Ó

Operative Dentistry, 0000, 00-0, 000-000

Molar Incisor Hypomineralization:

Etiology, Clinical Aspects, and a
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Restorative Treatment Case Report

D Sundfeld  LMS da Silva  OJ Kluppel  GC Santin
RCG de Oliveira  RR Pacheco  NIP Pini

Clinical Relevance
Total-etch adhesive systems and resin composite are clinically viable dental materials for
esthetic restorations in teeth presenting white/yellow/brown hypomineralization stains.
Operative Dentistry

SUMMARY INTRODUCTION
Molar-incisor hypomineralization (MIH) is a Among the pathologies that may negatively affect
condition that negatively affects enamel and the smile and dental structures, molar incisor
dentin, especially the first molars and perma- hypomineralization (MIH) is defined as a systemic
hypomineralization of qualitative character that
nent incisors, causing esthetic and functional
directly affects the enamel and dentin of the first
problems. The present clinical case report molars, with or without the involvement of the
presents and discusses the etiology and clini- incisors.1 Less frequently, MIH-like defects have
cal characteristics of MIH and describes a been reported in permanent canines, premolars, and
restorative protocol for MIH-affected teeth. primary second molars.2-4 As result of an altered (or
disturbed) matrix production, secretion, arrange-
*Daniel Sundfeld, DDS, MDS, PhD, assistant professor,
ment, crystal formation, or matrix resorption, a
Department of Restorative Dentistry and Prosthodontics,
Ingá University Center–UNINGÁ, Maringá, PR, Brazil compromised enamel structure may be observed.5
Defects during calcification/maturation stages usu-
Lucas Menezes Souza da Silva, DDS graduate student, Ingá
University Center–UNINGÁ, Maringá, PR, Brazil ally lead to normal volumes of enamel with insuffi-
cient mineralization (hypomineralization) and, con-
Oscar João Kluppel, DDS, MDS student, Department of
Restorative Dentistry and Prosthodontics, Ingá University sequently, altered translucency. MIH, amelogenesis
Center–UNINGÁ, Maringá, PR, Brazil imperfecta, and dental fluorosis are examples of such
Gabriela Cristina Santin, DDS, MDS, PhD, assistant profes- qualitative alterations.4,6,7 On the other hand,
sor, Department of Orthodontics and Pediatric Dentistry,
Nubia Inocêncya Pavesi Pini, DDS, MDS, PhD, assistant
Ingá University Center–UNINGÁ, Maringá, PR, Brazil
professor, Department of Restorative Dentistry and Prostho-
Renata Cristina Gobbi de Oliveira, DDS, MDS, PhD, assistant dontics, Ingá University Center–UNINGÁ, Maringá, PR,
professor, Department of Orthodontics and Pediatric Den- Brazil
tistry, Ingá University Center–UNINGÁ, Maringá, PR,
*Corresponding author: 6114 317-PR Rd, 200 Industrial
Brazil
Park, Maringá, PR, Brazil; e-mail: sundfeldneto@gmail.
Rafael Rocha Pacheco, DDS, MSc, PhD, assistant professor, com
Restorative Dentistry, University of Detroit Mercy, School of
https://doi.org/10.2341/19-138-T
Dentistry, Detroit, MI, USA
 Operative Dentistry

quantitative defects (hypoplasia) are caused by a CLINICAL CASE REPORT

disturbance during the amelogenesis matrix secre- A 17-year-old female patient presented to the
tion phase.8,9 Restorative Dentistry Clinic of Ingá University
MIH-affected teeth usually present the enamel Center–UNINGÁ (Maringá, PR, Brazil) with a chief
with opaque-white, yellow, or brown colorations, complaint of poor esthetics. The patient presented
with or without posteruptive degradation (PED), with stains on the maxillary and mandibular
varying according to its severity.1,5,10-12 The mild anterior teeth (Figures 1 and 2). During anamnesis,
form of MIH is associated with delimited opaque the patient’s guardian reported that she was born
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areas, varying from white to brown, in nonstress with low birth weight and was hospitalized due to a
areas on first permanent molars, with no structural severe condition of anemia during childhood (when
loss and no dental sensitivity.10,13-15 Moderate (with she was about 1 year old) and had antianemic
slight or no dental sensitivity)15 and severe forms of injections, recommended in cases of iron deficiency.
MIH are associated with opaque areas at the The use of amoxicillin was also frequent because of
occlusal/incisal third of teeth. This area occasional- respiratory tract infections (chronic bronchitis) that
ly undergoes PED due to reduced hardness and affected her during infancy (18 months old until 8
high porosity of enamel, leading to functional and years old), and associated with the use of nebulizers
esthetic complications and dental sensitivity.15-17 to help the pulmonary air ventilation as well.
PED commonly leads to surfaces that are more During dental examination, white, yellow, and
susceptible to biofilm accumulation and develop- brown stains were observed on the buccal surfaces of
ment of carious lesions.18 In severe cases, PED may the maxillary canines, laterals, and central incisors
lead to dental sensitivity due to dentin exposure.1,19 (Figures 1 and 2). On the mandibular teeth, white/
MIH usually presents asymmetrically, affecting ‘‘creamy’’ stains were found on the facial surface of
two-thirds of the crowns of molars and incisors. the left lateral incisor and in both central incisors
Operative Dentistry

