CLINICAL ARTICLE
Esthetic Treatment of a Diffuse Amelogenesis Imperfecta Using Pressed Lithium Disilicate and Feldspathic Ceramic Restorations: 5-Year Follow Up ANDREA SAVI, DDS*, OLIVIERO TURILLAZZI, DT†, ALDO CRESCINI, DDS*, MADDALENA MANFREDI, DDS, PhD‡
ABSTRACT Objective: The treatment of a diffuse and severe case of amelogenesis imperfecta represents a challenge for the dental team and in particular for the dentist who perform the prosthetic restorations. Clinical Considerations: The enamel alterations, which are characteristic of the disease, determine different problems that need to be carefully planned and solved before the beginning of the treatment, with particular regard to the materials used to perform the restorations. In order to create the best conditions to perform the prosthetic restoration, the treatment plan should be multidisciplinary. In addition, the young age of the patients usually affected by the disease imposes a very conservative and cautious approach. The main goals of the therapy are represented by the need to protect the occlusal dental surfaces from the abrasion and provide a satisfactory esthetic result. In particular, dental abrasions if not treated may determine the loss of the vertical dimension as well as a diffuse and marked dentinal hypersensitivity. Conclusions: A correct treatment plan and the use of the new adhesive ceramic materials made it possible to obtain good results both from a functional and esthetic point of view with a much more conservative approach compared with the traditional one.
CLINICAL SIGNIFICANCE This clinical report describes the prosthetic rehabilitation of an adult female patient with a diffuse amelogenesis imperfecta using feldspathic ceramics for the esthetic regions and monolithic lithium disilicate material for the posterior areas. (J Esthet Restor Dent ••:••–••, 2014)
AMELOGENESIS IMPERFECTA The term amelogenesis imperfecta (AI) refers to a heterogeneous group of genetic disorders characterized by defects in enamel formation of the teeth in the absence of any generalized or systemic diseases.1,2 It can affect all or some teeth in deciduous and/or permanent dentition.
The prevalence of AI varies according to different studies ranging from 1:700 in Northern Sweden to 1:12–14.000 in the United States.2,3 These differences are mainly due to diagnostic or demographic criteria or to mutant genes in the studied population.4 Recent studies have identified five genes as being responsible for AI by mutation or altered expression:
*Dental Practitioner, Brescia, Italy † Dental Technician, Brescia, Italy ‡ Researcher, Polo di Odontostomatologia, Unità di Odontostomatologia, SBiBiT Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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AMEL (amelogenin), ENAM (enamelin), MMP20 (matrix metalloproteinase-20), KLK4 (Kallikrein-4), and FAM83H4.5 Different classifications of AI have been reported in literature, usually related to phenotype characteristics (clinical and radiological appearance) or to the description of the mode of inheritance of the disease (autosomal dominant/recessive). Clinically four types of AI have been recognized according to enamel types: • Type 1: hypoplastic, with a deficiency in the quantity of enamel • Type 2: hypomaturation, with an opaque and chalky enamel • Type 3: hypocalcified, characterized by a normal amount of poorly mineralized enamel • Type 4: hypoplastic-hypomaturation enamel associated with taurodontism In some classifications, the type 4 is also related to other dental anomalies such as multiple impacted teeth and congenital missing teeth.6–9 Diagnosis and treatment of patients affected by AI require a specific and personalized dental treatment plan because of several problems that are usually associated with the disease. These include an increased incidence of plaque deposits and consequent gingivitis, dental hypersensitivity, loss of vertical dimension due to a rapid wear of the dentition, poor esthetic appearance, cost, and the potential need for lifelong, extensive restorative care.10 In addition, psychological outcomes need to be considered, mainly related to the difficulties that these patients report in their social interaction due to the unesthetic appearance of their smile. Clinical management may vary according to the type and severity of the disease, the age of the patients, as well as their socioeconomic status. For these reasons, a wide range of possible and different treatments for teeth restoration of patients affected by AI has been
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reported in literature. With regard to the possible treatments related to the clinical case here reported, the therapies vary from a conservative to a prosthetic approach.6,11,12 In particular, the conservative treatment of the affected teeth may be used during childhood, as transitional treatment, but cannot be used for a longer period because it does not satisfy esthetic needs and it would not prevent the abrasion of posterior occlusal surfaces over time with consequent loss of the vertical dimension.12 The prosthetic treatments proposed in literature are mainly based on full crowns using traditional metal-ceramic materials or all-ceramic restorations (such as zirconia and/or lithium disilicate) both for the anterior and posterior areas. Full crowns represent a good therapy that guarantees a good esthetic result and prognosis, although there are differences between the materials used. The metal-ceramic full crowns are the gold standard in terms of durability.13 However, there are some disadvantages to their use. In particular, there is a need for a greater removal of dental tissue in comparison to all-ceramic crowns. Furthermore in the anterior areas, esthetic results are not satisfactory due to the reflection of their metal frameworks and their opaque layers. In addition, the ceramic coating is always abrasive