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Table of Contents
Year : 2014  |  Volume : 4  |  Issue : 3  |  Page : 140-143

Interdisciplinary approach in conservative management of hypoplastic teeth restoring esthetics and function

1 Department of Conservative Dentistry and Endodontics, K.V.G. Dental College and Hospital, Kurunjibagh, Sullia. Dakshina Kannada, Karnataka, India
2 Department of Periodontics, K.V.G. Dental College and Hospital, Kurunjibagh, Sullia. Dakshina Kannada, Karnataka, India

Date of Web Publication18-Dec-2014

Correspondence Address:
Moksha Nayak
Department of Conservative Dentistry and Endodontics, K.V.G. Dental College and Hospital, Kurunjibagh, Sullia. Dakshina Kannada, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2229-5194.147334

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Esthetic dentistry is a combination of measurable dimensions and artistic sensitivity. Complete rehabilitation of smile of a patient with multiple esthetic challenges involves a multidisciplinary approach and presents a considerable clinical challenge. The interactions between new restorative materials and techniques allow the reproduction of dental structures, restoring form and function in such a way that restorative procedures become imperceptible. Porcelain laminate veneer has become one of the most predictable, most esthetic, and least invasive modalities of treatment. This case report describes a methodical procedure of successful esthetic rehabilitation of anterior hypoplastic teeth using a multidisciplinary approach recreating an esthetically and functionally acceptable dentition.
Clinical Relevance To Interdisciplinary Dentistry

  • Hypoplastic teeth present a serious challenge in esthetic dentistry due to reduced amount of enamel.
  • Interdisciplinary approach results in the improvement of the esthetic and functional aspects as well as quality-of-life were observed.

Keywords: Enamel hypoplasia, esthetic dentistry, multidisciplinary approach, veneer

How to cite this article:
Nayak M, Noronha GF, Prasada L K, Pai P. Interdisciplinary approach in conservative management of hypoplastic teeth restoring esthetics and function . J Interdiscip Dentistry 2014;4:140-3

How to cite this URL:
Nayak M, Noronha GF, Prasada L K, Pai P. Interdisciplinary approach in conservative management of hypoplastic teeth restoring esthetics and function . J Interdiscip Dentistry [serial online] 2014 [cited 2023 Jun 10];4:140-3. Available from: https://www.jidonline.com/text.asp?2014/4/3/140/147334

   Introduction Top

Success in esthetics requires a standard of treatment with skills to achieve a natural looking smile and not merely to correct pathologic irregularities. [1] Enamel hypoplasia is a serious disturbance that occurs during the stages of enamel formation which impact the quality and/or quantity of the enamel formed, depending on the phase of amelogenesis that is affected and the duration of the stimulus on the ameloblasts. It can be characterized as white flecks, narrow horizontal bands, lines of pits, grooves, and discoloration of the teeth varying from yellow to dark brown. [2] However, restoration of these defects is important not only due to esthetic and functional concerns but also because of the psychological impact this improvement effects. [3] Porcelain laminate veneers are modern ceramic materials with predictable and long-lasting esthetics requiring minimally invasive preparation designs. [4] The article highlights an interdisciplinary approach for a successful rehabilitation of smile of a patient with multiple esthetic challenges. [5]

   Case report Top

A 27-year-old male patient who was self-conscious about the appearance of his teeth with a chief complaint of "desire to improve esthetics" due to the existing fractured composite restoration and malformation had reported to Department of Conservative Dentistry and Endodontics, K.V.G Dental College, Sullia. Patient desired for a lighter color and a natural looking teeth without any orthodontic treatment [Figure 1].

Medical history was noncontributory. Complete facial and dentogingival esthetic analysis was performed leading to a diagnosis of enamel hypoplasia associated with diastemata and poor tooth and gingival proportions.

A treatment plan was designed with an aim of improving the gingival esthetics, malocclusion, improving the patient's appearance with gingivoplasty, bleaching, composite restoration, and porcelain laminate veneers which involved a multidisciplinary approach. The patient was informed of the diagnosis and treatment plan, which he accepted.

A wax-up was fabricated which indicated the necessary shape and level of gingiva and also the proportion, shape, position of the teeth. The stone cast with diagnostic wax-up was used to fabricate the surgical template, preparation guide, and a putty index.

Soft tissue therapy was initiated after initial oral prophylaxis. A soft acetate template, 1 mm in thickness was used as a guide to establish the pleasant gingival contour and to rearrange zenith positions. Gingivoplasty was done, and normal contour of the gingival margin was restored thus achieving the objectives of anterior pink esthetics.

