MIH Molar Incisor Hypomineralization

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MIH Molar Incisor Hypomineralization

• Sanjeev Sood
• Lecturer in Paediatric Dentistry
• BDS MFDS RCSEd M.Dent.Ch (Paediatric Dentistry)

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MIH

• Introduction
• Clinical Presentation
• Prevalence
• Aetiology
• Treatment

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MIH

• Molar-Incisor hypomineralization is defined as a
  hypomineralization of systemic origin that
  affects one to all of the first permanent molars
  and is often associated with affected permanent
  incisors (Weerheijm et al., 2001)

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MIH

• MIH molars can create serious problems for the
  dentist as well as for the child affected

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MIH

• Dentists
• rapid caries development
• inability to anaesthetize the MIH molar
• unpredictable behaviour of apparently intact
  opacities
• restoration difficulties

• Child
• experience pain and sensitivity (even when the
  enamel is intact)
• Pain during brushing
• appearance of their incisor teeth

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Clinical Features

• Primary teeth are not affected
• one, two, three or four permanent first molars
  affected
• white/yellow/brown opacities
• well demarcated compared to normal enamel

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Clinical Features

• usually presents on the buccal or occlusal
  surfaces of the molars and incisors
• asymmetrical defects
• the risk of defects to the incisors appears to
  increase when more first permanent molars have
  been affected

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Clinical Features

• the affected molars are sensitive to cold and
  appear to be more difficult to anaesthetise
• the lesions on the incisors are usually not as
  extensive as those in the molars and present
  mainly a cosmetic problem
• the remaining permanent dentition is usually not
  affected

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Diagnosis

• It is important to diagnose MIH, delineating it
  from other developmental disturbances of enamel

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Diagnosis

• Diagnostic criteria to establish the presence of
  MIH include
• the presence of a demarcated opacity (defect
  altering the translucency of the enamel)
• posteruptive enamel breakdown (loss of surface
  enamel after tooth eruption, usually associated
  with a pre-existing opacity)
• atypical restorations (frequently extend to the
  buccal or palatal smooth surfaces reflecting the
  distribution of hypoplastic enamel)

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Diagnosis

• Mild MIH
• Demarcated opacities are in nonstress-bearing
  areas of the molar
• No enamel loss from fracturing is present in
  opaque areas
• There is no history of dental hypersensitivity
• There are no caries associated with the affected
  enamel
• Incisor involvement is usually mild if present

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Diagnosis

• 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
• Dental sensitivity is generally reported as normal

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Diagnosis

• Severe MIH
• Posteruptive enamel breakdown is present
• There is a history of dental sensitivity
• 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

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Differential diagnosis

• MIH can sometimes be confused with fluorosis or
  amelogenesis imperfecta

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Differential diagnosis

• 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

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Differential diagnosis

• 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
• There is often a family history

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Prevalence

• The prevalence figures range from 3.625 and
  seem to differ between countries
• The number of hypomineralized first permanent
  molars in an individual can vary from one to four
  
• The frequency of MIH molars was not evenly
  divided among children

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Aetiology

• Amelogenesis is a highly regulated process
• The asymmetrical occurrence of MIH suggests that
  the ameloblasts are affected at a very specific
  stage in their development
• Children with poor health during the first 3
  years of life are more likely to be at increased
  risk for MIH

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Aetiology

• Ameloblast cells are irreversibly damaged
• Clinically these appear as yellow or yellow/brown
  opacities
• These opacities are more porous

• Ameloblasts have the potential to recover after
  the disturbance
• These defects appear creamy yellow or whitish
  cream demarcated opacities

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Aetiology

• Various causes of MIH have been implicated
• Environmental conditions
• Respiratory tract infections
• Perinatal complications
• Dioxins
• Oxygen starvation and low birth weight
• Calcium and phosphate metabolic disorders
• Childhood diseases
• Antibiotics
• Prolonged breast feeding
• the aetiology of MIH still remains unclear

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Restoration

• Children with MIH may have extensive treatment
  needs
• By the age of nine, children with MIH were
  treated ten times as often as children without
  such molars
• MIH children display more dental fear and anxiety
  
• Children with MIH exhibited greater DMFS and dmfs

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Restoration

• MIH molars are fragile, and caries may develop
  easily in these molars
• This is aggravated because children tend to avoid
  the sensitive molars when brushing
• In order to minimize the loss of enamel and any
  damage due to caries, both preventive and
  interceptive treatment is required

