Clinical Management and Evaluation of White Spot Lesions: A Report of 11 Cases

Introduction: Today’s society is always more interested to the concept of aesthetics. The patients frequently ask to dentist to resolve unaesthetic problems of teeth, in particular that of the upper frontal group. The WSLs are enamel white alterations due to alteration during the demineralization and remineralization of enamel. This effect is caused by alteration of the pH in the oral cavity and buffer action of saliva. An alteration of this relationship leads to a progressive demineralization of enamel until the formation of a dental cavitation. Materials and Methods: For this study are selected 11 patients, of which 3 men and 8 women, with total of 17 WSLs. The inclusion criteria included WLSs with ICDAS = 2 and WLSs caused by hypomineralization of traumatic origin. These patients were subjected to treatment with infiltrating resin according to operative procedure. Discussion: The therapy with infiltrating resin gave great results in 12 lesions out of 17. In the lesions where there weren’t a complete remission we obtained a great aesthetic improvement and a good reduction of lesions. The follow up could improve the result after a better rehydration of hard tissue. Conclusions: With a correct selection of cases and good operative procedure, the use of the micro-infiltrative technique by low viscosity resin is a good procedure to resolve WSLs problems of non-orthodontic origins. Other studies with a larger sample are required to validate this clinical approach.

bated the concept of aesthetics [1] and more and more patients go to the dentist in order to resolve the imperfections of the dental structure, especially in the area of the teeth of the upper frontal group [2]. At the dental enamel level we can divide the dyschromias into: extrinsic problems [3], due to pigmentations on the outermost layer of the enamel by chromogenic agents caused by smoking or contained in foods such as coffee, soya, etc. Instead intrinsic problems involve multiple layers or less internal layers of the enamel and they are divided in pre-eruptive and post-eruptive alterations [4] [5]. The pre-eruptive problems are alterations that occur on the enamel during its formation and can be divided into: -Fluorosis lesions: they are caused by an excessive absorption of fluoride, this alteration normally involves a group of teeth rather than individual elements.
According to the US National Institute of Dental Research, the prevalence of this alteration represents 9% of cases of fluorosis in the 15-year-olds from 1986 to 2002 [6].
-Traumatic hypomineralization lesions: they are lesions caused by trauma on milk teeth, often unrecognized as they normally occurred in the first years of life. Its prevalence is estimated at around 5.2% of the population [7]. These lesions are normally on individual dental elements and occur asymmetrically compared to the contralateral ones. At a clinical level, they can present with more or less defined and circumscribed whitish spots. Histologically these are also presented as hypomineralization zone of the superficial third of the enamel coated with a layer of well mineralized enamel which is formed after the tooth eruption due to a remineralization process by saliva. The lesion can present itself with an irregular pattern forming acute angles with the rest of the healthy enamel or with a convergent trend with respect to the healthy enamel forming obtuse angles.
-MIH lesions (molar-incisor hypomineralization): they are lesions that purely affect the first definitive molars (FPM) and they can be associated with lesions on the permanent incisors (PI).This lesion can occur with various forms of severity (Chawla severity index) [8], the prevalence of MIH stands around 14.2% [9].
The post-eruptive problems, on the other hand, are mainly given by carious problems and are generally defined as white spots lesions (WSLs) [10] [11] [12] [13]. WSLs are white alterations of the enamel due to an alteration in the demineralization-remineralization mechanism of the enamel. The alteration of this relationship leads to a progressive demineralization of the enamel until complete dental cavitation. The prevalence of these alterations is estimated around 24% of the population [14] but this percentage rises significantly in patients with braces, with variable percentage reaching 97% [15], on average at least 46% of patients develop at least 1 wsl at 12 months [16]. These lesions can be classified according to the ICDAS II scale in grades 1 and 2 [17] [18]. All the lesions listed above with a white appearance are due to an optical effect of light refraction in the enamel, a healthy enamel has a refractive index of light equal to that of hydroxyapatite (RI

Operating Procedure Application of Icon Infiltring Resin
The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Catanzaro.
The sample comprised patients selected from Magna Graecia University's dental clinic and orthodontic private practice. Patients were treated according to the following protocol.
Phase one: The dental surfaces were cleaned with a specific paste without fluorine (Clean-Polish Kerr), positioning the dam to isolate the operating field. In two patients it was necessary to perform a micro abrasion of the enamel with a 3M disc, patients are indicated in Table 1.
Phase two: The ICON Etch product (15% HCl) was applied for two minutes on the surfaces concerned, adapted to them by means of a special syringe with the final brush part to better homogenize the product ( Figure 1).  After applying ICON Etch, it was removed by aspirating it from the surfaces then rinsed with water for 30 seconds ( Figure 2) and then dried.

