molar incisor hypomineralisation

MOLAR INCISOR HYPOMINERALIZATION
(MIH)
Presented by :
Shilpa
Post graduate student
Dept. of pedodontics and
Preventive dentistry
Under the guidance of :
Dr. Nirapjeet Kaur
Head of Department

OUTLINE
 Introduction
 Epidemiology
 Etiology
 Diagnosis
 Differential diagnosis
 Treatment
 Conclusion

Introduction
 MIH is defined as a clinical appearnce of enamel
hypomineralization of systemic origin affecting one or more
permanent first molars(PFMs) that are associated frequently with
affected incisors(Weerheijm2001)
 Molar incisor hypomineralisation (MIH) is defined as the
developmentally derived dental defect that involves
hypomineralisation of 1 to 4 first permanent molars (FPM) and
frequently associated with similarly affected permanent incisors
(Weerheijm 2003)

 MIH was reported in the past as:
 Hypomineralized permanent first molars(PFMs)
 Idiopathic enamel hypomineralization
 Dysmineralized PFMs
 Nonfluoride hypomineralization
 cheese molars
 This condition was termed MIH in the European
academy of paediatric dentistry 2000.

Epidemiology
Pentapati KC, Yeturu SK, Siddiq H, Systematic review and meta-analysis of the
prevalence of molar-incisor hypomineralization. J Int Oral Health 2017;9:243-50.
SEARCH RESULTS - out of 853 publications 61 studies were included in the final meta analysis
Prevalence
The prevalence of MIH ranged from 0.48% to 40%. In the majority of the studies, prevalence ranged from
8% to 20%.
Gender variation
Five studies have reported that girls have a significant higher predilection for MIH than boys while 41
studies. The girl to boy ratio among the 37 studies ranged from 0.72 to 3.99. In more than half of these
studies, girls had a higher prevalence than boys.
Age variation
The age ranged from 6 to 17 years among the included studies.

•Geographical variation
•Lower prevalence in Asian countries when compared with European and South
American countries.
•No study was reported from North American countries.
•
•The highest prevalence estimate was from Brazilian middle social class school children
whereas the lowest prevalence estimate was of Indian urban school children.
Overall, it was concluded that the prevalence of MIH was 11.24% with a high degree of
geographic variation and mild variation with respect to gender.
M. E. C. Elfrink, A. Ghanim, D. J. Manton, K. L. Weerheijm,2015,Standardised studies on Molar Incisor
Hypomineralisation (MIH) (2.9-44%)and Hypomineralised Second Primary Molars (HSPM)(0- 21.8%): a
need, Eur Arch Paediatr Dent DOI 10.1007/s40368-015-0179-7

Garot, E.,2018,’ Are hypomineralised lesions on second primary molars
(HSPM) a predictive sign of molar incisor hypomineralisation (MIH)? A
systematic review and a meta-analysis Journal of Dentistry,
https://doi.org/10.1016/j.jdent.2018.03.005

Mishra A, Pandey RK. Molar Incisor Hypomineralization: An Epidemiological Study with Prevalence
and Etiological Factors in Indian Pediatric Population. Int J Clin Pediatr Dent 2016;9(2):167-171.
Aims: To determine the prevalence of molar incisor hypomineralization (MIH) in Indian children
and to analyze the possible etiological factors.
Materials and methods: First permanent molars and all permanent incisors were examined in
1,369 children aged 8 to 12 years. Examinations were performed by two calibrated observers.
The subjects were evaluated using judgment criteria proposed by Weerheijm et al in 2003. The
parents accompanying children were given a questionnaire regarding pre- and postnatal history
of the children.
Results: A total of 191 children were diagnosed with MIH with a prevalence of 13.9%. There was
a significant relation between risk of clinical infections, such as chicken pox, jaundice, renal
disorders, cardiac disorders, and affected molars with sex and type of delivery. Pre- and
postnatal history of infection in a child was significantly correlated with the prevalence of MIH.
Conclusion: The prevalence of MIH was 13.9% in the age group of 8 to 12 years. Prenatal and
postnatal infections play an important role in hypomineralization of molars and incisors.

