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CASE CASE CASE CASE REPORT REPORT REPORT REPORT 24 ARCHIVES OF DENT Enamel Hypoplasia and Tirath Ram Garg 1 , Shalu Kr 1 Post Graduate Student, Departme Hospital, Derabassi; 2 Professor an Dental College & Hospital, Derabas Address for Correspondence: Dr. Tirath Ram Garg, Post Graduat Dental College & Hospital, Derabas ABSTRACT: Enamel hypoplasia is defined hypocalcification and hypomin disturbance, associated to alterat narrow horizontal bands, lines o affected. These defects have b systemic and environmental fa formation are thought to be re premature infants, infections du hypoxia, exposure to toxic chem and discomfort but may be m restoratively with continuing trea anterior teeth affected by enamel Keywords: Enamel, Environmen INTRODUCTION Enamel is a hard tissue that has b as a cell less organic tissue whic of regeneration. Process of involves cells that secrete en which mineralize enamel to 30%. Once entire thickness has and structured it then acquir mineral content with remova proteins and water to yield a t more than 95% mineral. 1,2 Many conditions produce defe structure. These occur because a cells particularly sensitive to ch environment. They include deficiency (Vit. A, C and D), e diseases, congenital syphilis, h birth injury alongwith certain lo ingestion of chemicals (fluorid idiopathic causes. 3 Enamel hypoplasia of the variety due to nutritional de systemic disease occurs as the a TAL AND MEDICAL RESEARCH Vol 2 Issue 6 d Rehabilitation of Esthetics: A Case rishan 2 ent of Conservative Dentistry & Endodontics, Natio nd Head, Department of Conservative Dentistry & ssi. te Student, Department of Conservative Dentistry & ssi, India. d as deficiency of enamel formation and neralisation. Enamel hypoplasia (EH) is restr tions in the organic enamel matrix which can ca of pits and grooves. Both the quality and quant been connected with genetic and epigenetic ca actors. Environmental and genetic factors that esponsible for EH e.g. trauma to the teeth and uring pregnancy or infancy, poor prenatal and micals etc. The condition presents problems of so managed if early intervention is done early bo atment into adult life. This paper presents the esth l hypoplasia. ntal hypoplasia & discoloration, Hypoplastic teeth been described ch is incapable amelogenesis namel proteins approximately s been formed res additional al of enamel tissue made of ects in enamel ameloblasts are hanges in their e: nutritional exanthematous hypocalcaemia, ocal infections, de) and even environmental eficiency and ameloblasts are one of the most sensitive g body in terms of metabolic Most cases of enamel hyp involve those teeth that f year after birth, althoug somewhat later may be aff most frequently involve incisors, lateral incisors, molars. Premolars along w molars are seldom aff mineralization does not be of age or more. CASE REPORT A 17 year old female pa outpatient department o College and Hospital, Der complaint of discoloured f Clinical examination o revealed bilaterally sym horizontal enamel hyp anteriors and lower canine a yellowish brown discol third of 11, 21 (FDI sys AODMR Report onal Dental College & Endodontics, National Endodontics, National is associated with ricted to ectodermal ause the white flecks, tity of the enamel is auses such as local, interfere with tooth d jaws, intubation of d postnatal nutrition, ocialization, function oth preventively and hetic rehabilitation of h. groups of cells in the c function. 4 poplasia of this type form within the first gh teeth that form fected. Thus the teeth ed are the central , canines and first with second and third fected, since their egin by about 3 years atient reported to the of National Dental rabassi with the chief front teeth. of the oral cavity mmetrical pattern of poplasia of upper es which were having loration. The middle stem) were involved

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CASE CASE CASE CASE REPORTREPORTREPORTREPORT

24 ARCHIVES OF DENTAL AND MEDICAL RESEARCH

Enamel Hypoplasia and Rehabilitation o Tirath Ram Garg1, Shalu Krishan1Post Graduate Student, Department of Conservative Dentistry & EndodonticsHospital, Derabassi; 2Professor and Dental College & Hospital, Derabassi Address for Correspondence: Dr. Tirath Ram Garg, Post Graduate Student, Dental College & Hospital, Derabassi

