A 23-year-old Indian female patient reported to the Department of Conservative Dentistry and Endodontics with a chief complaint of yellowish discoloration and poor appearance of her teeth with the rehabilitation of the same. Family history and medical history was non-contributory. Patient was unmarried, well qualified medical student and there was no history of similar condition in the family. Her parents and siblings were fine and no other family member presented with similar dental findings. Her past dental history disclosed that she underwent root canal treatment of 36 due to caries involvement. Extra-oral examination disclosed normal mouth opening and no temporomandibular joint problems. The patient was healthy with no co-morbidities.\nOn intraoral examination, the enamel thickness was highly thinned down and partially flaked off from few surfaces of teeth. Teeth revealed well defined pitted surfaces along with yellowish brown discoloration. Surfaces of teeth were rough with minimal enamel present. The teeth also revealed short clinical crowns with multiple spacing between teeth. The occlusal plane was uneven worn-down posterior teeth. On frontal view, the patient presented with deep bite with less horizontal overlap. Dentin which was exposed were brown in color. The periodontal examination revealed normal healthy gingiva with no abnormalities (Fig ).\nRadiographic examination included full mouth Orthopantomogram (OPG) and Intraoral periapical radiograph (IOPA) showed features of AI. (Fig ) Occlusion was assessed after obtaining the diagnostic casts. Based on clinical and radiological examination, it was diagnosed as hypoplastic type of amelogenesis imperfecta. Based on the arrived diagnosis, a full mouth rehabilitation was planned. A well formulated treatment plan involving endodontic, and prosthetic department was charted out to furnish a functional occlusion with good esthetics and further prevent the tooth loss. The entire treatment plan was explained to the patient and informed consent was obtained. The initial phase of the treatment consisted of endodontic therapy. Based on OPG reports, it was decided that pulp space therapies should be performed on 37, 46, 47, 16, 17, 26 followed with retreatment with respect to 36 and fixed prosthesis was planned for the entire dentition.\nTreatment protocol: Patient was asked to check her on diet to maintain oral hygiene. The mock presentation of full coverage prosthesis were executed on upper and lower casts and presented to the patient. She was contented with the anticipated outcome and prognosis of the overall treatment plan was satisfactory. The subsequent rehabilitation plan was formulated.\nDefinitive treatment plan:Patient motivation for the treatment and maintenance of oral hygiene, Endodontic treatments of #37, 47, 47, 16, 26, Providing temporary bridges on all posterior teeth for reconstruction of the lost occlusal vertical dimension, Trial of fixed partial dentures and, Periodic follow-ups at 1 year and 2 year intervals followed by augmentation of oral hygiene measures.\nEndodontic treatment was performed with respect to #37, 47, 47, 16, 26 under rubber dam and local anesthesia. 3% sodium hypochlorite (Vishal Dentocare Pvt Ltd, India) was used as irrigant in all the treated teeth. The working lengths for all teeth was obtained using hand K file (Dentsply Inc, Maillefer, Dentsply India), Root ZX II Apex locator (Morita, Irvine, CA), and finally confirmed using intraoral periapical radiograph. #16, 26 showed the presence of MB2. Cleaning and shaping of all the canals were performed with hand K files and Protaper rotary files (Dentsply Inc, Maillefer, Dentsply India) under copious irrigation with 3% sodium hypochlorite and enlarged upto F2 file size. Retreatment was performed with respect to #36. Three rounds of calcium hydroxide as intracanal medicament (CALCICURE, Voco) were placed for #36. All the access cavities were given temporary seal dressing (cotton pellet and intermediary restorative material, Cavit G, 3M ESPE GmbH, Neuss, Germany). All the obturation was completed using F2 protaper gutta percha cone (Dentsply, Maillefer, Dentsply India) with AH Plus sealer (Dentsply, Sirona, Dentsply India). The next stage of treatment was the restorative and prosthetic phase. Fixed partial dentures were planned.\nRestorative treatment included the Post endodontic restoration of # 37, 46, 47, 16, 17, 26 and 36 with composite restoration (Filtek Z 350 XT, 3M ESPE, St, Paul, MN, USA). As per radiographic findings, the impacted teeth was retained as the patient was not willing for any surgical extrusion procedure. The deciduous 63 was included in the tooth preparation. All third molars (#18, 28, 38, 48) were not extracted as they had not erupted.\nProsthetic treatment included the tooth preparation on #17, 16, 15, 14, 24, 25, 26, 27, 34, 35, 36, 37, and 44, 45, 46, 47 to receive metal ceramic crowns. Diagnostic impressions were made using alginate (3M ESPE Alginate Impression Material). The diagnostic casts were then mounted on semi adjustable articulator (Hanau Articulator, Teledyne Hanau Buffalo, NY, USA) using Hanau facebow. The tooth preparations were performed quadrant wise so that the patient was adjusted with the new occlusion. First the posterior teeth were prepared and the temporary acrylic bridges (Integrity™ Temporary Crown & Bridge Material, DENTSPLY, USA) were fixed to increase the occlusal height. Temporary acrylic crowns were placed for 1 month to assess the patient’s forbearance to the new occlusion. Once the patient was habituated to the new occlusal height, then final maxillary and mandibular impressions were prepared with poly vinyl polysiloxane impression material (Aquasil Ultra Putty Soft Regular and Aquasil Ultra LV, Dentsply USA). Interocclusal records in centric occlusion were taken and the working casts were mounted on semi-adjustable articulator (Hanau Articulator, Teledyne Hanau Buffalo, NY, USA). Trial with metal ceramic restorations was done and finally cemented with self-adhesive resin (RelyX Unicem 2 Clicker A2 Universal Self-Adhesive Universal Resin, 3M-ESPE, USA). Then the anterior teeth were prepared for metal ceramic restorations. The patient was regularly monitored at 1 week, 1 month, 3 months, 6 months and at 1 year and 2 years intervals using clinical and radiographic examinations (Figs. , and ). Patient was highly satisfied with the treatment outcome and the gingival condition was maintained, esthetic impairment and the dentinal sensitivity was resolved.
