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Team Approach for the Management of Amelogenesis Imperfecta Case Report

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Case Report J Nepal Soc Perio Oral Implantol. 2018;2(1):23-5

Team Approach for the Management of Amelogenesis Imperfecta

Dr. Sonika Shakya,1 Dr. Shaili Pradhan,2 Dr. Munna Alam3

1
Department of Periodontics, KIST Medical College, Lalitpur, Nepal;
2
Department of Dental Surgery, Bir Hospital, Kathmandu, Nepal;
3
Department of Dental Surgery, Shree Birendra Army Hospital, Kathmandu, Nepal.

ABSTRACT
Amelogenesis imperfecta is a developmental disturbance that interferes with normal enamel formation in the absence of a systemic
disorder. This case report describes a multidisciplinary team approach for the oral rehabilitation of a young adult patient diagnosed with
hypocalcified amelogenesis imperfecta with anterior single tooth crossbite. The specific objectives of this treatment were to enhance
esthetics, eliminate tooth sensitivity and restore masticatory function. Treatment included maintenance of gingival health, correction of
crossbite, surgical crown lengthening of the maxillary and mandibular posterior teeth and placement of full mouth metal-ceramic crowns.
The patient was highly satisfied with the aesthetic and functional outcome of the treatment.

Keywords: Amelogenesis imperfecta; team; management.

INTRODUCTION while preventing further tooth loss, to maintain mastication

and to improve the appearance as this has great psychological
Amelogenesis imperfecta (AI) is a developmental disturbance
impact on the patient.6 This case report presents the
that interferes with normal enamel formation in the absence
diagnosis and treatment planning of a 17-year-old girl whose
of a systemic disorder.¹ Amelogenesis is a two-staged process
chief concern was unaesthetic appearance of her teeth.
where a protein rich matrix is initially laid down during
the secretary phase, followed by the mineralisation phase CASE REPORT
where the proteins are replaced by hydroxyapatite crystals.
A 17-year-old female patient reported to the Dental
This results in the highly mineralized enamel structure. AI
Department of Bir Hospital, Kathmandu with the chief
affects the formation of the enamel matrix or the enamel
complaint of yellow discolouration of teeth and sensitivity
mineralisation process of both the primary and secondary
of teeth to cold food and drinks. She had discolored teeth
dentition and affects the quantity and quality of the enamel
since childhood, and her deciduous teeth were similarly
structure and the overall appearance of all or nearly all the
discoloured too. Patient reported extreme dissatisfaction
teeth.²
with the unaesthetic appearance of her teeth. There was no
In its mildest form, AI causes discoloration while in its most contributing medical history and family history. On extra-
severe presentation; the enamel is hypomineralised causing oral examination no abnormality was detected. On intra-oral
it to be abraded from the teeth shortly after their emergence examination, there was generalised yellowish discoloration of
into the oral cavity.³ Apart from enamel defects, AI has all teeth. The incisal edges of upper incisors were chipped off.
also been associated with abnormalities in dental eruption, There was severe attrition on the occlusal surface of all molars.
congenitally missing teeth, anterior open bite, pulpal Examination of periodontium revealed chronic generalised
calcifications, root and crown resorption, hypercementosis, gingivitis with calculus deposition and pseudopocket
root malformations, and taurodontism.4 AI patients may formation (Figures 1 to 5). The orthopantomogram revealed
experience compromised chewing function due to tooth very thin or absent enamel on the occlusal surface of teeth
sensitivity and the short clinical crowns caused by attrition (Figure 6). However, the pulp chamber was within normal
and/or incomplete eruption.5 limits. Based on history, radiograph and clinical examination
Aim of the treatment should be to relieve pain or tooth a provisional diagnosis of AI-hypocalcified type was made.
sensitivity, to preserve as much tooth structure as possible

Correspondence:
Dr. Sonika Shakya
Department of Periodontics,
KIST Medical College, Lalitpur, Nepal.
email: tosonica@gmail.com

Citation
Shakya S, Pradhan S, Alam M, Team Approach for the Management
of Amelogenesis Imperfecta. J Nepal Soc Perio Oral Implantol.
2018;2(1):23-5. Figure 1: Yellowish discoloration of teeth.