N. P. Mittal, A. Goyal ,K. Gauba ,,A. Kapur, 2013, ‘ Molar incisor hypomineralisation: prevalence and clinical
presentation in school children of the northern region of India’ , Eur Arch Paediatr Dent
DOI 10.1007/s40368-013-0045-4
Aim - To report on prevalence and defect characteristics of MIH for school children of the northern
Indian region.
Methods - A cross-sectional survey including 1,792, 6–9 year-old school children of Chandigarh,
India was carried out using European Academy of Paediatric Dentistry (EAPD) 2003 criteria for
diagnosis of MIH. In addition to descriptive analysis for distribution of various defects, comparative
data analysis was carried out for inter-comparison of distribution and type of defect amongst two
phenotypes, MH [first permanent molar (FPMs) involvement] and M + IH (simultaneous involvement
of molars and incisors). Similar comparative analysis was performed for four subgroups on the basis
of number of affected surfaces/subjects.
Conclusion - MIH occurs in Indian children aged 6–9 years old at a prevalence rate of 6.31 %. Boys
and girls are affected similarly. Molars are involved more commonly than incisors. White/creamy
opacities without PEB were the most prevalent lesions. Restorative treatment needs were seen in
2.85 % (45.13 % of affected subjects). Concomitant involvement of incisors resulted in more severe
presentation of defects in molars. Subjects with a greater number of affected surfaces had more
severe lesions with a greater extent of lesions.

Bhaskar and Hegde, et al.: Molar-incisor hypomineralization in a young Indian population
Journal of Indian Society of Pedodontics and Preventive Dentistry | Oct-Dec 2014 | Vol 32| Issue 4
Objective: To assess the prevalence, clinical characteristics, distribution, severity and association with caries
of MIH defects in children aged 8-13 years of Udaipur, Rajasthan.
Study design: This cross-sectional descriptive study consisted of 1173 children aged 8-13 years selected by
random sampling procedure. The European Academy of Pediatric Dentistry criteria were followed for MIH
diagnosis. The presence of dental caries and treatment need for MIH-affected teeth were recorded as per
the WHO criteria.
Results: The prevalence of MIH in the children examined was 9.46%. Severity of the defects increased with
the age of the children. Involvement of incisors increased when more First permanent molars (FPMs) were
affected. An average of 3.65 teeth was involved per MIH-affected individual. Significantly larger numbers of
mandibular FPMs and maxillary central incisors were diagnosed with MIH. The association of dental caries
was significantly higher with MIH-affected FPMs. Primary molars and permanent canines and premolars
were also showed MIH like lesions in some of the MIH-affected children.
Conclusion: MIH was observed in about 10% of the children examined. MIH-affected FPMs appear to be
more vulnerable to early caries and subsequent pulp involvement with need for extensive dental treatment.

Aetiology
Parentally risks:
infection,
maternal
psychological
stress and
frequent exposure
to ultrasonic scans
Oxygen shortage
combined with low
birth weight
suspected to be
contributing factor
Multifactorial
Children
born with
poor general
health
Respiratory
diseases and
oxygen shortage of
the ameloblasts
Children with
systemic
conditions in
their first 3
years
Complication
during delivery

 Various causes of MIH have been implicated:
 Systemic condition (Nutritional deficiencies, brain injury and neurologic defects, cystic
fibrosis, syndromes of epilepsy and dementia , nephrotic syndrome, atopia, lead
poisoning, repaired cleft lip and palate, radiation treatment, rubella embryopathy,
epidermolysis bullosa, ophthalmic conditions, celiac disease, and gastrointestinal
disorders)
 Pre term birth defects (associated with respiratory difficulties, hyperbilirubinaemia,
metabolic disturbances including hypocalcemia and hypoglycemia, haematological
disorders, patent ductus arteriosus, and intracranial hemorrhage.)

 Respiratory tract infections
 Perinatal complications
 Oxygen starvation and low birth weight
 Calcium and phosphate metabolic disorders
 Childhood diseases
 Antibiotics
 Prolonged breast feeding
 the aetiology of MIH still remains unclear
Silva MJ, Scurrah KJ, Craig JM, Manton DJ, Kilpatrick N. Etiology of molar incisor hypomineralization – A
systematic review. Community Dent Oral Epidemiol 2016; 44: 342–353
It was concluded that a limited number of studies reported significant associations between MIH and pre-
and perinatal factors such as maternal illness and medication use in pregnancy, prematurity and birth
complications. Early childhood illness was implicated as an etiological factor in MIH in several studies, in
particular fever, asthma and pneumonia.

