Diseases and Conditions in Dentistry

Question 1

What is amelogenesis imperfecta?

Answer 1

an inherited disease that affects both deciduous and permanent dentition and is associated with mutations in different genes with a wide range of clinical presentations.

Question 2

what are the different phenotypes of amelogenesis imperfecta?

Answer 2

1. Type 1: hypoplastic type
   - reduced thickness and often with pitting and grooves on surface
   - enamel is hard and translucent
   - radiographically distinct from dentin
2. Type 2: hypocalcified type
   - normal thickness
   - opaque or chalky : poorly calcified and weak
   - teeth become stained and wear down fast.
   - radiographically, less opaque than the underlying dentin
3. Type 3: hypomaturation type
   - normal thickness
   - mottled appearance (resembling fluorosis)
   - slightly softer than normal and vulnerable to wear
   - radiographically similar to dentin
4. Type 4: mixed - hypoplastic + hypomaturation with taurodontium (enlarged pulp chamber)

Other clinical features:
1. delayed eruption of teeth
2. crowding
3. microdontia
4. pulp abnormality
5. gingival and periodontal disease
6. Skeletal abnormalities such as anterior open bite and cross bites.

Question 3

How deep can TEGDMA monomers (ICON) infiltrate?

Answer 3

0.5 mm

Question 4

What is the significance of infiltrating TEGDMA?

Answer 4

1. increasing the bonding of the overlying resins to the tooth tissue.
2. strengthening the micro-hardness of enamel
3. limiting bacterial growth

-> protects and maintain the residual structures as long as possible.

4. potentiates the cohesion of cracked enamal structure.

Question 5

Strategies to optimize bonding on enamel in patients with dentinogenesis imperfecta

Answer 5

1. mill enamel to remove aprismatic layer to make a prismatic enamel bond (~30 microns)
2. Sandblast to increase micro-clamping
3. Infiltration with low-molecular-weight resin (such as TEGDMA)
   - to strengthen the structure
   - to potentiate the adhesion of overlying biomaterials for bonding
4. Reference bonding protocols
   - favors cementation without adhesive potential
   - but, universal adhesive to improve chemical bonding of restoratrive tissues and biomaterials

Question 6

Strategies for bonding on dentin in patients with DI

Answer 6

1. Sandblasting the prep
2. Etch to remove the alumina particles that can fill the asperities created
3. Biomaterials with 10-MDP for chemical bonding to Ca and HA of dentine

Question 7

What is the aim of treating amelogenesis imperfecta?

Answer 7

1. early diagnosis of the disease
2. Pain management
3. Prevention and stabilization
4. Maintenance of facial height
5. Restoration of teeth with defects
6. Regular maintenance

Question 8

Management of children with amelogenesis imperfecta

Answer 8

1. create rapport as early as possible
2. Prevention!! - berry important
   - OHI
   - diet advice
   - fluoride treatment to reduce sensitivity and prevent caries
3. Periodontal management - may need several visits under L/A
4. Use non-latex rubber dam to reduce sensitivity
5. Minimal intervention and monitoring when there’s no evidence of wear
6. Once there’s occlusal wear and pt is complaining about sensitivity and poor aesthetics, intervention may be needed.
   - GI restoration or direct composite veneers on the anterior
   - SSC or GI restoration on occlusal surfaces on primary molars

Question 9

Management of patients in mixed dentition

Answer 9

1. permanent teeth can take a long time to erupt and damage can occur while waiting.
   -> GI restoration on occlusal surfaces of partially erupted teeth
   -> removing operculum to expose the whole crown can facilitate restorative procedures.
2. Cast adhesive onlays, SSC, or gold crowns on the first permanent molars when fully erupted.
3. ***Direct or indirect composite veneers for the permanent incisor teeth.
   -> needs to be done ASAP
   -> inform the patients and parent that the margins of any restoration may become visible due to continuing eruption and gingival maturation and that additional treatment will be required at intervals to maintain good aesthetics.

Question 10

How to manage permanent dentition with amelogenesis imperfecta

Answer 10

1. adhesive approach rather than preparing teeth for indirect restorations

Why?
- risk of damaging pulp with large size
- preservation of tooth structure

2. Definitive restorative management should be delayed until full maturation of teeth and gingiva
3. Interdisciplinary approach with GP, peds, ortho, resto, hygienist, and therapist.

Question 11

Aim of treating amelogenesis imperfecta in adulthood

Answer 11

1. reduce pain and sensitivity
2. improve any malocclusion, such as open bite
3. restore function and aesthetics.

Question 12

Managment of amelogenesis imperfecta in adulthood

Answer 12

1. Prevention - OHI, dietary advice, and fluoride application
2. Perio tx and maintenance
3. tx of caries or RCT
4. Multidisciplinary tx planning
5. Managment of tooth wear which may require crown lengthening
6. Compromised mx. anterior teeth:
   - Definitive direct composite restorations
   - Dentin bonded crowns with minimal prep
7. Compromised mn. anterior teeth:
   - Direct composite
   - Indirect labial porcelain veneers
   - Detin bonded crowns if retention is a concern.
8. Posterior teeth:
   - Induce eruption of the posterior teeth to occlusion via Dahl approach if the enamel is not too compromised.
   - Premolar: direct or indirect restorations
   - Molar: gold onlays or crowns
9. Long-term maintenance: OHI, plaque control, perio health, occlusal stability, and maintenance of any restorations
10. Occlusal splint. Esp in patients in parafunctional habits.