AMELOGENESIS IMPERFECTA - A CASE REPORT WITH FULL MOUTH REHABILITATION

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1 International Journal of Dental Research & Development (IJDRD) ISSN(P): ; ISSN(E): Vol. 6, Issue 5, Oct 2016, 1-8 TJPRC Pvt. Ltd. AMELOGENESIS IMPERFECTA - A CASE REPORT WITH FULL MOUTH REHABILITATION HEMALATHA. P 1 & SUNIL KUMAR 2 1 Professor, Department of Conservative Dentistry, Best Dental Science College, Madurai, Tamil Nadu, India 2 Assistant Professor, Department of Dental Technology, King Khalid University, Abha, Saudi Arabia ABSTRACT Amelogenesis Imperfecta is a hereditary disorder affecting enamel, with discoloration, pitting, partial to complete worn out of enamel resulting in reduced vertical dimension affecting the facial aesthetics. It may also manifest with congenital missing teeth and multiple impacted teeth. In the present clinical scenario of 19 years old female with amelogenesis imperfecta was reported. All her impacted teeth and root stumps were extracted. Owing to the reduced height of the crown an intentional root canal therapy with crown lengthening procedure were done for all the remaining teeth. Vertical dimension was increased and all the teeth were restored with ceramic crown. KEYWORDS: Amelogenesis Imperfecta, Crown Lengthening Received: Aug 20, 2016; Accepted: Sep 06, 2016; Published: Sep 08, 2016; Paper Id.: IJDRDOCT20161 INTRODUCTION Amelogenesis imperfect is a heterogeneous inherited disorder of the tooth that expresses a group of conditions that cause developmental alterations in the structure of enamel, affecting both primary and permanent teeth that causes teeth to be unusually small, discolored, pitted or grooved and prone to rapid wear and breakage. The manifestations vary greatly among individuals with discoloration yellow, brown or gray, generalized areas of dentin exposed, pitted enamel with an increased susceptibility to plaque accumulation, caries and hypersensitivity to temperature changes 1. Case Report Generally, the literature describes three types of AI: hypocalcified, hypoplastic and hypomaturation. In the hypoplastic type there is a deficiency in the quantity of enamel. In hypocalcified type the enamel is formed in relatively normal amount but is poorly mineralized, soft and friable and can be easily removed from the dentin. In hypomaturation type teeth has mottled appearances, opaque white to red-brown coloration and enamel tends to chip from underlying dentin, sensitive, brittle and shows atypical crown morphology. Other dental anamolies associated with amelogenesis imperfect include poor dental aesthetics, multiple impacted teeth, congenitally missing teeth, open occlusal relationship decreased occlusal vertical dimension and taurodontism 2-7. The aim of this article is to do complete rehabilitation to improve facial aesthetics and functional need of the patient. Case Report A 19 years old female patient has reported with a chief complaint of discoloured, ugly looking, small sized tooth, with sensitivity to thermal changes. She was self-conscious about appearance of her teeth and her mother confirmed that the patient has been socially affected by her teeth appearance (Figure 1). A detailed medical editor@tjprc.org

2 2 Hemalatha. P & Sunil Kumar and social history was obtained which were normal. Patient s hair, nails and skin were normal. Intra oral examination revealed missing teeth 13, 21, 23, 41, 43, 44, 46, retained deciduous 83, 86 and root stumps in relation to 36. Generalized yellowish brown discoloration of the teeth were seen and the tooth surface chipped on probing. Generalized attrition was present. Vertical height of the face looked reduced. Clinical crown height was short. Radiographic Examination (Figure 2) OPG and full mouth IOPA radiographs revealed impacted 13, 23,28,43,44 and 46. Total obliteration of pulp chamber with 16,12,22,24,26,37,45, and partial obliterate on of pulp chamber with 17,15,14,25,35,34,32 was seen. No evidence of any periapical pathology. Diagnosis Amelogenesis imperfect with multiple impacted teeth. Treatment Plan (Figure 3) Upper and lower arch diagnostic impressions were made with dust free chromatic alginate (Tropicalgin, Zhermack part no ). Study casts were poured with type III dental stone and were mounted in a three point articulator. After clinical and radiographic examination treatment plan was formulated. Oral prophylaxis. Extraction of root stumps and surgical removal of impacted teeth. Root canal treatment of all remaining teeth. Crown lengthening Increase of vertical dimension. Full mouth rehabilitation with metal ceramic crowns to restore the function & esthetics. Treatment Procedures Extraction of the impacted teeth 13, 23, 28, 43, 44, 46, root stumps -36 and retained deciduous teeth 83, 86 was carried out under local anesthesia quadrant wise. Patient was reviewed and sutures were removed accordingly. After satisfactory wound healing, oral prophylaxis was carried out. Root canal treatment was planned for all the teeth present in the oral cavity owing to the thin amount of tooth structure present over the pulp chamber. Under local anesthesia (Lignok 2% A Lignocaine + Adrenaline) access cavities were prepared with straight fissure bur ( SF ----). Pulps were extirpated with barbed broaches (Neme Braches Tire Nerfs). Working length was determined individually for all the canals in radio visnography (RVG- X Mind, Satelec Acteon). Cleaning and shaping was done with rotary NiTi files Protaper with EDTA. The sequence of files used were SX, S1, S2, F1, F2 with an Endomotar (NSK Endomate DT). Canals were irrigated with copious amount of saline and sodium hypochlorite. Then the canals were dried with paper points. Master cone radiographs were taken in RVG. Obturation was done with 6% Gutta Percha (Protaper GP) with root canal sealant. Coronally the access cavities were sealed with Impact Factor (JCC): Index Copernicus Value (ICV): 6.1

