A conservative approach to rehabilitate a molar-incisor hypomineralization case

Uma abordagem conservadora para reabilitar um caso de hipomineralização molar-incisivo

Rodrigo TEMUDO Patricia NEVES Irene VENTURA Luísa LOPES About the authors

ABSTRACT

Molar incisor hypomineralization is an increasingly common condition in our population. This condition can have great impact on the esthetics, function, and well-being of the child. This paper reports a case of a young patient diagnosed with this condition affecting all the first permanent molars and lower incisors, particularly teeth 31 and 41. The molars were treated with direct resin restorations with cusp coating and the incisors aesthetic was restored with different techniques such as bleaching with sodium hypochlorite, micro-abrasion and resin restorations. This treatment plan aimed to restore the proper teeth function, treat the already existing hypersensitivity and algic complains and to improve the aesthetic of the anterior sector. The presented case shows a conservative approach to deal with the molar incisor hypomineralization condition with satisfactory results after 1-year follow-up.

Indexing terms
Bleaching agents; Enamel microabrasion; Pediatric dentistry; Tooth demineralization

RESUMO

A hipomineralização incisivo-molar (HIM) é uma condição cada vez mais comum na nossa população. Esta condição pode ter um grande impacto na estética, função e bem-estar da criança. Este artigo relata um caso de um paciente jovem diagnosticado com esta condição afetando todos os primeiros molares permanentes e incisivos inferiores, principalmente os dentes 31 e 41. Os molares foram tratados com restaurações diretas em resina composta com recobrimento de cúspides e a estética dos incisivos foi restabelecida com diferentes técnicas, como branqueamento com hipoclorito de sódio, micro-abrasão e restaurações de resina composta. Este plano de tratamento teve como objetivo restaurar a função dos dentes, tratar a hipersensibilidade e as queixas álgicas já existentes e melhorar a estética do sector anterior. O caso apresentado mostra uma abordagem conservadora para lidar com casos de hipomineralização incisivo-molar com resultados satisfatórios após 1 ano de acompanhamento.

Termos de indexação
Clareadores; Microabrasão do esmalte; Odontopediatria; Desmineralização do dente

INTRODUCTION

Molar incisor hypomineralization (MIH) is the term used to describe a special pattern of Dental Developmental Defects [11 Allam E, Ghoneima A, Kula K. Definition and scoring system of molar incisor hypomineralization : a review. Dent Oral Craniofacial Res. 2017;3(2):1-9.]. The term was first proposed by Weerheijm et al. that defined MIH has being “hypomineralisation of systemic origin of 1-4 permanent first molars, frequently associated with affected incisors” [22 Weerheijm KL, Jälevik B, Alaluusua S. Molar-incisor hypomineralisation. Caries Res. 2001;(35):390-1.]. It was only in 2000, at the European Academy of Paediatric Dentistry (EAPD) Congress in Bergen, that this was state as Molar-Incisor Hypomineralization (MIH) and a nomenclature was sugested, given the existing clinical similarity [33 Jälevik B. Prevalence and diagnosis of molar-incisor- hypomineralisation (MIH) a systematic review. Eur Arch Paediatr Dent. 2010;11(2):59-64. https://doi.org/10.1007/BF03262714
https://doi.org/10.1007/BF03262714...
]. Enamel defects may appear as a change in tooth color, such as white, yellow, or brownish opacities. The enamel structure is also affected with grooves and depressions on the tooth surface [44 Wallace A, Deery C. Management of opacities in children and adolescents. Dent Update. 2015;42(10):951-8. https://doi.org/10.12968/denu.2015.42.10.951
https://doi.org/10.12968/denu.2015.42.10...
]. Affected teeth tend to accumulate more severe defects over time due to the post-eruptive breakdown of the hypomineralized enamel [55 Kopperud SE, Pedersen CG, Espelid I. Treatment decisions on Molar-Incisor Hypomineralization (MIH) by Norwegian dentists - a questionnaire study. BMC Oral Health. 2017;17(3):1-7.].

