Resin Infiltration Technique. Indication no. 2: Post Orthodontic White Spots.

This is case number 2 of a series of cases that have as their main goal to explain a technique to eliminate the enamel white spots. As Style Italiano members and friends we want to share our experience with the Resin Infiltration Technique using ICON. Icon is the name of the resin infiltrant produced by DMG. We present a series of cases where white spots lesions are present for different reasons.
In this clinical case the reason for the appearance of white spots (initial demineralization) is the presence of dental plaque around the orthodontic appliances.
In general, in dental practices, white spots are treated for aesthetic reasons (typically after an orthodontic treatment) with remineralization products (but did not solve the esthetic impairment in most cases because fluoride remineralizes only the surface) or with microabrasion and/or turbine (not well accepted for patients neither for dentists because is an aggressive approach, due to the lesions depth and extension much dental structure should be removed)
Between these two techniques we have now another option that is called resin infiltration. Until now, there has never really been a satisfactory solution for treating the white spots which often occur after removing dental braces. Resin infiltration with Icon leads to a caries arrest at an early stage and disappearance of white spots. This means aesthetic results with minimum intervention in the tooth structure are achieved.
At the beginning, the technique of resin infiltration was invented to arrest the caries progression. It was unexpected that the initial lesions (typical white spots) optically disappear.
In this clinical case it is possible to appreciate some white spots that disappeared thanks to the resin infiltration technique and some deeper lesions, that were treated with the conventional turbine and composite method.

style italiano styleitaliano dentistry

Fig.1
Salivary test was done and showed both a low buffering capacity and a low flow rate.

style italiano styleitaliano dentistry

Fig.2
Despite appearing to be a high caries risk patient, she showed a tooth crowding such that orthodontic interceptive treatment was to be carried out.

style italiano styleitaliano dentistry

Fig.3

style italiano styleitaliano dentistry

Fig.4
Occlusal view.

style italiano styleitaliano dentistry

Fig.5
During the orthodontic treatment.

style italiano styleitaliano dentistry

Fig.6
Close up of frontal teeth after braces removal. We can appreciate several white spots.

style italiano styleitaliano dentistry

Fig.7
Initial situation, lateral view. Tooth number 12 distal, we can appreciate a cavity. In cavitated lesions resin infiltration is contraindicated. Unfortunately, the patient has terrible oral hygiene habits in spite of the recommendations and frequent check-ups before, during and after orthodontic treatment. The braces were removed because of the inability of the patient to maintain clean teeth.

style italiano styleitaliano dentistry

Fig.8
Lateral close-up view. Even brown spots, which have developed over a longer period of time, can be treated aesthetically, as long as the surface is not cavitated.

style italiano styleitaliano dentistry

Fig.9
Frontal view.

style italiano styleitaliano dentistry

Fig.10
Initial situation. The patient, and especially her mother, were very interested in the conservative approach of the resin infiltration technique.

style italiano styleitaliano dentistry

Fig.11
After cleaning the affected teeth, isolation with dental dam is performed.

style italiano styleitaliano dentistry

Fig.12
Icon etch (15% HCl) applied onto the lesions directly from the syringe from the system and letting set for 2 minutes.

style italiano styleitaliano dentistry

Fig.13
After removing the etchant with abundant water, alcohol is applied to dry the tooth, with its refractive index (how the light travels through) simulates the final result. At this crucial moment if the lesion have visibly disappeared, resin infiltration can be performed. On the contrary the etching step has to be repeated. If after rinsing and drying with alcohol masking of the lesion seems favorable, infiltration of the resin can be performed and proper masking is obtained. Optical appearance of the teeth after application of Icon resin.

style italiano styleitaliano dentistry

Fig.14
Resin infiltration is applied onto the etched surface and let infiltrate for 3 minutes before light curing.

style italiano styleitaliano dentistry

Fig.15
In deep cavities, where resin infiltration is unsuccessful, the conventional technique is performed. So we prepared a cavity for 2.1 distal and 1.2 distal. In tooth 1.2 distal we already knew that the conventional technique should be used.

style italiano styleitaliano dentistry

Fig.16
Round diamond bur used to remove the lesion.

style italiano styleitaliano dentistry

Fig.17
During the procedure of cavity cleaning.

style italiano styleitaliano dentistry

Fig.18
Etching agent application (phosphoric acid) for 20 seconds and adhesive agent.

style italiano styleitaliano dentistry

Fig.19
Composite application. A single mass Body (BA3 Asteria, Tokuyama) was applied in a single layer.

style italiano styleitaliano dentistry

Fig.20
Composite already cured.

style italiano styleitaliano dentistry

Fig.21
Final result.

style italiano styleitaliano dentistry

Fig.22
Final result.

style italiano styleitaliano dentistry

Fig.23
Final result.

style italiano styleitaliano dentistry

Fig.24
Final result.

style italiano styleitaliano dentistry

Fig.25
Final result.

Conclusions

Masking of white spot lesions by resin infiltration with Icon after orthodontic treatment seems to be a very good option, even in severe white lesions like the ones we have seen in this clinical case. Most of the lesions disappeared with Icon leading to a minimal use of micro- or macroabrasion with turbine and therefore to a negligible undermining of sound enamel. Resin infiltration technique with Icon provides aesthetic result with minimal intervention on the tooth structure.
Thanks to Dr. Elisa Oneto, the orthodontist of this clinical case, with whom it is always a pleasure to collaborate for an interdisciplinary approach.

Bibliography

1. Sudjalim TR, Woods MG, Manton DJ. Prevention of white spot lesions in orthodontic practice: a contemporary review. Aust Dent J 2006;51:284–289.
2. Tassery H. Lésions amélaires: quand et comment agir? Clinic 2009;30:72–74.
3. Tirlet G, Attal JP. Le gradient thérapeutique: un concept médical pour les traitements esthétiques. L‘information dentaire 2009;41/42:2561–2568.
4. Sundfeld RH, Croll TP, Briso AL, de Alexandre RS, Sundfeld Neto D. Considerations about enamel microabrasion after 18 years. Am J Dent 2007;20:67–72.
5. Nahsan FP, da Silva LM, Baseggio W, Franco EB, Francisconi PA, Mondelli RF, et al. Conservative approach for a clinical resolution of enamel white spot lesions. Quintessence Int 2011;42:423–426.
6. Reston EG, Corba DV, Ruschel K, Tovo MF, Barbosa AN. Conservative approach for esthetic treatment of enamel hypoplasia. Oper Dent 2011;36:340–343.
7. Benbachir N, Ardu S, Krejci I. Indications and limits of the microabrasion technique. Quintessence Int 2007;38:811–815.
8. Paris S, Schwendicke F, Keltsch J, Dörfer C, Meyer-Lueckel H. Masking of white spot lesions by resin infiltration in vitro. Journal of Dentistry (2013)

RELATED CASES

Easy and fast one quadrant restorations by bulk-fill composite

Managing multiple large restorations is not as time-consuming as one might think. Learn how manage quadrants composite restorations using a bulk fill.