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Considerations about enamel microabrasion


after 18 years
Article in American journal of dentistry May 2007
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Rodrigo Sversut de Alexandre

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Araauba Dental School

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Original Article
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Considerations about enamel microabrasion after 18 years


RENATO HERMAN SUNDFELD, DDS, MS, PHD, THEODORE P. CROLL, DDS, ANDR LUIZ FRAGA BRISO, DDS, MS, PHD,
RODRIGO SVERSUT DE ALEXANDRE, DDS, MS, PHD & DANIEL SUNDFELD NETO, DDS
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

Introduction
In the past, teeth presenting color anomalies were restored
with direct or indirect restorative materials.1 Even though
satisfactory esthetics were obtained with those procedures,
replacement of restorative materials was frequent, since a
material with identical properties and characteristics to the
dental structure was not available in the dental market.
The literature shows that some, such as Kane, in 1916
(cited by McCloskey in 19842), Bailey & Christen5 in 1970,
Croll & Cavanaugh3 in 1986, and Croll4 in 1991, suggested
removing spotted dental enamel with acids.
Croll & Cavanaugh,3 in 1986, proposed the application of
a mixture of 18% hydrochloric acid combined with laboratory
pumice in order to solve the esthetic alterations present on the
enamel surface, as well as to obtain permanent results and
insignificant loss of enamel. The treatment would be
performed with a rubber dam in place, and the patient would
wear protective glasses. The mixture was applied with the aid
of a wooden stick and firm finger pressure for 5 seconds, not
surpassing a total of 15 applications. Between each
application, the enamel submitted to this technique should be
washed and dried (Fig. 1A-D). This technique, called enamel
microabrasion, allowed for a more conservative treatment,
and has been commonly indicated for the removal of intrinsic
enamel stains of any etiology and coloration, as well as for
correction of surface irregularities on the dental enamel3,6-12
caused either by imperfect enamel formation or acquired after
the removal of orthodontic appliances.7,13,14 Croll & Bullock,13
in 1994, reported that despite the best efforts of orthodontists
and their referring dentists to educate patients in proper oral
hygiene, some patients still developed dental caries or white
spot decalcification of the enamel adjacent to bands or
brackets. Such lesions can also occur in patients with poor
oral hygiene who are not in active orthodontic treatment.
Those alterations, however, should present hard texture and
be located in the superficial layers of the dental enamel.

However, it is sometimes difficult to know the real depth


of the intrinsic staining or of the present surface irregularity;
this was a good indication for the enamel microabrasion
technique as the first treatment option in cases with intrinsic
stains, regardless of their etiology, dimensions, and depths.
It is difficult to accomplish the precise diagnosis of
enamel stains, such as those of dental fluorosis, because the
excess systemic fluoride during the years of enamel formation
is not the only possible cause of discoloration of the most
superficial layers of dental enamel.15 Chromatic alterations of
brown or white coloration are frequently observed even when
the patient does not report excessive contact with fluoride
during the phase of enamel maturation.
Croll, in 1990,16 19913 and Killian, in 199317 used the
terms "enamel dysmineralization" and "fluorosis-type stains",
respectively, to describe the chromatic alterations present on
the surface of the dental enamel, resulting from some
disturbance in the mineralization process.
Based on the excellent esthetic results obtained in 18 years
of application of the microabrasion technique, it can be
reaffirmed that the etiology of intrinsic stains of enamel is not
a really decisive factor for the adoption or not of the enamel
microabrasion technique, but rather its texture, that is, a stain
of hard texture and of any color which affects the esthetics.
The patients age is irrelevant when adopting this esthetic
technique; however, its use can be limited by the difficulty of
using the rubber dam when teeth are not totally erupted, when
patients present deficient lip sealing,9 and when dental stains
are located within the dentin tissue.4,9
Development of the acid/abrasive products
and clinical technique
The caustic effect of 18% hydrochloric acid was a
concern4,7 as the toxicity of the chemical product used
demanded constant attention of the operator and assistant
during application. Thus, in order to obtain an ideal
acid/abrasive product that presented higher safety for the oral

American Journal of Dentistry, Vol. 20, No. 2, April, 2007

68 Sundfeld et al

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.)

tissues and easier application on the enamel surface, Croll4


evaluated several acids at different concentrations with many
types of abrasives in varying grits. The acids evaluated included
citric acid, hydrochloric acid, nitric acid and phosphoric acid
and the abrasive particles tested were dental laboratory pumice,
synthetic diamond dust, aluminum oxides and silicon carbide.
Since then, a number of formulas for enamel microabrasion
compounds were developed that proved to be successful in
removing superficial enamel discoloration.
Highly safe and efficient microabrasive products have been
marketed, such as Prema Compounda and Opalustre,b which
contain a mild concentration of hydrochloric acid (10% and 6%
respectively) for safe application in the mouth, and a fine-grit
silicon carbide abrasive in a water-soluble gel for easy remo-val
when combined with a low concentration acid. Such formulations offer a good margin of safety during application for both
operator and patient, among other advantages.3 Besides these
factors, the microabrasive systems use gear reduction rotary
handpieces for precise application of the compound onto the
tooth surface, which eliminates splattering of the compound
and makes the procedure safer, easier, and quicker.
These microabrasive products should be applied on the
spotted enamel or enamel with surface irregularities, following
the manufacturers instructions, i.e. with a rubber dam, followed by application of a layer of solid petroleum jelly9 or
copal vanish4,8 to the margins of the rubber dam/enamel, in
order to prevent contact of the product with the gingival tissue.
Application of sodium bicarbonate at the rubber dam margin or
free gingival margin has also been recommended to neutralize
the acid compound.3,7,18 It is interesting to point out the need to
protect the patients, assistants, and professionals eyes during
the entire operative procedure.
With the microabrasion technique, a small amount of the

