|Year : 2012 | Volume
| Issue : 3 | Page : 185-189
Esthetic and functional rehabilitation of a patient with Amelogenesis imperfecta
Radhika B Parekh, Omkar Shetty, Rubina Tabassum
Department of Prosthodontics, Dr. D. Y. Patil Dental College and Hospital, Nerul, Navi Mumbai, India
|Date of Web Publication||11-Jun-2013|
Radhika B Parekh
Department of Prosthodontics, Dr. D. Y. Patil Dental College and Hospital, Nerul, Navi Mumbai
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Congenital and developmental disorders such as Amelogenesis imperfecta play a vital role in the overall development of a growing adult. The extensive destruction and unsightly appearance of the teeth often have a detrimental effect on the social skills and self-confidence of these patients. Prosthetic and restorative treatment in these patients aims at restoring function of the masticatory apparatus as well as enhancing its esthetic and visual appeal. A multidisciplinary approach is imperative for the successful rehabilitation and overall psychosocial wellbeing of the patient. This case report highlights the various stages of treatment for the complete rehabilitation of a young adult with Amelogenesis imperfecta.
Clinical Relevance to Interdisciplinary Dentistry
A multidisciplinary approach facilitates the complete functional, esthetic and psychological management of a patient with Amelogenesis imperfecta.
- Intentional endodontic treatment was carried out on the posterior teeth due to severe attrition on the occlusal surfaces.
- Crown lengthening procedures were undertaken in the maxillary and mandibular posterior regions to allow for sufficient crown height for restorations.
- Full-coverage lithium disilicate crowns for the anterior teeth and ceramo-metal crowns for the posterior teeth were indicated to fulfill the esthetic and functional demands of the patient.
Keywords: Amelogenesis imperfecta , full mouth rehabilitation, lithium disilicate
|How to cite this article:|
Parekh RB, Shetty O, Tabassum R. Esthetic and functional rehabilitation of a patient with Amelogenesis imperfecta. J Interdiscip Dentistry 2012;2:185-9
|How to cite this URL:|
Parekh RB, Shetty O, Tabassum R. Esthetic and functional rehabilitation of a patient with Amelogenesis imperfecta. J Interdiscip Dentistry [serial online] 2012 [cited 2019 Sep 15];2:185-9. Available from: http://www.jidonline.com/text.asp?2012/2/3/185/113255
| Introduction|| |
Amelogenesis imperfecta has been defined as a complex group of hereditary enamel defects not associated with evidence of systemic disease.  It is an exclusive ectodermal disturbance, related to alterations in the organic enamel matrix which causes white flecks, narrow horizontal bands, lines of pits, grooves, and discoloration of the teeth varying from yellow to dark brown. ,
Witkop and Sauk  classified amelogenesis imperfecta based on clinical, histological and genetic criteria as:
Type I - Enamel Hypoplasia
Type II - Enamel Hypocalcification
Type III - Enamel Hypomaturation
Seow  stated that the primary clinical problems associated with amelogenesis imperfecta are esthetics, dental sensitivity, loss of occlusal vertical dimension, malaligned anterior teeth, occlusal disturbances, congenitally missing teeth, root malformations and taurodontism. Historically, treatment of patients has included multiple extractions and the fabrication of complete dentures. These options are psychologically harsh when the problem must be addressed in younger patients.  Treatment planning for patients with amelogenesis imperfecta is related to many factors: The age and socioeconomic status of the patient, the type and severity of the disorder, and the intraoral situation at the time the treatment is planned. Literature has demonstrated the benefit of corrective and restorative treatment on the self-esteem and social wellbeing of these patients. An interdisciplinary approach is necessary to evaluate, diagnose, and resolve esthetic problems using a combination of prosthodontic, periodontic, orthodontic and restorative treatment. When patient treatment requires a comprehensive approach, communication among the disciplines is critical in achieving improved esthetic and functional outcomes. This clinical report describes the multidisciplinary approach for the rehabilitation of a young patient with amelogenesis imperfecta.
| Clinical Report|| |
A 22-year-old male patient reported to the Department of Prosthodontics, Dr. D. Y. Patil Dental College and Hospital, Nerul, Navi Mumbai with a chief complaint of unsightly appearance of front teeth and poor chewing efficiency [Figure 1]. There was no significant medical and social history, thereby posing no contraindication to the proposed dental therapy.
