Ultraconcervative Approach for Treatment of Post Orthodontic White Spot Lesions with Infiltration Technique

Ultraconservative Approach for Treatment of Post Orthodontic White Spot Lesions with Infiltration Technique

A clinical case by our Community member Dr. Marina Papachroni

 

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.

 

Although fixed appliances treatment has become an integral part of modern orthodontics, it has also been associated with certain adverse effects. Among these white spot lesions (WSLs) are prominent, as they have a negative impact on the esthetic outcome of orthodontic treatment and might progress into carious lesions (1). The risk of development of WSLs, as a common side effect of fixed orthodontic treatment is rather high (2-4). Initially, a WSL shows an apparently intact surface layer, followed underneath by the more porous lesion body, giving a chalky opaque appearance, as light is scattered mainly within the lesion body (5-7). Scattering is caused at interfaces between substances with different refractive indices as enamel, water, and air (7). Generally, WSLs could appear as early as 1 month after bracket placement; meanwhile, the formation of dental cavitation might require up to 6 months. WSLs are frequently perceived on the dental buccal surfaces, around the brackets, mainly in the gingival area (7-8).
Caries infiltration is a new micro-invasive treatment option for such cases, where enamel porosities attributed to mineral loss during demineralization are occluded by infiltration with a low-viscosity, light-cured resin, which penetrates the entire lesion extension, mechanically stabilizes the fragile, porous enamel structure and isolates microbia from their nutritious environment (9).
The benefits of the resin infiltration technique have been clinically documented (9-11) in cases of proximal and free-surface enamel lesions, which were efficiently infiltrated instead of undergoing more invasive restorative approaches. Recently, in vitro evidence of enhanced infiltrant penetration has been corroborated by in situ (12) and short-term clinical trials (13-14) which have shown the effectiveness of resin infiltration in preventing further demineralization under cariogenic conditions.

teeth with multiple demineralisations

Fig.1

A 16-year old male patient complained the aesthetics of his smile being affected by white and yellowish lesions. The lesions were observed after removing fixed appliances at the end of a 3 year orthodontic treatment. The parents’ main concern was to stop lesion progression with a minimally invasive treatment.
Contrary to remineralization using fluoride or CPP–ACP, infiltrant resin can improve the color, even in deeper lesions, because it penetrates. Moreover, the result appears instantly after treatment(15,16). In addition, resin infiltration is much less invasive than microabrasion or composite restorations (15).

rubber dam isolation of upper incisors

Fig.2

For maximum protection of the patient during the infiltration procedure, rubber dam and floss ligatures were applied. Infiltration in the upper jaw was performed in two different appointments due to patient co-operation concerns.

clean teeth with cervical demineralizations

Fig.3

The tooth surface was cleaned with a rubber cup and prophylaxis paste.

acid etching before resin infiltration

Fig.4

The surface layer was eroded by the application of 15% hydrochloric acid gel (ICON -Etch; DMG, Hamburg, Germany) for 120 seconds to expose the body of the lesions. The procedure was repeated three times. Acid rinsed off for at least 30 seconds with water spray and dried.

eroded white spots before infiltration with resin

Fig.5

The lesions were desiccated using ethanol (ICON-Dry; DMG) for 30 sec followed by air-drying.

application of resin infiltrate on upper teeth

Fig.6

An infiltrant resin (ICON-Infiltrant; DMG) was applied to the surface and allowed to penetrate inside for 3 min. Excess material was wiped away using a cotton roll from the surface, and using dental floss in the proximal spaces before light curing.
After light curing for 40 seconds, the application of infiltrant resin was repeated once for 3 minutes, and light cured for 40 sec.The reason for applying the resin twice is because of the shrinkage of materials after the first application resulting in the generation of space that can then be occluded by a second application (15). Final view of infiltrated lesions.

infiltrated teeth before composite additions

Fig.7

While all teeth have experienced enamel loss to varying extent, 11(mesial), 21 (mesial and distal) and 22 (mesial) need to be restored with resin composite.

microbrush for selective and minimal composite application

Fig.8

After bonding procedures, a thin layer of enamel composite, the Enamel shade (SiE White Dental Beauty) was placed. The whole procedure was performed under microscope in order to be precise and to keep material addition to a minimum, only where it was necessary to reproduce the right anatomical contour.