Diagnosis
 Weerheijm et al. 2003 developed diagnostic criteria
for MIH:
 Demarcated opacities
 Posteruption breakdown (PEB)
 Atypical restorations
 Extracted PFMs due to MIH
 Diagnosis is best done at 8yrs of age and done on
a wet tooth.

 Based on the diagnostic criteria, severity of MIH is
classified into:
 Mild
 Moderate
 severe

 Mild MIH
 Demarcated opacities are in nonstress-bearing areas of the
molar
 No enamel loss from fracturing is present in opaque areas
 Occasional sensitivity to external stimuli e.g. air/water but
not brushing
 There are no caries associated with the affected enamel
 Incisor involvement is usually mild if present

 Moderate MIH
 Atypical restorations can be present
 Demarcated opacities are present on occlusal/incisal third
of teeth without posteruptive enamel breakdown
 Posteruptive enamel breakdown/caries are limited to 1 or 2
surfaces without cuspal involvement.
 There is sensitivity to external stimuli

 Severe MIH
 Posteruptive enamel breakdown is present
 Persistent/spontaneous hypersensitivity affecting function.
 Caries is associated with the affected enamel
 Crown destruction can advance to pulpal involvement
 Defective atypical restoration
 Aesthetic concerns are expressed by the patient or parent

Mild MIH Moderate MIH Severe MIH
•Opacities in non
stress bearing areas
•No caries in affected
enamel
•No hypersensitivity
•Incisor involvement is
usually mild if present
•Demarcated opacities
are present on molars
and incisors
•Post eruptive enamel
breakdown limited to 1
or 2 surfaces without
cuspal involvement
• Normal dental
sensitivity
•Post eruptive enamel
breakdown
•History of dental
sensitivity
•Crown destruction
•Aesthetic concerns

Differential diagnosis
 ENAMEL HYPOPLASIA
 Enamel hypoplasia (EH) is a quantitative defect associated with a reduced localized
thickness of enamel, following disruption of the secretory phase of amelogenesis. The
enamel may be translucent or opaque, with single or multiple pits or grooves and
partial or complete absence of enamel over significant areas of dentin.
 The EH defects tend to occur in the incisal or cuspal one third of the crown.
 Diagnostically, MIH and EH can be difficult to differentiate when affected molars have
PEB due to caries or masticatory trauma. In a child with a high caries rate, MIH can be
masked by extensive caries or restorations. Also, EH and MIH can occur together,
particularly at a histological level
 In hypoplasia, the borders of the deficient enamel are smooth, while in posteruptive
enamel breakdown the borders to normal enamel are irregular

 AMELOGENESIS IMPERFECTA
 Positive family history
 Choosing between amelogenesis imperfecta (AI) and MIH, only in very severe MIH
cases, the molars are equally affected and mimic the appearance of AI
 In MIH, the appearance of the defects will be more asymmetrical
 In AI, the molars may also appear taurodont on radiograph
 Generalized and can be detected preeruptively on radiograph
 FLUOROSIS
 It can be differentiated from fluorosis as its opacities are demarcated, unlike the
diffuse opacities that are typical of fluorosis
 Fluorosis is caries resistant and MIH is caries prone
 Fluorosis can be related to a period in which the fluoride intake was too high

Treatment
 MIH’s clinical management is challenging due to:
 The sensitivity and rapid development of dental caries
in affected PFMs.
 The limited cooperation of a young child.
 The difficulty in achieving anesthesia
 The repeated marginal breakdown of restorations.

 Six step management approach by William et al. 2006
 Risk identification.
 Early diagnosis.
 Remineralization and desensitization.
 Prevention of caries and posteruption breakdown.
 Restorations and extractions.
 Maintenance.

Risk identification, remineralization, and
preventive management
 Identify children at risk by relevant history of putative
aetiological factors in the first 3 years and from
careful study of the unerupted molar on radiographs
 Dietary assessment and necessary modification during
PFMs eruption.
 Commencement of Oral hygiene include in
it, a desensitizing toothpaste

 When the surface of the PFM is accessible,
remineralization therapy should commence.
 Remineralization and desensitization may be accomplished
with casein phosphopeptide-amorphous calcium phosphate
(CPP-ACP) oral care products. E.g. tooth mousse
 These products enhance remineralization by creating a
state of supersaturation followed by deposition of
calcium and phosphate ions at the enamel surface.

