Simplification of the erosion/infiltration by using a scalpel

A clinical case by our Community member Dr. Bounab Abdelkader

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.

It should be kept in mind that in the initial erosion/infiltration protocol, at a time when deep infiltration did not exist (before 2012), only superficial lesions were treated (early caries, mild fluorosis, and superficial trauma). The superficial layer of these lesions was hypermineralized. To access the lesion, the acid was employed for two minutes to dissolve the hypermineralized layer. However, with the evolution of the technique and the appearance of deep infiltration, the stains, white or coloured teeth, were infiltrated, in this situation it is necessary to have reached at least the hypomineralized lesion, which is most often deep for example in the case of Molar Incisor Hypomineralization (MIH).
Until now, dentists have carried out cycles of hydrochloric acid (HCL)/Alcohol/Sandblasting or milling until obtaining an optical modification of the stain with the alcohol. This optical modification meant:
a) that you reach the stain.
b) that the resin infiltration will be effective.

In this article, a simplification of the erosion/infiltration technique by using a scalpel will be clearly shown.

style italiano styletaliano Initial situation

Fig.1
A 26-year-old female patient was dissatisfied with the appearance of unpleasant spots on the anterior-superior sector (13-23) when she visited the dentist’s clinic. The diagnosis of MIH was made after evaluating the patient’s physical and clinical history.

style italiano styletaliano Complete intraoral view of the initial situation

Fig.2
The teeth are stained and discolored in the initial smile. The treatment will begin with a bleaching technique.

style italiano styletaliano Initial situation of the upper anterior teeth

Fig.3
Retractors and a flexipalette were used to take this photo. On teeth 11 and 21, the larger white spots could be readily seen.

style italiano styletaliano Polarized picture of the upper anterior teeth

Fig.4
The use of a cross-polarized image reveals the spots’ extension.

style italiano styletaliano Bleaching before the infiltration procedure and isolation

Fig.5
After 3 weeks of bleaching treatment, the color of the teeth was improved. Thus, the erosion/infiltration procedure can be initiated.
The first step of the treatment consists of isolation with the rubber dam from tooth 13 to tooth 23 with the clamp located on the rubber dam on tooth 14 and tooth 24.
The rubber dam has to be inverted in the sulcus in order to have a large and dry working field during the procedure.

style italiano styletaliano Scalpel usage

Fig.6
The scalpel will let you determine if you are in the lesion while minimizing the amount of time-consuming procedures.
In fact, nothing happens when healthy enamel is “scraped” with a scalpel; the scalpel’s edge simply glides over the tooth surface. On the other hand, because hypomineralized enamel is mechanically more brittle and friable, when it is “scraped” with a scalpel, chips form.

style italiano styletaliano Scalpel usage

Fig.7
Therefore, you will keep sanding, paying particular attention to the parts that do not produce chips when scraped. Applying HCL before obtaining these chips on the entire lesion is useless and even a waste of time. In fact, even with concentrated HCL (15%), the dissolution of healthy enamel is too slow; sandblasting or grinding are quicker methods.

style italiano styletaliano Infiltration procedure

Fig.8
Icon Etch (15% hydrochloric acid) is brushed for 2 minutes and then rinsed and dried for 30 seconds.

style italiano styletaliano Infiltration procedure

Fig.9
After the Icon Etch has been rinsed and dried. Apply the Icon Dry and let it sit for 30 seconds.
In this instance, it took four repetitions of the operation before the spots disappeared.

style italiano styletaliano Infiltration procedure

Fig.10
Icon Etch and Icon Dry were repeated four times after noticing that the white areas were almost undetectable. For 3 minutes, icon infiltration resin could be applied, and for 1 minute, it can be light-cured.

style italiano styletaliano Lateral view showing the enamel loss

Fig.11
On this lateral view, the enamel loss was showed, so resin composite was applied.

style italiano styletaliano Final result after 3 days

Fig.12
Final result after 3 days.

style italiano styletaliano Final situation

Fig.13
Final situation.

style italiano styletaliano Polarized picture of the upper anterior teeth after treating the white spots

Fig.14
Cross-polarized photos are still more convincing about the mitigation of opaque spots. In this kind of image, the dentist and the patient can see the disappearance of white spots.

style italiano styletaliano final situation

Fig.15
Final result with the new smile of the patient.

Conclusions

The scalpel makes it possible to determine whether the entire white or colored area the dentists are treating contains a hypomineralized lesion. Additionally, a conservative method to restore a smile with white spots is the erosion/infiltration protocol.

Bibliography

  1. Fagrell TG, Dietz W, Jälevik B, Norén JG. Chemical, mechanical and morphological properties of hypomineralized enamel of permanent first molars. Acta Odontol Scand. 2010 Jul;68(4):215–22.
  2. Tirlet G, Chabouis HF, Attal J-P. Infiltration, a new therapy for masking enamel white spots: a 19-month follow-up case series. Eur J Esthet Dent Off J Eur Acad Esthet Dent. 2013;8(2):180–90.
  3. Fagrell TG, Dietz W, Jälevik B, Norén JG. Chemical, mechanical and morphological properties of hypomineralized enamel of permanent first molars. Acta Odontol Scand. 2010 Jul;68(4):215–22.
  4. https://www.styleitaliano.org/white-spots-removal-volume-restitution/
  5. Paris S, Meyer-Lueckel H. Masking of labial enamel white spot lesions by resin infiltration—a clinical report. Quintessence Int. 2009;40: 713-718

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