Fig 2. Ground tooth section after enamel microabrasion. The yellowish


sections are enamel, and the deeper, darker regions are dentin. The
depressions in the enamel convexity of each specimen represent the area
where microabrasion was performed. Analyzed by polarized light
microscope. E: enamel; D: dentin; M: wear. A. Ground tooth section after
enamel microabrasion, which was submitted to 15 applications of mixture of
18% hydrochloric acid/pumice. Enamel loss of 140 m, x32 (Sundfeld et al7).
B. Ground tooth section after enamel microabrasion, which was submitted to
10 applications of Opalustre. Enamel loss of 200 m, x25 (Sundfeld et al9).
(Photos reprinted with permission, Revista Brasileira de Odontologia; Jornal
Brasileiro de Dentistica e Esttica.)

American Journal of Dentistry, Vol. 20, No. 2, April, 2007

Enamel microabrasion 69

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


corresponding to the stain or to the surface irregularities, with aid
of a rotary mandrel and synthetic rubber tips and 10:1 gear reduction angle for the product Prema Compound at 30-second intervals; or with a rubber cup especially developed for that purpose,
mounted on to 10:1 gear reduction angle, for the product
Opalustre, to intervals of 1 minute, and with periodic washes
with a water spray between each application of the compound.
After the last application, the tooth should be totally washed
and dried, and then polished with fluoride paste, washed and
dried. Then, a 2% neutral sodium fluoride gel should be applied
on the enamel for 4 minutes. After this, the rubber dam is removed and the patient is asked not to ingest solids for 30 minutes.
Enamel microreduction: how much enamel is removed?
In order to verify the amount of enamel removed according
to the number of applications of the concentrated hydrochloric
acid/pumice, Kendell19 observed under scanning electron
microscopy some enamel loss, which varied from 12 to 46 m,
for 1 and 10 applications of the mixture for 5 seconds each,
respectively. Sundfeld et al7 verified, for the same mixture but
using polarized light microscopy, an enamel loss varying from
25 and 140 m, for 3 and 15 applications, respectively (Fig.
2A). Sundfeld et al20 showed that in extracted teeth microabrasion with Opalustre produced enamel loss ranging from 25

to 200 m (Fig. 2B), corresponding to 1 and 10 applications of


the product for 1 minute on each tooth, respectively. Alves et
al12 analyzed the wear produced on dental enamel by Prema
Compound noticing a loss of 22 m after 12 applications of the
microabrasive product (Fig. 2C) for 30 seconds on each tooth.
Thus, the amount of enamel removed by microabrasion can be
considered irrelevant.
Appearance and use of enamel macroabrasion associated
with enamel microabrasion
The use of Prema Compound and Opalustre on intrinsic
stains or on accentuated surface irregularities that reach an
extensive area of the enamel surface may require a longer
application time for their total removal. Thus, based on our
findings and those of others,9,13,14,21-23 we also suggest
beginning the procedure by macroreduction of the affected
enamel using a fine-tapered diamond bur 3195 FFc to lightly
abrade the spotted area. This procedure reduces the time needed
for microabrasion for the removal of stain as well as the amount
of microabrasive material to be used. After the desired color is
obtained, smoothing of the enamel surface is performed using
the microabrasive product. With the previous application of the
fine-tapered diamond bur, 2 or 3 applications of microabrasive
products are required for achievement of the desired esthetic
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.)

This technique can be readily carried out at the dental


office,4,9,24 since the treatment has a "nondestructive" nature,
patient satisfaction is considerably high, and recurrence of
staining or loss of vitality of treated teeth has not been verified
or reported. During all these years working with this technique,
we have not observed any postoperative sensitivity. However, it
is possible that postoperative sensitivity may occur if too much
enamel is removed.4 It should also be highlighted that if enough
enamel is removed to allow thermal sensitivity, the stain
involved must be too deep for enamel microabrasion correction
alone, and a bonded restoration is indicated.
"Abrosion" effect
We have noticed clinically that teeth submitted to microabrasion present a considerably regular, smooth and lustrous
enamel surface that increases over time (Fig. 4 A-D). Olin et
al25 highlighted that this technique is believed to modify the
optical properties of enamel. Donly et al26 coined the term
"abrosion" for this phenomenon. Abrasion of enamel prism
combined with acid erosion results in the development of a
densely compacted prism-free layer on the enamel surface,
which is capable of reflecting and refracting the light in a differ-

