Ame

impa

mal

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Pravinkumar G.

1 A, Pretreatment pro

aAssistant Professor, Department ofbAssistant Professor, Department of

Patil and Patil

logenesis imperfecta with multiple

cted teeth and skeletal class III

occlusion: Complete mouth

abilitation of a young adult

Patil, MDSa and Smita P. Patil, MDSb

Government Dental College and Hospital, Nagpur, Maharashtra,India; SDKS Dental College and Hospital, Nagpur, Maharashtra, India

Amelogenesis imperfecta is an autosomal dominant disorder. It is a group of hereditary diseases showing abnormal enameldensity and crown malformation. This clinical report describes the oral rehabilitation of a young adult diagnosed with avariant of hypoplastic amelogenesis imperfecta with multiple impacted teeth and skeletal class III malocclusion. The treat-ment procedures of teeth extractions, endodontic treatment of remaining teeth followed by post and core restorations,esthetic and functional crown lengthening, and metal ceramic fixed dental prostheses were performed sequentially inthe maxillary arch. The mandibular arch was restored with an overdenture. One-year follow-up revealed satisfactory results.(J Prosthet Dent 2014;111:11-15)

Amelogenesis imperfecta (AI) is acomplex group of inherited conditionsthat disturbs the tooth enamel in eitherquality or quantity and appears withoutany associated systemic condition.1,2

The incidence of AI reported has variedbetween 1:700 and 1:16000 as studiedwith different diagnostic parametersat various geographic locations.3-6 The

file view

ProsthodoOrthodon

condition is an autosomal dominantdisorder, and the disease has familialassociation. At least 15 subtypes of AIexist, depending on phonotypic form andmode of inheritance.1,2,7 Regardless ofthe subtype, clinical findings reveal sim-ilar oral complications, including the ab-normal color and texture of the enamel,dental caries, tooth hypersensitivity, re-

. B, Pretreatment panoramic radiograph.

ntics, Government Dental College and Hospitatics and Dentofacial Orthopedics, SDKS Denta

duced occlusal vertical dimension, andabnormal esthetic appearance.8,9 Otherdental anomalies, including multipleimpacted teeth, congenitally missingteeth, taurodontism, and an open oc-clusal relationship, can also be associ-ated with the condition.10 Poulsen et al3

described the negative impact it can haveon a patient’s quality of life. Treatment

l.l College and Hospital.

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planning for patients with AI is depen-dent on many factors, including thetype and severity of the disorder, extentof destruction, and age and socioeco-nomic status of the patient. This reportpresents the complete mouth rehabil-itation of a young adult diagnosed asa subtype of AI with multiple impactedteeth, an open occlusal relationship, anda skeletal class III malocclusion.

CLINICAL REPORT

A 23-year-old man with features ofa variant of AI was referred to theDepartment of Prosthetic Dentistry fororal rehabilitation. The patient wasparticularly concerned about his old-looking appearance and poor mastica-tory efficiency, which was the resultof the destruction of the anteriorcrowns and multiple missing teeth.The medical and dental history revealed

2 A, Pretreatment occlusal view of maxilintraoral front view. Note open occlusal rvertical overlap in right molar region and

The Journal of Prosthetic Dentis

no abnormalities. The family historyrevealed that his elder sister had asimilar condition, but his youngerbrother had normal features, indicatingthe genetic origins of the condition.An extraoral examination revealedmaxillary retrognathism, mandibularprognathism, and left hemifacial hy-pertrophy on the lower third of the face(Fig. 1A). A panoramic radiographrevealed multiple impacted teeth inboth arches (Fig. 1B). On the basis ofclinical and radiographic examinations,multiple deciduous teeth in both archeswith compromised alveolar bone sup-port were extracted. After healing, anintraoral examination revealed oligo-dontia in the maxillary and mandibulararches, multiple spacing between teeth(Fig. 2A, B), anterior reverse articula-tion, an open occlusal relationship, andan Angle class III skeletal malocclusion(Fig. 2C, D). An increased vertical

lary arch. B, Pretreatment occlusal view ofelationship in anterior and left side of arcreverse articulation in anterior region.

try

overlap of the right posterior region andan open occlusal relationship of theanterior and left posterior region werealso observed (Fig. 2C, D). Accordingto the Prosthodontic Diagnostic Indexfor partially edentulous patients, thepatient was classified as class IV(severely compromised).11

After preliminary oral prophylaxis andthe extraction of the deciduous left firstmolar, diagnostic casts were obtained.The maxillomandibular relation wasrecorded with a mandibular occlusionrim, and the casts were mounted on asemiadjustable articulator (Hanau H2;Whip Mix Corp) in a conventionalmanner.12 The maxillary cast was diag-nostically prepared and a waxing wasdeveloped against mandibular dentureteeth.13 The interocclusal distance wasjudged to be approximately 2 mm inthe right posterior region, 9 mm in theanterior region, and 11 mm in the

mandibular arch. C, Pretreatmenth. D, Intraoral right lateral view. Note

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January 2014 13

left posterior region. A silicone puttyindex (Aquasil Putty; Dentsply) wasrecorded from the maxillary waxing andpreserved for the fabrication of interimrestorations.

The waxed denture was processed,finished, and polished in a conventionalmanner (Fig. 3A).14 Endodontic treat-ment of the mandibular abutment teeth

3 A, Mandibular overdenture.abutments prepared to receiveC, Denture relined with definiti

Patil and Patil

was completed, and the crowns wereprepared to receive metal overdenturecopings (Fig. 3B). The metal copings(Bellabond Plus; Bego Co) were fabri-cated in a dome shape to create theundercut (infrabulge) areas apical to theheight of the contour. The intaglio sur-face of the denture in the abutmentareas was trimmed to create space for a

B, Mandibular arch showingoverdenture metal copings.ve resilient liner.

relining material and relined with aresilient relining material (SofrelinerTough S; Tokuyama Dental Corp)(Fig. 3C).

