Non-invasive rehabilitation of hypoplastic amelogenesis imperfecta of a 14-year-old child

Majda Taher Elfseyie; Suha Ali Alfirjani; Bobaker Eed Said

doi:10.4103/SDJ.SDJ_23_22

CASE REPORTS

Year : 2022 | Volume : 6 | Issue : 2 | Page : 94-100

Non-invasive rehabilitation of hypoplastic amelogenesis imperfecta of a 14-year-old child

Majda Taher Elfseyie¹, Suha Ali Alfirjani², Bobaker Eed Said¹
¹ Department of Pediatric Dentistry, Faculty of Dentistry, University of Benghazi (UOB), Benghazi, Libya
² Department of Conservative Dentistry, Faculty of Dentistry, University of Benghazi (UOB), Benghazi, Libya

Date of Submission	15-Apr-2022
Date of Decision	03-Apr-2022
Date of Acceptance	20-Apr-2022
Date of Web Publication	12-Jul-2022

Correspondence Address:
Majda Taher Elfseyie
Department of Pediatric Dentistry, Faculty of Dentistry, University of Benghazi, Benghazi
Libya

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/SDJ.SDJ_23_22

Abstract

Background: Amelogenesis imperfecta is a rare developmental disorder. This condition can be quantitative as the hypoplastic type or qualitative as the hypomineralized hypomatured type. Case Report: This is the first clinical reported case in a 14-year-old Libyan female. It describes the oral management of hypoplastic amelogenesis imperfecta using a non-invasive technique. Management aims to reduce teeth sensitivity, improve esthetics, preserve the vertical dimension of occlusion, and restore masticatory function. Satisfactory results were performed with a more preservative restoration with less expensive treatment. Follow-up observation was designed every 6 months to preserve tooth structure and to prevent excessive wear until the patient reached a suitable age for crown coverage. Conclusion: The clinical significance of such a case is to shed light on the importance of early detection and diagnosis that will help choose an appropriate treatment plan to preserve teeth structure until a crown replacement is reached. Additionally, an increase in the knowledge of general practitioners regarding the early intervention approach of these cases and their effect on treatment outcomes is also provided.

Keywords: Amelogenesis imperfect, composite resin, enamel defect, non-invasive technique

How to cite this article:
Elfseyie MT, Alfirjani SA, Said BE. Non-invasive rehabilitation of hypoplastic amelogenesis imperfecta of a 14-year-old child. Sci Dent J 2022;6:94-100

How to cite this URL:
Elfseyie MT, Alfirjani SA, Said BE. Non-invasive rehabilitation of hypoplastic amelogenesis imperfecta of a 14-year-old child. Sci Dent J [serial online] 2022 [cited 2023 Apr 2];6:94-100. Available from: https://www.scidentj.com/text.asp?2022/6/2/94/350758

Background

Recently, enamel defects have been considered the most active research area in dental hygiene. However, many researchers have focussed their treatment modalities on children and adolescents.^[1] Enamel tooth structure is the hardest tissue in the body because it contains the highest rate of hydroxyapatite crystals compared with other tissues.^[2] Alteration in the molecular pattern and cellular activity during enamel genesis may lead to amelogenesis imperfecta.^[3] Typical enamel structures have increased radiopacities than dentin. Nevertheless, in the hypomature type, enamel and dentin have similar radiopacities.^[4] Despite Worktops’ classification^[5] being the most commonly used classification for amelogenesis imperfecta, the heterogeneity makes their diagnosis in clinical examination is complicated. Based on this classification, amelogenesis imperfecta is an abnormal enamel defect characterized by thin, soft, and discolored enamel. This condition is classified into four subtypes. The first type, the hypoplastic subtype, is characterized by a deficiency in the quantity of enamel and may be observed as thin mineralized enamel or complete absence of enamel in severe cases. Additionally, it is characterized by pitting, lines, and grooves. In radiography, the enamel can be contrasted typically with the dentin. In the second type, the hypomaturated subtype, the enamel is weak premature, slightly soft mottled, and has full thickness. In radiography, this subtype appears with radiodensity similar to dentin. In the third type, the hypocalcified enamel is weak, soft, chalky, opaque, and discolored with average thickness. In radiography, the enamel is observed to be less radio-opaque than dentin. In the fourth type, the enamel is hypomatured, hypoplastic with taurodontism.^[6],[7],[8]

