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CASE REPORT
Year : 2023 | Volume
: 14
| Issue : 2 | Page : 66-68
Management Of Clear Aligner-related Severe Enamel Demineralization With A Modified Resin Infiltration Technique: A Case Report
Vo Truong Nhu Ngoc1, Pham Thanh Ha2, Dang Trieu Hung1, Nguyen Viet Anh1
1 School of Dentistry, Hanoi Medical University, Hanoi 100000, Vietnam
2 National Hospital of Odonto-Stomatology, Hanoi 100000, Vietnam
Correspondence Address:
Nguyen Viet Anh
Hanoi Medical University, Hanoi 100000
Vietnam
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/denthyp.denthyp_18_23
Introduction: Enamel demineralization expressed as white spot lesions (WSLs) has been reported to be associated with both fixed and removable orthodontic appliances. Case report: This case report described the management of a patient with clear aligner-related severe enamel demineralization using a modified resin infiltration technique. Microabrasion with Opalustre (Ultradent, Utah, USA) was performed to remove the remineralized enamel surface followed by repeated etching with ICON Etch (DMG, Hamburg, Germany) until the WSLs disappeared after ethanol application. A #12 blade could be used to check whether the superficial layer was demineralized enough for the resin to infiltrate. The ICON-Infiltrant (DMG, Hamburg, Germany) was applied to the etched enamel and light-cured. After treatment, all the WSLs showed improvement with the color nearly matching the adjacent sound enamel. Discussion: Modified resin infiltration technique combined with microabrasion could be an effective noninvasive method to treat severe enamel demineralization including shallow localized enamel breakdown. However, more clinical studies are required to assess the efficacy and safety of this method.
Keywords: aesthetic dentistry, clear aligner, enamel demineralization, microabrasion, resin infiltration, white spot lesion
Enamel demineralization expressed as white spot lesions (WSLs) has been reported to be associated with fixed orthodontic appliances and poor oral hygiene.[1] These lesions also occur in patients treated with removable appliances such as clear aligners but with lower incidence.[2] The management of WSLs encountered in the postdebonding stage is usually an intervention as preventive measures’ remineralizing effect is restricted to only the lesion surface.[3],[4]
Among intervention approaches to managing WSLs, resin infiltration has been shown to be effective in the immediate restoration of aesthetics and fluorescence of demineralized enamel, in which the lesion surface was conditioned with hydrochloric acid and subsequently infiltrated with a low-viscosity resin.[5],[6],[7] However, deep WSLs may not be treated successfully with this method as the resin could not infiltrate into deep layers of the lesions due to the blockage of the unetched or remineralized enamel. Therefore, we have modified the technique to allow for deeper infiltration of the resin into the deep demineralized layers.
This case report described the management of a patient with clear aligner-related severe enamel demineralization using the modified resin infiltration technique.
Case ReportHistory, examination, and investigation
A 14-year-old female patient presented to our clinic (Nhu Ngoc Dental Clinic, Hanoi, Vietnam) with the chief complaint of multiple white spots on many teeth and tooth sensitivity. She was treated with clear aligners in another clinic 14 months ago in which many attachments were bonded. During the treatment, the patient’s oral hygiene was poor as the aligners were not removed during meals and the toothbrush was performed only once per day. The WSLs developed around the aligner attachments and the teeth became sensitive, hence, the previous orthodontists decided to stop aligner treatment 3 months ago. After that, the patient was treated with three sequences of in-office 5% sodium fluoride varnish application combined with a 0.21% sodium fluoride containing toothpaste at home but the WSLs and sensitivity were not improved. Therefore, the patient was referred to our clinic.
On the first examination, the patient had multiple WSLs on all teeth, in which most of the WSLs were categorized as Code 2 according to International Caries Detection and Assessment System (ICDAS) criteria, and some WSLs were classified as Code 3 with shallow localized enamel breakdown [Figure 1](a-c).[8] The normal saliva pH was revealed using a pH indicator (GC, Tokyo, Japan). As the preventive remineralizing measures were ineffective in this patient, we decided to treat the patient with a modified resin infiltration technique in combination with microabrasion.