transparent strip during proximal composite layering

Fig.9

The White Dental Beauty CompoSite system only features one enamel shade, with mimetic characteristics and significantly simplifies the whole procedure. Thanks to its calibrated translucency and opalescence, it is ideal to simply mimic enamel properties.

composite additions on upper incisors before finishing

Fig.10

Clinical image after application of the final enamel layer 11 and 21, before finishing.

incisors with unfinished composite restorations

Fig.11

Clinical image after application of the final enamel layer 21(distal) and 22 (distal), before finishing.

upper left incisors after resin infiltration and composite restoration

Fig.12

Immediately after rough finishing, polishing and removal of rubber dam.

polarized picture showing result after white spot infiltration

Fig.13

Immediate postoperative view under cross-polarization (polar_eyes Cross polarization filter).

upper right incisor and canine with brown and white spots

Fig.14

Next appointment involved the same procedure for 12 and 13. Under strict isolation, application of hydrochloric acid (ICON-etch) for 2 minutes, rinsed off for 30 seconds and repeated 3 times.

eroded incisor and canine with white spots

Fig.15

After rinsing and drying with compressed air, we proceeded with the application of ethanol (ICON-Dry) for 30 seconds and inspected thoroughly.

resin infiltration of lateral incisor and canine

Fig.16

Final step was the application of the infiltration resin (ICON infiltrant). Then, light curing for 40 seconds and reapplication of the resin infiltrant. Clinical image of 13 and 12 with the final view of the infiltrated lesions. Obviously infiltration masked yellow and brown areas, so we can be less invasive in the second approach.
Labial surface of 13 and mesial surface of 12 need to be restored with resin composite to result in an acceptable anatomical contour.

composite restoration of infiltrated teeth

Fig.17

After bonding procedures, placement of a thin layer of enamel composite, the Enamel shade (SiE White Dental Beauty) on the labial surface of 13 and mesial surface of 12.

upper teeth after resin infiltration

Fig.18

Immediately after finishing, polishing and removal of the rubber dam.

polarized picture of upper arch after resin infiltration

Fig.19

Immediate postoperative view under cross-polarization (polar_eyes Cross polarization filter).

lower teeth under rubber dam isolation with floss ligatures

Fig.20

Third appointment involved the lower teeth. The main difficulty was the location of the white spot lesions, very close to the gums. To manage this we used strict isolation and ligatures which were pulled during the procedure.

etching white spots on lower teeth

Fig.21

Application of 15% hydro-chloric acid gel (ICON -Etch; DMG, Hamburg, Germany) for 120 seconds to expose body of the lesion. The procedure was repeated three times.

after one etching cycle on dental white spots

Fig.22

Acid rinsed off for at least 30 seconds with water spray and dried. Follow with application of ethanol (ICON -Dry; DMG) for 30 sec and air drying. Clinical image immediately after thoroughly drying teeth with compressed air.

resin infiltration of lower teeth

Fig.23

Final step was the application of the infiltration resin (ICON infiltrant). Remove excess and floss. Then, light curing for 40 seconds. Clinical image after repeating the procedure.

flowable resin restoration after infiltration

Fig.24

A small amount of flowable resin was placed under the microscope, only at the lesions where the enamel loss was more extended.

lower arch after resin infiltration of white spots

Fig.25

Immediately after finishing, polishing and removal of rubber dam.

cross polarization showing disappearance of white spot lesions

Fig.26

Immediate postoperative view under cross-polarization (polar_eyes Cross polarization filter).

polarized and non-polarised picture of infiltrated teeth

Fig.27

Two-week postoperative view of the upper teeth and polarized view.

polarized and non-polarised picture of infiltrated lower incisors

Fig.28

Two-week postoperative view of the lower teeth and polarized view.

check up two weeks after resin infiltration of white spots

Fig.29

View of teeth at two-week recall. The outcome is highly acceptable for a no-prep approach and minimally invasive for a young patient. Micro-invasive treatment of post orthodontic white spot lesions, in this case was completed, without any mechanical removal of tooth structure.

