Early diagnose to early treat

Prevention is better than cure, we all agree on that. Thus, it is extremely important to enhance our possibilities to detect early caries. Traditional X-rays can underestimate to an almost complete extent small cavities, which is why we need technological equipment we can rely on, for an accurate and early caries diagnosis. This is not enough. We also should use minimally invasive techniques, to avoid removing sound tissue just to reach the affected one. In this context, microinfiltration is incredibly respectful of dental tissues, painless, fast and reliable. For many years now, DMG Icon has been providing clinicians with the possibility of easily managing interdental resin infiltration.
In this clinical case, a small cavity is detected on the mesial surface of a second premolar. In a case like this one, 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.

styleitaliano style italiano fluorescence and laser caries diagnosis

Fig.1
Fluorescence (A) and Diagnocam (B) images are incredibly helpful to diagnose small caries, compared to direct light one (C).

styleitaliano style italiano rubber band interdental space opening

Fig.2
Teeth separation needed to be achieved (A), so an orthodontic rubber band was applied the day before the appointment (B); after 24 hours (C) we can appreciate the open interdental space.

styleitaliano style italiano before and after rubber band dental separation

Fig.3
Lateral view of the open space.

styleitaliano style italiano open proximal space

Fig.4
Occlusal (A) and buccal (B) view of the initial situation. Rubber dam isolation is recommended for any kind of adhesive procedure, which obviously includes microinfiltration.

styleitaliano style italiano sandblasting interdental demineralized tissue

Fig.5
Glycine powder is used to clean dental surfaces. Erythritol can be really effective too.

styleitaliano style italiano wedge in open interdental space

Fig.6
A wedge can still be helpful to facilitate all the operative steps, to maintain the space, and to protect the rubber dam.

styleitaliano style italiano cleaning of proximal enamel by different tools

Fig.7
Enamel re-activation is very important to improve infiltration. We have a few strategies to choose among: Eva handpiece (A), abrasive metal stripes (B), diamond discs (C) and a sharp blade (D). In this case, both the Eva handpiece and the metal stripe were used.

styleitaliano style italiano proximal initial caries

Fig.8
Thanks to teeth separation, we can directly see the lesion.

styleitaliano style italiano dmg icon applicator

Fig.9
First operative step: the applicator was positioned in the interdental space, with the green side facing the surface to treat (A). This was followed by the application of a 15% hydrochloric acid gel (DMG Icon Etch) for 2 minutes (B). The gel only comes out from the green side of the applicator.

style italiano styleitaliano dmg icon brown spot
style italiano styleitaliano dmg icon brown spot
styleitaliano style italiano rinsing of icon etchant

Fig.10
After the etching time, the gel was carefully washed off with water, then everything is air dried. After that, the applicator can be removed.

styleitaliano style italiano ethanol alcohol being applied in interdental space

Fig.11
A solution of ethanol (DMG Icon Dry) was applied for 30 seconds, then air-dried, to maximize the surface drying.

styleitaliano style italiano resin infiltration of proximal caries

Fig.12
The third step is the actual infiltration. A methacrylate-based resin matrix (DMG Icon Infiltrant) is applied for 3 minutes. A new applicator is easily positioned, exploiting the interdental space created by the rubber band. The green side is always oriented to face the surface to be treated. The penetration of DMG Icon Infiltrant is ensured by capillary action; this implies that cavities should not be deeper than the first third of dentine. Additional light sources should be removed in order avoid accidental early curing of the resin.

styleitaliano style italiano before and after resin infiltration

Fig.13
After 3 minutes, all resin excess was carefully removed with suction, gentle air drying and the help of a clean brush. Dental floss can also be used to completely remove any possible resin excess. Light curing takes up to 40 seconds. We can appreciate the difference between before (A), and after (B) the infiltration.

styleitaliano style italiano tool for proximal caries microinfiltration

Fig.14
A second application of DMG Icon Infiltrant was performed with the same protocol but just for 1 minute.

styleitaliano style italiano brush removing excess resin

Fig.15
A brush can also be helpful to remove excess resin before light curing.

styleitaliano style italiano light curing infiltrant resin

Fig.16
Thanks to the rubber band separation, we can remove the wedge without losing the space. This allows us to perfectly remove the resin excess that usually is collected on the wedge. Then a final 40-second light curing is performed.

scaler cleaning proximal space styleitaliano style italiano

Fig.17
A scaler cane be useful in checking for excess material before finishing procedures.

abrasive tools for proximal finishing styleitaliano style italiano

Fig.18
A polishing stripe and a diamond disc can be used to finish and polish.

eva hand piece for proximal finishing styleitaliano style italiano

Fig.19
Such as the Eva hand-piece.

teeth after proximal resin infiltration styleitaliano style italiano

Fig.20
Final aspect 24 hours later, the space is no longer visible, and the contact area is perfectly normal.

healthy interdental space styleitaliano style italiano

Fig.21
Highlight of the completely restored interdental space.

Conclusions

Early diagnosis should nowadays be the routine approach. X-rays might still be the most common way to diagnose caries, and maybe still the gold standard, but new technologies allow us to be much more accurate. Furthermore, without the use of radiations, we can also repeat the exam anytime, even on pregnant patients.
Early diagnosis makes the perfect pairing with minimal intervention, and the quintessence of minimal invasive restoration is in the microinfiltration approach. A fast, gentle, painless, easy way to treat early caries.

Bibliography

1. Douglas et al. The American Dental Association Caries Classification System for clinical practice. Jada 2015
2. Meyer-Lueckel H, Paris S. When and how to intervene in the caries progress. Oper Dent. 2016;41 (S7): S35-47
3. Paris S, Meyer-Lueckel H, Kielbassa AM (2007) Resin infiltration of natural caries lesions. J Dent Res 86: 662-666.
4. 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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