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White spots removal and volume restitution

The problem of white spots is very real because it combines, in many cases, an aesthetic injury with teeth with anatomical integrity that significantly slows the use of too invasive restoration methods.In the case illustrated here, we see a smile that looked completely altered by severely spotted enamel that covered a large part of the buccal surfaces, especially teeth 11 and 21 which see their value and natural appearance masked by the opaque layer of the demineralized zones.So the temptation to resort, in such a case, to an invasive technique such as bonded ceramic veneers, is great.A precise analysis of the clinical situation combined with a good knowledge of the methods of bleaching and erosion / infiltration will allow to make a significant improvement to the problem. The use of a direct composite resins, in end point, will be limited to the establishment of a layer of surface enamel secondarily polished.In this case report, the patient’s request is the elimination of white spots on her upper anteriors teeth. On clinical and photographic examination, there is a significant loss of buccal enamel volume associated to these white spots. The erosion infiltration treatment will be followed by a restitution of 3D morphology with direct composites resins.

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Fig.1
Initial smile shows spotted and colored teeth. The first step of the treatment will be a bleaching procedure.

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Fig.2
Picture taken with retractors and flexipalettes, the larger white spots are on teeth 11 and 21.

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Fig.3
Cross polarized picture shows how opaque and deep the lesion are.

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Fig.4
First step is to go for a bleaching treatment to improve global color.

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Fig.5
After 3 weeks bleaching treatment, the color has improved. We can start erosion/infiltration procedure.

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Fig.6
First step is to isolate with the rubber dam from tooth 13 to 23 with clamp on the rubber dam on teeth 14 and 24

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Fig.7
The rubber dam has to be inverted in the sulcus so we can have a large and dry working field and the gum will be protected from the products used during the procedure.

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Fig.8
First step of the treatment is to sandblast carefully the white lesion with 50um aluminium oxyde.

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Fig.9
On this lateral view we can see the loss of enamel due to large white spots and the sandblasting.

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Fig.10
On this lateral view we can see the loss of enamel due to large white spots and the sandblasting

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Fig.11
DMG Icon  Etch (15% hydrochloric acid) is brushed for 2 minutes and then rinsed and dried for 30 seconds.

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Fig.12
TIP: We can use a prophylactic brush on endodontic reciprocating handpiece to brush the spotted surface.

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Fig.13
After rinsing and drying Icon etch.

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Fig.14
Icon dry is applied and sit for 30 seconds.

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Fig.15
White spots are still visible, we have to start the procedure again.

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Fig.16
In this case, we had to redo the procedure 4 times to see the spots disappear.

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Fig.17
Before applying infiltration resin, we need to use matrices to avoid the teeth being bonded to each other.

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Fig.18
We can now apply Icon infiltration resin for 3 minutes and light cure for 1 minute.

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Fig.19
On this lateral view, we can see the enamel loss which will be solved with direct enamel composite resin.

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Fig.20
On this lateral view, we can see the enamel loss which will be solved with direct enamel composite resin.

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Fig.21
Enamel composite is applied with LM Arte Applica Twist

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Fig.22
Enamel composite is softened with Compobrush.

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Fig.23
Final photocuring is done with glycerine gel to avoid the oxygene inhibited layer.

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Fig.24
Finishing and polishing procedure is done by using the Finishing Style bur kit and goat brush with diamonds twist polishing paste.

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Fig.25
Final result after rubber dam removal.

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Fig.26
Final result after 3 days. Teeth are rehydrated.

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Fig.27
Final result after 3 days. This lateral view shows that the enamel volume has been restored.

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Fig.28
Final result after 3 days. This lateral view shows that the enamel volume has been restored.

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Fig.29
Final results 9 months after treatment.

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Fig.30
Final results 9 months after treatment.

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Fig.31
Final smile 9 months after treatment.

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Fig.32
Before&after pictures. The final images show a very satisfactory result in terms of aesthetics. Cross polarized photos are still more convincing about the mitigation of opaque spots see their disappearance.

Conclusions

Every smile restoration treatment involves a feasible, teachable, repeatable and minimally invasive procedure to ensure a predictable and satisfying outcome. We can speak here of a global method, bringing together several approaches, for the purpose to be the least invasive possible.

Bibliography

Manauta J, Salat A. Layers: an atlas of composite resin stratification. Quintessence 2012.
Gauthier Weisrock, Jean-Louis Brouillet. Le champ opératoire évidemment. L’INFORMATION DENTAIRE n° 42 – 3 décembre 2008.
Devoto W, Saracinelli M, Manauta J. Composites in every day practice: How to choose the right material and simplify application techniques in the anterior teeth JEAD, Jan. 2010.
Paris JC, Faucher AJ. Le Guide esthétique: comment réussir le sourire de vos patients. Quintessence international 2003.
Faucher AJ, Ortet S, Camaleonte G, Weisrock G, Etienne O, Paris JC. Réussir les composites antérieurs au quotidien. Quintessence. 2017
Attal JP, Atlan A, Denis M, Vennat E, Tirlet G. L’infiltration en profondeur : un nouveau concept pour le masquage des tâches de l’émail (partie 1). L’information dentaire n°19- 15 mai 2013 : 74-79.
Attal JP, Atlan A, Denis M, Vennat E, Tirlet G. White spots on enamel: treatment protocol by superficial or deep infiltration (part 2). Int Orthod. 2014 Mar;12(1):1-31.Feb 3. English, French.
Tassery H. Lésions amélaires: quand et comment agir? Clinic 2009;30:72–74.
Salat Anna. http://styleitaliano.hime.host/post-orthodontic-white-spots
Clement Marie. http://styleitaliano.hime.host/infiltrate-and-restore.
Dan Lazar http://styleitaliano.hime.host/four-levels-of-inversion-for-rubber-dam-isolation/
Jordi Manauta http://styleitaliano.hime.host/polishing-lifelike-composite/
Paulo Monteiro http://styleitaliano.hime.host/the-step-by-step-in-finishing-and-polishing-part-i/

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