ABSTRACT: Enamel hypoplasia is defined as deficiency of enamel formation hypocalcification and hypomineralisation. Enamel hypoplasia (EH) is restricted to disturbance, associated to alterations in the organic enamel matrix which can cause the white flecks, narrow horizontal bands, lines of pits and affected. These defects have been connected systemic and environmental factors. Environmental and genetic factors that interfere with tooth formation are thought to be responsible for EH e.g. trauma to the teeth and jaws, intubation of premature infants, infections during pregnancy or infancy, poor prenatal and postnatal nutrition, hypoxia, exposure to toxic chemicals etc. The condition presents problems of socialization, function and discomfort but may be managed restoratively with continuing treatment into adult lifeanterior teeth affected by enamel hypoplasia. Keywords: Enamel, Environmental hypoplasia & discoloration INTRODUCTION Enamel is a hard tissue that has been describeas a cell less organic tissue which of regeneration. Process of amelogenesis involves cells that secrete enamel proteins which mineralize enamel to approximately 30%. Once entire thickness has been formed and structured it then acquires additional mineral content with removal of enamel proteins and water to yield a tissue made more than 95% mineral.1,2 Many conditions produce defects in enamel structure. These occur because acells particularly sensitive to changes in their environment. They include: nutritional deficiency (Vit. A, C and D), exanthematous diseases, congenital syphilis, hypocalcaemia, birth injury alongwith certain local infections, ingestion of chemicals (fluoride) and even idiopathic causes.3 Enamel hypoplasia of the environmental variety due to nutritional deficiency and systemic disease occurs as the ameloblasts are

ARCHIVES OF DENTAL AND MEDICAL RESEARCH Vol 2 Issue 6

Enamel Hypoplasia and Rehabilitation of Esthetics: A Case Report

Shalu Krishan2 Department of Conservative Dentistry & Endodontics, National Dental College &

Professor and Head, Department of Conservative Dentistry & Endodontics,Dental College & Hospital, Derabassi.

Post Graduate Student, Department of Conservative Dentistry & EndodonticsDerabassi, India.

Enamel hypoplasia is defined as deficiency of enamel formation and is associated with hypocalcification and hypomineralisation. Enamel hypoplasia (EH) is restricted to disturbance, associated to alterations in the organic enamel matrix which can cause the white flecks,

orizontal bands, lines of pits and grooves. Both the quality and quantity of the enamel is affected. These defects have been connected with genetic and epigenetic causes such as local, systemic and environmental factors. Environmental and genetic factors that interfere with tooth formation are thought to be responsible for EH e.g. trauma to the teeth and jaws, intubation of

nts, infections during pregnancy or infancy, poor prenatal and postnatal nutrition, hypoxia, exposure to toxic chemicals etc. The condition presents problems of socialization, function and discomfort but may be managed if early intervention is done early both preventively and

nuing treatment into adult life. This paper presents the esthetic rehabilitation of anterior teeth affected by enamel hypoplasia.

Environmental hypoplasia & discoloration, Hypoplastic teeth

has been described as a cell less organic tissue which is incapable of regeneration. Process of amelogenesis involves cells that secrete enamel proteins which mineralize enamel to approximately

thickness has been formed d structured it then acquires additional

content with removal of enamel a tissue made of

Many conditions produce defects in enamel structure. These occur because ameloblasts are cells particularly sensitive to changes in their environment. They include: nutritional

C and D), exanthematous s, hypocalcaemia,

birth injury alongwith certain local infections, hemicals (fluoride) and even

Enamel hypoplasia of the environmental variety due to nutritional deficiency and systemic disease occurs as the ameloblasts are

one of the most sensitive groups of cells in the body in terms of metabolic fuMost cases of enamel hypoplasia of this type involve those teeth that form within the first year after birth, although teeth that form somewhat later may be affected. Thus the teeth most frequently involved are the central incisors, lateral incisors, canines molars. Premolars along with molars are seldom affected, since their mineralization does not begin of age or more. CASE REPORT A 17 year old female patient reported to the outpatient department of National College and Hospital, Derabassicomplaint of discoloured front teeth.Clinical examination of the oral cavity revealed bilaterally symmetrichorizontal enamel hypoplasia of upper anteriors and lower canines which were having a yellowish brown discoloration. The middle third of 11, 21 (FDI system) were involved

AODMR

f Esthetics: A Case Report

National Dental College & Department of Conservative Dentistry & Endodontics, National

