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Clinical success of deproteinization in hypocalcified amelogenesis

imperfecta

Article  in  Quintessence international (Berlin, Germany: 1985) · March 2009

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Q U I N T E S S E N C E I N T E R N AT I O N A L

Clinical success of deproteinization

in hypocalcified amelogenesis imperfecta
Işıl Ş. Sönmez, DDS, PhD1/Şaziye Aras, DDS, PhD2/
Emine Şen Tunç, DDS, PhD3/Çiğdem Küçükeşmen, DDS, PhD4

Objective: To determine the effect of deproteinization on the success of composite

crowns in hypocalcified amelogenesis imperfecta–affected permanent teeth in intraoral
conditions. Method and Materials: A total of 32 permanent teeth in 4 healthy children
with hypocalcified amelogenesis imperfecta were restored with strip crowns and composite
resin. Teeth on the left side of the jaw were selected as the control group, and teeth on the
right side of the jaw were selected as the treatment group. In the treatment group, a solution
of 5% sodium hypochlorite was applied for 1 minute after acid conditioning of tooth
surfaces. Clinical success was determined by USPHS modified Ryge criteria up to 36
months. Results: The deproteinization procedure had no effect on the anatomic form of
the restorations. The cervical integrity of the restorations in both groups showed inferior
results after 36 months compared to baseline. For both groups, no recurrence of caries
was observed. Conclusion: The deproteinization had no significant effect on the success
of the adhesive restorations; however, composite restorations were clinically successful in
children affected by hypocalcified amelogenesis imperfecta in long-term follow-up.
(Quintessence Int 2009;40:113–118)

Key words: composite restorations, deproteinization, hypocalcified amelogenesis

imperfecta

Amelogenesis imperfecta (AI) is defined as a large variability.1,2 In an epidemiologic study,

hereditary disease whereby the phenotypic Sundell and Koch3 designed a clinical classi-
manifestations of mutant genes influence fication system of hereditary amelogenesis
different levels of enamel development. The imperfecta (Table 1).
clinical appearance of the disease shows a Hypocalcified amelogenesis imperfecta
(HCAI) is characterized by poorly calcified
enamel of a light yellow-brown to orange
1
University of Kırıkkale, Department of Pediatric Dentistry, color with normal thickness on eruption.
Kırıkkale, Turkey. After eruption, the enamel becomes brown
2
University of Ankara, Department of Pediatric Dentistry, Ankara, to black from food stains. In teeth affected by
Turkey. HCAI, enamel is less radiopaque than dentin
3
University of On Dokuz Mayıs, Department of Pediatric on radiographs.1
Dentistry, Samsun, Turkey.
There are disturbances in the process of
4
University of Süleyman Demirel, Department of Pediatric
degradation or the process of resorption—or
Dentistry, Isparta, Turkey.
both—of matrix proteins, including amelogenin,
Correspondence: Dr Işıl Şaroğlu Sönmez, Kırıkkale Üniversitesi,
Diş Hekimliği Fakültesi, Pedodonti ABD, Kırıkkale, Türkiye. Fax:
in the maturation phase of amelogenesis in
+90 318 224 69 07. E-mail: isilsaroglu@yahoo.com HCAI.4 This results in enamel protein content

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VOLUME 40 • NUMBER 2 • FEBRUARY 2009 113

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Ta b l e 1 Basic classification for the posite crowns in permanent teeth affected by

clinical types of hereditary HCAI in intraoral conditions.
amelogenesis imperfecta3

