RESEARCH ARTICLE
Esthetic Management of Developmental Enamel Opacities in Young Permanent Maxillary Incisors with Two Microabrasion Techniques—A Split Mouth Study NEHA SHEORAN, MDS*, SHALINI GARG, MDS†, SATYAWAN G. DAMLE, MDS, PhD, FNAMS‡, ABHISHEK DHINDSA, MDS§, SHIREEN OPAL, BDS¶, SHIVANI GUPTA, BDS¶
ABSTRACT Purpose: This study evaluated the effectiveness of two microabrasion materials for the removal of developmental enamel opacities in young permanent maxillary incisors. Materials and Methods: Using a split-mouth study design, 37% phosphoric acid and 18% hydrochloric acid were used for removal of visually unesthetic developmental enamel opacities of young permanent maxillary anterior teeth from 25 subjects (11–13 years old) by two microabrasion techniques for 10 and 5 seconds respectively. This procedure was repeated four to six times during each clinical appointment. The subjects were evaluated about their satisfaction with the treatment. Two blinded evaluators appraised both sides of the mouth using visual analog scale. The records were analyzed using Wilcoxon test. Results: The majority of the subjects (approximately 97%) reported satisfaction at the end of the treatment (p = 0.001**). Statistical significant reduction in enamel opacities was observed by evaluators immediately after microabrasion technique in group 1 (81.75%) and in group 2 (81.4%) (p < 0.002). Reduction was increased to 97.2% in group 1 and 96.7% in group 2 after 1 month. Conclusions: Both microabrasion techniques showed comparative highly significant successful results in esthetic management of enamel opacities clinically and in terms of subject’s satisfaction.
CLINICAL SIGNIFICANCE Developmental enamel defects like diffuse opacities due to high-fluoride content in water and demarcated opacities associated with positive dental history and are commonly seen in young permanent maxillary incisors of both boys and girls in their developing years. They are aware of unesthetic appearance of these newly erupted permanent anterior teeth and become highly motivated when informed about minimally invasive, patient friendly, cost-effective, and safe treatment like microabrasion for esthetic improvement. Both noninvasive microabrasion techniques using 37% phosphoric acid (group 1) and 18% hydrochloric acid (group 2) show comparatively high success results in treating enamel defects successfully to the subject’s satisfaction along with their parents. (J Esthet Restor Dent 26:345–352, 2014)
*Senior Lecturer, Department of Pediatric and Preventive Dentistry, Sudha Rastogi College of Dental Sciences and Research, Faridabad, Haryana, India † Professor and Head, Department of Pediatric and Preventive Dentistry, M. M. College of Dental Sciences and Research, Maharishi Markendeshwar University, Ambala, Haryana, India ‡ Professor and VC, Department of Pediatric and Preventive Dentistry, M. M. College of Dental Sciences and Research, Maharishi Markendeshwar University, Ambala, Haryana, India § Reader, Department of Pediatric and Preventive Dentistry, M. M. College of Dental Sciences and Research, Ambala, Haryana, India ¶ Postgraduate Student, Department of Pediatric and Preventive Dentistry, M. M. College of Dental Sciences and Research, Ambala, Haryana, India
© 2014 Wiley Periodicals, Inc.
DOI 10.1111/jerd.12096
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INTRODUCTION
MATERIALS AND METHODS
Tooth enamel is unique among mineralized tissues. The formation of dental enamel is highly specialized, and the proteins most directly involved in enamel bio-mineralization are specific for it. As a consequence, defects in the genes encoding enamel proteins generally cause enamel malformations.1 Developmental enamel defects can be qualitative or quantitative in nature and can present a wide range of clinical appearances.2 They can be classified into one of four types: hypoplasia, demarcated opacities, diffuse opacities, and discolored enamel.3
Subject Selection and Experimental Design
The enamel defects do not directly increase the risk for the development of caries in the affected teeth; the absence of normal enamel morphology invariably results in diminished occlusal function, and often in severely compromised esthetic in newly erupted young permanent teeth. So these enamel defects should be treated as early as possible.4 Esthetically desirable appearance of newly erupted permanent anterior teeth is of prime importance regarding development of self-esteem in growing children. A minimally invasive, safe, and child patient-friendly technique is required to manage these unesthetic enamel defects in newly erupted permanent anterior teeth of selected patients. Over the past decades, several techniques were employed to remove enamel defects, which include selective grinding and polishing, bleaching, microabrasion, veneering, or placement of porcelain crowns.5 In this era of minimal intervention, enamel microabrasion is a clinically restorative method to improve the appearance of affected teeth. As pointed out by Wong and Winter, esthetics is a subjective perception.6 It was concluded at the International Symposium on Non-Restorative Treatment of Discolored Teeth that microabrasion was a safe, conservative, and effective atraumatic method of removing superficial enamel defects. This study was aimed to compare the clinical efficacy of enamel microabrasion using 18% hydrochloric acid and 37% phosphoric acid on removal of visually unesthetic developmental enamel defects of young permanent anterior teeth in children.
