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Year : 2015  |  Volume : 3  |  Issue : 3  |  Page : 88-91

Spectrophotometric analysis of Icon® treatment outcome in two celiac siblings with developmental defects of enamel, a case report

Department of Oral and Maxillo-Facial Sciences, “Sapienza” University of Rome, Rome, Italy

Date of Web Publication30-Oct-2015

Correspondence Address:
Dr. Marta Mazur
Via Caserta 6, “Sapienza” University of Rome, Rome
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2321-4619.168729

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Developmental defects of enamel (DDE) are common oral manifestation of celiac disease whose onset can overlap to teeth calcification in permanent dentition. The defects of the enamel symmetrically and chronologically occur in all the four quadrants, particularly in maxillary and mandibular incisors and molars. Icon® infiltration technique is a minimally invasive procedure for DDE treatment. This paper reports two cases of treatment of celiac siblings with aesthetic purpose. The aesthetic evaluation was made by means of spectrophotometry as a standardized method. International Commision on Illumination (CIE) L*a*b*, ΔE variations, contrast ratio (CR), and opalescence, measured against black and white backgrounds before and after the treatment, provide all the quantitative information about the outcome of the Icon® infiltration technique. Icon® infiltration technique has been showed to be an effective procedure for DDE treatment.

Keywords: Aesthetic outcome, celiac disease, developmental defects of enamel (DDE), Icon® infi ltrative technique, spectrophotometry

How to cite this article:
Guerra F, Mazur M, Rinaldo F, Ottolenghi L. Spectrophotometric analysis of Icon® treatment outcome in two celiac siblings with developmental defects of enamel, a case report. J Res Dent 2015;3:88-91

How to cite this URL:
Guerra F, Mazur M, Rinaldo F, Ottolenghi L. Spectrophotometric analysis of Icon® treatment outcome in two celiac siblings with developmental defects of enamel, a case report. J Res Dent [serial online] 2015 [cited 2020 May 28];3:88-91. Available from: http://www.jresdent.org/text.asp?2015/3/3/88/168729

  Introduction Top

Celiac disease is a common, chronic, multisystem disorder that can start at any age with gluten diet. The villous atrophy damage to the small intestinal mucosa generated by an autoimmune mechanism causes malabsorption of macro- and micronutrients. Celiac disease can be treated by a strict lifelong gluten-free diet.

Developmental defects of enamel (DDE) and aphthous ulcers are the most common and well-documented oral manifestations among both children and adults with celiac disease; these have been proposed as a possible diagnostic sign of "silent" celiac disease.[1] Enamel hypoplasia and hypomineralization or a combination of the two can occur. Scanning electron microscopy (SEM) analysis of hypoplastic teeth of celiac children evidenced less mineralization and more irregular enamel organization.[2]

DDE symmetrically occur in permanent dentition, particularly in maxillary and mandibular incisors and molars.[1] The chronology of teeth calcification in permanent and temporary dentition can indicate the onset of celiac disease. According to Evans, the most critical period for developing DDE in the permanent central incisors is 15-24 months for males and 21-30 months for females.[3]

This case report describes the usage of a quantitative spectrophotometric method to evaluate the clinical outcome of a minimally invasive treatment of DDE in celiac patients performed with Icon ® (DMG, Hamburg, Germany).

Spectrophotometric measurements are International Commision on Illumination (CIE) L*a*b*, ΔE variations, contrast ratio (CR), and opalescence, measured before and after the treatment.

CIE L*a*b*: The L* value (y-axis) measures the lightness ranging from 0 (black) to 100 (white), the a* value measures redness (a* >0) or greenness (a* <0), and the b* value measures yellowness (b* >0) or blueness (b* <0). Color shade variation (ΔE) is calculated upon CIE L*a*b* variables, according to Ardu's formula.[4] CR measures transparency (i.e., opacity). Opalescence is the reflectance of blue wavelength when white light strikes the object perpendicularly.[4]

  Case Report Top

The cases of two celiac female siblings with DDE have been described.

Intraoral photographs (Nikon D90, 105mm Macro lens, R1C1 Macro flash, Nikon Europe) were taken that represent the visual clinical assessment, before and after the DDE treatment, to be compared to spectrophotometric measurements against black (L* = 1.6, a* = 1.2, b* = -1.0) and white (L* = 92.8, a* = -1.5, b* = 0.9) backgrounds.[5],[6]

A calibrated reflectance spectrophotometer (SpectroShade, MICRO, Serial N HDL1407, MHT, Arbizzano di Negrar, Verona, Italy) was used for quantitative assessment, the device being perpendicular to the clinical crown labial surface in order to obtain reproducible measurement conditions.

Trained operators performed Icon® infiltration and SpectroShade assessments, and digital photographs were taken.

Consent for the treatment was obtained. The teeth were cleaned, rubber dam was placed, and resin infiltration was performed according to the manufacturer indication (etching up to three times, followed by the drying agent). The Icon® infiltrant was applied and allowed to penetrate for 3 min. The excess material was removed and the teeth were flossed and light-cured for 40 s. The infiltrant was reapplied and light-cured for 40 s [Figure 1]. Then the teeth were polished. Measurements were noted again at a week's followup.
Figure 1: Icon® procedure

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To define the effectiveness of this treatment, the MHT software divides the vestibular tooth area into three equal zones (gingival, central, and incisal) along the median axis. Comparison with photographic images taken before the treatment was done to identify the sound and the DDE areas of the tooth. ΔE was calculated before and after the treatment in each of the three dental areas to assess the colorimetric variation. ΔE variation quantitatively assesses the amount of shade difference before and after the Icon treatment and correlates it to human eye perception. ΔE >3.3 indicates a detectable color difference, ΔE between 3.3 and 1.1 indicates no important difference to human eye evaluation, while ΔE <1.1 indicates no visible difference.

