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ORIGINAL

Auschill
ARTICLE
et al

Resin Infiltration for Aesthetic Improvement of Mild to


Moderate Fluorosis: A Six-month Follow-up Case Report

Thorsten M. Auschilla/Kristina E. Schmidtb/Nicole B. Arweilerc

Purpose: To determine whether fluorosed areas of teeth can be successfully treated with resin infiltration and whether
the results are long lasting.

Materials and Methods: For the present case of mild to moderate dental fluorosis, the microinvasive resin infiltration
technique was chosen, following suboptimal results of in-office vital tooth bleaching to improve the aesthetic appear-
ance of the affected teeth.

Results: Six months after treatment, the white opaque and brown discolourations remain masked.

Conclusion: This case report demonstrates that resin infiltration is an agreeable option for this type of tooth discol-
ouration, rather than choosing more invasive, conventional procedures. More studies need to be completed to deter-
mine longer-term outcomes of the technique.

Key words: dental fluorosis, long-term stability, tooth discolourations, resin infiltration

Oral Health Prev Dent 2015;13:317-322 Submitted for publication: 06.06.13; accepted for publication: 06.09.13
doi: 10.3290/j.ohpd.a32785

T ooth colour is of aesthetic importance to many


individuals, especially if the discolourations are
visible.6,14,18 Stains can be located on the outside
during tooth development. These stains are classi-
fied as intrinsic discolourations.14,18 Alternative
treatment options are required depending on the
tooth surface or within the tooth structure. Factors location of the stain. Therefore, it is essential to
that result in external staining of the tooth surface know the origin of the stain in order to be able to
or acquired pellicle can include the consumption of establish the most appropriate treatment plan that
tobacco, coffee or certain other beverages/foods. will minimise or eliminate the discolouration of the
If these discolourations are not removed by dental affected dentition.18
prophylaxis they can over time become incorporat- Dental fluorosis is an enamel defect caused by
ed into the tooth structure through developmental an excessive systemic absorption of and repeated
or acquired defects.18 These internalised stains exposure (i.e. low chronic doses) to fluoride during
are thus classified as extrinsic discolourations. An- all stages of tooth development.1,4,5,14,15 Although
other form of internal staining results from trauma fluoride is an effective agent in preventing caries by
or is of systemic or pulpal origin, such as dental inhibiting demineralisation and stimulating remin-
fluorosis or tetracycline staining; this causes the eralisation of enamel,1,15 a linear relationship exists
discolourations to begin within the tooth structure between the amount and duration of fluoride ingest-
ed and the development and severity of dental fluo-
a
Professor, Department of Periodontology, Philipps University, rosis.2,4 Long-term exposure and high doses of sys-
Dental School and Hospital, Marburg, Germany. Idea, hypothesis, temic fluorides can cause the enamel as well as
performed the case, wrote the manuscript. dentin and cementum to become hypomineralised
b
Research Assistant, Department of Periodontology, Philipps Uni- and more porous.1,3,4 Hypomineralised tissue fre-
versity, Dental School and Hospital, Marburg, Germany. Contrib-
uted substantially to discussion, proofread the manuscript. quently alternates with hypermineralised bands of
c
Professor and Head, Department of Periodontology, Philipps Uni- enamel.5 Deeper layers of enamel can become se-
versity, Dental School and Hospital, Marburg, Germany. Contrib- verely hypomineralised, making the affected teeth
uted substantially to discussion, proofread the manuscript. increasingly fragile.5,15 Dean’s Fluorosis Index, de-
Correspondence: Prof. Dr. Thorsten M. Auschill, Department of veloped by H.T. Dean in 1942, is the gold standard
Periodontology, Philipps University, Georg-Voigt-Strasse 3, 35039
Marburg, Germany. Tel: +49-6421-58-63235, Fax: +49-6421-58- in classifying the varying degrees of severity of den-
63270. Email: auschill@med.uni-marburg.de tal fluorosis. The six scores according to their clinic-

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Auschill et al

a b c

Fig 1  Mild to moderate fluorosis of teeth prior to treatment: a) right side view; b) front view; c) left side view.

