Cse Report Print ISSN: 2321-6379 Online ISSN: 2321-595X DOI: 10.17354/ijss/2016/641 Dentl Rehilittion of Ptients with Amelogenesis Imperfect using Zirconi Crowns, Stinless Steel Crowns, nd Composite Veneers: A Cse Report Rghdh Emd Adruh 1, Ahmed Mohmmed Howidi 2 1 Specilist, Deprtment of Peditric Dentistry, King Adulziz University Dentl Hospitl, Jeddh, Sudi Ari, 2 Stff Dentist, Deprtment of Restortive Dentistry, Ntionl Gurd Helth Affirs Hospitl, Jeddh, Sudi Ari Astrct Amelogenesis imperfect (AI) is relted to group of developmentl tooth normlities (lso referred s hereditry dysplsi), which ffect the genome of the individul nd retrd t lest one of the stges of enmel formtion. AI is, in generl, hereditry disorder with clinicl impct on oth deciduous nd permnent teeth. Ptients with AI often complin of tooth sensitivity, difficulty in chewing, self-consciousness out the ppernce of their teeth, nd n nterior open ite. We present cse report of AI (hypoclcified), which ws dignosed sed on clssicl clinicl nd rdiogrphic fetures. Key words: Amelogenesis imperfect, Composite, Esthetics, Stinless steel crowns, Zirconi crowns INTRODUCTION Amelogenesis imperfect (AI) is group of inherited disorders chrcterized y norml or incomplete formtion of the dentl enmel; it mnifests itself in oth the primry nd the permnent dentition. Estimtes of the prevlence of AI pper to vry from one popultion to nother. A Swedish study rrived t the conclusion tht one out of every 700 individuls is ffected y AI, while study conducted in North Americ determined tht it ffects one person out of every 14,000 individuls. 1 Ptients with AI re frequently complin of tooth sensitivity. Anterior open ite frequently occurs s consequence of AI. Four types of AI hve een identified, nd they re clssified ccording to the phenotypes ssocited with them. Type I is chrcterized y hypoplstic enmel; www.ijss-sn.com Access this rticle online Month of Sumission : 10-2016 Month of Peer Review : 11-2016 Month of Acceptnce : 11-2016 Month of Pulishing : 12-2016 the enmel tht is present is well minerlized, ut the mount of enmel present is less thn norml. Type II is chrcterized y hypominerlized enmel; its most noticele feture is discolored enmel. Hypominerlized enmel cn pper rown, yellow, or mottled. Type III is chrcterized y hypoclcified enmel; the enmel is drk nd so soft tht it is esily scrped y the instruments used in dentl prophylxis. Type IV is chrcterized y dentl enmel tht is oth hypomtured nd hypoplstic. By fr, the most common type of AI is the hypoplstic type, which ccounts more thn 60% of cses. The hypomturtion type ccounts for t lest 20% of cses, nd 7% of cses of AI re of the hypoclcified type. 1 Inheritnce ptterns of AI cn e utosoml dominnt, utosoml recessive, or X-linked. Hldne identified AI s the first dominnt X-linked trit found in humns. 2 While AI ffects oth sexes, its presenttion in mles is different from tht in femles. Schulze nd Lenz (1952) noted tht hypoplstic AI tends to present s uniform hypoplsi in mles. Wheres in femles, the hypoplsi ppers s verticl ridges in the dentl enmel. 3 Likewise, in mles with hypomturtion type AI, the mottling of tooth enmel is present ll over the tooth, ut in ffected femles, the mottling occurs in verticl nds nd is less noticele thn Corresponding uthor: Dr. Rghdh Emd Adruh, Deprtment of Peditric Dentistry, King Adulziz University Dentl Hospitl, P. O. Box 54390, 21514 Jeddh, Sudi Ari. E-mil: redroh@ku.edu.s 179 Interntionl Journl of Scientific Study Decemer 2016 Vol 4 Issue 9
