Bleaching and Erosion Infiltration treatment, 6 Years Follow-up

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).

patient smile before infiltration

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.

Patient smile before bleaching

Fig.2
Initial front view of her smile.

color shade recording VTA shade guide

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.

vita color shade bleaching

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.

fluorisis white spots on teeth

Fig.5
Frontal view after bleaching with retracted lips and black flexipalette (Smileline).

cross polarised picture of white spots on incisors

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).

professional dental cleaning

Fig.7
Rubber-dam isolation and cleaning.

acid erosion of enamel white spots

Fig.8
Application of 15 % hydrochloric acid for 2 minutes.

ethanol alcohol on upper incisors

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.

resin light curing after infiltration

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.

glycerin gel application

Fig.11
Glycerin application and light-curing.

diamond tooth polishing paste

Fig.12
Finishing and polishing whit brush and two diamond pastes, 3 microns and 1 micron grain.

gloss paste and felt for teeth

Fig.13
Polishing with aluminium oxide paste and felt wheel.

white teeth and gum

Fig.14
Result at the end of the infiltration session.

cross polarised picture for tooth color

Fig.15
Cross-polarized picture highlighted disappearance of the white spots and enamel details.

smile with white teeth

Fig.16
Final front view.

lateral smile

Fig.17
Lateral view of her smile 6 months after the Icon treatment.

white teeth after infiltration

Fig.18
Frontal view 6 months after treatment.

intra oral picture of teeth

Fig.19
Frontal view in occlusion 6 years after treatment. No polishing was necessary during this 6 years.

polarized photo for tooth color

Fig.20
Cross-polarized picture 6 years after Erosion Infiltration treatment.

teeth mouth display

Fig.21
Lateral view of her smile 6 years after treatment.

smile close up

Fig.22
Frontal view of her smile 6 years after treatment.

beofre and after whitening and infiltration 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

1. Tirlet G, Chabouis HF, Attal JP. Infiltration, a new therapy for masking enamel white spots: a 19-month follow-up case series. Eur J Esthet Dent. 2013 Summer; 8(2):180-90.
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

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