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Two microabrasion materials—18% hydrochloric acid and 37% phosphoric acid—were studied in a clinical, split mouth, double-blind study design. The protocol and consent form for this study were reviewed and approved by Institutional Ethical Committee. Written informed consent was obtained from all participants prior to the beginning of the clinical study. Each child patient was asked about their own perception of esthetics of maxillary incisors. Patient screening and pretreatment selection of teeth with developmental enamel defects were performed by two clinical investigators according to modified Developmental Defects Enamel (DDE) index7: code 0 = normal; code 1 = white/cream demarcated opacities; code 2 = yellow brown demarcated opacities; code 3 = diffuse opacity with lines; code 4 = diffuse patchy opacities; code 5 = diffuse confluent opacities; code 6 = loss of enamel with staining; code 7 = hypoplastic pits; code 8 = hypoplasia with missing enamel; code 9 = hypoplasia with any other defect. An initial intra- and inter-examiner agreement of at least 85% was necessary before the clinical evaluation in this study began. Teeth to be examined were cleaned with pumice and water to remove extrinsic stain. The investigators carried out the evaluation using a mouth mirror, a blunt explorer, and a periodontal probe. All subjects were given oral hygiene instructions before starting the treatment. Prevalence of maxillary incisors with developmental defects of tooth enamel was 22.8% (N = 114) in which diffuse opacities contributed 48% (N = 55), demarcated opacities 38% (N = 44), both demarcated and diffuse 1% (N = 1), and enamel hypoplasia and others 13% (N = 14). As determined by this method, each individual received a score corresponding to the clinical appearance of the most affected teeth in the mouth. Out of 114 children who presented with enamel defects, 59 children were dissatisfied due to color of which 28 had demarcated opacities, 30 had diffuse opacities and 01 presented with both demarcated and diffuse opacities on maxillary incisors. Subjects with extremely poor oral hygiene or periodontal diseases were excluded. Children with loss of enamel in anterior teeth in codes 6 to 9 according to
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the modified DDE index were also excluded. Out of 59 children, a convenience sample of 25 children was selected for the study as per their reporting to the department and consent to allow the microabrasion technique for the treatment. One operator performed all procedures. Anterior teeth in each selected patient were divided randomly by chit method regarding right or left pairs of permanent maxillary central and lateral incisors into two groups—group 1 (37% phosphoric acid) and group 2 (18% hydrochloric acid). All participants were informed of the nature and objectives of this study; however, they were unaware of the location of each material. Materials 37% phosphoric acid (Mission Dental, USA), 18% hydrochloric acid prepared in the biochemistry department of the university, and pumice powder (Kramer industries, Inc., Piscataway Township, NJ, USA) was used for microabrasion. The baseline percentage of opacities in group 1 was 48 and in group 2 was also 48. Preoperative clinical status and patient perception of enamel opacities was recorded for each patient (Figs. 1 & 2).
In both the groups, after microabrasion, a paste of sodium bicarbonate mixed in water was applied to neutralize the effect of acid. This was followed by polishing with a soflex disc at slow speed. At the end of procedure, the rubber dam was removed and GC Tooth Mousse (GC Europe N.V., Leuven, Belgium) was applied for 5 minutes. Before discharging the patient, an immediate post-operative photograph was taken (Figures 1 and 2) and esthetic assessment in the patient was made according to visual analog scale (VAS).8 The patient was asked to return for the recall at 1-month interval. At 1-month recall, post-operative clinical assessment and esthetic assessment was carried out as described earlier and recorded in patient assessment form. Patient satisfaction was performed using the VAS8 (1 = no
Clinical Microabrasion Technique Isolation was performed using rubber dam and margins were sealed using copal varnish. The eyes of the patient as well as the operator were protected using eyewear. The method of application followed the split-mouth design. In both the groups, acid was mixed with pumice powder in a ratio of 1:1 to make a paste like consistency in a dappen dish with the help of a wooden spatula. This mix was then applied on teeth as grouped using standard silicon polishing cup attached to contra-angled hand piece at a slow speed of approximately 1,000 rpm under rubber dam. Group 1—37% phosphoric acid and pumice paste was applied for 10 seconds followed by rinsing with copious water for 20 seconds. Total six applications were performed in a single visit. Group 2—18% HCl and pumice paste was applied for 5 seconds followed by rinsing with copious water for 5 seconds. Total four applications were performed in a single visit.
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FIGURE 1. Representative pre- and post-operative photographs of group 1 and group 2.
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RESULTS Immediately after treatment, the opacities reduction was 82% and 81% in groups 1 and 2 respectively. The 1-month reduction was 97% in group 1 and 97% in group 2. Results immediately after and 1-month post-treatment are shown in Table 1 with no significant difference between the groups. Table 2 depicts the comparison immediately after treatment and after 1 month in each group. The results showed that the treatment outcome was highly significantly different (t value −.001**) in both groups. Table 3 represents the change in VAS immediately and 1 month after treatment. This table depicts that on VAS from 1 to 7, the ratings for improvement in appearance significantly changed after second clinical appointment. Table 4 shows that out of 25 children treated with microabrasion, 84% of children were satisfied with the appearance immediately after treatment and 96% were satisfied after 1 month.