against the enamel.13,14 Zirconia-based crowns represent a more conservative therapy in terms of thickness of tooth preparations, and the monolithic solution for the posterior regions is less aggressive against the enamel in terms of abrasion, especially if the surface is treated by polishing.15–17 In the anterior regions, zirconia crowns offer good possibilities for a good esthetic result if the teeth affected by AI are very discolored, because of their ability to mask serious discromic defects at root level. In order to combine durability with excellent esthetics, lithium-disilicate glass ceramics have been developed. The range of indication includes anterior and posterior teeth. In particular, their use for the posterior regions has been introduced more recently, and for this reason, their follow-up is shorter in comparison to the other ceramic materials. However, it has been recently reported that anterior and posterior crowns made with
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lithium-disilicate framework material have a good cumulative survival rate (97.4% after 5 years and 94.8% after 8 years of clinical service)18 and that the location of the crowns (anterior versus posterior) did not significantly compromise the survival rate.13 Lithium-disilicate crowns can also be adhesively cemented and this reduces the thickness of tooth preparations. In addition, the monolithic glazed or polished surface seems to be less damaging to enamel with values comparable with ceramic. In the anterior regions, disilicate crowns give excellent esthetic results.4,19,20 A recent systematic review of the literature makes it clear that defining what is the most appropriate treatment option for patients with AI is difficult.2 No data are currently available, at least in terms of high quality of evidence, of the superiority of a treatment for the rehabilitation of AI patients. Clinical performance is still based on case reports or case series. A promising ongoing randomized controlled trial21,22 that aims to compare new materials (IPS E-max, Ivoclar Vivadent, Naturno, BZ, Italy; Procera, Nobel Biocare, Switzerland; and Zirconia) for AI restoration in young patients was started in 2009, but the results have not yet been published. This clinical report describes the prosthetic rehabilitation of an adult female patient with a diffuse AI using feldspathic ceramics for the esthetic regions and monolithic lithium disilicate material for the posterior areas.
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FIGURE 1. A–B, Esthetic problem in a young female affected by a diffuse amelogenesis imperfecta (AI).
achieve an improvement of the overjet–overbite relation, as well as a correct canine guidance.
CASE REPORT A young female patient was referred with a diffuse AI, affecting almost all the permanent teeth (Figure 1A–B). The family history was negative for the disease. Radiographic examination showed a normal radiopacity of the enamel and no periodontal defects were present (Figure 2). In addition, inferior third molars were absent while the upper ones were retained. The occlusal function showed several characteristics typical of a second dental class, and for this reason, the patient underwent an orthodontic treatment in order to
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During the orthodontic therapy, the retained wisdom teeth were extracted. A macroscopic examination showed the third molar to be similar to the other molars present in the oral cavity, with a portion of the coronal enamel, which was brownish in color and a cervical one that was normal in appearance. These teeth were used to test the cervical and coronal enamel adhesion using different samples of composite materials. During the orthodontic treatment, all the brackets remained perfectly cemented to the teeth.
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FIGURE 2. Radiographic appearance before the prosthetic rehabilitation.
adequate tooth coronal height in order to carry out the restoration and to expose the healthy enamel of the coronal area to facilitate adhesion. In addition, in the posterior mandibular lingual areas, the presence of altered passive eruption was identified following a 4 mm probing, while in some interproximal superior areas, there were also initial interproximal bone defects. The crown lengthening enabled the elimination of these bone defects, so making it easier to obtain a more long-lasting result.
FIGURE 3. Esthetic appearance of the smile line.
The dental treatment of this patient had consisted of conservative therapies and a professional oral hygiene program every 3 months (Figure 3). This clinical profile suggested that the patient was a good candidate for an adhesive rehabilitation. The esthetic problem of this condition had caused difficulties in the social life of the patient, and for this reason, it was decided to carry out an esthetic prosthetic restoration. Initially, the patient underwent a crown lengthening of the posterior regions. The aim was to obtain an
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It was also possible to observe a diffuse abrasion of the occlusal surfaces (inferior and superior) (Figure 4A–B). In the frontal region, gingivectomies were also performed to align the asymmetries of gingival contours (Figure 5). Once the healing of gingival tissues was obtained, model casts were mounted on the articulator using a facial arc (Sam 2; Dentaurum Italia, Funo, BO, Italy) and centric relation waxes. The dental laboratory performed diagnostic wax-ups from which silicone keys were made to be used as a guide for the subsequent teeth preparations (Figure 6A–B). Upper and lower posterior teeth were simultaneously prepared to receive monolithic lithium disilicate crowns (IPS E-max; Ivoclar Vivadent)
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FIGURE 4. A–B, Occlusal view: note the abrasion of the occlusal surfaces.
