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Conservative cosmetic treatment of Amelogenesis Imperfecta

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CASE REPORT

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Introduction

Amelogenesis Imperfecta (AI) has been defined as a complex group of hereditary enamel defects, existing independent of any related systemic disorder.1,2 Dental enamel disturbance that occurs during the stages of enamel formation will impact the quality and/or quantity of the enamel formed, depend-ing on phase of amelogenesis.3,4 This enamel anomaly affects both the primary and permanent dentitions. Amelogenesis Imperfecta is a rare enamel mineralisation defect, described by Spokes in 1980 as “hereditary brown teeth”.1,5,6 Amelogene-sis Imperfecta cases necessitate careful diagnoses to improve function and esthetics because they present with a complex set of problems, such as decreased occlusal vertical height, deep bite, rampant caries attributable to plaque accumula-tion, abnormalities in dental eruption, tooth sensitivity, and psychosocial problems related to poor aesthetics.7,8

As Amelogenesis Imperfecta is a genetic disorder, preventive treatment is not possible; therefore, the treatment is focused on esthetic and functional rehabilitation.1,9-11 Treatment de-pends on the severity of the problem and the need for es-thetic enhancement, ranging from simple composite resin restorations to complete crown restorations in cases involving greater loss of tooth structure or loss of vertical dimension.1 The use of adhesive restorations has great popularity owing to many improvements such as excellent esthetics, conserva-tive approach and improved wear and mechanical properties.Minimal invasive conservative techniques obtain desirable es-thetics. The teeth and supporting structures were preserved and a harmonious relationship was maintained between the occlusion and temporomandibular articulation.12 The use of laminate veneers and composite resins has matured to a pre-dictable treatment methods in terms of longevity, periodontal status and patient satisfaction.13,14 This paper reports the func-tional and esthetic rehabilitation of a 22-year-old female pa-tient with AI with direct cosmetic composite resin restorations with two-year follow-up.

Case Report

A 22-year-old female patient reported to the Department of Conservative Dentistry and Endodontics, Panineeya Ma-havidyalaya Institute of Dental Sciences and Research Centre, Hyderabad, India, with a chief complaint of poor esthetics from the presence of irregularities and discolouration of up-per and lower front teeth. She had a related family history. Intra oral examination revealed that all her upper and lower anterior teeth were yellow brown in colour with an anatom-

ic variation. This includes macro sized upper central incisors and micro sized conoid lateral incisors (Figure 1,2). Diastema was noted in the lower anterior region (Figure 1,2). Incisal edg-es of both upper and lower anterior teeth were chipped off and irregular on palpation. Posterior teeth had white opaque frosted appearance with intact enamel. All teeth had surface roughness with enamel pitting. Examination of the periodon-tium revealed unhealthy gingival condition with presence of generalized marginal papillary gingivitis, calculus deposition and unsatisfactory oral hygiene. She was displeased with the appearance of teeth which had an adverse impact on her self image. Once the patient had expressed her treatment ex-pectations a detailed clinical examination, photographs and stone casts were prepared for initial documentation. Based on clinical examination and diagnostic tools the existing prob-lems and major elements of the treatment were explained to the patient. The treatment plan included oral prophylaxis and re-anatomization by direct resin bonded restorations for ante-rior teeth and written consent was taken.

The initial Phase consists of deep sub gingival scaling with proper oral hygiene instructions. Patient was recalled after a two weeks and assessed for improvement in gingival health. The inflammation was subsided with no bleeding on probing. During the second Phase suitable composite resin colour was selected using the shade guides. Maxillary and mandibular anterior teeth were prepared for direct composite resin lami-nate veneer restorations (Figure 3). Hypoplastic and darkened enamel that may negatively affect the final esthetic appear-ance of the rehabilitation were removed. For this purpose 0.5 mm facial and proximal reduction was performed. Teeth were etched with the phosphoric acid for prolonged time than nor-mal and rinsed for 30sec and dried with absorbent paper. A two component adhesive system was applied on the prepared tooth surface and was light cured for 20 sec with a blue phase LED light source. The direct veneer restorations were per-formed with Tetric N Ceram i.e., radiopaque nano-hybrid com-posite. A combination of incremental and stratified layering technique was used to fill the teeth. The composite was added in increments of 1.5-2mm and was light cured after each layer according to manufacturer’s instructions (Figure 4). Finishing and polishing was accomplished with ultrafine diamond burs and composite rubber polishing burs. Completed restoration of anterior teeth enhanced the esthetics and smile of the pa-tient (Figure 5,6).

