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Restorative therapy of primary teeth severely affected by amelogenesis

imperfecta

Article  in  Quintessence international · April 2006

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Ljubomir Vitkov Matthias Hannig

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Wolf Dietrich Krautgartner

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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

Restorative therapy of primary teeth severely

affected by amelogenesis imperfecta
Au: Please provide first and last names and academic degrees for all
authors.

Objective: Primary teeth severely affected by amelogenesis imperfecta (AI) often show an
extensive loss of enamel. Such defects are difficult to restore with resin composites, since
neither the correct anatomic form nor the marginal fit can be guaranteed. Methods and
Materials: After clinical and scanning electron microscopic examinations were performed
on replica models of five patients with primary teeth affected by AI, impressions were
made without previous preparation by rotary instruments. Composite crowns and veneers
were manufactured and luted adhesively using the total bonding technique and low-vis-
cosity resin composite. Results: The pre-restorative scanning electron microscopic analy-
sis showed that the dentinal tubules were exposed and that the border of the residual
enamel was in the process of splitting. The preoperative oral examination had revealed
tooth discoloration, masticatory disturbances, hypersensitivity, and speech problems. After
placement of the restorations, patients reported improvements in tooth sensitivity, articula-
tion, and mastication. Conclusions: A new protocol for restoration of primary teeth with an
extensive loss of enamel is offered. It is quick and easy to perform, highly esthetic, and
can be applied in children younger than 4 years old. (Quintessence Int 2006;37:xxx–xxx)

Key words: amelogenesis imperfecta, composite crown, composite veneer, total bonding

Amelogenesis imperfecta (AI), a group of
hereditary diseases affecting the tooth enam-
el in either quality or quantity, is associated
with crown malformation and abnormal
enamel density.1–3 In most of the teeth with AI
the mineral content of the enamel is lower
than in unaffected teeth.4 Clinically, the
advanced loss of tooth enamel leads to seri-
ously disturbed mastication, tooth hypersen-
sitivity, and a reduced self-confidence when-
Au:please supply affiliation information for all authors. Please
include the author’s title, department, university, ect. Also
please provide a complete mailing addres and contact infor-
mation including e-mail and fax for the corresponding
author.
ever anterior teeth are severely affected.
According to existing restorative concepts for
both permanent and primary teeth with
advanced enamel denudation, crown
restorations require tooth preparation with
rotating instruments.5–7 From this point of
view, two problems are of importance in pri-
mary teeth: small tooth dimensions and thus
a high risk for pulp injury during preparation,
and immense difficulty in performing the
tooth preparation with rotary instruments in
children 3 to 5 years old. Unlike with the per-
manent dentition, crown restorations in the
primary dentition are exposed to less masti-
catory loading and the period of use is limit-
ed in most cases to 5 years or less.
The application of total bonding and adhe-
sive luting techniques allows clinically reliable
placement of resin composite as well ceram-
ic veneers and crowns. In addition, adhesive
insertion of indirect restorations enables sta-
bilization of the remaining tooth hard sub-

VOLUME 37 • NUMBER 3 • MARCH 2006 41

Q U I N T E S S E N C E I N T E R N AT I O N A L
V itkov et al
Fig 1 Clinical view of the maxillary and mandibular teeth of a 5-year-old
patient severely affected by AI. Note the complete loss of enamel in tooth 55.
The yellow-brown color of the teeth results from exposure of dentin. In addi-
tion, the enamel of the maxillary incisors is discolored.
stances. Thus, adhesively luted resin com-
posite crowns and veneers might be appro-
priate for restoration of primary teeth severely
affected by AI. The aim of this work was to
present a new clinical method for crown
restoration in primary teeth affected by AI that
does not require previous preparation by
rotating instruments and is applicable in chil-
dren younger than 5 years old.
METHODS AND MATERIALS
Clinical examinations
Five patients (three girls and two boys)
between 3.5 and 10 years of age (mean age
6.5 years) with AI were examined. Patients
recruited for this study were transferred for
treatment from private practitioners or dental
clinics with the diagnosis AI. All patients
exhibited complete or partial loss of primary
enamel (Figs 1 and 2), and two patients (9
and 10 years old) also had partially
destroyed enamel of several permanent
teeth. The patients were questioned about
their complaints (mastication disturbance;
thermal, chemical, and osmotic irritations;
speech problems; and embarrassmentabout
the affected teeth[[Au: ok as edited?]). The
parents were asked for additional informa-
tion. Routine oral examinations were per-
formed in all patients.
42
Fig 2 Clinical view of the maxilla teeth of a 3.5-year-old
patient affected by AI. Tooth 54 was previously treated with a
resin composite restoration. Tooth 64 shows the same defect
and will be treated with a direct resin composite restoration.
Scanning electron microscopy
Impressions were made for all patients
except the 3.5-year-old using the combina-
tion of Permadyne Penta H and Penta L (3M
Espe), and replica models were produced
with Epon 812 (Serva), an epoxy resin used
for routine embedding of samples in the
transmission electron microscopy. After poly-
merization of the resin, the replicas were
sputtered with gold (about 10 nm) and exam-
ined in an environmental scanning electron
microscope (Philips ESEM XL30, Philips)
operating at 20 kV.
Fabrication of resin composite
crowns and veneers
Impressions were made with alginate
(Blueprint cremix, Dentsply DeTrey) for all
patients, and master castings were immedi-
ately completed. If necessary, gingival retrac-
tion was achieved by placement of retraction
cords before the impressions were made.
Restorations were fabricated with resin com-
posite (Symphony, 3M Espe) according to
the manufacturer’s instructions. In the maxil-
lary incisors, where extensive tooth discol-
oration was clinically manifest, Symphony
Opaquer was used to mask the stained
areas.
The crowns (Figs 3a and 3b) were
designed with a large coronal part (up to 1.5
mm) covering the exposed dentin and a thin
gingival part (0.1 to 0.25 mm thick) covering
VOLUME 37 • NUMBER 3 • MARCH 2006
 Q U I N T E S S E N C E I N T E R N AT I O N A L
V itkov et al