These severe defects that occur in the enamel structure are due to a disturbance in the calcification phase of dental development, since there is an insufficient deposition of minerals that leads to an incomplete removal of proteins in the enamel matrix [66 Sa Y, Liang S, Ma X, Lu S, Wang Z, Jiang T, et al. Compositional, structural and mechanical comparisons of normal enamel and hypomaturation enamel. Acta Biomater. 2014;10(12):5169-77. https://doi.org/10.1016/j.actbio.2014.08.023
https://doi.org/10.1016/j.actbio.2014.08...
].

MIH is a very common condition in many populations around the world, however, reports of prevalence of this defect show a very high variability (2.4 - 40.2%). Many treatment options have been described for the clinical management of MIH affected teeth, such as composite resin or glass ionomer cement restorations, as well as steel crowns, and in more severe cases the extraction of these teeth followed by orthodontics, if necessary [77 Grossi JDA, Cabral RN, Paula A, Leal SC. Glass hybrid restorations as an alternative for restoring hypomineralized molars in the ART model. BMC Oral Health. 2018;18(65):1-8. https://doi.org/10.1186/s12903-018-0528-0
https://doi.org/10.1186/s12903-018-0528-...
]. Other therapeutic approaches have been described to minimize aesthetic concerns arising from changes in dental structures in anterior teeth, such as whitening of the affected teeth, microabrasion or restorative techniques [88 Penumatsa NV, Sharanesha RB. Bleaching of fluorosis stains using sodium hypochlorite. J Pharm Bioallied Sci. 2015;7(2):766-8. https://doi.org/10.4103/0975-7406.163552
https://doi.org/10.4103/0975-7406.163552...
]. The decision on which treatment is most appropriate depends on several factors, such as the severity of the lesions, patient’s dental age and social context, and expectations of the child and parents [99 Lygidakis NA, Wong F, Jälevik B, Vierrou A-M, Alaluusua S, Espelid I. Best Clinical practice guidance for clinicians dealing with children presenting with molar- best clinical practice guidance for clinicians dealing with children presenting with. Eur Arch Paediatr Dent. 2010;11(2):75-85. https://doi.org/10.1007/BF03262716
https://doi.org/10.1007/BF03262716...
].

CASE REPORT

A 9-year-old male patient came to Egas Moniz University Clinic (Egas Moniz, Health Sciences Institute) referred from an external office. In this consultation, MIH was diagnosed, affecting all the first permanent molars and lower incisors, particularly teeth 31 and 41 (figure 1). Patient major complaints were localized pain when chewing and hypersensitivity to cold. In all the first permanent molars, in addition to the color change, there was already loss of tooth structure on the occlusal surface, but the cervical margins remained intact and no carious lesions were found. The lower incisors showed yellow-brown well demarcated opacities on the vestibular surface, particularly teeth 31 and 41 with about 2/3 of the surface covered. In the radiographic examination (figure 2), there were no cavities detected, however, it was already possible to observe loss of dental structure due to post eruptive breakdown in all first permanent molars.

Figure 1
Initial intra-oral photographs.
Figure 2
Initial orthopantomography.

Rehabilitation of the permanent molars

For the rehabilitation of the permanent molars it was planned to perform direct restorations with cusp coating using composite resin on all affected molars, to restore function, decrease algic complaints and prevent tooth decay. Before the restoration procedure, the most marked brown opacities were removed with a diamond bur. Prior to etching, we used NaOCl 5.25% for 15 seconds to remove the excess protein content from the hypomineralized enamel in order to improve bonding strength. After the deproteinization process, all first molars were etched for 20 seconds and restored using Scotchbond™ Universal adhesive and Filteck™ Z250 A3 and A3,5 resin under isolation with rubber dam (figure 3).

Figure 3
A) All first molars were restored using Scotchbond™ Universal adhesive and Filteck™ Z250 resin; B)Tooth 36 before and after direct restoration with cusp coating.

Rehabilitation of the permanent incisors:

To improve and to standardize the aesthetics of the anterior sector we used different techniques depending on the depth of enamel lesions such as bleaching, microabrasion and sealing with restorative materials (figure 4).

Figure 4
A) Initial view of the 6th sextant; B) after etch-bleach and seal technique; C) after micro-abrasion technique; D) after sealing teeth 32 and 42 and restauration of teeth 31 and 41.

