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ABSTRACT: Purpose: To review of the current status of enamel microabrasion method and its results 18 years after the
development and application of this method. Methods: A technique performing enamel microabrasion with
hydrochloric acid mixed with pumice and other techniques employing a commercially available compound of
hydrochloric acid and fine-grit silicon carbide particles in a water-soluble paste have been described. Much has been
learned about the application of this esthetic technique, long-term treatment results and microscopic changes to the
enamel surface that has significant clinical implications. The latest treatment protocol is presented and photographic
case histories document the treatment results. Clinical observations made over 18 years are discussed. Results:
According to our findings, the dental enamel microabrasion technique is a highly satisfactory, safe and effective
procedure. (Am J Dent 2007;20:67-72).
CLINICAL SIGNIFICANCE: The enamel microabrasion technique was developed as an method of eliminating enamel
texture irregularities and discoloration defects and improving the appearance of teeth. It is a conservative procedure that
has proven to be safe and clinically effective.
: Dr. Renato Herman Sundfeld, Department of Restorative Dentistry, Araatuba Dental SchoolUNESP, Rua Jos
Bonifcio 1193, So Paulo, CEP16015-050, Brazil. E-
: sundfeld@foa.unesp.br
Fig. 1. A. Post-orthodontic white enamel stain of hard texture seen in a young patient (Sundfeld et al7). B. Application
of 18% hydrochloric acid/pumice mixture onto tooth enamel with wooden stick. C. Three-year postoperative view. D.
After removal of stains using 18% hydrochloric acid/pumice and dental bleaching with 15% carbamide peroxide
Opalescenceb 18 years later. (Photos reprinted with permission, Revista Brasileira de Odontologia.)
Fig. 3. A. 12-year-old girl with white enamel stain of hard texture and some erosion areas, located only
on dental enamel in maxillary and mandibular teeth (Sundfeld et al9). B. Application of fine-tapered bur
3195 FF on the buccal surfaces of the maxillary and mandibular incisors and premolars. C. Application
of the Opalustre microabrasive product, for 1 minute, in each application of compound. D. After enamel
microabrasion and reconstruction of the maxillary central incisor with resin composite (TPHd), shades
A1 and A2. E. Six years after enamel microabrasion on the left maxillary and mandibular teeth. F. Six
years after enamel microabrasion on the right maxillary and mandibular teeth. (Photos reprinted with
permission, Jornal Brasileiro de Dentistica e Esttica.)
microabrasive compound should be firmly applied on the area to 200 m (Fig. 2B), corresponding to 1 and 10 applications of
corresponding to the stain or to the surface irregularities, with aid the product for 1 minute on each tooth, respectively. Alves et
of a rotary mandrel and synthetic rubber tips and 10:1 gear reduc- al12 analyzed the wear produced on dental enamel by Prema
tion angle for the product Prema Compound at 30-second inter- Compound noticing a loss of 22 m after 12 applications of the
vals; or with a rubber cup especially developed for that purpose, microabrasive product (Fig. 2C) for 30 seconds on each tooth.
mounted on to 10:1 gear reduction angle, for the product Thus, the amount of enamel removed by microabrasion can be
Opalustre, to intervals of 1 minute, and with periodic washes considered irrelevant.
with a water spray between each application of the compound. Appearance and use of enamel macroabrasion associated
After the last application, the tooth should be totally washed with enamel microabrasion
and dried, and then polished with fluoride paste, washed and The use of Prema Compound and Opalustre on intrinsic
dried. Then, a 2% neutral sodium fluoride gel should be applied stains or on accentuated surface irregularities that reach an
on the enamel for 4 minutes. After this, the rubber dam is re- extensive area of the enamel surface may require a longer
moved and the patient is asked not to ingest solids for 30 minutes. application time for their total removal. Thus, based on our
Enamel microreduction: how much enamel is removed? findings and those of others,9,13,14,21-23 we also suggest
In order to verify the amount of enamel removed according beginning the procedure by macroreduction of the affected
to the number of applications of the concentrated hydrochloric enamel using a fine-tapered diamond bur 3195 FFc to lightly
acid/pumice, Kendell19 observed under scanning electron abrade the spotted area. This procedure reduces the time needed
microscopy some enamel loss, which varied from 12 to 46 m, for microabrasion for the removal of stain as well as the amount
for 1 and 10 applications of the mixture for 5 seconds each, of microabrasive material to be used. After the desired color is
respectively. Sundfeld et al7 verified, for the same mixture but obtained, smoothing of the enamel surface is performed using
using polarized light microscopy, an enamel loss varying from the microabrasive product. With the previous application of the
25 and 140 m, for 3 and 15 applications, respectively (Fig. fine-tapered diamond bur, 2 or 3 applications of microabrasive
2A). Sundfeld et al20 showed that in extracted teeth micro- products are required for achievement of the desired esthetic
abrasion with Opalustre produced enamel loss ranging from 25 effect (Fig. 3 A-F).
