Q U I N T E S S E N C E I N T E R N AT I O N A L
RESTORATIVE DENTISTRY
Rehabilitation of molar-incisor hypomineralization
(MIH) complicated with localized tooth surface loss:
A case report
Walter Y.H. Lam, BDS, MDS (Pros)1/Edward H.T. Ho, BDS, MClinDent (Pros)2/
Edmond H.N. Pow, BDS, MDS (Pros Dent), PhD3
Molar-incisor hypomineralization (MIH) is a developmental
enamel hypomineralized condition characteristically involving
the first permanent molars and sometimes also the incisors.
The affected teeth are predisposed to tooth surface loss (TSL)
which may not only compromise the esthetics and function
but also endanger the pulp and longevity of the teeth. This
Key words: Dahl concept, erosion, minor axial tooth movement, molar-incisor hypomineralization, tooth surface
loss, tooth wear
Molar-incisor hypomineralization (MIH) is the demar-
cated enamel porosity of systemic origin, affecting one
or more permanent molars (usually the first molars)
with or without involvement of the incisors and
canines.1 Its prevalence varies widely from 2.5% to
40.2%.2 It is believed that both hereditary and develop-
mental factors are contributory. It usually compromises
the enamel hardness and therefore predisposes the
1 Postgraduate Student, Discipline of Oral Rehabilitation, Faculty of Dentistry, The
University of Hong Kong, Hong Kong SAR, People’s Republic of China.
2 Part-time Clinical Lecturer, Discipline of Oral Rehabilitation, Faculty of Dentistry,
The University of Hong Kong, Hong Kong SAR, People’s Republic of China.
3 Associate Professor, Discipline of Oral Rehabilitation, Faculty of Dentistry, The
University of Hong Kong, Hong Kong SAR, People’s Republic of China.
Correspondence: Dr Edmond Pow, 4/F, Oral Rehabilitation, Prince
Philip Dental Hospital, 34 Hospital Road, Sai Ying Pun, Hong Kong SAR,
People’s Republic of China. Email: ehnpow@hku.hk
VOLUME 45 • NUMBER 5 • MAY 2014
Walter Y.H. Lam
report describes the management of a patient with MIH com-
plicated with localized TSL and lack of occlusal clearance due
to dentoalveolar compensation. The atypical TSL pattern
involved all anterior teeth and required the placement of Dahl
appliances on both arches. (Quintessence Int 2014;45:377–379;
doi: 10.3290/j.qi.a31540)
affected tooth to mechanical breakdown. Tooth surface
loss (TSL) is the loss of surface tooth substance caused
by mechanical and chemical (erosion) factors. A strong
relationship between the presence of acid erosion and
enamel hypomineralization has also been reported.3
The hypomineralized enamel may be susceptible to TSL
processes.
MIH teeth might be associated with pathologic TSL,
and a case of linear enamel hypoplasia combined with
TSL has been reported.4 MIH complicated with TSL may
not only compromise the esthetics and function but
also endanger the pulp and longevity of the affected
teeth. TSL might be complicated by eruption of the
teeth with its dentoalveolar processes which obliterate
the space for any restorations.5 This report describes
the rehabilitation of a patient suffering from MIH com-
plicated with localized TSL.
377
Q U I N T E S S E N C E I N T E R N AT I O N A L
L am et al
a b
Figs 1a to 1c Preoperative views showing localized tooth surface loss and enamel defects.
a b
a b
Figs 3a to 3c Postoperative views showing the definitive restorations.
CASE REPORT
A 44-year-old man complained of shortened anterior
teeth deteriorating his appearance. No erosive factors
or parafunctional habits were found. Normal facial
height with freeway space of 2 mm was noticed. Mild
TSL confined to enamel was detected on the occlusal
surface of all first premolars. Severe TSL exposing den-
tin and/or pulp was found on all the anterior teeth, and
the left maxillary and right mandibular first molars.
Enamel opacity was observed on the remaining first
molars. A provisional restoration was found on the cin-
gulum of the discolored left maxillary central incisor.
Compensatory eruption of the anterior teeth and the
alveolar process complicated with deepened incisal
plane was observed. No interocclusal space was
observed between the anterior teeth in centric occlu-
sion (Fig 1). A diagnosis of MIH, and localized anterior
TSL with dentoalveolar compensation was made.
378
c
Figs 2a and 2b Diagnostic wax-up on
the articulated casts and Dahl appliances
in situ.
c
Preventive measures were instituted and TSL pro-
gression was evaluated to be stable for 6 months.
Based on the diagnostic wax-ups, 3 mm of interocclusal
space was required. A nickel-chromium bite plane and
provisional composite crowns (Sinfony, 3M Espe) were
fabricated and luted (Ketac Cem, 3M Espe) on maxillary
and mandibular anterior teeth respectively (Fig 2). Six
months later, simultaneous posterior occlusal contacts
were reestablished uneventfully. The appliances were
removed and all anterior teeth were provisionalized for
6 weeks. Full ceramic crowns (IPS e.max Press, Ivoclar
Vivadent) were fabricated and luted (Calibra, DeTrey,
Dentsply). The left maxillary and right mandibular first
molars were prepared for gold onlay and crown re-
spectively. The left maxillary central incisor was man-
aged nonsurgically and surgically, but the fistula
remained unresolved. It was replaced by an implant of
4.0 × 13 mm (Astra Tech Implant System, Dentsply)
with a screw-retained metal-ceramic restoration. The
VOLUME 45 • NUMBER 5 • MAY 2014

patient had been followed for 6 months. All teeth, res-
torations, and the implant-supported crown were
intact and firm (Fig 3). The patient was satisfied with
the esthetics and function.
DISCUSSION
In the present case, localized TSL was observed mainly
on the occlusal surfaces of the incisors and first molars,
which suggested that the affected teeth were first com-
promised by MIH followed by attrition and dentoalveo-
lar compensation over time.
Dahl appliance was used to correct the dentoalveo-
lar compensation, by intruding the teeth in contact
with the appliance and eruption of nonoccluded teeth,
and recreating the lost interocclusal space for restor-
ations. The amount of space required was determined
by esthetics and diagnostic wax-ups. The increase in
occlusal vertical dimension (OVD) of less than 4 mm has
been shown to be well adapted in dentate subjects.6 It
has been recommended to place the appliance on the
arch with TSL,5 but the atypical TSL pattern in this case
entailed its placement on both arches. After Dahl ther-
apy, the OVD was restored and the dentition was reha-
bilitated by contemporary full coverage restorations
and an implant-supported crown.
VOLUME 45 • NUMBER 5 • MAY 2014
Q U I N T E S S E N C E I N T E R N AT I O N A L
L am et al
CONCLUSION
MIH may predispose to TSL. With severe TSL and a lack
of interocclusal space, the Dahl concept can be utilized
to facilitate the rehabilitation.
ACKNOWLEDGMENTS
The authors thank John Lo, Assistant Professor of Oral and Maxillofa-
cial Surgery, Faculty of Dentistry, The University of Hong Kong, for
performing the implant surgery; and Mr Sam Tang for the dental la-
boratory work.
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