 Use of topical fluoride
 Fluoride varnish - Topical fluoride, delivered as concentrated
varnishes or gels, can remineralize enamel, reduce
sensitivity, and enhance resistance to demineralization by
providing a reservoir of fluoride ions for redeposition as
fluoroapatite during remineralization.
 Application of Fluoride gels several times in a week by the
parent.

 Use of fissure sealant.
 For partially erupted PFMs where moisture control is suboptimal,
glass ionomer cement (GIC)sealants can provide caries protection and
reduce surface permeability.
 Retention is poor and such sealants may need rebuilding later with a
resin-based sealant when optimal moisture control is possible.
 Without preventive care, hypomineralized PFMs are at risk of post
eruptive breakdown (PEB) in the acidic and masticatory challenges of
the oral cavity. When PEB occurs, the porous subsurface enamel or
dentin is exposed, resulting in teeth sensitive to cold air, warm water,
and tooth-brushing. Poor oral hygiene favors plaque retention and
promotes rapid caries development.

Restoration of hypomineralized PFMS
 Restoring affected PFMs is complicated frequently by:
 Difficulties in achieving anesthesia - The porous exposed
subsurface enamel or dentin may promote chronic
inflammation of the pulp, complicating anaesthesia. The
adjunctive use of nitrous oxide-oxygen analgesia may alleviate
anxiety and reduce dental pain, or general anesthesia may be
required for restorative treatment.
 Managing the child’s behavior

 Determining how much affected enamel to remove
 In determining cavity margin placement, 2 approaches are described:
1. All defective enamel is removed.
2. Only the very porous enamel is removed, until good resistance of the bur to
enamel is felt.
The former approach may avoid premature restoration failure, but sacrifices
tooth structure; the latter approach is conservative, but places restorations at
risk of marginal breakdown.
Removal of all defective enamel is recommended when bonding resin
composite restorations to hypomineralized PFMs due to the poor bond strength
of resin adhesives to hypomineralized enamel.

 Selecting a suitable restorative material
The choice of materials will depend on the defect severity and the age
and cooperation of the child.
Restorative options include glass ionomer cements (GIC), resin-
modified glass ionomer cements (RMGIC), polyacid modified resin
composites (PMRC), resin composites (RC), amalgam, stainless steel
crowns (SSCs), and indirect adhesive or cast onlays or crowns.
 Amalgam is the least durable due to:
1. poor retention in shallow cavity preparations; and
2. the inability to protect remaining tooth structure, which is likely to result
in restoration failure

Adhesive materials are usually chosen due to the atypical cavity outlines
following removal of hypomineralized enamel.
GIC provides: (1) placement ease; (2) fluoride release; and (3) chemical
bonding, for dentin replacement or as an interim restoration,
RMGICs offer similar advantages to GIC; the incorporation of resin and
photoinitiators improves: (1) handling; (2) wear resistance; (3) fracture
toughness; and (4) fracture resistance.
Restorations of GIC or RMGIC are not recommended in stress-bearing
areas, such as occlusal surfaces of hypomineralized molars, but may suffice
until a definitive restoration is achievable.

RESIN COMPOSITES - With physical properties superior to GIC and
RMGIC, the RCs are esthetic materials with high wear resistance and
adhesion when used with resin-based adhesives; they can be used solely
or in a sandwich technique following previous temporization with GIC.
RCs are technique sensitive, however, requiring good moisture control
under rubber dam and long placement time.
The RCs are materials of choice in MIH where defective enamel is well
demarcated and confined to 1 or 2 surfaces with supragingival margins
and without cuspal involvement

POLYACID MODIFIED RESIN COMPOSITE (PMRCS):
1. have good handling characteristics;
2. release and take up fluoride; and
3. have tensile and flexural strength properties superior to GIC and RMGIC, but
inferior to that of RC.
The use of PMRCs in permanent teeth is restricted to nonstress-bearing areas
with limited application in hypomineralized PFMs.

If not adapted properly, SSCs may produce an open bite, gingivitis,
or both. Properly placed, SSCs can preserve PFMs with MIH until
cast restorations are feasible.
Partial and full coverage indirect adhesive or cast crowns and
onlays may be considered for MIH in the late mixed and permanent
dentitions.
Such restorations are rarely indicated for PFMs in young children
due to placement difficulties associated with:
(1) short crowns
(2) large pulps
(3) long treatment time and high cost
(4) the child’s limited cooperation.

