A clinical case by our Community member Dr. Shiraz Khan
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Resin infiltration therapy is a more widely accepted ideal treatment approach to deal with white spot lesions on the teeth, including early (E1-E3) caries lesions interproximally (Torres et al 2011). Whilst the process is still invasive, utilisation of 15% HCl acid to etch the tooth surface and erode the superficial enamel, this technique can be considered the least invasive after bleaching alone. The reason for its minimally invasive nature, is based on the index of refraction. As this case demonstrates the white spot is still present underneath, however by placing a TEGDMA resin, we are able to mimic the refractive index of enamel (Torres et al 2011), thereby masking the white spot lesion. TEGDMA resin is used due to its optimal penetration coefficient capabilities. Paris and colleagues (2010) have trialled and tested several combinations of etchant and resin combinations, with 15% HCl and TEGDMA coming out on top.
More traditional methods require the removal of the white spot, whereas ICON resin infiltration simply needs access to the surface of the lesion, and then modification to the way the light interacts with the white spot by infiltration with a resin.
This is a case study of a young man, 16 years old, who was extremely unconfident in smiling due to the multiple forms of hypoplasia and discolouration’s on his teeth. Medically he was fit and well, and other than the generalised hypoplastic appearance of the teeth, the oral hygiene was exemplar, with no previous or current carious lesions. This case documents the process in which we were able to change the appearance of this young mans teeth over a three-week period.
Fig.1
The preoperative situation with multi-chromatic discolouration’s on the presence of the teeth.
Fig.2
Contrasted retracted preoperative view of the teeth.
Fig.3
This is the rate limiting step. A course of whitening therapy to convert all of the yellow/brown spot discolouration’s into white. ICON resin infiltration will not succeed in masking non-white spot lesions. Having done this step, we have markedly improved the appearance of the teeth, without any invasive treatment. We review the patient at cessation of whitening and then plan the infiltration appointment two weeks thereafter.
The protocol used here was 16% carbamide peroxide tray-based home whitening for 14-days.
Fig.4
Two weeks after cessation of whitening, the appointment for resin infiltration begins. Rubber dam isolation I would consider as mandatory whilst using 15% HCl etch.
Fig.5
Initial localised application of the etchant gel. Left on the teeth for 2 minutes, with a gentle scrubbing motion into the teeth.
Fig.6
Etchant thoroughly rinsed and the tooth dried. The immediate frosted appearance of the teeth, which localised white patches still visible.
Fig.7
Application of ICON-dry, 99% Ethanol. This has two functions, to dehydrate the teeth to maximise infiltration, but also a “test-drive” of what the teeth will look like once infiltrated.
Fig.8
Appearance of the teeth with ICON dry in place, showing some masking of the white spots, but not completely.
Fig.9
2nd two minute cycle of etching this time covering the entire labial surface as the ethanol stage showed cervical white patches.
Fig.10
2nd cycle completed and test-drive with the ICON dry (99% Ethanol). Note that the centrals have been masked completely, however there are still some patches on the laterals and canines.
Fig.11
3rd cycle with differential etching of the lesions that require an additional erosive cycle.
Fig.12
Final test drive showing complete masking of the previous white spots.
Fig.13
Resin infiltration step. Application of TEGDMA resin for 1 minute as a scrubbing motion, followed by a period of 2 minutes to allow the resin to penetrate into the exposed enamel prisms.
Fig.14
The excess resin is blotted dry, all of the contact points are flossed, and critically, each tooth is light-cured perpendicularly to the tooth surface for 40 seconds. Not 20, like composite, but 40. This step is repeated with another layer of resin infiltration being placed, and again cured for 40 seconds for each tooth. The infiltrant in an unfilled resin which undergoes significant shrinkage.
Therefore to counter this, we re-apply the resin infiltrant and re-cure with the same process.
Fig.15
Final cure for 20s on each tooth under oxygen barrier medium (glycerine gel).
Fig.16
Immediate post-operative pre-polishing.
Fig.17
Polishing protocol using Medium and fine polishing spirals.
Fig.18
Polishing protocol using Medium and fine polishing spirals.
Fig.19
Final high lustre polish using Diashine Lucida and paste.
Fig.20
Immediate post-polishing high lustre.
Fig.21
Immediate post-operative.
Fig.22
1 week control.
Fig.23
Before and after, retracted/contrasted.
Conclusions
In conclusion, this case demonstrates a relatively straightforward process to create a monumental change in appearance for this patient. Not only did we improve the appearance, but we also minimised any damage to the underlying enamel. A happy young man, and his mother, with a simple process for for improvement. The critical step was to transfer any yellowish-brown discolouration’s in to white, which leads to success of the infiltration procedure.
Bibliography
1. Torres, CRG, Borges, AB, Torres, LMS, Gomes, IS, Simões de Oliveira, R. Effect of caries infiltration technique and fluoride therapy on the colour masking of white spot lesions. Journal of dentistry 2011, 39 (3), 202-207
2. Paris S, Meyer-Lueckel H, Cölfen H, Kielbassa AM. Penetration coefficients of commercially available and experimental composites intended to infiltrate enamel carious lesions. Dent Mater 2007, 23(6):742-8
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.
