CASE PRESENTATION

Dr. M.Arsalan ZubairMDS Trainee (Semester III)

Operative Dentistry DepartmentDow Dental College

DUHS

PATIENT’S PERSONAL DATA

• Age: 22 years

• Sex: Female

• Address: Clifton Zamazama currently, previously

lived in Bufferzone

PRESENTING COMPLAINT

Patient presented with the complaint of unpleasant appearance of her teeth especially during smiling and also complain of sensitivity on anterior and

posterior teeth. (Sensitivity is more in anterior tooth)

HISTORY OF PRESENTING COMPLAINT

Patient has this problem since the age of 13 and was not able to give any history which reveals the cause of such appearance.

Patient deciduous tooth were normal but permanent at the time of eruption were effected.

MEDICAL HISTORYSuffered from tuberculosis 3yr ago but was treated 9 months

back. Patient was completely treated and claimed that reports were normal.

FAMILY HISTORYFather is hypertensive for 15-16 yr

Mother is diabetic for 2 years

DENTAL HISTORY

Restorations:

7 (amalgam class 1) 6 (amalgam Class 1)

6(composite Class 1)

Patient went to dentist in past with the same complain but he told her that treatment of these defects is not possible.

• Patient recently visited dow dental college for scaling again

CLINICAL EXAMINATION

• Teeth present:

• Teeth Missing:

• Hypoplastic Teeth:

8,7,5,4,3,2,1 1,2,3,4,5 6,7

7,6,5,4,3,2,1 1,2,3,4,5,6,7

8

1,2,3

INTRA ORAL EXAMINATION

8

8

1,2,3,6 6,3,1

6,3,2,1

Extraoral examination

• Facial asymmetries:

Not Significant

• Tmj Examination:

Not Significant

Periodontal ExaminationPocket Depths

11 0.5 0.5 0.5 0.5 0.5 0.5

12 0.5 0.5 0.5 0.5 0.5 0.5

13 2 0.5 0.5 1 0.5 0.5

14 0.5 0.5 0.5 0.5 0.5 0.5

15 1.5 1.5 2 0.5 0.5 0.5

16 0.5 0.5 0.5 0.5 0.5 0.5

No: F(Mes) Mid Distal P(Mes) Mid Distal

17 0.5 0.5 0.5 0.5 0.5 0.5

18 0.5 0.5 0.5 0.5 0.5 0.5

21 0.5 0.5 0.5 0.5 0.5 0.5

22 0.5 0.5 0.5 0.5 0.5 0.5

23 0.5 0.5 3 2 0.5 2

24 0.5 0.5 0.5 0.5 0.5 0.5

25 0.5 0.5 0.5 0.5 0.5 0.5

26 0.5 0.5 0.5 0.5 0.5 0.5

27 2 0.5 2 0.5 2 0.5

31 0.5 0.5 0.5 0.5 0.5 0.5

32 0.5 0.5 0.5 0.5 0.5 0.5

33 0.5 0.5 0.5 0.5 0.5 0.5

34 0.5 0.5 0.5 0.5 0.5 0.5

35 0.5 0.5 0.5 0.5 0.5 0.5

36 0.5 0.5 0.5 0.5 0.5 0.5

41 0.5 0.5 0.5 0.5 0.5 0.5

42 0.5 0.5 0.5 0.5 0.5 0.5

43 0.5 0.5 0.5 1.5 0.5 0.5

44 0.5 0.5 0.5 0.5 0.5 0.5

45 1.5 0.5 0.5 0.5 0.5 0.5

46 0.5 0.5 0.5 0.5 0.5 0.5

47 0.5 0.5 0.5 0.5 0.5 0.5

37 0.5 0.5 0.5 0.5 0.5 0.5

Occlusal Examination

• Group Function on left side

• Group Function on Right side

Plaque and Gingival index

A film of plaque adhering to the free gingival margin and adjacent area of the tooth, which can not be seen with the naked eye. But only by using disclosing solution or by using probe

No plaque

Moderate accumulation of deposits within the gingival pocket, on the gingival margin and/ or adjacent tooth surface, which can be seen with the naked eye

Abundance of soft matter within the gingival pocket and/or on the tooth and gingival margin.