American Journal of Dentistry, Vol. 20, No. 2, April, 2007
70 Sundfeld et al
Fig. 4. A. A 9-year-old boy with white enamel stain of hard texture and with some erosion areas, located only
on dental enamel in the maxillary and mandibular teeth (Sundfeld et al7). B. Three and a half years after removal
of white stains on the maxillary teeth, by application of 18% hydrochloric acid and pumice on the maxillary
central incisor; and after removal of white stains on the mandibular teeth, by application of the Prema
Compound microabrasive product. However, as the right mandibular lateral incisor presented deep white stain,
it was restored with composite resin (Prisma Fild). C. Six and a half years after removal of white stains on the
maxillary central incisors by application of 18% hydrochloric acid and pumice; and after removal of white stains
located on the other maxillary and mandibular teeth by application of the Prema Compound microabrasive
product. D. 15 years after removal of white stains on the maxillary and mandibular teeth. (Photos reprinted with
permission, Revista Brasileira de Odontologia.)
Fig. 6. A. Brown and white enamel stains of hard texture and unknown etiology (Sundfeld et al9). B. Five years after
macroabrasion with application of fine tapered diamond bur (3195 FF KG) on the buccal surface, microabrasion with
the Opalustre microabrasive product and dental bleaching with 15% Opalescence (Sundfeld et al9). (Photos reprinted
with permission, Jornal Brasileiro de Dentistica e Esttica.)
ed that this highly mineralized zone was evident. Due to this Also, the abrosion effect results in a smooth, prism-free
layer, for deeper stains that may not be removed by the layer of enamel and lustrous surface that increases over time,
microabrasion technique, the tooth to be restored should receive and is apparently not influenced by bleaching. The enamel
37% phosphoric acid etching prior to the application of the resin surface acquires a glass-like "enamel glaze" months after
adhesive materials in the same session. However, as mentioned treatment, just like the teeth of patients who were treated by
by Croll,4 before treatment, patients and/or their parents should enamel microabrasion (Fig. 6A-B).1,4,26 In the same way, no
be informed that the depth of enamel discoloration is uncertain alterations have been clinically observed in the hard and soft
and a bonded composite restoration might be required. We be- tissues of the oral cavity, as well as the sensitivity of bleached
lieve that when a slightly pessimistic prognosis is expected, teeth during and after application of the bleaching product. This
patients are much less disappointed if treatment is unsuccessful, fact confirms our clinical findings that the use of patient-
and they are exceptionally pleased if enamel microabrasion administered dental bleaching with a carbamide peroxide gel
does sufficiently improve tooth coloration. solution administered within custom-formed, soft vinyl mouth
trays can be indicated without concerns, if applied on teeth
Limitations of the enamel microabrasion technique
without carious lesion with well-adapted restorations and
Throughout the evaluation years, the obtained results are
without exposed dentin tissue at the cervical area, and, mainly
long-lasting, since the dental enamel stain was removed and did
when well supervised by the professional.15,17,29
not relapse on patients with adequate lip sealing, a clinical
According to these laboratory and clinical findings, the ena-
condition that excessively hinders the formation of a moisturi-
zing pellicle on enamel, when unprotected by the upper and mel microabrasion technique, associated or not with dental
bleaching with carbamide peroxide, is a highly satisfactory,
lower lips.9 These patients should be referred to the orthodontist
or speech therapist for achievement of correct lip positioning safe and effective procedure, which is an integral part of
before the enamel microabrasion technique is initiated. Our esthetic dentistry.
clinical experience with several patients over many years The clinical success obtained with this technique is the
confirms this fact (Fig. 5). result of a careful clinical approach that has proven its safe
clinical effectiveness throughout the years.
Combination of this treatment with patient-administered
a. Premier Dental Products Co, Norristown, PA, USA.
dental bleaching with a carbamide peroxide gel solution b. Ultradent Products Inc, South Jordan, UT, USA.
Enamel microabrasion promotes microreduction of the c. KG Sorensen, Barueri, SP, Brazil.
enamel surface4,7,9,12,23,29 and teeth submitted to microabrasion d. Dentsply/Caulk, Milford, DE, USA.
can acquire a darker or yellowish coloration after treatment.
Disclosure: Dr. Croll has financial interest in Prema Compound and Opalustre
This may be because the surface of the remaining enamel by virtue of patent licensing agreements with Premier Dental Products
becomes thinner, revealing the dentin. In those clinical Company and Ultradent Products, Inc.
conditions, color correction can be obtained with the use of a Dr. Sundfeld is Associate Professor, Dr. Briso is Assistant Professor, Department
hydrogen peroxide gel delivered on a polyethylene strip of Restorative Dentistry, Araatuba Dental School UNESP, Brazil. Dr. Croll is
system18 or, as recommended by Haywood & Heymann,30 by in private practice, Pediatric Dentistry, Doylestown, Pennsylvania, USA, and is
topical application of dental bleaching with carbamide peroxide Adjunct Clinical Professor, Department of Pediatric Dentistry, University of Texas
Health Science Center at San Antonio (Dental School) and Affiliate Professor,
gel administered within custom-formed, soft vinyl mouth trays. Department of Pediatric Dentistry, University of Washington School of Dentistry,
For those clinical conditions, a patient-administered dental Seattle, WA, USA. Dr. de Alexandre is a graduate student, and Mr. Neto is an
bleaching system with 10%, 15% or 16% carbamide peroxide undergraduate student, Department of Restorative Dentistry, Piracicaba School of
gel solution can be used. After the desired coloration is Dentistry, Unicamp, Piracicaba, Brazil.
obtained, topical applications of 2% neutral sodium fluoride gel
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