RESEARCH ARTICLE

Esthetic Management of Developmental Enamel Opacities

in Young Permanent Maxillary Incisors with Two
Microabrasion TechniquesA Split Mouth Study
NEHA 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 developmental
enamel opacities in young permanent maxillary incisors.
Materials and Methods: Using a split-mouth study design, 37% phosphoric acid and 18% hydrochloric acid were used
for removal of visually unesthetic developmental enamel opacities of young permanent maxillary anterior teeth from
25 subjects (1113 years old) by two microabrasion techniques for 10 and 5 seconds respectively. This procedure was
repeated four to six times during each clinical appointment. The subjects were evaluated about their satisfaction with
the treatment. Two blinded evaluators appraised both sides of the mouth using visual analog scale. The records were
analyzed 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 after
microabrasion 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 esthetic
management 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 opacities
associated with positive dental history and are commonly seen in young permanent maxillary incisors of both boys
and girls in their developing years. They are aware of unesthetic appearance of these newly erupted permanent
anterior teeth and become highly motivated when informed about minimally invasive, patient friendly, cost-effective, and
safe 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 treating
enamel 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, India

Professor and Head, Department of Pediatric and Preventive Dentistry, M. M. College of Dental Sciences and Research, Maharishi Markendeshwar University, Ambala,
Haryana, India

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

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

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

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INTRODUCTION

MATERIALS AND METHODS

Tooth enamel is unique among mineralized tissues. The

formation of dental enamel is highly specialized, and
the proteins most directly involved in enamel
bio-mineralization are specic for it. As a consequence,
defects in the genes encoding enamel proteins generally
cause enamel malformations.1 Developmental enamel
defects can be qualitative or quantitative in nature and
can present a wide range of clinical appearances.2
They can be classied into one of four types:
hypoplasia, demarcated opacities, diuse opacities, and
discolored enamel.3

Subject Selection and Experimental Design

The enamel defects do not directly increase the risk for

the development of caries in the aected teeth; the
absence of normal enamel morphology invariably
results in diminished occlusal function, and often in
severely compromised esthetic in newly erupted young
permanent teeth. So these enamel defects should be
treated as early as possible.4 Esthetically desirable
appearance of newly erupted permanent anterior teeth
is of prime importance regarding development of
self-esteem in growing children. A minimally invasive,
safe, and child patient-friendly technique is required to
manage these unesthetic enamel defects in newly
erupted permanent anterior teeth of selected patients.
Over the past decades, several techniques were
employed to remove enamel defects, which include
selective grinding and polishing, bleaching,
microabrasion, veneering, or placement of porcelain
crowns.5 In this era of minimal intervention, enamel
microabrasion is a clinically restorative method to
improve the appearance of aected teeth. As pointed
out by Wong and Winter, esthetics is a subjective
perception.6 It was concluded at the International
Symposium on Non-Restorative Treatment of
Discolored Teeth that microabrasion was a safe,
conservative, and eective atraumatic method of
removing supercial enamel defects.
This study was aimed to compare the clinical ecacy of
enamel microabrasion using 18% hydrochloric acid and
37% phosphoric acid on removal of visually unesthetic
developmental enamel defects of young permanent
anterior teeth in children.

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Two microabrasion materials18% hydrochloric acid