Fig 3a Resin composite crowns fabricated for a 5- Fig 3b Frontal view of the crowns shown in Fig 3a.
year-old patient (see Fig 1) with advanced enamel
denudation of all primary teeth. (Inset) A detailed view
of the crowns for teeth 55 and 65.

the remaining enamel (Fig 4). Margins of the

crowns ended 0.5 mm from the attached gin-
giva (see Fig 4).

Luting of restorations
After the teeth were cleaned with a cotton
pellet immersed in 3% hydrogen peroxide,
total etching of the affected teeth was per-
formed with 37% phosphoric acid (Total
Etch, Vivadent). Three subsequent treat-
ments with primer (Syntac Primer, Vivadent),
adhesive (Syntac Adhesive, Vivadent), and
light-curing bonding resin (Heliobond,
Vivadent) were carried out according to the
manufacturer’s instructions. The resin com- Fig 4 Schematic drawing of a resin composite crown and a veneer for
posite crowns were filled more than halfway treatment of advanced enamel denudation in primary teeth. The
with a low-viscosity composite (Tetric Flow, crown/veneer margins are 0.5 mm away from the attached gingiva. The
Vivadent) and positioned onto the teeth (Figs
large crown/veneer wall (up to 1.5 mm) covers the exposed dentin.The thin
(0.1 to 0.25 mm) crown/veneer margins cover the remaining enamel.
5 and 6). Excess composite was removed
with a spatula and a small plastic foam
sponge followed by a gentle air stream. The (Fig 7) and exposed dentin surfaces with
resin composite was light cured twice as open dentinal tubules (Fig 8). At the fractured
long (80 seconds) as recommended by the interface, residual enamel was in the process
manufacturer. After placement of all restora- of splitting (Fig 9). The oral examination
tions, the occlusion was checked and adjust- revealed advanced enamel detachment of
ed to the correct vertical dimension. the primary incisors in the 3.5-year-old
patient (see Fig 2) and complete as well as
partial enamel loss in the primary teeth of the
older patients (see Fig 1). The 5- and 5.5-
RESULTS year-old patients had also an open bite.
Permanent teeth were partially affected in
The scanning electron microscopic analysis patients with mixed dentition. All affected
revealed partial or complete loss of enamel teeth were discolored and exhibited yellow to

VOLUME 37 • NUMBER 3 • MARCH 2006 43

Q U I N T E S S E N C E I N T E R N AT I O N A L
V itkov et al

Fig 5 Adhesively luted crowns in the first quadrant of the 5-year-old Fig 6 Adhesively luted veneers in the first quadrant of the
patient shown in Fig 1. 3.5-year-old patient shown in Fig 2.

Fig 7 SEMs of a replica from a primary molar (tooth 85) affected by AI. (left) Fig 8 SEM of a tooth affected by AI revealing exposed
Enamel and dentin are clearly distinguishable (occlusal view). (right) Lateral dentin surface with open dentin tubules.
view of the same tooth indicating enamel loss up to the gingiva level.[AU:
Please verify that legends for Fig 7 and 8 are correct]

Fig 9 SEMs of a tooth affected by AI. (left) The border of the residual enamel was in the process of splitting. (right) Fraying of the tooth enam-
el margin.

