40_Esthetic Management of Developmental Enamel Opacities

Esthetic Management of Developmental Enamel Opacitiesin Young Permanent Maxillary Incisors with TwoMicroabrasion TechniquesA Split Mouth StudyNEHA 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 developmentalenamel opacities in young permanent maxillary incisors.Materials and Methods: Using a split-mouth study design, 37% phosphoric acid and 18% hydrochloric acid were usedfor removal of visually unesthetic developmental enamel opacities of young permanent maxillary anterior teeth from25 subjects (1113 years old) by two microabrasion techniques for 10 and 5 seconds respectively.This procedure wasrepeated four to six times during each clinical appointment.The subjects were evaluated about their satisfaction withthe treatment.Two blinded evaluators appraised both sides of the mouth using visual analog scale.The records wereanalyzed 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 aftermicroabrasion 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 estheticmanagement of enamel opacities clinically and in terms of subjects satisfaction.

CLINICAL SIGNIFICANCE

Developmental enamel defects like diffuse opacities due to high-fluoride content in water and demarcated opacitiesassociated with positive dental history and are commonly seen in young permanent maxillary incisors of both boysand girls in their developing years.They are aware of unesthetic appearance of these newly erupted permanentanterior teeth and become highly motivated when informed about minimally invasive, patient friendly, cost-effective, andsafe 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 treatingenamel defects successfully to the subjects satisfaction along with their parents.

(J Esthet Restor Dent 26:345352, 2014)

*Senior Lecturer, Department of Pediatric and Preventive Dentistry, Sudha Rastogi College of Dental Sciences and Research, Faridabad, Haryana, IndiaProfessor and Head, Department of Pediatric and Preventive Dentistry, M. M. College of Dental Sciences and Research, Maharishi Markendeshwar University, Ambala,

Haryana, IndiaProfessor and VC, Department of Pediatric and Preventive Dentistry, M. M. College of Dental Sciences and Research, Maharishi Markendeshwar University, Ambala,

Haryana, IndiaReader, Department of Pediatric and Preventive Dentistry, M. M. College of Dental Sciences and Research, Ambala, Haryana, IndiaPostgraduate Student, Department of Pediatric and Preventive Dentistry, M. M. College of Dental Sciences and Research, Ambala, Haryana, India

RESEARCH ARTICLE

2014 Wiley Periodicals, Inc. DOI 10.1111/jerd.12096 Journal of Esthetic and Restorative Dentistry Vol 26 No 5 345352 2014 345

INTRODUCTION

Tooth enamel is unique among mineralized tissues. Theformation of dental enamel is highly specialized, andthe proteins most directly involved in enamelbio-mineralization are specic for it. As a consequence,defects in the genes encoding enamel proteins generallycause enamel malformations.1 Developmental enameldefects can be qualitative or quantitative in nature andcan present a wide range of clinical appearances.2They can be classied into one of four types:hypoplasia, demarcated opacities, diuse opacities, anddiscolored enamel.3

The enamel defects do not directly increase the risk forthe development of caries in the aected teeth; theabsence of normal enamel morphology invariablyresults in diminished occlusal function, and often inseverely compromised esthetic in newly erupted youngpermanent teeth. So these enamel defects should betreated as early as possible.4 Esthetically desirableappearance of newly erupted permanent anterior teethis of prime importance regarding development ofself-esteem in growing children. A minimally invasive,safe, and child patient-friendly technique is required tomanage these unesthetic enamel defects in newlyerupted permanent anterior teeth of selected patients.Over the past decades, several techniques wereemployed to remove enamel defects, which includeselective grinding and polishing, bleaching,microabrasion, veneering, or placement of porcelaincrowns.5 In this era of minimal intervention, enamelmicroabrasion is a clinically restorative method toimprove the appearance of aected teeth. As pointedout by Wong and Winter, esthetics is a subjectiveperception.6 It was concluded at the InternationalSymposium on Non-Restorative Treatment ofDiscolored Teeth that microabrasion was a safe,conservative, and eective atraumatic method ofremoving supercial enamel defects.

This study was aimed to compare the clinical ecacy ofenamel microabrasion using 18% hydrochloric acid and37% phosphoric acid on removal of visually unestheticdevelopmental enamel defects of young permanentanterior teeth in children.

