1034 Indian Journal of Public Health Research & Development, July 2020, Vol. 11, No. 7 Prosthetic Rehabilitation of Hypoplastic Type of Using Semi Permanent Crowns – A Case Report

Divya Subramanyam Assistant Professor, MDS, Department of Pediatric and Preventive , Asan Memorial Dental College and Hospital, Tamilnadu

Abstract Amelogenesis imperfecta (AI) is a group of tooth developmental disorder which has genetic causes otherwise referred to as hereditary dysplasia, in the absence of systemic disorders. It affects both deciduous and permanent dentition. The common problems associated with amelogenesis imperfecta (AI) is the risk of wear of the and dental caries susceptibility. This clinical report describes esthetic and functional prosthetic rehabilitation of hypoplastic type of Amelogenesis Imperfecta in a 13-year-old female patient with generalised sensitivity in all her teeth, yellow-brown discolouration and wearing of the posterior teeth. On clinical and radiographic examination, it was identified as hypoplastic type of Amelogenesis imperfecta according to Witkop’s classification of AI. Prosthetic rehabilitation using semi permanent restoration for permanent posterior teeth was performed quadrant wise in four appointments with minimally invasive crown preparations and followed up at three months.

Keywords: Stainless steel crowns, Hypoplastic, Amelogenesis Imperfecta, Deciduous Dentition, Permanent Dentition

Introduction According to literature, mutations of amelogenin gene (AMELX) causes X-linked AI and enamelin gene Amelogenesis imperfecta (AI) is a hereditary (ENAM) causes autosomal dominant type of AI. 3 One enamel defect. It is inherited either as an autosomal of the most common classification of AI was introduced dominant or recessive, or X-linked disorder of the by Witkop in 1988. Classification of Amelogenesis 1 teeth. Several variants of Amelogenesis Imperfecta Imperfecta includes four main types: hypoplastic (type are seen based on clinical, radiographic, genetic, and I), hypomaturation (type II), hypocalcification (type III), histological findings. The prevalence of AI varies and hypomaturation‐hypoplasia with (type from 1 in 718 to 1 in 14000 live births depending on IV) with fourteen subtypes.4 It shows a wide range of 2 the population studied. Transmission of the gene characteristics generally affecting nearly all of the teeth takes place either by autosomal, dominant X-linked, or in primary as well as in permanent dentition. 5 recessive modes. The pathogenesis of AI occurs during the secretory stage of amelogenesis. In amelogenesis, The most common and frequent clinical characteristic enamel matrix proteins like amelogenin, enamelin features of hypoplastic type of Amelogenesis imperfecta and ameloblastin are secreted by enamel forming cells includes loss of enamel in occlusal and proximal which play an important role in enamel crystal growth. surfaces with yellow-brown discolouration, glossy, smooth or rough surface, loss of proximal contact with Corresponding Author: the adjacent teeth, attrited occlusal surface of posterior Divya Subramanyam teeth, square-shaped crown, and with grooves/pitting Afflitation: Assistant Professor, MDS, Department of buccal and lingual/palatal surface.1 AI has also been of pedodontics, Asan Memorial Dental College and associated with abnormal dental formation and eruption, Hospital, Tamilnadu, Address: No 20, school road, congenital absence of teeth, anterior open bite, pulpal venkateshwara nagar east phase, kodungaiyur, Chennai calcification, taurodontism, abnormal formation of roots, -600118, Phone number: 9003226380 dysplasia, crown and root resorption, excess Mail ID: [email protected] deposition. About 50 percent of population has the incidence of anterior open bite.6 Treatment Indian Journal of Public Health Research & Development, July 2020, Vol. 11, No. 7 1035 should be aimed at relieving the dentin hypersensitivity, and second molars, each quadrant per day. restoring the vertical dimension, to preserve the natural tooth structure and to maintain occlusion. This results in In the first visit, oral prophylaxis was done. improving the psychological health of the patient. After local anaesthetic administration, preformed stainless steel crowns were placed after adequate tooth Patient’s cooperation is important in managing preparation, crown contouring and crimping. Occlusal the AI, as it needs multiple treatment phases, which interferences were also adjusted (Figure 3,4). Adequate would last for several years. In this case report, we fit of the stainless steel crown was confirmed by present a case of management of hypoplastic type of using radiograph. At 3 months follow up visit, patient Amelogenesis Imperfecta in a 9-year-old female patient satisfaction and proper was observed. via prosthetic rehabilitation

Case Report A 13-year-old, female patient was reported to the OP, Department of Pedodontics and Preventive Dentistry with the chief complaint of generalised sensitivity in all her teeth, presence of yellowish coloured teeth which was chipping off while chewing hard food and the patient felt it was aesthetically unpleasing. Patient’s familial history revealed that no other member in the family had this change. The patient’s medical history was non- contributory. Following this, clinical examination was done which showed that the enamel layer of the teeth Figure 1: Pre-operative maxillary occlusal view was very thin and yellowish brown in colour. It showed generalised wear of the posterior teeth and dentin was hypersensitive. Teeth showed diffuse pitting on the buccal surfaces (Figure 1,2). On evaluating the oral hygiene of the patient using OHI-S index, patient had chronic generalized . Radiographically, it showed that all the teeth showed loss of tooth structure, on occlusal and proximal surfaces. After clinical and radiographic examination and exclusion of other possible conditions, this condition was diagnosed as hypoplastic type of Amelogenesis Imperfecta.