After complete healing of soft tissue, the next phase of therapy consisted of in-office bleaching of his teeth. This was done to reduce the discoloration of teeth so that it is not seen through veneers. Preoperative shade was determined. Teeth were cleaned with pumice and water slurry. Gingival barrier was applied and cured. Fast acting bleaching material (Pola office) was then applied according to manufacturer instructions. The postoperative shade of teeth obtained was one shade lighter then preoperative shade.

Prior to preparation of teeth, the shade of ceramic veneers was chosen. Since the patient wanted a lighter shade, A3 in the gingival one third, A2 in incisal two-thirds, were considered. As the veneers were given only for anterior six teeth, the adjacent premolars which were mildly hypoplastic were restored with a composite restoration of A2 shade. The maxillary anterior teeth were also restored with composite in areas of dentinal exposure and irregularities to aid in preparation for veneer restoration.

Tooth reduction began using a 0.5 mm depth cutting bur on the labial surface [Figure 1]. Further reduction was done using a long tapered round ended diamond bur, creating definite finishing lines gingivally and interproximally [Figure 2]. Preparation guides which were fabricated using poly viny siloxane were used to determine the amount of tooth reduction to obtain the desired results.
Figure 1: Preoperative retracted view

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Figure 2: Veneer tooth preparation

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Once the preparation was complete ultrapak #00 plain knitted retraction cord was placed on the prepared teeth using single cord technique and putty wash double stage impression of full arch was taken with a polyvinyl siloxane impression material and an occlusal registration was made, photographs of the prepared teeth with and without shade tabs were sent to lab along with wax up and notation for any alteration on the wax-up.

The putty matrix was used as a matrix for the temporary restorations. The preparations were spot-etched using phosphoric acid for 30 s in the middle of each prepared toot. Then the teeth were rinsed and dried. A small amount of bonding agent was placed on the area that was etched, and light cured for 5-10 s.

The putty matrix loaded with an auto mix temporary material (Luxatemp) using an A2 shade was inserted into the mouth and allowed to set for 5 min. On the removal of matrix, a highly detailed esthetic provisional restoration was in place which was an exact duplication of the wax-up. Excess of temporary material was trimmed off using #12 scalpel blade and finished using composite finishing instruments.

In the next appointment, try in was done with veneers obtained from the laboratory to evaluate the fit, shade and contours. Since there were still modifications to be made in the veneers, it was sent back to the laboratory with written laboratory prescription with details on the desired final result.

The desired modifications were made in the veneers and were now ready for cementation. The teeth were isolated, etched with 37% phosphoric acid solution for 30 s and then rinsed and dried. Next, a bonding agent was applied, air thinned and light-cured for 10 s/tooth. The etched and silanized veneers were then individually loaded with A2 shade dual-cure resin cement and carefully seated to place. Excess cement was removed after 2 s of light curing and continued to light cure for a total of 60 s. Successful results were obtained, and patient was extremely satisfied with the final outcome of the treatment [Figure 3].
Figure 3: Postoperative retracted view

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   Discussion Top

Enamel hypoplasia has been rated based on the classification system published by the International Dental Federation for Developmental Defects of Enamel, which determines four types: (a) Pits or cavities, (b) horizontal recesses, (c) vertical recesses, and (d) areas lacking enamel. This system determines 3° of severity: Mild, medium and intense, based on the breadth and depth of the imperfections. [6] In the present case, patient presented with a medium degree of enamel hypoplasia lacking areas of enamel.

Evidence-based dentistry is the use of current best evidence in making decisions about the care of individual patients. [7] Tooth bleaching represents a minimally noninvasive step; composite resin restorations can produce excellent esthetic results. As stated by  Andrews et al., in most severe cases, porcelain veneers appear to be the best option. [8] Porcelain veneers have an excellent esthetics and considerable longevity. However, lack of enamel is one of the main cause of failure of porcelain laminate veneers. [9]

The biological width is essential for the preservation of periodontal health, which itself is dependent on a properly designed restoration. [10] Kois has suggested that the position of the osseous crest be used to determine margin placement. The clinician can place the crown margin 3 mm from the crest of bone. [11] Favorability was assessed, and gingivoplasty was planned to establish a healthy oral environment with the tissue in the desired location and expose more of the enamel for bonding to occur. The postoperative photograph shows gingival symmetry, improvement of oral health and a much more esthetic appearance. Discolored teeth are also a challenge in obtaining an esthetic outcome in the anterior region. [12] Bleaching of mild or moderate hypoplasia is often considered practical because it may negate the need for masking by the ceramist. Potential adverse effects of bleaching on bonding strength have been well-recognized. A possible mechanism is the inhibition of polymerization of the bonding agent by the residual oxygen formed during bleaching. An interval of 2 weeks is found to be adequate to avoid such adverse effects. [13]