No inflammation

Mild inflammation, slight change in color, slight edema, no bleeding on probing.

Moderate inflammation, moderate glazing, redness, bleeding on probing

Severe inflammation, marked redness and hypertrophy, ulceration, tendency to spontaneous bleeding

0

1.

3

2

1.

3

2

0

• On the basis of above criteria the plaque status was“2” because plaque was observed with the naked eyeand gingival status was given score 1 because mildinflammation was seen.

• Gingival recession was observed on 43

• No mobility of tooth was observed

Clinical findings

• After reviewing the periodontal status it is observed that thereare small pits on the entire surface of maxillary central incisorsalong with the canines (on cusp tips and cuspal slopes) andlateral incisors. But these pits are scattered and are not parallelto the incisal edges.

• These defects are also seen on the 1st molars of both sides inmaxilla. Molars are morphologically altered, brown lines arealso observed especially on the buccal surface.

• When mandibular dentition is observed , Linear defects areseen on the lower central incisors , lateral incisors and canineswhich are parallel to the incisal edges.

• When the inner surfaces of upper and lower arches no defectsare seen

• Clinically there is surface loss of the enamel or pitting of theenamel surface.

• When mandibular molars are observed, both side 1st molarsare involved with same clinical presentation

• Patient has retained deciduous canine in upper 1st quadrant with the absence lateral incisor along with the presence of permanent canine.

• These defects are limited to the enamel only but exposed dentine due to loss of enamel is sensitive.

Investigation

Radiographic feature• Linear radiolucency seen in mandibular anterior teeth from

canine to canine

• It is also seen that in upper first quadrant lateral incisor is congenitally absent

• Multiple circular radiolucency is seen in both the central incisors and upper left lateral incisor and canine

• Small radiolucencies are present especially in enamel regions of left upper and lower 1st molars denoting malformation of enamel

• It is also seen that permanent canine has taken place of permanent lateral incisor because roots are longer and fully formed along with retention of deciduous canine.

• Impacted 3rd molars.

DIFFERENTIAL DIAGNOSIS

• Enamel Hypoplasia

• Molar incisor hypomineralization

•

• Amelogenesis Imperfecta

• Flurosis

• Early decalcification due to caries

Comparison

Enamel Hypoplasia

• Enamel hypoplasia stain relatively clear, and are parallel to the ridge line enamel.

• Enamel hypoplasia can occur in a single tooth or a set of teeth

Dental Fluorosis

• Dental fluorosis as a long-term damage, so the patches were scattered in a cloudy pattern, and not in a well defined pattern

• Dental fluorosis occurs in most teeth, particularly in the maxillary anterior teeth .

J Clin Exp Dent. 2009. Dental fluorosis: Exposure, prevention and management

• Tooth Colour generalized Yellow

• Tooth size Small

• Tooth Shape is also changed

• Enamel leads to attrition which leads to loss of enamel

• Generalized enamel loss

• All the teeth are involved

Comparison B/w Enamel Hypoplasiaand Amelogenesis Imperfecta (clinical)

• Tooth Colour is normal

• Tooth size is normal

• Tooth Shape is normal

• No sign of attrition

• Localized enamel loss

• Involving Incisor canine and molars

• Dark brown bands on gingival part of crown

• No Such thing can be noticed• No Such thing can be noticed• No complain of sensitivity

• Low risk of caries • Not Specific can be generalized or

localized • There is no enamel loss

Comparison B/w Enamel hypoplasiaand Fluorosis (clinical)

• No dark brown stains are seen

• Enamel pitting is seen

• Enamel defects are parallel to the Incisal edge

• Patient complains of sensitivity

• High risk of caries

• Involving Incisor canine and molars

• There is enamel loss

Evidences for ruling out AmelogenesisImperfecta and Fluorosis and making aDiagnosis that this condition is EnamelHypoplasia

Enamel Hypoplasia

• What is Enamel Hypoplasia?

• What are it’s causes?

• What are it’s types?

• How is it classified according to pattern?

• How is it classified

according to severity?

