MCCORDETAL

10. Sloan P. Current concepts of the role of fibroblasts and extracellular matrix in wound healing and their relevance to oral implantology. 3 Dent 1991;19:10’7-9. 11. Hassel TM, Gilbert GH. Phenytoin sensitivity of fibroblasts as the basis for susceptibility to gingival enlargement. Am J Pathol1983;12:21823. 12. Kinane DF, Davies RM. Periodontal manifestations of systemic disease. In: Jones JR, Mason DK, eds. Orai manifestations of systemic disease. 2nd ed. London: Balliere-Tindall, 1990:512-36.

Periodontal imperfecta:

and prosthodontic A clinical report

Richard Greenfield, Paul Baer, DDSd State University

DDS,” Vincent

UNWERSITY DENTAL HOSPITAL HIGHER CAMBRIDGE ST. MANCHESTER

Ml5 6FH, UNITED KINGDOM

treatment

of New York at Stony Brook, School of Dental Medicine,

BPrivate Practice of Prosthodontics, Roslyn, N.Y. bProfessor and Director of Postgraduate Periodontics. Tlinical Assistant Professor of Periodontics. dProfessor and Chairman of Periodwntics. 10/l/39921

Fig. 1. Preoperative loss around mandibular

of amelogenesis

Iacono, DMD,b Steven Zove, DDS,” and

melogenesis imperfecta is an inherited disorder associated with defective ameloblasts. It is reported to have an incidence of one person in every 16,OOO.l Amelogenesis imperfecta was first described in 1890, but not until 1938 did Finn2 classify it as a separate entity from dentinogenesis imperfecta.

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Reprint requests to: DR. P. SLOAN

Stony Brook, N.Y.

Defects in enamel formation fall in two categories, each of which develops by a different mode of inheritance. The characteristics of the first group, termed enamel hypoplasia, include an imperfectly formed matrix, deficiencies in the quantity of enamel formed, and irregular deposition of enamel. Enamel hypoplasia seems to be inherited by sexlinked incomplete dominant genes.3 Individuals in the second group, termed enamel hypocalcification, have a normal matrix that is not fully calcified, resulting in easily abraded enamel (unlike enamel hypoplasia). Enamel hypocalcification is inherited in an autosomally dominant manner.3 This report describes the treatment sequence for a patient with complete amelogenesis imperfecta and illus-

complete mouth series of periapical molars and affected crowns.

radiographs

shows alveolar bone

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OF AMELOGEtiESIS

IMPERFECTA

Fig. 2. Preoperative condition of teeth and gingivae showing generalized inadequate clinical crown length.

Fig.

3. Tissue healing 4 weeks after surgery.

trates the desired interrelationship and prosthodontics.

PATIENT

between periodontics

REPORT

A G-year-old white woman presented with amelogenesis imperfecta and inability to function with existing complete maxillary and mandibular overdentures. Her dental history revealed many years of wearing overdentures made for esthetics, function, and dentinal hypersensitivity with simultaneous fluoride iontophoresis. All teeth were present except the maxillary right third and left second molars. Analysis of periapical radiographs (Fig. 1) and complete periodontal charting revealed localized mild to moderately advanced periodontitis restricted to the mandibular molars. Pocket depths ranged from 2 to 8 mm throughout the mouth, with the most significant pocket depths in the mandibular molars. Mobility patterns were within normal limits except for the left mandibular posterior teeth, which Yanged from type Yz to 1. Diastemas ranging from 1 to 3 mm

THE

JOURNAL

OF PROSTHETIC

DENTISTRY

Fig. 4. Postoperative restorations.