One group of teeth may be more affected than the (Figures 1 and 2A). Milder enamel stains were
other.20 observed on both mandibular canines and on the
right lateral incisor. Residual bonding materials
There are multiple treatment options for MIH-
were found after bracket debonding on the right
affected teeth, which include preventive, desensitiz-
maxillary lateral incisor and canine and on the
ing, and remineralizing products; calcium and
maxillary left lateral incisor. The guardian also
vitamin supplements; resin infiltration; fissure seal-
reported that the patient’s first mandibular perma-
ants; enamel microabrasion; direct or indirect resto-
nent molars presented severe structure loss and
rations; extractions; and orthodontic alignment.4,19
were submitted to surgical extractions when the
The choice and indication of treatment depend on the
patient was 10 years old. The depths of each stain
severity, patient age, socioeconomic factors, and were assessed by positioning the tip of a light-
treatment expectations.21,22 Restorative procedures emitted diode (LED) light-curing unit from the
are great treatment options for teeth with structure palatal/lingual surfaces (Figure 3). Considering both
loss, requiring restoration of function and esthetics. clinical and medical history, MIH was diagnosed.
Some materials and procedures may be considered, The clinicians proposed the following treatment
including resin composite direct restorations, ceram- plan, which was accepted by the patient and
ic indirect restorations, and prefabricated metallic guardian: 1) at-home vital dental bleaching; 2)
crowns (posterior teeth).23 However, adhesive proce- enamel microabrasion on teeth #6, #7, and #10;
dures on MIH-affected teeth are critical and may and 3) direct composite resin restorations on teeth
affect the bond strength and longevity of these #8, #9, and #11.
restorations.16,24-26 More invasive procedures, such
At-home dental bleaching was performed by using
as extractions, are adopted for teeth with major
10% carbamide peroxide (Opalescence PF, Ultradent
structural impairment, aiming for a future ortho-
Inc, South Jordan, UT, USA) for 2 hours per day, for
dontic/prosthetic rehabilitation after dental sur-
20 days. Alginate impressions of the maxillary and
gery.22
mandibular arches were made, and stone models
Therefore, the aim of the present clinical case were poured and used to fabricate the custom acetate
report is to demonstrate an esthetic restorative bleaching trays. The patient was instructed to place
procedure performed on MIH-affected teeth. The a small drop of bleaching product into each tooth
18-month clinical follow-up and articles concerning section and to contact the clinician if any discomfort
MIH are presented and discussed. or sensitivity occurred. The bleaching treatment
 Sundfeld & Others: Molar Incisor Hypomineralization Treatment
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Operative Dentistry

Figure 1. Initial clinical aspect showing white/yellow/brown stains in maxillary and mandibular anterior teeth.

Figure 2. (A): Intraoral view during mandibular protrusion (note the white/yellow/brown stains in maxillary and mandibular anterior teeth). (B) Initial
teeth shade evaluation (color A2 using Ivoclar shade guide).

Figure 3. (A): Close-up view of stained central incisors. Transillumination assessment positioning the tip of the light-curing unit at the palatal surface
on the right (B and D) and left (C and E) maxillary central incisors. Dark and intense color indicates deep stains.

