The journal of

PROSTHETIC
AND IMPLANT
DENTISTRY
Official Publication of Indian Prosthodontic Society
Kerala State Branch
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FULL MOUTH REHABILITATION OF

DILAPIDATED DENTITION DUE TO
AMELOGENESIS IMPERFECTA
*Ashmi Sebastian, *S. Anantha Narayanan, **Sanjayagouda B Patil, *Amith Vengalath
*PG Student, **Professor and HOD, Department of Prosthodontics, *PG Student, Department of Conservative Dentistry
& Endodontics, Sri Hasanamba Dental College and Hospital, Vidyanagar, Hassan-573202 | Corresponding Author:
Dr. S. Anantha Narayanan, E-mail: [email protected]
https://doi.org/10.55231/jpid.2022.v05.i03.02

independent of any related systemic disorder.1–2

Abstract:
Both deciduous and permanent dentitions are
Amelogenesis imperfecta is a congenital disorder affected by this enamel anomaly.3 It is entirely
which affects deposition, calcification and/ ectodermal, and the mesodermal components of
or maturation of dental enamel. This genetic the teeth are unaffected. Amelogenesis imperfecta
disorder affects teeth in both deciduous and trait can be transmitted either by autosomal
succedaneous dentition leading to functional dominant, autosomal recessive or X-linked
as well as esthetic inadequacies. This condition
mode of inheritance. It is caused by mutation or
exerts radical repercussions on stomatognathic
altered expression of genes such as: enamelin,
system and intangible effects on the confidence of
the patient. This clinical report elaborates on the
ameloblastin, tuftelin, MMP‑20, and kallikrein.2
multidisciplinary approach adopted for full mouth Amelogenesis imperfecta [AI] can be broadly
rehabilitation of a dentition affected by this genetic
classified into four primary groups based on
disorder in young adult patient. The treatment
phenotype—hypoplastic, hypomaturation,
plan aimed at upheaving esthetics, restoring the
hypocalcified and hypomaturation-hypoplastic.
vertical dimension and reinstating the masticatory
function. Pankey–Mann–Schuyler philosophy of However, at least fifteen subsets of amelogenesis
full mouth rehabilitation was adhered to achieve imperfecta have been identified when phenotype
these treatment objectives. Full mouth rehabilitation and mode of inheritance are considered3. Clinical
albeit restoring esthetics and function also imparts findings of AI include, enamel deficiencies, root
a substantial positive psychological upliftment and malformations, impaired tooth eruption, pulpal
therefore revamps the patient confidence. calcifications, impaction of permanent teeth,
progressive root and crown resorption, congenitally
Key words: Amelogenesis Imperfecta, Full
missing teeth and tooth sensitivity. Since enamel
Mouth rehabilitation, Pankey-Mann-Schyuler
thickness is severely affected, teeth are undersized
philosophy, Broadricks Occlusal Plane Analyser
with prominent spaces between the adjacent teeth,
compromised oral hygiene and mouth breathing
Introduction with associated gingivitis, gingival hyperplasia and
other periodontal problems. Other clinical findings
Amelogenesis imperfecta has been described associated with amelogenesis imperfecta include
as a complex group of genetic disorder that congenitally anodontia, open occlusal relationship,
primarily affects the enamel structure and exists multiple impacted teeth and taurodontism.4

JPID – The journal of Prosthetic and Implant Dentistry / Volume 5 Issue 3 / May–August 2022 / 125
The journal of Ashmi Sebastian, S. Anantha Narayanan, Sanjayagouda B Patil, Amith Vengalath

PROSTHETIC
AND IMPLANT
DENTISTRY
Official Publication of Indian Prosthodontic Society
Kerala State Branch

