This study had been presented (poster presentation) in the International Dental Congress. 29 September-01 October 2005, Izmir/TURKEY.

Introduction

Amelogenesis imperfecta is an inherited disease that disturbs the formation of enamel. (₁,₂) The hereditary pattern is autosomal or X-related dominant or ressesive. (₂) It's prevalance varies widely between studies, from 1 in 14.000 (₁) to 1 in 718 (₃), depending on the diagnostic criteria used and the population group studied. This condition has been divided into four main types (hypoplastic, hypomaturation, hypocalcification and hypomaturation-hypoplasia with taurodontizm) based on clinical, histological, radiographic and genetic features. (₄) The hypoplastic types are characterized by deficiency in the quantity of enamel, which can be expressed clinically through fine enamel, or with grooves and pits on its surface. The hypocalcified types show enamel that has low mineralization, manifested clinically by pigmented, softened and easily detachable enamel. Hypomaturation is an abnormal occurrence in the final stages of the mineralization proces. Hypomaturation differs from hypocalcification in that the enamel is harder with a mottled opaque white to yellow brown or red-brown color. (₃,₅,₆) Restoration of these defects is important not only because esthetic and functional concerns, but also because there may be a positive psychological impact for the patient. (₅,₇)

This clinical report presents the use and short term clinical performance of direct composite resin restorations in the treatment of a case of hypocalcified type of AI.

Case Report

Examination and Diagnosis

A 14-year-old patient presented to the dental school at the Dicle University of Diyarbakir, Turkey, complaining about the poor appearance of her teeth. A detailed medical, dental, and social history was obtained. The patient was examined dentally and medically. Photograps and dental and panoromic radiographs were obtained. Tissue loss affected all teeth. The enamel was yellow-brown. The molars were most severely affected and completely absent. The exposed dentin was brown and hypersensitive. There were no proximal contact points between posterior teeth.(Figure 1,2,3)

Figure 1

Figure 1,2,3: The figures of the patient prior to treatment

Figure 2

Figure 3

Periapical and panaromic radiographs revealed the loss of enamel, especially of posterior teeth. The approximal enamel of the teeth appeared to have the same radiodensity as dentin. (Figure 4)

Figure 4

Figure 4: A radiograph of the patient prior to treatment

Mandibular right first molar had been extracted because of severe attrition and caries previously. Oral hygine was not satisfactory, and there was evidence of gingivitis. Maxiller right and left second molars, and mandibular left second molar were exracted due to caries and severe attrition. After examination, the patient was diagnosed as having a hypocalcified type of AI.

Treatment

In the treatment plan, the restorative procedure alternatives were explained to the patient, including the differences in costs, the levels of tooth structure removal, the expected clinical longevity, the time period necessery the conclude the treatment, and the possible esthetic results. She could not afford prosthetic and orthodontic treatment due to her socioeconomic status. A treatment plan was developed with the aims of improving the gingival health, reducing the tooth sensivity, and improving the patient's appearance with direct composite restorations. Gingival health of patients was improved by used periodontal therapy. The occlusal contacts were determined in intercuspal position before cavity preparation. After ward, a rubber dam was placed to prevent contamination of the adhesive surface with saliva or blood. The cavity preparation was performed only encompass caries and dark areas of dentin that may interfere with the final esthetic result. Teeth were conditioned and primed with a self-etching adhesive (Clearfil SE Bond, Primer; Kuraray Medical, Tokyo, Japan) for 20 seconds. Enamel marjining were then covered with a bonding agent (Clearfil SE Bond; Kuraray Medical Inc) and polymerized for 10 seconds with a polymerizing unit (Bluephase C5, Ivoclar, Vivadent). The restorations were formed using a hybrid resin composite (Ecusit System, DMG, Hamburg, Germany), which was placed using an incremental technique. The resin composite restorations were polymerized for at least 2 minutes with the polymerization unit (Bluephase C5, Ivoclar Vivadent). (Figure 5,6) After restoration of teeth, the patient's dental sensivity disappeared completely, and normal eating habits were established.

Figure 5

Figure 5,6: The figures of the patient after treatment

Figure 6

The patient was recalled at 3-month intervals. Clinical examination 12 months after treatment revealed no evidence of disorders associated with the restored teeth or their supporting structures.

Discussion

There are a number of alternatives for the treatment of teeth afected by AI. However, the treatment plaining for patients with AI is related to many factor: the age and socioeconomic status of the patient, the type and severity of the disorder, and the intraoral situation at the time the treatment is planned. (₃,₅,₇) Patient and dentist should together, analyze the benefits and limitations of each technique and then decide what would be the best treatment. Patients with limited financial means can not always afford costly treatment.

Direct composite resin restorations may an alternative treatment. But, bonding composite resin to enamel of teeth affected by AI is often problematic, especially in cases with poorly mineralized, friable enamel. (₈) Because of tremendous advences in the fied of esthetic dentistry, especially in bonding to dentin, it is today possible to restore function and esthetics to an acceptable level. This adhesive restorative procedure preserves tooth structure and is not very time consuming or costly to the patient. (₂,₇)

In this report, direct composite resin restorations were chosen because they cost less than prosthetic restorations and with the hope that they would ensure esthetic and functional rehabilitation until the patient could cover cost of prosthetic restorations. These restorations were satisfactory both esthetically and functionally after one year of clinical use.

Correspondence to

Buket AYNA. DDS, PhD. Assistant Prof Dr. Dicle University, Dental Faculty, Department of Pedodontics Diyarbakir-TURKEY. Phone: 00904122488101-06 Fax: 00904122488100 E-Mail: buketayna@hotmail.com