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Q u i n t e s s e n c e I n t e r n at i o n a l

Diagnosis and esthetic functional rehabilitation of a patient with amelogenesis imperfecta Ilione Kruschewsky Costa Sousa Oliveira, DDS, MS1/ Jussara de Fátima Barbosa Fonseca, DDS2/ Flavia Lucisano Botelho do Amaral, DDS, MS, PhD3/ Vanessa Gallego Arias Pecorari, DDS, MS, PhD3/ Roberta Tarkany Basting, DDS, MS, PhD3/ Fabiana Mantovani Gomes França, DDS, MS, PhD3 Amelogenesis imperfecta is a hereditary disease that causes structural anomalies in dental enamel of both the primary and permanent dentition. The anomaly may present a variety of clinical forms and appearances, with its main characteristics being the loss of tooth structure, compromised esthetic appearance, and dental sensitivity. The aim of this study was to present the clinical report of a 16-year-old patient with severely compromised esthetics as a result of amelogenesis imperfecta of the hypocalcified type who was rehabilitated with composite resin and ceramic crowns. (Quintessence Int 2011;42:463–469)

Key words: amelogenesis imperfecta, diagnosis, treatment

Amelogenesis

a

Amelogenesis imperfecta occurs in 1 in

group of hereditary developmental defects

imperfecta

comprises

14,000 to 1 in 16,000 cases, presenting a

of the dental enamel that affect the enamel

variety of clinical forms2 and appearances

structure in the primary and permanent

according to the subtype and severity, but

dentition. The development of normal dental

the main problems are esthetics, dental

enamel occurs in three stages. In the forma-

sensitivity, and loss of vertical dimension.3,4

tive stage, there is deposition of organic

The pulp and dentin are usually normal.5

matrix. The matrix is mineralized in the

Amelogenesis imperfecta has been associ-

calcification stage, and in the maturation

ated with impacted teeth and abnormalities

stage, the crystals increase and are com-

in tooth eruption, congenital absence of

pleted. Consequently, three basic types

teeth, anterior open occlusal relationships,

of amelogenesis imperfecta exist: hypo-

pulp calcification, root and coronal resorp-

plasia (deficient formation of the matrix),

tion, hypercementosis, root malformation,

hypocalcified (hypomineralized; deficient

and taurodontism.6–8

mineralization of the formed matrix), and

Radiographic exams provide important

hypomaturation (the enamel crystals remain

information relative to the degree of enamel

immature).1

mineralization. In hypoplastic amelogenesis imperfecta, the enamel is thin, giving the

Research Assistant, São Leopoldo Mandic Dental School, 

crown a funneled appearance with a lack

Campinas/São Paulo, Brazil.

of contact between the teeth. In spite of the

Masters Student and Research Assistant, São Leopoldo Mandic

thin enamel, it shows contrast with the den-

Dental School, Campinas/São Paulo, Brazil.

tin. In the hypocalcified and hypomatured

Professor, São Leopoldo Mandic Dental School, Campinas/São

types, there is no contrast between the

Paulo, Brazil.

enamel and dentin due to the low degree of

1

2

3

Correspondence: Dr Fabiana Mantovani Gomes França, Faculdade de Odontologia e CPO São Leopoldo Mandic, Rua José Rocha Junqueira, 13 Ponte Preta, CEP 13041-445, Campinas/SP, Brazil. Email: biagomes@yahoo.com

VOLUME 42  •  NUMBER 6  •  JUNE 2011

enamel mineralization.9 Amelogenesis imperfecta has a significant impact on the psychosocial health of the

463

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Q u i n t e s s e n c e I n t e r n at i o n a l Oliveira et al

a

b

Fig 1    Initial intraoral (a) frontal, (b) maxillary, and (c) mandibular views.

c

Fig 2    Initial extraoral view.

Fig 3    Initial panoramic radiograph.

affected person, especially in young individu-

ing greater loss of tooth structure or loss of

als.10 Because amelogenesis imperfecta is

vertical dimension. Careful planning associ-

genetic, preventive treatment is not possible;

ated with adequate follow-up will enable

therefore, treatment is focused on esthetic

patients to attain a dentition with satisfactory

and functional rehabilitation.4,11 Treatment

esthetics and function.4 The aim of this paper

depends on the severity of the problem and

was to present the diagnosis, planning, and

the need for esthetic enhancement,2 ranging

treatment of a clinical case of amelogenesis

from simple composite resin restorations to

imperfecta.

complete crown restorations in cases involv-

464

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Q u i n t e s s e n c e I n t e r n at i o n a l Oliveira et al

