technique has been widely proven to eliminate unaesthetic enamel spots, if the depth is correctly evaluated and the indications followed correctly; in other words, in deep lesions infiltration will not be very effective alone.

Moreover, bleaching is not a vanity procedure anymore: for many years now, the benefit of non-invasive techniques has been put on trial and getting amazing results when the indications are followed correctly. The bleaching therapy to diminish and treat white spots has been subject to controversy, rejected by many and adopted by many others.

In the Author’s experience, bleaching of white and amber spots before treatment is a winning strategy with the following statements:

Amber spots: Generally turn into white spots which are more subject to the acid treatment of the infiltration therapy

• White Spots: Two phenomena happen, the first is the reduction in their opacity due to a balance in the refraction index of the disarranged prisms. And the second, little or no bleaching happen to the white spot, blending better due to the low contrast between the newly bleached surrounding tissues and the white spot itself.

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Fig.1
Initial evaluation of the patient. 23 year old woman, very dissatisfied of the present situation and the aggressive treatment optioned shed had been proposed.

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Fig.2
A cross-polarized picture is taken to better asses the extent of the lesion. On the other hand, transillumination is used to estimate the depth of the lesion (not in pictures). It is decided to start a bleaching therapy to try to minimize the contrast between the spots and the tooth and to bleach the amber spots which are generally not attackable.

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Fig.3
Bleaching trays must be extremely precise, cervical sealing should be perfect in order to keep the bleaching product in place and safe of intraoral moisture. Construction of the bleaching tray will be deeply discussed in upcoming articles.

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Fig.4
Fitting of the bleaching tray. The selected bleaching therapy was Carbamide Peroxide 10% during 20 days (White Dental Beauty Teeth Whitening gels) during the full sleep time. No sensitivity was reported, and we are seeing this phenomenon more often with this new generation products.

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Fig.5
After 20 days bleaching. Picture with lateral flashes.

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Fig.6
Cross polarized image showing the new situation of the spots, some of them vanished, the amber turned into white and other spots softened its saturation.

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Fig.7
Side to side comparison, note the amber spot

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Fig.8
Mirror like comparison

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Fig.9
Mirror-like comparison of before bleaching (low) and after (up) with Deep-view contrast

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Fig.10
After bleaching evaluation, the patient starts the treatment with resin infiltration. The first step, rubber dam isolation.

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Fig.11
15% hydrochloric acid application for 2 minutes (ICON etch, DMG, Germany), this step can be repeated up to 4 times. Applying it more times comes with the risk of deeply eroding the teeth.

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Fig.12
Air drying, note how the spots become tremendously white.

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Fig.13
Preview with alcohol (ICON dry, DMG, Germany). Manufacturer suggests a 30 seconds application of this agent. This is the result after 30 seconds.

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Fig.14
In the author’s experience, this product applied for 2 minutes gives a better penetration and thus a better preview of the real outcome. Is in this step where the clinician should decide if repeating the full erosion cycle or starting the resin infiltration.

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Fig.15
Air dry of the alcohol is very easy and, if the last step was successful, is time to infiltrate.

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Fig.16
Many times erosion is even visible, especially when doing 4 cycles or more.

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Fig.17
Resin infiltration. This resin of extremely low density and solvent free is able to penetrate as much as the alcohol did. It is advisable to keep the lights low and allow the infiltrant to penetrate for about 3 minutes; failure in doing so may end up in an incomplete infiltration and a different result than the one obtained in the preview with the ICON dry.

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Fig.18
After infiltration, a small layer of enamel is placed to cover up the erosion caused during therapy.

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Fig.19
Polishing is mandatory with or without the use of a final composite layer.

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Fig.20
Final result after 3 weeks

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Fig.21
Cross polarization image, shows a good result, which is not excellent, but not visible to plain sight.

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Fig.22
Deep-view contrast of the final situation (contrast increase, brightness decrease of the digital image) help very much in the picture analysis and true estimation of the remaining lesions.

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Fig.23
Deep-view contrast of the initial situation

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Fig.24
Mirror-like comparison of before (low) and after (up)

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Fig.25
A similar case was planned to be treated in the same way, but after 30 days bleaching, all the spots disappeared (digital mock-up, right of the image before the treatment, left side after)

Conclusions

Bleaching should be a mandatory resource before stain treatment and restorative therapy. Some of the benefits are little known by the dental professionals and harmless side effects are often feared. Infiltration therapy should be a primary choice together with bleaching for the treatment of these kind of problems.
ICON dry, which is used as a preview of the resin filtration after erosion, should be applied for 2 minutes to obtain proper visual assessment. ICON infiltration resin has to penetrate completely and a 3 minute application is advised.

Bibliography

Kim S, Kim EY, Jeong TS, Kim JW. The evaluation of resin infiltration for masking labial enamel white spot lesions. International Journal Paediatric Dentistry 2011;21:241–8.
Denis M, Atlan A, Vennat E, Tirlet G, Attal JP. White defects on enamel: diagnosis and anatomopathology: two essential factors for proper treatment (part 1). Int Orthod 2013;11 ?(2):139–65.
Matis BA, Cochran MA, Eckert G, Carlson TJ. The efficacy of a 10% carbamide peroxide bleaching gel. Quintessence Int 1998;29:555-63.
Dahl JE, Pallesen U. Tooth Bleaching – A critical review of the biological aspects. Crit Rev Oral Biol Med. 2003;14(4):292-304.
Haywood VB, Leonard RH, Nelson CF, Brunson WD. Effectiveness, side effects and long-term status of nightguard vital bleaching. J Am Dent Assoc 1994 Sep;125(9):1219-26.
Carey CM. Tooth Whitening: What We Now Know. J Evid Based Dent Pract. 2014 June;14 Suppl:70-76.
Haywood VB. Nightguard vital bleaching: current concepts and research. J Am Dent Assoc 1997; Suppl. 128 (4): 19S–25S.
Salat A, Devoto W, Manauta J: Achieving a precise color chart with common computer software for excellence in anterior composite restorations. Eur J Esthet Dent; 2011;6(3):280-96
Manauta J, Salat A. Layers, An atlas of composite resin stratification. Chapter 5. Quintessence Books, 2012.

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