DISCUSSION FIGURE 2. Representative pre- and post-operative photographs of group 1 and group 2.
improvement; 2, 3 ,4 = slight; 5, 6 = moderate; 7 = exceptional improvement).
Data Transfer and Statistical Analysis For the assessment of improvement of enamel opacities in two acid groups, the preoperative, immediate, post-operative, and after 1-month follow up clinical assessment records of 25 subjects were analyzed by two blinded independent evaluators to assess reduction in opacities in groups 1 and 2. Cohen’s Kappa statistics (0.86) showed strong agreement between the examiners. Presence or absence of enamel opacities was taken as a unit for analysis. Success of treatment was identified by the decrease in the number of enamel opacities. Esthetic improvement was determined by the VAS reading and satisfaction of the child.
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Esthetics is a subjective perception. The clinical management of tooth discoloration aims to produce an acceptable cosmetic result as conservatively as possible. Conservative treatment with microabrasion can produce dramatic improvements in brown and yellow discoloration.9 The available literature on it shows that this technique should be considered as the first treatment option when trying to improve the esthetics of teeth that present intrinsic stains and extrinsic superficial enamel stains.10 The first report about hydrochloric acid application used to improve esthetics of teeth with fluorosis was given by Dr Kane in 1916.11 Since then, favorable studies verified the effectiveness of the microabrasion technique using different concentrations of hydrochloric acid (6.6–18%) and phosphoric acid (30–40%) in association with abrasives.12 Microabrasion is indicated for fluorosis, post-orthodontic demineralization, localized hypoplasia
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TABLE 1. Mean distribution of enamel opacities in group 1 and group 2 immediately and 1 month after treatment
Baseline opacities
Group 1: 37% phosphoric acid
Group 2: 18% hydrochloric acid
Mean
N
% change
Standard deviation
Mean
N
% change
Standard deviation
48.13
25
81.7
5.61
47.96
25
81.4
27.69
2.39
8.70
.85
1.72
Opacities immediately after treatment
8.67
Opacities 1 month after treatment
1.43
97.3
12.53 96.7
5.00
TABLE 2. Percentage change in children immediately after microabrasion and 1 month after microabrasion in both the groups Paired differences Mean Mean Standard Standard Standard Standard 95% Confidence interval Group Group deviation deviation error error of the difference 1 2 Group 1 Group 2 mean mean Lower Lower Upper Upper Group Group Group Group 1 2 1 2 Baseline 39.46 opacities— opacities immediately after treatment
39.26
27.26
27.68
5.45
5.54
28.21
Baseline 46.70 opacities— opacities after 1 month
46.24
28.07
27.70
5.61
5.54
35.11
27.84
50.71
50.68
t t df Group Group Group 1 1 2 and group 2
Sig. (twotailed) Group 1 and group 2
7.23
.001**
7.09
24
Group 1: 37% phosphoric acid. Group 2: 18% hydrochloric acid. **When baseline opacities are compared with opacities immediately after treatment then the comparision/ result is highly significant.
TABLE 3. Visual scale readings immediately and 1 month after treatment Visual scale reading immediately after treatment Frequency
Percentage (%)
1 = no improvement
0
0
2–4 = slight improvement
1
5–6 = moderate improvement 7 = exceptional improvement Total
Visual scale reading 1 month after treatment Mean
Standard deviation
5.80
.91
Percentage (%)
0
0
4
0
0
17
68
15
60
7
28
10
40
25
100
25
100
due to infection or trauma, and idiopathic hypoplasia where the discoloration is limited to the outer enamel layer.13–16 This technique is simple to perform and the depth of enamel removed in 10 applications is
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Frequency
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Mean
Standard deviation
6.24
.72
approximately 100 μm (0.1 mm). The clinical result obtained is directly related to the depth of the stain/defect.10 Among the 25 treated patients in present study, it was observed that baseline opacity area was
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TABLE 4. Esthetic satisfaction in children immediately after enamel microabrasion treatment and 1 month after treatment Esthetic satisfaction in children immediately after enamel microabrasion treatment
Esthetic satisfaction in children 1 month after treatment
Satisfied
Satisfied
Long-term satisfied
Unsatisfied
Frequency (N = 25)
21
4
24
1
Percent %
84
16
96
4
similar in both groups and mean percentage opacity reduction was 82% in group 1 and 81% in group 2 immediately after treatment. Brown stains had better results than white stains. It was also observed that patients with a mild degree of developmental enamel defects showed better results. Same data have also been reported by Train and colleagues13 and Bezerra and colleagues.17 The split-mouth clinical study was used in this study to evaluate the efficacy of two microabrasion materials in vivo. The baseline percentage of opacities in group 1 was 48 and in group 2 was also 48. One-month reduction in enamel opacity was 97% in group 1 and 97% in group 2. The results were statistically significant in both groups showing a marked reduction in total area occupied by opacities. However, there was no statically significant difference between the two groups. The most important aspect of this treatment to the patient is the advantage that no further treatment is required after this minimally invasive technique, as has been observed by Tashima and colleagues10 and Bezerra and colleagues.17 The patient and parents were 84% satisfied immediately after and 96% after 1 month. The parents generally complied with the follow-up visit. The difference between mean percentage reduction of opacities and after a month in group 1 and group 2 was not statistically significant. The appearance of enamel surfaces had a tendency to improve as time transpired, clinically decreasing the area and size of opacities. These observations were also seen in several studies done by Croll.18–20 Croll TP performed microabrasion treatment for hundreds of children and adult patients from 1985 to 1989. Treatment results observed by him supported the contention that enamel microabrasion
