Restoring function and esthetics in a patient with amelogenesis imperfecta:

A clinical report
Tuğrul Sari, DDS,a and Aslıhan Usumez, DDS, PhDb
Faculty of Dentistry, Selcuk University, Konya, Turkey
This clinical report describes the prosthodontic treatment for an 18-year-old man diagnosed with
amelogenesis imperfecta. The aim of treatment was to reduce dental sensitivity and to restore esthetics
and masticatory function. Metal-ceramic fixed partial dentures were placed on posterior teeth to mod-
ify the occlusion, and porcelain laminate veneers were placed to improve the esthetics of the maxillary
anterior teeth. Clinical examination 12 months after treatment revealed no evidence of disorders asso-
ciated with the restored teeth or their supporting structures. (J Prosthet Dent 2003;90:522-5.)

A melogenesis imperfecta (AI) has been defined as a

group of hereditary enamel defects not associated with
disorder, and the intraoral situation at the time the treat-
ment plan is developed. This clinical report describes the
evidence of systemic disease.1 Investigators have dem- treatment of an 18-year-old with amelogenesis imper-
onstrated that it is possible to delineate at least 12 dis- fecta using porcelain laminate veneers in the anterior
tinct types of amelogenesis imperfecta2-6 using a combi- region and metal-ceramic fixed partial dentures (FPDs)
nation of clinical, radiographic, histological, and genetic in the posterior region.
criteria.7,8 On the clinical and radiographic basis alone, 3
broad groups can be distinguished: (1) hypoplasia, in CLINICAL REPORT
which the enamel is reduced in quantity but is relatively An 18-year-old man was referred for treatment of
well-mineralized; (2) hypocalcification, in which enamel attrition and considerable sensitivity of his teeth. He was
is formed in relatively normal amounts but is poorly very self-conscious about the appearance of his teeth. A
mineralized; and (3) hypomaturation, in which the final detailed medical, dental, and social history was obtained.
stages of the mineralization process are abnormal. Photographs and dental radiographs were made.
The clinical features distinguish the hypoplastic and The patient’s maxillary right and left second premo-
hypocalcified types.9 In the hypoplastic forms, the lars, mandibular right second premolar, and mandibular
enamel does not develop to its normal thickness. In the left second molar had been extracted due to caries. Tis-
hypocalcified forms, the enamel thickness on the newly sue loss affected all teeth. The enamel layer was nearly
erupted teeth closely approaches that of normal teeth, absent in the occlusal portion of the molars, and enamel
but the enamel is soft, friable, and can easily be removed pit defects were present in the anterior teeth (Figs. 1-3).
from the dentin. In contrast to hypoplastic types, the The exposed dentin was hypersensitive. It was con-
hypomaturation types develop enamel of normal thick- cluded that the patient likely suffered from a hypoma-
ness. The hypomaturation forms differ from hypocalci- ture type of AI.
fication in that the enamel is harder, with a mottled Diagnostic casts were made, as were face-bow and
opaque white to yellow-brown or red-brown color, and protrusive records. Casts were mounted in centric rela-
tends to chip from the underlying dentin rather than
wear away.6,9-11
According to Seow,12 the primary clinical problems
of AI are esthetics, dental sensitivity, and loss of occlusal
vertical dimensions. However, the severity of dental
problems experienced by patients varies with each type
of AI. Historically, treatment of patients has included
multiple extractions and the fabrication of complete
dentures.12 These options are psychologically harsh
when the problem must be addressed in adolescent pa-
tients.13
The treatment plan for patients with AI is related to
many factors including the age of the patient, the socio-
economic status of the patient, the type and severity of

a
Post-graduate student, Department of Prosthodontics.
b
Assistant Professor, Department of Prosthodontics. Fig. 1. Pretreatment view of teeth in occlusion.

