Molar incisor hypo

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Molar incisor hypomineralization: supplementary,
restorative, orthodontic, and esthetic long-term treatment
Chiara Baroni, MD, DDS, CAGS (Pediatr Dent), RAM/Annalisa Mazzoni, DDS, PhD, FADM/
Lorenzo Breschi, DDS, PhD, FADM
Objective: This article describes the esthetic results in a para-
digmatic case of hypomineralized enamel correction on both
anterior and posterior teeth to establish a minimal intervention
protocol for similar cases. Clinical considerations:The subject
was initially provided with casein-calcium-phosphate mineral
supplementation. Unpublished laboratory images collected as
part of a previously published study depict the results of initial
calcium-phosphate supplementation on molar incisor hypo-
mineralization (MIH) molar enamel morphology and indicate
that this procedure is mandatory in moderate/severe cases.
Prior to defect restoration, in-office bleaching of the anterior
segment was conducted with bioactivated Opalescence Boost.
Filtek Supreme Ultra Universal Restorative was used as a mask-
ing agent, and Filtek A2 enamel was applied as the final layer.
Conclusion: An 8-year follow-up period is necessary in most
moderate/severe MIH cases involving orthodontics and bleach-
ing. (Quintessence Int 2019;50:412–417; doi: 10.3290/j.qi.a42327)
Key words: MIH diagnosis, MIH supplementation, MIH treatment, molar incisor hypomineralization (MIH), orthodontic treat-
ment, restorative treatment
This article describes the esthetic results in a paradigmatic case
of hypomineralized enamel correction on both anterior and
posterior teeth to establish a minimal intervention protocol for
similar cases.
The severity of the case described was diagnosed in accor-
dance with the molar incisor hypomineralization (MIH) classifi-
cation provided by Oliver et al1
and Chawla et al2
using the new
Molar Hypomineralization Severity Index (MHSI)1,2
based on
defects, color, location, post-eruptive breakdown (PEB), resto-
rations placed/replaced, and atypical sensitivity. These charac-
teristics can be useful to predict treatment efficacy in affected
first permanent molars and may guide clinical management.
Reduced mineral content of the MIH enamel is frequently
associated with increased organic content.3
Treatment of
enamel with high organic content using bonding technologies
can be problematic, as the organic material in the enamel fre-
quently prevents effective etching. Retention of enamel matrix
proteins or uptake of organic material into hypomineralized
enamel can cause enamel discoloration, often resulting in a yel-
low-brown appearance. Since 2011, this has been the rationale
for calcium-phosphate supplementation.
The provision of fluoride ions in mineralizing media during
the development of biogenic apatites increases the crystal
growth rate by augmenting precipitation. The inclusion of
fluoride in casein phosphopeptide-amorphous calcium phos-
phate (CPP-ACP) supplements represents a breakthrough in
treatment effectiveness and speed of hypomineralized areas.4
Only a few small studies, mainly concerning high-risk caries/
abrasion, have investigated treatment options for MIH enamel.5
Application of fissure sealants or remineralization appear suitable
fortreatmentofMIHmolarswithlimitedseverityand/orhypersen-
sitivity.6
More severe cases may require restorations, including
direct/indirect resin restorations or preformed metal crowns. Cur-
rently,therearenoclearrecommendationsregardingMIHincisors.
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SEM method and materials
Scanning electron microscopy (SEM) micrographs depicting MIH
molar enamel specimens collected for the study published in
2011 are shown.3
Fragments of MIH molars were fixed in 4% glu-
taraldehyde, 0.2 mol/L sodium cacodylate buffer solution for 48
hours, dehydrated through a graded alcohol series, and sputter
coated with gold–palladium (Sputter Coater SC7620, Polaron)
for SEM (JSM-5200, JEOL) for analysis at various magnifications.
SEM results and discussion
Figures 1a and 1b depict SEM magnifications of non-supple-
mented and supplemented MIH enamel; Figs 1c and 1d shows
samples of fragments from the same series as reported by Bar-
oni and Marchionni3
with different images.
At the beginning of treatment, crystals showed loose and
irregular packing with a “snowy forest” appearance and were
immersed in a low-density substance. The enamel prisms were
Figs 1a to 1d Beginning of treatment:
(a) 5,000× and (b) 20,000× magnifications.
Crystals seem to be loose as if they were
ready to break away from each other. There
is protrusion of pointed prisms from a layer
with no established framework. End of treat-
ment: (c) 5,000× and (d) 20,000× magnifica-
tions. Crystal elongation along the c-axis is
initiated by deposition of small protrusions
on the basal plane. Prism morphology is
shown to evolve into an almost hexagonal
shape.