1. Hypoplastic
1.1. Rough
1.1.1. Basic form METHOD AND MATERIALS
1.1.2. Thin enamel
1.1.3. Pitted basic form Four healthy children 8 to 11 years old with
1.1.3.1. Pitted thin enamel
HCAI according to clinical and radiographic
1.1.3.2. Pitted with horizontal grooves
1.1.3.3. Pitted with vertical grooves examinations participated in this study. A
1.1.4. Horizontal grooves total of 32 permanent teeth (30 incisors and
1.1.5. Unspecified appearance 2 first premolars) were restored with strip
1.2. Smooth crowns and composite resin restorations.
1.2.1. Thin enamel
Clinical success was determined by US
2. Hypomineralized
2.1. Hypomaturated Public Health Service (USPHS) modified
2.1.1. Localized opacities Ryge criteria10 up to 36 months (Table 2). The
2.1.2. Generalized opacities study was undertaken with the understand-
2.2. Hypocalcified ing and written consent of each subject’s
2.2.1. Localized or generalized
parents.
The deproteinization procedure used was
the same as that described in Şaroğlu et al.11
much greater in HCAI than in normal enamel, Teeth on the left side of the jaw were select-
and there may be an association between ed as the control group, and teeth on the
higher protein content and more severely right side of the jaw were selected as the
affected enamel.5,6 treatment group.
Adhesive restorations made to improve Control group. Teeth surfaces were
the poor esthetics in patients with HCAI show etched for 20 seconds with 20% phosphoric
high failure rates associated with inadequate acid (Heraeus Kulzer), rinsed with water for 5
bonding between the restoration and HCAI- seconds, and gently air dried for 1 to 2 sec-
affected teeth.7 The bond between enamel onds. After conditioning, 2 layers of Gluma
and restoration is highly dependent on the One Bond (Heraeus Kulzer) were applied
enamel surface alterations.5,8 using an application tip and light cured for
Venezie et al5 were the first to predict that 20 seconds (Polofil Lux Unit, Voco). Strip
pretreating enamel affected by AI with sodium crowns (Swedent, Akarp) previously adapted
hypochlorite (NaOCl) would make the enamel to the teeth were filled with Charisma com-
crystals more accessible to the etching solu- posite (Heraeus Kulzer) and light cured for
tion, resulting in a clinically more favorable 40 seconds from each side.
etched surface. Yet, they reported that Treatment group. A solution of 5%
NaOCl pretreatment produced clinical suc- NaOCl was applied for 1 minute after acid
cess in bonding an orthodontic bracket to a conditioning of the teeth surfaces and then
tooth affected by HCAI. rinsed with water spray before application of
In a previous in vitro study, it was shown the bonding agent. Procedures after condi-
that removing excess proteins via NaOCl tioning were the same as for the control
(deproteinization), the bonding between group. After removal of the strip crowns, stan-
enamel and restoration was enhanced in dard polishing procedures were performed.
deciduous teeth affected by HCAI.9 However, All 32 permanent teeth (18 teeth in the con-
intraoral conditions are very different from in trol group, 14 teeth in the treatment group)
vitro conditions, and bond strength is not the were followed for 36 months. Figure 1 shows
only variable affecting the success of the the clinical appearance of an 11-year-old
restoration. From this point of view, the pur- patient before restoration, and Fig 2 shows
pose of this study was to evaluate the effect the clinical appearance after 36 months’
of deproteinization on the success of com- follow-up.

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Fig 1 Intraoral view of a patient before treatment. Fig 2 View of the restorations at the 36-month follow-up.

Ta b l e 2 USPHS modified Ryge criteria10

Anatomic form
1. Restoration is continuous with existing anatomic form.
2. Restoration is discontinuous with existing anatomic form, but missing material is not sufficient to expose
dentin.
3. Sufficient material is missing to expose dentin.
Cervical integrity
1. Explorer does not catch, and/or no crevice is visible.
2. Explorer catches and crevice is visible, but there is no exposure of dentin and restoration is not mobile.
3. Explorer penetrates crevice, defect extends to dentinoenamel junction.
4. Restoration is fractured, mobile, or missing, either in part or in toto.
Cervical discoloration
1. There is no visual evidence of marginal discoloration.
2. Marginal discoloration is present.
Surface texture
1. Surface texture is similar to polished enamel.
2. Surface texture is gritty (similar to white stone).
3. Coarse surface pitting.
Maintenance of interproximal contact
1. Proximal contact is present.
2. Proximal contact is light but present.
3. There is no proximal contact.
4. There is no adjacent proximal surface.
Recurrent caries
1. No caries is present.
2. Caries present is associated with restoration.

An experienced pediatric clinician indepen- detect differences among the test groups for
dent from restoration placement evaluated the each criterion and a Wilcoxon test to deter-
clinical success of the restorations. The data mine differences for each group between
were subjected to a Mann-Whitney U test to recalls (P < .05).

