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Dentinogenesis Imperfecta: Full-Mouth Rehabilitation Using Implants and Sinus Grafts − a Case Report

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Dentinogenesis Imperfecta: Full-Mouth Rehabilitation Using Implants and Sinus Grafts − a Case Report RestorativeDentistry David W Seymour Martin F W-Y Chan and Peter J Nixon Dentinogenesis Imperfecta: Full-Mouth Rehabilitation using Implants and Sinus Grafts − A Case Report Abstract: This case report outlines one possible treatment modality to manage the developmental abnormality dentinogenesis imperfecta (DI). In this case, the patient’s dentition is restored using a combination of full-coverage crowns for the remaining teeth and implant- supported crowns to replace missing teeth in a re-organized occlusal scheme. The case also demonstrates the effective use of the sinus graft procedure with simultaneous placement of dental implants. This paper also aims to make the reader aware of the current thinking behind treatment delivered to this group of patients, focusing on full-mouth rehabilitation using a combination of implant-supported and conventional metal ceramic crowns. Clinical Relevance: For the general dental practitioner this case outlines the prevalence and cause of DI. It demonstrates how early diagnosis and appropriate referral has an impact on future treatment. Dent Update 2012; 39: 498–504 Dentinogenesis imperfecta (DI) is a Type I occurs as part of osteogenesis Treatment in the primary genetically determined developmental defect imperfecta, which is caused by mutations in dentition of dentine. The condition is broadly grouped collagen (Type 1 collagen alpha 1 and alpha The aims of treatment are to into three categories:1 2 chains) genes. The inheritance pattern of remove sources of infection or pain, restore 1. Type I: the dental manifestation of DI type II and type III is autosomal dominant. aesthetics and protect posterior teeth from osteogenesis imperfecta. Mutations in the DSPP gene have been wear.6,7 Patients present with this condition 2. Type II: classical hereditary opalescent identified in both types of DI occurring as an affecting their teeth to various degrees so it is dentine. isolated trait. Research indicates that Type II not possible to make generalized treatment 3.Type III: Bradywine isolate opalescent and Type III are different expressions of the plans. In general, all patients require a dentine.2 same gene.3 thorough preventive regime, including diet The prevalence of DI is 1:8000. Histologically, the dentine advice and oral hygiene instruction. appears normal. However, the scalloping Restoration of the dentition at the dentino-enamel junction is missing. ranges from the simple placement of resin- This scalloping acts to hold the two tooth DW Seymour, BChD, MFDS RCSEd, modified glass ionomer cement in areas of structures together mechanically; in its Specialty Trainee in Restorative Dentistry, enamel loss in the very young and unco- absence enamel is easily chipped off the M F W-Y Chan, BDS, MDSc, FDS(Rest operative child, to placement of stainless dentine.4,5 Clinically, teeth appear bluish- Dent) RCPS(Glasg), DRD, MRD RCSEd, steel crowns and direct composite for the brown and opalescent. The enamel tends to Consultant in Restorative Dentistry and more co-operative child.8 Placement of chip and wear away, exposing the malformed PJ Nixon, BChD(Hons), MFDS RCSEd, these crowns is advised where there is more abnormal dentine which wears rapidly. MDentSci, FDS RCSEd(Rest Dent), extensive tissue loss. Where tissue loss is Radiographically, the crowns are bulbous Consultant in Restorative Dentistry, Leeds more severe and little is remaining above while the roots are short and thin. The pulp Dental Institute, Clarendon Way, Leeds, the gingivae, extraction of the primary tooth chambers are wide initially but obliterate LS2 9LU, UK. is indicated. If the teeth become non-vital, soon after eruption. 498 DentalUpdate September 2012 RestorativeDentistry a or abscess formation occurs, primary tooth an unstable and unretentive upper partial pulp treatment is contra-indicated and again denture. She gave a history of brown, mottled extraction is necessary.9 teeth since childhood that were very brittle and wore easily. She had a long history of dental treatment ranging from simple fillings Mixed dentition to complex crown and bridge work (Figure 1). As the permanent dentition Her main wish was to have fixed replacement develops it should be monitored closely of her missing teeth rather than a removable for tooth surface loss. The amount and partial denture. distribution of the loss will dictate the type Medically, the patient had b of treatment at this stage. The majority of controlled hypertension. She was also a non- patients may be treated with cast occlusal smoker. She had no apparent family history of onlays on the molar and premolar teeth the condition affecting her teeth. as this minimizes tooth surface loss whilst Clinically, the patient had a maintaining the correct OVD.10 This is also heavily restored dentition. Bridges were a minimally invasive technique which is of present UR3−1 replacing the UR2 and LL3−6 paramount