Adruh nd Howidi: Amelogenesis Imperfect the mottling in the teeth of ffected mles. These findings re consistent with the Lyon hypothesis. 4 All types of AI present sustntil chllenges from the perspective of dentl cre nd orthodontics. Ptients with AI usully hve tooth sensitivity tht mkes everydy mintennce of dentl hygiene even more difficult. Mnifesttions such s decresed occlusl verticl dimension nd nterior open ite cn mke chewing difficult; ecuse of these orthodontic fctors nd ecuse of the tooth sensitivity, some ptients with AI void eting hrd foods. 5 Other complictions of AI cn include congenitlly missing teeth, impcted teeth, root nd crown resorption, norml root formtion, pulpl clcifiction, nd turodontism. 6 Despite these prolems tht cn rise from AI, the concerns tht led mny prents of children with AI to seek tretment for the condition re esthetic ones. The normlities ssocited with AI re so noticele nd so trouling to ffected children nd their prents tht erly nd rdicl interventions should e done s erly s possile on erly mixed dentition to reduce tooth sensitivity, restore norml chewing function, nd improve the esthetic ppernce of the teeth to minimize negtive socil consequences. 7 Tretment Pln The prents were informed of the dignosis, nd ll the tretment modlities were discussed with them. As prt of the tretment pln, the tretment lterntives were explined to the child nd his prents. This included the mount of tooth structure tht needs to e removed, the expected clinicl longevity of the restortions, nd the length of the tretment period. After considering ll the tretment options, it ws decided to plce direct composite veneers (3M ESPE Filtek Z250 universl restortive) on the permnent lower nd upper incisors, zirconi crowns (NuSmile) on the primry molrs nd cnines, nd stinless steel crowns (SSCs) (3M ESPE ) on the 1 st permnent molrs. After completing the dentl rehilittion, the ptient will e referred to n orthodontist. Clinicl Mngements Initil periodontl therpy consisted of orl prophylxis nd orl hygiene instructions, scling, nd root plning. A universl restortive composite ws chosen to restore the defective tooth structure of the permnent incisors. No preprtions were performed on the incisors, other thn clening with rotry ristle rush with pumice CASE REPORT An 8-yer-old mle reported to the Peditric Dentistry Deprtment t King Adulziz University Dentl Hospitl with the chief complint of yellowish discolortion of his primry nd permnent teeth, which mnifested therml sensitivity nd d reth. A detiled medicl, dentl, nd socil history ws otined. The ptient ws exmined dentlly nd mediclly. However, medicl history nd fmily history were unremrkle. Cliniclly, the child s orl hygiene ws unstisfctory, he rushes his teeth irregulrly, nd he exhiited chronic mrginl gingivitis. Clinicl exmintion lso showed tht enmel thickness of ll teeth ws reduced, nd in some teeth, dentin ws exposed. The teeth hd drk yellowish discolortion with severe nterior open ite (Figure 1-e). Rdiogrphic investigtion included n orthopntomogrm done (Figure 2). Tretment Ojectives The tretment ojectives were to improve the esthetics, eliminte the tooth sensitivity, prevent further loss of tooth structure, modify the child s ttitude nd ehvior towrd dentl tretment, nd improve his periodontl helth y using model to demonstrte proper rushing techniques to the ptient nd his fmily. c d e Figure 1: (-e) Pre-opertive clinicl picture showing irregulr drk yellow-discolored lil surfce of mxillry nd mndiulr teeth Figure 2: Pre-opertive pnormic rdiogrph Interntionl Journl of Scientific Study Decemer 2016 Vol 4 Issue 9 180
Adruh nd Howidi: Amelogenesis Imperfect prior to cid etching with 35% phosphoric cid for 30 s followed y rinsing with wter spry nd fter tht, onding nd light curing. The lil surfces of the mxillry nd mndiulr incisors were then directly restored with resin composite. Mndiulr right lterl incisor ws left un-restored s it prtilly erupted (Figure 3). Preformed SSCs (3M) were plced following miniml slice preprtions of the permnent 1 st molrs (Figure 4 nd ). Preformed zirconi crowns (NuSmile) were plced following moderte preprtion of the primry molrs nd cnines (Figure 4 nd ). The dpttion nd qulity of the mrgins of the preformed SSCs nd the zirconi crowns were evluted using pnormic (Figure 5) nd itewings rdiogrphs (Figure 6 nd ). The SSCs on the first permnent molrs re temporry restortions only. Once the second permnent molrs nd premolrs estlished the level of the occlusl plne, nd the SSCs on the first permnent molrs were replced y cst full-coverge restortions, the ptient ws referred to n orthodontist. Follow-up Every 6 monthly follow-ups were done t 18-month period. 