USA). In addition, a facial arc was used to transfer the data to the dental laboratory. In particular, the stone casts of the temporary restoration were cross-mounted with the master casts. The patient was discharged with temporary resin crowns made in a day from a second impression of the prepared teeth and cemented with polycarboxylate cement (Durelon 3M ESPE Italia, Pioltello, MI, Italy). FIGURE 5. Appearance of the smile line: frontal view after gingivectomies. Please note the marginal gingivitis due to the porous and rough surface of the enamel.
(Figure 7A–B). In particular, two criteria were used to prepare the abutments: the first was to remove only the portion of the enamel that appeared macroscopically altered and the second was to follow the occlusal morphology obtained from the diagnostic wax-up. All the finishing lines of the teeth preparations were on the enamel. For this reason, tissue conditioning was not necessary before the impression (Aquasil Ultra LV Regular Set e Ultra XLV Fast Set; Dentsply Italia, Rome, Italy), which was performed using a single impression double-mixed technique. Occlusal bite registrations were obtained using wax and zinc oxide (Temp Bond; Kerr Corporation, Orange, CA,
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The laboratory developed at the same time the upper and lower monolithic lithium disilicate pressed crowns with different thicknesses, from 0.5 mm on the axial surface to 1–1.5 mm on the occlusal surface. The cementations were performed using a rubber dam (Nic-Tone; MDC Dental, Zapopan Jalisco, Mexico). The dental surface was sanded with aluminum oxide using 50 μm Al2O3 airborne-particle abrasion (Dento-prep; Micerium, Avegno, GE, Italy), etched for 30 seconds on enamel and 10 seconds on dentin with 37.5% phosphoric acid (Ultra-Etch; Ultradent Products, Inc, Ultradent Italia, Corsico, MI, Italy), rinsed, and dried. Subsequently, a primer was applied (Optibond FL bottle no. 1; Kerr Corporation) and then air-dried for 15 seconds. Both fitting surfaces restorations and teeth were coated with adhesive resin
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FIGURE 6. A, Wax-up silicone matrix. B, Wax-up silicone matrix: a particular of tooth extra-gingival preparation.
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FIGURE 7. A–B, Monolithic disilicate crowns on the model cast ready to be cemented.
(Optibond FL, Bottle no. 2; Kerr Corporation) and left unpolymerized. Ceramic restorations were etched with 9% hydrofluoric acid (Porcelain Etch; Ultradent Products, Inc) for 20 seconds. After rinsing for 30 seconds, the crowns were subjected to post-etching cleaning using phosphoric acid (Ultra-Etch; Ultradent Products, Inc) with a brushing motion for 1 minute, followed by rinsing for 30 seconds, and then immersion in distilled water in an
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ultrasonic bath for 3 minutes. After this, surfaces were silanated (Calibra Silane Coupling Agent; Dentsply) and heat dried. A microhybrid composite resin (Enamel plus, Micerium) was preheated to 55 C (Ena Heat Composite Heating Conditioner, Micerium), applied to the tooth and the restoration was inserted. After insertion, the restorations were subjected to ultrasound tips, to eliminate the excess of composite
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FIGURE 8. A–B, Frontal area tooth preparations: insertion of double wires.
resin as well as to reduce bubble formation, followed by initial light polymerization. The use of ultrasound also enabled the reduction of the thickness of the composite resin. Each surface was exposed for 60 seconds and all margins were covered with an air-blocking. Once the cementation of the posterior regions was completed, the upper and inferior frontal regions were also simultaneously prepared (Figure 8A–B). Teeth preparations were performed using iuxtagingival finishing lines on enamel. In this area, as in the posterior regions, the enamel removal in thickness was reserved for highly discolored tissue. The impressions were performed using the double wire technique (Ultrapack, Ultradent verificare) using polyether with the same technique previously described (Impregum/Permadyne Penta, 3M ESPE Italia). In the frontal area, feldspathic ceramic veneers were made with an average thickness of 0.5 mm (Figure 9A–B). The cementation technique was the same used for the posterior regions. The patient was then discharged with a specific oral hygiene protocol and occlusal control every 3 months (Figure 10A–B). The application of the veneers produced a remarkable improvement in the tooth surface passing from a porous and rough surface, due to the altered enamel, to the smooth surface of the ceramic. This change, together with the patient’s motivation, helped to solve
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FIGURE 9. A–B, Feldspathic veneers ready to be cemented.
the chronic marginal gingivitis already present before the beginning of the prosthetic treatment (Figure 5) with the restoration of a normal gum appearance (Figure 11). The patient has been periodically recalled for clinical and radiographic controls: after 5-year follow-up period, the restoration were in excellent condition, with an excellent esthetic result that has definitely affected the quality of life of the patient (Figures 12–14).