Fig.

processed acrylic resin provisional

5. Final restorations

5 years after placement.

were noted throughout the dentition. The gingivae appeared firm and healthy, but the length of all clinical crowns was considered inadequate to allow restoration with fixed prostheses (Fig. 2). The first phase of treatment was periodontal preparation by scaling, root planing, and oral physiotherapy. Soft tissue contours were studied on diagnostic casts mounted on a fully adjustable articulator. Presurgical planning included thorough examination of these casts to determine the most favorable redevelopment of soft tissue and osseous and dental contours. Because of the patient’s anxiety and sensitivity to any instrumentation, periodontal surgery was performed under general anesthesia in a hospital environment. Surgery consisted of complete-mouth crown-lengthening by osteoectomy and osteoplasty with both hand and high-speed rotary instruments. The patient was followed up postoperatively on a weekly basis and the healing was uneventful (Fig. 3). During the healing phase, the patient functioned

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GREENFIELD

ET AL

Fig. 6. Radiographs taken 5 years after completion of treatment. The mandibular left third molar was extracted during the crown-lengthening surgery and the mandibular right second molar was endodontically treated at the time of crown preparation.

for several weeks with the existing maxillary and mandibular overdentures lined with tissue conditioner (Soft-Tone, Henry T. Bosworth Co., Skokie, Ill.). These interim prostheses were later replaced with maxillary and mandibular acrylic resin provisional restorations until final healing occurred (Fig. 4). The patient was ready for the second phase of prosthodontic procedures 12 weeks after surgery. The vertical dimension of occlusion was carefully maintained during the period of provisionalization and through to completion of the restoration. The patient has been followed up for 5 years on a regular 3- to 4-month recall appointment schedule and has been maintained in a state of periodontal health, function, and most acceptable esthetics (Figs. 5 and

6). DISCUSSION Historically, patients with amelogenesis imperfecta have been treated with multiple extractions or with the construction of complete dentures” This is psychologically harsh when the problem must be addressed in adolescent patients. Several studies have illustrated the use of composite resins, sealants, and other bonded resins, polycarbonate crowns, stainless steel crowns, and space maintainers to restore mutilated dentition that may only be the result of severe attrition.43 5 Overdenture therapy has been a successful alternative in that it can very often be adapted for use with unaltered natural teeth.‘j This approach has been described in the literature for patients with cleft palate, oligodontia, microdontia, cieidocranial-dysostosis malalignment, erosion,

574

and abrasion of the teeth.7, 8 The technique described provides a fixed prosthodontic alternative to the dental devastation caused by amelogenesis imperfecta.

SUMMARY A multidiscipline procedure has been described that provided prosthodontic restoration of esthetics and function for a patient with amelogenesis imperfecta. REFERENCES 1. Burzynski NJ, Gonzalez WE, Snawder KD. Autosomal dominant smooth hypoplastic amelogenesis imperfecta: Report of case. Oral Surg 1973;36:818-23. 2. Finn SB. Hereditary opalescent dentition. I. An analysis of the literature on hereditary anomalies of tooth color. J Am Dent Assoc 1938;25: 1240.9. 3. Pinborg JJ. Pathology of the dental hard tissues. Copenhagen: Munksgaard, 1970. 4. Widdop FT. Extending the range of composite resin in everyday practice. Aust Dent J 1979;85-9. 5. Lamb DJ. The treatment of amelogenesis imperfecta. J PROSTHET DENT 1976;36:286-91.

6. Renner RP, Ferguson FS. Overdenture management of amelogenesis imperfecta. Quintessence Int 1983;10:1009-22. 7. Abadi BJ, Kimmel NA, Falace D.A. Modified overdentures for the management of oligodontia and developmental defects. J Dent Child 1982;March-April:123-6. 8. Light EI, Rakow B, Fraze RL. An esthetic transitional treatment for amelogenesis imperfecta: report of two cases.J Am Dent Assoc 1975;90: 166-70. Reprint requests to: DR. VINCENT J. IACONO DEPARTMENT OF PERIODONTICS SCHOOL OF DENTAL MEDICINE STATE UNIVERSITY OF NEW YORK AT STONY BROOK STONY BROOK, NY 11794-8703

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1992

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4