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58
Malaysian Dental Journal
Vol 2/2018
Ilham Wan Mokhtar, Aminda Faizura Omar Khan
Center of Comprehensive Care Studies, Faculty of Dentistry Universiti
Teknologi MARA, Sungai Buloh Campus, Sungai Buloh, Selangor, Malaysia.
_____________________________________________________________________
ABSTRACT
Alterations during tooth structure formation, especially of the anterior teeth,
are known to cause compromised aesthetics. This case discusses the
management of a 13- year-old girl with enamel hypoplasia, presenting with
aesthetic concerns and complaint of hypersensitivity. Treatment with
composite restoration was successfully undertaken in a single visit. Planned
preventative management includes dietary advice, oral hygiene instruction
and regular follow-ups. The case also highlights the importance of
establishing awareness and patient education on the importance of regular
personal and professional oral health care to ensure long-term treatment
success and prevention of oral diseases.
Keywords: Enamel hypoplasia, hypomineralised, genetic, nutrition.
MALAYSIAN DENTAL JOURNAL
Conventional composite treatment for
generalised enamel hypoplasia in permanent
teeth: A case report.
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Malaysian Dental Journal
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INTRODUCTION
Enamel hypoplasia results from incomplete or defective formation of the
enamel’s organic matrix, usually associated with genetic or environmental
factors. It is also a defect in quantity that affects the surface of the enamel.
Such is usually due to a defect in enamel protein deposition, as well as
disrupted mineralisation process which results in post-eruption loss of enamel
substance. The aetiology may arise from some suggested factors such as
nutritional, viral or bacterial infections, birth injury, pre-term birth, trauma to
deciduous teeth or systemic disease 1,2.
Treatment of the defects, usually presenting as white or yellow-
brown spots, may cause problems that are more aesthetic than functional.
This treatment may vary depending on the depth of the spots. A composite
resin restoration may be favourable for deeper white-spot lesions due to its
low cost and efforts made to maintain the healthy tooth structure 1,2.
This case study focuses on the patient’s comprehensive treatment,
that considers her expectation of feeling an immediate impact while still
providing a more holistic management of generalised enamel hypoplastic
defect pattern, in compliance with the existing literature.
CASE REPORT
A 13-year-old Malay girl was brought into the clinic by her parents and her
younger sister. She was very quiet and did not respond much in conversation.
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Malaysian Dental Journal
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She avoided eye contact with the operator and refused direct communication.
After a thorough interview with both the patient and her father, the father
eventually mentioned that she was constantly bullied in school because of the
appearance of her teeth.
She complained of generalised tooth sensitivity with no particular
food or drink triggering it. Upon examination, the labial surfaces of all the
upper and lower anterior teeth appeared irregular and rough with poor enamel
consistency (Figure 1).
Figure 1: Frontal view of upper and lower anterior teeth
She was the eldest of two and attended a secondary school in a
district of Selangor, Malaysia. She enjoyed sweet treats and carbonated
beverages which her father mentioned that the family usually has once or
twice a day. Her father claimed that she has no systemic disorders or history
of hospitalisation. She was born with no complication. Also, both her parents
were self-employed.
The first visit took place in April 2017. After several years of
persuading, the father managed to convince the patient to seek dental care as
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Malaysian Dental Journal
Vol 2/2018
he insisted that she had never experienced school dental service. Her oral
hygiene was fair as she brushes her teeth twice daily with fluoridated
toothpaste. She did however report having sensitivity during tooth-brushing.
The patient exhibited a symmetrical face with Class III skeletal
profile. Extra-oral and intra-oral examinations revealed no significant findings,
including signs of inflammation or infection. All deciduous teeth had exfoliated
naturally and all permanent teeth, except for the second and third molars, had
erupted. All the first permanent teeth showed distinctive enamel breakdown
that involved the dentin. With rough canine surfaces, the upper canines had a
pointed surface. The consistency of the enamel was irregular, while the
incisor edges and labial surfaces were coarse (Figure 2 (a) and (b)) (Figure 3)
Figure 2: Occlusal view of a) Upper arch b) Lower arch
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Malaysian Dental Journal
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Figure 3: Side up-close view showing the irregular and coarse enamel
surfaces
In the presence of both parents, a comprehensive socio-
demographic and genetic background history-taking was carried out. Based
on the interview, it was found that her younger sister also displayed the same
hypoplastic pattern on her primary teeth. However, during her own primary
dentition phase, her parents could not recall whether she demonstrated a
similar presentation. Some of the potential risk factors were highlighted and
discussed while formulating the aetiology. These factors included i) neo-natal
infection , ii) pre-term birth, iii) living in heavily industrialised area, iv) prenatal
exposure to anti-epileptic drugs, v) gene mutation, vi) nutritional deficiencies
and vii) potential diseases.