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Ta b l e 3 Clinical results of all recalls for both groups

6 mo 18 mo 24 mo 36 mo

1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4

Anatomic form
Control group 18a 0 0 — 18a 0 0 — 18a 0 0 — 17a 0 1 0
Treatment group 14a 0 0 — 13a 0 1 — 13a 0 1 — 13a 0 1 0
Cervical integrity
Control group 18a 0 0 0 16a 2a 0 0 4a 14 0 0 4a 14 0 0
Treatment group 14a 0 0 0 12a 2a 0 0 12b 2 0 0 4a 10 0 0
Cervical discoloration
Control group 18a 0 — — 7a 11 — — 3a 15 — — 3a 15 — —
Treatment group 14a 0 — — 14b 0 — — 11b 3 — — 11b 3 — —
Surface texture
Control group 18a 0 0 — 18a 0 0 — 12a 5 1 — 10a 7 1 —
Treatment group 14a 0 0 — 14a 0 0 — 6a 8 0 — 6a 6 2 —
Maintenance of interproximal contact
Control group 18a 0 0 0 18a 0 0 0 18a 0 0 0 17a 0 1 0
Treatment group 14a 0 0 0 14a 0 0 0 14a 0 0 0 14a 0 0 0
Recurrent caries
Control group 18a 0 — — 18a 0 — — 18a 0 — — 18a 0 — —
Treatment group 14a 0 — — 14a 0 — — 14a 0 — — 14a 0 — —
(—) Not applicable. *See Table 2 for a definition of criteria. Different superscript letters for each Ryge criteria mean significant
statistical difference at P < .01 between the 2 groups.

RESULTS DISCUSSION

Table 3 shows the results of the assessment Amelogenesis imperfecta represents a

of the clinical performance of control and group of hereditary conditions that manifest
treatment groups at each examination. enamel defects without evidence of any sys-
The deproteinization procedure had no temic disorders.2 Treatment objectives for the
effect on the anatomic form of the restoration young adult patient include the relief of ther-
(P > .05). The anatomic form of the restora- mal sensitivity and improvement of facial
tions was successful in 94% of the control esthetics and function. Initial restorative treat-
group and 93% of the treatment group after ments should be conservative, using direct
36 months. adhesive materials that are appropriate in a
Regarding cervical integrity, the treatment growing child.11–13 These restorations solve
group showed significantly superior results the problem of sensitivity and esthetics until
after 24 months (P < .01). Cervical integrity of the definitive full-crown restorations are indi-
the restorations was impaired after 36 cated. However, in many patients with AI,
months in both groups, but ratios did not dif- adhesive restorations may show high failure
fer significantly from one another (P > .01). rates associated with inadequate bonding
Statistically significant differences were between the restorations and enamel.7,14
found between the groups at the 18-, 24-, Several investigators have demonstrated
and 36-month recalls for cervical discol- that organic content is higher in the enamel
oration (P < .01). of teeth with HCAI than in those with normal
Statistical analysis revealed no significant enamel.5,6 It has been speculated that this
differences among groups at all recalls protein excess is the cause of composite
regarding surface texture, maintenance of restoration failure in HCAI-affected teeth.4–6,15
interproximal contact, and recurrent caries. In a study aiming to determine the effect of

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removing the excess protein on the bond effect on the clinical success of adhesive
strength of restorations in primary teeth restorations in permanent teeth affected by
affected by HCAI, it was shown that depro- HCAI except marginal discoloration. The
teinization with NaOCl pretreatment enhances result that deproteinization does not affect
the bond strength of adhesive restorations in the success of adhesive restorations may be
HCAI.9 So, in this study, the goal was to eval- explained by the lower enamel content of the
uate the effect of deproteinization on the suc- permanent teeth affected by HCAI compared
cess of bonded restorations in permanent to primary teeth affected by HCAI. However,
teeth affected by HCAI. as in the study by Lygidakis et al,18 composite
In this study, deproteinization procedure resin restorations in teeth affected by HCAI
had no significant effect on the anatomic were found to be an acceptable restorative
form of the restorations after 36 months. procedure with satisfactory long-term results.
Although the cervical integrity of the restora-
tions was not maintained in the treatment
group, cervical discoloration was found to be
significantly lower than in the control group. CONCLUSION
This can be explained by the enhanced bond
strength of the restorations to the enamel, Deproteinization had no significant effect on
which reduces marginal leakage.16 the success of the adhesive restorations;
After 36 months, 77.7% of the restorations however, composite restorations were found
in the control group and 71.4% of the restora- to be clinically successful in children affected
tions in the treatment group had a visible by hypocalcified amelogenesis imperfecta in
crevice along the margin of the restoration. long-term follow-up.
This may be a result of not removing the cer-
vical enamel that is less affected in HCAI
teeth than coronal enamel. The thinner com-
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