Article_5_3_7

RESTORATIVE DENTISTRY
Case Report
RESIN INFILTRATION AS A MINIMAL INVASIVE ESTHETIC TREATMENT
FOR A MILD FLUOROSIS CASE
Rasha Owda1a , Hande Şar Sancaklı1b*

1Department of Restorative Dentistry, Faculty of Dentistry, Istanbul University, Çapa, TR-34093 Istanbul, Turkey

DDS, PhD
a

DDS, PhD, Associate Professor
b

ABSTRACT DOI: 10.25241/stomaeduj.2018.5(3).art.7

Aim: The present case report aimed to describe a minimally invasive method to OPEN ACCESS This is an Open Access
mask the white opaque lesions of enamel in a mild fluorosis case (Dean’s Index article under the CC BY-NC 4.0 license.

code 3) to improve its esthetic outcome. Peer-Reviewed Article

Summary: Dental fluorosis (DF) is a developmental disturbance of enamel caused Citation: Owda R, Sancaklı HŞ. Resin infiltration
as a minimal invasive esthetic treatment for a mild
by excessive ingestion of fluoride on ameloblasts during enamel formation. The fluorosis case. Stoma Edu J. 2018;5(3):184-188.
clinical manifestations depend on the severity of fluorosis. In mild cases, there
Academic Editor: Constantin Marian Vârlan, DDS,
are white opaque striations across the enamel surface, whereas in more severe PhD, Professor, “Carol Davila” University of Medicine
cases, the porous regions increase in size, with enamel pitting, and secondary and Pharmacy, Bucharest, Romania

discoloration of the enamel surface. Patients often suffer from the discoloration Received: September 03, 2018
and the pitted surface of the teeth which are the major characteristics leading Revised: September 12, 2018
Acccepted: September 18 2018
to an unaesthetic appearance. A minimally invasive treatment approach of in- Published: September 18, 2018
office bleaching followed by a resin infiltration technique was applied to enhance *Corresponding author: Assoc. Prof. Dr. Hande Şar
the porous fluorosed enamel surface. The combination of the two techniques Sancaklı, DDS, PhD , Department of Restorative Dentistry
Faculty of Dentistry, Istanbul University
resulted in a perfectly satisfactory aesthetic outcome with a clinical follow-up for Çapa, TR-34093 Istanbul, Turkey Tel: 00905333668370
12 months. Fax: +902125250075e-mail: handesar@hotmail.com

Key learning points: fluorosis, minimal invasive approach, bleaching, resin Copyright: © 2018 the Editorial Council for the
infiltration, esthetic. Stomatology Edu Journal.

1. Introduction microinvasive treatment approach (micro or macro
Enamel pathologies like enamel hypoplasia, abrasion) other ultra- minimal invasive treatment
amelogenesis imperfecta and dental fluorosis occur options such as bleaching and resin infiltration
as a result of disturbances during the last stage of technique should be considered [5].
sound enamel formation. In the maturation stage; the Patients with fluorosed teeth usually complain
ameloblasts lose their protein secretory properties due of the unaesthetic appearance of teeth and seek
to increased growth activity [1]. Dental fluorosis is caused aesthetic treatments. The unaesthetic fluorosed teeth
by excessive intake of fluoride in drinking water during discoloration may be due to enamel hypomineralization
enamel formation [2]. When the fluoride concentration and the subsequent extrinsic stains into the porous
is 1 ppm, fluorapatite is formed instead of hydroxapetite subsurface enamel that range from yellowish, light
which has more protein content, is hypermineralized brown to dark brown or black. This type of discoloration
and thereby has increased appetite crystallinity. could be treated by in-office or at home bleaching or a
The clinical manifestations of dental fluorosis depend combination of both using different bleaching agents.
on its severity [3]. In mildest fluorosis form, the Hydrogen peroxide and carbamide peroxide are the
enamel is characterized by white lines that represent commonly used bleaching agents [6].
accentuated perikyamata or rod ends. The white lines A resin infiltration technique was developed for the
maybe confluent or discrete areas with white lines in treatment of incipient caries lesions by using a low-
between. However, in moderate dental fluorosis cases, viscosity resin that fills the porous structure of the
the entire enamel surface maybe chalky white and the carious lesions and when light cured can stop caries,
sub-surface porosities may attract extrinsic stains and inhibit further demineralization and mask white spot
cause enamel discoloration. In sever dental fluorosis lesions. The resin infiltration technique showed good
cases post-eruptive trauma of the extensive subsurface applicability and high acceptance by dentists [7-9].
porosity enamel surface causes detachment and The purpose of this article is to discuss the clinical result
pitting enamel surfaces [4]. with a 12-month follow-up of a mild fluorosis case treated
The treatment option of dental fluorosis depends on by resin infiltration proceeded by dental bleaching.
its severity as well. For severe fluorosis cases, invasive
approaches such as resin composite veneers, ceramic
veneers, or ceramic crowns, are generally chosen. But 2. Case Report
for mild to moderate fluorosis cases more conservative A 23-year old male patient presented to the
treatment options are preferred. In addition to the Conservative Dentistry Department at Istanbul