Journal of Nepalese Society of Periodontology and Oral Implantology : Vol. 2, No. 1, Jan-Jun, 2018 23
Shakya et al : Team Approach for the Management of Amelogenesis Imperfecta

Figure 2: Right buccal view. Figure 3: Left buccal view.

Figure 4: Upper occlusal view. Figure 5: Lower occlusal view. Figure 6: Orthopantomogram.

Diagnostic casts were made. In consultation with the patient was improved orthodontic treatment was started to correct
full maxillary and mandibular rehabilitation with porcelain the crossbite with respect to 11 (Figure 7).
fused metal (PFM) crowns extending to the second molars
The next phase of treatment included restoration of carious
was considered to be the best therapeutic option. As the
lesions and root canal treatment where required. As planned
clinical crowns were inadequate for the placement of the PFM
earlier, surgical crown lengthening was done in all the
crowns, surgical crown lengthening was planned.
posterior teeth. In the first and second quadrant, external
There was generalised gingival overgrowth which almost bevel gingivectomy was planned due to the presence of
covered the occlusal third of the crown especially in the upper pseudopockets (Figure 8).
and lower molars. The patient had poor oral hygiene due to
In the third quadrant, internal bevel gingivectomy with
sensitivity during brushing. By looking at the gingival status
osteotomy was done (Figure 9).
the first phase of treatment included patient motivation and
education and reinforcement on brushing techniques. Scaling In the fourth quadrant, internal bevel gingivectomy along
was done followed by rootplaning. Once the gingival health with distal wedge surgery was done (Figure 10). Provisional

Figure 7: After completion of scaling & root planing & orthodontic treatment. Figure 8: External bevel gingivectomy.

Figure 9: Osteotomy. Figure 10: Distal wedge surgery.

24 Journal of Nepalese Society of Periodontology and Oral Implantology : Vol. 2, No. 1, Jan-Jun, 2018
 Shakya et al : Team Approach for the Management of Amelogenesis Imperfecta

Figure 11: Provisional restoration. Figure 12: Final restoration.

restoration was given in all the quadrants (Figure 11). After six poor esthetics. All of her posterior teeth were attrited
weeks tooth preparation for porcelain fused to metal crown causing severe sensitivity. So, full coverage porcelain fused
restoration was started for all teeth and final restoration was to metal crowns were planned. Due to severe sensitivity her
given (Figure 12). oral hygiene was poor leading to gingival overgrowth almost
covering the already short clinical crowns. We all know
DISCUSSION that periodontal health is the cornerstone of any successful
Clinical appearances of AI may vary among individuals, restorative procedure. Therefore, the correct handling of
from discoloration of teeth (yellow, brown or gray) to the periodontal tissues during restoration of the tooth is
generalized areas of exposed dentine and enamel pitting. important for the long term success of the restoration.10
Increased susceptibility to plaque accumulation, caries, Thus, it is necessary to prepare periodontal tissues properly
hypersensitivity and loss of vertical dimensions are the before restorative treatment to ensure good form, function,
common clinical presentations.6 Management of patients and esthetics of masticatory apparatus and patient comfort.
with AI provides great challenges to clinicians both from a So, scaling and root planing was performed and surgical
functional and an esthetic perspective.7 Treatment objectives crown lengthening was done where required to maintain the
may vary depending on the age of the patient, socioeconomic biologic width during restoration.
status of the patient, severity of the disorder and the Hence, early treatment of patient with AI is necessary to
intraoral status at the time of treatment planning.8 The prevent progressive damage of dentition and the psychological
primary goal of the treatment should address each concern impact of this condition on the patient. Unfavorable effects
as it presents but with an overall comprehensive plan that on aesthetic, function, occlusion necessitate different
outlines the anticipated future treatment needs.9 Hence a approaches from traditional dental treatments. So, by
multidisciplinary team approach is very much essential to systematic and sequential interdisciplinary treatment
treat patients with AI. approach patient’s esthetic and functional requirements can
In the present case, the patient’s chief complaint was her be fulfilled.

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Journal of Nepalese Society of Periodontology and Oral Implantology : Vol. 2, No. 1, Jan-Jun, 2018 25
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