Figure 1 (a-c) Pretreatment photographs showed many WSLs in all teeth. (d) Microabrasion with Opalustre. (e) Etching with ICON Etch. (f) Infiltration with ICON Infiltrant. (g) Polishing. (h-j) Posttreatment photographs showed the improvement of WSLs.Treatment procedures
Before treatment, the patient was given informed consent to the modified resin infiltration technique. After rubber dam placement, a #12 blade (KIATO, Uttar Pradesh, India) was used to check whether the superficial layer was demineralized enough for the resin to infiltrate. The #12 blade was carefully manipulated in a parallel direction with the enamel surface, the appearance of chalky dust meant that it was not necessary to perform microabrasion. If there was no chalky dust, microabrasion with Opalustre (Ultradent, Utah, USA) was done in each tooth in 60 seconds to remove the remineralized enamel surface [Figure 1](d). Then, a hydrochloric acid containing etchant (ICON Etch, DMG, Hamburg, Germany) was applied to the WSLs and sound adjacent enamel for 120 seconds followed by drying with the ethanol desiccation solution (ICON Dry, DMG, Hamburg, Germany) [Figure 1](e). The etching was repeated three to four times until the WSLs disappeared after 99% ethanol (ICON Dry, DMG, Hamburg, Germany) application, which reflected the expected results after infiltration.[6] Checking with the #12 blade repeated to be sure about the demineralized condition of the superficial enamel.
The resin infiltrant (ICON-Infiltrant, DMG, Hamburg, Germany) was applied to the etched enamel for 3 minutes and light-cured for 40 seconds [Figure 1](f). An additional resin infiltration was performed for 1 minute as the etching time was prolonged. Then, glycerin (DEOX, Ultradent, Utah, USA) was applied and light-cured. Finally, the enamel surface was polished with a pumice and polishing kit (Sof-Lex, 3M, Minnesota, USA) [Figure 1](g). The patient was also instructed to use a 1450 ppm sodium fluoride containing mouthwash (Kin Ortho, Laboratorios KIN, Barcelona, Spain), brush with Clinpro Tooth Crème (3M, Minnesota, USA) using a modified BASS technique,[9] and apply topical remineralization (Tooth Mousse Plus, GC, Tokyo, Japan) containing 900 ppm fluoride and casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) for 1 month.
Treatment result
The posttreatment photographs showed a significant improvement in dental esthetics [Figure 1] (h-j). All the WSLs showed improvement with the color nearly matching the adjacent sound enamel. The tooth sensitivity was discontinued after 1 week. The second molars were only treated by another remineralizing measure (Tooth Mousse Plus, GC, Tokyo, Japan) without resin infiltration because of low esthetic significance and difficulty in rubber dam placement due to short clinical crowns.
DiscussionTreatment of postorthodontic WSLs with resin infiltration not only improves dental esthetics but also arrests the progressions of caries formation by completely occluding pores of the lesion body.[10] The infiltrated WSLs may have similar refractive indices with surrounding sound enamel and significantly increased microhardness.[11] Microabrasion could also be an effective method in reducing the WSLs’ sizes and improving microhardness.[12]
In this patient, a modified resin infiltration technique combined with microabrasion was used in which a #12 blade was utilized for checking the demineralizing condition of the superficial layer of WSLs. The microabrasion and #12 blade were used because the WSLs had been treated unsuccessfully with remineralizing measures and the remineralized enamel surface would block the resin infiltrant from infiltrating into the body of the lesions. If the desiccation solution application did not cause the WSLs to disappear, a repetition of etching localized within only the persistent white spot area would be necessary to remove the infiltrating blockage. The treatment result proved the effectiveness of the modified technique with the significant improvement of all treated WSLs including Code 3 lesions showing shallow localized enamel breakdown.
With WSLs located near or below the gingival margin, the lesions need to be exposed completely by placing gingival retraction cords before rubber dam placement. Dental floss could also be used to retract the gingival margin apically which exposes the subgingival WSLs better. Oral hygiene instruction is very important in both fixed and removable orthodontic patients, despite the lower frequency of WSLs in clear aligner treatment.
This case report has some limitations. First, long-time follow-up is not yet available to evaluate the stability of the treatment result. Second, the second molars with short clinical crowns could not be treated with the modified resin infiltration technique due to the isolation inability. Finally, more clinical studies are required to assess the efficacy and safety of this method.
Financial support and sponsorship
Nil.
Conflicts of interest
The authors declare that they do not have any conflict of interest.
References
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