DISCUSSION Enamel alterations that characterize the most widespread type of AI involve not only a clear esthetic problem but can also cause abrasion defects, with particular regard to the occlusal surfaces of posterior teeth. At a young age, these abrasions do not cause the loss of vertical dimension but, if not treated, the
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FIGURE 10. A–B, Occlusal views of the case completed.
FIGURE 11. Normal gum appearance after the prosthetic restoration.
FIGURE 12. Frontal view after the prosthetic restoration.
consequent dental eruption may not compensate for dental wear. For this reason, the vertical dimension was not increased in this patient. In addition, the removal of the affected enamel provided a sufficient thickness for the ceramics. Furthermore, the abrasion of the biting surface caused the loss of occlusal anatomy as well as the appropriate relation between cusp and pit.
restorative treatment should take into account the characteristics of each type of AI alterations.27 The greatest difficulties for bonding to enamel have been described in the hypocalcified type which is characterized by a lower mineral content that seems to be deleterious to the bonding procedure.23,28
One of the problems associated with the treatment of AI patients is the adhesive performance of teeth affected by enamel alterations. It has been clearly reported that chemical, morphological, and micromorphological differences between healthy teeth and AI teeth are responsible for the possible failures in resin bonding to AI teeth.23–26 In addition, any esthetic
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However, it has been also reported that in less severe cases, normal enamel can be found around the affected one and so the adhesion procedures can be optimally performed.27,29 In the case here described, the discromic enamel had shown a good adhesion both during the transitional restorative treatment and during the orthodontic
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FIGURE 13. Radiographic control at 5-year follow-up.
FIGURE 14. Appearance of the smile after the prosthetic restoration.
treatment. In addition, although the alteration of the enamel was widespread, below the brown-colored surface, an enamel appeared with characteristics which were more similar to the normal one, as found in the cervical areas. For these reasons, it was decided that this patient may be a good candidate for an adhesive rehabilitation. A direct conservative treatment is characterized by some limitations. In particular, the level of dental wear shown by this patient made it impossible to obtain a
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stable and durable prosthetic restoration. For this reason, the selection of the material to be used in such a complex restoration is essential for a treatment that should not only restore function and esthetics but also try to be minimally invasive and ensure a good prognosis. A traditional prosthetic restoration with full crowns would certainly obtain a good esthetic result and a good prognosis, but it leads to a significant removal of dental tissue. In addition, the placement of crown margins in the gingival sulcus would expose the patient to possible problems in the interactions with periodontal tissues. For this reason, partial preparations were preferred with the use of new all-ceramic materials that are resistant even though they are extremely thin. Furthermore, they are characterized by favorable abrasion coefficients compared with natural enamel.30–33 In the posterior regions, a lithium disilicate monolithic pressed ceramic was selected because, at thickness of less than 2 mm, it seems to resist to occlusal loads.30,34,35 In addition, the possibility of performing an adhesive cementation offered by this material allows the performance of partial and non-retentive preparations characterized by extra-gingival closure margins on enamel. Consequently, minimal invasive preparations, made by removing only the altered occlusal enamel, were prepared following the directions of the diagnostic wax-up. In this way, it was possible to limit the thickness of the preparations and at the same time
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maintain the finishing extra-gingival lines. As in the case of this patient, extra-gingival preparations simplify all the procedures for taking impressions and the management of temporary restorations.36,37 A conservative prosthetic preparation was also selected in the anterior region removing only the discromic enamel. A feldspathic ceramic was preferred to a pressed one because it can offer a higher level of esthetic result at the same thickness. The lower mechanical strength of the feldspathic veneers was compensated for by a cementation only on enamel and by the protection of canine guides obtained with the orthodontic therapy.38–40 The orthodontic splinting of the inferior incisors was removed before the beginning of the prosthetic treatment and it was not repositioned at the end of the therapy. In order to give more stability, the interproximal contact areas were transformed from points to contact surfaces. A 5-year follow-up showed no signs of overcrowding.
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CONCLUSIONS
8.
A correct treatment plan and the use of the new ceramic materials made it possible to obtain good results both from a functional and esthetic point of view with a much more conservative approach compared with the traditional one.
9.
10.
Recent long-term follow-up research on these new materials support their use in esthetic and functional rehabilitations of this type. In addition, considering the young age of the patient, the preservation of hard tissues and the complete non-interference of periodontal tissues will not prejudice the possibility of any further dental treatment.
The authors do not have any financial interest in any of the companies whose products are included in this article.