al signs are:5,15 0 for normal or unaffected teeth desired. Treatment of moderate levels of fluorosis
that have a smooth, uniform, creamy white surface; has been shown to be successful with veneers. More
0.5 for teeth that are questionable and have some severe levels of fluorosis require more highly invasive
white flecks or spots; 1 for very mild where less procedures such as crowns, especially if there is
than 25% of the tooth is covered with small white mottling and loss of occlusal vertical dimension.15 It
opaque areas; 2 for mild where no more than 50% is important to remember that any treatment option
of the tooth is covered with white opaque areas; 3 has its advantages and disadvantages (such as be-
for moderate where more than 50% of the entire ing more or less invasive) and also depends on the
tooth surface is affected and may have brown stain- patient’s needs and the desired outcome.15
ing; and 4 for teeth that are severely corroded or The microinvasive resin infiltration procedure is
pitted and often have brown staining affecting 100% a new technique developed as a preventive treat-
of the enamel surface. A single source of fluoride or ment to inhibit the progression of incipient white-
usually a combination of different factors can cause spot carious lesions.7 Following the three-step pro-
different degrees of severity of dental fluorosis. Two cess of etching, drying and infiltrating the affected
main sources of fluoride that likely lead to the in- area with a resin, the end result has a positive out-
creased occurrence of dental fluorosis are (1) great- come of improving the appearance of the carious
er than 1 ppm of added or naturally occurring fluor- lesion by masking it.13
ide in drinking water18 and (2) dental products Therefore, the aim of this case report was to de-
containing fluoride (e.g. toothpastes and mouthrins- termine if fluorosed areas of teeth can be success-
es if swallowed during tooth development, or fluor- fully treated with resin infiltration and if the results
ide supplements).5 Other sources of fluoride can be are long-lasting.
found in foods or baby food.1,5 Findings from the
United States National Health and Nutrition Examin-
ation Survey 1999–20043 show that a high per- Case report
centage (40.6%) of individuals between the ages of
12 and 15 have some form of dental fluorosis. The A 24-year-old woman attended the dental clinic at
prevalence decreases as age increases. Further- Philipps University of Marburg (Germany) for treat-
more, 22.9% of individuals between the ages of 6 ment of anterior-tooth discolouration. She present-
and 49 who were surveyed had some form of de- ed with white, opaque and several light-brown dis-
tectable dental fluorosis (i.e. very mild, mild, moder- coloured areas on the facial aspect of her six
ate or severe according to Dean’s Fluorosis Index). maxillary anterior teeth. The affected enamel ex-
Several treatment options, ranging from bleaching tended from the incisal edge of each tooth to al-
(less invasive) to full crowns (more invasive), have most halfway up the crown (Fig 1a to c). After tak-
been used to treat dental fluorosis depending on the ing the patient’s medical history and completing an
extent of enamel destruction.15 Sherwood15 and intra- and extraoral examination, the white and
Alvarez et al1 have documented cases of varying se- brown discolourations were diagnosed as being a
verities of fluorosis and the chosen treatment; for mild to moderate form of dental fluorosis. This cor-
instance, for mild levels of fluorosis, in-office vital responds to scores 2 and 3 of Dean’s Fluorosis
bleaching has been partially successful. Micro- and Index, as more than 25% and less than 50% of
macro- abrasion have also been moderately suc- each tooth was affected and some brown staining
cessful,14,15 but this has the potential to remove was evident on the fluorosed portions of the teeth.
greater amounts of tooth structure than needed or No pitting of the fluorosed areas was detected.

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Auschill et al

Fig 2  In-office tooth bleaching for the


maxillary anterior teeth (a) and the
a b mandibular anterior teeth (b).