The decision to restore hypomineralized PFMs with either cast
adhesive copings or preformed SSCs is based on:
1. the patient’s immediate and long-term needs;
2. their cooperation;
3. treatment cost; and
4. the clinician’s skills and material choices.

Factors affecting molar prognosis that need to be assessed when
considering molar extraction are:
Vitality and restorability,
Dental age,
Buccal segment crowding,
Occlusal relationships
The condition of other erupted and unerupted teeth

Restoration of the hypomineralized permanent incisors
 Hypomineralized incisors in MIH may present esthetic concerns to
children and their parents.
 Microabrasion can be an effective treatment in shallow defects.
 A conservative approach in managing yellow-brown
hypomineralized enamel involves:
 etching the lesion with 37% phosphoric acid;
 bleaching with 5% sodium hypochlorite; and then
 re-etching the enamel prior to placing a sealant over the surface
to occlude porosities and prevent restaining
 Enamel reduction combined with opaque resins.
 Porcelain veneer are delayed until late adolescence because of
continued eruption exposing the margin.

•Aim - The objective of this investigation was to evaluate the clinical performance of composite restorations in enamel
hypomineralised posterior teeth.
•Methods - 52 composite restorations were placed in 52 permanent molars of 46 children, aged 8-10 years. All the teeth
were clinically diagnosed as hypomineralised and restorations were placed on two or more surfaces of the teeth,
including cusps. All treated teeth had at least 2 sound surfaces, thus excluding defective teeth with total disruption of
the crown. The materials used were a hybrid composite and a fourth generation one bottle adhesive material and
manufacturer's instructions were carefully followed. The restorations were initially evaluated 7 days after the treatment
and subsequent evaluation was performed at 12, 24, 36, 48 months. Clinical evaluation of the restorations was made
according to the criteria of Ryge [1980].
•Results - In 6 cases, postoperative complaint was relieved after occlusal readjustment at the second appointment, 7
days later. At the end of the 48 months study period, 49 restorations were available for evaluation, all with full retention.
Radiographically there was no periapical pathology. Problems were found in colour match in 10, surface appearance in 3
and anatomic form in 4 restorations. Hypersensitivity was recorded in 17 teeth after one week and in 3 teeth one year
later. All teeth were sensitivity free after two years and until the end of the study period.
•Conclusions - Composite resin restorations using contemporary materials, in certain cases of hypomineralised
permanent molars, can be an acceptable restorative procedure with satisfactory longterm
N.A. Lygidakis, A. Chaliasou, G. Siounas, 2003, ‘Evaluation of composite restorations in hypomineralised
permanent molars: a four year clinical study’ European Journal of Paediatric Dentistry Volume 4
Number 3 September

The purpose of this study was to evaluate the 12-month clinical performance of glass ionomer restorations in teeth with
MIH.
First permanent molars affected by MIH (48) were restored with glass ionomer cement (GIC) and evaluated at baseline,
at 6 and at 12 months, by assessing tooth enamel breakdown, GIC breakdown and caries lesion associations.
The likelihood of a restored tooth remaining unchanged at the end of 12 months was 78%.
No statistically significant difference was observed in the association between increased MIH severity and caries at
baseline for a 6-month period,
The likelihood of maintaining the tooth structures with GIC restorations is high, invasive treatment should be postponed
until the child is sufficiently mature to cooperate with the treatment, mainly of teeth affected on just one face.
Fragelli et al, 2015,’Molar incisor hypomineralization (MIH): conservative treatment management to
restore affected teeth’ Braz Oral Res [online]. 2015;29(1):1-7

Conclusion
MIH is an enamel defect with multifactorial etiology which require early identification of
the affected population so that monitoring of their PFMs can be done by instituting
remineralization and preventive measures as soon as affected surfaces are accessible.
The complex care involved must address the child’s behaviour and anxiety, aiming to
provide durable restorations under pain-free conditions.
Restoration of surfaces with limited involvement with resin composite is recommended
following:
1. removal of all discolored hypomineralized enamel;
2. placement of cavity margins on apparently normal enamel; and
3. bonding with a self-etching primer adhesive.
Extensively affected molars may require extracoronal restorations or extraction.

molar incisor hypomineralisation

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