3 Amelogenesis Imperfecta - A Case Report with Full Mouth Rehabilitation 3 temporary restorative material - Provi Plast 3M. Patient was recalled after 15 days and temporary restoratiove materials were removed, teeth were permanently restored with light cure composite resin (Etchant 37% Phosphoric acid, 3M bonding agent 3M ESPE Adper, Tetric N- Ceram Ivoclar were used). Restoration was cured with LED polymerization unit (LEDition from Ivoclar) (Figure 4 & 5). During review period 2mm thick composite resin was added to the occlusal aspect of17, 27, 37, 47 to achieve the increase in vertical dimension. Crown lengthening was planned for better exposure of the tooth structure, to permit proper tooth preparation, and to ensure good marginal seal with retention for both provisional and final restoration. External bevel incisions were placed using 15 sized blade, directed coronally with bevels at 45 to the tooth surface to recreate the normal festooned pattern of the gingiva. After six weeks of evaluation, tooth preparation procedures were carried out. All teeth were prepared except 17, 27, 37 and 47, with shoulder margin to receive metal ceramic crowns (Figure 6). 17,27,37,47 acts as a vertical stop. Impressions were made with alginate (Tropicalgin, Zhermack part no ), casts were poured with type V dental stone. Casts were mounted. Heat cure acrylic temporary crowns were fabricated according to increased V.D.O. Temporary crowns were cemented with non eugenol temporary cement (Freegenol). Patient was reviewed weekly for about one month. She was comfortable with increased V.D.O. and did not show any discomfort in the muscle and TMJ joint. Temporary crowns were removed, teeth were cleaned. Excess cement was removed. Final impressions were recorded by following two stage impression technique by using putty and light body A- silicon impression material (Flexceed, GC lot no ) (Figure 7). Master casts were poured by using type V dental stone. Facebow transfer was carried out using Hanau spring bow (Figure 8). Upper cast was mounted with face bow record in Hanau wide view semi adjustable articulator. Lower cast was mounted (Figure 9). Mounted casts were sent to laboratory for fabrication of metal ceramic restorations. Metal try in was obtained and evaluated for marginal fit and occlusal clearance (Figure 10). It was satisfactory and was sent to the lab for ceramic firing. Semi trial (before glazing) was done to reevaluate the marginal fit and occlusion. High points were checked and relieved in all excursive movements (Figure 11). Esthetics, increased vertical dimension of occlusion and marginal fit were found to be satisfactory. Under proper isolation metal ceramic crowns were cemented using Type I GIC (GC, Lot no ) after final glazing. Excess cement was removed (Figure 12). Patient was reviewed after 6months (Figure 13) and after a year (Figure 14). CONCLUSIONS Previous days restoring esthetics and function were a separate entity. With the advancement of materials, techniques and careful treatment planning by the restorative dentist, managing both esthetics and function has been made a single entity. This case presentation holds a good example for the above mentioned. REFERENCES 1. Hart PS, Wright JT, Savage M, Kang G, Bensen JT,et al.(2003) Exclusion of candidate genes in two families with autosomal dominant hypocalcified amelogenesis imperfect. Eur J Oral Sci, 111, Sengun A, Ozer F. (2002) Restoring function and esthstruetics in a patient with amelogenesis imperfect: a case report.quintessence Int, 33, Rao S. Witkop CJ Jr. (1971) Inherited defects in tooth structure. Birth Defects Orig Artic Ser, 7, editor@tjprc.org

4 4 Hemalatha. P & Sunil Kumar 4. Sundell S, Valentin J. (1986) Hereditary aspects and classification of hereditary amelogenesis imperfect. Community Dent Oral Epidemiol, 14, Aldred MJ,Crawford PJ. (1988) Variable expression in Amelogenesis imperfect with taurodontism.j Oral Pathol, 17, Ooya K, J Nalbandian, Noikura T. (1988) Autosomal recessive rough hypoplastic amelogenesis imperfecta. A case rort with clinical, light microscopic, radiographic and electron microscopic observations. Oral Surgery Oral Medicine and Oral Pathology, 65, KMS Ayers, BK Drummond, Harding WJ, Salis SG, PN Liston (2004) Amelogenesis imperfect- multidisciplinary management from eruption to adulthood. Review and case report. N Z Dent J, 100, APPENDICES Figure 1: Pre Operative View Figure 2: Pre Operative OPG Figure 3: Pre Operative Casts Impact Factor (JCC): Index Copernicus Value (ICV): 6.1

5 Amelogenesis Imperfecta - A Case Report with Full Mouth Rehabilitation 5 Figure 4: Intra Oral Views after Root Canal Treatment With Permanent Composite Resin Entrance Restorations Figure 5: OPG Showing RCT Completed In All Teeth Figure 6: Crown Preparation Figure 7: Rubber Base Putty Impression editor@tjprc.org

6 6 Hemalatha. P & Sunil Kumar Figure 8: Inter Occlusal Record Registration Figure 9: Articulated Models Figure 10: Metal Trail Figure 11: Metal Ceramic Crowns in Cast Impact Factor (JCC): Index Copernicus Value (ICV): 6.1

7 Amelogenesis Imperfecta - A Case Report with Full Mouth Rehabilitation 7 Figure 12: Post Operative View Figure 13: Review after 6 Months Figure 14: Review after 1 Year editor@tjprc.org

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