ENDODONTOLOGY Case Report

Full mouth rehabilitation of amelogenesis imperfecta

- A case report.

K. PRIYADARSHINI *
ROOPA R. NADIG **

ABSTRACT
This case report deals with the multidisciplinary approach of an 18 year old with Amelogenesis Imperfecta of the
Hypoplastic type. The patient came with a chief complaint of small sized teeth and unsatisfactory aesthetics. No
abnormalities were detected in her past medical history. Her family history revealed similar condition in her
father and her sibling (sister).On clinical examination, the crowns of all teeth were small, discoloured, worn out
and hypoplastic. The roots appeared normal on radiographic examination.
The aim of the treatment was to preserve the tooth structure, restore the vertical dimension, improve esthetics and
masticatory function. The treatment procedures involved endodontic, restorative and periodontic interventions.
After recording the vertical height by a facebow transfer, endodontic treatment and crown lengthening were
performed w.r.t the upper anteriors. As the patient showed a high smile line, periodontal surgery was carried out
for the upper anterior teeth to obtain an average smile line. The lost vertical dimension was regained in a phased
manner by placing full coverage crowns for all the teeth. Thus by systematic and sequential interdisciplinary
treatment approach the patient’s esthetic and functional requirement was fulfilled.
Key-words: Full mouth rehabilitation; Amelogenesis Imperfecta(AI).
Key Messages: A planned and sequential interdisciplinary approach is essential in treating cases that require full
mouth rehabilitation. The outcome is dependent on the clinical complexity of the case and execution of the
properly designed treatment plan.

Introduction approximately 1:700 to 1:14,000.Transmission of

Variation of teeth has been an enduring interest the gene is autosomal dominant, recessive or X
to the clinical practitioner and the scientist. It is linked. Clinical findings of AI include: Enamel
the odd, peculiar, and strange group of teeth upon deficiencies, pulpal calcification, root
which we focus our attention here. Amelogenesis malformations, failed tooth eruption, impaction of
Imperfecta (AI) is a heterogeneous inherited permanent teeth, progressive root and crown
disorder that disturbs the developing enamel resorption, congenitally missing teeth and tooth
structure and exists independent of any related sensitivity. Due to reduced enamel thickness the
systemic disorder. It affects both the primary and teeth are undersized with lack of contact between
permanent dentitions. adjacent teeth, poor oral hygiene and mouth
breathing with associated gingivitis and gingival
Prevalence has been reported to vary between
hyperplasia may also be seen.
* Senior Lecturer, ** Professor and H.O.D, Dept of Conservative Dentistry and Endodontics and P.G Director of Dayananda Sagar College of Dental Sciences, Bangalore

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ENDODONTOLOGY K. PRIYADARSHINI, ROOPA R. NADIG

Each case of AI is unique, and warrants careful The objectives of treatment were to conserve
consultation with a variety of experts to obtain the the tooth structure, increase the lost vertical
best outcome 3 .Treating a patient with AI is dimension to a comfortable position (physiologic
important not only from a functional standpoint, neuromuscular position)7 , to restore masticatory
but also from a psychological point of view and function and improve esthetics. The treatment was
hence the aim of the treatment should be to both planned in three phases.
restore form, esthetics and improve masticatory
In the first phase of treatment (fig:3a): 2 sets of
function.
study models were made. One set was used as
Case History diagnostic and the other set was used for the
A 17 year old female patient reported to the fabrication of occlusal splints. A face bow transfer
Department of Conservative Dentistry and was made to record the cranio-maxillary and
Endodontics, Dayananda Sagar College of dental maxillo-mandibular relationship and it was decided
Sciences, Bangalore, with a chief complaint of to increase the vertical height by 4mm to restore
abnormally small sized teeth and unsatisfactory the lost vertical height due to attrition(fig 3b). It
appearance while smiling. was then mounted on a semi adjustable
articulator(fig:3c).Occlusal splints (fig:3d) of 2mm
Her medical history did not reveal any
each were fabricated using Biostar material for
abnormalities. Her past dental history revealed
upper and lower arches and the patient was asked
extraction of 27 due to caries. Her family history
to wear it for 3 months10 to acclimatize her to the
revealed that her father and her sister had
change in the vertical dimension.
abnormally small sized teeth. She did not report of
any parafunctional habits. Soft tissue examination Second phase of treatment: As the patient did
showed mild gingivitis. On analysing her smile not have any discomfort on recall it was decided
there was high smile line. Hard tissue examination to move into the second phase of treatment where
revealed the following (fig:1). Abnormally small the posterior teeth and the lower anteriors were
sized teeth, generalized spacing, calculus deposits, prepared to receive the provisional restorations in
generalized attrition, thin enamel on most of the the form of heat cure acrylic resin crowns
areas and absence of enamel on the occlusal maintaining a similar vertical height (4mm).Root
surfaces due to attrition. canal treatment was performed w.r.t
11,12,13,21,22,23 (fig:4a) as there was insufficient
Radiographic examination revealed (fig:2):
tooth structure and further reduction of tooth would
Impaction w.r.t 18,28,48,17,37,47. Though a thin
lead to pulpal exposure. A fibre post and composite
layer of enamel could be observed clinically, no
core build up was done w.r.t 13 (fig:4b).Crown
enamel could be appreciated in the radiograph as
lengthening by means of gingivectomy in
it was hypomineralized. From history, clinical and
conjunction with gingivoplasty was performed w.r.t
radiographic examination it was diagnosed as -
11,12,13,21,22,23 (fig:4c) not only to gain an
Amelogenesis imperfecta of the Hypoplastic type.1
increase in the clinical crown length but also to

