Direct restorations in patient with imperfect amelogenesis

Abstract

Amelogenesis Imperfecta is a genetic condition that results in the malformation of dental enamel, affecting both primary and permanent teeth. This condition can lead to issues with occlusion, dentin sensitivity, and aesthetic damage. The rehabilitation approach depends on the severity of the condition, the patient's financial resources, and age. The objective of this report is to demonstrate the effectiveness of direct restorations in a patient with amelogenesis imperfecta.

A 21-year-old male patient sought treatment complaining about the appearance of some of his teeth. During the evaluation, enamel alterations were noted on teeth 11, 13, 16, 31, and 42, with an unsatisfactory Class IV restoration on tooth 21. Tooth 16 exhibited the most significant enamel alteration and had caries on the occlusal surface. Tooth 13 was not achieving proper canine guidance, and tooth 11 presented aesthetic issues. Teeth 31 and 42 lacked incisal edges. After the evaluation, three possible diagnoses were considered: sickle cell anemia, generalized hypoplasia, or amelogenesis imperfecta. A blood test to check hemoglobin levels was within normal ranges. To finalize the diagnosis, literature research, clinical characteristics analysis, and patient information indicating that these features were common in his family (including his father) led to a diagnosis of amelogenesis imperfecta, a hereditary alteration.

With the diagnosis confirmed, the patient’s rehabilitation could begin. We started by preparing the dental environment with prophylaxis and supragingival scaling.

Tooth 16 was the first to be restored. Absolute isolation was performed, and a spherical bur was used to remove the carious tissue. A 3118 bur was then used to smooth the surfaces. After preparation, etching was done with 37% phosphoric acid for 30 seconds on the enamel and 15 seconds on the dentin, followed by thorough rinsing and drying with absorbent paper. With the tooth conditioned, the adhesive system was applied using a universal adhesive in two layers. The first layer was applied, left for 20 seconds, and air-dried for 5 seconds. The second layer was also left for 20 seconds and light-cured for 40 seconds. Composite resin OA1 was applied incrementally. An opaque composite resin was chosen to avoid aesthetic issues that a more translucent resin might cause. After sculpting the tooth crown, occlusion was checked in MIH positions and canine guidance, with polishing scheduled for the next session.

In the following session, teeth 31 and 42 were restored. Absolute isolation was installed, and a 3118 bur was used to smooth the incisal third of the vestibular surface. After smoothing, 37% phosphoric acid was applied for 30 seconds on the enamel, followed by rinsing and drying. The adhesive system was applied as in the previous restoration. Composite resin A1 was used to sculpt the incisal edges of both teeth, following an incremental technique. Occlusion was checked with carbon paper as before, and polishing was scheduled for the next session.

In the subsequent session, in addition to polishing, the resin in the vestibulomesiobuccal third of tooth 21 was replaced. Absolute isolation was performed, followed by removal of the resin using a 1014 bur in high rotation. After removal, a 3118 bur was used to smooth the vestibulomesiobuccal and mesiolingual thirds. Phosphoric acid 37% was applied for 30 seconds on the enamel, followed by rinsing and drying. The adhesive system was then activated. Resin A1 was used to reconstruct the mesiolingual third, following the anatomy of tooth 11. Once the palatal layer was redone, resin OA1 was used to reproduce dentin opacity and mask the restoration line.

Resin A1 was applied again to redo the vestibular surface. Finally, occlusion was checked using carbon paper.

At the end of the aesthetic rehabilitation, a composite resin veneer was made on tooth 11. The first step was to install absolute isolation. Preparation began with a 1012 bur in high rotation to create a channel on the vestibular surface from the vestibulomesiobuccal third to the vestibulodistal third, passing through the cervical third. With the channel uniform, a 1014 bur was used to remove imperfections in the center of the vestibular surface. Phosphoric acid 37% was then applied for 30 seconds, followed by rinsing and drying. The next step was applying the adhesive system. Composite resin A1 was applied to the entire surface, following the anatomy of the preparation and tooth 21. After completing the composite veneer, occlusion was checked as in previous sessions, with polishing scheduled for the next session.

Finally, the canine guidance of tooth 13 was restored. A 3118 bur was used in high rotation to smooth the area. Phosphoric acid 37% was applied for 30 seconds on the enamel, followed by rinsing and drying. The adhesive system was applied, and restoration began with resin A1, using tooth 23 as a reference. Occlusion was checked for all teeth in MIH, canine guidance, and incisal guidance positions. Aesthetic rehabilitation was completed in the next session with polishing.

The results were favorable, both aesthetically and functionally, satisfying the patient and demonstrating the durability of the restorations. A notable improvement in the patient's smile was observed when comparing initial and final photos.

In conclusion, direct restorations with proper acid etching and correct application of the adhesive system offer good outcomes in patients with Amelogenesis Imperfecta.