MATERIALS AND METHODS

Subject Selection and Experimental Design

Two microabrasion materials18% hydrochloric acidand 37% phosphoric acidwere studied in a clinical,split mouth, double-blind study design. The protocoland consent form for this study were reviewed andapproved by Institutional Ethical Committee. Writteninformed consent was obtained from all participantsprior to the beginning of the clinical study. Each childpatient was asked about their own perception ofesthetics of maxillary incisors. Patient screening andpretreatment selection of teeth with developmentalenamel defects were performed by two clinicalinvestigators according to modied DevelopmentalDefects Enamel (DDE) index7: code 0 = normal; code1 = white/cream demarcated opacities; code 2 = yellowbrown demarcated opacities; code 3 = diuse opacitywith lines; code 4 = diuse patchy opacities; code5 = diuse conuent opacities; code 6 = loss of enamelwith staining; code 7 = hypoplastic pits; code8 = hypoplasia with missing enamel; code 9 = hypoplasiawith any other defect. An initial intra- andinter-examiner agreement of at least 85% was necessarybefore the clinical evaluation in this study began. Teethto be examined were cleaned with pumice and water toremove extrinsic stain. The investigators carried out theevaluation using a mouth mirror, a blunt explorer, anda periodontal probe. All subjects were given oralhygiene instructions before starting the treatment.Prevalence of maxillary incisors with developmentaldefects of tooth enamel was 22.8% (N = 114) in whichdiuse opacities contributed 48% (N = 55), demarcatedopacities 38% (N = 44), both demarcated and diuse 1%(N = 1), and enamel hypoplasia and others 13% (N = 14).As determined by this method, each individual receiveda score corresponding to the clinical appearance of themost aected teeth in the mouth. Out of 114 childrenwho presented with enamel defects, 59 children weredissatised due to color of which 28 had demarcatedopacities, 30 had diuse opacities and 01 presentedwith both demarcated and diuse opacities on maxillaryincisors. Subjects with extremely poor oral hygiene orperiodontal diseases were excluded. Children with lossof enamel in anterior teeth in codes 6 to 9 according to

ESTHETIC MANAGEMENT USING MICROABRASION TECHNIQUE Sheoran et al.

DOI 10.1111/jerd.12096 2014 Wiley Periodicals, Inc.Vol 26 No 5 345352 2014 Journal of Esthetic and Restorative Dentistry346

the modied DDE index were also excluded. Out of 59children, a convenience sample of 25 children wasselected for the study as per their reporting to thedepartment and consent to allow the microabrasiontechnique for the treatment. One operator performedall procedures. Anterior teeth in each selected patientwere divided randomly by chit method regarding rightor left pairs of permanent maxillary central and lateralincisors into two groupsgroup 1 (37% phosphoricacid) and group 2 (18% hydrochloric acid). Allparticipants were informed of the nature and objectivesof this study; however, they were unaware of thelocation of each material. Materials 37% phosphoricacid (Mission Dental, USA), 18% hydrochloric acidprepared in the biochemistry department of theuniversity, and pumice powder (Kramer industries, Inc.,Piscataway Township, NJ, USA) was used formicroabrasion. The baseline percentage of opacities ingroup 1 was 48 and in group 2 was also 48.Preoperative clinical status and patient perception ofenamel opacities was recorded for each patient (Figs. 1& 2).

Clinical Microabrasion Technique

Isolation was performed using rubber dam and marginswere sealed using copal varnish. The eyes of the patientas well as the operator were protected using eyewear.The method of application followed the split-mouthdesign. In both the groups, acid was mixed with pumicepowder in a ratio of 1:1 to make a paste like consistencyin a dappen dish with the help of a wooden spatula.This mix was then applied on teeth as grouped usingstandard silicon polishing cup attached to contra-angledhand piece at a slow speed of approximately 1,000 rpmunder rubber dam.

Group 137% phosphoric acid and pumice paste wasapplied for 10 seconds followed by rinsing with copiouswater for 20 seconds. Total six applications wereperformed in a single visit.

Group 218% HCl and pumice paste was applied for 5seconds followed by rinsing with copious water for 5seconds. Total four applications were performed in asingle visit.

In both the groups, after microabrasion, a paste ofsodium bicarbonate mixed in water was applied toneutralize the eect of acid. This was followed bypolishing with a soex disc at slow speed. At the end ofprocedure, the rubber dam was removed and GC ToothMousse (GC Europe N.V., Leuven, Belgium) wasapplied for 5 minutes. Before discharging the patient,an immediate post-operative photograph was taken(Figures 1 and 2) and esthetic assessment in the patientwas made according to visual analog scale (VAS).8 Thepatient was asked to return for the recall at 1-monthinterval.