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Reprint requests: Maddalena Manfredi, DDS, PhD, Polo di Odontostomatologia, Unità di Odontostomatologia, SBiBiT Department, Via Gramsci 14, Parma 43100, Italy; Tel.: +39-0521-033641; email: [email protected]
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Esthetic Treatment of a Diffuse Amelogenesis Imperfecta Using Pressed Lithium Disilicate and Feldspathic Ceramic Restorations: 5-Year Follow Up ANDREA SAVI, DDS*, OLIVIERO TURILLAZZI, DT†, ALDO CRESCINI, DDS*, MADDALENA MANFREDI, DDS, PhD‡
ABSTRACT Objective: The treatment of a diffuse and severe case of amelogenesis imperfecta represents a challenge for the dental team and in particular for the dentist who perform the prosthetic restorations. Clinical Considerations: The enamel alterations, which are characteristic of the disease, determine different problems that need to be carefully planned and solved before the beginning of the treatment, with particular regard to the materials used to perform the restorations. In order to create the best conditions to perform the prosthetic restoration, the treatment plan should be multidisciplinary. In addition, the young age of the patients usually affected by the disease imposes a very conservative and cautious approach. The main goals of the therapy are represented by the need to protect the occlusal dental surfaces from the abrasion and provide a satisfactory esthetic result. In particular, dental abrasions if not treated may determine the loss of the vertical dimension as well as a diffuse and marked dentinal hypersensitivity. Conclusions: A correct treatment plan and the use of the new adhesive ceramic materials made it possible to obtain good results both from a functional and esthetic point of view with a much more conservative approach compared with the traditional one.
CLINICAL SIGNIFICANCE This clinical report describes the prosthetic rehabilitation of an adult female patient with a diffuse amelogenesis imperfecta using feldspathic ceramics for the esthetic regions and monolithic lithium disilicate material for the posterior areas. (J Esthet Restor Dent ••:••–••, 2014)
AMELOGENESIS IMPERFECTA The term amelogenesis imperfecta (AI) refers to a heterogeneous group of genetic disorders characterized by defects in enamel formation of the teeth in the absence of any generalized or systemic diseases.1,2 It can affect all or some teeth in deciduous and/or permanent dentition.
The prevalence of AI varies according to different studies ranging from 1:700 in Northern Sweden to 1:12–14.000 in the United States.2,3 These differences are mainly due to diagnostic or demographic criteria or to mutant genes in the studied population.4 Recent studies have identified five genes as being responsible for AI by mutation or altered expression:
*Dental Practitioner, Brescia, Italy † Dental Technician, Brescia, Italy ‡ Researcher, Polo di Odontostomatologia, Unità di Odontostomatologia, SBiBiT Department, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
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AMEL (amelogenin), ENAM (enamelin), MMP20 (matrix metalloproteinase-20), KLK4 (Kallikrein-4), and FAM83H4.5 Different classifications of AI have been reported in literature, usually related to phenotype characteristics (clinical and radiological appearance) or to the description of the mode of inheritance of the disease (autosomal dominant/recessive). Clinically four types of AI have been recognized according to enamel types: • Type 1: hypoplastic, with a deficiency in the quantity of enamel • Type 2: hypomaturation, with an opaque and chalky enamel • Type 3: hypocalcified, characterized by a normal amount of poorly mineralized enamel • Type 4: hypoplastic-hypomaturation enamel associated with taurodontism In some classifications, the type 4 is also related to other dental anomalies such as multiple impacted teeth and congenital missing teeth.6–9 Diagnosis and treatment of patients affected by AI require a specific and personalized dental treatment plan because of several problems that are usually associated with the disease. These include an increased incidence of plaque deposits and consequent gingivitis, dental hypersensitivity, loss of vertical dimension due to a rapid wear of the dentition, poor esthetic appearance, cost, and the potential need for lifelong, extensive restorative care.10 In addition, psychological outcomes need to be considered, mainly related to the difficulties that these patients report in their social interaction due to the unesthetic appearance of their smile. Clinical management may vary according to the type and severity of the disease, the age of the patients, as well as their socioeconomic status. For these reasons, a wide range of possible and different treatments for teeth restoration of patients affected by AI has been
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reported in literature. With regard to the possible treatments related to the clinical case here reported, the therapies vary from a conservative to a prosthetic approach.6,11,12 In particular, the conservative treatment of the affected teeth may be used during childhood, as transitional treatment, but cannot be used for a longer period because it does not satisfy esthetic needs and it would not prevent the abrasion of posterior occlusal surfaces over time with consequent loss of the vertical dimension.12 The prosthetic treatments proposed in literature are mainly based on full crowns using traditional metal-ceramic materials or all-ceramic restorations (such as zirconia and/or lithium disilicate) both for the anterior and posterior areas. Full crowns represent a good therapy that guarantees a good esthetic result and prognosis, although there are differences between the materials used. The metal-ceramic full crowns are the gold standard in terms of durability.13 However, there are some disadvantages to their use. In particular, there is a need for a greater removal of dental tissue in comparison to all-ceramic crowns. Furthermore in the anterior areas, esthetic