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gave permanent color modification of superficial enamel coloration defects because enamel microabrasion actually removed discolored enamel rather than altering or masking the tooth stain. Also, microabraded enamel surfaces achieved a brilliant luster as time passed by. Similar results were also observed in the present study. He also observed that many intrinsic enamel surface defects were superficial enough to be eliminated without replacing the lost enamel. Slight and moderate, white and brown fluorosis discolorations are good examples how this type of demineralization which can be treated by enamel microabrasion. Enamel microabrasion corrects surface enamel hypomineralization and discolorations defects by removing superficial enamel.7 If the discolored defect is superficial and microabrasion exposes underlying enamel of normal quality, the tooth acquires a glassy lustrous quality due to changes in the intrinsic properties of enamel following simultaneous abrasion and erosion of the surface. This has been described as the “abrosion effect.”21 In the proposed technique, we suggest the use of microabrasion to remove the unesthetically desirable enamel defects under rubber dam protection followed by application of fluoride solution or casein phosphopeptide – amorphous calcium phosphate paste for 5 to 15 minutes. This approach is justified for two reasons: first, it reduces the risk of post-treatment sensibility, and second, it protects teeth from possible external demineralization.22 Additionally, it could be said that this technique has a positive psychological effects on patients. The children presenting esthetically compromised anterior teeth might develop a low self-esteem and confidence. During
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follow up, most of the parents reported that their children had positive changes in their behavior, after treatment by becoming more outgoing and exhibited unrestricted smiling without fear of showing their teeth after treatment. The same observation was made by Powel, Craig and colleagues.23–25
9.
10.
11.
CONCLUSIONS 1 Both microabrasion techniques showed comparatively high success in treating enamel opacities resulting in both patient and parents satisfaction. 2 Microabrasion is a simple, safe, atraumatic, conservative, and minimally invasive technique that removes the superficial part of enamel and eliminates defects such as brown or white opacities.
DISCLOSURE
12.
13.
14.
15.
The authors do not have any financial interest in any of the companies whose products are included in this article.
16.
REFERENCES 1.
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Simmer JP. Dental enamel formation and its impact on clinical dentistry. J Dent Educ 2001;65: 896–905. Elcock C. The new Enamel Defects Index: testing and expansion. Eur J Oral Sci 2006;114(Suppl 1):35–8. Wozniak K, Lagocka R, Lipski M, et al. Changes in developmental defects of dental enamel within the space of centuries. Durham Anthropol J 2005;12:2–3. Bhussry BR, Bibby BG. Surface changes in enamel. J Dent Res 1957;36:409–16. Peariasamy K, Anderson P, Brook AH. A quantitative study of effect of pumicing and etching on the remineralisation of enamel opacities. Int J Paediatr Dent 2001;11:193–200. Wong FS, Winter GB. Effectiveness of microabrasion technique for improvement of dental aesthetics. Br Dent J 2002;193:155–8. Clarkson J, O’Mullane D. A modified DDE index for use in epidemiological studies of enamel defects. J Dent Res 1989;68(3):445–50. Price RB, Loney RW, Doyle MG, Moulding MB. An evaluation of a technique to remove stains from teeth
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using microabrasion. J Am Dent Assoc 2003;134: 1066–71. Ng F, Manton DJ. Aesthetic management of severely fluorosed incisors in an adolescent female. Aust Dent J 2007;52:243–8. Tashima AY, Aldrigui JM, Bussadori SK, Wanderley MT. Enamel microabrasion in pediatric dentistry: a case report. ConScientiae Saude 2009;8:133–7. Welbury RR, Shaw L. A simple technique for removal of mottling, opacities and pigmentation from enamel. Dent Update 1990;17:161–3. PubMed. Wray A, Welbury R. Treatment of intrinsic discoloration in permanent anterior teeth in children and adolescents. Int J Paediatr Dent 2001;11:309–15. Train TE, Mc Whorter AG, Seale NS, et al. Examination of esthetic improvement and surface alteration following microabrasion in fluorotic human incisors in vivo. Pediatr Dent 1996;18:353–62. Wang Y, Sa Y, Liang S, Jiang T. Minimally invasive treatment for esthetic management of severe dental fluorosis: a case report. Oper Dent 2013;38:358–62. [Epub ahead of print]. Hoeppner MG, Mauro SJ, Alexandre RS, et al. Evaluation “in situ” of tag formation in dental enamel submitted to microabrasion technique. Effect of two etching times. Acta Odontol Latinoam 2010;23: 153–7. Khandelwal V, Nayak UA, Nayak PA, Ninawe N. Aesthetic management of dental fluorosis. BMJ Case Rep 2013;2013:pii: bcr2013010029. doi: 10.1136/bcr-2013-010029. Bezerra AC, Leal SC, Otero SA et al. Enamel opacities removal using two different acids: an in vivo comparison. J Clin Pediatr Dent 2005;29(2):147–50. Croll TP, Cavanaugh RR. Enamel color modification by controlled hydrochloric pumice abrasion. Technique and examples. Quintessence Int 1986;17:81–7. Croll TP, Cavanaugh RR. Hydrochloric acid pumice enamel surface abrasion for colour modification: results after six months. Quintessence Int 1986;17:335–41. Croll TP. Enamel Microabrasion the technique. Quintessence Int 1989;20(6):395–400. Donly KJ, O’Neill M, Croll TP. Enamel microabrasion: a microscopic evaluation of the “abrosion effect”. Quintessence Int 1992;23:175–9. Ardu S, Stavridakis M, Krejci I. A minimally invasive treatment of severe dental fluorosis. Quintessence Int 2007;38:455–8. Powel KR, Craig GG. A simple technique for the esthetic improvement fluorotic—like lesions. J Dent Child 1982;50:112–7. Rodd HD, Abdul-Karim A, Yesudian G, et al. Seeking children’s perspectives in the management of visible
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enamel defects. Int J Paediatr Dent 2011;21(2): 89–95. 25. Pontes DG, Correa KM, Cohen-Carneiro F. Re-establishing esthetics of fluorosis-stained teeth using enamel microabrasion and dental bleaching techniques. Eur J Esthet Dent 2012;7(2):130–7.