522 THE JOURNAL OF PROSTHETIC DENTISTRY VOLUME 90 NUMBER 6

SARI AND USUMEZ
Fig. 2. A and B, Pretreatment occlusal views. First molar teeth are highly affected.
Fig. 3. Panoramic radiograph. Radiodensities of enamel and dentin were similar.
tion in a semi-adjustable articulator. The patient had
canine-protected occlusion. It was determined that the
patient had 3 to 4 mm of interocclusal distance; there-
fore, the patient’s vertical dimension was not altered.
A treatment plan was developed with the following
aims: to reduce the reported sensitivity of the teeth, to
improve the esthetics, and to restore masticatory func-
tion. Fabrication of metal-ceramic FPDs for maxillary
and mandibular posterior teeth and porcelain laminate
veneers for anterior teeth was planned. The patient was
informed of the diagnosis and treatment plan, which he
accepted.
The facial surfaces of the maxillary anterior teeth were
prepared. A 0.5-mm facial reduction was performed,
creating a chamfer cervical finish line. The incisal por-
tions of the teeth were prepared to allow overlap of the
restoration. Self-limiting depth-cutting disks of 0.5-mm
DECEMBER 2003
THE JOURNAL OF PROSTHETIC DENTISTRY
thickness (834-31-021; Gebr. Brasseler, Lemgo, Ger-
many) were used to define the depth of the cuts, and
1.4-mm chamfer diamond burs (6844-314-014; Gebr.
Brasseler) were used to refine the preparations. All tooth
preparations were completed without sharp line angles.
Impressions for prepared teeth were made with sili-
cone material (Speedex; Coltène/Whaldent Inc, Cuya-
hoga Falls, Ohio). A definitive maxillary cast was formed
and mounted in an articulator with trimmed dies of
prepared teeth. All restorations were fabricated with IPS
Empress 2 materials (Ivoclar Vivadent AG, Schaan,
Liechtenstein) according to the manufacturer’s direc-
tions.
After completion, the porcelain laminate veneers
were evaluated for fit on the prepared teeth. They were
then luted with a resin luting agent (Variolink II high
viscosity; Ivoclar Vivadent AG) in combination with a
523
THE JOURNAL OF PROSTHETIC DENTISTRY
Fig. 4. Post-treatment occlusal views. A, Maxillary; B, mandibular.
Fig. 5. A and B, Facial views of prostheses 12 months after insertion.
dentin adhesive (Syntac; Ivoclar Vivadent AG) and a
bonding agent (Heliobond; Ivoclar Vivadent AG) with
the use of rubber-dam isolation. Photo-polymerization
was performed with a light polymerizing unit (Hilux
350; First Medica, NC) at 350 mW/cm2 for 40 seconds
for incisal, mesial, and distal surfaces.
After all the posterior teeth were prepared, impres-
sions were made with vinyl polysiloxane material (Spee-
dex; Coltène/Whaledent Inc) in stock trays. From these
impressions, casts were made and mounted in an artic-
ulator to produce metal-ceramic FPDs (Ivoclar Vivadent
AG). The metal frameworks were evaluated intraorally
to determine the marginal fit. A metal trial insertion,
prior to glazing of the ceramic material, enabled final
occlusal refinement. The patient’s natural occlusal
scheme (canine-protected occlusion) and anterior guid-
ance were preserved in the definitive restorations to de-
crease lateral forces on the posterior dentition. The
crowns were then completed in the laboratory and ce-
mented with zinc-polycarboxylate cement (Poly F Plus;
Dentsply DeTrey GmbH, Konstanz, Germany) (Fig. 4)
according to manufacturer’s power/liquid ratio.
The anterior porcelain laminate veneers and posterior
metal-ceramic FPDs were satisfactory both esthetically
524
SARI AND USUMEZ
and functionally at the end of 1 year of clinical service
(Fig 5).
SUMMARY
This clinical report describes the use of metal-ceramic
FPDs and porcelain laminate veneers for restoration of a
hypomature type of amelogenesis imperfecta. Metal-ce-
ramic FPDs were placed on the posterior teeth, and
porcelain laminate veneers were placed on the maxillary
teeth to improve the occlusion and esthetics.
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