results are not satisfactory due to the reflection of their metal frameworks and their opaque layers. In addition, the ceramic coating is always abrasive against the enamel.13,14 Zirconia-based crowns represent a more conservative therapy in terms of thickness of tooth preparations, and the monolithic solution for the posterior regions is less aggressive against the enamel in terms of abrasion, especially if the surface is treated by polishing.15–17 In the anterior regions, zirconia crowns offer good possibilities for a good esthetic result if the teeth affected by AI are very discolored, because of their ability to mask serious discromic defects at root level. In order to combine durability with excellent esthetics, lithium-disilicate glass ceramics have been developed. The range of indication includes anterior and posterior teeth. In particular, their use for the posterior regions has been introduced more recently, and for this reason, their follow-up is shorter in comparison to the other ceramic materials. However, it has been recently reported that anterior and posterior crowns made with
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lithium-disilicate framework material have a good cumulative survival rate (97.4% after 5 years and 94.8% after 8 years of clinical service)18 and that the location of the crowns (anterior versus posterior) did not significantly compromise the survival rate.13 Lithium-disilicate crowns can also be adhesively cemented and this reduces the thickness of tooth preparations. In addition, the monolithic glazed or polished surface seems to be less damaging to enamel with values comparable with ceramic. In the anterior regions, disilicate crowns give excellent esthetic results.4,19,20 A recent systematic review of the literature makes it clear that defining what is the most appropriate treatment option for patients with AI is difficult.2 No data are currently available, at least in terms of high quality of evidence, of the superiority of a treatment for the rehabilitation of AI patients. Clinical performance is still based on case reports or case series. A promising ongoing randomized controlled trial21,22 that aims to compare new materials (IPS E-max, Ivoclar Vivadent, Naturno, BZ, Italy; Procera, Nobel Biocare, Switzerland; and Zirconia) for AI restoration in young patients was started in 2009, but the results have not yet been published. This clinical report describes the prosthetic rehabilitation of an adult female patient with a diffuse AI using feldspathic ceramics for the esthetic regions and monolithic lithium disilicate material for the posterior areas.
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FIGURE 1. A–B, Esthetic problem in a young female affected by a diffuse amelogenesis imperfecta (AI).
achieve an improvement of the overjet–overbite relation, as well as a correct canine guidance.
CASE REPORT A young female patient was referred with a diffuse AI, affecting almost all the permanent teeth (Figure 1A–B). The family history was negative for the disease. Radiographic examination showed a normal radiopacity of the enamel and no periodontal defects were present (Figure 2). In addition, inferior third molars were absent while the upper ones were retained. The occlusal function showed several characteristics typical of a second dental class, and for this reason, the patient underwent an orthodontic treatment in order to
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During the orthodontic therapy, the retained wisdom teeth were extracted. A macroscopic examination showed the third molar to be similar to the other molars present in the oral cavity, with a portion of the coronal enamel, which was brownish in color and a cervical one that was normal in appearance. These teeth were used to test the cervical and coronal enamel adhesion using different samples of composite materials. During the orthodontic treatment, all the brackets remained perfectly cemented to the teeth.
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FIGURE 2. Radiographic appearance before the prosthetic rehabilitation.
adequate tooth coronal height in order to carry out the restoration and to expose the healthy enamel of the coronal area to facilitate adhesion. In addition, in the posterior mandibular lingual areas, the presence of altered passive eruption was identified following a 4 mm probing, while in some interproximal superior areas, there were also initial interproximal bone defects. The crown lengthening enabled the elimination of these bone defects, so making it easier to obtain a more long-lasting result.
FIGURE 3. Esthetic appearance of the smile line.
The dental treatment of this patient had consisted of conservative therapies and a professional oral hygiene program every 3 months (Figure 3). This clinical profile suggested that the patient was a good candidate for an adhesive rehabilitation. The esthetic problem of this condition had caused difficulties in the social life of the patient, and for this reason, it was decided to carry out an esthetic prosthetic restoration. Initially, the patient underwent a crown lengthening of the posterior regions. The aim was to obtain an
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It was also possible to observe a diffuse abrasion of the occlusal surfaces (inferior and superior) (Figure 4A–B). In the frontal region, gingivectomies were also performed to align the asymmetries of gingival contours (Figure 5). Once the healing of gingival tissues was obtained, model casts were mounted on the articulator using a facial arc (Sam 2; Dentaurum Italia, Funo, BO, Italy) and centric relation waxes. The dental laboratory performed diagnostic wax-ups from which silicone keys were made to be used as a guide for the subsequent teeth preparations (Figure 6A–B). Upper and lower posterior teeth were simultaneously prepared to receive monolithic lithium disilicate crowns (IPS E-max; Ivoclar Vivadent)
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FIGURE 4. A–B, Occlusal view: note the abrasion of the occlusal surfaces.