The endodontic treatment of all theclinically present maxillary teeth wascompleted. Surgical crown lengthening(to improve esthetics and to provide aferrule) was performed on all maxillaryteeth and allowed to heal for 2 weeks.Post and core restorations were fabri-cated in a conventional manner for themaxillary right central incisor, leftlateral incisor, canine, and molar withprefabricated metal posts.15 All maxil-lary teeth were prepared to receivemetal ceramic restorations (Fig. 4A).The interim restorations, made fromautopolymerizing acrylic resin (Alike;GC America), were fabricated by usinga putty index prepared from the diag-nostic waxing and cemented in aconventional manner.16 A definitiveimpression was made with a polyvinylsiloxane impression material (AquasilSoft Putty and Light Body; DentsplyIntl). The anterior interocclusal recordswere made with the posterior interimrestorations and the mandibularoverdenture in place. Similarly, theposterior interocclusal records weremade with the anterior records andthe mandibular overdenture in place.The maxillary definitive cast and themandibular cast (prepared from theimpression of the polished surfaceof the denture) were mounted in asemiadjustable articulator (Hanau H2;Whip Mix Corp). The metal ceramic(Vita Omega 900-low fusing feld-spathic porcelain; Vita Zahnfabrik)restorations were fabricated by usingthe articulator settings and puttyindices made from the diagnosticwaxing (Fig. 4B). The restorations wereglazed after satisfactory evaluation andcemented with a definitive luting agent(GC Fuji I; GC Corp). The patient wasrecalled initially after 2 months andfollowed every 6 months. The mostrecent recall visit of the patient was1 year after treatment, and he waspleased with the treatment outcome(Fig. 5A, B) and the esthetic improve-ment (Fig. 6A, B).

4 A, Maxillary arch showing preprosthetic treatments, including post and core restorations. Note regular gingival marginachieved with esthetic/functional crown lengthening. B, Occlusal view of maxillary fixed dental prosthesis.

5 A, Panoramic radiograph, 1-year posttreatment. B, Intraoral view, 1-year posttreatment. Note restored vertical dimen-sion and eliminated anterior reverse articulation.

6 A, Pretreatment extraoral view. B, Posttreatment extraoral view.

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The Journal of Prosthetic Dentistry

DISCUSSION

The patient was classified by theProsthodontic Diagnostic Index as classIV11; therefore, a treatment was plannedwith the aim of fulfilling both the pa-tient’s functional and esthetic demands.Although orthodontic intervention wasconsidered, the presence of multipleimpacted teeth in both arches made thisoption unsuitable. Implant-supportedfixed or removable prostheses areconsiderably more extensive and have agreater incidence of clinical complica-tions than conventional fixed andremovable prosthodontics.17 For thispatient, the impacted teeth occupiedmaximum basal bone both in themaxilla and mandible. The removal ofthese teeth to allow for implant therapywas considered inappropriate because

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January 2014 15

of the risk of weakening the jaw bone.Therefore, the complete denture waschosen as the most suitable option. Inthe mandibular arch, 3 teeth were clin-ically suitable for use as overdentureabutments.

Managing the single complete den-ture occlusion is a difficult task becauseof malposed, tipped, or supraeruptedteeth and uneven occlusal surfaces inthe opposing arch.13 Balanced occlu-sion was developed to stabilize thedenture in relation to supporting struc-tures during functional and parafunc-tional movements.18,19 Patients shouldbe encouraged to attend regular recallappointments at intervals of at most 6months so that the condition of theresilient liner can be evaluated and thedenture relined if necessary. The deteri-oration of resilient liners with loss ofresiliency, bond failure between the linerand denture base, or increased surfaceroughness will contribute to bacterialadherence, increasing the risk of oralinfections. Care must be taken to keepthe liner surface clean and intact.20

SUMMARY

The teeth of a young adult diag-nosed with a hypoplastic AI with mul-tiple impacted teeth and skeletal classIII malocclusion were restored. Sequen-tial treatments, including extraction ofquestionable abutments, endodontictreatment of remaining teeth followedby post and core restorations, andmetal ceramic fixed dental prostheses,were performed in the maxillary arch.The mandibular arch was restored withan overdenture as a result of fewersupporting abutments.

Patil and Patil

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16. Gegauff AG, Holloway JA. Interim fixed res-torations. In: Rosenstiel SF, Land MF,Fujimoto J, editors. Contemporary fixedprosthodontics. 4th edition. New York:Elsevier; 2006. p. 466-504.

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18. French FA. The problem of building satis-factory dentures. J Prosthet Dent 1954;4:769-81.

19. Ortman HR. The role of occlusion in preser-vation and prevention in complete dentureprosthodontics. J Prosthet Dent 1971;25:121-38.

20. Mese A, Guzel KG. Effect of storage dura-tion on the hardness and tensile bondstrength of silicone- and acrylic resin-basedresilient denture liners to a processed den-ture base acrylic resin. J Prosthet Dent2008;99:153-9.

Corresponding author:Dr Pravinkumar G. PatilRoom 121, Department of ProsthodonticsGovernment Dental College & HospitalGMC Campus, Medical SquareNagpur (Maharashtra) 440003INDIAE-mail: pravinandsmita@yahoo.co.in

AcknowledgmentsThe authors thank Dr Husain Sabir (MDS,Assistant Professor, Department of Oral Medicineand Radiology) and Dr Suroopa Das (MDS,Assistant Professor, Department of ConservativeDentistry and Endodontics) for their support.

Copyright ª 2014 by the Editorial Council forThe Journal of Prosthetic Dentistry.