JIndianProsthodontSoc6143-2711759_073157

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Case Report

Restoration of esthetics and function in a patient with

amelogenesis imperfecta: A clinical report

Kamal Shigli, Gangadhar Shivappa Angadi, Anand Lingaraj Shigli*Department of Prosthodontics, K. L. E. Societys Institute of Dental Sciences, Belgaum, Karnataka;

*Department of Pedodontics and Preventive Dentistry, K. L. E. Societys Institute of Dental Sciences,

Belgaum, Karnataka, India

For correspondence

Kamal Shigli, A-9, J. N. M. C. Staff Quarters, Nehru Nagar, Belgaum- 590 010, Karnataka, India. E-mail: [email protected]

Amelogenesis Imperfecta is a dental condition that affects only the enamel, as it is an entirely ectodermal

disturbance. A 16-year-old individual presented with discolored natural dentition. Composite restorations were

fabricated for the maxillary and mandibular anterior teeth and metal-ceramic crowns were cemented on the

posterior teeth. The final treatment result provided the patient with improved dental aesthetics that enhanced his

self-image.

Key words: Aesthetics, amelogenesis imperfecta

INTRODUCTION

Amelogenesis imperfecta (AI) includes a variety ofgenetically determined disorders that primarily affect

the enamel of all or nearly all teeth, without causingdetectable alterations elsewhere in the body. This definition implies that the genetic mutations involve highlyspecialized genes that regulate only enamel formationand do not affect structural or enzymatic protein formation in other tissue systems, or in the regulation ofgeneral metabolic processes.[1] AI is reported to havean incidence of one person in every 16,000 and wasfirst described in 1890, but not until 1938 did Finn (ascited by Greenfield) classify it as a separate entityfrom dentinogenesis imperfecta.[2]

Three types of amelogenesis imperfecta are describedin the literature: hypoplasia, hypocalcification andhypomaturation. Enamel hypoplasia is an exclusiveectodermal disturbance related to alterations in theorganic enamel matrix, which can cause white flecks,narrow horizontal bands, lines of pits, grooves anddiscoloration of the teeth, varying from yellow to darkbrown. [3] Enamel hypocalcification is a defect in themineralization process, which causes the enamel tobecome soft and friable. The hypomaturation varianceis determined by abnormality in the final stages of the

mineralization process and differs fromhypocalcification in that the enamel is harder with amottled opaque white to yellow-brown or red-brown

color.[4] According to Seow,[5] common clinical problems of AI are poor aesthetics, teeth sensitivity andloss of occlusal vertical dimension, although distinctive clinical features may be observed in each type of

AI.The treatment plan for patients with AI is related to

many factors including the age of the patient, the socioeconomic status, the type and severity of the disorderand its intraoral manifestation.[6] This clinical reportdescribes the treatment sequence of a 16-year-old individual with AI using composite resin restorations forthe anterior teeth and metal-ceramic crowns for theposterior teeth.

Clinical report

A 16 yr old individual reported to our departmentwith a chief complaint of unesthetic smile due to discolored teeth [Figure 1]. No family history of this condition was reported. Panoramic radiographs revealedthat the patient had retained maxillary deciduous canines on the right and left sides. The maxillary rightand left canines were impacted. Mandibular third molarson both right and left sides were retained [Figure 2].

The patients generalized oral hygiene was poor anddepths recorded were 3 mm or more. Mandibular rightcanine and maxillary right second molar were exten

sively damaged by caries and were completely covered with gingival tissue. The maxillary left secondmolar had been previously extracted due to caries. The

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Shigli, et al.: Restoration of aesthetics and function in a patient with amelogenesis imperfecta

A

A

Figure 1: A and B, Pretreatment right and left buccal view of teeth in

maximal intercuspation

B

Figure 4: Post-treatment occlusal views. A, Maxillary; B, Mandibular.

B

Figure 2: Panoramic radiograph. Radiodensities of enamel and dentin

were similar

Figure 5: Composite restorations on the maxillary and mandibular

anterior teeth

Figure 3: Frontal view of occlusal splint in place

enamel layer was very thin and yellowish-brown incolor and the occlusal anatomy was completely absent. The molars were most severely affected and alltooth surfaces were dull and rough leading to a diagnosis of hypomaturation type of AI.

The first phase of treatment involved periodontalpreparation by scaling and root planning. Crownlengthening by gingivectomy was carried out on themandibular right canine and a healing period of 12weeks was allowed for the soft tissues to mature ad

equately.[7]

After gingivectomy, endodontic treatmentof the mandibular right canine was carried out and aprefabricated threaded post (SB post, Pre-sandblasted

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Dental Post System; J. Morita USA) was used to support a core fabricated with composite resin (ClearfilPhotocore Kuraray Co. Ltd, Osaka, Japan).The prognosis for the maxillary right second molar was deemedhopeless and therefore the tooth was extracted.

