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.

 

 

styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching

Fig.1

Initial smile shows spotted and colored teeth. The first step of the treatment will be a bleaching procedure.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching

Fig.2

Picture taken with retractors and flexipalettes, the larger white spots are on teeth 11 and 21.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching

Fig.3

Cross polarized picture shows how opaque and deep the lesion are.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.4

First step is to go for a bleaching treatment to improve global color.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.5

After 3 weeks bleaching treatment, the color has improved. We can start erosion/infiltration procedure.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

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
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

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.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.8

First step of the treatment is to sandblast carefully the white lesion with 50um aluminium oxyde.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.9

On this lateral view we can see the loss of enamel due to large white spots and the sandblasting.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.10

On this lateral view we can see the loss of enamel due to large white spots and the sandblasting
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.11

DMG Icon Etch (15% hydrochloric acid) is brushed for 2 minutes and then rinsed and dried for 30 seconds.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.12

TIP: We can use a prophylactic brush on endodontic reciprocating handpiece to brush the spotted surface.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.13

After rinsing and drying Icon etch.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.14

Icon dry is applied and sit for 30 seconds.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.15

White spots are still visible, we have to start the procedure again.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.16

In this case, we had to redo the procedure 4 times to see the spots disappear.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.17

Before applying infiltration resin, we need to use matrices to avoid the teeth being bonded to each other.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.18

We can now apply Icon infiltration resin for 3 minutes and light cure for 1 minute.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.19

On this lateral view, we can see the enamel loss which will be solved with direct enamel composite resin.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.20

On this lateral view, we can see the enamel loss which will be solved with direct enamel composite resin.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.21

Enamel composite is applied with LM Arte Applica Twist
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.22

Enamel composite is softened with Compobrush.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.23

Final photocuring is done with glycerine gel to avoid the oxygene inhibited layer.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.24

Finishing and polishing procedure is done by using the Finishing Style bur kit and goat brush with diamonds twist polishing paste.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching finishing

Fig.25

Final result after rubber dam removal.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.26

Final result after 3 days. Teeth are rehydrated.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.27

Final result after 3 days. This lateral view shows that the enamel volume has been restored.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.28

Final result after 3 days. This lateral view shows that the enamel volume has been restored.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.29

Final results 9 months after treatment.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.30

Final results 9 months after treatment.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

Fig.31

Final smile 9 months after treatment.
styleitaliano style italiano white spots icon smile aesthetics resin infiltration bleaching etching

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

 

  1. Manauta J, Salat A. Layers: an atlas of composite resin stratification. Quintessence 2012.
  2. Gauthier Weisrock, Jean-Louis Brouillet. Le champ opératoire évidemment. L’INFORMATION DENTAIRE n° 42 – 3 décembre 2008.
  3. 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.
  4. Paris JC, Faucher AJ. Le Guide esthétique: comment réussir le sourire de vos patients. Quintessence international 2003.
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  7. 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.
  8. Tassery H. Lésions amélaires: quand et comment agir? Clinic 2009;30:72–74.
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  10. Clement Marie. http://styleitaliano.hime.host/infiltrate-and-restore.
  11. Dan Lazar http://styleitaliano.hime.host/four-levels-of-inversion-for-rubber-dam-isolation/
  12. Jordi Manauta http://styleitaliano.hime.host/polishing-lifelike-composite/
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