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Year : 2013  |  Volume : 1  |  Issue : 1  |  Page : 31-35

Using resin infiltration to treat developmental defects of enamel: Three case reports

Advanced Speciality Education Program in Paediatric Dentistry/Loma Linda University School of Dentistry, Loma Linda, California, USA

Date of Web Publication29-Apr-2013

Correspondence Address:
Samah I Omar
Advanced Education Program in Paediatric Dentistry, Loma Linda University School of Dentistry, 11092 Anderson Street, Prince Hall 3301, Loma Linda, California - 92350
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-4619.111231

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White spots or patches on permanent incisors are common among young adolescents; this may cause aesthetic concerns for both the patient and the parents equally. Management of developmental defects of enamel (DDE) is challenging and highly dependent on the type, severity, and appearance of the defect. Resin infiltration procedure is simple and conservative, and the procedure is generally well tolerated by patients. The material was introduced in the market to treat initial interproximal carious lesions and for post-orthodontic decalcifications. It was noticed that enamel lesions treated with resin infiltration would lose their whitish appearance as the microporosities are filled with the resin. In this case report, we have demonstrated the successful use of resin infiltration (ICON® ) for masking the white color resulting from mild DDE. The pleasing aesthetic results and the conservative nature of this approach make it a good alternative to microabrasion and conventional resin restorations.

Keywords: Developmental defects of enamel, resin infiltration, white spots

How to cite this article:
Omar SI. Using resin infiltration to treat developmental defects of enamel: Three case reports. J Res Dent 2013;1:31-5

How to cite this URL:
Omar SI. Using resin infiltration to treat developmental defects of enamel: Three case reports. J Res Dent [serial online] 2013 [cited 2021 Jan 28];1:31-5. Available from: http://www.jresdent.org/text.asp?2013/1/1/31/111231

  Introduction Top

The prevalence of developmental defects of enamel (DDE) is increasing in otherwise healthy children as well as in children with other medical or genetic disorders. [1] Management of DDE is challenging and highly dependent on the type, severity, and appearance of the defect. [2] Minor defects may be managed with bleaching or microabrasion, while severe defects need restorations, veneers, or full-coverage crowns. Microabrasion was introduced by Croll in the late 80s and is proven to be efficient for treating DDE. [3],[4],[5]

Resin infiltration is a conservative and non-invasive technique developed recently to inhibit the further progression of non-cavitated carious lesions. [6],[7],[8],[9],[10],[11],[12],[13] Resin infiltration aims to penetrate lesion porosities using special low viscosity resin with high penetration properties, whereby the lesion caries progression is slowed down or even arrested. It was observed that the white chalky appearance of the natural caries lesion was improved after the use of resin infiltration. [14],[15],[16] The purpose of this case report was to demonstrate the successful use of resin infiltration to treat white spots resulting from DDE.

  Case Reports Top

Case 1

An 8-year old girl with a non-remarkable health history attended our clinic for a routine examination and complaining of chalky white spots on her front teeth [Figure 1]. The mother of the patient reported that the patient started expressing some concerns regarding the look of her front teeth and that her peers teased her at school. The mother noticed that the child was scraping the teeth with her nails and brushing harder in an attempt to remove the white patches. Moderate size enamel white lesions on both upper permanent central incisors were noticed. Although the patient has dental class III malocclusion and her upper teeth normally do not show when she smiles [Figure 2], she was still bothered by the appearance of her teeth and wanted them fixed. We presented the treatment options to the patient and her mother, and our recommendations included resin infiltration, microabrasion, or resin restoration. Mother decided to try the most conservative and least invasive option (resin infiltration) first. The procedure was explained to the mother and the patient, treatment consent was signed and intraoral photographs were taken. Teeth were cleaned with pumice using a rubber cup before rubber dam was placed and resin infiltration was applied according to the manufacturer's instructions. The teeth were etched with 15% hydrochloric acid gel (ICON® -Etch; DMG, Hamburg, Germany) for 2 min to remove the highly mineralized surface and expose the lesion body. Thorough rinsing with water for 10 seconds followed this step. Ethanol (ICON® -Dry) was applied for 30 seconds and then air-dried. The etching process was repeated two more times, followed by drying agent use. The infiltrant (ICON® -Infiltrant) was applied to the teeth and allowed to penetrate for 3 minutes. The excess material was removed with an explorer and the teeth were flossed. Finally, a curing light was used for 40 seconds. The application of the infiltrant was repeated, followed by 40 seconds of light curing. The teeth were polished with composite finishing discs (Sof-Lex disk; 3M ESPE, Saint Paul, MN, USA). The white lesions almost disappeared and both the patient and mother were impressed with the results [Figure 3]. The patient came back a week later for follow-up and was very happy and satisfied with the treatment results. The mother believed that the successful result of the treatment had reflected positively on the patient's self esteem.
Figure 1: White patches on the upper permanent incisors

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Figure 2: Incisal relationship - class III malocclusion

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Figure 3: After the application of resin infiltration, lesions almost disappeared