ABSTRACTAmelogenesis imperfecta (AI) is a complex group of hereditary enamel defects, existing independent of any related

systemic disorders. This paper reports the functional and esthetic rehabilitation of a 22-year-old female patient with AI with direct cosmetic composite resin restorations.

Keywords: Amelogenesis Imperfecta; Composite Resin; Enamel Defects; Restoration

Swetha Bollineni, P Prashanthi, P Karunakar, Raji V SolomonConservative CosmetiC treatment of amelogenesis imperfeCta

Discussion

The term esthetics is extremely subjective in the field of den-tistry. During the evaluation of aesthetically compromised teeth, dentists encounter adverse clinical conditions of great complexity, marked by the invasion of the mineralized struc-tures at depth. Amelogenesis imperfecta of anterior teeth re-sults in poor psychologic image in young patients. This makes the problem urgent from psycho-social point of view. Most defects in enamel are cosmetic rather than functional dental problems.7 The main clinical characteristic is extensive loss of tooth tissue, carious lesions, tooth sensitivity and poor esthet-ics. In amelogenesis imperfecta the enamel is insufficiently mineralized, extremely soft and may show a chalky, dull color or a cheesy consistency with the possibility of a rapid break down. These teeth have an abnormal shape when they erupt. Loss of enamel from wear and staining tends to increase with age. Interestingly, the enamel at the cervical portion is fre-quently better calcified than that on the rest of the crown.5

A variety of treatment approaches have been proposed to address the esthetic concern and functional rehabilitation of defective enamel in amelogenesis imperfecta patients. The treatment plan is related to factors such as age, socio-eco-nomic status, type and severity of the disorder and intraoral situation at the time the treatment.2 Attempts should be made to achieve esthetics while keeping the loss of tooth substance to a minimum.15

Direct veneers have been increasingly used in clinical den-tistry to restore anterior teeth that have alterations in color or anatomical shape.16 Direct veneering with composite resin is a conservative and economical option that provides good and long lasting esthetics and functional restoration.17 In order to achieve good bonding strength of defective enamel, extend-ed etching periods have been recommended for conventional adhesive systems.18

Composite resins are challenging ceramics because they offer excellent aesthetic potential and acceptable longevity, with a much lower cost than equivalent porcelain restorations for the treatment of both anterior and posterior teeth.19,20 The res-toration of the tooth volume utilizing composite veneers not only re-establish the smile but also allows the biomimetic re-covery of the crowns. In cases which necessitate correction or alteration in tooth shape or position and changes in morphol-ogy composite veneers display promising esthetic results.21

The clinician must consider that a dry, clean working field and proper use of bonding protocol is the key to achieve success in adhesive dentistry.22,23

Conclusion

In conclusion, The use of direct laminate veneer technique with adhesive bonding system and composite resin materials benefits, correction of tooth shapes and dimensions that re-sult in improved tooth proportions with an aesthetically pleas-ing appearance.

Authors Affilations1. Swetha Bollineni, MDS, Senior Lecturer, Department of Conserva-tive Dentistry and Endodontics, Pinnamaneni Siddhartha Institute of Dental Sciences, Vijayawada, Andhra Pradesh, India, 2. P Prashanthi, MDS, Department of Conservative Dentistry and Endodontics, Pinna-maneni Siddhartha Institute of Dental Sciences, Vijayawada, Andhra Pradesh, India, 3. Karunakar P, MDS, Professor and Head, Department of Conservative Dentistry and Endodontics, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, Andhra Pradesh, India, 4. Raji.V.Solomon, MDS, Professor, Department of Conservative Dentistry and Endodontics, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, Andhra Pradesh, India.

References1. Gönülol N, Bulucu B. Diagnosis and conservative rehabilitation

of a patient with amelogenesis imperfecta and 5-year follow-up: a case report. Clinical dentistry and research. 2013;37(1):51-6.

2. Sengun A, Ozer F. Restoring function and esthetics in a patient with amelogenesis imperfecta: a case report. Quintessence in-ternational (Berlin, Germany: 1985). 2002;33(3):199-204.

3. Musale PK, Yadav TK, Bijle MNA. Clinical Management of an Epi-genetic Enamel Hypoplasia-A Case Report. International Journal of Clinical Dental Science. 2011;1(1):77-80.

4. Hu J-C, Chun YH, Al Hazzazzi T, Simmer JP. Enamel formation and amelogenesis imperfecta. Cells Tissues Organs. 2007;186(1):78-85.

5. Akin H, Tasveren Sh, Yeler DY. Interdisciplinary approach to treat-ing a patient with amelogenesis imperfecta: A clinical report. Journal of Esthetic and Restorative Dentistry. 2007;19(3):131-5.