At 1-month recall, post-operative clinical assessmentand esthetic assessment was carried out as describedearlier and recorded in patient assessment form. Patientsatisfaction was performed using the VAS8 (1 = no

FIGURE 1. Representative pre- and post-operativephotographs 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 enamelopacities in two acid groups, the preoperative,immediate, post-operative, and after 1-monthfollow up clinical assessment records of 25 subjectswere analyzed by two blinded independent evaluators toassess reduction in opacities in groups 1 and 2. CohensKappa statistics (0.86) showed strong agreementbetween the examiners. Presence or absence of enamelopacities was taken as a unit for analysis. Success oftreatment was identied by the decrease in the numberof enamel opacities. Esthetic improvement wasdetermined by the VAS reading and satisfaction ofthe child.

RESULTS

Immediately after treatment, the opacities reductionwas 82% and 81% in groups 1 and 2 respectively. The1-month reduction was 97% in group 1 and 97% ingroup 2. Results immediately after and 1-monthpost-treatment are shown in Table 1 with no signicantdierence between the groups. Table 2 depicts thecomparison immediately after treatment and after 1month in each group. The results showed that thetreatment outcome was highly signicantly dierent(t value .001**) in both groups. Table 3 represents thechange in VAS immediately and 1 month aftertreatment. This table depicts that on VAS from 1 to 7,the ratings for improvement in appearance signicantlychanged after second clinical appointment. Table 4shows that out of 25 children treated withmicroabrasion, 84% of children were satised with theappearance immediately after treatment and 96% weresatised after 1 month.

DISCUSSION

Esthetics is a subjective perception. The clinicalmanagement of tooth discoloration aims to produce anacceptable cosmetic result as conservatively as possible.Conservative treatment with microabrasion canproduce dramatic improvements in brown and yellowdiscoloration.9 The available literature on it shows thatthis technique should be considered as the rsttreatment option when trying to improve the estheticsof teeth that present intrinsic stains and extrinsicsupercial enamel stains.10

The rst report about hydrochloric acid applicationused to improve esthetics of teeth with uorosiswas given by Dr Kane in 1916.11 Since then,favorable studies veried the eectiveness of themicroabrasion technique using dierentconcentrations of hydrochloric acid (6.618%) andphosphoric acid (3040%) in association withabrasives.12

Microabrasion is indicated for uorosis,post-orthodontic demineralization, localized hypoplasia

FIGURE 2. Representative pre- and post-operativephotographs of group 1 and group 2.



due to infection or trauma, and idiopathic hypoplasiawhere the discoloration is limited to the outer enamellayer.1316 This technique is simple to perform and thedepth of enamel removed in 10 applications is

approximately 100 m (0.1 mm). The clinical resultobtained is directly related to the depth of thestain/defect.10 Among the 25 treated patients in presentstudy, it was observed that baseline opacity area was

TABLE 1. Mean distribution of enamel opacities in group 1 and group 2 immediately and 1 month after treatment

Group 1: 37% phosphoric acid Group 2: 18% hydrochloric acid

Mean N % change Standard deviation Mean N % change Standarddeviation

Baseline opacities 48.13 25 81.7 5.61 47.96 25 81.4 27.69

Opacities immediately after treatment 8.67 2.39 8.70 12.53

Opacities 1 month after treatment 1.43 97.3 .85 1.72 96.7 5.00

TABLE 2. Percentage change in children immediately after microabrasion and 1 month after microabrasion in both the groups

Paired differences tGroup1

tGroup2

dfGroup 1andgroup 2

Sig.(two-tailed)Group1 andgroup2

MeanGroup1

MeanGroup2

StandarddeviationGroup 1

StandarddeviationGroup 2

Standarderrormean

Standarderrormean

95% Confidence intervalof the difference

LowerGroup1

LowerGroup2

UpperGroup1

UpperGroup2

Baselineopacitiesopacitiesimmediatelyaftertreatment

39.46 39.26 27.26 27.68 5.45 5.54 28.21 27.84 50.71 50.68 7.23 7.09 24 .001**

Baselineopacitiesopacitiesafter1 month

46.70 46.24 28.07 27.70 5.61 5.54 35.11

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 Visual scale reading 1 month after treatment