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Reprint requests: Shalini Garg, MDS, Department of Pediatric and Preventive Dentistry, M. M. College of Dental Sciences and Research, Maharishi Markendeshwar University, Mullana, Ambala, Haryana 133207, Pin 133203, India; Tel.: +91-9215668621; Fax: 0091-1731-274325; email: [email protected]
DOI 10.1111/jerd.12096
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Esthetic Management of Developmental Enamel Opacities in Young Permanent Maxillary Incisors with Two Microabrasion Techniques—A Split Mouth Study NEHA SHEORAN, MDS*, SHALINI GARG, MDS†, SATYAWAN G. DAMLE, MDS, PhD, FNAMS‡, ABHISHEK DHINDSA, MDS§, SHIREEN OPAL, BDS¶, SHIVANI GUPTA, BDS¶
ABSTRACT Purpose: This study evaluated the effectiveness of two microabrasion materials for the removal of developmental enamel opacities in young permanent maxillary incisors. Materials and Methods: Using a split-mouth study design, 37% phosphoric acid and 18% hydrochloric acid were used for removal of visually unesthetic developmental enamel opacities of young permanent maxillary anterior teeth from 25 subjects (11–13 years old) by two microabrasion techniques for 10 and 5 seconds respectively. This procedure was repeated four to six times during each clinical appointment. The subjects were evaluated about their satisfaction with the treatment. Two blinded evaluators appraised both sides of the mouth using visual analog scale. The records were analyzed using Wilcoxon test. Results: The majority of the subjects (approximately 97%) reported satisfaction at the end of the treatment (p = 0.001**). Statistical significant reduction in enamel opacities was observed by evaluators immediately after microabrasion technique in group 1 (81.75%) and in group 2 (81.4%) (p < 0.002). Reduction was increased to 97.2% in group 1 and 96.7% in group 2 after 1 month. Conclusions: Both microabrasion techniques showed comparative highly significant successful results in esthetic management of enamel opacities clinically and in terms of subject’s satisfaction.
CLINICAL SIGNIFICANCE Developmental enamel defects like diffuse opacities due to high-fluoride content in water and demarcated opacities associated with positive dental history and are commonly seen in young permanent maxillary incisors of both boys and girls in their developing years. They are aware of unesthetic appearance of these newly erupted permanent anterior teeth and become highly motivated when informed about minimally invasive, patient friendly, cost-effective, and safe treatment like microabrasion for esthetic improvement. Both noninvasive microabrasion techniques using 37% phosphoric acid (group 1) and 18% hydrochloric acid (group 2) show comparatively high success results in treating enamel defects successfully to the subject’s satisfaction along with their parents. (J Esthet Restor Dent 26:345–352, 2014)
*Senior Lecturer, Department of Pediatric and Preventive Dentistry, Sudha Rastogi College of Dental Sciences and Research, Faridabad, Haryana, India † Professor and Head, Department of Pediatric and Preventive Dentistry, M. M. College of Dental Sciences and Research, Maharishi Markendeshwar University, Ambala, Haryana, India ‡ Professor and VC, Department of Pediatric and Preventive Dentistry, M. M. College of Dental Sciences and Research, Maharishi Markendeshwar University, Ambala, Haryana, India § Reader, Department of Pediatric and Preventive Dentistry, M. M. College of Dental Sciences and Research, Ambala, Haryana, India ¶ Postgraduate Student, Department of Pediatric and Preventive Dentistry, M. M. College of Dental Sciences and Research, Ambala, Haryana, India
© 2014 Wiley Periodicals, Inc.
DOI 10.1111/jerd.12096
Journal of Esthetic and Restorative Dentistry
Vol 26 • No 5 • 345–352 • 2014
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ESTHETIC MANAGEMENT USING MICROABRASION TECHNIQUE Sheoran et al.