44 VOLUME 37 • NUMBER 3 • MARCH 2006


brown coloration. The following were detect-
ed as a consequence of AI:
• Severe masticatory dysfunction (partial
nonocclusion, inability to bite off and to
chew tough food)
• Thermal irritation (extreme tooth sensitivity
to heat and particularly to cold, defined by
the patients as inability to eat ice cream)
• Chemical irritation (extreme sensitivity of
the teeth to acidic foods)
• Belittled self-esteem (the patients per-
ceived their teeth as unnatural, ugly, and
morbid)
• Speech impediments (the patients with
affected anterior teeth had articulation
problems with the dental consonants and
had a lisp)
One day after placement of the restora-
tions, control examinations were made in all
patients. They did not report any complaints
about the treatment. They further reported a
reduction of hypersensitivity and speech
problems and mentioned improved ability to
bite off and chew tough food, which was not
possible prior to placement of the crowns. All
patients were delighted in the appearance of
their new teeth. The recalls 1 week and 6
months later revealed no negative changes
in the teeth treated with composite crowns
and veneers. Increasing compliance in all
patients, including the 3.5-year-old, was evi-
dent during treatment and recalls.
DISCUSSION
Minor affections of tooth enamel caused by
AI can be excellently treated by adhesively
placed direct resin composite restorations.6,8
However, if most of the enamel is lost, a
direct resin composite restoration is difficult
to place in children. An extension of a direct
restoration onto all surfaces of the tooth
crown often results in an incorrect or at least
not optimal anatomic form and insufficient
marginal adaptation. Therefore, teeth severe-
ly affected by AI have been restored with
crowns luted after tooth preparation by rotary
instruments.5–7
VOLUME 37 • NUMBER 3 • MARCH 2006
Q U I N T E S S E N C E I N T E R N AT I O N A L
V itkov et al
However, the use of rotating instruments
in children younger than 4 years old is diffi-
cult, and the danger for injury of the pulp is
obvious. In cases where enamel and dentin
are not affected by caries, tooth preparation
without rotating instruments is possible.
Thus, we developed the concept of laborato-
ry-fabricated resin composite crowns and
veneers luted on totally etched and bonded
teeth affected by AI without preparation by
rotating instruments.
The large part of the restoration covers
the exposed dentin and restores the crown
shape and volume. The thin margins of the
restoration replaces the enamel, protects the
remaining but insufficient enamel, masks the
enamel discoloration, and enables the exact
positioning during setting. Possible under-
cuts on the tooth surface are filled by the lut-
ing resin during placement of the restoration.
Sufficient adhesion to primary teeth can
be achieved by total bonding to the surface
of the exposed dentin as well as to the
remaining enamel.9 It should be kept in
mind, however, that bonding of resin com-
posites to the residual enamel of teeth affect-
ed by AI is often problematic, especially in
individual cases with poorly mineralized, fri-
able enamel. In contrast to enamel, dentin
affected by AI does not reveal any alterations
and provides a clinically reliable substrate for
composite-to-dentin bonding and hybridiza-
tion of the exposed dentin surface. For this
reason a well-proven dentin bonding agent
was chosen for the clinical cases in this
study.9
The SEM investigation revealed that the
rough dentin surface and the enamel mar-
gins supply a multitude of retentive areas,
increasing the restoration’s interfacial bond-
ing and stability. Moreover, sealing of the
dentinal tubules remedied the osmotic
hypersensitivity. In addition, adhesive luting
of the restorations to the remaining enamel
supplies a high quantity of microretentions
enabling very stable anchorage of the
restorations. The esthetic appearance of the
restoration can be additionally improved by a
layer of opaquer, particularly in teeth with
severe discoloration.
45
Q U I N T E S S E N C E I N T E R N AT I O N A L
V itkov et al
CONCLUSIONS
An easy-to-follow protocol has been offered
that provides a new noninvasive approach for
restoration of clinical crowns of primary teeth
with complete or partial loss of enamel.
Since both direct resin composite restora-
tions and indirect crowns and veneers have
their limitations in restoring primary teeth
affected by amelogenesis imperfecta, advan-
tages of both types of restoration are com-
bined with this method. The restorative tech-
nique using indirect crowns and veneers
requires no tooth preparation with rotary
instruments and can be used in children as
young as 3.5 years. Extraoral prefabrication
of the restorations on castings makes treat-
ment shorter and more reliable and, in this
study, resulted in high compliance of the
patients.[[Au: A paragraph from the end of
the Discussion has been incorporated here. ]
ACKNOWLEDGMENTS
The authors thank master dental technician Mr Herwig
Burger-Ringer for masterful fabrication of the compos-
ite crowns and veneers, Mrs Adda Maenhardt for excel-
lent technical assistance, and Mrs Adelina Vitkov for sec-
retarial assistance.
46
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