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Authors : Dr. Monalisa Das.

Abstract:

Microabrasion is a minimally invasive conservative technique suitable for young children. It enhances dental esthetic by removing superficial stain without major structural loss. This article reports a case with hypomineralized, pigmented newly erupted maxillary permanent central incisors, treated with microabrasion using 37% phosphoric acid and 18% hydrochloric acid and resulted improvement of dental appearance.

Key words: Microabrasion; Minimally invasive technique; Hypomineralization.

Introduction:

Enamel microabrasion is a controlled and conservative removal of superficial microporus zone entrapped with extrinsic stain to improve the appearance of tooth by restoring the superficial smoothness. Kane 1 in 1916 reported the first case of microabrasion using hydrochloric acid and phosphoric acid in a dental fluorosis case. The effectiveness of the microabrasion technique using different concentration of hydrochloric acid and phosphoric acid in association with abrasives are practiced in dentistry. In the modern days, this technique is considered useful in young children and adolescents as an effective, safe, comfortable method for better esthetics.

This article reports a case of hypomineralization with extrinsic stain using microabrasion in the newly erupted permanent maxillary central incisors, to get an esthetic result in a minimally invasive way.

Case report:

A 7 years old girl reported with white enamel demineralization and brownish discoloration of upper front teeth. Her parents were seeking a treatment with minimal tooth structure loss. Parents gave history that the child often avoids smiling for her poor esthetic and complaints them. Clinically it was found that she has enamel demineralization and brownish discoloration in newly erupted maxillary and mandibular incisors (51, 61, 71,72,81,82) along with newly erupted molars with minimal signs of discoloration.

The hypomineralization prominently found with the maxillary incisors for their larger shape and size. There is a midline diastema (probably self correcting), worsening the dental esthetic. [Fig-1] Patient and parent gave no history of systemic illness at early infancy except recent medication containing iron supplements. Parents gave another significant history of migration from Gujrat to West Bengal at 5 years age of the child. Patients past histories and clinical findings were strongly suggestive of enamel hypomineralization due to high concentration fluoride exposure during early years of life. There is no significant importance of recent iron supplements as the teeth are already mineralized (enamel completed 4-5 years of age).
 
[Fig-1: Hypomineralized maxillary central incisors with mild brownish discoloration] [Fig-2: Application of 37% phosphoric acid mixed with pumice slurry]


After evaluating all the clinical data, the treatment was planned to perform microabrasion with 37% phosphoric acid and 18% hydrochloric acid. At the appointed date, the maxillary central incisors are isolated with rubber dam, dental floss was tied around the cervical margin of the teeth to secure the position of the dam along with high suction. First, teeth were air dried and cleaned with 37% phosphoric acid mixed pumice slurry with the help of slow speed bristle brush attached to micromotor hand piece for 1 minute and thoroughly rinsed with water. [Fig-2] In the later step, teeth were air dried again and 18% hydrochloric acid applied over the teeth with cotton applicator for 10 seconds.

After 4 applications in a single session teeth were rinsed with water. [Fig-3] The teeth were polished with fluoride containing prophylactic paste (Propol-DPI) with bristle brush attached in slow speed contra angle hand piece. The incisors were visualized in a wet condition revealing a better esthetic and accepted by both patient and parents.[Fig-4] Six months follow up showed no significant evidence of further staining or discoloration.[Fig-4]
 
[Fig-3: Application of 18% hydrochloric acid] [Fig-4: Esthetic enhancement after microabrasion technique]
 
[Fig-5: Six months follow up]


Discussion:

Welbrury and Shaw (1990) mentioned the esthetic problems as the possible causes of psychological disorder. 2 Though the esthetic consideration is more important to teenagers but with the changing civilization, it’s a big problem to school going children too. Now a days, children and parents are becoming more and more conscious about the dental esthetic and it is truly evident in this case.

There are several etiologies of external stain of teeth and these are quite common findings in regular day to day practice. Discoloration of teeth is the most common reason why patients seek treatment of fluorosed teeth. The discoloration may be due to white opacity resulting from enamel hypomineralization. 3 When a child ingests excessive amounts of fluoride during the years of amelogenesis, superficial layers of enamel can acquire brown or white chromatic alterations.4 Tetracycline dentin staining or injuries are considered acquired intrinsic staining that may be related to the stages of pre or post eruption 5 The characteristic black staining of teeth in people using iron supplements and iron foundry workers is well documented.6 In this case, patient gave the history of iron supplementation which is quite insignificant with the white–brownish discoloration of the central incisors. The possible cause may be the high fluoride level in water during the early stage of life.

In the reported case, 37% phosphoric acid mixed with pumice slurry was effective as mild abrasive to remove superficial layer. 18% hydrochloric acid cause mild erosion and further removal of stains. Here, the polishing with zirconium paste done to improve the smoothness of incisors. This technique removes the need of composite restoration in mild to moderate dental stain and also incipient caries cases. Application of fluoride after the treatment may improve the strength of the teeth by the process of remineralization.

Conclusion:

The combination of 37% phosphoric acid and 18% hydrochloric acid found comfortable, safe, cost effective, non invasive technique to improve the esthetic of the non carious hypomineralized newly erupted teeth. However, further evaluation with advanced techniques will be promising.

References:
  1. McClosky RJ. A technique for removal of fluorosis stains. J Am Dent Assoc.1984;109:63-4.
  2. Welbrury RR. Shaw L. A simple technique for removal of mottling, opacities and pigmentation from dental enamel. Dent Update. 1990;17:161-3
  3. Enosakhare. Therapeutic management of dental fluorosis: A critical review of literature.2014;1:3-13
  4. Kendell RL. Hydrochloric acid removal of brown fluorosis stains: clinical and scanning electron micrographic observations. Quintessence Int. 1989;20:837–839. [PubMed]
  5. Sundfeld RH, Croll TP, Briso AL, Alexandre RS, Sundfeld D., Neto Considerations about enamel microabrasion after 18 years. Am J Dent. 2007;20:67–72. [PubMed]
  6. Nordbo H, Eriksen H M, Rolla G, Attramadal A, Solheim H. Iron staining of the acquired enamel pellicle after exposure to tannic acid or chlorhexidine. Scand J Dent Res 1982; 90: 117–123.


References are available on request

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