First of all, we used a bleaching protocol with sodium hypochlorite described by Wright [1010 Wright JT. The etch-bleach-seal technique for managing stained enamel defects in young permanent incisors. Pediatr Dent. 2002;24(3):249-52.] in the enamel lesions observed in the lower permanent incisors in order to whiten the more superficial lesions.

The teeth were sanitized with pumice powder using a polishing brush to remove any plaque and any discoloration of the extrinsic surface. Absolute isolation was performed with rubber dam. To allow better penetration of the bleaching agent, acid etching to the enamel surface was done with 37% orthophosphoric acid for 60 seconds.

Sodium hypochlorite (5.25%) was then applied to the entire surface of the tooth using a cotton applicator. The bleaching agent was continuously reapplied to the tooth as it evaporated. At the end of this process it was decided to make a new cycle by doing a new acid conditioning for 60 seconds, followed by rinsing with water and reapplying the bleaching agent.

The treated teeth must be sealed after achieving the optimal whitening result, to prevent organic material from reentering the porous and hypomineralized enamel. However, as some of the lesions were deeper than expected, prior to sealing the teeth 31 and 41 we performed a microabrasion protocol, polishing these teeth with a prophylactic brush using a paste with 37% orthophosphoric acid gel associated with extra fine grain pumice in equal proportions.The final stage was sealing the treated teeth after washing and drying the teeth to remove any bleaching and microabrasion agent. A further acid etching of the teeth was performed for 30 seconds with 37% orthophosphoric acid followed by a flowable resin Filtek™ Supreme XTE white shade to seal teeth 32 and 42 after the bleaching protocol. On teeth 31 a 41 we had to use a restorative approach using Enamel Plus HFO (UD2) and Enamel Plus HRI (EF3) resin to restore the vestibular surface after the microabrasion of the deeper lesions.

Follow-up

After 1-year follow-up (figure 5), the molars presented restorations with good adaptation, no fractures or infiltrations and absence of painful symptomatology.

Figure 5
1-year follow up intra-oral photographs.

The permanent lower incisors also showed good results after 1-year follow-up (figure 6), with great aesthetic improvement and good color stability.

Figure 6
A) Initial view of the 6th sextant; B) final result; C) 1-year follow-up.

DISCUSSION

In affected permanent molars, the goals of treatment are to prevent the development of dental caries, to help prevent or reduce loss of enamel, restore shape, restore function and solve cosmetic problems. In more severe cases, another concern should be considered, like the hypersensitivity associated with hypomineralized enamel [1111 Jane S. Handbook of clinical techniques in pediatric dentistry. Oxford: Wiley & Sons, Inc.; 2015.].

Currently, there are no standard treatments that can be recommended for all teeth affected by MIH. According to the best guideline of clinical practice and evaluation of relevant literature, composite resins are a viable option as a long-term restorative material for teeth affected by MIH [55 Kopperud SE, Pedersen CG, Espelid I. Treatment decisions on Molar-Incisor Hypomineralization (MIH) by Norwegian dentists - a questionnaire study. BMC Oral Health. 2017;17(3):1-7.,99 Lygidakis NA, Wong F, Jälevik B, Vierrou A-M, Alaluusua S, Espelid I. Best Clinical practice guidance for clinicians dealing with children presenting with molar- best clinical practice guidance for clinicians dealing with children presenting with. Eur Arch Paediatr Dent. 2010;11(2):75-85. https://doi.org/10.1007/BF03262716
https://doi.org/10.1007/BF03262716...
].

Souza et al. [1212 Souza JF De, Fragelli CB, Jeremias F, Aurélio M, Paschoal B, Santos-pinto L. Eighteen-month clinical performance of composite resin restorations with two different adhesive systems for molars affected by molar incisor hypomineralization. Clin Oral Investig. 2017;21:1725-33. https://doi.org/10.1007/s00784-016-1968-z
https://doi.org/10.1007/s00784-016-1968-...
] evaluated the success of composite resin restorations and reported a success rate of 73% when restorations were performed with a self- etch adhesive and 59% when performed with a total- etch adhesive at 12 months. At 18 months, the success rate dropped to 68.4% when restorations were performed with a self- etch adhesive and 54.6% when performed with a total-etch adhesive.

