Deep white dyschromia. Do you always need a bur?

Although resin infiltration techniques are not the first choice in treating most MIH lesions, many patients refuse to have their teeth drilled, while they come seeking for a solution to this esthetic issue.

styleitaliano style italiano teeth with severe discoloration

Fig.1
A patient aged 46 came to my clinic asking me to solve her aesthetic problem. As I usually do, whenever I have to treat white spots on dark teeth, or basically when I approach treatments with a high aesthetic impact, I recommend a bleaching to improve the base we work on.

styleitaliano style italiano whitening gel and tray

Fig.2
A 16% carbamide peroxide-based home whitening gel (White Dental Beauty) with custom trays without reservoirs was selected for bleaching.

style italiano styleitaliano white dental beauty teeth whitening gels
style italiano styleitaliano white dental beauty teeth whitening gels
styleitaliano style italiano white spots after whitening

Fig.3
After 3 weeks whitening for 4 hours a day, and after an additional 20 days wait, teeth were ready for treatment of the discolorations.

styleitaliano style italiano discolorations after teeth whitening

Fig.4
The white portion of the spots had faded but the orange portion was still evident.

styleitaliano style italiano transillumination of MIH lesion

Fig.5
The K-lite allows me to understand the actual depth of the stain due to MIH (K-Lite – SmileLine)

styleitaliano style italiano sandblasting discolorations

Fig.6
Although MIH is not the ideal condition to apply resin infiltration, I tried to apply this minimally invasive approach, but the position of the spot in the thickness of the enamel forced me to sandblast before letting the etching work (AquaCare).

styleitaliano style italiano etching of white spots for infiltration

Fig.7
Because of the depth of the lesions, I knew from the beginning that I would have to repeat the cycle several times.

styleitaliano style italiano previsualization of infiltration outcome

Fig.8
Using ICON dry after each erosion I simulated the action of the infiltrant resin. The dyschromia was still evident after the first cycle.

styleitaliano style italiano second cycle of etching for infiltration

Fig.9
I repeated the etching step.

styleitaliano style italiano third etching cycle before infiltration

Fig.10
Third cycle.

styleitaliano style italiano etching of white spots

Fig.11
Since the patient had two shallow white spots on the lateral incisors as well, I decided to extend the treatment involving them, as two erosion cycles should be enough to make them disappear.

styleitaliano style italiano fifth erosion cycle for resin infiltration

Fig.12
I repeated the etching step for the fifth and last time.

styleitaliano style italiano previsualization of infiltration outcome

Fig.13
The action of Icon Dry revealed that the stains were ready to be infiltrated.

styleitaliano style italiano light curing of infiltration resin

Fig.14
After infiltrating dyschromias and curing, I needed to restore the involved teeth.

styleitaliano style italiano composite layering on darker infiltrated areas

Fig.15
A thin layer of white enamel was applied on 11 and 21 to increase the value on the incisal third and to thicken it.

styleitaliano style italiano teeth after infiltration and composite layering

Fig.16
A greyish halo still remained, but for final evaluation we needed to wait for rehydration.

styleitaliano style italiano after resin infiltration before rehydration

Fig.17
Final outcome after removing the rubber dam.

styleitaliano style italiano teeth after infiltration and rehydration

Fig.18
Smile after finishing and polishing procedures 2 weeks later.

styleitaliano style italiano 6 months follow up after infiltration

Fig.19
6 months after professional oral hygiene recall.

styleitaliano style italiano 15 months follow up

Fig.20
15 months later.

Conclusions

An approach with a bur would have been faster and more performing, but certainly more destructive. If the patient does not consent to such kind of treatment, whitening and infiltration can be used to reduce the difference between the refractive index of the stain and healthy enamel, providing a basis for a minimal restoration. Either way, bleaching can help to even out the color and simplify the choice of the restorative material.

Bibliography

    1. Colella A. When should I really stop etching a white spot? 2020 Styleitaliano.org
    2. Subramaniam P, Girish Babu KL. Evaluation of penetrating depth of a Commercially available resin infiltrate into artificially created enamel lesions: An in vitro study. J Conserv Dent. 2014;17(2):146-148.
    3. Arnold WH, Haddad B, Schaper K, Hagemann K, Lippold C, Danesh G. Enamel surface alterations after repeated conditioning with HCl. Head Face Med. 2015;11:32.
    4. Fejerskov O, Nyvad B, Kidd E. (eds) (2015) Dental Caries: The Disease and Its Clinical Management. 3rd Edn. Oxford, Wiley Blackwell.
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