6. Coley-Smith A, Brown CJ. Case report: radical management of an adolescent with amelogenesis imperfecta. Dental update. 1996;23(10):434-5.

7. Seow WK. Clinical diagnosis and management strategies of amelogenesis imperfectavariants. Pediatric dentistry. 1992;15(6):384-93.

8. Dawasaz AA, Zakirulla M, Allahbaksh M. Hypocalcified autoso-mal recessive amelogenesis imperfecta—A case report. Open Journal of Stomatology. 2012;2:251-4.

9. Oliveira IK, Fonseca JF, do Amaral FL, Pecorari VG, Basting RT, França FM. Diagnosis and esthetic functional rehabilitation of a patient with amelogenesis imperfecta. Quintessence interna-tional (Berlin, Germany: 1985). 2011;42(6):463-9.

10. Saha MK, Saha SG. Restoration of anterior teeth with direct com-posite veneers in Amelogenesis Imperfecta. International Jour-nal of Dental Clinics. 2011;3(2).

11. Chengappa M, Ramamoorthi M, Sivagami N. Rehabilitation of Mutilated Natural Dentition associated with Amelogenesis Im-perfecta–A Case Report. International Journal of Dental Clinics. 2010;2(4).

Figure1,2. Preoperative, Figure 3. Teeth prepared for composite res-toration, Figure 4. Composite restoration done, Figure 5,6. Post op-erative.

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12. Sholapurkar AA, Joseph RM, Varghese JM, Neelagiri K, Acharya SR, Hegde V, et al. Clinical diagnosis and oral rehabilitation of a patient with amelogenesis imperfecta: a case report. The journal of contemporary dental practice. 2007;9(4):92-8.

13. Pena CE, Viotti RG, Dias WR, Santucci E, Rodrigues JA, Reis AF. Es-thetic rehabilitation of anterior conoid teeth: comprehensive ap-proach for improved and predictable results. Eur J Esthet Dent. 2009;4(3):210-24.

14. Magne P. Composite resins and bonded porcelain: the postamalgam era? Journal of the California Dental Association. 2006;34(2):135-47.

15. Toksavul S, Ulusoy M, Türkün M, Kümbüloğlu O. Amelogenesis imperfecta: the multidisciplinary approach. A case report. Quin-tessence international (Berlin, Germany: 1985). 2004;35(1):11-4.

16. Franco EB, Francischone CE, Medina-Valdivia JR, Baseggio W. Re-producing the natural aspects of dental tissues with resin com-posites in proximoincisal restorations. Quintessence internation-al-english edition-. 2007;38(6):505.

17. Lygidakis NA, Chaliasou A, Siounas G. Evaluation of compos-ite restorations in hypomineralized permanent molars: a four year clinical study. European journal of paediatric dentistry. 2003;4:143-8.

18. Lopes GC, Vieira LC, Monteiro S, de Andrada MC, Baratieri CM. Dentin bonding: effect of degree of mineralization and acid etching time. Operative dentistry-university of washington-. 2003;28(4):429-39.

19. Macedo G, Raj V, Ritter AV, Swift EJ. Longevity of anterior com-posite restorations. Journal of Esthetic and Restorative Dentistry. 2006;18(6):310-1.

20. Peumans M, Van Meerbeek B, Lambrechts P, Vanherle G. The 5-year clinical performance of direct composite additions to correct tooth form and position. Clinical oral investigations. 1997;1(1):12-8.

21. Magne P, Belser UC. Novel porcelain laminate preparation ap-proach driven by a diagnostic mock‐up. Journal of Esthetic and Restorative Dentistry. 2004;16(1):7-16.

22. Magne P, So W. Optical integration of incisoproximal resto-rations using the natural layering concept. Quintessence Int. 2008;39(8):633-43.

23. Dietschi D. Optimizing smile composition and esthetics with res-in composites and other conservative esthetic procedures. Euro-pean Journal of Esthetic Dentistry. 2008;3(1):14-29.

How cite this articleBollineni S, Prashanthi P, Karunakar P, Solomon RV. Conservative cos-metic treatment of amelogenesis imperfecta. International Journal of Dental Clinics. 2014;6(2):32-34.

Address for CorrespondenceDr. Swetha Bollineni, MDS,

Senior Lecturer, Department of Conservative Dentistry and Endodontics,

Pinnamaneni Siddhartha Institute of Dental Sciences, Vijayawada, Andhra Pradesh, India

Email: drswethakotagiri@gmail.com

Source of Support: Nil Conflict of Interest: None Declared