It was reported in previous studies that amelogenesis imperfecta patients experienced many difficulties during typical activities, such as teeth sensitivity, open bite, reduced oral health quality of life, and poor esthetic and masticatory functions.^[1],[9],[10] The treatment plan depends on several factors: patient age, socio-economic status, periodontal condition, patient cooperation, treatment time, and severity of the disorder.^{[11],[12],[13]} Many treatment options have been designed for amelogenesis imperfecta, ranging from preventive to prosthetic treatments. However, a better understanding of amelogenesis imperfecta is required to make the correct diagnosis and an appropriate treatment plan.^[7]

The management of such cases depends on early diagnosis, pain relief, restoration, preventive measures, and follow-up observation.^[8] On the contrary, late-diagnosed cases until adulthood will lead to extensive tooth wear, requiring more complicated dental treatment, extensive time, and cost.^[14] The extension and depth of the lesion play a critical role in treatment planning procedures, either in the use of adhesive restoration by preserving the enamel layer or in the use of crown coverage by removing the enamel completely.^[15]

Several restorative materials have been introduced in the last few years, such as resin-modified glass ionomer cement, modified resin composites, indirect adhesives, and metal-ceramic crowns.^[1] It has been reported in previous studies that fixed and orthodontic treatment can be a challenging issue because weak enamel may not withstand orthodontic force.^[16] Some individuals prefer adhesive plastic restoration rather than crowns because it is a more attractive restoration with a regular appearance in their adolescent lives.^[17] Amelogenesis imperfecta cases showed more social avoidances and low self-esteem than subjects without the condition.^[18] Most individuals with amelogenesis imperfecta avoid social life because of tooth discoloration and reduced crown size. Because of these conditions, such individuals are concerned about the comments of other people on their esthetic appearance.^[19] An association between amelogenesis imperfecta and renal disease has been shown in previous studies.^[20]

Therefore, it is strongly recommended that such cases be referred to a nephrologist for further investigation.^[12] Early diagnosis of teeth irregularities could help modify the treatment plan and reduce the time and cost of procedures.^[21],[22] This is the first reported case of amelogenesis imperfecta in Libya. Therefore, early detection of such anomalies will increase baseline data in Libya. This could help reduce the complexity and minimize the future cost of treatment. Moreover, it highlights the importance of early diagnosis and intervention to help general practitioners make differential diagnoses from molar incisor hypomineralization and fluorosis.

Case Report

A Libyan female aged 14 years came to the dental clinic complaining of severe pain related to the lower right first permanent molar, badly discolored teeth, a history of easily fractured teeth, and sensitive teeth. The personal information of the patient, along with the family history and medical history of the child and the mother, was recorded in detail to exclude the differential diagnosis and to determine the possible etiological factors. The clinical examination was performed using a diagnostic kit (probe-mirror-periodontal probe). It was shown in an intraoral examination that the patient had poor hygiene with multiple caries teeth, with the presence of calculus on the lingual surface of lower anterior teeth and bleeding on probing. Hypoplasia of all upper and lower anterior teeth (central and lateral incisors and canines) with grooves and pigmented line pits and thin enamel was shown in the clinical and radiographic examination. The labial view had pigment pits, grooves, and fractured enamel areas with diffuse opacities and irregular enamel surfaces, with severe attrition of the incisal edges of all anterior teeth.

In contrast, the upper and lower posterior teeth (first and second molars) had a crown to wear and diffuse opacities with discoloration and reduction on the occlusal height. Lip competence, a straight facial profile without facial asymmetry, and neither palpable lymph node nor joint disorder were revealed in an extraoral examination [Figure 1] and [Figure 2].

