ethanol solution drop on central incisor

The Path to Ultraconservative Dentistry – Bleach, Infiltrate, Restore

In this case report we will see our treatment choice in an early stage caries, i.e. white spots, and some more advanced lesions. Some dentists still prefer to abstain from proposing any treatment or using any invasive strategy, yet today we have a basic range of appropriate minimally invasive treatments, e.g. whitening, erosion/infiltration and micro- or macro-abrasion combined with restorative. Understanding the origin of the lesion we can have an idea of the lesion configuration and treat it accordingly. In this clinical case, the plaque accumulation due to poor oral hygiene was the origin of the lesions. With a non invasive approach in mind, the strategy to follow was undoubtedly the bleaching, the resin infiltration technique and the classical cavities only when no more options were available. The bleaching is almost always our starting point when having something to do on the anterior teeth.

smile before treatment

Fig.1

Even with a low lip line, the aesthetic problems are obvious.

severe gingivitis with enamel demineralization

Fig.2

With the lips retracted we appreciate the severe gingivitis, abundant dental plaque accumulation and the presence of white and brown spots, as well as residual composite from the bracket cementation, and proximal caries. The patient had not finished the orthodontic treatment when braces were removed, and his teeth had quickly gone back to being misaligned.

retracted lips showing severe gingivitis

Fig.3

We decided to proceed with: dental hygiene, home bleaching, resin infiltration technique/ deep infiltration technique (resin infiltration and composite)/ conventional composite only in lesions involving dentin.

relaxed lip position

Fig.4

In a relaxed position the whole problem is almost completely hidden.

smile before restorative treatment

Fig.5

White spots and caries frequently occur around the orthodontic braces area, especially towards the the gingival contour and in the interproximal area.

color check before whitening treatment

Fig.6

Color estimation before bleaching with the Classical Vita Shade Guide. The initial color was close to an A3,5.

polarized filter for spot limit identification

Fig.7

The polarized filter is especially useful when treating white or brown dental spots. Thanks to the annihilation of light reflections, the spots and their localization are easily identified (13).

white dental beauty whitening gel concentrations

Fig.8

From alginate impressions, the laboratory created a custom soft tray. A soft 1 mm thickness tray was delivered to the patient. We chose a 10% Carbamide Peroxide gel for at least 2 hours a day. We chose the Carbamide Peroxide as a tooth bleaching agent (instead of Hydrogen Peroxide) because the urea component seems to have positive effects on plaque, gingival health and caries (13).

color shade check after teeth whitening

Fig.9

After the two-week treatment of custom-fit soft trays with 10% carbamide peroxide, 2 hours a day. The color evaluation was done with the VITA Bleachedguide 3D-MASTER®. Although many people use the Classical Vita shade guide, you should know that it lacks a logical order for the bleaching treatments. A guide to evaluate bleaching should be arranged from the lightest to the darkest as it is on the Bleachedguide 3D-Master. That’s why we changed our protocol and from now on we are using the Bleachedguide 3D-Master to evaluate color during bleaching treatments.

result after teeth whitening and oral hygiene

Fig.10

After the dental hygiene and 2 weeks of treatment with peroxides, the gingival health improved considerably!

result after bleaching

Fig.11

As you can see, not only the color improved, but also gingival health. White spots are still visible, as they don’t disappear with bleaching: yet, they can mutate and become more favourable for the infiltration procedure.

before and after bleaching

Fig.12

Here is the before & after situation. The before picture is on your left and the after bleaching picture on your right.

before and after whitening

Fig.13

The white spots are still there after the dental bleaching, but they’re much less visible thanks to the reduced contrast as, although they didn’t change the teeth are now whiter.

ICON resin infiltration kit

Fig.14

In this picture you can see the syringes included in the Icon kit.
The only genuine “minimally invasive” treatment available on the market, to both stop the caries and restore good aesthetics, is the resin infiltration technique. The only product currently marketed that corresponds to this principle is Icon (DMG, Hamburg, Germany).
On the Styleitaliano website you can find plenty of free-access articles about the resin infiltration technique strategy. We have described step by step with clinical cases-white spots from different aetiology.

rubber dam isolation with floss ligatures

Fig.15

The infiltration technique is strongly indicated for white spots after orthodontic treatment.
With the white spot cases we need some special considerations to isolate as the lesions are located not only on the visible part but also under the gingival margin. The dental dam and extra dam retraction in the cervical area are required. We created an extra-retraction with dental floss (Johnson and Johnson Reach, Waxed Dentotape) ligatures. We placed the floss in the sulcus as far it could go, after placing the dental dam (Nictone, 6×6 blu medium). As usual the dental dam goes from first premolar to first premolar, and is fixed with two clamps (W2A, Ivory).

etchant application

Fig.16

Through hydrochloric acid erosion we permeabilize the non-porous enamel surface. According to the manufacturer’s instructions, a 2 minute etching is recommended. (Icon-Etch, DMG, Hamburg, Germany).

etching gel application tip

Fig.17

The tip allows to evenly distribute the etching gel on the buccal surface.

previsualization solution icon dry

Fig.18

We apply the alcohol solution (Icon-dry®, DMG, Hamburg, Germany) to have a preview of the situation. We need to wait for the alcohol to penetrate inside the etched porous enamel in order to fill the gaps. We applied multiple drops of alcohol during approximately 2 minutes in order to ensure the gaps were filled with alcohol and we could have a real previsualization of the final result.

etching of white spots for infiltration

Fig.19

The white spots were still visible after the alcohol application. The etching procedure was repeated.

icon etching gel for post-orthodontic spots

Fig.20

Icon-etch on the enamel surface. Each time that we apply the etching gel, it dissolves a thin layer of enamel.

previsualizing with ethanol solution

Fig.21

Second application of alcohol (Icon-dry®, DMG, Hamburg, Germany) to get another previsualization of the result.

etching gel on upper teeth

Fig.22

We applied the Icon-etch for a third. After the third time we end up in a total median enamel surface loss of 77 μm (12).

ethanol alcolhol before resin infiltration.

