Esthetic recovery of teeth presenting fluorotic enamel stains using enamel microabrasion and home-monitored dental bleaching.

This clinical report describes the enamel microabrasion technique for removing maxillary and mandibular hard fluorotic enamel stains followed by home-monitored home dental bleaching. The removal of fluorotic enamel stains utilized macroabrasion with a water-cooled, fine-tapered 3195 FF diamond bur followed microabrasion with the application of Prema Compound (Premier Dental Products Co, Norristown, PA, USA). Home-monitored dental bleaching was performed 14 days after enamel microabrasion using a 10% carbamide peroxide gel for 2 h/day. The wearing time of the acetate tray/dental bleaching was quantified by a microsensor from TheraMon microelectronic system (Sales Agency Gschladt, Hargelsberg, Austria) that was completely embedded in the acetate trays. The teeth were bleached effectively during 23 days. The mean wearing time of the acetate trays/dental bleaching product was 1.54 h/day, for the upper and lower arches. The patient reported satisfaction with the treatment. The association of enamel microabrasion and home dental bleaching was an excellent clinical treatment for teeth affected with enamel fluorosis. Copyright:

INTRODUCTION

The excessive and chronic ingestion of fluoride during amelogenesis may lead to the appearance of dental fluorosis, characterized by white opaque areas or discolorations ranging from yellow to dark brown occasionally in combination with porosities on the enamel surface.[1] Its severity is directly related to the excessive fluoride intake,[23] which may be present in tap water, dietary supplements, and other fluoride-containing dental products.[4567] The undesirable enamel stains may be masked by restorative or prosthetic treatments, or by a more conservative approach, to include enamel microabrasion and dental bleaching.[8910111213]

The enamel microabrasion technique is one of the most effective and safest procedures for removing superficial enamel stains (macroreduction), using a water-cooled, fine-tapered diamond bur followed by the application of abrasive materials associated with chemical solutions.[9101112] Enamel microabrasion is commonly used for removing intrinsic enamel stains of any color and etiology, as well as for the correction of superficial irregularities on the enamel surface, to include fluorosis stains, idiopathic white enamel demineralization, imperfect amelogenesis, or white spots caused by orthodontic brackets.[8910111213141516]

Currently, enamel microabrasion is a safe procedure with many “ready-to-use” products in the market, such as Prema Compound microabrasive product (Premier Dental Products Co, Norristown, PA, USA), which is composed of 10% hydrochloric acid associated with fine-grit silicon carbide abrasive particles.[9] After being submitted to enamel microabrasion, the teeth may acquire a darker or yellow coloration, due to the fact that the remaining enamel surface becomes thinner, presenting more of the dentin tissue color. In view of this clinical condition, correction of the dentinal color pattern can be obtained with the application of carbamide peroxide-based products, which are inserted in acetate custom trays and present a considerable margin of clinical success.[17]

Pavani et al.[13] in 2018 evaluated and quantified the wear time/day of acetate trays/bleaching products commonly employed during home dental bleaching using the TheraMon® electronic device (TheraMon®, Sales Agency Gschladt, Hargelsberg, Austria) that has been inserted into the custom acetate tray.

The aim of the present clinical case report is to describe the removal of hard fluorotic enamel stains, employing the enamel microabrasion technique associated with home-monitored dental bleaching using 10% carbamide peroxide.

CASE REPORT

A 16-year-old girl presented with white hard fluorotic enamel stains located on the maxillary and mandibular teeth and with some localized eroded areas [Figure 1a]. Within the treatment options presented to the patient and her guardian, a more conservative approach was chosen: enamel microabrasion (incisors, canines, and premolars) associated with home-monitored dental bleaching and later, diastemata closure using a direct resin composite between the upper central incisors.

Figure 1

(a) A 16-year-old girl presenting with hard white fluorotic enamel stains and with some localized eroded areas. (b) Application of a high-speed tapered fine diamond bur for removing the superficial layer of the stained enamel. (c) Application of microabrasive product under rubber dam to remove the remaining fluorotic enamel stains and superficial irregularities promoted by the fine diamond bur. (d) Polishing with fluoridated prophylaxis paste. (e) Application of a 2% neutral sodium fluoride gel for 4 min. (f) Frontal view 14 days after enamel microabrasion of the upper and lower arches

After a dental prophylaxis with pumice and water, the superficial layer of the stained enamel was removed (macroreduction) using a high-speed, fine-tapered diamond bur (#3195 FF, KG Sorensen Industria e Comercio Ltda, Barueri, SP, Brazil) under copious irrigation [Figure 1b]. Immediately after enamel macroabrasion, the maxillary dental arch was isolated with a rubber dam preparatory to the application of Prema Compound microabrasive product (Premier Dental Products Co, Norristown, PA, USA) to remove the remaining enamel stains and superficial irregularities promoted by the fine diamond bur [Figure 1c]. During the enamel microabrasion technique, the operator, patient, and assistants wore eye protection.

