A 22-year-old female presented with complaints of unpleasant appearance of teeth during smiling and sensitivity in anterior and posterior teeth. Clinical examination revealed hypoplastic defects on the enamel surface of maxillary and mandibular anterior teeth as well as first molars. Differential diagnoses considered were enamel hypoplasia, fluorosis and amelogenesis imperfecta. Enamel hypoplasia was determined to be the most likely diagnosis based on the localized pattern of enamel loss, lack of discoloration and normal tooth size and shape. The treatment plan included nonsurgical therapies like oral hygiene instructions, topical fluoride and direct composite restorations.

2. CASE PRESENTATION
Dr. M.Arsalan Zubair
MDS Trainee (Semester III)
Operative Dentistry Department
Dow Dental College
DUHS

3. PATIENT’S PERSONAL DATA
• Age: 22 years
• Sex: Female
• Address: Clifton Zamazama currently, previously
lived in Bufferzone

4. PRESENTING COMPLAINT
Patient presented with the complaint of unpleasant appearance of her teeth
especially during smiling and also complain of sensitivity on anterior and
posterior teeth. (Sensitivity is more in anterior tooth)
HISTORY OF PRESENTING
COMPLAINT
Patient has this problem since the age of 13 and was not able to give any
history which reveals the cause of such appearance.
Patient deciduous tooth were normal but permanent at the time of eruption
were effected.

5. MEDICAL HISTORY
Suffered from tuberculosis 3yr ago but was treated 9 months
back. Patient was completely treated and claimed that
reports were normal.
FAMILY HISTORY
Father is hypertensive for 15-16 yr
Mother is diabetic for 2 years
DENTAL HISTORY
Restorations:
7 (amalgam class 1)6 (amalgam Class 1)
6(composite Class 1)

6. Patient went to dentist in past with the same
complain but he told her that treatment of
these defects is not possible.
• Patient recently visited dow dental college for
scaling again

10. CLINICAL EXAMINATION
• Teeth present:
• Teeth Missing:
• Hypoplastic Teeth:
8,7,5,4,3,2,1 1,2,3,4,5 6,7
7,6,5,4,3,2,1 1,2,3,4,5,6,7
8
1,2,3
INTRA ORAL EXAMINATION
8
8
1,2,3,66,3,1
6,3,2,1

11. Extraoral examination
• Facial asymmetries:
Not Significant
• Tmj Examination:
Not Significant

12. Periodontal Examination
Pocket Depths
11 0.5 0.5 0.5 0.5 0.5 0.5
12 0.5 0.5 0.5 0.5 0.5 0.5
13 2 0.5 0.5 1 0.5 0.5
14 0.5 0.5 0.5 0.5 0.5 0.5
15 1.5 1.5 2 0.5 0.5 0.5
16 0.5 0.5 0.5 0.5 0.5 0.5
No: F(Mes) Mid Distal P(Mes) Mid Distal
17 0.5 0.5 0.5 0.5 0.5 0.5
18 0.5 0.5 0.5 0.5 0.5 0.5

13. 21 0.5 0.5 0.5 0.5 0.5 0.5
22 0.5 0.5 0.5 0.5 0.5 0.5
23 0.5 0.5 3 2 0.5 2
24 0.5 0.5 0.5 0.5 0.5 0.5
25 0.5 0.5 0.5 0.5 0.5 0.5
26 0.5 0.5 0.5 0.5 0.5 0.5
27 2 0.5 2 0.5 2 0.5

14. 31 0.5 0.5 0.5 0.5 0.5 0.5
32 0.5 0.5 0.5 0.5 0.5 0.5
33 0.5 0.5 0.5 0.5 0.5 0.5
34 0.5 0.5 0.5 0.5 0.5 0.5
35 0.5 0.5 0.5 0.5 0.5 0.5
36 0.5 0.5 0.5 0.5 0.5 0.5
41 0.5 0.5 0.5 0.5 0.5 0.5
42 0.5 0.5 0.5 0.5 0.5 0.5
43 0.5 0.5 0.5 1.5 0.5 0.5
44 0.5 0.5 0.5 0.5 0.5 0.5
45 1.5 0.5 0.5 0.5 0.5 0.5
46 0.5 0.5 0.5 0.5 0.5 0.5
47 0.5 0.5 0.5 0.5 0.5 0.5
37 0.5 0.5 0.5 0.5 0.5 0.5