Management of amelogenesis imperfecta is 1]. The patient had no history of any major systemic
quite challenging and arduous to accomplish. illnesses. Clinical and radiographic examination
Comprehensive treatment planning shouldn’t of the patient revealed no abnormality in
be undermined and the critical procedure in the temporomandibular joint movements, generalized
treatment planning is the evaluation of vertical mild attrition and discoloured teeth with irregular
dimension using mounted diagnostic casts and a pattern of mineralisation. The patient did not
diagnostic wax-up. Age of the patient , type and have any loss of vertical dimension of occlusion.
severity of the disorder, socioeconomic status Based on the clinical and radiographic findings,
and intraoral condition at the time of treatment the patient was diagnosed with amelogenesis
planning are some of the influential factors that imperfecta and the patient was advocated for
impact the treatment planning in such patients. full mouth rehabilitation to address her chief
The final objective of the treatment plan should complaint.
be to weave esthetics, masticatory function and
general oral health into harmony. Preliminary impression of maxillary and
mandibular arch was made using irreversible
The rehabilitation of entire dentition for patients hydrocolloid and diagnostic casts were mounted
with amelogenesis imperfecta can be achieved on a semi-adjustable articulator using interocclusal
successfully by using the philosophies of full record after a facebow transfer. Protrusive record
mouth rehabilitation. They provide tangible and was obtained from the patient to program the
everlasting esthetic result in tandem with occlusal articulator.. Preliminary analysis was carried
harmony. Full mouth rehabilitation procedures out on the mounted casts followed by diagnostic
are a complex set of procedures which restore the wax-up without altering the vertical dimension
teeth to their natural form, function, and enhances was performed on the maxillary and mandibular
esthetics in harmony with the temporomandibular anterior teeth [Fig 2].
joint and the associated hard and soft tissues.5-6
After preparing the maxillary and mandibular
Although several philosophies and protocols anterior teeth [Fig 3] the provisional crowns
have been widely documented, two of them are which were fabricated using the putty index of the
routinely employed. They are, Hobo’s twin stage diagnostic wax‑up were luted using a provisional
technique and Pankey‑Mann‑Schuyler (PMS) cement. The provisional restorations given to the
technique. This clinical case report illustrates the patient were utilised to assess the anterior esthetics
treatment procedures carried out sequentially in a and help determine the anterior guidance for the
full mouth rehabilitation using porcelain fused to patient. Once the patient got accustomed to the
metal crowns strictly adhering to Pankey–Mann– established anterior guidance, a custom incisal
Schuyler philosophy in a patient with dilapidated guide table was fabricated on the articulator [Fig
dentition due to amelogenesis imperfecta. 4]. The final restorations for the maxillary and
mandibular anterior teeth were fabricated and
Case Report cemented after metal try-in procedure [Fig 5].

A 22‑year‑old female patient reported to the The subsequent procedure was to restore the
Department of Prosthodontics with a chief mandibular posterior teeth. Diagnostic wax-up of
complaint of generalized discolouration & stained mandibular posterior teeth was performed on the
appearance of her teeth. She also expressed mounted cast prior to preparation of teeth in the
concerns regarding her teeth size, shape and patient. The occlusal plane and Curve of Spee were
shade along with poor masticatory efficiency [Fig established by using Broadricks Occlusal Plane
Analyser [Fig 6]. Then, to fabricate the provisional

126 / JPID – The journal of Prosthetic and Implant Dentistry / Volume 5 Issue 3 / May–August 2022
The journal of Full Mouth Rehabilitation of Dilapidated Dentition due to Amelogenesis Imperfecta

PROSTHETIC
AND IMPLANT
DENTISTRY
Official Publication of Indian Prosthodontic Society
Kerala State Branch

restorations, putty index of the wax-up was made. maxillary master cast. Centric relation record was
The temporary crowns fabricated were cemented made and utilised to mount the maxillary and
provisionally after teeth preparation. Tooth mandibular casts to the articulator. The patient
preparation and provisionalization of mandibular was asked to perform the centric and eccentric
posterior teeth were completed segmentally.7 movements which were recorded using functional
Patient’s occlusion and comfort were evaluated for wax. This provided the FGP record. Quick setting
the next three weeks. When provisional restorations plaster was poured into this record to obtain the
were considered acceptable, they were used to functional core index which was articulated against
develop form and contour of definitive restorations the maxillary master cast [Fig 8] to develop the
for the mandibular posterior teeth. The final wax patterns for maxillary crowns in group function
restorations of the mandibular posterior teeth occlusion. After a bisque trial, final restorations
were cemented and succeeded by the fabrication were luted and group function occlusion was
of maxillary posterior restorations using the achieved. [Fig 9]
functionally generated pathway [FGP] technique.
Regular recall and review protocol were effectively
The maxillary posterior teeth were prepared [Fig employed and oral hygiene maintenance
7] and a final impression was made to obtain the

Fig 1. Preoperative photograph Fig 2. Diagnostic wax up of maxillary and Fig 3 A,B. A. Maxillary
mandibular anterior teeth anterior teeth preparation.
B. Mandibular anterior
teeth preparation

Fig 4. Custom incisal guide table Fig 5 A,B. A. Anterior metal try in. B. Anterior permanent
restorations

JPID – The journal of Prosthetic and Implant Dentistry / Volume 5 Issue 3 / May–August 2022 / 127
The journal of Ashmi Sebastian, S. Anantha Narayanan, Sanjayagouda B Patil, Amith Vengalath

PROSTHETIC
AND IMPLANT
DENTISTRY
Official Publication of Indian Prosthodontic Society
Kerala State Branch

instructions were reiterated and reinforced. The satisfied with the outcome of the treatment and was
patient was recalled after one week, one month gratified with the enhanced esthetics and function.
and three months for follow-up. [Fig 10] The patient
was comfortable and had gotten accustomed to the Discussion
rehabilitated stomatognathic system. Oral hygiene
instructions were reiterated and reinforced. On Amelogenesis imperfecta is a genetic condition
completion of the treatment, the masticatory that causes mottling of enamel in both primary
efficiency was improved and esthetics also was and permanent dentitions. This condition leads
enhanced in harmony with the temporomandibular to crippled appearance and deprived function of
joint. After a follow up of one year, the patient was the masticatory system. The permanent solution to

Fig 8. Functional core index

Fig 6. Anterior and posterior survey points on Fig 7. Maxillary posterior teeth preparation
obtained using functionally
Broadricks occlusal plane analyser
generated pathway mounted
against prepared maxillary teeth

Fig 9. A, B. Right side excursive movement of mandible. A.