and 37% phosphoric acidwere studied in a clinical,
split mouth, double-blind study design. The protocol
and consent form for this study were reviewed and
approved by Institutional Ethical Committee. Written
informed consent was obtained from all participants
prior to the beginning of the clinical study. Each child
patient was asked about their own perception of
esthetics of maxillary incisors. Patient screening and
pretreatment selection of teeth with developmental
enamel defects were performed by two clinical
investigators according to modied Developmental
Defects Enamel (DDE) index7: code 0 = normal; code
1 = white/cream demarcated opacities; code 2 = yellow
brown demarcated opacities; code 3 = diuse opacity
with lines; code 4 = diuse patchy opacities; code
5 = diuse conuent opacities; code 6 = loss of enamel
with staining; code 7 = hypoplastic pits; code
8 = hypoplasia with missing enamel; code 9 = hypoplasia
with any other defect. An initial intra- and
inter-examiner agreement of at least 85% was necessary
before the clinical evaluation in this study began. Teeth
to be examined were cleaned with pumice and water to
remove extrinsic stain. The investigators carried out the
evaluation using a mouth mirror, a blunt explorer, and
a periodontal probe. All subjects were given oral
hygiene instructions before starting the treatment.
Prevalence of maxillary incisors with developmental
defects of tooth enamel was 22.8% (N = 114) in which
diuse opacities contributed 48% (N = 55), demarcated
opacities 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 received
a score corresponding to the clinical appearance of the
most aected teeth in the mouth. Out of 114 children
who presented with enamel defects, 59 children were
dissatised due to color of which 28 had demarcated
opacities, 30 had diuse opacities and 01 presented
with both demarcated and diuse opacities on maxillary
incisors. Subjects with extremely poor oral hygiene or
periodontal diseases were excluded. Children with loss
of enamel in anterior teeth in codes 6 to 9 according to

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the modied DDE index were also excluded. Out of 59

children, a convenience sample of 25 children was
selected for the study as per their reporting to the
department and consent to allow the microabrasion
technique for the treatment. One operator performed
all procedures. Anterior teeth in each selected patient
were divided randomly by chit method regarding right
or left pairs of permanent maxillary central and lateral
incisors into two groupsgroup 1 (37% phosphoric
acid) and group 2 (18% hydrochloric acid). All
participants were informed of the nature and objectives
of this study; however, they were unaware of the
location of each material. Materials 37% phosphoric
acid (Mission Dental, USA), 18% hydrochloric acid
prepared in the biochemistry department of the
university, and pumice powder (Kramer industries, Inc.,
Piscataway Township, NJ, USA) was used for
microabrasion. The baseline percentage of opacities in
group 1 was 48 and in group 2 was also 48.
Preoperative clinical status and patient perception of
enamel opacities was recorded for each patient (Figs. 1
& 2).

In both the groups, after microabrasion, a paste of

sodium bicarbonate mixed in water was applied to
neutralize the eect of acid. This was followed by
polishing with a soex disc at slow speed. At the end of
procedure, the rubber dam was removed and GC Tooth
Mousse (GC Europe N.V., Leuven, Belgium) was
applied for 5 minutes. Before discharging the patient,
an immediate post-operative photograph was taken
(Figures 1 and 2) and esthetic assessment in the patient
was made according to visual analog scale (VAS).8 The
patient was asked to return for the recall at 1-month
interval.
At 1-month recall, post-operative clinical assessment
and esthetic assessment was carried out as described
earlier and recorded in patient assessment form. Patient
satisfaction was performed using the VAS8 (1 = no

Clinical Microabrasion Technique

Isolation was performed using rubber dam and margins
were sealed using copal varnish. The eyes of the patient
as well as the operator were protected using eyewear.
The method of application followed the split-mouth
design. In both the groups, acid was mixed with pumice
powder in a ratio of 1:1 to make a paste like consistency
in a dappen dish with the help of a wooden spatula.
This mix was then applied on teeth as grouped using
standard silicon polishing cup attached to contra-angled
hand piece at a slow speed of approximately 1,000 rpm
under rubber dam.
Group 137% phosphoric acid and pumice paste was
applied for 10 seconds followed by rinsing with copious
water for 20 seconds. Total six applications were
performed in a single visit.
Group 218% HCl and pumice paste was applied for 5
seconds followed by rinsing with copious water for 5
seconds. Total four applications were performed in a
single visit.

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FIGURE 1. Representative pre- and post-operative

photographs of group 1 and group 2.