184 Stoma Edu J. 2018;5(3): 184-188 http://www.stomaeduj.com
RESIN INFILTRATION AS A MINIMAL INVASIVE ESTHETIC TREATMENT
FOR A MILD FLUOROSIS CASE

Case Report
Figure 1. Mild fluorosis, Dean’s Index code 3. Figure 2. The patient’s teeth after bleaching with 35% Hydrogen
peroxide gel.

Figure 3. Preoperative view, teeth were isolated by rubber dam. Figure 4. 15% HCl acid gel application.

Figure 5. 100% Ethanol dehydration, Alcohol index. Figure 6. Resin infiltration application.

Figure 7. Resin infiltrant polymerization. Figure 8. Resin infiltration re-application.

Figure 9. Resin infiltrant polymerization. Figure 10. Resin infiltration re-application.

University complaining of unaesthetic appearance used for isolation (Fig. 3).
of his teeth due to the presence of white lesions and The bleached fluorosed enamel surface was etched
discoloration. After his clinical examination this patient with 15% HCl gel (ICON etch®, DMG) for 2 minutes (Fig.
was diagnosed as mild fluorosis Dean’s index code 3. 4) as instructed by the manufacturer.
(Fig. 1). After etching, the enamel surface was rinsed with air-
For this patient a combination of in-office bleaching water spray for 30 s, dried, and then dehydrated with
and resin infiltration was planned. First, one session in- 100 % ethanol (ICON dry®, DMG) for 30 s (Fig. 5).
office bleaching was applied to the patient using the Alcohol is an efficient visual examination way to control
35% Hydrogen peroxide bleaching gel (Whitness HP, the effectiveness of penetration capacity of the etched
FGM, Joinville, SC, Brazil) (Fig. 2). enamel by its high infiltrative capability. When 100%
Resin infiltration was applied according to the Ethanol (ICON dry®, DMG) used the white spot lesions
manufacturer’s instructions; first the teeth were on the fluorosed enamel surface should have almost
cleaned and polished. Then rubber dam and floss were disappeared as a result of porous lesions, otherwise the