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Case 2

A 10-year old girl with a history of mild asthma came to our clinic to restore a white lesion on the facial surface of maxillary left central incisor. The tooth had a small to moderate oval-shaped white DDE on the incisal third of her tooth [Figure 4]. The lesion was hard and non-cavitated and her dental history did not reveal any trauma or infection in the primary incisors. Resin infiltration and microabrasion were suggested and mother elected to try resin infiltration. ICON® resin infiltration was used according to the manufacturer's instructions. The lesion almost disappeared and the results were surprisingly good. [Figure 5] shows the immediate post-operative results and, although the tooth was dehydrated at that time, the aesthetic results were still pleasing. When the patient came back 2 weeks later for a follow-up, there were no traces of the white lesion and the enamel translucency was normal [Figure 6]. The patient and her family were extremely happy and satisfied with the results. Stable aesthetic results were still evident during the 18 months follow-up [Figure 7].
Figure 4: White spot lesion on the upper left central incisor

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Figure 5: Post resin infiltration treatment; notice that the teeth are still dehydrated

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Figure 6: 2 weeks after treatment

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Figure 7: 18-months follow-up

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Case 3

Mother and father of another 10-year-old girl expressed their concerns about her white patches on the maxillary central incisors [Figure 8]. Resin infiltration was offered, risks and benefits were discussed with the parents, and they consented for treatment. ICON® was used according to the manufacturer's instructions. Although the lesions did not disappear completely, the outcome was still satisfactory and considered successful [Figure 9]. The patient came back 2 weeks after the treatment for a post-operative evaluation. The teeth looked much better than that at the day of treatment [Figure 10]. We explained to the parents that the delayed improvement was expected since the teeth were rehydrated and the normal enamel color was restored. [Figure 11] demonstrates color stability until 1 year later.
Figure 8: Diffuse white lesions on the maxillary central incisors

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Figure 9: Immediately after resin infiltration treatment

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Figure 10: 2-weeks follow-up showing improved color masking

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Figure 11: Color stability 1 year later

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  Discussion Top

Ameloblasts are highly susceptible to relatively minor changes in their environment. The resulting enamel defects vary depending on the nature and severity of the insult on one hand and the stage of tooth development on the other hand. [2],[17] It is believed that the whitish opaque appearance of (DDE) may be caused by subsurface porosities in the enamel below a well-mineralized surface layer. It has been demonstrated that hypomineralized enamel is resistant to conventional acid etching. [18] This, in turn, may contribute to poor micro-tag formation at the interface between hyopmineralized enamel and adhesives leading to bonding failure and microleakage. [2],[19] In this case report, we focused on minor to moderate defects, mainly on white non-cavitated lesions.

The decision to use resin infiltration (ICON® , DMG) to treat the white developmental lesions in our patients was taken after reviewing the observations of Paris. [14] It was noticed that lesions infiltrated by ICON® took on the appearance of the surrounding enamel. Enamel lesions lose their whitish appearance when their microporosities are filled with resin and look similar to the sound enamel. [20] Sound enamel has a refractive index of 1.62. Porous enamel appears opaque compared to sound tissues when filled with water (refractive index 1.33). [21] On the other hand, when these pores are infiltrated with the resin infiltrant, the refractive index increase to 1.52 and the lesions appear similar to the surrounding enamel. [16] The masking effect of resin infiltration on DDE was studied by Kim et al., [16] The study showed that the masking effect was dramatic in some cases, but not in others and that only 60% of teeth with DDE were completely masked. However, aesthetic improvement was still observed in teeth with incomplete penetration.

It is worth mentioning that all treated teeth showed improved appearance and better color match with the surrounding unaffected enamel after 1 or 2 days. Paris studied the effect of resin infiltration on the visual appearance of artificial caries lesions in 2010. [20] The study concluded that infiltration combined with re-mineralization resulted in better assimilation of the appearance of artificial enamel lesions to adjacent sound enamel than re-mineralization alone or infiltration alone. Resin infiltration is simple and conservative when compared with conventional resin restorations. Although microabrasion is considered a conservative approach for treating enamel defects, and its success is proven in the literature, its association with loss of enamel structure is controversial and highly dependent on the operator and the technique used. [22],[23],[24] The use of resin infiltration to mask the white opaque color of white lesions was based on clinical observations of some practitioners and is not advertised by ICON® manufacturer.

The practitioner should select the cases carefully. Teeth with brown discoloration may not be good candidates for resin infiltration, since the later will not mask the brown color and, in fact, it may saturate the color and make it look worse clinically. Microabrasion or conventional resin restorations may be better options for treating teeth with brown discoloration. Patients treated with resin infiltration should be monitored closely. Until the writing of this report, there have been no published data on the long-term surface hardness or the color stability of resin infiltrated lesions. The risks and benefits should be discussed with the patient or the legal representative. If bleaching is desired, the author advises that the patient pursue bleaching before resin infiltration is applied. Theoretically the infiltrated enamel may not get bleached, which may lead to color mismatch within the same tooth. Effect of bleaching on infiltrated need to be further studied.