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RESULTS
Immediately after treatment, the opacities reduction
was 82% and 81% in groups 1 and 2 respectively. The
1-month reduction was 97% in group 1 and 97% in
group 2. Results immediately after and 1-month
post-treatment are shown in Table 1 with no signicant
dierence between the groups. Table 2 depicts the
comparison immediately after treatment and after 1
month in each group. The results showed that the
treatment outcome was highly signicantly dierent
(t value .001**) in both groups. Table 3 represents the
change in VAS immediately and 1 month after
treatment. This table depicts that on VAS from 1 to 7,
the ratings for improvement in appearance signicantly
changed after second clinical appointment. Table 4
shows that out of 25 children treated with
microabrasion, 84% of children were satised with the
appearance immediately after treatment and 96% were
satised after 1 month.

DISCUSSION
FIGURE 2. Representative pre- and post-operative
photographs 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 enamel
opacities in two acid groups, the preoperative,
immediate, post-operative, and after 1-month
follow up clinical assessment records of 25 subjects
were analyzed by two blinded independent evaluators to
assess reduction in opacities in groups 1 and 2. Cohens
Kappa statistics (0.86) showed strong agreement
between the examiners. Presence or absence of enamel
opacities was taken as a unit for analysis. Success of
treatment was identied by the decrease in the number
of enamel opacities. Esthetic improvement was
determined by the VAS reading and satisfaction of
the child.

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Esthetics is a subjective perception. The clinical

management of tooth discoloration aims to produce an
acceptable cosmetic result as conservatively as possible.
Conservative treatment with microabrasion can
produce dramatic improvements in brown and yellow
discoloration.9 The available literature on it shows that
this technique should be considered as the rst
treatment option when trying to improve the esthetics
of teeth that present intrinsic stains and extrinsic
supercial enamel stains.10
The rst report about hydrochloric acid application
used to improve esthetics of teeth with uorosis
was given by Dr Kane in 1916.11 Since then,
favorable studies veried the eectiveness of the
microabrasion technique using dierent
concentrations of hydrochloric acid (6.618%) and
phosphoric acid (3040%) in association with
abrasives.12
Microabrasion is indicated for uorosis,
post-orthodontic demineralization, localized hypoplasia

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

Baseline opacities

Group 1: 37% phosphoric acid

Group 2: 18% hydrochloric acid

Mean

% change

Standard deviation

Mean

% change

Standard
deviation

48.13

25

81.7

5.61

47.96

25

81.4

27.69

2.39

8.70

.85

1.72

Opacities immediately after treatment

8.67

Opacities 1 month after treatment

1.43

97.3

12.53
96.7

5.00

TABLE 2. Percentage change in children immediately after microabrasion and 1 month after microabrasion in both the groups
Paired differences
Mean Mean Standard Standard Standard Standard 95% Confidence interval
Group Group deviation deviation error
error
of the difference
1
2
Group 1 Group 2 mean
mean
Lower Lower Upper Upper
Group Group Group Group
1
2
1
2
Baseline
39.46
opacities
opacities
immediately
after
treatment

39.26

27.26

27.68

5.45

5.54

28.21

Baseline
46.70
opacities
opacities
after
1 month

46.24

28.07

27.70

5.61

5.54

35.11

27.84

50.71

50.68

t
t
df
Group Group Group 1
1
2
and
group 2

Sig.
(twotailed)
Group
1 and
group
2

7.23

.001**

7.09

24

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
Frequency

Percentage
(%)

1 = no improvement

24 = slight improvement

56 = moderate improvement
7 = exceptional improvement
Total

Visual scale reading 1 month after treatment

Mean

Standard
deviation

5.80

.91

Percentage
(%)

17

68

15

60

28

10

40

25

100

25

100

due to infection or trauma, and idiopathic hypoplasia

where the discoloration is limited to the outer enamel
layer.1316 This technique is simple to perform and the
depth of enamel removed in 10 applications is

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Frequency

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Mean

Standard
deviation

6.24

.72

approximately 100 m (0.1 mm). The clinical result

obtained is directly related to the depth of the
stain/defect.10 Among the 25 treated patients in present
study, it was observed that baseline opacity area was