USA). In addition, a facial arc was used to transfer the data to the dental laboratory. In particular, the stone casts of the temporary restoration were cross-mounted with the master casts. The patient was discharged with temporary resin crowns made in a day from a second impression of the prepared teeth and cemented with polycarboxylate cement (Durelon 3M ESPE Italia, Pioltello, MI, Italy). FIGURE 5. Appearance of the smile line: frontal view after gingivectomies. Please note the marginal gingivitis due to the porous and rough surface of the enamel.
(Figure 7A–B). In particular, two criteria were used to prepare the abutments: the first was to remove only the portion of the enamel that appeared macroscopically altered and the second was to follow the occlusal morphology obtained from the diagnostic wax-up. All the finishing lines of the teeth preparations were on the enamel. For this reason, tissue conditioning was not necessary before the impression (Aquasil Ultra LV Regular Set e Ultra XLV Fast Set; Dentsply Italia, Rome, Italy), which was performed using a single impression double-mixed technique. Occlusal bite registrations were obtained using wax and zinc oxide (Temp Bond; Kerr Corporation, Orange, CA,
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The laboratory developed at the same time the upper and lower monolithic lithium disilicate pressed crowns with different thicknesses, from 0.5 mm on the axial surface to 1–1.5 mm on the occlusal surface. The cementations were performed using a rubber dam (Nic-Tone; MDC Dental, Zapopan Jalisco, Mexico). The dental surface was sanded with aluminum oxide using 50 μm Al2O3 airborne-particle abrasion (Dento-prep; Micerium, Avegno, GE, Italy), etched for 30 seconds on enamel and 10 seconds on dentin with 37.5% phosphoric acid (Ultra-Etch; Ultradent Products, Inc, Ultradent Italia, Corsico, MI, Italy), rinsed, and dried. Subsequently, a primer was applied (Optibond FL bottle no. 1; Kerr Corporation) and then air-dried for 15 seconds. Both fitting surfaces restorations and teeth were coated with adhesive resin
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FIGURE 6. A, Wax-up silicone matrix. B, Wax-up silicone matrix: a particular of tooth extra-gingival preparation.
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FIGURE 7. A–B, Monolithic disilicate crowns on the model cast ready to be cemented.
(Optibond FL, Bottle no. 2; Kerr Corporation) and left unpolymerized. Ceramic restorations were etched with 9% hydrofluoric acid (Porcelain Etch; Ultradent Products, Inc) for 20 seconds. After rinsing for 30 seconds, the crowns were subjected to post-etching cleaning using phosphoric acid (Ultra-Etch; Ultradent Products, Inc) with a brushing motion for 1 minute, followed by rinsing for 30 seconds, and then immersion in distilled water in an
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ultrasonic bath for 3 minutes. After this, surfaces were silanated (Calibra Silane Coupling Agent; Dentsply) and heat dried. A microhybrid composite resin (Enamel plus, Micerium) was preheated to 55 C (Ena Heat Composite Heating Conditioner, Micerium), applied to the tooth and the restoration was inserted. After insertion, the restorations were subjected to ultrasound tips, to eliminate the excess of composite
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FIGURE 8. A–B, Frontal area tooth preparations: insertion of double wires.
resin as well as to reduce bubble formation, followed by initial light polymerization. The use of ultrasound also enabled the reduction of the thickness of the composite resin. Each surface was exposed for 60 seconds and all margins were covered with an air-blocking. Once the cementation of the posterior regions was completed, the upper and inferior frontal regions were also simultaneously prepared (Figure 8A–B). Teeth preparations were performed using iuxtagingival finishing lines on enamel. In this area, as in the posterior regions, the enamel removal in thickness was reserved for highly discolored tissue. The impressions were performed using the double wire technique (Ultrapack, Ultradent verificare) using polyether with the same technique previously described (Impregum/Permadyne Penta, 3M ESPE Italia). In the frontal area, feldspathic ceramic veneers were made with an average thickness of 0.5 mm (Figure 9A–B). The cementation technique was the same used for the posterior regions. The patient was then discharged with a specific oral hygiene protocol and occlusal control every 3 months (Figure 10A–B). The application of the veneers produced a remarkable improvement in the tooth surface passing from a porous and rough surface, due to the altered enamel, to the smooth surface of the ceramic. This change, together with the patient’s motivation, helped to solve
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FIGURE 9. A–B, Feldspathic veneers ready to be cemented.
the chronic marginal gingivitis already present before the beginning of the prosthetic treatment (Figure 5) with the restoration of a normal gum appearance (Figure 11). The patient has been periodically recalled for clinical and radiographic controls: after 5-year follow-up period, the restoration were in excellent condition, with an excellent esthetic result that has definitely affected the quality of life of the patient (Figures 12–14).