15. Occlusal Examination
• Group Function on left side
• Group Function on Right side

16. Plaque and Gingival index
A film of plaque adhering to the free gingival margin and
adjacent area of the tooth, which can not be seen with
the naked eye. But only by using disclosing solution or by
using probe
No plaque
Moderate accumulation of deposits within the gingival
pocket, on the gingival margin and/ or adjacent tooth
surface, which can be seen with the naked eye
Abundance of soft matter within the gingival pocket
and/or on the tooth and gingival margin.
No inflammation
Mild inflammation, slight change in color, slight
edema, no bleeding on probing.
Moderate inflammation, moderate glazing, redness,
bleeding on probing
Severe inflammation, marked redness and
hypertrophy, ulceration, tendency to spontaneous
bleeding
0
1.
3
2
1.
3
2
0

17. • On the basis of above criteria the plaque status was
“2” because plaque was observed with the naked eye
and gingival status was given score 1 because mild
inflammation was seen.
• Gingival recession was observed on 43
• No mobility of tooth was observed

18. Clinical findings
• After reviewing the periodontal status it is observed that there
are small pits on the entire surface of maxillary central incisors
along with the canines (on cusp tips and cuspal slopes) and
lateral incisors. But these pits are scattered and are not parallel
to the incisal edges.
• These defects are also seen on the 1st molars of both sides in
maxilla. Molars are morphologically altered, brown lines are
also observed especially on the buccal surface.
• When mandibular dentition is observed , Linear defects are
seen on the lower central incisors , lateral incisors and canines
which are parallel to the incisal edges.

19. • When the inner surfaces of upper and lower arches no defects
are seen
• Clinically there is surface loss of the enamel or pitting of the
enamel surface.
• When mandibular molars are observed, both side 1st molars
are involved with same clinical presentation
• Patient has retained deciduous canine in upper 1st quadrant
with the absence lateral incisor along with the presence of
permanent canine.
• These defects are limited to the enamel only but exposed
dentine due to loss of enamel is sensitive.

20. Investigation

22. Radiographic feature
• Linear radiolucency seen in mandibular anterior teeth from
canine to canine
• It is also seen that in upper first quadrant lateral incisor is
congenitally absent
• Multiple circular radiolucency is seen in both the central
incisors and upper left lateral incisor and canine
• Small radiolucencies are present especially in enamel regions
of left upper and lower 1st molars denoting malformation of
enamel

24. • It is also seen that permanent canine has taken place of
permanent lateral incisor because roots are longer and fully
formed along with retention of deciduous canine.
• Impacted 3rd molars.

25. DIFFERENTIAL DIAGNOSIS
• Enamel Hypoplasia
• Molar incisor hypomineralization
•
• Amelogenesis Imperfecta
• Flurosis
• Early decalcification due to caries

26. Comparison
Enamel Hypoplasia
• Enamel hypoplasia stain
relatively clear, and are
parallel to the ridge line
enamel.
• Enamel hypoplasia can
occur in a single tooth or a
set of teeth
Dental Fluorosis
• Dental fluorosis as a long-
term damage, so the
patches were scattered in a
cloudy pattern, and not in a
well defined pattern
• Dental fluorosis occurs in
most teeth, particularly in
the maxillary anterior teeth
.
J Clin Exp Dent. 2009. Dental fluorosis: Exposure, prevention and
management

27. • Tooth Colour generalized Yellow
• Tooth size Small
• Tooth Shape is also changed
• Enamel leads to attrition which
leads to loss of enamel
• Generalized enamel loss
• All the teeth are involved
Comparison B/w Enamel Hypoplasia
and Amelogenesis Imperfecta (clinical)
• Tooth Colour is normal
• Tooth size is normal
• Tooth Shape is normal
• No sign of attrition
• Localized enamel loss
• Involving Incisor canine and
molars

28. • Dark brown bands on gingival part of
crown
• No Such thing can be noticed
• No Such thing can be noticed
• No complain of sensitivity
• Low risk of caries
• Not Specific can be generalized or
localized
• There is no enamel loss
Comparison B/w Enamel hypoplasia
and Fluorosis (clinical)
• No dark brown stains are seen
• Enamel pitting is seen
• Enamel defects are parallel to the
Incisal edge
• Patient complains of sensitivity
• High risk of caries
• Involving Incisor canine and molars
• There is enamel loss

29. Evidences for ruling out Amelogenesis
Imperfecta and Fluorosis and making a
Diagnosis that this condition is Enamel
Hypoplasia

30. Enamel Hypoplasia
• What is Enamel
Hypoplasia?
• What are it’s causes?
• What are it’s types?
• How is it classified
according to pattern?
• How is it classified
according to severity?