The low success rates presented in the study of Souza et al. [1212 Souza JF De, Fragelli CB, Jeremias F, Aurélio M, Paschoal B, Santos-pinto L. Eighteen-month clinical performance of composite resin restorations with two different adhesive systems for molars affected by molar incisor hypomineralization. Clin Oral Investig. 2017;21:1725-33. https://doi.org/10.1007/s00784-016-1968-z
https://doi.org/10.1007/s00784-016-1968-...
] may be due to the hypomineralization of the affected teeth, which can compromise the adhesion of the resin to the dental surface [1313 Coelho ASE da C, Mata PCM, Lino CA, Macho VMP, Areias CMFGP, Norton APMAP, et al. Dental hypomineralization treatment : a systematic review. J Esthet Restor Dent. 2019;31(1):26-39. https://doi.org/10.1111/jerd.12420
https://doi.org/10.1111/jerd.12420...
].

Another study comparing the success rates between restorations using the self-etch and total-etch adhesives in sound enamel did not show significant differences between this two systems [1414 Burke FJT, Crisp RJ, Cowan AJ, Raybould L, Redfearn P, Sands P, et al. A randomised controlled trial of a universal bonding agent at three years: self etch vs total etch. Eur J Prosthodont Restor Dent. 2017;25(4):220-7. https://doi.org/10.1922/EJPRD_01692Burke08
https://doi.org/10.1922/EJPRD_01692Burke...
].

Bonding to hypomineralized enamel can be a great challenge due to its altered physical and chemical characteristics, namely the high amount of protein load present in the hypomineralized enamel [1515 Ekambaram M, Anthonappa RP, Govindool SR, Yiu CKY. Comparison of deproteinization agents on bonding to developmentally hypomineralized enamel. J Dent. 2017;67:94-101. https://doi.org/10.1016/j.jdent.2017.10.004
https://doi.org/10.1016/j.jdent.2017.10....
].

To remove the excess protein content from hypomineralized enamel to improve bonding with dental adhesives, many authors have suggested the use of NaOCl as it is an oxidative solution [1616 Mathu-Muju K, Wright J. Diagnosis and treatment of molar incisor hypomineralization. Compend Contin Educ Dent. 2006;27(11):604-10.,1717 Sönmez H, Saat S. A clinical evaluation of deproteinization and different cavity designs on resin restoration performance in mih-affected molars: two-year results. J Clin Pediatr Dent. 2017;41(5):336-42. https://doi.org/10.17796/1053-4628-41.5.336
https://doi.org/10.17796/1053-4628-41.5....
].

Another factor to consider is whether the affected enamel is completely removed or not. Removing only the porous enamel is less invasive but can lead to high risk of marginal breakdown due to defective bonding. Removing all defective enamel provides sound enamel for bonding, however, the undesirable side-effect is that excessive tooth tissue is removed [99 Lygidakis NA, Wong F, Jälevik B, Vierrou A-M, Alaluusua S, Espelid I. Best Clinical practice guidance for clinicians dealing with children presenting with molar- best clinical practice guidance for clinicians dealing with children presenting with. Eur Arch Paediatr Dent. 2010;11(2):75-85. https://doi.org/10.1007/BF03262716
https://doi.org/10.1007/BF03262716...
].

Sönmez and Saat [1717 Sönmez H, Saat S. A clinical evaluation of deproteinization and different cavity designs on resin restoration performance in mih-affected molars: two-year results. J Clin Pediatr Dent. 2017;41(5):336-42. https://doi.org/10.17796/1053-4628-41.5.336
https://doi.org/10.17796/1053-4628-41.5....
] aimed to evaluate the clinical performance of composite resin restorations in MIH affected molars placed into cavities prepared invasively or noninvasively and with or without deproteinization of the affected enamel. They reported that the removal of the whole affected enamel significantly increased the success of the treatment compared with noninvasive techniques without removal of all clinically defective tissue. Furthermore, they also observed that the success rate of the restorations in the group where they used a noninvasive technique and the deproteinization using 5% sodium hypochlorite, was not significantly different than the groups where they removed all the affected enamel and the group without MIH. These findings suggest that in cavities without removal of all hypomineralized enamel, sodium hypochlorite may help in achieving better bond strength while preventing major tissue loss.