resulted in a color alteration from A2 to B1 (Ivoclar 3M ESPE, St Paul, MN, USA) was applied only to
Shade Guide, Vita Shade System) using a visual dentin. Solvent from the primer was allowed to
assessment method (Figure 4). evaporate using air from the syringe for 15 seconds,
After 1 month, the restorative procedures with followed by the unfilled adhesive resin application
resin composite were performed. The chromatic (adhesive, step 3; Figure 8). The adhesive was light
mapping was made by placing small resin composite activated for 10 seconds using a polywave LED light-
increments (Vit-l-escence, Ultradent Inc) on the curing unit (Valo Cordless, Ultradent Inc) in the
buccal surface of the maxillary incisors (Figure 5). regular mode (1,000 mW/cm2). Resin composite
After rubber dam isolation, the hypomineralized restoration (Vit-l-escence) was made using an incre-
stains were removed using a spherical diamond bur mental technique, respecting the original dental
(#1014, KG Sorensen, Cotia, SP, Brazil) coupled to a anatomy (Figure 9).27
high-speed handpiece with water irrigation (Figure The enamel microabrasion was performed for
6). After complete removal, the enamel was etched residual orthodontic bonding materials, intrinsic
for 30 seconds and dentin for 15 seconds using 35% stain removal, and regularization of the enamel
phosphoric acid (Ultra-Etch, Ultradent Inc; Figure surface (Figure 10).28,29 The surface layers of the
7). Then, the primer (step 2) of a total-etch three-step stained enamels located on the buccal surface of both
adhesive system (Adper Scotchbond Multi-Purpose, maxillary lateral incisors and right maxillary canine
 Operative Dentistry
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Figure 4. (A): Clinical aspect after at-home dental bleaching. (B) Teeth shade selection using a visual color scale (color B1 using Ivoclar shade
Operative Dentistry

guide).

Figure 5. Resin composite (Vit-l-escence, Ultradent Inc) color mapping prior to direct restorations: [B2D] Dentin, B2; [B1D] Dentin, B1; [PN] Enamel,
Pearl Neutral; [IrB] Incisal, Iridescent Blue; [A1E] Enamel, A1; [B1D] Dentin, B1; [Incisal] Incisal shade (Forma, Ultradent Inc.).

Figure 6. Complete removal of hypomineralized stains using a spherical diamond bur (#1014, KG Sorensen) on the buccal surface of both maxillary
central incisors.

Figure 7. (A, C): Acid etching with 35% phosphoric acid for 30 seconds on enamel. (B, D): Acid etching with 35% phosphoric acid for 15 seconds on
dentin.

Figure 8. (A): Application of primer (step 2) on dentin only. (B): Application of the unfilled adhesive (step 3) on the entire preparation. Same protocol
was adopted for the left maxillary central incisor.

Figure 9. (A): Increment of B2 Dentin resin composite. (B): Increment of B1 Dentin resin composite. (C): Increment of Iridescent Blue at the incisal
third. (D): Increment of Pearl Neutral Enamel shade as the last increment.

were removed using a super-fine (macroabrasion) ESPE), followed by abrasive rubber discs (Jiffy,
tapered bur (#3195FF, KG Sorensen) under copious Ultradent Inc; Figure 12). Later, a silicon-carbide–
water irrigation attached to a high-speed handpiece impregnated brush (Jiffy Brush, Ultradent Inc) was
(Figure 10A,C). A microabrasive product (Opalustre, used, followed by the application of a diamond paste
Ultradent Inc) was used to remove the remaining (Diamond Polish, Ultradent Inc) using a goat-hair
stains, using a specially designed rubber cup (Opal- brush. The patient was satisfied with the treatment
Cups, Ultradent Inc) with a low-speed handpiece (Figure 13) and did not want to remove the stains
(Figure 10B,D). After two weeks, it was observed
located in the mandibular teeth. Figure 14 repre-
that the incisal stains were not completely removed
sents the 18-month follow-up of the procedures.
on teeth #6 and #7 since they were deeper than the
enamel microabrasion was able to remove. Thus,
DISCUSSION
direct resin composite restorations were made on
both maxillary lateral incisor and right maxillary The present clinical case report describes the
canine (Figure 11) following the technique described esthetic restorative treatment of MIH-affected teeth
above for both maxillary central incisors. using a combination of dental bleaching, direct resin
Finishing and polishing procedures were per- composite restorations, and enamel microabrasion.
formed using an aluminum oxide disc (Sof-Lex, 3M The last procedure was performed to remove resid-
 Sundfeld & Others: Molar Incisor Hypomineralization Treatment
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Operative Dentistry

Figure 10. (A, C): Macroabrasion using a super-fine tapered diamond bur (#3195, KG Sorensen) on the buccal surface of both maxillary lateral
incisors and right maxillary canine. (B): Application of the microabrasive product (Opalustre, Ultradent Inc) using the specific rubber cup (Opalcup,
Ultradent Inc).

Figure 11. (A): Resin composite shade mapping on the left maxillary canine before direct resin composite restoration ([B2D] Dentin, B2 and Pearl
Neutral Enamel shade). (B): Complete removal of the stained opacity at the incisal third. (C): Stained buccal surface at the incisal surface. (D):
Removed stains prior to direct resin composite restoration. Although the stain is evident in the left lateral incisor during rubber damn isolation, it was
not necessary to perform a direct restoration since the stain disappears when hydrated in saliva.

