Anterior Hypomineralisation - How To Improve The Aesthetics

Molar-Incisor Hypomineralisation (MIH) is common affecting around 1-in-6 children. This post will provide tips on how to deal with anterior hypomineralisation in your practice

Hypomineralised incisors with poor aesthetics

Hypomineralised incisors do not commonly undergo the breakdown that is experienced with posterior teeth. Generally, they are also less sensitive than the posterior teeth. As such, they can be ‘easier’ to manage as they pose less issues for the child and you as the practitioner. HOWEVER, they can look quite poor with large white-chalky-brown areas being very noticeable. This is the main issue you have to deal with.

Assessment

Generally, the way in which to manage the incisors depends upon several factors. These include:

  • Age

  • Compliance

  • Finance

  • Number of affected teeth

  • Extent of opacity

  • Colour of opacity

  • Depth of opacity

  • Sensitivity

  • Any post-eruptive breakdown present

The primary factors do relate to the opacity. That is, how extensive is it and what colour is it. The colour will provide you with a guide of what technique may work

Techniques Available

There are many techniques available for management of the discoloured hypomineralised areas. Any destruction of tooth structure should be a measure of LAST resort. Also and easy and accessible option is to just place a resin veneer. However, resin veneers will have ongoing maintenance issues and once again should only be used when other, less invasive techniques have been trialed. Children continue to have periodontal maturation until growth ceases, so any resin margin will become noticeable.

The below techniques can be used in isolation. However, we commonly use a combination of techniques depending on the colour and success (or-lack-thereof) we are having. The 2-most used techniques for us are etch-bleach-seal and ICON. We do use these in combination as well. If you sign up below, we will send you a copy of our etch-bleach-seal protocol and when coupled with ICON.

The techniques include:

•        Microabrasion

•        Resin Infiltrations

•        Etch-Bleach-Seal

•        Whitening (external)

•        Composite restoration/Macroabrasion

•        Composite Veneers

•        Porcelain Veneer

We have a table below, for recommended techniques based on the colour. You will see combination is suitable for all lesions.

A suggested guide for what works depending upon the colour

How to Do Them?

The post would be quite long if we went into every step of the above techniques. We can email you our instructions for etch-bleach-seal and ICON instructions come with the box. One thing with ICON is you may need to do several cycles. We have done upwards of 6 cycles before, prior to getting a result we were happy with.

Pre-Op, we used Etch-Bleach-Seal for this patient

Immediate post-op after etch-bleach-seal. It is not perfect, but a substantial improvement and they were very happy.

Whitening can be done with whitening strips or take-home trays. Just warn the child/parent that the white areas immediately after the whitening will look more noticeable. As the teeth rehydrate the colour discrepancy will fade. The main aim of whitening is to lift the shade of the unaffected tooth structure to more closely match the opaque/white hypomineralised areas. Commonly you may do whitening first and then say ICON/Etch-bleach-seal.

The patient was concerned with #12 and 22. She had previously had resin veneers placed on #11 and 21 prior to us seeing her. She has multiple medical issues and is unable to tolerate long-periods in the dental chair.

Immediate post-op. We used a combination of ICON, I was not happy initially so sent her home with toothmousse (leaving the enamel ‘open). However, her compliance with the toothmousse was very terrible, so we did not quite get the result we wanted. We wanted to go another week, but she was happy with the result.

Warning!!!

The hardest part of managing hypomineralistion of anterior teeth is the unpredictable nature of it. It can make it a challenge to know how much to charge and how much time you require. As such, we always tell patients that we could require several attempts and we may need to change tack midway. Also do not always expect perfection! You will get an improvement it is just a matter of how much. .

If you are not happy with the outcome, please do not cure the resin layer! Once you do, it will be a permanent change you have created, and you will need to remove the resin infiltrated layer to do any future whitening/microabrasion etc.

Is It Worth It?

A study conducted looking into the impact of aesthetic improvements of incisors for children found there was a significant improvement in oral health related quality of life (Chang in Oral Health-Related Quality of Life Following Minimally Invasive Aesthetic Treatment for Children with Molar-Incisor Hypomineralisation: A prospective Study, Hasmun et al). So the short answer if you don’t want to read the article the answer is… Yep It’s Worth It

Conclusion

Management of anterior hypomineralisation can be a rewarding experience for you and the patient. The techniques are relatively simple and can result in moderate-to-excellent improvements to the area. It can sometimes be less-than-perfect, but you will be surprised how any improvement can make a big difference to little lives! We hope that has been helpful for you

We do run a one day hands on hypomineralisation course. If you click the link below you can find out information about it (and other courses we run).

All the best,


Sarah and Tim

Tim Keys