Stomatology Edu Journal 185
RESIN INFILTRATION AS A MINIMAL INVASIVE ESTHETIC TREATMENT
FOR A MILD FLUOROSIS CASE

etching step should be repeated. The resin infiltration technique was considered a novel
Case Report Resin infiltration (ICON®, DMG) was applied on the approach of dental fluorosis when compared to the
etched surface using the applicator with rubbing for other treatment options [14]. The resin infiltration
2 minutes, then one should wait 1 minute before the system (ICON) was produced by DMG company
surface is slightly dried with compressed air for 10 s. (Hamburg, Germany) for non-cavitated carious lesions
(Fig. 6). in proximal and smooth surfaces in which the resin seals
Then it should be light-cured for 40 s (Fig. 7) and the lesion and works as a barrier on the lesions surface
reapplied for 1 minute more to compensate the [16,17]. This technique aims to fill the subsurface
polymerization shrinkage (Fig. 8). lesions porosities (with depth up to 450 μm) by the low-
Changes were evident and immediate improvement viscosity and high penetration coefficient resin [17].
could be observed after resin infiltration in this case Before the application of the resin infiltrant the carious
(Fig. 9). The aesthetic outcome improvement and lesions surface should be prepared by an acid etch
durability could be observed 12 months after the agent to eliminate the hypermineralized superficial
treatment (Fig. 10). layer (average thickness 30 - 40 μm) and allow the resin
to infiltrate deep into the subsurface porosities. Usually
2 minutes of 15% HCl acid is used for this purpose
3. Discussion [18]. In addition to caries progression inhibition resin
Discoloration stands as the main concern of patients infiltration could be indicated to enhance and restore
suffering from fluorosis and the reason why they the natural enamel appearance of enamel surface in
seek treatment. Regarding mild fluorosis, bleaching cases of fluorosis and enamel hypoplasia. The resin
is indicated to enhance the natural appearance of the infiltrant has a refractive index (RI = 1.62) similar to that
discolored superficial porosities (mean depth approx. of sound enamel furthermore allowing the masking
200 μm). If the lesion displays deeper porosities in effect over the subsurface enamel porosities [19]. In
conjuction with the entrapped extrinsic stains then this case a combination of two treatment options were
it should be removed by micro or macro abrasion applied for the discolored mild fluorosis teeth, first in-
depending on the surface characteristics of the lesion office bleaching using 35 % hydrogen peroxide was
that should be taken in consideration. However, some applied. Thus, it was possible to attenuate the contrast
fluorosis cases reveal deep subsurface porosities (300 μm) between the opaque white spot lesions part and the
which could not easily be removed by minimal invasive healthy luminous enamel parts. For some instances, the
treatment methods. In these cases, resin composite camouflaging effect could be adequate for satisfying
or porcelain veneer restorations could be indicated the patients. But when bleaching is not sufficient as
as an invasive treatment modality. Considering much demonstrated in the present case, resin infiltration
more severe cases existing more than 50% of flourosed could be chosen in consequence. However, since the
enamel surface with loss of enamel and compromised infiltration would be in conjuction with the bleaching,
remaining substrate structure, the adhesion capacity of it is mandatory to wait for two weeks before application
the dental hard tissues threatens the adhesive efficiency of the resin infiltrant in order not to interfere with the
thus crowning of the tooth could be considered [10]. resin curing capability [20].
The basic philosophy of minimally invasive dentistry The resin infiltrant penetration capacity into the carious
is the integration of prevention, remineralization and lesions had been investigated in many in vitro studies
minimal intervention for placement or replacement and had shown almost complete penetration depth
of restorations [11]. The aim of minimal invasive [21,22]. However, the histopathological features of
intervention is tissue preservation by prevention of the enamel affected by fluorosis, especially the presence of
disease, intercepting its progression and applications of hypermineralised surface layer reduces the penetration
treatment techniques with the possible least tissue loss capacity of the resin infiltrant into the subsurface
[11]. With respect to the present fluorosis case treatment lesions body of the fluorosed enamel. The resin
outcome, an outstanding aesthetic improvement had infiltration penetration depth was limited in moderate
been achieved immediately following bleaching and fluorosis and a little higher in mild fluorosis teeth [23].
resin infiltration treatment, which both are considered Many clinical studies have demonstrated the efficacy of
as minimal invasive treatment approach. These resin infiltration technique in arresting carious lesions as
treatment approaches are especially tailored for young well as improvement in esthetics of white spot lesions,
patients with optimum oral health care, sound non- fluorosis, MIH and other enamel hypoplasia stains 9,24-
carious teeth without any pathological signs or further 26. The aesthetic improvement was noted over time,
periodontal abnormalities. but this might be as a result of water absorption by
The discoloration of mild fluorosed enamel could resin, which was not completely removed by ethanol.
be enhanced by in-office or at-home bleaching or a This absorption reduces the optical interfaces in the
combination of both. Bleaching aims to match the light path. The aesthetic outcome of many clinical cases
color and opacity difference of the natural unaffected followed for more than 12 months showed adequate
portion of enamel structure and the opaque white spot durability [9,25].
lesions part of the affected enamel surface by exerting
camouflage effect [6,12,13]. The camouflaging effect
tries to elevate the opacity of the bleached enamel 4. Conclusions
thus lowering the contrast of the distinction of the In this case, a 12-month follow-up of the resin infiltration
unaffected and effected enamel [13]. technique after bleaching showed a satisfying outcome