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

Esthetic satisfaction in children

1 month after treatment

Satisfied

Satisfied

Long-term
satisfied

Unsatisfied

Frequency (N = 25)

21

24

Percent %

84

16

96

similar in both groups and mean percentage opacity

reduction was 82% in group 1 and 81% in group 2
immediately after treatment. Brown stains had better
results than white stains. It was also observed that
patients with a mild degree of developmental enamel
defects showed better results. Same data have also been
reported by Train and colleagues13 and Bezerra and
colleagues.17
The split-mouth clinical study was used in this study to
evaluate the ecacy of two microabrasion materials in
vivo. The baseline percentage of opacities in group 1
was 48 and in group 2 was also 48. One-month
reduction in enamel opacity was 97% in group 1 and
97% in group 2. The results were statistically signicant
in both groups showing a marked reduction in total
area occupied by opacities. However, there was no
statically signicant dierence between the two groups.
The most important aspect of this treatment to the
patient is the advantage that no further treatment is
required after this minimally invasive technique, as has
been observed by Tashima and colleagues10 and Bezerra
and colleagues.17
The patient and parents were 84% satised immediately
after and 96% after 1 month. The parents generally
complied with the follow-up visit. The dierence
between mean percentage reduction of opacities and
after a month in group 1 and group 2 was not
statistically signicant. The appearance of enamel
surfaces had a tendency to improve as time transpired,
clinically decreasing the area and size of opacities.
These observations were also seen in several studies
done by Croll.1820 Croll TP performed microabrasion
treatment for hundreds of children and adult patients
from 1985 to 1989. Treatment results observed by him
supported the contention that enamel microabrasion

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gave permanent color modication of supercial

enamel coloration defects because enamel
microabrasion actually removed discolored enamel
rather than altering or masking the tooth stain. Also,
microabraded enamel surfaces achieved a brilliant luster
as time passed by. Similar results were also observed in
the present study. He also observed that many intrinsic
enamel surface defects were supercial enough to be
eliminated without replacing the lost enamel. Slight and
moderate, white and brown uorosis discolorations are
good examples how this type of demineralization which
can be treated by enamel microabrasion.
Enamel microabrasion corrects surface enamel
hypomineralization and discolorations defects by
removing supercial enamel.7 If the discolored defect is
supercial and microabrasion exposes underlying
enamel of normal quality, the tooth acquires a glassy
lustrous quality due to changes in the intrinsic
properties of enamel following simultaneous abrasion
and erosion of the surface. This has been described as
the abrosion eect.21
In the proposed technique, we suggest the use of
microabrasion to remove the unesthetically desirable
enamel defects under rubber dam protection followed
by application of uoride solution or casein
phosphopeptide amorphous calcium phosphate paste
for 5 to 15 minutes. This approach is justied for two
reasons: rst, it reduces the risk of post-treatment
sensibility, and second, it protects teeth from possible
external demineralization.22
Additionally, it could be said that this technique has a
positive psychological eects on patients. The children
presenting esthetically compromised anterior teeth
might develop a low self-esteem and condence. During

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follow up, most of the parents reported that their

children had positive changes in their behavior, after
treatment by becoming more outgoing and exhibited
unrestricted smiling without fear of showing their teeth
after treatment. The same observation was made by
Powel, Craig and colleagues.2325

9.

10.

11.

CONCLUSIONS
1 Both microabrasion techniques showed
comparatively high success in treating enamel
opacities resulting in both patient and parents
satisfaction.
2 Microabrasion is a simple, safe, atraumatic,
conservative, and minimally invasive technique that
removes the supercial part of enamel and eliminates
defects such as brown or white opacities.

DISCLOSURE

12.

13.

14.

15.

The authors do not have any nancial interest in any of

the companies whose products are included in this
article.

16.

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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: shaloosandeep@gmail.com

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