Causes• Exposure to dioxine by prolonged

breast-feeding • Nutritional deficiency [vitamin A,C,D]• Exanthematous diseases• [eg: measles, chicken pox, scarlet

fever]• Congenital syphilis• Hypocalcemia• Birth injury, prematurity, Rh hemolytic

disease• Local infection or trauma• Ingestion of chemicals• Idiopathic causes• Antibiotic used during pregnancy

(Tetracycline)EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY • 3/2003

Types

• Hereditary

• Environmental

Severity of hypoplasia was recorded according to Schultz (1988):

• 1st degree: mild

• 2nd degree :moderate

• 3rd degree :severe

Pattern of Enamel Hypoplasia

• Linear

• Circular

Variability and Evolution, 2001, Vol. 9: 7587

MILD HEREDITARY TYPE WITH MIXED PATTERN (CIRCULAR AND LINEAR BOTH)

ETIOLOGY CAN BE CONTRIBUTED TOPRE-NATAL USE OF ANTIBIOTICS (TETRACYCLINES)

DIAGNOSIS (CONTINUED)

TREATMENT PLAN (initial)

• Oral hygiene instructions

• Diet modification

• Fluoridated tooth paste and mouth wash

• Topical fluoride application

• Ultrasonic Scaling

•

• Direct composite restoration of :

1,2,33,2,1

3,2,1 1,2,3

Treatment options

• Bleaching

• Microabrasion

• Composite resin

• Porcelain Veneers

• Zirconia crown

Bleaching and microabrasion

• Ashkinazi et al. demonstrated the use of microabrasion technique in patients with enamel hypoplasia. At four-year follow up they showed that the improvements in aesthetics were maintained.

BRITISH DENTAL JOURNAL VOLUME 215 NO. 9 NOV 9 2013

• Enamel which is easily penetrated with an explorer is not a good candidate for microabrasion. Superficial brown and white discolorations on hypomaturated enamel can be easily removed by microabrasion.

Braz J Oral Sci. January-March 2006 - Vol. 5 - Number 16

• When the enamel is intact but discolored, bleaching and/or microabrasion may be used to enhance the appearance

• Clinical guidelines – AMERICAN ACADEMY OF PEDIATRIC DENTISTRY 2013

Composite resin

• Despite the lack of good evidence, due to its reversible and minimally invasive nature, rehabilitation with composite

resins should be considered as the first line of treatment.BRITISH DENTAL JOURNAL VOLUME 215 NO. 9 NOV 9 2013

• Indirect resin composite restorations have shown promising success rates. One study showed a 93% success rate of indirect composite restorations on premolars and molars over a three-year period

BRITISH DENTAL JOURNAL VOLUME 215 NO. 9 NOV 9 2013

Porcelain Veneers

• When restoring teeth affected by MIH with either composite or porcelain veneers, some of the underlying tooth structure may be relatively dark and the translucent nature of these restorations is often unable to adequately mask the discolouration. This can result in poor aesthetics of the restored teeth.

BRITISH DENTAL JOURNAL VOLUME 215 NO. 9 NOV 9 2013

Full coverage restorations

• Some authors have been described the use of all-ceramic crowns as a possible restorative approach particularly in the hypoplastic form - chipping is reported to be a major complication associated with the use of all-ceramic materials, especially zirconia

The Journal of Contemporary Dental Practice, March-April

2013;14(2):320-326

• Porcelain fused to metal crown for posterior teeth and all ceramic crowns for anterior teeth.

The Journal of Contemporary Dental Pracitice, Volume 8, No.4, May 1,2007

• If the enamel or dentin cannot be bonded, full coverage restorations will be required

Clinical guidelines – AMERICAN ACADEMY OF PEDIATRIC DENTISTRY 2013

Final treatment plan was done according to severity

Mild hypoplasia can be treated by direct composite restoration.

1. In the First step, the composite shade selection is done which is A1 Enamel.

2. In the 2nd step little preparation is done of all the defects with round bur creating a bevel in the defects.

3. Adequate isolation is needed so rubber dam is placed, quadrant isolation is done from 1st premolar to 1st

premolar of both the arches4. Then the basic steps of restorations is followed5. Then rubber dam is removed6. Then finishing of the composite is done

Quadrant isolation is done from 1st

premolar to 1st premolar

Composite Restoration placed but not finished

Rubber dam removed and After finishing

Before After

Thank you