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Malaysian Dental Journal

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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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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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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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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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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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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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(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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