Fig 2 Anterior view of 7-year-old patient before supplement
treatment.
Fig 3 Maxillary right molar before supplement
treatment.
2 3
1a 1b
1c 1c

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covered with an amorphous layer, from which irregular prisms
protruded. The isolated prisms were rock-shaped.
At the end of treatment, SEM at 20,000× magnification
showed that the rod structure had evolved into a more mature
and mineralized tissue, almost geometric in shape, but it was
smaller than normal. Deposition of small protrusions on the
basal plane initiated crystal elongation along the c-axis.
The increased mineralization may result from decreased
calcium content and increased calcium and phosphate content.
This study also examined the influence of chemical content
on the morphology of MIH enamel prisms.
Case report
The case of a 7-year-old girl is presented from among a group
of children diagnosed with MIH participating in the aforemen-
tioned study3
(Fig 2). Initial treatment was no-fluoride Recal-
dent, GC Tooth Mousse (GC Corporation), which was the only
product available at the time.
Subsequently, an improved GC Toothpaste with fluoride4
(TM PLUS, GC Europe; 10% CPP-ACP with 0.2% NaF) was used
for 2 years during the eruption of permanent teeth.
The photographs of molars and incisors illustrate the initial
situation before supplementation (Figs 2 and 3). Clinically, the
mandibular left first molar was restored with a composite resin
cusp covering (Clearfil Majesty A2, Kuraray) and was not
re-treated (Fig 3).
Unaffected molars were sealed over time during full arch
eruption (Clinpro, 3M Espe). Orthodontic treatment for Class 2
malocclusion lasted 3 years (Fig 4). After continuous follow-up for
8 years following diagnosis, a two-visit bleaching protocol was
applied in the anterior region, which showed moderate severity,
using Opalescence Boost (Ultradent Products) bioactivated for
20 minutes with a diode laser 840 (Pocket Laser, Orotig Med).
Esthetic restoration of the maxillary left incisor involved
slight ameloplasty of abraded and discolored white-yellow
defects using red band, rugby ball-shaped finishing burs
(Intensiv SA, Montagnola) to create a bevel.
4 5
Fig 4 Initial restoration of mandibular left molar 8 years later. Fig 5 Maxillary arch before orthodontic treatment.
Fig 6 Intraoral anterior view pre-orthodontic treatment.
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Filtek Supreme Ultra Universal Restorative (color A2 body,
3M Espe) was used as a masking agent, and Filtek A2 enamel
(3M Espe) was applied as the final layer (Figs 5 to 8).
Final cuspal and occlusal covering of the worn and stained
maxillary right molar was performed with both flowable (Filtek
XTE Supreme Ultra Flowable Restorative, color A2, 3M Espe)
and brushed nanofilled composites (Filtek Supreme Ultra Uni-
versal Restorative A2) as the final step (Figs 9 and 10).
All restorations were polished using Sof-Lex Extra-Thin
Contouring and Polishing Discs (3M Espe) and rubber cups
(Eve).
Discussion
White-yellow discoloration of the enamel in esthetically visible
areas is clinically undesirable. Minimally invasive approaches to
minimize the discoloration include the resin infiltration tech-
nique.7,8
However, there is no strong evidence for clinical rec-
ommendation of this technique, and further randomized con-
trolled trials (RCTs) with long-term follow-up are required.9-11
As it is neither fully transparent nor fully opaque, the optical
characteristics of tooth enamel cannot be reproduced easily.10
Alternative approaches for correcting discoloration of the
Fig 7 Smile view pre-orthodontic treatment. Fig 8 Anterior view of the patient post orthodontic treatment.
Fig 9 Maxillary right first molar restored after orthodontic treatment. Fig 10 Final outcome after bleaching and composite restoration.
7 8
9 10

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enamel include micro-abrasion, esthetic conservative restor-
ations, and dental whitening for the incisors.12,13
In the present case, a delayed but stable approach was
applied, which fulfilled both restorative and orthodontic needs,
matching the tooth’s polychromatic characteristics and thereby
potentially improving self-confidence in adolescence, as sug-
gested byWright.14
Occlusal morphology could not be reestab-
lished, as it was in the other unaffected molars, due to addi-
tional wear produced by Class 2 molar correction.
The outcome of restoration of the maxillary right molar was
imperfect, as it showed islands of deteriorated, worn-off enamel,
and some exposed heavily pigmented dentin; also, the occlusal
plane was altered by the orthodontic treatment.
The location of PEBs is highlighted in the literature,1
with a
2.5-fold increase in PEB prevalence in brown cuspal defects com-
pared with other surfaces.