The enamel microabrasive compound was applied to the teeth for 20–30 s, under firm pressure, with a rubber point supplied by the manufacturer, which was adapted at a low-rotation micromotor at a slow speed to prevent splattering of the microabrasive product [Figure 1c]. Between each application, the enamel surface was rinsed with water/air spray and dried. Three applications of the microabrasive compound were performed on each of the three teeth, for a period of 20–30 s. The treated enamel surfaces were polished with fluoridated prophylaxis paste (Herjos, Vigodent SA Indústria e Comércio, Rio de Janeiro, Brazil) [Figure 1d], and later received a 2% neutral sodium fluoride gel for 4 min (Apothicário Manipulation Pharmacy, Araçatuba, SP, Brazil) [Figure 1e]. An excellent clinical outcome was observed for the buccal enamel stain removal [Figure 1f].

Two weeks after enamel microabrasion, home-monitored dental bleaching was performed using 10% carbamide peroxide gel (Opalescence, Ultradent Products Inc. South Jordan, UT, USA). The initial color observed after enamel microabrasion was B2 (Vitapan Classical Shade Guide-Vita Zahnfabrik, Bad Sa¨ckingen, Germany) [Figure 2a]. After maxillary and mandibular alginate impressions were taken, soft vinyl mouth trays were fabricated on the stone models and an electronic microsensor TheraMon (TheraMon® micro eletronic system; Sales Agency Gschladt, Hargelsberg, Austria) was inserted in the labial region of each acetate tray in order to measure the wearing time/day of the acetate trays/bleaching product, during the entire treatment period. The patient was notified about the presence and reason for its presence inside the acetate trays which did not affect their comfort during bleaching treatment [Figure 2b].

Figure 2

(a) Assessing the initial color of the teeth. (b) Acetate custom trays positioned on the upper and lower arches for home-monitored dental bleaching. (c) Diagram of the wear time/daily of the upper and lower acetate trays/bleaching product. (d) Evaluation of final color achieved after dental bleaching. (e) Two weeks after, diastema closure between upper central incisors was performed using a composite resin. (f) Extraoral view before enamel microabrasion. (g) Extraoral view after enamel microabrasion and dental bleaching. (h) Extraoral view after diastema closure between upper central incisors

The patient was instructed to place a small drop of the bleaching gel into each tooth impression of the tray, from the second premolar to second premolar, and advised to use the tray 2 h per day (hours/day) [Figure 2b]. Four tubes of the bleaching gel were used during the bleaching treatment.

The microsensor measures the temperature of the mouth with an accuracy of ± 0.1°C and the temperature is recorded every 15 min. The collected data by microsensor TheraMon were transferred using a wireless connection between the functional unit and a reading station coupled to a Universal Serial Bus connection. These wear time/daily data were exported and interpreted in the Excel program which pointed out that during 23 days of the home-monitored dental bleaching treatment period, the mean wearing time of the acetate trays was 1:54 h/day for the upper and lower arches [Figure 2c].

It can be observed that even the patient not wearing the acetate trays/dental bleaching product for only 1 day of treatment, she followed satisfactorily the recommendations of wearing of the acetate trays/dental bleaching product, using both trays simultaneously every day. It should be considered that the TheraMon microsensor, inserted in the trays, documents the wear time only in 15-min intervals,[18] this can justify the slight fluctuating variation of 15-min of wearing time/day observed between both trays on the 1st, 13th, and 14th days of treatment [Figure 2c]. The final color obtained was B1 (Vitapan Classical Shade Guide-Vita Zahnfabrik, Bad Sa¨ckingen, Germany) [Figure 2d]. No tooth sensitivity and gingival irritation were reported during and after the bleaching treatment.

Two weeks later, a composite resin (Forma, shade A1B, Ultradent Inc., South Jordan, UT, USA) was used to close the diastema between the maxillary central incisors [Figure 2e]. The patient was very satisfied with the final result [Figure 2f–h].