Figure 1: Pre-treatment: (a) Frontal view. (b) Lateral view. (c, d) Smile view. (e) Occlusal view. (f) Mandibular view

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Figure 2: Digital panoramic radiograph showing hypoplastic amelogenesis imperfecta

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Treatment Plan

Because of an improper diagnosis, the patient had a history of an extracted upper left first permanent molar due to decay and fracture amalgam restoration with recurrent caries in the lower right first permanent molar. A poor prognosis of the previously filled first molar and extraction were revealed by radiographic examination and clinical evaluation. The lower anterior teeth were scaled, and oral hygiene instruction was explained to the patient to maintain oral health. Non-invasive treatment with direct composite resin was considered the first option in the management of this case because of the less destructive and low-cost procedures. First, a rubber dam was constructed to achieve a desirable isolation level. Then, all pits, grooves, and weak cusps were trimmed in the lower right and left posterior teeth (first and second molars).

Caries were removed and then restored with composite resin. The upper right and left molars (first and second) were prepared and restored on the following appointment. Composite resin restoration was performed to preserve the occlusal dimension and functional demand. Therefore, the posterior teeth were restored first. All upper central incisors and laterals were prepared with the rotary instrument during the next visits. Enamel was etched with 34% phosphoric acid. Then, the surface dried, and the bond and adhesive were applied and polymerized. Next, the direct composite resins were applied by the increment technique and polymerized according to the manufacturer’s recommendations. The lower incisors and laterals and the upper and lower canines were restored. The incisal edge was termed carbon strips. Finishing and polishing were performed to remove excess resin. The composite resin maintains the reaming teeth structure and restores its esthetic appearance and function. The patient was satisfied with the treatment outcome [Figure 3].

Figure 3: Post-treatment views. (a) Frontal view. (b) Lateral view of the left side. (c) Lateral view of the right side

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Discussion

The management of amelogenesis imperfecta is a complex interdisciplinary approach to achieving optimal treatment outcomes. The treatment takes a long time, from childhood to adulthood.^[23],[24] Additionally, many researchers have reported that the oral rehabilitation of amelogenesis imperfecta requires a multidisciplinary approach. Reversible non-invasive treatment with composite resin should be considered the first option before invasive technique for patients in their late teens and early twenties.^[25] The management of severely affected patients can be challenging for dentists. The age, and the quality of the affected enamel of the patient must be carefully evaluated to select the best treatment option. Restoring function and esthetics in the early diagnosis of amelogenesis imperfecta is the most favorable situation.^[26],[27] However, iatrogenic treatment will be unavoidable in late diagnosis cases. Many researchers have recommended covering the first permanent molars with stainless steel crowns and the other teeth with composite resin or veneer until adult age.^[18] This agrees with the researchers who recommended delaying the invasive technique until the late teens, which involves porcelain veneer, gold coverage, porcelain-bonded metal, dentin-bonded crown, and an all-ceramic crown.^[25]

Recently, researchers revealed the short longevity of composites in hypomineralized or hypomatured cases rather than hypoplastic amelogenesis imperfecta because the poor bonding strength of hypomineralized enamel leading to failure of restoration may be compensated with multiple restoration replacements. Moreover, quality of composite resin and glass ionomer cement was lower than that in subjects without the condition.^[18] Therefore, 5% sodium hypochlorite was used to manage hypoplastic amelogenesis imperfecta in 11-year-old females to improve the bonding step for the orthodontic and composite restoration of the affected teeth.^[28] It was revealed in another similar study that applying sodium hypochlorite after acid etching can improve the bonding step of a composite.^[29] Because of the low financial status of the patient, metal-ceramic was performed as a final restoration to cover all canines and posterior teeth of 21-year-old males who presented with discolored hypoplastic enamel. Initially, the teeth were covered with provisional restoration after the crown lengthening procedure.^[15]

