Saudi Dental Journal (2019) 31, S106–S111

King Saud University

Saudi Dental Journal

www.ksu.edu.sa
www.sciencedirect.com

Esthetic smile rehabilitation of enamel

hypomineralized teeth with E-max prosthesis: Case
report
AlHanouf M. Alkaabi a,*, Abdulkareem A. AlHumaidan b, Firas K. AlQarawi c,
Faris A. AlShahrani c

a
Dental Intern, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
b
Department of Preventive Dental Science, College of Dentistry, Imam Abdulrahm an Bin Faisal University, Dammam, Saudi Arabia
c
Department of Substitutive Dental Sciences, College of Dentistry, Imam Abdulrahamn Bin Faisal University, Dammam,
Saudi Arabia

Received 29 January 2019; accepted 4 February 2019

Available online 10 February 2019

KEYWORDS Abstract Developmental enamel hypomineralization is a condition affect quality of enamel result
Enamel hypomineralization; in low translucency and opacity area that compromise patient smile. Lithium disilicate Emax pros-
Lithium disilicate; thesis report a superior properties in esthetic treatment. This report is aimed to determine the effec-
E-max; tiveness of lithium disilicate (E-max) prosthesis in managing esthetic demand of patient with enamel
Rehabilitation; hypomineralized teeth.
Esthetic; Production and hosting by Elsevier B.V. on behalf of King Saud University. This is an open access article
Crown lengthening under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction Teeth discoloration consider one of the most esthetic prob-

lems encourage person to seek dental treatment. There are
Today the esthetic dentistry attracts patient’s attention many factors can cause teeth discoloration mainly divided to
through the social media and community. That result in raise extrinsic factors affecting outer surface of the tooth like food
patient’s demands to get perfect smile with high quality mate- or drinks, or intrinsic factors affecting inner surface like drugs,
rials and techniques and involving the patient more in decision excessive exposure to fluoride, trauma or systemic diseases.
making (Naura Venâncio et al., 2014). Other reasons like enamel or dentine anomalies are consider
(Menon, 2014). Developmental enamel defects one of common
conditions affecting both dentition and classified mainly to two
groups: enamel hypomineralization and hypoplasia. The dif-
* Corresponding author.
ference between them that in hypomineralization quality of
E-mail address: dr.hano19@gmail.com (AlHanouf M. Alkaabi).
enamel is affected so it appears with low translucency while
Peer review under responsibility of King Saud University.
the hypoplasia is quantitative defect of enamel (Jälevik and
Norén, 2000).
Diagnosis of discoloration is essential step to plan and
Production and hosting by Elsevier select proper treatment for each case in order to get predictable

https://doi.org/10.1016/j.sdentj.2019.02.017
1013-9052 Production and hosting by Elsevier B.V. on behalf of King Saud University.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Esthetic smile rehabilitation of enamel hypomineralized teeth S107

mechanical properties (Kelly and Benetti, 2011). Among all

ceramic types, lithium disilicate, named also E-max, consider
one of best choices for esthetic anterior teeth. A study com-
pared ceramic materials zirconia and lithium disilicate proper-
ties, reporting superior ability of natural tooth color matching
due to its variable level of translucency. Also, it can be used in
different forms in mean of prosthesis, as full contoured crown
or substructure which give both dentist and lab technician
wide range of choices (Succaria and Morgano, 2011).
The aim of this report is to determine the effectiveness of
lithium disilicate (E-max) prosthesis in managing esthetic
demand of patient with enamel hypomineralized teeth.
Fig. 1 Pre-operative panoramic radiograph.
2. Case report

A 16 years old Saudi female was come to comprehensive clin-

ical dentistry clinics, Collage of Dentistry, Imam Abdulrah-
man bin Faisal University, complain of unsatisfied of the
appearance of her smile. Patient deny any medical condition
or allergy. Consent was signed by patient for treatment accep-
tance in the collage. All patient records include impression,
radiographs and photos were taken (Figs. 1–3).