Conclusions

Manifestation of white spot lesions after bracket removal is a common side effect due to the poor oral hygiene adjacent to fixed appliances (7,17). In contrast with other treatments, infiltration technique with ICON offers a micro-invasive tool without any drilling or tooth substance removal(18, 20). Moreover, it can stop progression of the lesions and make resin-embedded enamel more resistant to future acid attack (18).
In cavitated lesions, infiltration treatment can be combined with composite application in one step for better results, in parts of the lesion where loss of tooth substance occurs (19). Use of microscope was a valuable parameter because gave us the opportunity to estimate accurately the topography of each lesion and manage the resin application exactly in the parts where resin infiltration was inadequate to restore enamel loss. The satisfactory clinical result has made it possible to avoid more invasive treatments.

Bibliography

1.Höchli D, Monika Hersberger-Zurfluh M., Papageorgiou S., Eliades T. Interventions for orthodontically induced white spot lesions: a systematic review and meta-analysis. Eur J Orthod 2017 Apr 1;39(2):122-133.
2.Paris S, Meyer-Lueckel H, Colfen H, Kielbassa AM. Resin infiltration of artificial enamel caries lesions with experimental light curing resins. Dent Mater J 2007;26:582-588.
3.Paris S, Meyer-Lueckel H, Kielbassa AM. Resin infiltration of natural caries lesions. J Dent Res 2007;86:662-666.
4.Hammad, Shaza & Banna, Mai & El Zayat, Inas & Mohsen, Mohamed. (2012). Effect of resin infiltration on white spot lesions after debonding orthodontic brackets. American journal of dentistry. 25. 3-8.
5.Belli R, Rahiotis C, Schubert EW, Baratieri LN. Wear and morphology of infiltrated white spot lesions. J Dent. 2011;39:376–85.
6.Khoroushi M, Kachuie M. Prevention and treatment of white spot lesions in orthodontic patients. Contemp Clin Dent. 2017;8:11–9.
7.Abbas BA, Marzouk ES, Zaher AR. Treatment of various degrees of white spot lesions using resin infiltration-in vitro study. Prog Orthod. 2018;19(1):27.
8.Øgaard B, Rølla G, Arends J. Orthodontic appliances and enamel demineralization. Part 1. Lesion development. Am J Orthod Dentofacial Orthop. 1988;94:68–73
9.Rahiotis C, Zinelis S, Eliades G, Eliades T. Setting characteristics of a resin infiltration system for incipient caries treatment. J Dent. 2015;43(6):715-719.
10.Kielbassa AM, Muller J, Gernhardt CR. Closing the gap between oral hygiene and minimally invasive dentistry: a review on the resin infiltration technique of incipient (proximal) enamel lesions. Quintessence International 2009;40:663–81.
11.Paris S, Meyer-Lueckel. H. Masking of labial enamel white spot lesions by resin infiltration—a clinical report. Quintessence International 2009;40:713–8.
12.Paris S, Meyer-Lueckel. H. Inhibition of caries progression by resin infiltration in situ. Caries Research 2010;44:47–54.
13.Paris S, Hopfenmuller W, Meyer-Lueckel. H. Resin infiltration of caries lesions: an efficacy randomized trial. Journal of Dental Research 2010;89:823–6.
14.Ekstrand KR, Bakhshandeh A, Martignon S. Treatment of proximal superficial caries lesions on primary molar teeth with resin infiltration and fluoride varnish versus fluoride varnish only: efficacy after 1 year. Caries Research 2010;40: 41–6.
15.Kim S, Kim EY, Jeong TS, Kim JW. The evaluation of resin infiltration for masking labial enamel white spot lesions. Int J Paediatr Dent. 2011 Jul;21(4): 241-8.
16.Meyer-Lueckel H, Paris S. Improved resin infiltration of natural caries lesions. J Dent Res 2008; 87: 1112–1116.
17.Denis M, Atlan A, Vennat E, Tirlet G, Attal JP. White defects on enamel: diagnosis and anatomopathology: two essential factors for proper treatment (part 1). Int Orthod. 2013 Jun;11(2):139-65.
18.Perdigão J. Resin infiltration of enamel white spot lesions: An ultramorphological analysis. J Esthet Restor Dent. 2020 Apr;32(3):317-324.
19.Jia L, Stawarczyk B, Schmidlin PR, Attin T, Wiegand A. Effect of caries infiltrant application on shear bond strength of different adhesive systems to sound and demineralized enamel. J Adhes Dent. 2012 Dec;14(6):569-74.
20.Zafer Cehreli, Infiltration: Ultraconservative Management of Hypomineralization, https://www.styleitaliano.org/infiltration-ultraconservative-management-ofhypomineralization/