The use of a flow composite to build up the palatal wall to
achieve better polishing influenced the esthetic results, suggest-
ing that a thicker layer of very clear micro-filled or liquid masking
agent should have been employed to occlusally cover the flow.
Conclusions
Calcium-phosphate supplementation of MIH defects may
improve etching and bonding efficacy in PEB molar resto-
rations. Bleaching effectively reduced the area of white-yellow
incisor defects before final restoration.
Acknowledgment
The authors thank Dr Silvia Marchionni for laboratory work,
Prof David Manton for correcting the lab work final draft, and
Prof Giulio Bonetti and Dr Giulia Garulli for orthodontic docu-
mentation. The English in this document has been checked by
at least two professional editors, both native speakers of
English. For a certificate, please see: http://www.textcheck.com/
certificate/I8vfeJ.
Disclosure
The authors have no financial interest in the companies whose
materials are included in this article.
References
1. Oliver K, Messer LB, Manton DJ, et al.
Distribution and severity of molar hypo-
mineralisation: trial of a new severity index.
Int J Ped Dent 2014;24:131–151.
2. Chawla N, Messer LB, Silva M. Clinical
studies on molar-incisor-hypomineralisation
part 2: development of a severity index.
Eur Arch Paediatr Dent 2008;9:191–199.
3. Baroni C, Marchionni S. MIH supplemen-
tation strategies: prospective clinical and
laboratory trial. J Dent Res 2011;90:371–376.
4. Baroni C, Marchionni S, Bazzocchi MG,
Cadenaro M, Nucci C, Manton DJ. In vivo
remineralization by CPP-ACPF: SEM and light
profilometry. Scanning 2013;9999:1–8.
5. Elhennawy K, Schwendicke F. Managing
molar-incisor hypomineralisation:
a systematic review. J Dent 2016;55:16–24.
6. Crombie F, Manton D, Reynolds E.
Therapie der Molaren-Inzisiven-Hypominer-
alisation (MIH) in einem schwierigen Umfeld
[MIH therapy under difficult conditions:
special characteristics of MIH teeth].
Quintessenz 2011;62:1593–1599.
7. Borges AB, Caneppele TM, Masterson D,
Maia LC. Is resin infiltration an effective
esthetic treatment for enamel development
defects and white spot lesions? A systematic
review. J Dent 2017;56:11–18.
8. Kumar H, Palamara JE, Burrow MF,
Manton DJ. An investigation into the effect
of a resin infiltrant on the micromechanical
properties of hypomineralised enamel.
Int J Paediatr Dent 2017;27:399–411.
9. Martos J, Gewer A, Paim E. Aesthetic
approach for anterior teeth with enamel
hypoplasia. Contemp Clin Dent 2012;3
(Suppl 1):82–85.
10. Fernandez-Villares C. Solving white
spots with composites. www.styleitaliano.
org. Accessed 20 January 2017.
https://www.styleitaliano.org/macroabrasion-
an-alternative-for-anterior-deep-white-spots/
11. Soares CJ, Borges Fonseca R, Martins
LR, Giannini M. Esthetic rehabilitation of
anterior teeth affected by enamel hypoplasia:
a case report. J Esthet Restor Dent 2002;14:
340–348.
12. Sulieman MA. An overview of tooth-
bleaching techniques: chemistry, safety and
efficacy. Periodontology 2000 2008;48:
148–169.
13. Aytac F, Karaarslan ES, Agaccioglu M,
Tastan E, Buldur M, Kuyucu E. Effects of novel
finishing and polishing systems on surface
roughness and morphology of nanocompos-
ites. J Esthet Restor Dent 2016;28:247–261.
14. Wright T. The etch–bleach–seal tech-
nique for managing stained enamel defects
in young permanent incisors. Pediatr Dent
2002;24:249–252.

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Chiara Baroni Chiara Baroni Alma Mater Researcher, Dental School, Depart-
ment of Biomedical and Neuromotor Sciences, DIBINEM, Universi-
ty of Bologna, Alma Mater Studiorum, Italy.
Annalisa Mazzoni Assistant Professor of Restorative Dentistry,
Restorative Unit, Department of Dental Sciences (DIBINEM), Alma
Mater, University of Bologna, Italy.
Lorenzo Breschi Full Professor of Restorative Dentistry, Restor-
ative Unit, Department of Dental Sciences (DIBINEM), Alma Mater,
University of Bologna, Italy.
Correspondence: Prof Chiara Baroni, Dental School, Department of Biomedical and Neuromotor Sciences, DIBINEM, University of Bologna,
Alma Mater Studiorum, Via San Vitale 59, 40125 Bologna, Italy. Email: chiara.baroni@unibo.it