Table 1 Intra-oral findings in both mandibular and maxillary

teeth.
Teeth number (#) Findings
Maxillary teeth Generalized staining
All teeth Plaque and calculus
2, 3, 15, 31 Occlusal caries
Fig. 2 Pre-operative full mouth radiographs. 4, 9, 12, 13, 18, 19, Proximal caries
20
28 Buccal caries
5, 7 Root canal treatment (RCT) with large
result. Minimal invasive methods can be used such as different
restoration
abrasive techniques or bleaching (Menon, 2014). Recently, dif- 8, 9 Fracture composite veneers
ferent types of ceramic become more widely used in field of 30 Defective occlusal restoration with fracture
esthetic dentistry due to their properties of matching enamel lingual wall
and dentine characteristic, biocompatibility in addition to the

Fig. 3 Intra-oral and extra-oral pre-operative photos. (a) Smile view, (b) frontal view, (c) right side view, (d) left side view, (e) maxilla
occlusal view, (f) mandible occlusal view.
S108 AlHanouf M. Alkaabi et al.

stained and lack of family history of same condition, teeth

Table 2 Treatment plan on 3 phases with all treatment steps.
were finally diagnosed to enamel hypomineralization (Garg
Treatment phases Treatment steps et al., 2012).
number (#) Treatment plan on phases were finalized after multiple con-
Phase 1 Patient education, Oral Hygiene sultations and patient agreement on time, cost and methods
instructions that will be used (Table 2). In phase 1, patient education
Scaling and root planing regarding oral hygiene and instruction along with Scaling
Impression and wax-up for teeth #4–13 and root planing were performed as a first step to ensure estab-
and 30 lish good habits of oral health care, gingival health and prevent
Mock up for teeth #4–13
further dental issues. Smile was analyzed using diagnostic cast
Phase 2 Crown lengthening #3–6, #11–14 and and preoperative photos and future crown margins were deter-
#29–31 mined indicate the need of crown lengthening procedure. Wax
Gingivectomy on #7–10 up was made for teeth #4–13 based on previous analyzing and
RCT #12, 30 duplicated (Fig. 4). In addition, wax up was made for tooth
Post and core #5, 7, 30
#30 to aid in evaluation of its restorability and needs for crown
Phase 3 Multiple Composite restoration: lengthening. Mock up was done for the patient to get her opin-
Cl. I on #2, 3, 15 ion and comments for any further adjustment need before
Cl. II on #18, 19, 20 starting of next phase.
Cl. V on #28 In phase 2, RCT was performed for teeth #12, 30 and post,
Build up for #31
initial core build-up and provisional crown for tooth #30.
E-max crowns on #5–12 and 30
Also, surgical guide made based on wax up to be used in crown
E-max veneers on #4, 13
lengthening procedure. In order to determine periodontal sur-
gery type and amount of removal of both soft and bony tissue
needs, bone sounding was used to assess facial osseous-gingival
tissue relationship. These measurements were located on solid
cast of maxilla then connected to draw a line in gray color
determine bone crest location. Future crown margin line was
draw in green color using surgical guide while current gingival
margin line draw in red color (Fig. 5). Crown lengthening pro-
cedure including both soft and bony tissue removal for teeth
#3–6, #11–14 and #29–31 indicated due to close distance
between future crown margin and bone crest. However, only
gingivectomy was performed on #7–10 (Fig. 6). Patient was
come after 2 months for post-operative follow up.
Fig. 4 Duplicated wax up. In phase 3, post and core build up were done for teeth #5, 7
and temporized. All carious teeth were restored by composite
on multiple visits. Teeth #5–12 and 30 were prepped for all
ceramic crowns while teeth #4, 13 prepared for veneers,
Intra-oral findings were recorded in order to diagnose and
impression was taken by stock tray, ImpregumTM PentaTM Soft
prepare comprehensive treatment plan in phases (Table 1).
Heavy-Body and Light body Impression Material 3M ESPE
After complete periodontal charting, patient was diagnosed
then temporized using putty and ProtempTM Plus Temporiza-
with localized mild to moderate periodontitis (Of et al.,
tion Material 3M ESPE. Bite registration was taken for pre-
2015). For endodontic assessment, tooth #12 was diagnosed
pared teeth and shade was selected as A1 for more natural
as irreversible pulpitis with normal preapical tissue and tooth
look and according to patient preference. Full layering E-
#30 was diagnosed as necrotic pulp wit diagnosed as normal
max crowns and veneers were used and tried in patient mouth
preapical tissue, so both are required root canal treatment
and get her acceptance before cementation. All prosthesis
(RCT). However, teeth #5, 7 were checked and diagnosed as
cemented using Multilink Automix-Adhesive Cementation
endodontically treated teeth with normal preapical tissue
System. Excess cement was removed, esthetic and phonetic
(Edition et al., n.d.). Based on clinical presentation of teeth

Fig. 5 Solid cast of maxilla show bone crest line (gray color), Future crown margin line (green color), current gingival margin line (red
color). (a) Left side view, (b) frontal view, (c) right side view.
Esthetic smile rehabilitation of enamel hypomineralized teeth S109

Fig. 6 Crown lengthening procedure result, (a) pre-operative, (b) post-operative photos for maxillary teeth, (c) pre-operative, (d) post-
operative photos for tooth #30.