Fig 10. Postoperative photograph
Group function on [right] working side. B. Disclusion on
[left] nonworking side. C,D. Left side excursive movement
of mandible. C. Group function on [left] working side. D.
Disclusion on [right] nonworking side.

128 / JPID – The journal of Prosthetic and Implant Dentistry / Volume 5 Issue 3 / May–August 2022
The journal of Full Mouth Rehabilitation of Dilapidated Dentition due to Amelogenesis Imperfecta

PROSTHETIC
AND IMPLANT
DENTISTRY
Official Publication of Indian Prosthodontic Society
Kerala State Branch

revitalise the teeth would be to rebuild them using in the patient as well. Functionally generated
the various philosophies of full mouth rehabilitation pathway technique (FGP) was employed to achieve
laid down by several authors. group function occlusion. The plane of occlusion
was developed in tandem with the Curve of Spee
The routinely followed techniques are the Pankey- and Curve of Monsoon. Broadricks Occlusal Plane
Mann-Schyuler (PMS) and Hobo’s technique. Analyser was used for this purpose.
Schyuler proposed the concept of “Freedom in
Centric”8 and in 1960, Pankey and Mann advocated PMS technique allows stepwise sequential
an organised sequential approach to full mouth restoration of teeth. The significance of that is the
rehabilitation based on the principles of occlusion treatment outcome can be envisaged even before
advocated by Schuyler. Hobo adopted the concept preparing any teeth in the patient. This philosophy
of posterior disclusion and gave the Twin-tables breaks down the complex treatment procedures
Technique. The Twin-Stage Procedure was into fathomable quantum. The other advantages
developed as the advanced version of the Twin- of PMS technique include freedom in creating
Table technique. Youdelis scheme is advocated desired occlusal plane, occlusal scheme and
for advanced periodontitis cases and for extremely intercuspation, creating and controlling porcelain
advanced cases of periodontitis Nyman and Lindhe esthetics, teeth are prepared one quadrant/
scheme is employed.9 All these philosophies have segment at a time, chairside temporary restorations
deep rooted concepts and fundamentals upon can be constructed by quadrant or segment, final
which occlusal rehabilitation is carried upon. impressions involve few teeth per impression. It
However, it is the clinician’s discretion to choose eliminates the chances of alterations to the vertical
an appropriate occlusal scheme for a particular dimension established since teeth are prepared
reconstruction case after a holistic review of the and restored in segmented simultaneous and
presenting clinical condition so as to intertwine phased manner.12
predictable results with a stable functional
occlusion. The utilisation of PMS technique in this patient was
a deliberate choice considering its merits and the
The present case, occlusal rehabilitation was patient factors. Simultaneous preparation of all
carried out using Pankey-Mann-Schyuler [PMS] teeth for reconstruction could have jeopardised
concept. The anterior guidance was established the established vertical dimension. Since the teeth
first followed by rehabilitation of the mandibular were brittle due to genetic condition, a conscious
posteriors and finally the maxillary posteriors.7,10 choice was made to adopt PMS technique over
Restoring the anterior teeth serves as a precursor to others. The patient reaped maximum benefits from
achieve functional and aesthetically viable anterior this in the form of a well laid out treatment protocol
guidance. Anterior guidance is the dynamic and reduced appointment length. Also, sufficient
relationship of the lower anterior teeth against the gap between each appointment provided adequate
lingual slopes of the upper anterior teeth through time for the patient to adapt and make corrections
all ranges of function. Anterior guidance forms the to the prosthesis if required. The temporaries made
anterior control to provide posterior disclusion.11 were ensured to be devoid of any discrepancies
The three main things that were taken care of and only after sufficient evaluation, they were
while replacing posterior teeth viz establishing the converted to permanent restoration. Porcelain
plane of occlusion, achieving posterior disclusion fused to metal restorations were used for all the
and deciding the type of occlusal scheme. PMS teeth and subgingival margins with appropriate
concept endorses the development of group shade matching were done to achieve superlative
function occlusion which has been incorporated esthetic results. The definitive restorations were

JPID – The journal of Prosthetic and Implant Dentistry / Volume 5 Issue 3 / May–August 2022 / 129
The journal of Ashmi Sebastian, S. Anantha Narayanan, Sanjayagouda B Patil, Amith Vengalath

PROSTHETIC
AND IMPLANT
DENTISTRY
Official Publication of Indian Prosthodontic Society
Kerala State Branch

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