Managing fluorosis with minimally invasive techniques

A clinical case by our Community member Dr. Fahad Taub

This article and its content are published under the Author’s responsibility as an expression of the Author’s own ideas and practice. Styleitaliano denies any responsibility about the visual and written content of this work.

Fluorosis occurs when there is a disturbance in the mineralization and maturation of enamel matrix proteins caused by high fluoride intake during tooth development. Historically, these cases were treated aggressively with heavy tooth reduction followed by an indirect restoration. However, today it is possible to treat such clinical scenarios using minimally invasive techniques. In most cases different modalities of treatment must be carried out to deliver the best result.

style italiano styleitaliano brown fluorosis spots

Fig.1
In the case presented, a 23-year-old female patient was unhappy with the appearance of the white and brown spots covering her anterior teeth (13-23). It was possible to classify hers as a moderate to severe case of fluorosis due to the dark brown stains present with the white spot lesions. In addition, there had been some historical trauma to the incisal edges of teeth 11 and 21.

style italiano styleitaliano faded brown spots after home bleaching

Fig.2
The first task was to eliminate the brown spots using a prolonged bleaching treatment. 16% carbamide peroxide was prescribed to the patient to be used overnight for 2 weeks. Not only did this brighten the natural tooth shade, the dark brown stains had faded from teeth 12, 11 and 21. A break of 2 weeks post-whitening was taken before moving to the next phase of treatment, to prevent any oxygen residues from inhibiting the bond strength of any adhesive agent involved in the following steps of the treatment.

style italiano styleitaliano inversion of rubber dam

Fig.3
So, after two weeks, an infiltration session was scheduled. Teeth were isolated with the rubber dam not only for moisture control, but to protect the gingiva and soft tissues from the acidic slurry from microabrasion and the etching procedure of resin infiltration.

styleitaliano style italiano cleaning teeth with abrasive paste

Fig.4
Microabrasion was carried out using Ultradent’s Opalustre. The paste was spread over the anterior teeth and agitated with a rubber cup at approximately 500 rpm (1:1 handpiece) with heavy pressure. This was done for 2 cycles of 60 seconds before being rinsed with water for 30 seconds.

styleitaliano style italiano sandblasting of enamel surface

Fig.5
As you can see in the picture, the microabrasion successfully removed the dark brown stains affecting 12, 11 and 21. Before any resin-based treatment, 29μm aluminium oxide was used to clean the teeth and to gain better access to the white spots, to facilitate the penetration of the resin during infiltration.

style italiano styleitaliano etching before resin infiltration

Fig.6
Resin infiltration was performed as the next step using DMG’s ICON Etch. The gel was applied and agitated using the applicator for a period of 2 minutes.

style italiano styleitaliano dmg icon brown spot
style italiano styleitaliano dmg icon brown spot
style italiano styleitaliano application of ethanol alcohol to check refractive index

Fig.7
DMG’s ICON Dry (Ethanol) was then used to check if the refractive index of the porosities created by the etching process had become similar to sound enamel. In this case it can be seen that the white spot lesions were still present after a single cycle of etching. Therefore, another cycles of ICON etch was applied.

styleitaliano style italiano white spot infiltration previsualization

Fig.8
Finally, after 4 cycles of ICON etch of two minutes each, ICON dry was applied to tooth 21 which was the most affected by fluorosis. It can be seen that the white spots lesions had been infiltrated and the enamel porosities were then producing a similar refractive index to that of sound enamel.

style italiano styleitaliano dmg infiltrant resin application tip

Fig.9
The ICON infiltrant was applied to all the anteriors for 2 minutes. The interproximal areas were then flossed before a 40 second light-curing process took place. Then a second layer of ICON infiltrant was applied for a further minute to compensate for the resin shrinkage. The interproximal contacts were, again, flossed and the teeth were ultimately light-cured for a further 40 seconds.

style italiano styleitaliano composite buttons before layering

Fig.10
As, there were a few enamel defects of teeth 12, 11, 21 and 22 created by the chemo-mechanical abrasive procedures carried out previously (less than 1mm approximately), and the aforementioned inicsal trauma defects on teeth 11 and 21 which needed restoring, adhesive restorations were performed by applying and light-curing a single layer of Kerr’s Optibond FL adhesive followed by an achromatic layer of Edleweiss’ Inspiro ‘Skin Bleach’.

style italiano styleitaliano brush spreading composite resin

Fig.11
The composite resin was applied and gently blended on to the teeth using GC flat No.1 brush which had been wet with Ultradent’s Wetting Resin. Once this was done each tooth was light cured for 40 seconds.

style italiano styleitaliano glycerin air block for complete light curing

Fig.12
Glycerin was then applied to the teeth and a further 40 second cure was carried out under oxygen isolation.

style italiano styleitaliano finishing and polishing inserts

Fig.13
Finishing was performed using 3M Sof-flex strips for were used for interproximal finishing, 3M sof-flex discs for incisal and buccal finishing. The polishing procedure was then carried out using Clinician’s Choice’s ASAP polishers followed by Coltene’s Diatech Shapegueard Composite polisher.

style italiano styleitaliano lucida composite polishing paste

Fig.14
The final stage of polishing to obtain a high lustre was the application of Styleitaliano’s Lucida gloss system. This was buffed with a star felt before water was used to wash off the the paste. The rubber dam was removed and the patient was dismissed.

style italiano styleitaliano diashine lucida
style italiano styleitaliano diashine lucida
style italiano styleitaliano result after bleaching infiltration and restoration of brown spots

Fig.15
Check-up after 2 weeks. After rehydration the resin restorations seemed to have integrated well. The patient was delighted with the result.

style italiano styleitaliano smile after elimination of brown spots

Fig.16
The patient’s smile.

Conclusions

Solving this kind of case resorting to minimally invasive techniques require correct diagnosis, extensive planning and preparation. Microabrasion in conjunction with resin infiltration techniques appear to have good success in treating severe fluorosis. In addition, enamel defects created by such procedures can be easily restored using composite resins. The choice of composite material is dependant on the size of the defect. Large defects which are greater than 1mm will inherently need a more chromatic material something like a ‘dentin’ or ‘body’ shade. This will avoid the final restorations from dropping in value.

Bibliography

1. Akuno MH, Nocella G, Milia EP, Gutierrez L. Factors influencing the relationship between fluoride in drinking water and dental fluorosis: a ten-year systematic review and meta-analysis. Journal of water and health 2019;17(6), 845–862
2. Greenwall LH. Treatment considerations for bleaching and bonding white lesions in the anterior dentition. The Alpha omega. 2009;102(4), 121–127
3. Haywood VB, Leonard RH. Nightguard vital bleaching removes brown discoloration for 7 years: a case report. Quintessence international, 1998;29(7), 450–451
4. Spyrides GM, Perdigão J, Pagani C, Araújo MA, Spyrides SM. Effect of whitening agents on dentin bonding. Journal of esthetic dentistry. 2000;12(5), 264–270
5. Attal JP, Atlan A, Denis M, Vennat E, Tirlet G. White spots on enamel: treatment protocol by superficial or deep infiltration (part 2). International orthodontics. 2014; 12(1), 1–31.
6. Manauta J, Salat A. Layers, An atlas of composite resin stratification. Quintessence Books, 2012.

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