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ENDODONTOLOGY FULL MOUTH REHABILITATION OF AMELOGENESIS IMPERFECTA - A CASE REPORT.

allow placement of the permanent crowns. An in recognition of the condition so preventive

average smile line was also achieved in the process measures can be provided at an early stage. Treating
which rectified the gummy smile. the patient with AI is important for functional and
psychosocial reasons. Some patients may need only
The prepared teeth were then restored with
oral hygiene instructions, while others need
temporary heat cure acrylic crowns(fig:4d)and the
extensive dental treatment. Historically, treatment
patient was kept under observation for 3
of such patients had included extractions and
months.After 3 months, as there were no TMJ
fabrications of complete dentures.However, these
functional abnormalities and pathology, the third
options are psychologically displeasing to the
phase of treatment was planned.
patient4. Because of the recent advances in the field
Third phase of treatment (fig:5): The temporary of esthetic and prosthetic dentistry, it is possible to
crowns were replaced by all ceramic crowns in the restore the function and esthetics to an acceptable
anterior teeth and porcelain fused to metal crowns level even in severe AI cases.
in the posterior teeth.
It has been reported that adhesive restorative
Oral hygiene instructions were given and the techniques, overdentures, porcelain-fused-to metal
patient was recalled after 1 month for follow up. crowns, fixed partial dentures, full porcelain
On completion of the treatment, all our objectives crowns, and inlay/onlay restorations are all used
were achieved. We could not only conserve the for the prosthodontic treatment of AI patients5,6.
remaining tooth structure but could also restore
In the present case, treatment was carried out
masticatory function and improve esthetics with
in 3 phases.In the first phase temporary occlusal
average smile line (fig:5).After a follow up of 24
splints were used to acclimatize and find if the
months (fig:6),the patient was satisfied with both
patient could tolerate the increase in the vertical
function and esthetics.Preoperative and
dimension of 4mm 7,8 .Increase in the vertical
postoperative figures are shown in fig:7.
dimension of 4mm was done in another case
Discussion: reported by Makarita where satisfying esthetics and
Genetic defects of the enamel are the most function were achieved.
frequent congenital anomalies of dental hard
In this study, the occlusal splints were
tissues.1 Based on the clinical presentation and
employed for a period of 3 months which also
strong family history a diagnosis of AI
happens to be the minimum recommended
(hypocalcified, autosomal recessive type) was
duration (for a minimum of 22 hours per day).10
made. An accurate diagnosis is important clinically
for several reasons. First, one has to exclude the Only after confirming that the patient could
presence of systemic diseases that may show tolerate an increase in the vertical dimension, the
generalized enamel hypoplasia. Secondly, it second phase of treatment, which involved tooth
enables affected families to seek genetic preparation and placement of full mouth temporary
counselling. Finally, an accurate diagnosis helps crowns, was carried out. During this phase we

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ENDODONTOLOGY K. PRIYADARSHINI, ROOPA R. NADIG

could not only ascertain the above but also carry placed. The entire treatment duration was
out the necessary interdisciplinary treatment approximately 6 months and we were able to
procedures like endodontic treatment and achieve both functional and esthetic goals to the
periodontal surgical procedures such crown satisfaction of the patient.
lengthening before the ceramic crowns were

Fig: 1: Hard tissue examination

Fig:2: Radiographic examination

FIRST PHASE OF TREATMENT

Fig:3a: Diagnostic casts Face bow transfer (Fig:3b) Fig:3c: Casts mounted on semiadjustable
articulator

Occlusal splints (Fig:3d)

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ENDODONTOLOGY FULL MOUTH REHABILITATION OF AMELOGENESIS IMPERFECTA - A CASE REPORT.

SECOND PHASE OF TREATMENT

Fig 4b: Fibre post and composite core build up

Fig 4a: Pulp space therapy wrt 11,12,13,21,22,23

Fig:4c: Crown lengthening

Fig:4d: Temporary crowns

THIRD PHASE OF TREATMENT

Fig:5: Post operative photographs - all ceramic and PFM crowns

Fig:6: Follow up photographs after 24 months

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ENDODONTOLOGY K. PRIYADARSHINI, ROOPA R. NADIG

Fig:7

Pre-op Post-op

Conclusion patient with amelogenesis imperfecta using all ceramic

crowns: A clinical report,J Prosthet Dent,98:85-88,2007.
The cosmetic rehabilitation of a patient with
4.Storie DQ, Cheatham J:Management of amelogenesis
Amelogenesis Imperfecta has been described in this imperfecta by periodontal and prosthetic therapy, J Prosthet
case report. The restoration of esthetics and function Dent, 24:608-15,1970.
in patients with Amelogenesis Imperfecta may be 5.Williams WP, Becker LH: Amelogenesis imperfecta:
Functional and esthetic restoration of a severely compromised
achieved by accurate diagnosis, meticulous
dentition, Quintessence Int,31:397-403,2000.
treatment planning together with dedicated
6.Nel JC, Pretorius JA, Weber A, Marais JT: Restoring function
interdisciplinary team based approach. Further, the and esthetics in a patient with amelogenesis imperfect,Int J
use of modern dental materials and a justifiable Periodontics Restorative Dent 1997;17: 478-83.

reliance on the predictable artistic abilities of the 7.Jankelson RR: Neuromuscular Dental Diagnosis and
Treatment, Tokyo: Ishiyaku EuroAmerica, Vol 1 (2nd ed.),
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restorations.
8.Neill DJ, Howell PG: Computerized kinesiography in the
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