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Journal of Indian Society of Pedodontics and Preventive Dentistry Official publication of Indian Society of Pedodontics and Preventive Dentistry
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Year : 2011  |  Volume : 29  |  Issue : 1  |  Page : 53-56

Dental rehabilitation of amelogenesis imperfecta using thermoformed templates

Paediatric Unit, Department of Operative Dentistry, Faculty of Dentistry, Universiti Kebangsaan Malaysia, Kuala Lumpur - 50300, Malaysia

Date of Web Publication23-Apr-2011

Correspondence Address:
SNMP Sockalingam
Paediatric Unit, Department of Operative Dentistry, Faculty of Dentistry, Universiti Kebangsaan Malaysia, Jalan Raja Muda Abdul Aziz, Kuala Lumpur - 50300
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-4388.79938

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Amelogenesis imperfecta represents a group of dental developmental conditions that are genomic in origin. Hypoplastic AI, hypomineralised AI or both in combination were the most common types seen clinically. This paper describes oral rehabilitation of a 9-year-old Malay girl with inherited hypoplastic AI using transparent thermoforming templates. The defective surface areas were reconstructed to their original dimensions on stone cast models of the upper and lower arches using composite, and transparent thermoform templates were fabricated on the models. The templates were used as crown formers to reconstruct the defective teeth clinically using esthetically matching composite. The usage of the templates allowed direct light curing of the composite, accurate reproducibility of the anatomic contours of the defective teeth, reduced chair-side time and easy contouring and placement of homogenous thickness of composite in otherwise inaccessible sites of the affected teeth.

Keywords: Amelogenesis imperfecta, enamel, genetic, reconstruction, restoration

How to cite this article:
Sockalingam S. Dental rehabilitation of amelogenesis imperfecta using thermoformed templates. J Indian Soc Pedod Prev Dent 2011;29:53-6

How to cite this URL:
Sockalingam S. Dental rehabilitation of amelogenesis imperfecta using thermoformed templates. J Indian Soc Pedod Prev Dent [serial online] 2011 [cited 2023 Jan 28];29:53-6. Available from: http://www.jisppd.com/text.asp?2011/29/1/53/79938

   Introduction Top

Amelogenesis imperfecta (AI) represents a group of developmental conditions, genomic in origin, which affect the structure and clinical appearance of enamel of all or nearly all the teeth in a more or less equal manner and may be associated with morphologic or biochemical changes elsewhere in the body. [1] Four major categories of AI based on phenotype can be recognized clinically, namely hypoplastic, hypomaturation, hypocalcified and hypomaturation-hypoplastic with taurodontism. [2] The prevalence of AI also varies between 1:700 and 1:14,000, depending on the studied populations. [3] AI may show several modes of genetic inheritance and can affect both the primary and the permanent dentitions. [4] It may relate to single gene defect or arise from microdeletion or chromosomal defects. Mutation or alteration in any of the genes encoding specific enamel proteins such as Enamelin gene (ENAM), Amelogenin gene (AMELX), Kallikrein 4 gene (KLK4), Matrix Metalloproteinase 20 gene (MMP-20) and Distal-less homeobox 3 gene (DLX3) have been linked with AI. [5]

This case report describes the dental rehabilitation of a young AI patient with direct composite restorations using thermoformed templates, which not only act as crown formers to re-establish the anatomical contour of the defective teeth but also control the amount of restorative material used and minimize the patient's chair side-time.

   Case Report Top

A 10-year-old Malay girl was referred to the Pediatric Unit of the Universiti Kebangsaan Malaysia (UKM) Dental Faculty for management of generalized anomaly of her dentition. She was first seen by a general dental practitioner (GDP) for extraction of grossly carious right mandibular first permanent molar (46). Her medical history was noncontributory.

Intraoral examination revealed that the teeth present were in permanent dentition stage with a class II dental occlusion, a deep overbite and an overjet of 4 mm. Both her right and her left maxillary permanent canines (13 and 23) were partially erupted and her left maxillary second premolar (24) was not visible clinically. All her teeth showed generalized presence of marked grooves with loss of enamel without any evidence of active caries. Her remaining maxillary and mandibular permanent first molars were grossly carious and unsalvageable [Figure 1],[Figure 2],[Figure 3]. Other relevant findings noted were occlusal attrition on posterior teeth, loss of occlusal vertical dimension and compromised esthetics. Her oral hygiene was moderate, with plaque retention observed on most of the teeth.
Figure 1: General appearance of the dentitions with amelogenesis imperfecta

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Figure 2: Occlusal view of the maxillary teeth with amelogenesis imperfecta

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Figure 3: Occlusal view of the mandibular teeth with amelogenesis imperfecta

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According to the patient's mother, the child's primary teeth appeared normal when first erupted but later broke down gradually. Her eldest sister also has this problem and this was confirmed through clinical examination. Based on-clinical finding, a diagnosis of inherited hypoplastic AI was made and an appropriate treatment plan was outline based on the patient's needs.

The restorations of the defective teeth were carried out in stages. Each treatment sessions lasted between 1 and 2 h depending on the child's tolerance and acceptability toward treatment. Initially, the upper four permanent incisors were restored with a hybrid composite using a free-hand technique. Prior to this, the affected tooth surfaces were pumiced, etched with 35% phosphoric acid and a thin layer of bonding agent was applied and light cured. No tooth structure was removed in order to prevent unnecessary tooth sensitivity that may arise. The structural grooves were used as retentive element to aid adhesion of the restorative material. However, as the treatment progressed, one problem that was encountered when attempting to restore the palatal or lingual sites of the affected teeth using the free-hand technique was to create a proper anatomical contouring and to obtain a homogenous thickness of the material used.