186 Stoma Edu J. 2018;5(3): 184-188 http://www.stomaeduj.com
RESIN INFILTRATION AS A MINIMAL INVASIVE ESTHETIC TREATMENT
FOR A MILD FLUOROSIS CASE

with enhanced aesthetic and function. Thus, resembling 9. Cocco AR, Lund RG, Torre E, Martos J. Treatment of fluorosis

Case Report
spots using a resin ınfiltration technique:14-month follow-up.
a minimal invasive treatment approach, a combination Oper Dent. 2016;41(4):357-362. doi: 10.2341/14-335-S
of resin infiltration technique following bleaching [Full text links] [PubMed] Google Scholar (5) Scopus (0)
should be considered for the treatment of such mild 10. Akpata ES. Occurrence and management of dental fluorosis.
Int Dent J. 2001;51(5):325-333. doi: 10.1002/j.1875-595X.2001.
fluorosis teeth. It is considered as an economic and tb00845.x.
effective solution. Furthermore, beside the expanded [PubMed] Google Scholar(69) Scopus(29)
11. Mm J, Nk B, A P. Minimal intervention dentistry - a new frontier
recall intervals to evaluate the treatment outcome, in in clinical dentistry. J Clin Diagn Res. 2014;8(7):ZE04-08. doi:
vitro studies are also required to discuss the effect of the 10.7860/JCDR/2014/9128.4583.
bleaching agents on the penetration depth of the resin [Full text links] [Free PMC Article] [PubMed] Google Scholar(33)
Scopus(9)
infiltrant into the lesions and its effect on the fluorosed 12. Greenwall LH. Treatment considerations for bleaching and
enamel surface mechanical properties. bonding white lesions in the anterior dentition. Alpha Omegan.
2009;102(4):121-127. PMID:20151561.
[PubMed] Google Scholar(7) Scopus(1)
13. Knösel M, Attin R, Becker K, Attin T. External bleaching effect
Author contributions on the color and luminosity of inactive white-spot lesions after
fixed orthodontic appliances. Angle Orthod. 2007;77(4):646-652.
RO: contributed to the case treatment, follow-up control, doi: 10.2319/060106-224.
data collection, analysis and drafting the manuscript; [Full text links] [PubMed] Google Scholar(54) Scopus(22)
14. Perez R, Quijada V, Uribe S. Confocal laser microscopy analysis
HŞS: contributed to the design of the work, treatment of resin infiltration in fluorotic teeth. Rev Clin Periodoncia
plan, analysis of data, revising the draft for important Implantol Rehabil Oral. 2014;7(2):53-58. doi: 10.4067/S0719-
intellectual content and giving the final approval for the 01072014000200002.
Google Scholar(1)
version to be published. 15. Kielbassa AM, Muller 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(8):663-681 PMID:19639091.
Acknowledgments [Full text links] [PubMed] Google Scholar(177) Scopus(84)
Not applicable. The study was self-funded. The authors 16. Splieth CH, Ekstrand KR, Alkilzy M, et al. Sealants in dentistry:
outcomes of the ORCA Saturday Afternoon Symposium 2007.
have no conflicts of interest or financial interests to be Caries Res. 2010;44(1):3-13. doi:10.1159/000271591.
disclosed either. [Full text links] [PubMed] Google Scholar(97) Scopus(53)
17. Paris S, Meyer-Lueckel H, Cölfen H, Kielbassa AM. Resin
infiltration of artificial enamel caries lesions with experimental
light curing resins. Dent Mater J. 2007;26(4):582-588. doi:
References 10.4012/dmj.26.582.
1. Den Besten P, Giambro N. Treatment of fluorosed and white- [Full text links] [PubMed] Google Scholar(139) Scopus(71)
spot human enamel with calcium sucrose phosphate in vitro. 18. Paris S, Dörfer CE, Meyer-Lueckel H. Surface conditioning of
Pediatr Dent. 1995;17(5):340-345. PMID:8524682. natural enamel caries lesions in deciduous teeth in preparation
[PubMed] Google Scholar(13) Scopus(8) for resin infiltration. J Dent. 2010;38(1):65-71. doi: 10.1016/j.