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Restoration

• Besides normal brushing and education, prevention
  also includes fluoride varnish application and
  application of glass ionomer sealants
• Sometimes the sensitivity of the teeth is
  decreased by these applications
• In some cases of hypersensitivity the use of
  casein phosphopetide-amorphous calcium phosphate
  (CC-ACP) (Tooth Mousse) products have been
  advised as they remineralize and desensitize the
  tooth

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Extraction

• Extraction combined with orthodontic treatment,
  should be considered as an alternative treatment,
  especially if the molars have a poor longterm
  prospect.
• The optimal time for extraction is indicated by
  the calcification of the bifurcation of the roots
  of the lower second permanent molar

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Short-Term Treatment

• The immediate treatment planning needs of young
  children with MIH must reflect
• Behavioural
• Preventive
• growth and development
• restorative requirements
• The objective is to
• maintain function
• preserve tooth structure
• plan for any required orthodontic care

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Partially Erupted Molars

• Prone to caries development and highly sensitive
• Applying desensitizing agent in combination with
  fluoride varnish applications could be of some
  help in decreasing sensitivity
• GI to cover the affected surfaces of a partially
  erupted molar can act as an interim method of
• decreasing sensitivity
• reducing caries susceptibility
• preserving tooth structure

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Mild MIH Short-Term Treatment

• Prevention and maintaining the dentition
• Teeth should be carefully monitored
• applying fluoride varnish and placing sealants on
  the occlusal surfaces of molars
• where the enamel is intact and the patient does
  not report any sensitivity, sealants are the
  current treatment of choice
• 60-second pretreatment with 5 sodium
  hypochlorite (NaOCl) to remove intrinsic enamel
  proteins may be beneficial

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Moderate MIH Short-Term Treatment

• preventive measures previously outlined
• intervention may be required
• Anterior teeth with isolated demarcated opacities
  that are of aesthetic concern can be treated with
  NaOCl or other bleaching techniques,
  microabrasion, or resin restorations
• Yellow or yellow/brown spots in incisors or
  molars can lighten and become less noticeable
  with bleaching, but whitish opacities may become
  more prominent after applying the bleach

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Moderate MIH Short-Term Treatment

• For posterior teeth with enamel loss or decay
  limited to 1 or 2 surfaces that does not involve
  cuspal tooth structure, resin is the material of
  choice if the tooth can be adequately isolated
• The outline of the restoration should be made in
  non-hypomineralized enamel, but it can be very
  difficult to find out where sound enamel begins,
  resulting in repeated restorations due to
  disintegration of adjacent enamel or opacities on
  other spots.

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Moderate MIH Short-Term Treatment

• Two approaches have been described in determining
  the location of the cavity margin but neither is
  ideal
• Fall the visibly defective enamel is removed
• Only the very porous enamel is removed until good
  resistance is felt between the bur and the sound
  enamel
• Existing, intact restorations on molars should be
  carefully monitored

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• Available adhesive dental materials
• GI
• RMGI
• Compomer
• RBC
• Glass ionomers and resin-modified glass ionomers
  have poor wear resistance and are not recommended
  for placement in stress-bearing areas
• The enamel-adhesive interface
• Porous
• Cracks
• Decreased bond strength
• Cohesive failure

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Severe MIH Short-Term Treatment

• Treatment of children with severe MIH presents a
  tremendous challenge
• Early intervention is necessary to prevent PEB
• To minimize discomfort and decrease the
  likelihood of behaviour management problems,
  profound local analgesia is necessary
• Some patients may benefit from the use of nitrous
  oxide sedation in conjunction with local
  anaesthesia

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• Once the molar has erupted, preformed
  stainless-steel crowns are the treatment of
  choice for severely hypoplastic molars
• Stainless-steel crowns protect the tooth against
• masticatory forces
• protect enamel from acid attack
• decrease sensitivity
• increase the childs OH compliance

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Long-Term Treatment

• Once children have a mature dentition and a more
  stable gingival to clinical crown height,
  full-coverage cast restorations should be
  considered to replace the interim stainless-steel
  crowns on molars
• Anterior teeth can be managed with veneers or
  crowns should they be indicated for severe cases
  of enamel defects, and where aesthetic concerns
  continue to be an issue

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Summary

• Early Diagnosis
• High risk prevention protocol
• Make a decision regarding prognosis of the molars
• Extract if prognosis is poor or if behaviour
  management will be an issue

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Summary

• Replace missing tooth structure
• Use best available restorative material
• SSC ideal
• Regular recall
• Delay aesthetic treatment of the incisors until
  the child requests treatment

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Thank You