Department of Conservative Dentistry & Endodontics, National

and is associated with hypocalcification and hypomineralisation. Enamel hypoplasia (EH) is restricted to ectodermal disturbance, associated to alterations in the organic enamel matrix which can cause the white flecks,

grooves. Both the quality and quantity of the enamel is with genetic and epigenetic causes such as local,

systemic and environmental factors. Environmental and genetic factors that interfere with tooth formation are thought to be responsible for EH e.g. trauma to the teeth and jaws, intubation of

nts, infections during pregnancy or infancy, poor prenatal and postnatal nutrition, hypoxia, exposure to toxic chemicals etc. The condition presents problems of socialization, function

oth preventively and . This paper presents the esthetic rehabilitation of

Hypoplastic teeth.

one of the most sensitive groups of cells in the body in terms of metabolic function.4 Most cases of enamel hypoplasia of this type involve those teeth that form within the first year after birth, although teeth that form somewhat later may be affected. Thus the teeth most frequently involved are the central

ors, canines and first molars. Premolars along with second and third molars are seldom affected, since their mineralization does not begin by about 3 years

male patient reported to the department of National Dental

College and Hospital, Derabassi with the chief front teeth.

Clinical examination of the oral cavity revealed bilaterally symmetrical pattern of horizontal enamel hypoplasia of upper

wer canines which were having llowish brown discoloration. The middle

third of 11, 21 (FDI system) were involved

Garg & Krishan

25 ARCHIVES OF DENTAL AND MEDICAL RESEARCH

with cervical and incisal third intact whereas the middle and incisal third in maxillary lateral incisors and caninesaffected. In case of mandibular canines middle third of tooth structure was involved. Tenamel was lost on affected portions and

A.

Medical history revealed that the patient was frequently admitted in hospital in the first 3 years of his life and the patient was subjected to parenteral and systemic antibiotics every time although she is not aware ofadministered. In teeth 12, 13, 22 and 23 due to extensive tooth involvement intentional root canal treatment followed by fibre post placement, core build-up using ParaCore and all ceramic crown placement were planned. In 11, 21, 33 and 43 after conservative tooth preparations composite restorations were done. Due to the involvement of distal proximal surfaces in 33 and 43, there was mesial drifting of 34, 44 in the affected portions. So to establish proper proximal contact and contour betwand 43, 44, elastic separators were placed between them for 7 days prior to composite restorations.

Figure 2: Composite restorations

Figure 3: After placing separators distal to canine

Garg & Krishan: Enamel Hypoplasia and Rehabilitation of Esthetics

ARCHIVES OF DENTAL AND MEDICAL RESEARCH Vol 2 Issue 6

vical and incisal third intact whereas middle and incisal third in case of

maxillary lateral incisors and canines were . In case of mandibular canines middle

third of tooth structure was involved. The affected portions and

underlying dentin was heaffected portion did not have the normal contour. There was lack of contact between adjacent teeth due to reduced enamel thickness.

B. C. Figure 1: Pre- operative

edical history revealed that the patient was frequently admitted in hospital in the first 3 years of his life and the patient was subjected

ystemic antibiotics every are of the drugs

n teeth 12, 13, 22 and 23 due to extensive tooth involvement intentional root canal

ibre post placement, ore and all ceramic

crown placement were planned. In 11, 21, 33 after conservative tooth preparations

composite restorations were done. Due to the involvement of distal proximal surfaces in 33 nd 43, there was mesial drifting of 34, 44 in

the affected portions. So to establish proper proximal contact and contour between 33, 34 and 43, 44, elastic separators were placed between them for 7 days prior to composite