2. Bronckers AL, Lyaruu DM, DenBesten PK. The impact of fluoride jdent.2009.09.001.
on ameloblast and the mechanisms of enamel fluorosis. J Dent [Full text links] [PubMed] Google Scholar(62) Scopus(28)
Res. 2009;88(10):877-893. doi: 10.1177/0022034509343280. 19. Fejerskov O, Manji F, Baelum V. The nature and mechanisms of
[Full text links] [Free PMC Article] [PubMed] Google Scholar(173) dental fluorosis in man. J Dent Res. 1990; 69 Spec No:692-700;
Scopus(96) discussion 721. doi:10.1177/00220345900690S135.
3. Torres-Gallegos I, Zavala-Alonso V, Patiño-Marín N, et al. Enamel [Full text links] [PubMed] Google Scholar(294) Scopus(141)
roughness and depth proﬁle after phosphoric acid etching of 20. Goldberg M, Grootveld M, Lynch E. Undesirable and adverse
healthy and ﬂuorotic enamel. Aust Dent J. 2012;57(2):151-156. effects of tooth-whitening products: a review. Clin Oral Investig.
doi:10.1111/j.1834-7819.2012.01677.x. 2009;14(1):1-10. doi: 10.1007/s00784-009-0302-4.
Google Scholar(35) Scopus(14) [Full text links] [PubMed] Google Scholar(237) Scopus(107)
4. Denis M, Atlan A, Vennat E, et al. White defects on enamel: 21. Paris S, Bitter K, Renz H, et al. Validation of two dual fluorescence
diagnosis and anatomopathology: two essential factors for techniques for confocal microscopic visualization of resin
proper treatment (part 1). Int Orthod. 2013;11(2):139-165. doi: penetration into enamel caries lesions. Microsc Res Tech.
10.1016/j.ortho.2013.02.014. 2009;72(7):489-494. doi: 10.1002/jemt.20701.
[Full text links] [PubMed] Google Scholar(38) [PubMed] Google Scholar(50) Scopus(31)
5. Muñoz MA, Arana-Gordillo LA, Gomes GM, et al. Alternative 22. Meyer-Lueckel H, Chatzidakis A, Naumann M, et al. Influence
esthetic management of fluorosis and hypoplasia stains: of application time on penetration of an infiltrant ınto natural
blending effect obtained with resin ınfiltration techniques. enamel caries. J Dent. 2011;39(7):465-469. doi:10.1016/j.
J Esthet Restor Dent. 2013;25(1):32-39. doi: 10.1111/j.1708- jdent.2011.04.003.
8240.2012.00527.x. [Full text links] [PubMed] Google Scholar(69) Scopus(34)
[Full text links] [PubMed] Google Scholar(66) Scopus(21) 23. Gugnani N, Pandit IK, Goyal V, et al. Esthetic improvement of
6. Bussadori SK, do Rego MA, da Silva PE, et al. Esthetic alternatives white spot lesions and non-pitted fl uorosis using resin infi
for fluorosis blemishes with usage of a dual bleaching system ltration technique: series of four clinical cases. J Indian Soc
based on hydrogen peroxide at 35%. J Clin Pediatr Dent. Pedod Prev Dent. 2014;32(2):176-180. doi: 10.4103/0970-
2004;28(2):143-146. PMID:14969374. 4388.130996.
[PubMed] Google Scholar(30) Scopus(14) Google Scholar(23)
7. Paris S, Meyer-Leuckel H, Cölfen H, Kielbassa AM. Penetration 24. Greenwall L. White lesion eradication using resin infiltration.
coefficients of commercially available and experimental International Dentistry - African Edition. 2013;3(4):54-62.
composites intended to infiltrate enamel carious lesions. Dent Google Scholar(2)
Mater. 2007;23(6):742-748. doi:10.1016/j.dental.2006.06.029. 25. Eckstein A, Helms HJ, Knösel M. Camouflage effects following
[Full text links] [PubMed] Google Scholar(141) Scopus(66) resin infiltration of postorthodontic white-spot lesions in vivo:
8. Paris S, Meyer-Leuckel H. Infiltrants inhibit progression of natural one-year follow-up. Angle Orthod. 2015;85(3):374-380. doi:
caries lesions in vitro. J Dent Res. 2010;89(11):1276-1280. doi: 10.2319/050914-334.1.
10.1177/0022034510376040. [Full text links] [PubMed] Google Scholar(28) Scopus(10)
[Full text links] [PubMed] Google Scholar(72) Scopus(41)