6 months After the completion of tretment, no deteriortion ws visile in the restortions. The gingiv ws slightly inflmed, nd hevy clculus ccumultion ws seen due to insufficient rushing. The lterl incisors erupted (Figure 7-c). Scling nd root plning were done, nd orl hygiene ws reinforced. 18 months No deteriortion ws visile in the restortions. The 1 st upper left premolr erupted, gingiv ws slightly inflmed due to insufficient rushing nd clculus ccumultion (Figure 8-c). Scling nd root plnning were done, nd orl hygiene ws reinforced. Tretment Outcomes The ppliction of zirconi crowns, composite veneers, nd SSCs ws success. The tretment improved the verticl dimension of the ptient s teeth, mde chewing esier, nd reduced tooth sensitivity. The zirconi crowns nd composite veneers on the nterior teeth hd the desired esthetic ppernce. Figure 3: Post-opertive clinicl picture showing esthetic composite veneering in mndiulr nd mxillry incisors Figure 5: The post-opertive pnormic rdiogrph fter restortions of ll the erupted teeth Figure 4: () Post-opertive clinicl picture showing composite veneering nd stinless steel crowns in 1 st permnent molrs nd zirconi crowns in primry molrs nd cnines in mndiulr rch. () Post-opertive clinicl picture showing composite veneering nd stinless steel crowns in 1 st permnent molrs nd zirconi crowns in primry molrs nd cnines in mxillry rch Figure 6: () The post-opertive itewing rdiogrph showing dpttion nd qulity of the mrgins of the preformed stinless steel nd zirconi crowns in the right side. () The post-opertive itewing rdiogrph showing dpttion nd qulity of the mrgins of the preformed stinless steel nd zirconi crowns in the left side 181 Interntionl Journl of Scientific Study Decemer 2016 Vol 4 Issue 9
Adruh nd Howidi: Amelogenesis Imperfect If this does not improve his rushing hits, he my need to visit the dentist s office more frequently for prophylxis. DISCUSSION The ptient ws dignosed with Type III AI, sed on review of the literture nd of the ptient s signs nd symptoms. His tretment consisted of the ppliction of SSCs, zirconi crowns, composite veneer, counseling on diet nd orl hygiene, nd referrl to n orthodontist. 8 Figure 7: () 6-month follow-up clinicl picture showing intct restortions in the mxillry rch. () 6-month follow-up clinicl picture showing intct restortions nd hevy clculus ccumultion in the mndiulr rch. (c) 6-month follow-up clinicl picture showing intct veneering composite with slightly inflmed gingiv nd the lterls incisors were fully erupted in the frontl view c c Figure 8: () 18-month follow-up clinicl picture showing intct restortions. The left 1 st premolr ws erupted in the mxillry rch. () 18-month follow-up clinicl picture showing intct restortions nd clculus ccumultion in the mndiulr rch. (c) 18-month follow-up clinicl picture showing intct veneering composite with slightly inflmed gingiv in the frontl view The iggest chllenges in the mngement of this ptient s orl helth remin his diet nd rushing hits. Despite tht the ptient nd his prents were counseled on how to rush the ptient s teeth nd were dvised tht he should reduce his intke of sugry foods nd drinks, his orl hygiene did not improve, nd clculus ccumultion nd gingivl inflmmtion remined prolem. Possile next steps in improving the ptient s orl hygiene my include suggesting rewrd system for rushing his teeth ech dy. The prents should lso e counseled to tke more ctive role in rushing the child s teeth if he is unwilling to rush his own teeth. Cses of AI vry in type nd severity, nd it is importnt to ssess ech ptient s cse on n individul sis efore deciding on the course of tretment. It is importnt to look fter the ptient