Patient 1

C. M., aged 14 years, presented with celiac diagnosis in 2008. Yellow, brown, and white multiple diffuse opacities on the clinical crown of the four upper incisors and a patchy yellow defect on the vestibular surface of both the lower central incisors were detected. According to Aine et al.,[7] all the defects were scored as Grade 1. The etching procedure was repeated thrice [Figure 2].
Figure 2: (a and b) pt 1 before Icon® treatment (c and d) pt 1 after Icon® treatment

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Patient 2

C. G., aged 18 years, presented with celiac diagnosis in 2008. At that time, the girl presented osteoporosis with vitamin D3 and calcium deficiency. Increased calcium and vitamin D3 intake, sun exposure, and weight training did not lead to satisfactory results; so oral administration of bisphosphonate (Actonel) was prescribed. Grade 1 white and yellow diffused DDE with confluent yellow and brown strié were detected on all the upper teeth. The etching procedure was repeated twice [Figure 3].
Figure 3: (a and b) pt 2 before Icon® treatment (c and d) pt 2 after Icon® treatment

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  Discussion Top

According to Um et al.,[8] we analyzed ΔE of each zone before and after Icon ® treatment. The ΔE, opalescence, and CR (transparency) results of the two cases are reported in [Table 1] and [Table 2]. Consistent with the finding of Paris et al.,[9] in these cases the infiltrated lesions "took the appearance of the surrounding sound enamel," while the sound areas (as per photographs) scored <1.1. ΔE values ranged 0.90-6.32. Every zone presenting a defect showed ΔE >3.3. Values <1.1 refer to sound enamel as shown in the clinical photographic documentation [Figure 2] and [Figure 3]. Due to diffuse DDE distribution, it was impossible to identify the specific demarcated affected/sound areas. Thus, we evaluated the whole area (incisal, central, and gingival) shade variation. The goal of our treatment is to show a visible change (i.e., higher ΔE between the measurements) in color matching in the affected areas and low ΔE scores in the unaffected areas [Figure 4] and [Figure 5].
Table 1: Patient 1 upper incisors ΔE, CR, and opalescence before and after Icon® treatment

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Table 2: Patient 2 upper incisors ΔE, CR and opalescence before and after Icon® treatment

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Figure 4: Pt 1 spectrophotometric analysis

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Figure 5: Pt 2 spectrophotometric analysis

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Overall opalescence in the incisal zone was higher after treatment, much higher in the central zone, and was equal or lower than before in the gingival zone. CR in all the zones decreased after the treatment.

Although manufacturer indication does not define brown discoloration as a good candidate for resin infiltration, our results show substantial improvement in the clinical appearance, independent of the initial DDE color. DDE management is challenging both for clinical procedure and for aesthetic subjective perception. The clinical outcome and consistent spectrophotometric analysis in the reported cases were overall satisfactory, especially considering the young age of the patients, when minimally invasive approach is desired.[10]

  References Top

Rashid M, Zarkadas M, Anca A, Limeback H. Oral manifestations of celiac disease: A clinical guide for dentists. J Mich Dent Assoc 2011;93:42-6.  Back to cited text no. 1
Bossù M, Bartoli A, Orsini G, Luppino E, Polimeni A. Enamel hypoplasia in coeliac children: A potential clinical marker of early diagnosis. Eur J Paediatr Dent 2007;8:31-7.  Back to cited text no. 2
Evans RW, Darvell BW. Refining the estimate of the critical period for susceptibility to enamel fluorosis in human maxillary central incisors. J Public Health Dent 1995;55:238-49.  Back to cited text no. 3
Ardu S, Feilzer AJ, Devigus A, Krejci I. Quantitative clinical evaluation of aesthetic properties of incisors. Dent Mater 2008;24:333-40.  Back to cited text no. 4
Ardu S, Braut V, Gutemberg D, Krejci I, Dietschi D, Feilzer AJ. A long-term laboratory test on staining susceptibility of aesthetic composite resin materials. Quintessence Int 2010;41:695-702.  Back to cited text no. 5
Ardu S, Gutemberg D, Krejci I, Feilzer AJ, Di Bella E, Dietschi D. Influence of water sorption on resin composite color and color variation amongst various composite brands with identical shade code: An in vitro evaluation. J Dent 2011;39(Suppl 1):e37-44.  Back to cited text no. 6
Aine L, Mäki M, Collin P, Keyriläinen O. Dental enamel defects in celiac disease. J Oral Pathol Med 1990;19:241-5.  Back to cited text no. 7
Um CM, Ruyter IE. Staining of resin-based veneering materials with coffee and tea. Quintessence Int 1991;22:377-86.  Back to cited text no. 8
Paris S, Keltsch J, Dörfer CE, Meyer-Lückel H. Visual assimilation of artificial enamel caries lesions by infiltration in vitro. Caries Res 2010;44:171-248.  Back to cited text no. 9
Guerra F, Mazur M, Corridore D, Capocci M, Ottolenghi L. Developmental Defects of Enamel: An increasing reality in the everyday practice. Senses Sci 2014;1:87-95.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2]


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