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.
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.
Fig.2
The teeth are stained and discolored in the initial smile. The treatment will begin with a bleaching technique.
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.
Fig.4
The use of a cross-polarized image reveals the spots’ extension.
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.
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.
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.
Fig.8
Icon Etch (15% hydrochloric acid) is brushed for 2 minutes and then rinsed and dried for 30 seconds.
Fig.11
On this lateral view, the enamel loss was showed, so resin composite was applied.
Fig.12
Final result after 3 days.
Fig.13
Final situation.
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.
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
- 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.
- 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.
- 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.
- https://www.styleitaliano.org/white-spots-removal-volume-restitution/
- Paris S, Meyer-Lueckel H. Masking of labial enamel white spot lesions by resin infiltration—a clinical report. Quintessence Int. 2009;40: 713-718