omposite restorations - 11, 21

fter placing separators distal to canine

Figure 4: Radiographs showing RCT followed by placement in 22 & 23

Figure 5: Core build up & Crown P

Figure 6: Showing temporary crowns

Figure 7: All Ceramic Crowns

and Rehabilitation of Esthetics

dentin was heavily stained. The did not have the normal

contour. There was lack of contact between nt teeth due to reduced enamel

: Radiographs showing RCT followed by Fibre post placement in 22 & 23

Core build up & Crown Preparation - 12,13,22 & 23

temporary crowns- 12,13,22 & 23

rowns – 12,13,22 & 23

Garg & Krishan

26 ARCHIVES OF DENTAL AND MEDICAL RESEARCH

Figure 8: Comparing Pre-operative & Post-operative photographs

DISCUSSION Enamel hypoplasia was first used by Zsigmondy in 1894. Hypoplasia is preferable to the old term “enamel atrophy” because the condition is characterized by an underdevelopment of the enamel whereas the word “atrophy” indicates a wasting or reduction in size of a fully develorgan3. Two basic types of enamel hypoplasia exist: (1) a type caused by environmental factors; and (2) a hereditary type (amelogenesis imperfecta). environmentally induced enamel defects can be classified into 3 groups : 1. Hypoplasia 2. Diffuse opacities 3. Demarcated opacities Usually the enamel is light yellow to grayish white in color but at the incisal edges where no dentin is present they appear slightly blue in color. Since the primary teeth enamel have opaque crystals, they appear whiter than the permanent dentition. Since enamel is semi translucent, the color of dentin and any material underneath the enamel strongly affects the appearance of a tooth and when not fully matured, it can give rise to various clinical appearances depending on the degree of mineralization and the color of the dentin which can be seen through the enamelaffected enamel is present on all or parts of surfaces of teeth involved. This may be in the form of pit/grooves or larger areas of missing enamel. The translucency of enamel may be affected so that diffuse opacities are visible which has no clear demarcations from the normal enamel lying next to it. Although the enamel has normal thickness the opaque area may have white/cream/yellow or brown In mild environmental hypoplasia, only a few

Garg & Krishan: Enamel Hypoplasia and Rehabilitation of Esthetics

ARCHIVES OF DENTAL AND MEDICAL RESEARCH Vol 2 Issue 6

operative photographs

was first used by Zsigmondy in 1894. Hypoplasia is preferable to the old term “enamel atrophy” because the condition is characterized by an underdevelopment of the enamel whereas the word “atrophy” indicates a wasting or reduction in size of a fully developed tissue or

. Two basic types of enamel hypoplasia exist: (1) a type caused by environmental factors; and (2) a hereditary type (amelogenesis imperfecta). The environmentally induced enamel defects can

Usually the enamel is light yellow to grayish white in color but at the incisal edges where no

is present they appear slightly blue in Since the primary teeth enamel have

y appear whiter than the Since enamel is semi

translucent, the color of dentin and any material underneath the enamel strongly affects the appearance of a tooth and when not fully matured, it can give rise to various

es depending on the degree of mineralization and the color of the dentin which can be seen through the enamel5. The affected enamel is present on all or parts of surfaces of teeth involved. This may be in the form of pit/grooves or larger areas of missing enamel. The translucency of enamel may be affected so that diffuse opacities are visible

rcations from the normal enamel lying next to it. Although the enamel has normal thickness the opaque area may have white/cream/yellow or brown hue. In mild environmental hypoplasia, only a few

pits, grooves or fissures may be present on enamel surface. If the condition is more severe, the enamel may exhibit rows of deep pits arranged or a linear smooth surface fissure horizontally across the sumay be only single row or several rows indicating a series of injuries. In severe cases, a considerable portion of enamel may be absent, suggesting a prolonged disturbance in ameloblast function. Usually, a narrow zone of hypoplastic defects is indicative of enamel formation affected for a shorter time (acute); a wide zone indicates enamel formation affectfor a longer time (chronic). enamel defects may be the site of discolouration.3 Enamel hypoplasia may be visible as a distinct white spot on individual tooth. It is called as ‘Turner’s tooth’ usually a result of trauma to the tooth in its mineralisation phase. Turner’s term used to describe a permanent tooth with a local hypoplastic defect in its cIf the interference takes place in the first year (called the infancy period), the permanent teeth affected are the first molars, the incisors (except the maxillary lateral incisors), and the canine teeth. It is striking that the maxillary lateral incisors mineralize after the central incisors and canines, approximately after the age of 10 months. If interference takes place in early childhood (approximately 13 to 34 months) the upper laterals and premolars which begin to calcify during this periodalso affected.3 Enamel hypoplasia is typically caused by malnutrition, illness, infection or fever during tooth formation. Some medications like Tetracycline can also affect the teeth if they were undergoing mineralization during the time of dosage. Tetracycline reacts with calcium to form a tetracyclineorthophosphate complex. Tetracycline stains have a typical clinical appearance of yellowish to brownish-gray stained teeth. chemicals chiefly fluorides in large quantities at a young age may interfere with tformation. The appearance varies from localized white, opaque spots, pitting to