Case report A 16-year-old boy with leukoderma sought treatment at the postgraduate clinic of the São Leopoldo Mandic School of Dentistry for the poor esthetics of his smile. The patient had low self-esteem and difficulty with social interaction. His teeth were an orangy color and covered with a rough surface of thin enamel. The patient also had gingivitis, calculus, loss of vertical dimension, absence of contact between

a

the teeth, and generalized dentinal sensitivity. During anamnesis, it was reported that other members of the family had the same characteristics. After anamnesis and clinical and radiographic exams, amelogenesis imperfecta was diagnosed (Figs 1 to 3). The treatment was divided into three stages: adaptation of the oral medium, direct esthetic rehabilitation of the anterior teeth, and indirect rehabilitation of the posterior teeth by means of leucite-reinforced ceramic crowns. Treatment began by root scrap-

b

ing and smoothing, prophylaxis, and oral hygiene guidance. Endodontic treatment was performed on the maxillary right second premolar and first molar and mandibular first molars, all of which presented compromised pulps. Afterward, these teeth were restored with composite resin (Opallis, FGM Dental Products), which served as filling core. In the maxillary right second premolar, which had lost a great deal of its structure, a glass fiber post was used (White Post DC, FGM Dental Products) to help retain the composite resin. Restorative treatment began with the placement of direct composite veneers to recover the esthetics of the anterior teeth and, consequently, the patient’s self-

c

Fig 4    Anterior teeth restorations. (a) Maxillary veneer preparations, (b) mandibular veneer preparations, and (c) maxillary direct resin restorations.

esteem. A mouth opener was used to withdraw the lips so that the vestibular faces of the teeth could be prepared for direct veneers (Fig 4). After this, the dental tissues

ization, in accordance with the manufac-

were acid etched with 37% phosphoric

turer‘s recommendations.

acid (37 Condac, FGM Dental Products) for

Microhybrid composite resin (Opallis)

15 seconds. They were then washed for 15

was used in shade DA1 for dentin and

seconds and gently dried. Two consecu-

EA1 for enamel and T-Blue to give translu-

tive layers of conventional monocomponent

cence to the incisal edge. The resins were

adhesive (Single Bond 2, 3M ESPE) were

inserted by the stratified incremental tech-

then applied, followed by gentle drying with

nique; that is, the dentin and enamel colors

jets of air and 20 seconds of light polymer-

were inserted according to the thickness

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465

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Q u i n t e s s e n c e I n t e r n at i o n a l Oliveira et al

Fig 5    Anterior direct veneers with composite resin.

a

b

Fig 6    (a) Leucite-reinforced ceramic copings. (b) Mandibular teeth try-in.

of each substrate in the restored regions.

Esthetic) were fabricated for the try-in (Fig

Each layer was individually light activated

6). After applying the ceramic lining, the

for 20 seconds with a light-emitting diode

complete crowns were cemented with res-

(LED) curing appliance (Radii, SDI) with

inous cement (Enforce, Dentsply). Occlusal

an intensity of 1,200 mW/cm2. Finally, the

adjustments were made with the aid of

facets were finished and polished using alu-

carbon paper (Angelus, Londrina) (Figs 7

minum oxide disks with decreasing granu-

and 8). A final panoramic radiograph was

lation (FGM Produtos Odontológicos) and

taken (Fig 9).

diamond polishing paste (Diamond Excel, FGM Produtos Odontológicos) (Fig 5). Next,

preparations

were

made

for

complete crowns on the posterior teeth. Provisional

crowns

were

fabricated

of

DISCUSSION

acrylic resin (JET Artigos Odontológicos Clássico) by the direct technique. At this

The esthetics of the smile had improved

stage, the vertical dimension of occlu-

greatly. Young patients with esthetically

sion was reestablished at 2 mm by means

compromised teeth usually have low self-

of a semiadjustable articulator (Bio-Art).

esteem that often harms their psychosocial

The impressions were made with poly-

health.10 In oral rehabilitation of estheti-

vinyl siloxane (Express, 3M ESPE), and

cally compromised patients, it has become

leucite-reinforced ceramic copings (Vision

imperative to satisfy their psychosocial

466

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Q u i n t e s s e n c e I n t e r n at i o n a l Oliveira et al

a

b

Fig 7  Final intraoral (a) frontal, (b) maxillary, and (c) mandibular views.

c

Fig 8    Final extraoral view.