Complete arch maxillary and mandibular impressionswere made with irreversible hydrocolloid (Alginoplast;

Heraeus Kulzer, South Bend, Ind),and used to obtaindiagnostic casts, using Type III dental stone (Labstone,Kalabhai Karson, Mumbai, Ind). Face-bow transfer wasdone and interocclusal records were made to mountthe casts in centric relation on a semi-adjustablearticulator(Hanau Series H2; Water Pik, Fort Collins,U.S.A). As the patient had less vertical dimension ofocclusion, the vertical dimension had to be increasedby 3 mm using an occlusal splint [Figure 3]. The patient was treated with occlusal splint for a period of4 weeks and report back. Phonetics was used to assess

that the increase of vertical height was within thephysiologic limits.In treatment planning special attention was given to

improve the aesthetics and function. Fabrication ofmetal-ceramic crowns for maxillary and mandibularposterior teeth and composite restorations for the anterior teeth was planned. The patient was informed ofthe diagnosis, the treatment planned and his consentwas taken before the start of the procedure. Compositerestorations were chosen for the anterior teeth becausethey were cost effective. Porcelain laminate veneerswere advised at a later date.

The maxillary premolars and first molars along withthe mandibular premolars, first and second molars onboth right and left sides, were prepared and rehabilitated simultaneously to receive metal-ceramic crowns.The teeth were prepared to allow for 1.5 mm of restorative material on the occlusal surfaces. The porcelainon the facial surface extended over the cusp tip andhalf of the way down the lingual incline of the facialcusp on maxillary premolars and molars. A shoulderof 1.5 mm on the facial side and a chamfer of 0.5 mmwidth was prepared on the lingual side. Tooth reduc

tion was kept to a minimum. All tooth preparationswere completed without sharp line angles.

Impressions of prepared teeth were made withvinylpolysiloxane (Reprosil; Dentsply, USA) in stocktrays. Definitive maxillary and mandibular casts wereformed, mounted to an articulator with trimmed diesof prepared teeth and the maxillomandibular relationship record was made with vinyl polysiloxane(EXABITE II NDS). Provisional restorations were given(TEMPRON, GC Corp, Tokyo, Japan) and the occlusalplane was established.

A trial evaluation of the metal substructure, prior tobuild up of the ceramic material, enabled final occlusal refinement. The crowns were cemented withglass ionomer cement (GC Fuji I, GC Corporation, Tokyo,

Japan) using the manufacturers recommended powder/liquid ratio. The vertical dimension of occlusionwas carefully maintained during the period ofprovisionalization and through the completion of restoration [Figure 4].

The maxillary and mandibular anterior teeth werethen prepared to receive composite restorations (CHA

RISMA, Heraeus Kulzer, Germany). Shade matchingwas done according to the skin tone, because all theteeth were being restored. [Figure 5].

The patient was followed up for 1 year on a regular3-month recall appointment schedule. Emphasis wasgiven on the maintenance of oral hygiene and regularcheck-up visits.

DISCUSSION

There are a number of alternatives for the treatment

of teeth affected by amelogenesis imperfecta. For manyyears, the most predictable and durable esthetic restoration of anterior teeth has been achieved with complete crowns. However, this approach requires thepreparation of a substantial amount of tooth structure.[4]

The popularity of porcelain laminate veneers hasincreased since being introduced, because tooth preparation is conservative and the restorations are aesthetic. However, an in vitro study has described somedisadvantages such as marginal adaptation and bonding problems.[4]

Composite resin restorations have been tried for theanterior teeth. Unfortunately, composite resins showpolymerisation shrinkage, thermal dimensional change,staining, poor wear resistance, and its use veneers hasa limited life of 4 years or less.[8] Patients and dentistsshould discuss the advantages and disadvantages ofvarious treatment options available in deciding the

best treatment plan.

CONCLUSION

This clinical report describes the use of compositerestorations and metal-ceramic crowns for restorationof a hypomaturation type of amelogenesis imperfecta.Composite restorations were placed on the anteriorteeth and metal-ceramic crowns were placed on theposterior teeth to improve the aesthetics and function.This boosted the patients self-confidence and alsoincreased his responsibility to maintain adequate levels of oral hygiene.

ACKNOWLEDGMENTS

The authors would like to express their gratitude toMr. Krishnamurthy Bhat for technical assistance rendered.

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REFERENCES with amelogenesis imperfecta and malocclusion: Aclinical report. J Prosthet Dent 2004;92:112-5.

1. Sengun A, Ozer F. Restoring function and esthetics in 5. Seow WK. Clinical diagnosis and management strat

a patient with amelogenesis imperfecta: A case report. egies of amelogenesis imperfecta variants. Pediatr Dent

Quintessence Int 2003;33:199-4. 1993;15:384-3.

2. Greenfield R, Iacono V, Zove S, Baer P. Periodontal 6. Sari T, Usumez A. Restoring function and esthetics in

and prosthodontic treatment of amelogenesis imperfecta: a patient with amelogenesis imperfecta: A clinical re-A clinical report. J Prosthet Dent 1992;68:572-4. port. J Prosthet Dent 2003;90:522-5.

3. Soares CJ, Fonseca R B, Martins LR, Giannini M. Es- 7. Nel JC, Pretorius JA, Weber A, Marais JT. Restoringthetic rehabilitation of anterior teeth affected by enamel function and esthetics in a patient with amelogenesishypoplasia: A case report. J Esthet Restor Dent imperfecta. Int J Periodontics Restorative Dent2002;14:340-8. 1997;17:479-83.

4. Ozturk N, Sari Z, Ozturk B. An interdisciplinary ap- 8. Clyde JS, Gilmour A. Porcelain veneers: a preliminaryproach for restoring function and esthetics in a patient review. Br Dent J 1988;164:9-14.

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