importance at this stage of the replacing the LL4 and 5. Crowns were present c patient’s dental development. on the UR5,4, UL1,2,3, LL1,2, LR1,2,3,6,7. Aesthetics is normally a concern Retained roots were present UL4,5 and as the permanent incisors erupt. In the retained LRD,E were present whilst the LR4,5 short term, the treatment of choice is direct were developmentally absent. composite veneers. These are minimally The patient had a Class II division invasive, aesthetic and also help towards 1 incisal relationship with a 7 mm overjet d better oral hygiene as the irregular chipped and increased overbite. Owing to the loss of enamel surface is now replaced by a polished tooth structure over the years, the patient composite surface. was apparently overclosed. In the maxilla an acrylic denture replaced the missing teeth. Permanent dentition The denture was tissue-supported. Clinically it was unretentive and unstable, and the patient Again, the amount and found it difficult to tolerate. The patient’s oral distribution of tooth surface loss will dictate e the level of treatment. At this stage, many patients are considered for full-mouth rehabilitation. However, there are some a major differences when treating this group of patients compared to the general population. Classically, these patients have teeth with short, thin roots which have a decreased root surface area available to distribute physiologic forces generated during function.11 However, this is not a contra- indication to crowning the teeth. Endodontically, the teeth have f obliterated pulp chambers and canals. Loss of vitality and subsequent development b of apical pathologies are rare,12 however, if orthograde endodontic treatment is indicated it is often technically impossible, generally resulting in tooth loss. Retrograde root treatment is another option but should be contra-indicated for teeth with short roots.13 Figure 1. (a) Extra-oral view pre-treatment; (b) intra-oral view pre-treatment; (c) right lateral Case report view; (d) left lateral view; (e) upper arch; (f) lower The 48-year-old female patient Figure 2. (a) LL6 pre-treatment; (b) lower right arch. was referred by her GDP complaining of quadrant pre-treatment. September 2012 DentalUpdate 499 RestorativeDentistry wax-up at a reorganized occlusal scheme months of healing is allowed, followed by a giving full interdigitation, incisal guidance further procedure to place dental implants. and canine guidance in lateral excursions and In some cases, it is possible to combine the an increased occlusal vertical dimension; sinus lift procedure with implant placement in Radiographic stent UR6, UL4,5,6; a combined procedure. This is indicated when Cross-sectional radiographs UR6, UL4,5,6 there is at least 4 mm of bone available under and LRD,E areas. the sinus floor to give initial primary stability After the initial treatment and for implant placement. It is critical that interpretation were completed it became primary stability of the implants is achieved. If apparent that the LL6 was unrestorable, so residual bone height is less than 4 mm and/or Figure 3. Lateral approach for sinus graft. Note, the bridge in the area would need sectioning, primary stability of the implant is inadequate, different patient from case report. leaving the LL3 as a crown. It also became a 2-stage sinus graft procedure is necessary.15 apparent that the UL3 was unrestorable due The advantages of the single stage procedure to insufficient coronal structure and would are decreased treatment time and reduced require removal. The wax-up was discussed morbidity due to the decreased number of hygiene was good with a BPE score of 0 in all with the patient and the definitive treatment surgical stages undertaken. but the lower anterior sextant, which scored 2 plan was completed. It was as follows: The autogenous bone graft has due to supra-gingival calculus deposits. Extraction LL3 and LL6; long been considered the gold standard.16 Radiographic examination Implant placement UL3,4 (Friadent Xive® The bone is either harvested from an revealed general root canal obliteration of implants); intra-oral or extra-oral site. Intra-oral sites the remaining teeth and root morphology Construct upper and lower temporary include the maxillary tuberosity, the ramus characteristic of dentinogenesis imperfecta partial dentures; and mental region of the mandible. Extra- (Figure 2). It also showed caries in the LL6 Cross-sectional radiographs with oral sites include the iliac crest, tibia and bridge abutment, a mesial marginal gap in radiographic stents in situ; calvarium. One disadvantage of these sources the crown restored LR7, retained roots UL4,5 Right and left maxillary sinus grafts and of bone is the morbidity from the donor site. and retained LRD,E. No periapical pathology simultaneous implant placement under local It is now commonplace to use was present and bone levels were normal. anaesthetic UR7,6 and UL5,6; bovine bone alone to graft the sinus or a The diagnoses reached were Implant placement LR4,5,6 and the LL4,5,6; composite autogenous bone-xenograft as follows: Reorganizing the occlusion by increasing bovine bone graft.
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