Frequency Percentage(%)

Mean Standarddeviation

Frequency Percentage(%)

Mean Standarddeviation

1 = no improvement 0 0 5.80 .91 0 0 6.24 .72

24 = slight improvement 1 4 0 0

56 = moderate improvement 17 68 15 60

7 = exceptional improvement 7 28 10 40

Total 25 100 25 100



similar in both groups and mean percentage opacityreduction was 82% in group 1 and 81% in group 2immediately after treatment. Brown stains had betterresults than white stains. It was also observed thatpatients with a mild degree of developmental enameldefects showed better results. Same data have also beenreported by Train and colleagues13 and Bezerra andcolleagues.17

The split-mouth clinical study was used in this study toevaluate the ecacy of two microabrasion materials invivo. The baseline percentage of opacities in group 1was 48 and in group 2 was also 48. One-monthreduction in enamel opacity was 97% in group 1 and97% in group 2. The results were statistically signicantin both groups showing a marked reduction in totalarea occupied by opacities. However, there was nostatically signicant dierence between the two groups.The most important aspect of this treatment to thepatient is the advantage that no further treatment isrequired after this minimally invasive technique, as hasbeen observed by Tashima and colleagues10 and Bezerraand colleagues.17

The patient and parents were 84% satised immediatelyafter and 96% after 1 month. The parents generallycomplied with the follow-up visit. The dierencebetween mean percentage reduction of opacities andafter a month in group 1 and group 2 was notstatistically signicant. The appearance of enamelsurfaces had a tendency to improve as time transpired,clinically decreasing the area and size of opacities.These observations were also seen in several studiesdone by Croll.1820 Croll TP performed microabrasiontreatment for hundreds of children and adult patientsfrom 1985 to 1989. Treatment results observed by himsupported the contention that enamel microabrasion

gave permanent color modication of supercialenamel coloration defects because enamelmicroabrasion actually removed discolored enamelrather than altering or masking the tooth stain. Also,microabraded enamel surfaces achieved a brilliant lusteras time passed by. Similar results were also observed inthe present study. He also observed that many intrinsicenamel surface defects were supercial enough to beeliminated without replacing the lost enamel. Slight andmoderate, white and brown uorosis discolorations aregood examples how this type of demineralization whichcan be treated by enamel microabrasion.

Enamel microabrasion corrects surface enamelhypomineralization and discolorations defects byremoving supercial enamel.7 If the discolored defect issupercial and microabrasion exposes underlyingenamel of normal quality, the tooth acquires a glassylustrous quality due to changes in the intrinsicproperties of enamel following simultaneous abrasionand erosion of the surface. This has been described asthe abrosion eect.21

In the proposed technique, we suggest the use ofmicroabrasion to remove the unesthetically desirableenamel defects under rubber dam protection followedby application of uoride solution or caseinphosphopeptide amorphous calcium phosphate pastefor 5 to 15 minutes. This approach is justied for tworeasons: rst, it reduces the risk of post-treatmentsensibility, and second, it protects teeth from possibleexternal demineralization.22

Additionally, it could be said that this technique has apositive psychological eects on patients. The childrenpresenting esthetically compromised anterior teethmight develop a low self-esteem and condence. During

TABLE 4. Esthetic satisfaction in children immediately after enamel microabrasion treatment and 1 month after treatment

Esthetic satisfaction in children immediatelyafter enamel microabrasion treatment

Esthetic satisfaction in children1 month after treatment

Satisfied Unsatisfied Satisfied Long-termsatisfied

Frequency (N = 25) 21 4 24 1

Percent % 84 16 96 4



follow up, most of the parents reported that theirchildren had positive changes in their behavior, aftertreatment by becoming more outgoing and exhibitedunrestricted smiling without fear of showing their teethafter treatment. The same observation was made byPowel, Craig and colleagues.2325

CONCLUSIONS

1 Both microabrasion techniques showedcomparatively high success in treating enamelopacities resulting in both patient and parentssatisfaction.

2 Microabrasion is a simple, safe, atraumatic,conservative, and minimally invasive technique thatremoves the supercial part of enamel and eliminatesdefects such as brown or white opacities.

DISCLOSURE

The authors do not have any nancial interest in any ofthe companies whose products are included in thisarticle.

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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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40_Esthetic Management of Developmental Enamel Opacities

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