Deep Resin Infiltration for the conservative management of Proximal Anterior Class III lesions

To avoid unnecessarily removing sound tissue we should use minimally invasive techniques. In this context, microinfiltration is incredibly respectful of dental tissues, painless and fast. For many years now, Icon (DMG, Germany) has been providing clinicians with the possibility of easily managing interdental caries with the resin infiltration technique. The resin can block the progression of an early caries to prevent the need for drilling and filling.
In this clinical case, initial caries were detected on the mesial surface of the lateral incisors and distal suface of central incisors. Here, the infiltration approach is for sure the least aggressive. In this article, we will see a simple protocol starting with the creation of an interdental working space (teeth separation), followed by different strategies to re-activate the enamel in order to achieve the best results in terms of infiltration.

style italiano styleitaliano dmg icon brown spot
style italiano styleitaliano dmg icon brown spot
styleitaliano style italiano orthodontic elastic bands to separate teeth

Fig.1
The main problem with minimally invasive approaches and interproximal lesions, is access. We must see and we need space to treat. To solve this problem, the day before the appointment we placed orthodontic elastic bands to create space between teeth.

styleitaliano style italiano isolation with rubber dam

Fig.2
The day after, as you can see in the picture, the space created with the elastics was enough to allow us to access the area. Direct vision is important when treating interproximal white spots, because we need to assess the absence/presence of cavitation. The presence of a cavitated lesion is the limit of our minimally invasive approach. In this situation, we had the typical white and brown surface and subsurface spot on the 22 mesial, 11 distal and 21 distal.

styleitaliano style italiano white and brown spot on central incisor

Fig.3
Close-up showing the distal white and brown spot on tooth 11.

styleitaliano style italiano white and brown spot on lateral incisor

Fig.4
Close up showing the 22 mesial typical white and brown spot.

styleitaliano style italiano palatal view of small carious lesions

Fig.5
A palatal picture with the occlusal photographic mirror is very useful to visually detect caries.
We can see that on tooth 22 mesial we had caries progress beyond the first third of the dentin, so we needed to treat this lesion with the turbine and with a conventional cavity preparation.
The infiltrating resin can penetrate into demineralized enamel, but cannot fill the formed cavities. Therefore, the infiltrating resin is only suitable for non-cavitated lesions, and the ones confined to the enamel surface or upper third of the dentin (1).

styleitaliano style italiano superfloss used to clean proximal space

Fig.6
The step by step resin infiltration technique is shown in the following pictures of the procedure carried out on 22 mesial.
The first and most important step is to clean the surface. It can be done with airflow systems, manual instruments like the Eccesso (LM), with finishing strips like the sof-lex (3M) and/or with the Superfloss (Oral B).

styleitaliano style italiano applicator for icon etchant treating enamel spots

Fig.7
Here you can see the green etching gel from the Icon system, 15% hydrochloric acid gel (Icon-Etch, DMG, Germany).

styleitaliano style italiano ethanol alcohol application on white spot

Fig.8
A drop of ethanol (Icon-Dry, DMG, Germany) is applied with the dedicated tip for 30 seconds and air dried. Drying of the teeth to be treated reveals if the etching process was successful and facilitates successful penetration of the infiltrant into the depth of the lesion.

style italiano styleitaliano dmg icon brown spot
style italiano styleitaliano dmg icon brown spot
styleitaliano style italiano applying HCl gel to treat white and brown spot

Fig.9
Here we are re-applying the HCl gel with the applicator, which must remain on the tooth during the whole application time of the gel (2 minutes) in order to protect the adjacent tooth. The gel only comes from one side from the applicator.

styleitaliano style italiano ethanol alcohol solution to previsualize result of resin infiltration

Fig.10
Re-applying the ethanol (Icon-Dry, DMG, Germany) for another 30 seconds and then air drying.

styleitaliano style italiano mesial wall after white brown and white spot removal

Fig.11
When the lesion optically disappears with the alcohol (Icon-Dry, DMG, Germany), it means that the resin will also penetrate. We are ready to infiltrate (Icon-Infiltrant, DMG, Germany).

styleitaliano style italiano application of resin infiltrant

Fig.12
Applying the methacrylate infiltrant (Icon-Infiltrant, DMG, Germany) with the special interproximal applicator from the kit.

styleitaliano style italiano use of flowable composite after resin infiltration

Fig.13
We apply flowable resin (DMG Ecosite Elements Highlight OA2) to the surface of the infiltrated area. We can use the Icon infiltrant as our adhesive layer, so we can just add on a flowable resin, to better highlight the transition line.

styleitaliano style italiano finishing strip for proximal polishing

Fig.14
Finishing the surface with a sof-lex strip (3M).

styleitaliano style italiano brush used to polish composite

Fig.15
Polishing was done with the Brush Shiny S (Micerium, Italy) and the Lucida diamond paste (Diashine, US). A felt star was then used for extra gloss (Diashine, US).

style italiano styleitaliano diashine lucida
style italiano styleitaliano diashine lucida
styleitaliano style italiano final outcome after resin infiltration

Fig.16
After finishing and polishing, the surface looks shiny and perfect.

styleitaliano style italiano teeth after resin infiltration treatment

Fig.17
Post-operative view immediately after the procedure.

styleitaliano style italiano : teeth after resin infiltration treatment

Fig.18
At one week check-up. Left side.

styleitaliano style italiano teeth after resin infiltration treatment

Fig.19
At one week check-up. Frontal view.

styleitaliano style italiano teeth after resin infiltration treatment

Fig.20
At one week check-up. Right side.

styleitaliano style italiano teeth after resin infiltration treatment

Fig.21
Palatal view.

Conclusions

A considerable number of professionals still tend to practice invasive techniques with lesions confined to enamel.
The resin infiltration technique with ICON by DMG in interproximal caries lesions is a less invasive technique compared to a cavity preparation.
The resin infiltration technique should be an alternative to cavity preparation, thus at least postponing, if not avoiding, sacrifice of sound structures.

Bibliography

1. Chen M, Li Z, Zuo QL, Liu C, Jiang H, Du MQ. Accelerated aging effects on color, microhardness and microstructure of ICON resin infiltration. European Review for Medical and Pharmacological Sciences 2019; 23: 7722-7731
2. Schmidlin PR, Kluck I, Zimmermann J, Roulet JF, Seemann R. Caries-preventive potential of an adhesive patch after thermomechanical loading—a microbial-based in vitro study. J Adhes Dent 2006;8:7-12.
3. Kantovitz KR, PasCon Fm, noBRe-dos-santos m, PuP- Pin-Rontani Rm. Review of the effects of infiltrants and sealers on non-cavitated enamel lesions. Oral Health Prev Dent 2010; 8: 295-305.
4. Meyer-Lueckel H, Paris S. When and how to intervene in the caries progress. Oper Dent. 2016;41 (S7): S35-47
5. Paris S, Meyer-Lueckel H, Kielbassa AM (2007) Resin infiltration of natural caries lesions. J Dent Res 86: 662-666.
6. Paris S, Hopfenmuller W, Meyer-Lueckel H (2010) Resin infiltration of caries lesions: An efficacy randomized trial. J Dent Res 89: 823-826.

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