The dietary history indicated a non-ideal eating pattern. Mom
alleged that she had difficulty breastfeeding while she experienced a lack of
milk supply. Therefore, they resorted to diluting condensed milk at the time.
Currently, they have proper dinners comprising of rice and a side dish but had
light breakfasts and simple lunches.
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An investigation with bitewing radiographs revealed that both the
quality and quantity of the enamel were affected (Figure 4).
a) b)
Figure 4: Bitewing radiographs a) Right and b) Left
An orthopantomogram showed no signs that there was congenital
absence of permanent teeth, tooth germ and other pathologies of hard tissue
(Figure 5).
Figure 5: Orthopantomogram
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In order to rule out any systemic disorders that may lead to the
diagnosis, a referral to a paediatric physician was made. Unfortunately, her
father refused to fulfil the referral for personal reasons.
A detailed examination of the features and patterns of the affected
tooth surfaces revealed chronological enamel hypoplasia. The aetiology of the
disease, however, was difficult to be determined. On the image and sequence
table of the permanent tooth eruption, a simple superimposition was made;
and it was found that this insult might have taken place when she was
between 2 - 4 years old (Figure 6). With these investigative findings and
limited information provided by the parents, nutritional deficiencies and/or
suspected viral or bacterial infections during the neo-natal period may be the
potential predisposing factors that contributed to her condition.
Figure 6: The superimposition of imaginary line following the pattern of the
disorders.
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Malaysian Dental Journal
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The treatment plan was designed with these aims: i) to educate the
family on the importance of optimal oral hygiene, ii) to advice the family on the
possibility of the patient’s younger sister developing the same condition if
there is no proper oral hygiene care and ii) to improve the aesthetic
appearance, in order to restore patient’s low self-esteem. The definitive
treatment plan was as follows: dietary advice, oral hygiene instruction,
restorative treatment and a 3-monthly review.
The anterior upper region was treated with composite veneers
(Figure 7) while the posterior teeth were restored using composite to secure
the occlusal-vertical dimension (OVD).
Figure 7: Conventional composite build-up on both upper and lower anterior
affected region.
Unfortunately, after the successful restoration of all the first
permanent molars and upper anterior region (right canine (13) to left canine
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Malaysian Dental Journal
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(23)), the patient decided to default the rest of her appointments as the family
insisted that the main issue had been addressed.
DISCUSSION
The definition of aesthetics is highly subjective in dentistry but is linked to
appearance, harmony and the patient's needs. The advancement of dental
restorative materials and innovative techniques allow dental structures to be
replicated, while the shape and function of the teeth are being restored 3-5.
Occlusal purpose and restorative material properties must be given specific
attention in addition to aesthetic reasons 6.
In the present case, the patient presented with enamel surfaces
that were hard and glassy. However, without appropriate intervention, these
surfaces would break down upon dental probing. This characteristic is due to
a dysfunction in the secretion of enamel matrix during mineralization or
maturation of enamel tissue 2.
There were important issues considered during the derivation of
treatment planning: 1) to advise on avoidance of acidic and/or sugary food as
means of reducing the hypersensitivity; 2) to perform a realistic assessment
on the longevity of affected first permanent molars from an early age; 3) to
consider elective loss of these teeth as part of an occlusal development plan
for the child; 4) to delay complex restorative treatment involving porcelain-
fused-to-metal crowns and prefabricated veneers until late adolescence.
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The restoration of her anterior teeth were prioritised in order to
restore her self-esteem, which was her main complaint. It was done in hopes
that her attitude and motivation towards oral health would improve after
observing the outcome of the treatment, as previously reported in other
studies 7.
Her failure to continue treatment highlights the importance of
patient education and motivation, not only on the patient, but also her support
system. Lack of family support may lead to an avoidance in attending
professional dental care, rendering the treatment outcome and oral health
unsuccessful. Therefore, continuous public education is important to instil oral
health awareness among society, which is crucial in ensuring long-term
treatment success and preventing occurrence of oral diseases. A more
personalised approach, such as motivational interviewing, may also be
beneficial in improving patients’ compliance, by addressing barriers that may
restrict their personal and professional oral health care 8.
CONCLUSION
Immediate conventional composite restoration could provide an instant
solution for enamel hypoplasia where, the tooth structure did not undergo
extensive severe tooth loss. Aesthetic and functional explanation may be
complete in a single sitting procedure. Continuous reinforcement of the
importance of regular personal and professional oral health care is important
to ensure treatment success and prevention of oral diseases.
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CONFLICT OF INTEREST
The authors have no conflict of interest within the study.
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