DISCUSSION

The clinical case presented enamel stains with the clinical characteristics of moderate dental fluorosis. When recording the patient's dental history, the mother and patient reported the use of a very large amount of flavored dentifrice (Tandy, Kolynos do Brasil, São Paulo, SP, Brazil; 1100 μg F/g)[1920] on the toothbrush, which the patient used to swallow until 10 years of age. The patient also reported that she liked brushing her teeth with this toothpaste because it had a grape or strawberry flavor, which certainly must have favored the frequent ingestion of toothpaste during daily dental brushing throughout the years.

In view of the esthetic results obtained, a moderate case of enamel fluorosis, represented by white enamel stains with localized erosion areas, can be successfully treated with enamel microabrasion associated with dental bleaching. It is also worth noting that Sundfeld et al.[10] reported that the etiology of intrinsic enamel stains is not a determining factor for the application of the enamel microabrasion technique; however, enamel microabrasion can be used for hard enamel stain, of any color, that compromises the esthetics.

The procedure in the current case report was initiated using macroreduction of the affected enamel with a fine-tapered diamond bur 3195 FF (KG Sorensen Industria e Comercio Ltda, Barueri, SP, Brazil) to lightly abrade the stained area.[9101112] This procedure reduces the time needed for stain removal and the amount of microabrasive material to be used, especially when faced with more pronounced intrinsic stains. The application of a fine-tapered diamond bur is optional; the microabrasive product can be applied by itself to remove the stains, although it would lead to a longer treatment time.

As Sundfeld et al. have reported,[9101112] a microabrasive product was used in the case report to complement the stain removal and the smoothing of the enamel surface. The Prema Compound (Premier Dental Products Co, Norristown, PA, USA) microabrasive product, which is composed of 10% hydrochloric acid associated with silica carbide particles, was used due to its excellent performance in enamel stain removal and in the smoothing of the enamel surface irregularities left by the diamond bur.[9] The previous application of the fine-tapered diamond bur allowed for two or three applications of the microabrasive product, which is usually required to achieve the desired esthetic effect.

Clinical observation of enamel microabrasion has demonstrated that the dental enamel surface submitted to microabrasion presents considerable regularity, smoothness, and brightness, which is accentuated over time,[8101213] due to the compaction of mineral substances from the erosive and abrasive action of the microabrasive compound on the enamel surface.[21] In addition, enamel microabrasion presents greater resistance to demineralization and colonization of Streptococcus mutans.[22] The clinical results observed are permanent and highly satisfactory, presenting a dental enamel surface with considerable regularity, smoothness, and brightness that improves over time.[101213]

The dental elements of the present case report that were microabraded showed a marked yellow color due to a decrease in the thickness of the buccal enamel. In the face of this clinical condition, dental bleaching was performed using 10% carbamide peroxide (Ultradent Products Inc., UT, USA), which is commonly used to improve esthetics.[17]

The success of the dental bleaching treatment depends of the patient's co-operation in the application of the acetate trays/dental bleaching product during all treatment, which was verified by Pavani et al.[13] in 2018, when using a microsensor embedded in the acetate custom tray. We can observe that the patient satisfactorily followed the instructions regarding the wearing time of 2 h/day of the bleaching product during the 23 days of dental bleaching treatment, presenting the mean daily wearing time of the acetate trays/dental bleaching of 1.54 h/day for the upper and lower acetate trays. The patient justified that she did not wear the acetate trays/dental bleaching product in only day of treatment because she forgot to wear them.

Certainly, the fact that patient was aware of the presence and function of the microsensor inserted in the acetate trays/dental bleaching product, influenced the motivation of the patient for their use, for the time previously stipulated by us. However, it should be considered that the short daily time of 2 h/day that was oriented to the patient wear the trays should have contributed to obtaining an adequate level patient's co-operation during all treatment. This made possible to observe that wear time of 2 h/day employed was sufficient to obtain adequate bleaching according to the patient's desire.[23] Sensitivity was not observed in the current case report, likely due to the absence of carious lesions, defective restorations, abfraction, and abrasion lesions, or by the protection of exposed dentin tissue using an adhesive system.[10]

One month after removing the fluorotic stains, a diastema closure between the upper central incisors was performed using a zirconia nano-hybrid composite resin (Forma, color A1B; Ultradent Products Inc. South Jordan, UT, USA). All of the combined esthetic treatments in the clinical case report demonstrated an effective method for improving/recovering the esthetics of fluorotic teeth [Figure 2f–h].

According to the clinical results observed, it can be concluded that the removal of moderate fluorotic enamel stains by enamel microabrasion technique followed by home-monitored dental bleaching is a safe, effective, and controlled clinical treatment option for patients. The direct composite resin restorations performed for the diastema closure greatly contributed to the esthetic restoration of the patient's smile as well.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.