Clinical management of DDE is challenging and aesthetic outcome demonstrated in the cases treated in our clinic is pleasing, especially in young patients when other restorative options are not feasible. The use of ICON® to treat white lesions is promising. However, it is a new material and we lack the long-term follow-up on its clinical performance and stability. Further research is needed to evaluate the physical and clinical properties of this new material.

  References Top

1.Mejare I, Bergman E, Grindfjord M. Hypomineralized molars and incisors of unknown origin: Treatment outcome at age 18 years. Int J Pediatr Dent 2005;15:20-8.  Back to cited text no. 1
2.William V, Burrow MF, Palamara JE, Messer LB. Microshear bond strength of resin composite to teeth affected by molar hypomineralization using 2 adhesive systems. Pediatr Dent 2006;28:233-41.  Back to cited text no. 2
3.Croll TP. Enamel microabrasion for removal of superficial discoloration. J Esthet Dent 1989;1:14-20.  Back to cited text no. 3
4.Killian CM, Croll TP. Enamel microabrasion to improve enamel surface texture. J Esthetic Dent 1990;2:125-8.  Back to cited text no. 4
5.Benbachir N, Ardu S, Krejci I. Indications and limits of the microabrasion technique. Quintessence Int 2007;38:811-5.  Back to cited text no. 5
6.Paris S, Meyer-Lueckel H, Kielbassa AM. Resin infiltration of natural caries lesions. J Dent Res 2007;86:662-6.  Back to cited text no. 6
7.Mayer-Lueckel H, Paris S. Improved resin infiltration of natural caries lesions. J Dent Res 2008;87:1112-6.  Back to cited text no. 7
8.Kielbassa AM, Müller 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 Int 2009;40:663-81.  Back to cited text no. 8
9.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 Res 2010;44:41-6.  Back to cited text no. 9
10.Paris S, Meyer-Lueckel H. Infiltrants inhibit progression of natural caries lesions by in vitro. J Dent Res 2010;89:1276-80.  Back to cited text no. 10
11.Paris S, Bitter K, Naumann M, Dörfer CE, Meyer-Lueckel H. Resin infiltration of proximal caries lesions differing in ICDAS codes. Eur J Oral Sci 2011;119:182-6.  Back to cited text no. 11
12.Paris S, Hopfenmuller W, Meyer-Lueckel H. Resin infiltration of caries lesions: An efficacy randomized trial. J Dent Res 2010;89:823-6.  Back to cited text no. 12
13.Paris S, Meyer-Lueckle H. Inhibition of caries progression by resin infiltration in situ. Caries Res 2010;44:47-54.  Back to cited text no. 13
14.Paris S, Meyer-Lueckle H. Masking of labial enamel white spot lesions with resin infiltration-A clinical report. Quintessence Int 2009;40:713-8.  Back to cited text no. 14
15.Belli R, Rahiotis C, Schubert EW, Baratieri LN, Petschelt A, Lohbauer U. Wear and morphology of infiltrated white spot lesions. J Dent 2011;39:376-85.  Back to cited text no. 15
16.Kim S, Kim EY, Jeong TS, Kim JW. The evaluation of resin infiltration for masking labial enamel white spot lesions. Int J Pediat Dent 2011;31:241-8.  Back to cited text no. 16
17.Suckling GW. Developmental defects of enamel-historical and present-day perspectives of their pathogenesis. Adv Dent Res 1989;3:87-94.  Back to cited text no. 17
18.Klipatrick N. New development in understanding development defects of enamel: Optimizing clinical outcomes. J Orthod 2009;36:277-82.  Back to cited text no. 18
19.Mahoney E, Ismail FS, Kilpatrick N, Swain M. Mechanical properties across hypomineralized/hypoplastic enamel of first permanent molar teeth. Eur J Oral Sci 2004;112:497-502.  Back to cited text no. 19
20.Paris S, Keltsch J, Dorfer CE, Meyer-Luckel H. Visual assimilation of artifical enamel lesions by infiltration in vitro. Caries Res 2010;44:171-248.  Back to cited text no. 20
21.Kidd EA, Fejerkov O. What constitutes dental caries? Histopathology of carious enamel and dentin related to the action of cariogenic biofilms. J Dent Res 2004:83:C35-8.  Back to cited text no. 21
22.Kendell RL. Hydrochloric acid removal of brown fluorosis: Clinical and scanning electron micrographic observations. Quintessence Int 1989;20:837-9.  Back to cited text no. 22
23.Tong LS, Pang MK, Mok NY, King NM, Wei SH. The effect of etching, microabrasion, and bleaching on surface enamel. J Dent Res 1993;72:67-71.  Back to cited text no. 23
24.Olin PS, Lehner CR, Hilton JA. Enamel surface modification in vitro using hydrochloric acid pumice: An SEM investigation. Quintessence Int 1988;19:733-6.  Back to cited text no. 24


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]

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