DISCUSSION Enamel alterations that characterize the most widespread type of AI involve not only a clear esthetic problem but can also cause abrasion defects, with particular regard to the occlusal surfaces of posterior teeth. At a young age, these abrasions do not cause the loss of vertical dimension but, if not treated, the
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FIGURE 10. A–B, Occlusal views of the case completed.
FIGURE 11. Normal gum appearance after the prosthetic restoration.
FIGURE 12. Frontal view after the prosthetic restoration.
consequent dental eruption may not compensate for dental wear. For this reason, the vertical dimension was not increased in this patient. In addition, the removal of the affected enamel provided a sufficient thickness for the ceramics. Furthermore, the abrasion of the biting surface caused the loss of occlusal anatomy as well as the appropriate relation between cusp and pit.
restorative treatment should take into account the characteristics of each type of AI alterations.27 The greatest difficulties for bonding to enamel have been described in the hypocalcified type which is characterized by a lower mineral content that seems to be deleterious to the bonding procedure.23,28
One of the problems associated with the treatment of AI patients is the adhesive performance of teeth affected by enamel alterations. It has been clearly reported that chemical, morphological, and micromorphological differences between healthy teeth and AI teeth are responsible for the possible failures in resin bonding to AI teeth.23–26 In addition, any esthetic
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However, it has been also reported that in less severe cases, normal enamel can be found around the affected one and so the adhesion procedures can be optimally performed.27,29 In the case here described, the discromic enamel had shown a good adhesion both during the transitional restorative treatment and during the orthodontic
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FIGURE 13. Radiographic control at 5-year follow-up.
FIGURE 14. Appearance of the smile after the prosthetic restoration.
treatment. In addition, although the alteration of the enamel was widespread, below the brown-colored surface, an enamel appeared with characteristics which were more similar to the normal one, as found in the cervical areas. For these reasons, it was decided that this patient may be a good candidate for an adhesive rehabilitation. A direct conservative treatment is characterized by some limitations. In particular, the level of dental wear shown by this patient made it impossible to obtain a
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stable and durable prosthetic restoration. For this reason, the selection of the material to be used in such a complex restoration is essential for a treatment that should not only restore function and esthetics but also try to be minimally invasive and ensure a good prognosis. A traditional prosthetic restoration with full crowns would certainly obtain a good esthetic result and a good prognosis, but it leads to a significant removal of dental tissue. In addition, the placement of crown margins in the gingival sulcus would expose the patient to possible problems in the interactions with periodontal tissues. For this reason, partial preparations were preferred with the use of new all-ceramic materials that are resistant even though they are extremely thin. Furthermore, they are characterized by favorable abrasion coefficients compared with natural enamel.30–33 In the posterior regions, a lithium disilicate monolithic pressed ceramic was selected because, at thickness of less than 2 mm, it seems to resist to occlusal loads.30,34,35 In addition, the possibility of performing an adhesive cementation offered by this material allows the performance of partial and non-retentive preparations characterized by extra-gingival closure margins on enamel. Consequently, minimal invasive preparations, made by removing only the altered occlusal enamel, were prepared following the directions of the diagnostic wax-up. In this way, it was possible to limit the thickness of the preparations and at the same time
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maintain the finishing extra-gingival lines. As in the case of this patient, extra-gingival preparations simplify all the procedures for taking impressions and the management of temporary restorations.36,37 A conservative prosthetic preparation was also selected in the anterior region removing only the discromic enamel. A feldspathic ceramic was preferred to a pressed one because it can offer a higher level of esthetic result at the same thickness. The lower mechanical strength of the feldspathic veneers was compensated for by a cementation only on enamel and by the protection of canine guides obtained with the orthodontic therapy.38–40 The orthodontic splinting of the inferior incisors was removed before the beginning of the prosthetic treatment and it was not repositioned at the end of the therapy. In order to give more stability, the interproximal contact areas were transformed from points to contact surfaces. A 5-year follow-up showed no signs of overcrowding.
REFERENCES 1.
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CONCLUSIONS
8.
A correct treatment plan and the use of the new ceramic materials made it possible to obtain good results both from a functional and esthetic point of view with a much more conservative approach compared with the traditional one.
9.
10.
Recent long-term follow-up research on these new materials support their use in esthetic and functional rehabilitations of this type. In addition, considering the young age of the patient, the preservation of hard tissues and the complete non-interference of periodontal tissues will not prejudice the possibility of any further dental treatment.
The authors do not have any financial interest in any of the companies whose products are included in this article.
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Reprint requests: Maddalena Manfredi, DDS, PhD, Polo di Odontostomatologia, Unità di Odontostomatologia, SBiBiT Department, Via Gramsci 14, Parma 43100, Italy; Tel.: +39-0521-033641; email: [email protected]
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