Professional Documents
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History
Complaint
The child complains of pain from his back teeth on both
sides. The pain is worse with sweet foods and cold liquids
and persists for several minutes after stimuli. Toothbrushing with cold water is also painful but the teeth do not cause
pain on biting.
History of complaint
The pain has been present for a few months and has
increased in severity over the last month. The child now
reports that one of his back teeth feels broken. The first
permanent molars erupted on time and his mother noticed
that some of them appeared to crumble as soon as they
emerged through the gum. She has read in magazines that
fluoride can damage teeth and has switched to a toothpaste
without fluoride on the assumption that this is the cause.
Medical history
The patient is a healthy child, the only history of note being
neonatal jaundice.
Dental history
The child has no experience of operative dental care. A diet
history reveals a reasonably well-balanced diet, with limited
consumption of refined carbohydrates and carbonated
beverages. Toothbrushing has been performed with adultformula fluoride-containing toothpaste, starting at approximately 1 year and continuing until 7 years of age.
Examination
Extraoral examination
The child has no facial swelling or asymmetry and no lymph
nodes are palpable.
Intraoral examination
He is in the early mixed dentition stage. All four first permanent molars have areas of brown, rough, irregular
enamel. The severity varies between the teeth and the worst
affected are the maxillary molars whose enamel appears to
be completely absent in some areas. These teeth have soft
dentine exposed occlusally. The lower right first permanent
molar is the least severely affected with only a small localized brown enamel defect on the buccal aspect. This is hard
on probing. In addition, there are areas of white enamel
opacity in the incisal third of the labial surface of all permanent central and lateral incisors, which are most pronounced
in the maxillary central incisors. The remaining primary
dentition is caries free, and appears normal in structure and
morphology. Oral hygiene appears good. The appearances
of the dentition are shown in Figures 56.1 and 56.2.
CASE
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Rapid b r e a k d o wn o f f i r s t p e r m an e n t m o la r s
extrinsic stains. The molars are so severely affected that
diagnosis is difficult, but the opaque white zones on the
central incisors are characteristic of enamel hypoplasia.
Hypoplasia is the result of reduced ameloblast numbers or
activity. Enamel is missing so that the surface contour is
abnormal. A hypomineralized enamel usually has normal
contour initially but is softer than normal and may be worn
away.
Differential diagnosis
What is the likely cause of the childs pain?
The hot and cold sensitivity is characteristic of pain mediated
by a vital pulp. It could be a result of caries in the dentine or
exposed occlusal dentine. Molarincisor hypoplasia is
frequently associated with pain and sensitivity.
hypoplasia?
Years
6
4
2
Birth
Central
incisor
Lateral
incisor
Canine
1st
premolar
2nd
premolar
1st
molar
2nd
molar
Rapid b r e a k d o wn o f f i r s t p e r m an e n t m o la r s
56
Investigations
What investigations are indicated and why?
Intraoral radiographs are indicated to assess the proximity of
the coronal defects to the dental pulp. A panoramic
tomograph is indicated, to ascertain the presence and stage
of development of the remaining permanent dentition, in
view of the possibly poor long-term prognosis of some of the
first permanent molars. The panoramic tomograph is shown
in Figure 56.4.
Diagnosis
What is your diagnosis?
The patient has enamel hypoplasia that does not follow a
completely chronological pattern, and in the absence of a
known insult to account for the defects, idiopathic molar
incisor hypoplasia/hypomineralization is the most appropriate
working diagnosis. The diagnosis may need to be reviewed if
evidence of early illness can be obtained from the general
medical practitioner or if more teeth erupt with similar defects.
The diagnosis is sufficiently accurate to embark on treatment.
Treatment
What treatment options are available for the molars?
The appropriate treatment for grossly hypoplastic first
permanent molar teeth is extraction, particularly when, as
here, caries is also present. Preservation of these molars
through adulthood would require provision of full-coverage
crowns. These have a finite lifespan and their intermittent
replacement, the risks of undetected leakage, caries and
pulpal involvement, localized periodontitis and the expense
and inconvenience would amount to significant morbidity in
the lifetime of the patient.
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CASE
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Table 56.1 Factors in the timing of extractions
Factor
Reason
Second permanent molars are most likely to erupt passively into a favourable position when there is radiographic evidence of calcification of a small
crescent of interradicular dentine (mineralizing of the furcation). This is the ideal time to extract the first molar and is generally between 8 12 and
10 12 years of age.
This must be assessed radiographically. Hard tissue formation should be visible at age 910 years. The crypt may be visible as early as 7 years.
Orthodontic analysis
A complete assessment must be made. The space gained might be utilized for active orthodontic treatment. Extraction of first permanent molars is
rarely ideal for orthodontic purposes and treatment may be complex. If no third molars are present, the need for orthodontic treatment may be critical
in deciding whether or not to extract the first molars.
Advantages
Disadvantages
Composite veneers
Enamel microabrasion
Irreversible, weakens tooth structure and large areas of dentine may be uncovered.
Colour change and marginal discolouration with time.
Porcelain veneers
Good appearance
Contraindicated in this age group as gingival contour not mature and stable tooth
position not yet established.
Good appearance
Inappropriate until late second decade because immature pulp horns may be exposed.
Gingival contour not mature and stable tooth position not yet established.