As for the lesions visible on the incisors, the range of treatments vary depending on the type and depth of the lesion. Isolated brown or white defects of less than few tenths of millimeter depth can be easily treated with microabrasion. However, deeper enamel defects need a combination of various techniques such as microabrasion, macroabrasion, bleaching, resin restorations, full or partial veneers or a combination of the above [1818 Ali S, Jha P, Khan U. Esthetic management of a patient with severely fluorosed enamel and pigmented gingiva: a conservative approach. Contemp Clin Dent. 2018;9(2):323-5. https://doi.org/10.4103/ccd.ccd_36_18
https://doi.org/10.4103/ccd.ccd_36_18...
,1919 Sundfeld RH, Sunfeld-Neto D, Machado LS, Franco LM, Fagundes TC, Briso ALF. Microabrasion in tooth enamel discoloration defects: three cases with long-term follow-ups. 2014;22(4):347-54. https://doi.org/10.1590/1678-775720130672].

Wright [1010 Wright JT. The etch-bleach-seal technique for managing stained enamel defects in young permanent incisors. Pediatr Dent. 2002;24(3):249-52.] developed a bleaching technique called Etch-bleach-seal, which shows good results in the treatment of enamel hipomineralization lesions of incisors affected by molar-incisor hypomineralization.

Bleaching of hypomineralized enamel lesions using 5% sodium hypochlorite has been clinically useful. This technique is simple, inexpensive, fast, safe and non-invasive, which allows the enamel to maintain its structure. It does not require special materials and can be used safely on young permanent teeth [88 Penumatsa NV, Sharanesha RB. Bleaching of fluorosis stains using sodium hypochlorite. J Pharm Bioallied Sci. 2015;7(2):766-8. https://doi.org/10.4103/0975-7406.163552
https://doi.org/10.4103/0975-7406.163552...
].

The application of sodium hypochlorite degrades and removes the chromogenic organic material located in the hypomineralized enamel [88 Penumatsa NV, Sharanesha RB. Bleaching of fluorosis stains using sodium hypochlorite. J Pharm Bioallied Sci. 2015;7(2):766-8. https://doi.org/10.4103/0975-7406.163552
https://doi.org/10.4103/0975-7406.163552...
,1010 Wright JT. The etch-bleach-seal technique for managing stained enamel defects in young permanent incisors. Pediatr Dent. 2002;24(3):249-52.].

This technique provides a conservative alternative treatment for yellow-brown hypomineralized enamel lesions that have demonstrated good clinical success. The application of conservative treatment techniques should be considered prior to the application of techniques that require substantial removal of enamel for the treatment of enamel discolorations [88 Penumatsa NV, Sharanesha RB. Bleaching of fluorosis stains using sodium hypochlorite. J Pharm Bioallied Sci. 2015;7(2):766-8. https://doi.org/10.4103/0975-7406.163552
https://doi.org/10.4103/0975-7406.163552...
].

However, in some cases the bleaching technique alone is not enough to reach a satisfactory result as we found in our case. This technique showed good results in the more superficial lesions but required other approaches in the deeper lesions.

Enamel microabrasion is also a conservative method to consider for removing enamel to improve discoloration limited to the outer layer of the enamel [1919 Sundfeld RH, Sunfeld-Neto D, Machado LS, Franco LM, Fagundes TC, Briso ALF. Microabrasion in tooth enamel discoloration defects: three cases with long-term follow-ups. 2014;22(4):347-54. https://doi.org/10.1590/1678-775720130672]. This method involves mild acid etching in combination with rotary application of an abrasive medium such as pumice [2020 Deshpande AN, Joshi NH, Pradhan NR, Raol RY. Microabrasion-remineralization (MAb-Re): An innovative approach for dental fluorosis. J Indian Soc Pedod Prev Dent. 2017;35(4):384-7. https://doi.org/10.4103/JISPPD.JISPPD_216_16
https://doi.org/10.4103/JISPPD.JISPPD_21...
].