Fig. 9 Immediate post-operative photo.

Fig. 7 Post-operative panoramic radiograph.

3. Discussion

Continuous improvement and change in modern prosthodon-

tics dentistry are marked internationally in all aspects. Increase
the patient demands for more esthetic and natural appearance
raise the standers of treatment and require a high quality of
both materials and methods used to provide without compro-
mising the biomechanics properties and essential principles of
successful accepted prosthesis (Kumar et al., 2016).
Developmental enamel hypomineralization is condition
where enamel mineralization (maturation phase) is affected.
The exact etiology is unknown as it complex and can be due
to several factors such as systemic diseases affect the child
before or after birth, use some antibiotics low weight birth
or may because of toxic in breast feeding. Therefore, proper
history evaluation and clinical presentation is important to dif-
ferentiate it from other condition. In this case, patient present
Fig. 8 Post-operative full mouth radiographs. with white-yellowish chalky, opaque areas spread over many
teeth in maxilla along with slight amount of low translucency
(Garg et al., 2012).
were checked. Post-operative radiographs and photos were Esthetic treatment should consider proper diagnosis of the
taken immediately after cementation then post-operative pho- case in biological and mechanical aspects along with esthetic
tos taken after 3 days (Figs. 7–10). Follow up after 6 months aspect. Ceramic prosthesis considers one of excellent materials
show proper gingival health and improvement of oral hygiene. in providing predictable result in cosmetic dentistry. However,
Scaling and root planing performed after taken some photos contraindication like parafunctional habits such as bruxism
for documentation (Fig. 11). and very poor oral hygiene can limit its use. Also, as ceramic
S110 AlHanouf M. Alkaabi et al.

Fig. 10 Intra-oral and extra-oral post-operative photos after 3 days. (a) Smile view, (b) frontal view, (c) right side view, (d) left side view,
(e) maxilla occlusal view, (f) mandible occlusal view.

Provisional restorations play important role in maintain

gingival countered around the preparation, protect the tooth
from oral environment and improve final crown fit. Each pro-
visional material has its own properties that perfect for certain
case. In this case, Bis-acrylic resin based with direct technique.
It is reported with high flexural strength and acceptable
esthetic (Bellot-arcı et al., 2018).
The case was checked after 3 days where initial gingival
healing and patient adaptation to new smile start to establish.
Follow up after 6 months show maintained of proper oral
Fig. 11 A 6-months follow up.
hygiene and improvement in function and health of teeth
and oral health overall. Patient was satisfied with treatment
require certain amount of tooth preparation, dentin sensitivity outcome and become more confident.
can be a possible disadvantage occur in addition to difficulty in
repairing in case of failure and higher wear resistance than nat- 4. Conclusion
ural teeth and restoration (Naura Venâncio et al., 2014).
In this case, patient present with multiple dental problems Using lithium disilicate (E-max) prosthesis show optimum
require several treatments in order to achieve optimum result. result in managing enamel hypomineralization condition. A
Multidiscipline treatment approach show successful result proper history evaluation and diagnosis to is essential to differ-
where team work address different problems that can affect entiate between other enamel anomalies. Management of such
the quality of patient’s main complain (Galler et al., 2009). cases must consider improving esthetic condition of the teeth
Oral hygiene instruction is essential in any case to establish a along with enhance their function and strengthen the struc-
healthy base line of oral cavity and reduce the incidence of car- tural weakness following standard guidelines.
ious and periodontal diseases (Al-Ahmad et al., 2010). Plan-
ning for a comprehensive case include many steps of taken Conflict of interests
accurate records and measurements. Using of both wax up
and mock up can give a clinician a visual accurate imagination
of future prosthesis properties and required procedures to The authors declare that there is no conflict of interests in
achieve it. In patient side, communication and understanding regard the publication.
of demands and each step in treatment phases is better
(Thomas and David, 2014). References
On of important step in smile rehabilitation is to analyze
crown diminution and amount of soft tissue displacement. Al-Ahmad, Ali, Roth, Dominik, Wolkewitz, Martin, Wiedmann-Al-
Short crown can compromise the appearance of patient smile Ahmad, Margit, Follo, Marie, Ratka-Krüger, Petra, Deimling,
Daniela, Hellwig, Elmar, Hannig, Christian, 2010. Change in diet
and the stability of future crown. Several etiologies can be con-
and oral hygiene over an 8-week period: effects on oral health and
tributed to cause this condition like excessive teeth wear, exces- oral biofilm. Clin. Oral Invest. 14 (4), 391–396. https://doi.org/
sive maxillary growth, caries or partial eruption of anatomical 10.1007/s00784-009-0318-9.
crown. Corrective periodontal surgery is consider in order to Bellot-arcı, Carlos, Astudillo-rubio, Daniela, Almerich-silla, Manuel,
maintain a biological width. Minimal of 3 mm from crown 2018. Mechanical properties of provisional dental materials : a
margin to crest of the bone should be maintained to ensure systematic review and meta- analysis, 1–20. https://doi.org/10.1371/
preserve gingival health (De Oliveira et al., 2015). journal.pone.0193162.
Esthetic smile rehabilitation of enamel hypomineralized teeth S111