31. Causes
• Exposure to dioxine by prolonged
breast-feeding
• Nutritional deficiency [vitamin A,C,D]
• Exanthematous diseases
• [eg: measles, chicken pox, scarlet
fever]
• Congenital syphilis
• Hypocalcemia
• Birth injury, prematurity, Rh hemolytic
disease
• Local infection or trauma
• Ingestion of chemicals
• Idiopathic causes
• Antibiotic used during pregnancy
(Tetracycline)
EUROPEAN JOURNAL OF PAEDIATRIC
DENTISTRY • 3/2003
Types
• Hereditary
• Environmental

32. Severity of hypoplasia was recorded according to Schultz
(1988):
• 1st degree: mild
• 2nd degree :moderate
• 3rd degree :severe
Pattern of Enamel Hypoplasia
• Linear
• Circular
Variability and Evolution, 2001, Vol. 9: 7587

33. MILD HEREDITARY TYPE WITH MIXED PATTERN
(CIRCULAR AND LINEAR BOTH)
ETIOLOGY CAN BE CONTRIBUTED TO
PRE-NATAL USE OF ANTIBIOTICS (TETRACYCLINES)
DIAGNOSIS (CONTINUED)

34. TREATMENT PLAN (initial)
• Oral hygiene instructions
• Diet modification
• Fluoridated tooth paste and mouth wash
• Topical fluoride application

35. • Ultrasonic Scaling
•
• Direct composite restoration of :
1,2,33,2,1
3,2,1 1,2,3

36. Treatment options
• Bleaching
• Microabrasion
• Composite resin
• Porcelain Veneers
• Zirconia crown

37. Bleaching and microabrasion
• Ashkinazi et al. demonstrated the use of microabrasion technique in
patients with enamel hypoplasia. At four-year follow up they showed
that the improvements in aesthetics were maintained.
BRITISH DENTAL JOURNAL VOLUME 215 NO. 9 NOV 9 2013
• Enamel which is easily penetrated with an explorer is not a good
candidate for microabrasion. Superficial brown and white
discolorations on hypomaturated enamel can be easily removed by
microabrasion.
Braz J Oral Sci. January-March 2006 - Vol. 5 - Number 16
• When the enamel is intact but discolored, bleaching and/or
microabrasion may be used to enhance the appearance
• Clinical guidelines – AMERICAN ACADEMY OF PEDIATRIC DENTISTRY 2013

38. Composite resin
• Despite the lack of good evidence, due to its reversible and
minimally invasive nature, rehabilitation with composite
resins should be considered as the first line of treatment.
BRITISH DENTAL JOURNAL VOLUME 215 NO. 9 NOV 9 2013
• Indirect resin composite restorations have shown promising
success rates. One study showed a 93% success rate of
indirect composite restorations on premolars and molars over
a three-year period
BRITISH DENTAL JOURNAL VOLUME 215 NO. 9 NOV 9 2013

39. Porcelain Veneers
• When restoring teeth affected by MIH with either composite
or porcelain veneers, some of the underlying tooth structure
may be relatively dark and the translucent nature of these
restorations is often unable to adequately mask the
discolouration. This can result in poor aesthetics of the
restored teeth.
BRITISH DENTAL JOURNAL VOLUME 215 NO. 9 NOV 9 2013

40. Full coverage restorations
• Some authors have been described the use of all-ceramic
crowns as a possible restorative approach particularly in the
hypoplastic form - chipping is reported to be a major
complication associated with the use of all-ceramic materials,
especially zirconia
The Journal of Contemporary Dental Practice, March-April
2013;14(2):320-326

41. • Porcelain fused to metal crown for posterior teeth and all
ceramic crowns for anterior teeth.
The Journal of Contemporary Dental Pracitice, Volume 8, No.4, May 1,2007
• If the enamel or dentin cannot be bonded, full coverage
restorations will be required
Clinical guidelines – AMERICAN ACADEMY OF PEDIATRIC DENTISTRY 2013

42. Final treatment plan was done
according to severity
Mild hypoplasia can be treated by direct composite
restoration.
1. In the First step, the composite shade selection is done
which is A1 Enamel.
2. In the 2nd step little preparation is done of all the defects
with round bur creating a bevel in the defects.
3. Adequate isolation is needed so rubber dam is placed,
quadrant isolation is done from 1st premolar to 1st
premolar of both the arches
4. Then the basic steps of restorations is followed
5. Then rubber dam is removed
6. Then finishing of the composite is done

43. Quadrant isolation is done from 1st
premolar to 1st premolar

44. Composite Restoration placed but not
finished

45. Rubber dam removed and After
finishing

46. Before After

47. Thank you