Thorough dental examination revealed poor esthetics due to stained, pitted and worn down maxillary anterior teeth, a missing maxillary left canine, malaligned lower anterior teeth and poor intercuspation of the posterior teeth.
On evaluation of the vertical dimension of occlusion using phonetics,  interocclusal measurements  and facial appearance as guides, it was determined that the vertical dimension of occlusion was maintained, despite the occlusal wear facets seen on the posterior teeth [Figure 2] and [Figure 3].
Radiographic examination revealed high pulp horns in most of the posterior teeth and generalized occlusal wear of the enamel resulting in most of the pulp horns of the posterior teeth approaching exposure [Figure 4]. A multidisciplinary approach involving orthodontic correction of the malaligned mandibular anterior teeth would have been the ideal treatment plan, but due to time constraints full-mouth rehabilitation was planned instead.
After a thorough oral prophylaxis, maxillary and mandibular full-arch impressions were made using alginate, an irreversible hydrocolloid impression material [Tropicalgin, Zhermack, Badia Polesim (RO), Italy]. Diagnostic casts were made and mounted on a semi-adjustable articulator [Hanau H2 series, WhipMix Corporation, Fort Collins (CO) USA] using a fascia face-bow [Figure 5]. The patient was deprogrammed using tightly rolled cotton placed between the incisors, then guided into centric relation, and an interocclusal record was made with a free-flowing recording material [Aluwax, Aluwax Dental Products Co, Allendale (MI) USA]. The articulator was programmed using a mean of the protrusive records obtained from the patient and the lateral condylar guidance values calculated using Hanau's formula (L = H/8 + 12).  The incisal table was kept 5 degrees steeper than the horizontal condylar guidance values to facilitate posterior teeth disocclusion on protrusion. The occlusal plane was developed using a customized Broadrick's Occlusal Plane Analyzer  [Figure 6] and a diagnostic wax-up incorporating a mutually protected occlusion with a group function on lateral excursion was made as the left maxillary canine was missing. ,,
Vacuform trays were fabricated on duplicated stone models of the diagnostic wax-up of both the arches and were used as a template for the final tooth preparations as well as moulds for the fabrication of the temporary restorations.
Pre-prosthetic procedures like third molar extractions and intentional root canal therapy on the maxillary and mandibular posterior teeth were performed. Crown lengthening procedures in the posterior regions were done using stents to increase the available clinical crown height to enhance the retention of the restorations.
Histopathological examination of the extracted third molars confirmed the diagnosis as Hypomaturation Amelogenesis Imperfecta.
The final treatment plan suggested to the patient involved maintaining the current vertical dimension of occlusion with full-coverage lithium disilicate crowns [IPS e.max, Ivoclar Vivadent AG, Schaan, Germany] in the maxillary anterior region and porcelain fused to metal restorations on all the remaining teeth.
Prefabricated stainless steel posts [Parapost X, Coltene Whaledent AG, Cuhyahoga Falls (OH) USA] were used in the posterior root canal-treated teeth for increased radicular retention and the cores were built up using a dual cure composite resin [Luxacore Z Dual, DMG Chermisch Pharmazeutische Fabrik Gmbh, Hamburg, Germany]. Full-mouth tooth preparations [Figure 7] were done and direct temporization for both arches was carried out with auto-polymerizing temporary restorative material [Luxatemp Star, DMG Chermisch Pharmazeutische Fabrik Gmbh, Hamburg, Germany] using the vacuform trays fabricated from the wax-up. The temporary restorations were finished, polished and cemented with a eugenol-free temporary luting cement [TempoSil, Coltene Whaledent AG, Cuhyahoga Falls (OH) USA] [Figure 8]. Minor occlusal adjustments were performed intraorally to attain the desired group function occlusal scheme. This temporary phase of treatment was maintained for an evaluation period of six weeks after which final impression were made.
