Having a nice, aesthetic smile is important in a person’s social life. We dentists have many resources available to correct minor flaws such as white spot lesions, from direct composite, to veneers and crowns. However, these procedures are considered invasive, as they require the clinician to prepare the tooth, thus removing sound tooth structure. In front of my patient with fluorosis white spots, and when the predictability and the longevity of the traditional restorations are considered, it seems obvious to try the most conservative treatment first. The chosen treatment included at home external bleaching with carbamide peroxide 10% during 2 weeks and erosion-infiltration of the spots. Infiltration, though it was initially intended to treat incipient caries, is a great to mask white spots, as it changes the optical properties of the tooth. Indeed, the hypomineralization due to the fluorosis has a refractive index different than that of the healthy enamel. Infiltration is carried out with a low-viscosity resin, with a refractive index close to that of the healthy enamel. Tissue preservation with this treatment is maximum. The product I used for this erosion-infiltration treatment is ICON®(DMG).
Fig.1
Initial appearance of the 35 years old patient. She didn’t like her smile because of the white spots on her central incisors.
Fig.2
Initial front view of her smile.
Fig.3
Starting color shade was identified with the Vita 3D master Bleach Shade Guide, the best shade guide for whitening for different reasons. We choose the most similar sample, 2M1 of the shade guide and we placed it near the patient’s tooth, on the same vertical plane as the natural tooth, and with a black photographic background (Flexipalettes, Smile Line).
Treatment began with at-home bleaching with trays and carbamide peroxyde 10% during 15 nights.
External whitening using thermoformed trays and 10% carbamide peroxide gel increasing the overall brightness of the teeth, acts as masking of small white defects in the enamel.
Fig.4
The result after 15 days bleaching was satisfying for the patient but she still wanted to try to completely eliminate the white spots.
Fig.5
Frontal view after bleaching with retracted lips and black flexipalette (Smileline).
Fig.6
Cross-polarized picture highlighted fluorosis white spots after the two weeks teeth whitening.
As mentioned, the most conservative treatment plan was chosen, so we used an erosion-infiltration protocol to carry out with Icon® (DMG).
Fig.7
Rubber-dam isolation and cleaning.
Fig.8
Application of 15 % hydrochloric acid for 2 minutes.
Fig.9
After rinsing (30 seconds) and drying, the result is previsualized thanks to the ethanol solution (30 seconds).The result was satisfying so infiltration was possible.
Fig.10
Infiltration of hydrophobic resin with a sponge (3 min) and then light-cure infiltrant resin for 40 seconds. The infiltration step was done twice.
Fig.11
Glycerin application and light-curing.
Fig.12
Finishing and polishing whit brush and two diamond pastes, 3 microns and 1 micron grain.
Fig.13
Polishing with aluminium oxide paste and felt wheel.
Fig.14
Result at the end of the infiltration session.
Fig.15
Cross-polarized picture highlighted disappearance of the white spots and enamel details.
Fig.16
Final front view.
Fig.17
Lateral view of her smile 6 months after the Icon treatment.
Fig.18
Frontal view 6 months after treatment.
Fig.19
Frontal view in occlusion 6 years after treatment. No polishing was necessary during this 6 years.
Fig.20
Cross-polarized picture 6 years after Erosion Infiltration treatment.
Fig.21
Lateral view of her smile 6 years after treatment.
Fig.22
Frontal view of her smile 6 years after treatment.
Fig.23
Before and after. The patient is now 42 years old, and still likes her smile!!!
Conclusions
The combination of bleaching and resin-infiltration treatment represents a very conservative option, with predictable aesthetic result. Six years after the result is still satisfying.
Bibliography
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2. Carvalho L, Bernardon J, Bruzi G, Andrada M, Vieira L. Hypoplastic Enamel Treatment in Permanent Anterior Teeth of a Child. Oper Dent. 2013 Jan 17.
3. Meyer-Lueckel H, Chatzidakis A, Naumann M, Dörfer CE, Paris S. Influence of application time on penetration of an infiltrant into natural enamel caries. J Dent. 2011 ; 39(7):465-9.
4. Newburn E, Brudevold F. Studies on the physical properties of fluorosed enamel. I. Microradiographic studies. Arch Oral Biol. 1960 ; 12:15-20.
5. Newburn E. Studies on the physical properties of fluorosed enamel. II. Microhardness. Arch Oral Biol. 1960 ; 12:21-7.
6. Paris S, Meyer-Lueckel H. Masking of labial enamel white spot lesions by resin infiltration – a clinical report. Quintessence Int. 2009 ; 40(9):713-8