The initial treatment chosen was the non-inva- was applied to the affected fluorosed area of the
sive method of in-office vital tooth bleaching (Opal- tooth. This step ensures that enough of the miner-
escence Boost, 40% H2O2, Ultradent; South Jor- alised surface layer of the tooth is etched away7,13
dan, UT, USA). The goal of bleaching was to match to allow the resin to adequately infiltrate into the
the healthy or non-fluorosed areas of the teeth with porous (hypomineralised) white opacities13 as well
the lighter fluorosed portions of the teeth as well as alternating hypermineralised layers within the
as to lighten the shade of teeth (i.e. mandibular an- affected enamel matrix.5 A generous amount of
terior teeth 34 to 44) not affected by fluorosis. The etchant is applied and let sit for a period of 2 min
pre-treatment tooth colour was determined to be (Fig 4e and f), followed by a 30-s rinse with water
A3 using the Vitashade guide to observe colour (Fig 3c). After rinsing with water (Fig 3d) the white
changes following bleaching. Bleaching was con- opacity of the fluorosed area of the tooth de-
ducted in several cycles (15 min each) at different creased, but increased again following the drying
appointments to reduce side effects such as tooth procedure with the air syringe. Prior to each appli-
hypersensitivity, with a total of eight cycles per- cation of the etching agent, the moisture was con-
formed on the maxillary anterior teeth (Fig 2a) and trolled (Fig 3e).
three cycles on the mandibular anterior teeth and After the third etching procedure, an air syringe
first premolars (Fig 2b). The numerous bleaching was used to thoroughly dry the surface of the
procedures resulted in an improvement in shade of etched left central incisor (Fig 3f) prior to the ap-
the treated portions of the teeth, but were unable plication of a liquid drying agent (95%–100% etha-
to match the colour of the fluorosed areas. The pa- nol). The drying agent is applied to the affected
tient inquired about alternative treatment options tooth surface once and let sit for 30 s (Fig 3g), fol-
to further improve the aesthetic appearance of the lowed by air drying. The ethanol-containing agent
conspicuous white and brown discolourations on confirms that the surface layer of enamel has been
the maxillary anterior teeth. stripped away, allowing sufficient penetration of
The microinvasive resin infiltration technique the infiltrant13 into the etched fluorosed area. When
(Icon, DMG; Hamburg, Germany) was chosen despite the drying agent is applied, the white colour of af-
the product being designed for use on cariogenic fected enamel should decrease or disappear, en-
non-cavitated white spot lesions.7 Treatment of the suring that the treatment is effective.13
fluorosed areas of the teeth using resin infiltration The resin infiltrant containing acrylate resin was
began two months following the last bleaching pro- applied to the fluorosed tooth (Fig 3h). On an etched
cedure of the teeth. The first step before beginning tooth surface, the low viscosity resin has the ability
the resin infiltration procedure was to remove any to fill and seal the porous surface via capillary ac-
external stains and to polish the teeth to be treated tion.12 The first application of the infiltrant to tooth
with a polishing paste and a soft rotary bristle brush 21 was let sit for 3 min. This was determined to be
to ensure a clean tooth surface (Fig 3a). Any remain- an adequate amount of time for sufficient penetra-
ing polishing residue was rinsed away using the wa- tion into microporosities of enamel (such as non-
ter syringe. A liquid dam (LC Dam, Voco; Cuxhaven, cavitated carious lesions).10 The excess resin was
Germany) was applied to the gingiva around the removed prior to light curing the area for 40 s (Fig
teeth to be treated to protect the oral mucosa during 3i). A second application of the infiltrant was car-
certain parts of the procedure (Fig 3b). ried out for 1 min to ensure that the resin penetrat-
The left central incisor was treated first. An etch- ed into any remaining open microporosities.12 Ex-
ing agent containing 15% to 20% hydrochloric acid cess resin was removed again before the area was

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Auschill et al

a b c

d e f

g h i

Fig 3  Resin infiltration treatment of mild to moderate fluorosis of maxillary anter-


ior teeth: a) polishing; b) application of liquid dam; c) application of etching solu-
tion to tooth 21; d) rinsing of etching agent with water; e) moisture control of
etched tooth; f) drying of tooth 21; g) application of drying agent to tooth 21; h)
application of resin infiltrant to tooth 21; i) light curing of infiltrant of tooth 21; j)
j
resin infiltration completed for tooth 21.

