How To Restore A MIH Affected Molar

Molar-Incisor Hypomineralisation (MIH) is a very common and burdensome condition to treat. The prevalence varies greatly across countries, however, is estimated globally at 13.1%.(1)

In Australia, it is predicted that 3+ million people are affected by MIH. As such, you are likely to encounter these patients in your clinic.

We will not review MIH pathogenesis and diagnosis, or other treatment options, such as; extraction of compromised 6’s (which is very important to consider). This post will only focus on tips to restore MIH affected molars.

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There are many difficulties in treating children with MIH including:

  • 10 x increased number of dental treatments

  • Compromised enamel structure leading to decreased bonding

  • Inability to know where affected tooth structure ends

  • Increased restorative failures

  • Increased caries risk

  • Post-eruptive breakdown (PEB)

  • Relatively young age and compliance

  • Hypersensitive pulps

All of this may lead to increased dental anxiety

So, the primary issues you will have when restoring an MIH affected 6 are;

  • Properly anaesthetising the tooth

  • Deciding where to place the restorative margins and what material to use

  • Managing compliance and dental anxiety.

How To Anaesthetise A MIH Affected Molar

The pulp in MIH affected teeth can be hypersensitive and changes in pulpal tissues have been noted which may negate the effectiveness of your normal local anaesthetic techniques. As such it is likely you will need alternate/abstract techniques. If during the examination the patient complains of pain to cold air, or when drinking cold water etc… you are prewarned this tooth may be hard to anaesthetise. As such, possible variations you can try include: (2-4)

  • Always place an inferior dental nerve block for MIH affected lower 6’s

    • Consider also placing a buccal infiltration with Articaine

  • An intra-osseous injection has reportedly high success rates, but is not common nor practical in many children

  • If possible, use warm water as the handpiece irrigant

  • Limit the use of high speed suction

  • Consider using nitrous oxide, which will help to reduce anxiety and can also offer some pain relief

  • Consider placing silver diamine fluoride (SDF) on the tooth prior to treatment. SDF is increasing in popularity in Australia for the treatment of dental caries and dental sensitivity and has shown some promising results in MIH affected teeth (5)

Restorative Technique

Once your tooth is anaesthetised, tips to increase restorative success include; (2, 4)

  • For intra-coronal restorations, place restorative margins on visually sound enamel. This is more destructive of tooth structure and there is no guarantee the enamel will be unaffected, but bonding should hopefully be improved.

  • Use 5% NaOCL for 60 seconds. There is limited research regarding this, but the theory is to breakdown the abnormal organic (protein) component in the enamel and improve bonding.(6)

  • Restore with a combination of glass ionomer cement to replace dentine and resin composite to replace enamel

    • *GIC on its own has a very low success rate(4)

MIH Resto.jpg

In some cases, the tooth may be moderately-to-severely affected, and one may consider extraction. However, there are some occasions when it is best to avoid/delay extraction. In cases like this, or when you have been unable to gain anaesthesia, placement of a stainless-steel crown (SSC) will result in the best treatment outcomes and has superior long-term outcomes compared to intra-coronal restorations. Placing separators prior and performing minimal reduction can leave the greatest amount of tooth structure for definitive restoration in the future. Other options include minimally invasive indirect inlays and onlays. However, until the dental and supporting structures have matured, less costly, time-consuming and invasive methods are recommended; such as a SSC.(2,4)

MIH Teeth2.jpg

These teeth can be very difficult to treat and stressful for all involved. MIH is a massive topic in dentistry and this post only addresses one small part of management. Many of the severely affected teeth do benefit from an extraction (with orthodontic input). However, for those that are less affected and that you wish to keep, hopefully these tips help you to achieve this.

All the best

Tim and Sarah

References

1.            Schwendicke F, Elhennawy K, Reda S, Bekes K, Manton DJ, Krois J. Global burden of molar incisor hypomineralization. Journal of Dentistry 2018;68:10-18.

2.            William V, Messer LB, Burrow MF. Molar incisor hypomineralization: review and recommendations for clinical management. Pediatr Dent 2006;28:224-232.

3.            Jalevik B, Klingberg GA. Dental treatment, dental fear and behaviour management problems in children with severe enamel hypomineralization of their permanent first molars. Int J Paediatr Dent 2002;12:24-32.

4.            Lygidakis NA. Treatment modalities in children with teeth affected by molar-incisor enamel hypomineralisation (MIH): A systematic review. Eur Arch Paediatr Dent 2010;11:65-74.

5.            Horst JA, Ellenikiotis H, Milgrom PL. UCSF Protocol for Caries Arrest Using Silver Diamine Fluoride: Rationale, Indications and Consent. J Calif Dent Assoc 2016;44:16-28.

6.            Chay PL, Manton DJ, Palamara JEA. The effect of resin infiltration and oxidative pre-treatment on microshear bond strength of resin composite to hypomineralised enamel. International Journal of Paediatric Dentistry 2014;24:252-267.

Tim KeysHow To Restore A MIH Affected Molar