Enamel hypoplasia is often associated with sclerotic dentin. Reduced bonding efficacy has been documented in sclerotic dentin due to obliteration of dentinal tubules and the presence of an acid-resistant hypermineralized layer. In order to overcome these problems extending etching periods have been recommended for conventional adhesive systems, while the application of acids is suggested prior to self-etching adhesives. [8]

Various techniques for accurate tooth reduction include using silicone matrices, freehand preparation, and depth limiting burs [14] Retraction cord allows an impression of the tooth surface beyond the margins to be captured which ensures accurate and complete capture of the entire margin and aids in obtaining the correct cervical profile for the restorations. The veneers were fabricated from Pressed lithium disilicate porcelain. This allows the incorporation of multiple shades and characterizations into the porcelain while maintaining minimal thickness. [15] When the postoperative photos were viewed, it was apparent that the black triangle was present between the two central incisors.   Wu et al. demonstrated that if the alveolar crest distance to the contact point is equal to or <5 mm, the papilla will be present in almost 100% of cases. [16] The patient was recalled after 3 months, and the black triangle was filled with interdental papilla thus restoring esthetics.

A well-developed treatment plan with an esthetic objective is a prerequisite in treating enamel hypoplasia alleviate the self-esteem of an individual. Cosmetic dentistry in correlation with other disciplines and modern dental materials like porcelain veneers makes possible to achieve a healthy radiant smile.

   References Top

Goldstein RE. Esthetic treatment planning. Esthetics in Dentistry. 2 nd ed., Vol. 1. Ch. 2. Hamilton, London: B.C. Decker Inc.; 1998. p. 17-49  Back to cited text no. 1
Martos J, Gewehr A, Paim E. Aesthetic approach for anterior teeth with enamel hypoplasia. Contemp Clin Dent 2012;3:S82-5.  Back to cited text no. 2
Soares CJ, Fonseca RB, Martins LR, Giannini M. Esthetic rehabilitation of anterior teeth affected by enamel hypoplasia: A case report. J Esthet Restor Dent 2002;14:340-8.  Back to cited text no. 3
Lerner JM. Conservative aesthetic enhancement of the maxillary anterior using porcelain laminate veneers. Pract Proced Aesthet Dent 2006;18:361-6.  Back to cited text no. 4
Polack MA, Mahn DH. Biotype change for the esthetic rehabilitation of the smile. J Esthet Restor Dent 2013;25:177-86.  Back to cited text no. 5
Pitsios T, Zafiri V. Frequency and distribution of enamel hypoplasia in ancient skulls from different eras and areas in greece. Int J Caring Sci 2012;5:179-90.  Back to cited text no. 6
Ballini A, Capodiferro S, Toia M, Cantore S, Favia G, De Frenza G, et al. Evidence-based dentistry: What's new? Int J Med Sci 2007;4:174-8.  Back to cited text no. 7
Andrews P, Levine N, Milnes A, Pulver F, Sigal M,Titley K. Advances in the treatment of acquired and developmental defects of hard dental tissues. Curr Opin Dent 1992;2:66-71.  Back to cited text no. 8
Nalbandian S, Millar BJ. The effect of veneers on cosmetic improvement. Br Dent J 2009;207:E3.  Back to cited text no. 9
Sharma A, Rahul GR, Gupta B, Hafeez M. Biological width: No violation zone. European J Gen Dent 2012;5:137-41.  Back to cited text no. 10
Sonick M. Esthetic crown lengthening for maxillary anterior teeth. Compend 1997;18:807-20.  Back to cited text no. 11
Calamia JR, Levine JB, Lipp M, Cisneros G, Wolff MS. Smile design and treatment planning with the help of a comprehensive esthetic evaluation form. Dent Clin North Am 2011;55:187-209, vii.  Back to cited text no. 12
Li Y. Safety controversies in tooth bleaching. Dent Clin North Am 2011;55:255-63, viii.  Back to cited text no. 13
Mizrahi B. Porcelain veneers: Techniques and precautions. Int Dent SA 2007;9:6-16.  Back to cited text no. 14
Radz GM. Minimum thickness anterior porcelain restorations. Dent Clin North Am 2011;55:353-70, ix.  Back to cited text no. 15
Wu YJ, Tu YK, Huang SM, Chan CP. The influence of the distance from the contact point to the crest of bone on the presence of interproximal dental papilla. Chang Gung Med J 2003;26:822-8.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3]


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