The patient was a 9-year-old girl with a family history of AI. At the time of the visit, the patient was in a stage of mixed dentition but all the primary teeth had been extracted by her primary dental care provider due to multiple secondary decays. The permanent first molars and the upper central incisors were less severely involved and successfully restored with direct composite.
The patient was referred for treatment of the lower incisors very sensitive upon thermal stress and unsightly due to abnormal shape, size, and color. The appearance of the lower incisors made the girl uncomfortable with her smile, and she reported bullying at school because of her teeth.
Intraoral clinical examination of the lower incisors revealed missing enamel in the incisal half and reduced enamel thickness in the cervical half of the teeth (Figure 1). Radiographic examination showed normal enamel radiopacity and normal contrast with the underlying dentin (Figure 2).
Based on the clinical and radiological examinations, a diagnosis was made of AI type I according to the Witkop classification. Type l is the most common form of AI caused by a mutation in the enamelin gene ENAM 4q215 transmitted by autosomal dominant inheritance. This mutation introduces a disruption in the presecretory and secretory stages of amelogenesis resulting in a layer of hypoplastic enamel with normal mineralization but reduced thickness.
The treatment options for restoration of the lower incisors were discussed with the patient and her parents, and a final decision was made to restore the teeth with prefabricated composite veneers.
Once the treatment plan with prefabricated composite veneers was approved, the clinical procedure started with veneer size selection.
The prefabricated composite veneers for the patient in this report (Edelweiss Veneers, Edelweiss Dentistry, Wolfurt, Austria) (Figure 3) are available in four sizes (XS, S, M, and L) based on average tooth dimensions in the human population. A custom sizing guide is included in the system to select the veneer that best fits the patient (Figure 4).
If none of the available sizes fits the patient's teeth, the width and length of Edelweiss Veneers can be altered to accommodate specific dimensional requirements. For the patient in this report, Edelweiss Veneer size M was selected, and no width or length alteration was required. However, the thickness of the veneer was reduced with a football shape diamond bur (8379, Komet USA, Rock Hill, SC, USA) to allow a more conservative tooth preparation (Figures 5 and 6). Using the same football shape diamond bur, the cervical margin of the veneer was finished to a knife-edge configuration for maximum tissue preservation in the gingival area where the enamel layer is thinner. Thanks to the combination of minimal thickness of the composite laminate and knife-edged configuration of the cervical margin, no tooth preparation was required and the thin hypoplastic enamel layer of the AI patient was fully preserved.
After veneer size selection, the next step was choosing the shade of the luting composite (Figure 7). Luting composite color selection is a critical step for successful restoration with Edelweiss Veneer because the laminate is fabricated with a colorless enamel shade, and the final color of the veneer is determined by the color of the luting composite. The Edelweiss Veneer System includes a high-viscosity nanohybrid composite for cementation available in several dentin and enamel shades (Edelweiss NH, Edelweiss Dentistry, Wolfurt, Austria). For the patient in this report, Edelweiss NH shade A2 was selected with the addition of an opalescent flowable composite in the incisal area (Effect Blue, Edelweiss Dentistry, Wolfurt, Austria) to increase incisal translucency and highlight the halo effect.
After size and shade selection, the intaglio of the veneer was conditioned with a proprietary resin primer (Veneer Bond, Edelweiss Dentistry, Wolfurt; Austria) applied with a microbrush and light cured 20 seconds according to the manufacturer recommendations (Figure 8). No acid-etching, no sandblasting, and no silane application are required inside Edelweiss Veneer. However, the manufacturer recommends internal conditioning with Veneer Bond to promote chemical adhesion and to increase bond strength between the highly inorganic laminate and the luting composite.
After Veneer Bond application, the veneers were ready for delivery and the working field was isolated with a rubber dam and a 212 Hu-Friedy clamp and the first lower incisor was etched with 37% H3PO4 (Gel Etchant, KerrHawe, Bioggio, Switzerland). Etching gel application started from enamel and after 15 seconds moved to dentin for another 15 seconds for 30 s (Figure 9) followed by water rinsing for 30 s and application of a single-step adhesive according to the manufacturer instructions (Scotchbond Universal, 3 M ESPE, Seefeld, Germany) (Figure 10).
Then, the veneer was loaded with the selected composite shade (Figure 11) and seated on the deserving tooth (Figure 12).
After gently pressing the veneer in position, the extra composite was removed with a thin spatula (CompoSculp DD 9/10, Hu-Friedy, Chicago, Ill, USA) and carefully sculpted to achieve optimal adaptation between the veneer and the tooth. Then, the veneer was light cured 20 seconds from the lingual and 20 seconds from the buccal using a high-power (1.330 mW/cm2) curing light (Demi Plus, Kerr Corporation, Brea, CA USA) (Figure 13).
Finally, the margins of the veneer were finished with composite finishing discs (Sof-Lex XT, 3M ESPE, Seefeld, Germany) (Figure 14) and interproximal finishing strips (Sof-Lex, 3M ESPE, Seefeld, Germany) (Figure 15) followed by a diamond-impregnated silicone cup (Dia step 2, Ravelli, Milano, Italy) at 7500-10,000 rpm under water to produce the final luster.
Once the same step by step clinical procedure was completed for all the four veneers, the patient was dismissed and rescheduled for postoperative evaluation after two weeks. At the recall appointment functional evaluation (absence of fractures, marginal adaptation), biological evaluation (soft tissue response, postoperative sensitivity), and esthetic evaluation (gloss, color matching) were completed and resulted fully satisfactory (Figure 16). Radiological examination showed successful integration of the restorations (Figure 17). The patient was happy with the esthetic outcome and reported that hypersensitivity disappeared after placing the veneer.
A second recall appointment was scheduled 6 months after delivering the veneers. At the new follow-up visit, the veneers resulted fully functional with no marginal discoloration and no alteration of the original superficial luster (Figure 18). The veneers showed good soft tissue response, and the patient's oral hygiene was significantly improved as reported by the RDH who has been following the patient since the initial phase of the treatment. AI patients often experience difficulty in maintaining good oral hygiene on account of the increased tooth sensitivity that makes tooth brushing uncomfortable and the rough tooth surface that facilitates plaque accumulation. Also the impaired smile appearance with abnormal tooth shape, size, and color contributes to poor oral hygiene motivation. Previous research demonstrates that a strong correlation exists between attractive smile appearance and positive oral health behaviors, and a secondary benefit of the esthetic restoration of the young AI patient presented in this report was the positive impact on the patient's strive to maintain optimal oral health.