s dentl, periodontl, nd orthodontic helth s erly s possile. AI tends to present in primry teeth, usully with cries nd tooth sensitivity. It cn dversely ffect the child psychologiclly nd socilly, s the tooth sensitivity nd orthodontic prolems ssocited with AI cn mke chewing difficult. Children with AI my lso e self-conscious out the norml ppernce of their teeth. Some children with AI only et soft or pureed foods, nd in tht cse, restortive tretments nd diet counseling should e gered towrd introducing the child to more ge-pproprite diet. It is necessry to consider socil fctors in deciding on course of tretment for children with AI. Orthodontic tretments, restortive dentl tretments such s crowns, nd even frequent visits to the dentist cn e expensive. Often, the most estheticlly ppeling tretments re not the most ffordle ones. Dentists should discuss with prents regrding the vrious options for tretment of AI nd wht ech option costs. Restortive tretment for AI consists of crowns nd veneers pplied to primry nd permnent teeth. If tooth requires pulpl tretment, the pulpl tretment should e completed efore ny type of crown is pplied. SSCs re pproprite for posterior teeth, especilly primry posterior teeth. Mterils used for crowns on permnent nterior teeth include porcelin nd zirconi. 9 Ptients with AI re prone to orthodontic prolems, especilly loss of verticl dimension nd complictions tht rise from it, such s temporomndiulr joint (TMJ) prolems. Mlocclusion nd delyed eruption of permnent teeth re lso ssocited with AI. Restortive procedures cn restore verticl dimension, ut temporry ite-rising jigs cn e used efore the restortive tretments re done to help the peditric ptients TMJ dpt to the new verticl dimension. 10 Interntionl Journl of Scientific Study Decemer 2016 Vol 4 Issue 9 182
Adruh nd Howidi: Amelogenesis Imperfect CONCLUSION AI is n inherited condition tht cn e mnged through restortive dentl nd orthodontic tretment. Ptients who receive proper tretment to mnge their AI hve good prognosis estheticlly nd in terms of dentl function. SSCs, zirconi crowns, nd composite veneers re n effective intervention nd cn e pplied to erly permnent dentition. As shown in this cse report, mngement of orl hygiene in peditric ptients remins chllenge. REFERENCES 1. Rjendrn R. Developmentl disturnces of orl nd prorl structures. In: Rjendrn R, Sivpthsundhrm B, editors. Shfer s Textook of Orl Pthology. 5 th ed. Ch. 1. New Delhi: Elsevier; 2007. p. 67. 2. Hldne JB. A prole new sex-linked dominnt in mn. Hum Hered 1937;28:58-60. 3. Schulze C, Lenz F. Hypoplsi of dentl enmel with incomplete dominnt sex linked heredity. Z Mensch Verer Konstitutionsl 1952;31:104-14. 4. Witkop CJ Jr. Prtil expression of sex-linked Amelogenesis imperfect in femles comptile with the Lyon hypothesis. Orl Surg Orl Med Orl Pthol 1967;23:174-82. 5. Chudhry M, Dixit S, Singh A, Kunte S. Amelogenesis imperfect: Report of cse nd review of literture. J Orl Mxillofc Pthol 2009;13:70-7. 6. Mrkovic D, Petrovic B, Peric T. Cse series: Clinicl findings nd orl rehilittion of ptients with Amelogenesis imperfect. Eur Arch Peditr Dent 2010;11:201-8. 7. Khrkwl R. Dentl rehilittion of Amelogenesis imperfect in the mixed dentition. Int J Sci Stud 2014;1:56-9. 8. Wright JT. The moleculr etiologies nd ssocited phenotypes of Amelogenesis imperfect. Am J Med Genet A 2006;140:2547-55. 9. Jym C, Soni S, Roy D. Amelogenesis imperfect: Review nd cse report. Rnchi Univ J Dent Sci 2013;2:115-8. 10. Rowley R, Hill FJ, Winter GB. An investigtion of the ssocition etween nterior open-ite nd Amelogenesis imperfect. Am J Orthod 1982;81:229-35. How to cite this rticle: Adruh RE, Howidi AM. Dentl Rehilittion of Ptient with Amelogenesis Imperfect using Zirconi Crowns, Stinless Steel Crowns, nd Composite Veneers: A Cse Report. Int J Sci Stud 2016;4(9):179-183. Source of Support: Nil, Conflict of Interest: None declred. 183 Interntionl Journl of Scientific Study Decemer 2016 Vol 4 Issue 9