An appropriate treatment plan was made with Figure 2: Pre-operative frontal profile view an objective to restore the esthetics of the patient, to prevent further loss of tooth structure and to reduce dentin hypersensitivity. After explaining the treatment schedule and the length of the time period, informed consent was obtained from the parent. After considering the factors such as age of the patient, socioeconomic status, all the possible treatment options to restore the teeth, it was decided to place semi-permanent crowns like Stainless steel crowns (3MTM ESPETM) to restore the permanent first and second molars in all the four quadrants and jacket crowns to restore the anterior teeth. Patient was not willing for restoration of anterior crowns, so we decided to restore only the permanent first Figure 3: Intraoral maxillary occlusal view after restoration with stainless steel crowns 1036 Indian Journal of Public Health Research & Development, July 2020, Vol. 11, No. 7 Instructions on oral hygiene maintenance and dietary habits should be maintained to achieve successful treatment. Oral health in AI patient’s will be compromised due to the rough surface, which increases the caries susceptibility and sensitivity while having cold and hot foods. 10 In this case, semi-permanent restoration such as stainless steel crowns were placed in the permanent first and second molars with minimal crown preparation to avoid damage to the and other tooth structure. The stainless steel crowns have superior durability, cost effective and requires only minimal technique. 11 Stainless steel crowns will be replaced with tooth coloured permanent crown after the completion Figure 4: Intraoral mandibular occlusal view after of growth after eighteen years. Regular follow up visit restoration with stainless steel crowns was done to assess the durability of the restoration and 11 Discussion patient satisfaction. The term Amelogenesis imperfecta (AI) is a AI is a rare hereditary defect encountered in clinical clinically and genetically heterogeneous group of practice with variable frequency. The management disorders that affect the enamel, occasionally in of teeth affected with AI should begin from primary conjunction with dentin,pulp,cementum, and extraoral dentition stage continued through mixed dentition into tissues.7 Hypoplastic type of AI shows reduced enamel permanent dentition stage till adolescence. It affects the density and calcification, which can be observed enamel of all the teeth present in the dentition uniformly. clinically and well as radiographically compared to other It has been found that the success of restorations in this types of phenotypes. Histologically, the enamel shows type of AI affected teeth was greater compared to other reduced enamel thickness and loss of enamel prism on types. 12 the tooth surface. 8 It is different from other types with its unique clinical characteristics. Hypocalcified type of Conclusion AI is clinically characterized by soft enamel with normal Diagnosis and restoring Amelogenesis imperfecta size and shape of crown, dark brown discolouration. is always a challenging task to the dental health care Radiographically, the thickness of the enamel is normal clinicians. The inherent risks and benefits should with less density compared to dentin. Histologically, be considered and explained to the patient’s before the enamel shows defect in the enamel matrix and providing appropriate treatment. Periodical follow up is 9 mineralization. There are multi-disciplinary treatment essential for long term success. approaches, materials and techniques for management of AI. Clinical practitioners should consider restoring Conflicts of Interest: There are no conflicts of the form, function and to reduce the hypersensitivity interest. of the posterior teeth. Multiple therapeutic treatment Source of Funding: Self options are available in restoring the teeth affected by Amelogenesis imperfect such as onlays, preformed Ethical Clearance: Taken from Institutional semi-permanent stainless steel crowns, metallic or Review Board ceramic crowns for posterior teeth, and direct/indirect composite restorations, veneers, and ceramic crowns for References anterior teeth. 3 1. Crawford PJ, Aldred M, Bloch-Zupan A. Treatment planning should be done based on various Amelogenesis imperfecta. Orphanet J Rare Dis. factors like patient’s age, type, severity of the anomaly 2007; 2:17. and the signs and symptoms at the time of management. 2. C. J. Witkop. Amelogenesis imperfecta, If there is an associated , it should be dentinogenesis imperfecta and discussed with an orthodontist and orthodontic treatment revisited: problems in classification. Journal of should be completed prior to the prosthetic rehabilitation. Oral Pathology.1989; 17:547-53. Indian Journal of Public Health Research & Development, July 2020, Vol. 11, No. 7 1037

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