light cured for another 40 s. Light curing ensures visible, such as the facial surfaces of the anterior
that the infiltrant is retained within the microporo- teeth. The correct diagnosis is needed to deter-
sities of the tooth surface (Fig 3j).10 mine the best treatment options;18 however, it is
The patient was very pleased with the results of difficult to distinguish between dental fluorosis and
the resin infiltration technique, as there was an other types of hypoplastic or hypomineralised
aesthetic improvement of the white opacities and enamel (e.g. molar incisive hypomineralisation),
brown discolourations of all maxillary anterior teeth both clinically and histologically.18,19 Based on the
directly following treatment (Figs 4a to c). Figures patient’s history, the visible white hypomineralised
5a to c demonstrate that the outcome of the treat- opacities in the enamel subsurface4,5,15 and the
ment was effective and had long-term stability six description of the Dean’s Fluorosis Index, the indi-
months after treatment. vidual described here was diagnosed with mild to
moderate dental fluorosis.
Several treatment options exist and have been
DISCUSSION shown to improve the aesthetic appearance of var-
ying degrees of dental fluorosis. In this case, the
Tooth discolourations such as those from dental minimally invasive in-office bleaching technique
fluorosis are an aesthetic concern for many indi- was first chosen to attempt to lighten the shade of
viduals,6,14,18 especially if the discolourations are the non-fluorosed apical portions of the maxillary

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a b c

Fig 4  Short-term results of resin infiltration of maxillary anterior teeth: a) right side view; b) front view; c) left side view.

a b c

Fig 5  Long-term results of resin infiltration of maxillary anterior teeth 6 months after treatment: a) right side view; b) front
view; c) left side view.

anterior tooth crowns to more closely match the white and opaque in colour.4,5,15 Therefore, infiltrat-
white-opaque incisal thirds of the fluorosed teeth. ing the microporosities with a resin should cause
The mandibular anterior teeth and first mandibular the fluorosed areas of the teeth to acquire an ap-
premolars were also bleached to match the colour pearance similar to the non-fluorosed healthy
of the bleached maxillary anterior teeth. Bleaching teeth.7,11,13,16,17 This case report demonstrated
has been shown to be an accepted form of treat- that the resin infiltration technique had a positive
ment for mild to moderate dental fluorosis1,15 and outcome in masking the discolourations of the mild
teeth generally become lighter in shade with in- to moderately fluorosed portions of the teeth.
creased exposure to and concentration of the The resin is a clear, unfilled composite material
bleaching agent.8 In the present case, the treated that has very low viscosity, low contact angles to
areas of the teeth improved in shade following the enamel and high surface tension, enabling the
bleaching therapy. Bleaching was performed over resin to infiltrate into the microporosities of the
several appointments to prevent tooth hypersensi- tooth via capillary forces.7 The resin fills the air and
tivity. However, the bleached non-fluorosed por- water microporosities within the enamel, which
tions were unable to match the fluorosed areas of have lower refractive indices (1.0 and 1.33, re-
the teeth. In-office bleaching is indicated in this spectively) than sound enamel (1.62). The differ-
case because a 14-day home-bleaching procedure ence in refractive indices between these air- or
would have caused both fluorosed and the non- water-filled microporosities and sound enamel
fluorosed areas of the teeth to be exposed to the causes light to scatter and reflect more, thus mak-
bleaching agent. ing the affected fluorosed tooth surfaces to appear
With this suboptimal bleaching outcome, the pa- whiter and opaque in colour.7,9,13 The refractive in-
tient underwent the microinvasive resin infiltration dex of the resin-filled microporosities is 1.46, close
treatment to attempt to improve the aesthetic ap- to that of normal enamel. Thus, less light is scat-
pearance of the fluorosed incisal thirds of the facial tered due to the smaller difference between the
surface of the maxillary anterior teeth. This treat- refractive indices of the resin-infiltrated and sound
ment option was chosen despite the resin infiltra- enamel, thereby allowing the infiltrated enamel to
tion technique being initially developed for white acquire an appearance similar to that of the unaf-
spot caries lesions.7 However, similar to caries de- fected enamel.9,13
velopment, dental fluorosis is a hypomineralisation In the present case, the non-fluorosed portions
of the enamel that causes the fluorosed portion of of the affected teeth were first bleached, while the
the tooth to have increased porosity and appear fluorosed portions of the teeth were subsequently

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