Spot the Difference: A minimally invasive approach to masking early caries white spots post-orthodontics

A clinical case by our Community member Dr Shiraz Khan

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.

Resin infiltration therapy represents a widely embraced minimally invasive treatment strategy for addressing white spot lesions on teeth. Clinicians are familiar with the early demineralization stages of caries, which manifest as white spots, often posing aesthetic concerns for patients. These white spots signify initial surface caries, manageable through Icon resin infiltration. In the presented case, while the white spot remains underneath, the application of a specialized resin enables the replication of enamel’s refractive index (Torres et al.,, 2011), effectively concealing the lesion. This resin is selected for its superior penetration coefficient properties. Paris and colleagues (2010) conducted trials exploring various combinations of etchants and resins, identifying 15% HCl and TEGDMA as the most effective.

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 case study focuses on a 14-year-old female who recently completed orthodontic treatment. Despite being medically healthy, she exhibited suboptimal oral hygiene, resulting in early white spot caries on the upper anterior teeth (3-3). Apart from these carious lesions, her oral hygiene was poor and required intensive reinforcement practices, followed by a scale and prophylaxis. There were no previous or current carious lesions detected. The patient had composite restorations on the incisal third of the upper right central incisor (UR1) and upper left central incisor (UL1), which were functionally and aesthetically satisfactory. This case outlines the procedure involved in sealing the early-stage carious lesions and improving the appearance of the white spots on the patient’s teeth.

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style italiano styleitaliano initial situation post-orthodontic carious lesions

Fig.1
The initial condition showed early carious lesions presenting as white spots around the areas where orthodontic brackets had been previously placed.

style italiano styleitaliano Transillumination

Fig.2
Transillumination image showing the depth and severity of the early carious lesions. It is important to note that the light is completely occluded by some of the lesions on the lateral incisors, this implies that the lesions may be thicker and will likely require supplemental composite. This demonstrates the importance of having transillumination as a pre-requisite, diagnostic step.

style italiano styleitaliano isolation

Fig.3
The teeth were isolated with rubber dam with the upper premolars being clamped. The teeth were cleaned with a prophylaxis brush and then gentle air abrasion with Aquacare 27 um Al2O3 in preparation for the etching cycles. Furthermore, it is imperative to air abrade the existing composite restorations to ensure surface activation for adhesion.

style italiano styleitaliano DMG Icon Etch

Fig.4
First cycle of Icon Etch (15% HCl) application with a gentle scrubbing motion for 2 minutes.

style italiano styleitaliano Following etching

Fig.5
Teeth profusely washed and dried. Frosted appearance was present, and the existing composite that had been previously placed was visible.

style italiano styleitaliano DMG Icon Dry

Fig.6
Applying Icon Dry involves using 99% Ethanol. This serves two purposes: to dehydrate the teeth for optimal infiltration and also to provide a preview of the anticipated appearance post-infiltration.

style italiano styleitaliano DMG Icon Dry

Fig.7
After the application of Icon Dry, the appearance or “test drive” reveals that white spots are still visible on the incisors and canines, indicating the need for a repeat procedure.

style italiano styleitaliano DMG Icon Etch

Fig.8
Second and more localized application of the Icon Etch to the regions in which the white spots were localized (cervical). Left for 2 minutes.

style italiano styleitaliano Washing the spots

Fig.9
Tooth washed and dried with white spots still being present.

style italiano styleitaliano DMG Icon Dry

Fig.10
2nd cycle completed and test-drive with the Icon Dry (99% Ethanol). Note that the UL1 has been masked completely, however there are still some patches on the UR1, laterals, and canines.

style italiano styleitaliano DMG Icon Etch

Fig.11
3rd cycle with differential etching of the lesions that require an additional erosive cycle.

style italiano styleitaliano Washing the spots

Fig.12
Teeth washed and dried again. Note that the white spots are present when the teeth are dry.

style italiano styleitaliano Final test-drive

Fig.13
Final test-drive showing complete masking of the previous white spots with 99% Ethanol, which will lead to complete masking of the white spots on infiltration therapy. At this stage there were visible concavities present to the labial contour of both lateral incisors. Therefore, it was a requirement to restore the labial volume, which was completed with the EL shade of ecosite elements (DMG).

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style italiano styleitaliano Resin infiltration step

Fig.14
Resin infiltration step. Application of TEGMA resin for 1 minute in a scrubbing motion, followed by an elongated period of 4 minutes to allow the resin to penetrate deeper into the exposed enamel prisms as some of the lesions are deeper.

style italiano styleitaliano Resin infiltration step

Fig.15
The excess resin is carefully blotted dry, ensuring that all contact points are flossed. Each tooth is then light-cured perpendicularly to the tooth surface for a duration of 40 seconds, unlike composite, which typically requires 20 seconds. This step is repeated with another layer of resin infiltration applied, this time for 1 minute, followed by curing for 40 seconds for each tooth. Since the infiltrant is an unfilled resin that experiences significant shrinkage, this effect was counteracted by reapplying the resin infiltrant and recuring using the same process.

style italiano styleitaliano Enamel placement

Fig.16
Small increments of composite placed in the cervical areas of the UR2 and UL2 as the combined use of sandblasting and acid etching had created a visible concavity. This was pre-determined by the transillumination stage as the lateral incisors had occluded the light transillumination, indicating a thicker lesion. Ecosite Elements EL shade (DMG) (Enamel only) was used.

style italiano styleitaliano final curing

Fig.17
Final cure for 20 seconds on each tooth under oxygen barrier medium (glycerine gel).

style italiano styleitaliano Before and after resin infiltration caries white spots Icon treatment post-orthodontics

Fig.19
Before and after comparison.

style italiano styleitaliano Before and after resin infiltration caries white spots Icon treatment post-orthodontics

Fig.20
Before and after with transillumination to demonstrate infiltration and sealing of early enamel caries lesions.

Conclusions

In conclusion, this case demonstrates a relatively straightforward process to create a monumental change in appearance for this patient. Not only was the appearance improved, but also any damage to the underlying enamel was minimized, and any underlying carious process that had started was sealed. The result was a happy young lady and her mother, benefiting from a simple process for improvement.

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 39 (3), 202-207, 2011.
  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.

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