To overcome this, alginate impressions of both the dentitions were taken and stone casts were made. The defective areas of the tooth structure on the stone casts were filled and reconstructed anatomically using unused composite material [Figure 4] and [Figure 5].
Figure 4: Mock composite build-up of defective teeth on the maxillary stone cast

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Figure 5: Mock composite build-up of defective teeth on the mandibular stone cast

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The reconstructed stone casts were sent to the laboratory for fabrication of transparent thermoform "Essix" templates that conform to the anatomical shape of the reconstructed crowns. A 1.0-mm-thickness transparent thermoforming disc made of copolyester was heated up to 170 o C for 50 s and, once the disc softened, it was pressed onto the stone casts [Figure 6] and [Figure 7]. The pressed templates were allowed to cool and later removed and trimmed [Figure 8]. The produced templates act as crown formers to reconstruct the defective teeth.
Figure 6: Appearance of heat-pressed "Essix" thermoform disc on the maxillary stone cast

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Figure 7: Appearance of heat-pressed "Essix" thermoform disc to the mandibular stone cast

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Figure 8: Trimmed maxillary and mandibular transparent templates ready for use

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Adequate volume of composite material was packed into the template that corresponds to the desired area of teeth to be restored. The template was then placed over the affected teeth and light cured. Upon curing, the template was removed from the teeth and the restored areas were examined for any defectiveness. The composite restorations were polished and contoured using a combination of rotary discs of various grades of polishing burs to create esthetically pleasing restorations.

During each visit, two teeth from each side of the jaw were reconstructed in order to maintain a balance in occlusal contact between the teeth. The restorative outcome of the treatment is as shown in [Figure 9],[Figure 10],[Figure 11]. The patient was reviewed 6 months later, and only minimal adjustments to the restorations were necessary in otherwise intact dentitions.
Figure 9: General appearance of the rehabilitated dentitions using composite

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Figure 10: Occlusal view of the rehabilitated maxillary teeth

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Figure 11: Occlusal view of the rehabilitated mandibular teeth

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   Discussion Top

Clinical appearances of AI vary among individuals, from discoloration of teeth (yellow, brown or gray) to generalized areas of exposed dentine and enamel pitting. Increased susceptibility to plaque accumulation, caries, hypersensitivity and loss of vertical dimensions were also common clinical presentations seen. [6] Management of patients' AI provides great challenges to clinicians both from a functional and an esthetic perceptive. [7] Treatment objectives may vary depending on the age of the patient, socioeconomic status of the patient, severity of the disorder and the intraoral status at the time of treatment planning. [8] The primary goal of the treatment should address each concern as it presents but with an overall comprehensive plan that outlines the anticipated future treatment needs. [9]

In the present case, the patient was in an early adolescent stage. The posterior teeth were still in the erupting phases and, therefore, restoration of the defective teeth with permanent and complex restorations was contraindicated. Composite restorative material is selected as a suitable replacement of the defective structures because of its esthetics and high sustainability and because it provides excellent conservative transitional treatment for protection of AI in weakened teeth. [10]

Initially, the defective anterior teeth were restored using a free-hand technique. However, due to small mouth opening and inaccessibility to some of the sites, especially on the palatal and lingual aspects of the teeth, it was not possible to carry out proper restorations. The time spent to restore a single tooth was prolonged and each restored tooth needed more trimming and polishing. Thus, these templates act as an adjunct to allow easy restoration of the defective teeth.

   References Top

1.Alderd MJ, Crawford PJ, Savarirayan R. Amelogenesis imperfecta - classification and catalogue for the 21 st century. Oral Dis 2003;9:19-23.   Back to cited text no. 1
2.Witkop CJ Jr. Amelogenesis imperfect, dentinogenesis imperfect and dentin dysplasia revisited: Problem in classification. J Oral Pathol 1988;17:547-53.  Back to cited text no. 2
3.Crawford PJ, Aldred M, Bloch-Zupan A. Amelogenesis Imperfecta (Review). Orphanet J Rare Dis 2007;2:17.   Back to cited text no. 3
4.Bäckman B. Amelogenesis imperfecta - clinical manifestations in 51 families in a northern Swedish county. Scand J Dent Res 1988;96:505-16.   Back to cited text no. 4
5.Stephanopoulos G, Garefalaki ME, Lyroudia K. Genes and related proteins involved in amelogenesis imperfecta. J Dent Res 2005;84:1117-26.  Back to cited text no. 5
6.Seow WK. Clinical diagnosis and management strategies of amelogenesis imperfecta variants. Pediatr Dent 1993;15:384-93.   Back to cited text no. 6
7.Ayers KM, Drummond BK, Harding WJ, Salis SG, Liston PN. Amelogenesis imperfect - multidisciplinary management from eruption to adulthood. Review and case report. N Z Dent J 2004;100:101-4.  Back to cited text no. 7
8.Gokce K, Canpolat C, Ozel E. Restoring function and esthtetics in patient with amelogenesis imperfecta: A case report. J Contemp Dent Pract 2007;8:95-10.   Back to cited text no. 8
9.American Academy of Pediatric Dentistry. Guideline on oral health care/dental management of heritable dental developmental anomalies. Pediatr Dent 2008-2009;30:196-201.  Back to cited text no. 9
10.Sabatini C, Armstrong SG. A conservative treatment for amelogenesis imperfecta with direct resin composite restorations: A case report. J Esthet Restor Dent 2009;21:161-71.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11]

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