In contrast, the invasive technique becomes unavoidable in late diagnosis cases with aggressive teeth destruction, such as a reported case aged 19 years who presented with extreme teeth sensitivity, poor esthetic, and masticatory function. Several teeth were extracted, including maxillary and mandibular lateral incisors, second premolars, and second and third molars. Additionally, crown lengthening and a metal-ceramic crown were performed for the rest of the teeth. No pathological change was observed in the follow-up observation, and the patient was satisfied with the treatment outcome.^[30] In contrast, a prosthetic appliance was performed to achieve better esthetic and occlusal function in Iranian females aged 18 years who presented with discolored, stained, and pitted hypoplastic teeth.^[31] Additionally, there was also a reported case of hypomatured amelogenesis imperfecta in an 18-year-old Turkish male. In this case, multiple teeth were extracted due to caries, such as the maxillary second premolars, mandibular right second premolar, and the second left molar. A metal-ceramic fixed partial denture was constructed for the posterior teeth, whereas porcelain laminate veneers were built for the maxillary.^[32] Similarly, a rough, irregular surface without a difference in density between enamel and dentin and teeth extracted due to decay was revealed by the reported amelogenesis imperfecta.^[33]

There was another reported case of hypoplastic amelogenesis imperfecta in a 19-year-old Iranian female. In this case, the female presented with discolored teeth and thin incisor edges, an anterior open bite, and a short posterior crown. A porcelain laminate crown was constructed for the anterior teeth, whereas an all-ceramic crown was performed for premolar teeth and a metal-ceramic crown for upper posterior teeth.^[34] Similarly, a case of a 28-year-old Turkish female reported with hypoplastic amelogenesis imperfecta was managed with porcelain laminated veneers, metal-ceramic fixed partial denture, and composite restoration.^[35]

Another significant impact of hypoplastic amelogenesis imperfecta, tooth sensitivity, and mastication difficulty was reported in an 8-year-old Brazilian girl. In this case, fluoride was applied to prevent and reduce tooth sensitivity. Interceptive orthodontic treatment was used to preserve the vertical dimension. The indirect composite crown and direct composite resin were also performed to restore the posterior and anterior teeth.^[36]

Two affected cases had severe tooth wear, extensive caries, and poor bonding of hypoplastic enamel. In the first case, patients aged 18 years were managed with porcelain veneers for anterior teeth. When the patients reached 19–22 years, all posterior teeth were restored with metal-ceramic restoration. Then, it was replaced with ceramic crowns for esthetic purposes. The second case was a 22-year-old male who had severely affected the enamel, loss of occlusal dimension, gingival overgrowth of anterior teeth, and gingiva recession on posterior teeth. Thus, complex treatment was required to restore the esthetic and function, whereas extraction of badly destructive canines was performed. Then, an implant replacement was followed. Additionally, crown lengthening surgery of the anterior teeth was performed. Afterward, the anterior teeth were covered with an indirect composite veneer and a thin gold crown for the posterior teeth.^[14]

In contrast, some researchers have reported that composite fractures could be easily repaired. However, metal-ceramic crown failure tended to involve endodontic therapy and extraction.^[29] However, some researchers have complained about the technique sensitivity that can be managed by adding a new restoration layer. At the same time, the staining of the composite can be removed by polishing the restoration.^[25]

Also, the composite resin is a more conservative material with excellent esthetic results.^[37] There are many alternative approaches for the oral rehabilitation of amelogenesis imperfecta, as crown covering is a more invasive technique. However, most researchers focus on using porcelain laminate veneers because they are more conservative with high patient satisfaction. It has the disadvantages of marginal adaptation and bonding problems.^[35] As skeletal growth is completed, prosthodontic rehabilitation is indicated to prevent further tissue loss.^[4] Children with amelogenesis imperfecta are considered a significant challenge in dental clinics. However, multidisciplinary teams involving the general practitioner, pediatric, and restorative specialists are essential to achieve a better and more satisfying treatment outcome. Finally, the direct bond composite resin is considered an excellent transitional restoration for maintaining the teeth structure of weakened teeth.

Conclusion

Amelogenesis imperfecta has many impacts on the quality of life of patients, leading to social avoidance, psychological problems, and extensive treatment procedures. Therefore, early management of these cases is essential to reduce the progress of damaged tooth structures. Additionally, the financial status of the patient has a significant effect on the success of the treatment plan. This approach is considered a semi-permanent solution that helps in reducing teeth damage until the patient reaches a suitable age to receive complete oral rehabilitation with either a full-coverage composite or a metal-ceramic crown.

Acknowledgment

The authors are grateful to the Future Clinic Center for providing all the assistance, facilities, and equipment needed to manage the reported case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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