D. Aiello et al. Open Journal of Stomatology
Phase three: After being carefully dried, ICON Dry was applied on the surfaces (ethanol) ( Figure 3) to obtain complete dehydration, and therefore favor the infiltration of the resin, and to have a preview of the treatment. This ethanol application evaporates quickly, leaving the teeth with a chalky appearance ( Figure 4).
We repeated this procedure three times on each patient involved.
Phase four: After making the evaluation of the WSL we used ICON Infriltrant to carry out the resin infiltration with a special tip with a brush for 3 minutes ( Figure 5) and removing excess with a cotton roller.
Then we light-cured for 40 seconds ( Figure 6). Open Journal of Stomatology     Of the selected cases, two were subjected to micro abrasion using a fine grain 3M disc (Soflex Pop On 2382SF) at a speed of 20,000 rpm.
The evaluation photographs were taken pre and immediately after the operation, using the Reflex digital camera (Canon 800 d).
All patients were treated according to the protocol previously described with three applications as it can be seen from the table.      University in Catanzaro. In the anamnesis there were not previous orthodontic therapies. The patient had a lesion extended over the entire middle and distal incisal portion of the 11 with irregular margins and a smaller and more limited WSL in the area of the incisal and distal third of 21. The 21 also had a discolouration of traumatic origin but the patient didn't want to perform internal bleaching procedures. At the end of the treatment it can be seen a good resizing of the lesions mostly on 21 but this can be due to dehydration (pre-treatment Figure 12, post-treatment Figure 13).

Case Series
• Patient 3: woman, 22 years old, presented at our dental clinic of "Magna Graecia" University in Catanzaro. In the anamnesis there were not previous orthodontic therapies. The patient had a very extensive WSL in the middle and incisal area up to the interdental contact point, the margins of the lesion were well defined. Before the infiltration, the patient was subjected to a microabrasion for about 30 seconds, because of the doubtful nature of the lesion, probably of traumatic origin.
In the immediate post-treatment, a complete disappearance of the lesion can be seen (pre-treatment Figure 14, post-treatment Figure 15).
• Patient 4: woman, 11 years old, comes to our attention at the dental clinic of "Magna Graecia" university in Catanzaro for orthodontic examination. The patient presented two WSLs extended on elements 11 and 21 in the incisal area from the distal area to the mesial area without interruption, the lesions had undefined margins. After infiltrative therapy, complete resolution of the lesions was achieved (pre-treatment Figure 16, post-treatment Figure 17).       Figure 19).
• Patient 6: woman, 40 years old, no previous orthodontic therapy. The patient came to our attention in a private practice due to a double WSL on element 11; it was very marked by an irregular appearance and defined margins. Because of the probable traumatic origin of the lesion, the dental element was subjected to a micro abrasion before infiltration. After the treatment, the double WSL was not resolved definitively but certainly an important aesthetic improvement was achieved (pre-treatment Figure 20, post-treatment Figure 21).
• Patient 7: man, 18 years old, no previous orthodontic therapy. He comes to our dental clinic in Catanzaro University of "Magna Graecia" for unattractive WSL in the central and incisal area of element 21, the lesion had fairly well defined margins for this reason we treated it as a traumatic lesion, the patient was subjected to a microabrasion procedure before infiltration. The therapy allowed to fully resolve the lesion with a high aesthetic improvement (pre-treatment

Maintaining the Integrity of the Specifications
The template is used to format your paper and style the text. All margins, column widths, line spaces, and text fonts are prescribed; please do not alter them. You may note peculiarities. For example, the head margin in this template measures proportionately more than is customary. This measurement and others are deliberate, using specifications that anticipate your paper as one part of the entire journals, and not as an independent document. Please do not revise any of the current designations.

Discussion
Nowadays, more and more patients turn to professionals of the dental sector for aesthetic, for this reason, even small imperfections such as WSL can be perceived by the patient as a highly invalidating problem in the field of smile aesthetics. Low viscosity resin infiltration therapy is now widely used and studied in daily dental practice, the removal of the surface enamel is carried out by means of an acid, the 15% hydrochloric acid. It allows an adequate removal of the pseudoimpact layer favoring the deep penetration of the resin. The infiltrating resin based on TEDMA, being not very viscous manages to penetrate deeply inside the porosity of the lesion, improving the aesthetic impact and the index of light refraction. Moreover it increases the dental hardness compared to the injured tooth and promotes a long-term reduction of surface roughness (Yazkan, 2018). Using the right protocol and adequate preventive measures, this type of therapy allows an excellent aesthetic result, even in the long-term. This therapy is simpler and more practical than the conventional therapies used today (Senestraro, 2013). The particularly favorable aspect is given by the fact that this type of therapy seems to give extraordinary results as regards the prevention of carious pathology even after many years from the application (Yoo et al., 2018). In our work, the low viscosity resin infiltration therapy gave excellent aesthetic results in 12 out of 17 lesions, in the lesions where there weren't complete remission, an excellent aesthetic improvement and a good reduction of the lesion visibility has been obtained. Long-term control could improve the aesthetic result following a better rehydration of hard tissues.
All patients were satisfied with the outcome of the treatment. In cases of incomplete resolution, the association with microabrasion could probably improved the final aesthetic result by favoring a better penetration of the infiltration resin and returning a further better aesthetic appearance.
A better evaluation method of the lesions could certainly improve the therapeutic appropriateness and better select the cases in order to obtain a complete success of each type of lesion.

Conclusion
According to the bibliography, the cases treated in this article through the use of low density micro-infiltrative resin gave excellent results in a high percentage of WSL, 12 out of 17 treated [28]. While in those not completely resolved it allowed