An 11-year-old girl reported to the Department of Pedodontics and Preventive Dentistry, Dr. D.Y. Patil Dental College and Hospital, Pune, with the chief complaint of discolored teeth since childhood.\nThis little girl's parents did not seek any treatment previously, thinking that since the condition was not resulting in any other systemic manifestations and since she had inherited the condition from her father, there was little they could really do about it and accepted it as part of her appearance. It was only now, when they realized that the girl avoided hard food substances, they got her to a dentist.\nOn enquiry, it was revealed that her deciduous teeth were also similarly discolored, and her father, younger brother of eight years, and younger sister of six years, also suffered from the same condition. The pedigree chart could be constructed as in .\nApart from this, her past medical history was noncontributory. The history did not reveal any eruption disturbances. From a functional point of view, she had been avoiding hard food substances; at the same time, remaining caries free, except for a sole proximal carious lesion in 36, involving the enamel and dentin.\nOn intraoral examination, it was found that she had a normal complement of teeth. The thickness of enamel was reduced on the teeth and was completely chipped off from some teeth exposing the dentin. The surfaces of the teeth were rough. The teeth, in general, exhibited a yellowish brown discoloration, with diffuse pitting present on the exposed tooth surfaces, more prominent on the labial and buccal aspects. The emergence pattern and timing of teeth seemed to be within the normal range. No open bite was present. Examination of the periodontium revealed the presence of chronic, generalized, marginal, and papillary gingivitis, with calculus deposition and unsatisfactory oral hygiene [Figures –].\nA provisional diagnosis of hypoplastic, rough autosomal dominant AI was proposed along with a differential diagnosis of environmental enamel hypoplasia, dentinogenesis imperfecta, dentin dysplasia, regional odontodysplasia, and the tricho-dento-osseous syndrome.\nRadiographic investigations included an orthopantomogram (OPG) and full mouth intraoral periapical (IOPA) radiographs. The OPG showed the presence of all unerupted third molars, as well as a seemingly normal pattern and timing of eruption of teeth []. Examination of the IOPA radiographs revealed a normal pulp chamber and root canal spaces with no signs of obliteration. The enamel was almost half its expected thickness, but was more radiodense than the dentin.\nThe ground section of an over-retained deciduous molar extracted from the girl showed that the enamel was thin and was composed of laminations of irregularly arranged enamel prisms. No abnormality was apparent in the dentin []. shows a ground section of a normal tooth, where regularly arranged enamel prisms along with the normal thickness of enamel can be appreciated [].\nThe diagnosis of hypoplastic, rough, autosomal dominant AI was confirmed on the basis of typical, clinical, radiographic, and histopathological features.\nEsthetics along with functional limitations were the reason the patient's parents brought her to the hospital for treatment. The treatment proposed for her ranged from bonded veneer restorations to tooth preparations for the placement of a full crown. Restoration of the carious lesion in 36 would be accompanied by a full coverage restoration. The coronal pulp in these children tends to recede faster than in normal teeth and hence crown preparations for full coverage crowns can often be done for relatively young patients.\nAttrition of teeth is a major problem in cases of AI. Therefore, the use of stainless steel crowns as a preventive measure is advocated. Hand scaling was advocated and oral hygiene instructions were given to the patient. Regular brushing of the teeth using the modified Bass technique was taught to the patient to be practiced twice a day (morning and at night before going to bed) using a soft toothbrush and a fluoridated toothpaste (containing 1000 ppm of available fluoride) followed by rinsing with 2% w/v of chlorhexidine gluconate for 15 days.