INTRODUCTION
MATERIALS AND METHODS
Tooth enamel is unique among mineralized tissues. The formation of dental enamel is highly specialized, and the proteins most directly involved in enamel bio-mineralization are specific for it. As a consequence, defects in the genes encoding enamel proteins generally cause enamel malformations.1 Developmental enamel defects can be qualitative or quantitative in nature and can present a wide range of clinical appearances.2 They can be classified into one of four types: hypoplasia, demarcated opacities, diffuse opacities, and discolored enamel.3
Subject Selection and Experimental Design
The enamel defects do not directly increase the risk for the development of caries in the affected teeth; the absence of normal enamel morphology invariably results in diminished occlusal function, and often in severely compromised esthetic in newly erupted young permanent teeth. So these enamel defects should be treated as early as possible.4 Esthetically desirable appearance of newly erupted permanent anterior teeth is of prime importance regarding development of self-esteem in growing children. A minimally invasive, safe, and child patient-friendly technique is required to manage these unesthetic enamel defects in newly erupted permanent anterior teeth of selected patients. Over the past decades, several techniques were employed to remove enamel defects, which include selective grinding and polishing, bleaching, microabrasion, veneering, or placement of porcelain crowns.5 In this era of minimal intervention, enamel microabrasion is a clinically restorative method to improve the appearance of affected teeth. As pointed out by Wong and Winter, esthetics is a subjective perception.6 It was concluded at the International Symposium on Non-Restorative Treatment of Discolored Teeth that microabrasion was a safe, conservative, and effective atraumatic method of removing superficial enamel defects. This study was aimed to compare the clinical efficacy of enamel microabrasion using 18% hydrochloric acid and 37% phosphoric acid on removal of visually unesthetic developmental enamel defects of young permanent anterior teeth in children.
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Two microabrasion materials—18% hydrochloric acid and 37% phosphoric acid—were studied in a clinical, split mouth, double-blind study design. The protocol and consent form for this study were reviewed and approved by Institutional Ethical Committee. Written informed consent was obtained from all participants prior to the beginning of the clinical study. Each child patient was asked about their own perception of esthetics of maxillary incisors. Patient screening and pretreatment selection of teeth with developmental enamel defects were performed by two clinical investigators according to modified Developmental Defects Enamel (DDE) index7: code 0 = normal; code 1 = white/cream demarcated opacities; code 2 = yellow brown demarcated opacities; code 3 = diffuse opacity with lines; code 4 = diffuse patchy opacities; code 5 = diffuse confluent opacities; code 6 = loss of enamel with staining; code 7 = hypoplastic pits; code 8 = hypoplasia with missing enamel; code 9 = hypoplasia with any other defect. An initial intra- and inter-examiner agreement of at least 85% was necessary before the clinical evaluation in this study began. Teeth to be examined were cleaned with pumice and water to remove extrinsic stain. The investigators carried out the evaluation using a mouth mirror, a blunt explorer, and a periodontal probe. All subjects were given oral hygiene instructions before starting the treatment. Prevalence of maxillary incisors with developmental defects of tooth enamel was 22.8% (N = 114) in which diffuse opacities contributed 48% (N = 55), demarcated opacities 38% (N = 44), both demarcated and diffuse 1% (N = 1), and enamel hypoplasia and others 13% (N = 14). As determined by this method, each individual received a score corresponding to the clinical appearance of the most affected teeth in the mouth. Out of 114 children who presented with enamel defects, 59 children were dissatisfied due to color of which 28 had demarcated opacities, 30 had diffuse opacities and 01 presented with both demarcated and diffuse opacities on maxillary incisors. Subjects with extremely poor oral hygiene or periodontal diseases were excluded. Children with loss of enamel in anterior teeth in codes 6 to 9 according to
DOI 10.1111/jerd.12096
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the modified DDE index were also excluded. Out of 59 children, a convenience sample of 25 children was selected for the study as per their reporting to the department and consent to allow the microabrasion technique for the treatment. One operator performed all procedures. Anterior teeth in each selected patient were divided randomly by chit method regarding right or left pairs of permanent maxillary central and lateral incisors into two groups—group 1 (37% phosphoric acid) and group 2 (18% hydrochloric acid). All participants were informed of the nature and objectives of this study; however, they were unaware of the location of each material. Materials 37% phosphoric acid (Mission Dental, USA), 18% hydrochloric acid prepared in the biochemistry department of the university, and pumice powder (Kramer industries, Inc., Piscataway Township, NJ, USA) was used for microabrasion. The baseline percentage of opacities in group 1 was 48 and in group 2 was also 48. Preoperative clinical status and patient perception of enamel opacities was recorded for each patient (Figs. 1 & 2).