Edition, Fourth, Torabinejad, Mahmoud, Walton, Richard E., n.d. Naura Venâncio, Gisely, Rosceline Rodrigues, Guimarães, Sybilla
Endodontics. Torres, Dias, Gisely Naura Venâncio Avenida, José Romão, no -
Galler, David, Caroline Quiong, D.D.S, Galler, Jeffrey, 2009. A multi- Colina do Aleixo -São José, 2014. Conservative esthetic solution
disciplinary approach to congenitally missing anterior teeth, no. with ceramic laminates: literature review. Rsbo 11 (2), 185–91.
January, 51–54. Of, U.S.E., Attachment Levels, I.N., Diagnosis, Periodontitis, O.F.,
Garg, Nishita, Jain, Abhay Kumar, Saha, Sonali, Singh, Jaspal, 2012. 2015. American academy of periodontology task force report on
Essentiality of early diagnosis of molar incisor hypomineralization the update to the 1999 classification of periodontal, no. July, 835–
in children and review of its clinical presentation, etiology and 38. https://doi.org/10.1902/jop.2015.157001.
management. Int. J. Clin. Pediatr. Dent. 5, 190–196. https://doi. Oliveira, Pablo Santos, De, Fabio Chiarelli, Rodrigues, José A., Shibli,
org/10.5005/jp-journals-10005-1164. Jamil A., Zizzari, Vincenzo Luca, Piattelli, Adriano, Iezzi, Gio-
Jälevik, B., Norén, J.G., 2000. Enamel hypomineralization of perma- vanna, Perrotti, Vittoria, 2015. Aesthetic surgical crown lengthen-
nent first molars: a morphological study and survey of possible ing procedure. Case Rep. Dent. 2015, 10–13. https://doi.org/
aetiological factors. Int. J. Pediatr. Dent. 10 (4), 278–289. https:// 10.1155/2015/437412.
doi.org/10.1046/j.1365-263x.2000.00210.x. Succaria, Faysal, Morgano, Steven M., 2011. Prescribing a dental
Kelly, J.R., Benetti, P., 2011. Ceramic materials in dentistry : historical ceramic material: zirconia vs lithium-disilicate. Saudi Dental J. 23
evolution and current practice, 84–96. https://doi.org/10.1111/j. (4), 165–166. https://doi.org/10.1016/j.sdentj.2011.10.001.
1834-7819.2010.01299.x. Thomas, Manuel S., David, K., 2014. Importance of anatomic mock-
Kumar, C. Pradeep, Amrutha, M.A., Mohammed Shahid, M.A., 2016. up for predictable esthetic smile design with ceramic veneers. J.
Trends in prosthodontics : an overview. 4 (2), 35–41. Interdiscipl. Dent. 4 (1), 55. https://doi.org/10.4103/2229-
Menon, Rakhi, 2014. A review on various reasons for teeth 5194.135014.
discolouration. 7 (July), 815–20.