Knitted retraction cords [000, Ultrapak, Ultradent Products Inc, South Jordan (UT) USA] were used for soft-tissue retraction and impressions were made using the double mix double step impression technique with polyvinyl siloxane impression material of putty and light body consistency [Aquasil Ultra, Dentsply Caulk, Milford (DE) USA]. The casts obtained were subsequently mounted at the desired vertical dimension of occlusion using a custom jig  fabricated from impression compound with the posterior temporaries in place and the bite was recorded using a polyvinyl siloxane bite registration material [Jet Bite, Coltene Whaledent AG, Cuhyahoga Falls (OH) USA] [Figure 9]. The articulator was reprogrammed with the patient's protrusive records at the established vertical dimension of occlusion. The incisal guidance established in the patient's mouth based on the esthetics and phonetics was transferred to the articulator with the help of the temporary restorations.
A metal trial of the copings was done to check for marginal discrepancy, followed by a bisque trial to evaluate the contour and shade of the restorations, as well the occlusal discrepancies; subsequent adjustments were made post which the final restorations were stained and glazed.
The maxillary anterior teeth were etched using 37% Phosphoric Acid and conditioned with a dentin bonding agent [Prime and Bond NT, Dentsply Caulk, Milford (DE) USA] and the lithium disilicate restorations were treated with porcelain etchant and silane [Ultradent Products Inc, South Jordan (UT) USA] and also coated with bonding agent; they were then cemented using only the base paste of a dual cure resin cement [Calibra, Dentsply Caulk, Milford (DE) USA] as this allows for greater working time and reduces internal discoloration on the restorations. All the porcelain fused to metal restorations were cemented using a Resin-Modified Glass Ionomer Cement [Fujicem, GC Corporation, Tokyo, Japan] [Figure 10],[Figure 11],[Figure 12]. The occlusal contacts were verified and regular follow-up was recommended and maintained for three months.
| Discussion|| |
In treating amelogenesis imperfecta, the patient's appearance and restoration of occlusion are of prime importance. Modern methods and materials along with a multidisciplinary approach have widened the range of available treatment. The teeth and supporting structures are preserved, and a harmonious relationship created between the teeth and the temporomandibular articulation. Treatment of anterior teeth places emphasis on appearance whereas treatment of posterior teeth is directed toward function.
In patients exhibiting excessive wear without loss of vertical dimension and with limited space available for restoration  continuous eruption of the worn tooth can be accompanied by eruption of the alveolus and associated soft tissues, this often results in an unaesthetic, uneven occlusal plane and gingival margin. Periodontal surgery is indicated to remove the tissues and expose more clinical crown thus allowing a more suitable occlusal plane and pleasing smile. Sufficient interocclusal space for dental materials can usually be obtained by altering the contours of opposing restorations and/or tooth structure as described by Dawson.  Endodontic therapy may be necessary if occlusal reduction during tooth preparation encroaches on the pulp chamber or if excessive wear threatens the health of the pulp.
Lithium disilicate glass ceramic crowns have an increased flexural strength  (360-400 MPa) to withstand the shearing and tensile forces that the anterior teeth undergo during mastication. They also refract light more naturally thus allowing a greater translucency in the restoration thereby increasing their esthetic appeal. The slight discolorations of the tooth stumps were masked using stain and glaze techniques. As the left maxillary canine was missing, a group function occlusal scheme ,, was incorporated into the prosthesis. This prevents it from undergoing undue stresses during lateral excursive movements, and uniformly distributes masticatory loads over a greater number of teeth.
Coordinated prosthodontic, endodontic and periodontic treatments, with careful consideration of the patients' expectations and requests, were critical for a successful outcome of the treatment and patient satisfaction.
| Conclusion|| |
Developmental disturbances such as amelogenesis imperfecta, not only impair the function but also have a profound psychological effect on the patients' self-esteem and confidence especially in young adults. Such patients need to be treated with the utmost care and understanding by the prosthodontist, who must ensure not only the functional capability of the rehabilitation but must also understand the psychosocial effect that it has on the individual. An interdisciplinary approach allows for an all-round treatment plant to be executed successfully. The discussed management of amelogenesis imperfecta using fixed prosthodontics is a highly preferred method of treatment. It was planned keeping the high esthetic demand of the patient in mind without compromising the strength and function.
| Acknowledgment|| |
The esthetic appeal of these restorations would not have been possible without the dedication and patience of Mr. Danesh Vazifdar, Adaro Dental Laboratory, Mumbai.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12]