and Rehabilitation of Esthetics

pits, grooves or fissures may be present on enamel surface. If the condition is more severe, the enamel may exhibit rows of deep pits arranged or a linear smooth surface fissure

rface of tooth. There may be only single row or several rows indicating a series of injuries. In severe cases, a considerable portion of enamel may be absent, suggesting a prolonged disturbance in ameloblast function. Usually, a narrow zone of

defects is indicative of enamel formation affected for a shorter time (acute); a wide zone indicates enamel formation affected for a longer time (chronic). Occasionally, the enamel defects may be the site of

Enamel hypoplasia may be e as a distinct white spot on individual

tooth. It is called as ‘Turner’s tooth’ usually a result of trauma to the tooth in its

. Turner’s hypoplasia is a term used to describe a permanent tooth with a local hypoplastic defect in its crown.6 If the interference takes place in the first year (called the infancy period), the permanent teeth affected are the first molars, the incisors (except the maxillary lateral incisors), and the canine teeth. It is striking that the maxillary

incisors mineralize after the central incisors and canines, approximately after the age of 10 months. If interference takes place in early childhood (approximately 13 to 34 months) the upper laterals and premolars which begin to calcify during this period are

Enamel hypoplasia is typically caused by malnutrition, illness, infection or fever during tooth formation. Some medications like Tetracycline can also affect the teeth if they were undergoing mineralization during the

Tetracycline reacts with calcium to form a tetracycline-calcium orthophosphate complex. Tetracycline stains have a typical clinical appearance of yellowish

gray stained teeth. Exposure to chemicals chiefly fluorides in large quantities

ng age may interfere with tooth . The appearance varies from

localized white, opaque spots, pitting to

Garg & Krishan: Enamel Hypoplasia and Rehabilitation of Esthetics

27 ARCHIVES OF DENTAL AND MEDICAL RESEARCH Vol 2 Issue 6

generalized white or brown discolorations. Here the patient’s geographic location of a high fluoride area can help in diagnosis. The exact reason for the cause of enamel hypoplasia may not be determined in all cases. In our case, conservative composite restorations were done on 11, 21, 33 and 43 because of limited tooth destruction. This is supported by case done by Martos et al 2012.7 In case of 12, 13, 22 and 23 due to extensive tooth destruction, intentional root canal treatment followed by fibre post placement was done. Core build-up in these teeth was done using ParaCore. In a study done by Agrawal and Mala 2014, dual cure composite material ParaCore was found superior to other core materials in terms of different physical properties.8 Then to provide optimum esthetics, all ceramic crowns were placed on them. Since enamel hypoplasia usually manifests before the age of three years, so any trauma happening later than that will not lead to enamel defects, because calcification of enamel has already occured.9 REFERENCES 1.Worth HM. Principles And Practice Of Oral Radiologic Interpretation. 1st ed.; Year book publisher: Chicago, 1963.

2.Cate T. Ten Cate’s oral histology, development, structure and function. 7th ed.; Elsevier : Canada, 2008. 3.Langlais P, Langland O, Nortje C. Diagnostic imaging of the jaws. 1st ed.; Williams and Wilkins: Baltimore, 1995. 4.Rajendran and Sivapathasundharam. Shafer’s Textbook of Oral Pathology, 5th ed.; Elsevier: India, 2006. 5.http://en.wikipedia.org/wiki/Tooth_enamel assessed on 6/12/2016. 6.White SC, Pharoah M. Oral radiology; principles and interpretation. 6th ed.; Mosby Elsevier: St. Louis, Mo, 2009. 7.Martos J, Gewehr A, Paim E. Aesthetic approach for anterior teeth with enamel hypoplasia. Contemporary Clinical Dentistry 2012;3:S82-5. 8.Agrawal A, Mala K. An in vitro comparative evaluation of physical properties of four different types of core materials. Journal of Conservative Dentistry 2014;17(3):230-3. 9.Neville, Damn, Allen, Bouquet. Oral and Maxillofacial Pathology. 2nd ed.; Elsevier: India, 2004.

How to cite this article: Garg TR, Krishan S. Enamel Hypoplasia and Rehabilitation of Esthetics: A Case Report. Arch of Dent and Med Res 2016;2(6):24-27.