A new case report from our community member Dr. Vincenzo Vitale
Case report: Treatment of traumatic hypomineralisation with a combination of infiltration and direct composite restoration.
Abstract
In the era of minimally invasive dentistry is crucial to solve aesthetic and functional defects striving to spare tooth structure as much as possible. The Resin infiltration concept perfectly suits this philosophy when treating enamel white-spot lesions.
The latter, based on the diagnosis and depth, can be treated by infiltration alone or pre-treated and finalized by a combination of resin infiltration and direct composite restoration.
Diagnosis
A young girl presents a white spot lesion on a tooth 2.1. (Fig. 1,2)
The white spot was located only on one tooth (differential diagnosis for MIH lesion pattern or metabolic origin lesion pattern) and did not come away with prophylaxis procedure (differential diagnosis for intrinsic or extrinsic origin of the lesion).
Based on the review by Sulieman, M. (2005) it has been classified as a white spot lesion of Intrinsic pre-eruptive traumatic origin.
Intro
The lesions of intrinsic origin lie deeply into enamel and, often, do not respond to the infiltration technique alone. For this reason, is necessary a pre-treatment of the enamel.
However, in this case, an attempt for the resin infiltration alone has been tried.
Lately, due to the scarce result obtained, the lesion was pre-treated with a diamond bur and subsequent resin infiltration and direct composite apposition.
Steps
Before isolation, the colours of tooth 2.1 were analysed and the tooth polished.(Fig.3)
Color selection has been performed placing small amounts of different shades of composite restorative material on tooth surface. Once light-cured, the mimesis has been evaluated.
After analysis, an Enamel mass (GE2, Micerium) has been chosen .
Before starting the treatment full rubber dam isolation is carried out to achieve a perfect dry environment and prevent contact of both the etchant and infiltrant with soft tissues.
The first application of etchant is performed applying a quantity slightly greater than that required for 2 minutes.
After, with suction and an abundant water rinsing of 30 seconds, the etchant is removed.
The tooth is then dried with oil-water free air syringe.
To simulate the effect of the resin infiltration the lesion is wetted with Icon-dry allowed to set for 30 seconds.
When wetted with Icon-Dry, the whitish-opaque coloration on the etched enamel should diminish. In this case, as expected (due to the origin of the lesion), the result is almost absent.
A second application of etchant and icon-dry is carried out exactly like the first.
Still, the result, previsualized with Icon-Dry, is not satisfying.
A third and fourth attempt is performed increasing the etching time to 5 minutes forcing a deeper penetration of the ICON etchant.
After these applications the result, previsualized with Icon Dry, is improved but still not completely satisfying.
A total of 4 applications of etchant were performed of which the last 2 for prolonged time.
The lesion is so pre-treated with a small round diamond bur.
Superficial removal and smoothening of the remaining little white-spot is carried out without reaching underling dentin.
Subsequently the remaining lesion is etched for 3 minutes to remove the smear layer and allow the resin infiltrant to improve its penetration.
After an abundant rinsing with water-oil free syringe, an amount of Icon-Dry material is placed onto the lesion and allowed to set for 30 seconds. When wetted with Icon-Dry, the whitish-opaque coloration on the etched enamel diminished, the result is now satisfactory.
To move on with the infiltration is necessary a meticulous drying of the tooth with water-oil free air syringe.
Apply an ample amount of Icon-Infiltrant and allow it to infiltrate for 3 minutes, occasionally activate with rubbing movement.
Improve the isolation with some dental floss (Superfloss. Oral B) which will be further moved to clean the interproximal space before light curing the resin infiltrant.
Light cure with a 450nm lamp (subjected to periodic inspection) for 40 sec.
It is necessary that the intensity of the light is at least equal to 800mW / cm2.
Apply a second time an ample amount of Icon-Infiltrant and allow penetration for 1 minute with rubbing movement.
Light cure with a 450nm lamp as close to the material as possible for at least other 40 sec. .
The lesion, now covered with resin infiltrant, has changed its colour from white to orange dentine colour. This will serve as liner substrate for the small composite restorative material that will be placed above it.
Restoration
Based on the fact the infiltrant, as a resin, has a superficial inhibited oxygen layer, the bonding procedure is performed applying only a self-etch adhesive system (Scotchbond Universal 3M). The adhesive is light cured for 20 sec.
A small amount of composite restorative material (GE2 ENAMEL, Micerium) is then applied.
With the Use of a Kolinsky brush the composite is handled and the defect restored.
Final light curing of composite is performed under glycerine (to allow the polymerization of the superficial inhibited oxygen layer)
Contouring and fishing procedures are performed using a medium and superfine grit disc mounted on low-speed handpiece.
The restoration is then lustred with a fine diamond paste on a wool wheel. (Fig. 4,5,6)
Once finished with the composite addition, the Rubber dam is disassembled.
Immediate post operatory is noted and photographed. (Fig. 7)
The rehydration of teeth to see the final result is attended for at least 7 days.
At 1 month the rehydration is completed, the result shows natural and mimetic integration. (Fig.8,9,10)
Evaluation
This case shows how the resin infiltrant works as a natural dentin colour mimetic substrate. Reflecting light from inside, with only a superficial amount of enamel composite, is possible to achieve a satisfactory aesthetic result with minimal invasive procedure.
This case report is published in collaboration with DMG.
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