In both the groups, after microabrasion, a paste of sodium bicarbonate mixed in water was applied to neutralize the effect of acid. This was followed by polishing with a soflex disc at slow speed. At the end of procedure, the rubber dam was removed and GC Tooth Mousse (GC Europe N.V., Leuven, Belgium) was applied for 5 minutes. Before discharging the patient, an immediate post-operative photograph was taken (Figures 1 and 2) and esthetic assessment in the patient was made according to visual analog scale (VAS).8 The patient was asked to return for the recall at 1-month interval. At 1-month recall, post-operative clinical assessment and esthetic assessment was carried out as described earlier and recorded in patient assessment form. Patient satisfaction was performed using the VAS8 (1 = no
Clinical Microabrasion Technique Isolation was performed using rubber dam and margins were sealed using copal varnish. The eyes of the patient as well as the operator were protected using eyewear. The method of application followed the split-mouth design. In both the groups, acid was mixed with pumice powder in a ratio of 1:1 to make a paste like consistency in a dappen dish with the help of a wooden spatula. This mix was then applied on teeth as grouped using standard silicon polishing cup attached to contra-angled hand piece at a slow speed of approximately 1,000 rpm under rubber dam. Group 1—37% phosphoric acid and pumice paste was applied for 10 seconds followed by rinsing with copious water for 20 seconds. Total six applications were performed in a single visit. Group 2—18% HCl and pumice paste was applied for 5 seconds followed by rinsing with copious water for 5 seconds. Total four applications were performed in a single visit.
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FIGURE 1. Representative pre- and post-operative photographs of group 1 and group 2.
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RESULTS Immediately after treatment, the opacities reduction was 82% and 81% in groups 1 and 2 respectively. The 1-month reduction was 97% in group 1 and 97% in group 2. Results immediately after and 1-month post-treatment are shown in Table 1 with no significant difference between the groups. Table 2 depicts the comparison immediately after treatment and after 1 month in each group. The results showed that the treatment outcome was highly significantly different (t value −.001**) in both groups. Table 3 represents the change in VAS immediately and 1 month after treatment. This table depicts that on VAS from 1 to 7, the ratings for improvement in appearance significantly changed after second clinical appointment. Table 4 shows that out of 25 children treated with microabrasion, 84% of children were satisfied with the appearance immediately after treatment and 96% were satisfied after 1 month.
DISCUSSION FIGURE 2. Representative pre- and post-operative photographs of group 1 and group 2.
improvement; 2, 3 ,4 = slight; 5, 6 = moderate; 7 = exceptional improvement).
Data Transfer and Statistical Analysis For the assessment of improvement of enamel opacities in two acid groups, the preoperative, immediate, post-operative, and after 1-month follow up clinical assessment records of 25 subjects were analyzed by two blinded independent evaluators to assess reduction in opacities in groups 1 and 2. Cohen’s Kappa statistics (0.86) showed strong agreement between the examiners. Presence or absence of enamel opacities was taken as a unit for analysis. Success of treatment was identified by the decrease in the number of enamel opacities. Esthetic improvement was determined by the VAS reading and satisfaction of the child.
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Esthetics is a subjective perception. The clinical management of tooth discoloration aims to produce an acceptable cosmetic result as conservatively as possible. Conservative treatment with microabrasion can produce dramatic improvements in brown and yellow discoloration.9 The available literature on it shows that this technique should be considered as the first treatment option when trying to improve the esthetics of teeth that present intrinsic stains and extrinsic superficial enamel stains.10 The first report about hydrochloric acid application used to improve esthetics of teeth with fluorosis was given by Dr Kane in 1916.11 Since then, favorable studies verified the effectiveness of the microabrasion technique using different concentrations of hydrochloric acid (6.6–18%) and phosphoric acid (30–40%) in association with abrasives.12 Microabrasion is indicated for fluorosis, post-orthodontic demineralization, localized hypoplasia
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TABLE 1. Mean distribution of enamel opacities in group 1 and group 2 immediately and 1 month after treatment
Baseline opacities
Group 1: 37% phosphoric acid
Group 2: 18% hydrochloric acid
Mean
N
% change
Standard deviation
Mean
N
% change
Standard deviation
48.13
25
81.7
5.61
47.96
25
81.4
27.69
2.39
8.70
.85
1.72
Opacities immediately after treatment
8.67
Opacities 1 month after treatment
1.43
97.3
12.53 96.7
5.00
TABLE 2. Percentage change in children immediately after microabrasion and 1 month after microabrasion in both the groups Paired differences Mean Mean Standard Standard Standard Standard 95% Confidence interval Group Group deviation deviation error error of the difference 1 2 Group 1 Group 2 mean mean Lower Lower Upper Upper Group Group Group Group 1 2 1 2 Baseline 39.46 opacities— opacities immediately after treatment
39.26
27.26
27.68
5.45
5.54
28.21
Baseline 46.70 opacities— opacities after 1 month
46.24
28.07
27.70
5.61
5.54
35.11
27.84
50.71
50.68
t t df Group Group Group 1 1 2 and group 2
Sig. (twotailed) Group 1 and group 2
7.23
.001**
7.09
24
Group 1: 37% phosphoric acid. Group 2: 18% hydrochloric acid. **When baseline opacities are compared with opacities immediately after treatment then the comparision/ result is highly significant.