Fig 9    Final panoramic radiograph.

needs and assure them of complete treat-

forms of amelogenesis imperfecta are also

ment by paying attention to the esthetic and

linked to the autosomes.12,13 Amelogenesis

functional aspects alike.

imperfecta can affect the dental enamel in

4

Amelogenin is the main protein associ-

various ways and manifestations,2 and as

ated with the formation of dental enamel

such, there is no defined treatment protocol.

and its characteristics such as shape and

Proper diagnosis and good treatment

thickness. The importance of this protein in

planning are fundamental to obtaining a

the formation of dental enamel is particularly

satisfactory result, since the treatment is

evidenced by genetic analysis of families

almost always multidisciplinary. The occur-

with amelogenesis imperfecta linked to the

rence of gingivitis in patients with amelo-

X chromosome, which presents mutations

genesis imperfecta, as found in this case,

that inactivate the amelogenin gene. Other

is frequently mentioned in the literature5,6,14

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467

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Q u i n t e s s e n c e I n t e r n at i o n a l Oliveira et al

and may be attributed to the difficulty of

interface appears to be a decisive factor in

cleaning caused by the irregularity of the

obtaining adequate fracture resistance of

enamel surface and tooth sensitivity in

porcelain restorations.23 Research on the

these patients.

effect of ceramic restorations on the frac-

With the development of adhesive sys-

ture of the tooth structure has shown that

tems15 and technologic development of com-

adhesive restorations made with ceromers

posite resins, especially with respect to their

and ceramics recovered the fracture resis-

mechanical and optical properties, direct

tance of the tooth, and there were no dif-

vestibular facets have been increasingly

ferences between the fracture resistance

used in clinical dentistry to restore anterior

of healthy teeth and those restored with

teeth that have alterations in color or ana-

ceramic or ceromer.20,24

tomical shape.

Hybrid composite resins,

Ceramic inlays cemented with zinc phos-

such as those used in this clinical case, have

phate cement or ionomer cement are char-

physical and mechanical properties superior

acterized by poor marginal quality, fractures,

16

to those of the microparticle resin compos-

and a low degree of retention.25 Resinous

ites and present good surface smoothness.17

cements are more appropriate for use with

Placement of direct veneers by means

indirect restorations made with pure por-

of adhesive techniques and the use of

celain and composite resin, and for these

composites can be advantageous. Among

cements,

the advantages of the direct techniques

mode appears to be the most recommend-

over their indirect counterparts are easy

ed, assuring better mechanical properties.

repair, no laboratory stages, less work-

However, light-activated polymerization is

ing time, lower cost, and more conser-

imperative, since the chemical phase does

vative preparation.18,19 Considering these

not guarantee complete polymerization and

reasons and patient’s age (16 years), the

satisfactory hardness.11,26 In the present

choice was made treat the anterior teeth

case, the purpose of the complete ceramic

with direct resin composite facets, and the

crowns fabricated for the patient’s posterior

expected esthetic and functional results

teeth was to resolve not only the esthetic

were obtained (see Figs 4 and 5). Although

issue but also to reestablish the vertical

structural changes on the teeth of patients

dimension compromised by the loss of the

suffering from amelogenesis imperfecta

tooth structure and to restore the function of

might interfere in the bonding of adhesive

these teeth. In this connection, indirect res-

restorative materials,20,21 it was verified that

torations were made with leucite-reinforced

this dentin substrate showed  color and

ceramic to provide a bond to the tooth

hardness characteristics similar to those

structure, mechanical strength, and a good

of normal dentin after the veneers and total

esthetic result.

the

dual-phase

polymerization

crowns were prepared (see Fig 4). Due to the nature, composition, and structure of ceramic materials, they are friable and unable to resist high forces of stress. Over the course of time, the formu-

CONCLUSION

lations and modes of obtaining ceramics have changed; more resistant, less friable

In cases where the esthetics and function of

materials with a lower degree of shrinkage

teeth have been compromised as a result

and more esthetic appearances have been

of amelogenesis imperfecta, diagnosis and

developed. Aluminized-reinforced porce-

treatment planning are essential to achieve a

lains (In-Ceram Vita), aluminized glass-infil-

satisfactory esthetic and functional result. The

trated porcelains (Procera, Nobel Biocare),

treatment of choice using the direct restor-

leucite-reinforced procelains (IPS Empress,

ative technique for anterior teeth and the

Ivoclar), and lithium disilicate–reinforced

metal-free, ceramic-reinforced indirect restor-

porcelains (Empress 9IPS II, Ivoclar) have

ative technique for the posterior teeth was

appeared on the market.22

efficient for achieving esthetic and functional

The capacity of the restorative material to support masticatory loads and ade-

rehabilitation. At the end of the treatment, the patient was very pleased with the result.

quately distribute stresses at the adhesive

468

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Q u i n t e s s e n c e I n t e r n at i o n a l Oliveira et al

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Diagnostico y rehabitlitacion estetica y funcional de Amelogenesis imperfecta.  

Articulo sobre rehabilitacion de un transtorno de desarrollo.