Stomatology Edu Journal 187
RESIN INFILTRATION AS A MINIMAL INVASIVE ESTHETIC TREATMENT
FOR A MILD FLUOROSIS CASE

Case Report Rasha OWDA
DDS, PhD
Department of Restorative Dentistry, Faculty of Dentistry
Istanbul University
Çapa, TR-34093 Istanbul, Turkey

CV
Rasha Owda, DDS, PhD, is currently a member of the research staff in the Department of Restorative Dentistry, Faculty of
Dentistry at the Istanbul University, Istanbul, Turkey. Her field of interest covers minimal invasive and adhesive dentistry. Her
field of research includes minimal invasive treatment approch for incipient caries, fluorosis, enamel hypoplasia, amelogenesis
imperfecta and other type of enamel lesions. She authored/co-authored many case studies published in international
congresses and articles in peer-reviewed journals. She is also in private practice in Istanbul, Turkey.

Questions
1. Which are the clinical manifestations of mild fluorosis enamel:
qa. Confluent or discrete white lines on the enamel surface;
qb. Chalky white smooth enamel surface;
qc. Chalky white enamel surface with sub-surface porosities;
qd. Chalky white pitted enamel surface with stains and discoloration.

2. Resin infiltration technique is used for all except:
qa. Smooth surface incipient caries treatment;
qb. Pit and fissure incipient caries treatment;
qc. Dental fluorosis;
qd. Enamel hypoplasia.

3. The resin infiltrant (ICON) has a refractive index which is similar to:
qa. Water;
qb. Enamel;
qc. Air;
qd. Dentin.

4. In this case, we assessed:
qa. The efficacy of the invasive treatment approach in dental fluoroses cases;
qb. The efficacy of bleaching camuoflage on mild fluorosis teeth;
qc. The efficacy and durability of a combination of bleaching and resin infiltration technique in mild fluorosis
case;
qd. The treatment options based on dental fluorosis severity.

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