Fig.23

Third application of alcohol. (Icon-dry®, DMG, Hamburg, Germany).

alcohol previsualisation after etching

Fig.24

On this occasion the spots were much less visible when we applied the alcohol.

infiltration with resin

Fig.25

We could still see the spots, but we were satisfied with the result after the alcohol evaporation. We decided to avoid further etching and infiltrate with the resin. We twisted the syringe and let the resin flow out, infiltrating the porous subsurface enamel with hydrophobic resin.

resin excess removal

Fig.26

Removing the excess resin with the brush (CompoBrush, Smile Line) and letting the resin infiltrate the enamel prisms.

light curing with transparent strips

Fig.27

Resin light-curing for at least 40 seconds (Lampara LED deepcure S, 3M). We separated the teeth with a transparent strip (Kerr Hawe).

pink wooden wedges to separate incisors

Fig.28

The pink wedges (Polydentia) are very useful for the anterior teeth because they are very thin and small.

clean proximal cavity

Fig.29

We cleaned the lesions after removing the carious dentin without water and with air (Low speed medium round carbide bur for caries removal). The patient didn’t report any sensitivity or other problems associated with the use of peroxides regardless of the presence of some proximal caries. He reported 0 sensitivity after 2 weeks using 10% CP 30 minutes a day (White Dental Beauty Teeth Whitening gels). The carious dentin was probably thick enough to buffer any possible deleterious effect of CP on the pulp.

cavities before restoration

Fig.30

We restored the class III on 11 distal and 12 mesial with composite A2 and EL from the new aesthetic composite Ecosite Elements (DMG, Hamburg, Germany) with the dual technique described by Styleitaliano (9,10).

polishing composite restorations

Fig.31

We used the polishing tips (HiLuster Plus, Polishing system, Kerr) to remove excess resin and to luster the surface. To contour the resins on 11 distal and 12 mesial we used metal strips (Metal strips, GC Europe) and then we used finishing strips (Sof-Lex finishing strips, 3M) to finish and polish the interproximal areas.

soflex spiral polishing

Fig.32

Then we polished with the Sof-Lex brown Spiral (3M). The beige rubberized pre-polishing spiral is impregnated with aluminum oxide to remove scratches. With this step we don’t obtain the final desired gloss, but we prepare the surface to receive the diamond particles to create a high-gloss polish. Adding water is recommended during use to optimize results and prolong tool life.

polishing with felt wheel

Fig.33

We polished with the felt wheel (Shiny F felt wheel with a Shiny mandrel, Optident) and a super charged polishing paste (Diamond Twist SCL, Premier). First without water at 3000 rpm with polishing paste for 30 seconds more or less, and then with water at high speed, with the touch and go technique at 10.000 rpm.

teeth after bleaching infiltration and composite restoration

Fig.34

After removing the dental dam.

intraoral picture after restoration

Fig.35

The situation the day after.

two months after bleaching and infiltration

Fig.36

Two months after the treatment he came to the check-up appointment, and he told us that he had had a motorbike accident and had broke his nose and chipped his central incisor.

style italiano styleitaliano

Fig.37

Gingival tissues looks much better now.

back light to see tooth cracks after trauma

Fig.38

With the light behind the tooth we wanted to evidence the internal fissures in tooth 11

direct composite restoration of incised margin

Fig.39

So we used a direct technique to restore the incisal margin of tooth 11 (Ecosite Elements A3, DMG) on the same check-up appointment with a single mass technique.

smile of happy patient after treatment

Fig.40

Portrait picture

Conclusions

The bleach & restore strategy (which means to bleach before restoring) is a strategy that we follow as a protocol. Even if the patient’s main concern is not about how white his teeth are, he usually trusts this approach and is very satisfied with the result, because everyone loves to bleach their teeth when I propose this strategy the patient usually trust our approach, because everyone loves white teeth, even though they might know it yet!

Thanks to anathomopathological knowledge, white spots and early caries can be treated with erosion infiltration (6). With deep lesions we still use this strategy: infiltration, caries removal and material filling on the same appointment.

Ecosite Elements Composite (DMG, Hamburg,Germany) was used in this clinical case with a dual shade layering technique (dentin and enamel). This new composite is a good composite to be used on anteriors cases (consideration based on a correct translucency/opacity, good handling and polishability. With a precise color selection, the outcome is very predictable. (9,10).

There is no written rule but in case of caries, when we think that we are safe enough in terms of distance from the pulp, we first bleach and then infiltrate or/and restore. When the caries are very close to the pulp we first restore, then bleach and then do composite modifications.

Bibliography

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3. Denis M, Atlan A, Vennat E, Tirelt G, Attal JP. White defects on enamel: Diagnosis and anatomopathology: Two essential factors for proper treatment (part 1) . International Orthodontics 2013; 11:139-165.
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10. Lazarchik D, Haywood Van B. Use of tray-applied 10% carbamide peroxide gels for improving oral health in patients with special-care needs. JADA 2010, vol.141.