Fig. 5. Patient presenting deficient lip sealing.

ent way than untreated enamel and is believed to camouflage


the underlying stain. This may be due to the compaction and
deposition of calcium and phosphate breakdown products that
result from the simultaneous erosive and abrasive action of the
microabrasion compound.4,26 In vitro polarized microscopic
studies have shown that the lustrous enamel glaze surface is
resistant to demineralization and colonization by Streptococcus
mutans.27
Similarly, Leite et al28 observed the effect of Prema
Compound on enamel by polarized light microscopy and report-

American Journal of Dentistry, Vol. 20, No. 2, April, 2007

Enamel microabrasion 71

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


layer, for deeper stains that may not be removed by the
microabrasion technique, the tooth to be restored should receive
37% phosphoric acid etching prior to the application of the resin
adhesive materials in the same session. However, as mentioned
by Croll,4 before treatment, patients and/or their parents should
be informed that the depth of enamel discoloration is uncertain
and a bonded composite restoration might be required. We believe that when a slightly pessimistic prognosis is expected,
patients are much less disappointed if treatment is unsuccessful,
and they are exceptionally pleased if enamel microabrasion
does sufficiently improve tooth coloration.
Limitations of the enamel microabrasion technique
Throughout the evaluation years, the obtained results are
long-lasting, since the dental enamel stain was removed and did
not relapse on patients with adequate lip sealing, a clinical
condition that excessively hinders the formation of a moisturizing pellicle on enamel, when unprotected by the upper and
lower lips.9 These patients should be referred to the orthodontist
or speech therapist for achievement of correct lip positioning
before the enamel microabrasion technique is initiated. Our
clinical experience with several patients over many years
confirms this fact (Fig. 5).
Combination of this treatment with patient-administered
dental bleaching with a carbamide peroxide gel solution
Enamel microabrasion promotes microreduction of the
enamel surface4,7,9,12,23,29 and teeth submitted to microabrasion
can acquire a darker or yellowish coloration after treatment.
This may be because the surface of the remaining enamel
becomes thinner, revealing the dentin. In those clinical
conditions, color correction can be obtained with the use of a
hydrogen peroxide gel delivered on a polyethylene strip
system18 or, as recommended by Haywood & Heymann,30 by
topical application of dental bleaching with carbamide peroxide
gel administered within custom-formed, soft vinyl mouth trays.
For those clinical conditions, a patient-administered dental
bleaching system with 10%, 15% or 16% carbamide peroxide
gel solution can be used. After the desired coloration is
obtained, topical applications of 2% neutral sodium fluoride gel
should be applied for 4 minutes daily9,14,20,23,30 for 1 week after
treatment. We prefer to wait several weeks after completion of
microabrasion, before bleaching commences, with the idea that
such delay will provide ample time for complete enamel
surface remineralization.

Also, the abrosion effect results in a smooth, prism-free


layer of enamel and lustrous surface that increases over time,
and is apparently not influenced by bleaching. The enamel
surface acquires a glass-like "enamel glaze" months after
treatment, just like the teeth of patients who were treated by
enamel microabrasion (Fig. 6A-B).1,4,26 In the same way, no
alterations have been clinically observed in the hard and soft
tissues of the oral cavity, as well as the sensitivity of bleached
teeth during and after application of the bleaching product. This
fact confirms our clinical findings that the use of patientadministered dental bleaching with a carbamide peroxide gel
solution administered within custom-formed, soft vinyl mouth
trays can be indicated without concerns, if applied on teeth
without carious lesion with well-adapted restorations and
without exposed dentin tissue at the cervical area, and, mainly
when well supervised by the professional.15,17,29
According to these laboratory and clinical findings, the enamel microabrasion technique, associated or not with dental
bleaching with carbamide peroxide, is a highly satisfactory,
safe and effective procedure, which is an integral part of
esthetic dentistry.
The clinical success obtained with this technique is the
result of a careful clinical approach that has proven its safe
clinical effectiveness throughout the years.
a.
b.
c.
d.

Premier Dental Products Co, Norristown, PA, USA.


Ultradent Products Inc, South Jordan, UT, USA.
KG Sorensen, Barueri, SP, Brazil.
Dentsply/Caulk, Milford, DE, USA.

Disclosure: Dr. Croll has financial interest in Prema Compound and Opalustre
by virtue of patent licensing agreements with Premier Dental Products
Company and Ultradent Products, Inc.
Dr. Sundfeld is Associate Professor, Dr. Briso is Assistant Professor, Department
of Restorative Dentistry, Araatuba Dental School UNESP, Brazil. Dr. Croll is
in private practice, Pediatric Dentistry, Doylestown, Pennsylvania, USA, and is
Adjunct Clinical Professor, Department of Pediatric Dentistry, University of Texas
Health Science Center at San Antonio (Dental School) and Affiliate Professor,
Department of Pediatric Dentistry, University of Washington School of Dentistry,
Seattle, WA, USA. Dr. de Alexandre is a graduate student, and Mr. Neto is an
undergraduate student, Department of Restorative Dentistry, Piracicaba School of
Dentistry, Unicamp, Piracicaba, Brazil.

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