TABLE 3. Visual scale readings immediately and 1 month after treatment Visual scale reading immediately after treatment Frequency
Percentage (%)
1 = no improvement
0
0
2–4 = slight improvement
1
5–6 = moderate improvement 7 = exceptional improvement Total
Visual scale reading 1 month after treatment Mean
Standard deviation
5.80
.91
Percentage (%)
0
0
4
0
0
17
68
15
60
7
28
10
40
25
100
25
100
due to infection or trauma, and idiopathic hypoplasia where the discoloration is limited to the outer enamel layer.13–16 This technique is simple to perform and the depth of enamel removed in 10 applications is
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Frequency
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Mean
Standard deviation
6.24
.72
approximately 100 μm (0.1 mm). The clinical result obtained is directly related to the depth of the stain/defect.10 Among the 25 treated patients in present study, it was observed that baseline opacity area was
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TABLE 4. Esthetic satisfaction in children immediately after enamel microabrasion treatment and 1 month after treatment Esthetic satisfaction in children immediately after enamel microabrasion treatment
Esthetic satisfaction in children 1 month after treatment
Satisfied
Satisfied
Long-term satisfied
Unsatisfied
Frequency (N = 25)
21
4
24
1
Percent %
84
16
96
4
similar in both groups and mean percentage opacity reduction was 82% in group 1 and 81% in group 2 immediately after treatment. Brown stains had better results than white stains. It was also observed that patients with a mild degree of developmental enamel defects showed better results. Same data have also been reported by Train and colleagues13 and Bezerra and colleagues.17 The split-mouth clinical study was used in this study to evaluate the efficacy of two microabrasion materials in vivo. The baseline percentage of opacities in group 1 was 48 and in group 2 was also 48. One-month reduction in enamel opacity was 97% in group 1 and 97% in group 2. The results were statistically significant in both groups showing a marked reduction in total area occupied by opacities. However, there was no statically significant difference between the two groups. The most important aspect of this treatment to the patient is the advantage that no further treatment is required after this minimally invasive technique, as has been observed by Tashima and colleagues10 and Bezerra and colleagues.17 The patient and parents were 84% satisfied immediately after and 96% after 1 month. The parents generally complied with the follow-up visit. The difference between mean percentage reduction of opacities and after a month in group 1 and group 2 was not statistically significant. The appearance of enamel surfaces had a tendency to improve as time transpired, clinically decreasing the area and size of opacities. These observations were also seen in several studies done by Croll.18–20 Croll TP performed microabrasion treatment for hundreds of children and adult patients from 1985 to 1989. Treatment results observed by him supported the contention that enamel microabrasion
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gave permanent color modification of superficial enamel coloration defects because enamel microabrasion actually removed discolored enamel rather than altering or masking the tooth stain. Also, microabraded enamel surfaces achieved a brilliant luster as time passed by. Similar results were also observed in the present study. He also observed that many intrinsic enamel surface defects were superficial enough to be eliminated without replacing the lost enamel. Slight and moderate, white and brown fluorosis discolorations are good examples how this type of demineralization which can be treated by enamel microabrasion. Enamel microabrasion corrects surface enamel hypomineralization and discolorations defects by removing superficial enamel.7 If the discolored defect is superficial and microabrasion exposes underlying enamel of normal quality, the tooth acquires a glassy lustrous quality due to changes in the intrinsic properties of enamel following simultaneous abrasion and erosion of the surface. This has been described as the “abrosion effect.”21 In the proposed technique, we suggest the use of microabrasion to remove the unesthetically desirable enamel defects under rubber dam protection followed by application of fluoride solution or casein phosphopeptide – amorphous calcium phosphate paste for 5 to 15 minutes. This approach is justified for two reasons: first, it reduces the risk of post-treatment sensibility, and second, it protects teeth from possible external demineralization.22 Additionally, it could be said that this technique has a positive psychological effects on patients. The children presenting esthetically compromised anterior teeth might develop a low self-esteem and confidence. During
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follow up, most of the parents reported that their children had positive changes in their behavior, after treatment by becoming more outgoing and exhibited unrestricted smiling without fear of showing their teeth after treatment. The same observation was made by Powel, Craig and colleagues.23–25
9.
10.
11.
CONCLUSIONS 1 Both microabrasion techniques showed comparatively high success in treating enamel opacities resulting in both patient and parents satisfaction. 2 Microabrasion is a simple, safe, atraumatic, conservative, and minimally invasive technique that removes the superficial part of enamel and eliminates defects such as brown or white opacities.
DISCLOSURE
12.
13.
14.
15.
The authors do not have any financial interest in any of the companies whose products are included in this article.
16.
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enamel defects. Int J Paediatr Dent 2011;21(2): 89–95. 25. Pontes DG, Correa KM, Cohen-Carneiro F. Re-establishing esthetics of fluorosis-stained teeth using enamel microabrasion and dental bleaching techniques. Eur J Esthet Dent 2012;7(2):130–7.
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Reprint requests: Shalini Garg, MDS, Department of Pediatric and Preventive Dentistry, M. M. College of Dental Sciences and Research, Maharishi Markendeshwar University, Mullana, Ambala, Haryana 133207, Pin 133203, India; Tel.: +91-9215668621; Fax: 0091-1731-274325; email: [email protected]
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