This technique has been suggested for aesthetic improvements using different mixtures and concentrations of hydrochloric acid, phosphoric acid gel, pumice or other particles like silica carbide [1919 Sundfeld RH, Sunfeld-Neto D, Machado LS, Franco LM, Fagundes TC, Briso ALF. Microabrasion in tooth enamel discoloration defects: three cases with long-term follow-ups. 2014;22(4):347-54. https://doi.org/10.1590/1678-775720130672]. We used a mixture of 37% phosphoric acid gel associated with extra fine grain pumice in equal proportions

Even if a restorative approach is necessary, microabrasion should be considered as a first treatment option, as it may reduce the need for enamel wear, thus being a more conservative treatment method [2121 Inocencya N, Pini P, Sundfeld-neto D, Henrique F, Aguiar B, Sundfeld RH, et al. Enamel microabrasion: An overview of clinical and scientific considerations. World J Clin Cases. 2015;3(1):34-41. https://doi.org/10.12998/wjcc.v3.i1.34
https://doi.org/10.12998/wjcc.v3.i1.34...
].

In our case, some of the enamel defects were deeper into the enamel and could not be resolved with microabrasion alone. In these cases a resin composite restoration may be a good complement in order to achieve an optimal aesthetic result like showed by Sundfeld et al. [1919 Sundfeld RH, Sunfeld-Neto D, Machado LS, Franco LM, Fagundes TC, Briso ALF. Microabrasion in tooth enamel discoloration defects: three cases with long-term follow-ups. 2014;22(4):347-54. https://doi.org/10.1590/1678-775720130672].

The presented case shows a conservative approach to deal with the MIH condition, in which we aimed to restore function and aesthetic using simple and efficient techniques. Usually, the recommended treatments for HIM, when affecting dental cusps, may be composite restoration, stainless steel crown or, in cases of markedly severe lesions of MIH, extraction may be considered, however, the need for orthodontic treatment may arise. For all these reasons, we realize that the dentist’s decision is not easy, but first of all, one of the questions that must be asked is whether the affected dental structures are for restoration or for extraction. This decision depends on multiple factors such as the child’s age, HIM severity, pulp involvement, tooth restorability, presence of third molar germs, cost of treatment, and whether short, medium- or long-term treatment is desired. In this particular case, after clinical and radiological evaluation, the proposed treatment was direct restoration because it was more conservative, since the cervical margins of the teeth in question did not presented hypomineralization and the patient showed acceptable oral hygiene. The use of stainless-steel crowns was not disregarded, but as it was more invasive, we saved that option in case the restorations presented infiltration during the follow-up. The bleaching technique described was able to disguise the yellow-brown stains on the lower permanent incisors but required other approaches in the deeper lesions. After one-year of follow up, the initial complaints disappeared, and the restorations showed no signs of wear and good margin adaptations, thus proving the use of resin restorations on MIH patients as a good conservative alternative to steel crowns.

Acknowledgments

This work was supported by grants from the Egas Moniz University Clinic.

  • ERRATUM

    No artigo <A conservative approach to rehabilitate a molar-incisor hypomineralization case>, com número de DOI: <http://dx.doi.org/10.1590/1981-8637202200082020055> publicado no periódico <RGO, Revista Gaúcha de Odontologia>, <70>:<e20220010>, na página <1>:
    Onde se lia:
    http://dx.doi.org/10.1590/1981-8637202200082020055
    Leia-se:
    http://dx.doi.org/10.1590/1981-86372022001020200140
    Onde se lia:
    Temudo R, Neves P, Ventura I, Lopes L. A conservative approach to rehabilitate a molar-incisor hypomineralization case. RGO, Rev Gaúch Odontol. 2022;70:e20220010. http://dx.doi.org/10.1590/1981-8637202200082020055
    Leia-se:
    Temudo R, Neves P, Ventura I, Lopes L. A conservative approach to rehabilitate a molar-incisor hypomineralization case. RGO, Rev Gaúch Odontol. 2022;70:e20220010. http://dx.doi.org/10.1590/1981-86372022001020200140

How to cite this article

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Publication Dates

  • Publication in this collection
    06 Apr 2022
  • Date of issue
    2022

History

  • Received
    23 Aug 2020
  • Reviewed
    08 Oct 2020
  • Accepted
    23 Oct 2020
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