Figure 12. (A): Finishing using aluminum oxide disc. (B-D): Abrasive rubber discs with progressive reduction of abrasive size. (E): Impregnated
silicon carbide brush. (F): Use of a diamond paste associated with a goat-hair brush.

ual orthodontic bracket bonding materials and white problems during the prenatal (ie, hypocalcemia and/
remineralized stains around them and, consequent- or diabetes), perinatal (ie, premature birth or
ly, smoothening the enamel surface after bracket prolonged delivery), and/or postnatal periods (ie,
debonding.29 The patient was satisfied with the antibiotic use and/or nutrition problems).33 The
clinical esthetic outcomes from the described tech- severe anemia reported was framed as one of the
niques. possible causes of MIH.34 The etiology of MIH is not
Disturbance (ie, illness) during the late enamel fully elucidated,5,33,35 and it is difficult to obtain
maturation phase of amelogenesis may negatively scientific evidence on the origins/causes of MIH
affect the function of ameloblasts (which are very development because of the lack of standardized
sensitive to changes in their surrounding environ- measurement protocols/guidelines. Therefore, well-
ment),30 leading to the qualitative defects found in designed future cohort studies are required.36-38
MIH.31 The MIH diagnosis was based on medical Scientific reports37,39-41 found that premature birth
and dental history. The best age for a correct and low birth weight are associated with MIH.
diagnosis of MIH is about eight years, as the Moreover, there is considerable evidence of an
maxillary and mandibular permanent incisors and association between early childhood illness (fever,
first molars are fully erupted.32 The patient’s asthma, and pneumonia, up to three or four years of
guardian reported that the patient presented with age) and MIH.38,42 A positive correlation was reported
severe anemia during early childhood. This infor- between respiratory disease and a severe variant of
mation is of great value, since the etiology of MIH MIH with incisor involvement,43 including bronchi-
may be related to some systemic factors and changes/ tis,39,44 and ear, nose, and throat diseases.11 A genetic
 Operative Dentistry

hardness that can withstand occlusal forces and

chewing. The other 5% consists of water (4%) and
traces of organic content.51,52 Generally, the MIH-
affected enamel presents a reduction in the quantity
and quality of mineral content compared with
normal enamel. Thus, MIH-affected enamel has a
reduced content of calcium and phosphate, and
consequently, there is a reduction in the hardness
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and elasticity, increased porosity,31,53-56 increased

carbon and carbonate concentrations, and greater
protein content, 31,45,54,55,57 which hamper the
growth of hydroxyapatite crystals.58,59 Also, the
MIH-affected enamel is not organized into hydroxy-
apatite crystals, usually presenting loosely packed
crystals, less-dense prismatic structure, partial loss
of the prismatic pattern, less distinct prism borders,
and more evident interprismatic space.53,55,57,60,61
Studies54-57 have demonstrated that MIH lesions
start at the enamel-dentin junction and end at the
enamel surface; thus, MIH lesions are located
throughout the whole enamel thickness. All of this
information attests to the fact that hypomineralized
enamel is more fragile than sound enamel.
Operative Dentistry

The degree of lesion opacities is directly related to

the degree of porosity: creamy/white lesions and
those without posteruptive breakdown are less
porous when compared with yellow/brown–colored
Figure 13. Clinical aspect after 1 week. enamel.55,56,62 Thus, yellow/brown opacities are
more prone to evolve into PED when compared with
Figure 14. Clinical aspect after 18 months (resin composite
restorations were repolished). white/creamy opacities.12 Dentin may also be nega-
tively affected by MIH, presenting lower mineral
density when compared with nonaffected dentin, at
component from multifactorial pathogenesis was also
the cervical region.56 Heijs and colleagues63 reported
hypothesized.37,42,45 A systematic review42 reported
that MIH-affected dentin under MIH-affected enam-
several studies indicating that chickenpox, renal
el presents few morphological alterations, of which
disease, measles, gastrointestinal disease, tonsillitis, the most significant is the increased interglobular
otitis, and adenoiditis might be related to the etiology dentin compared with a normal dentin. However, no
of MIH. Medication intake (eg, antibiotics such as structural differences were verified when compared
amoxicillin or penicillin) is strongly associated with with nonaffected enamel.
MIH etiology and development.11,46-48 Corticosteroids
and bronchodilators (asthma drugs) were related to In MIH-affected teeth, the restoration stage is
enamel defects as well.49 It is noteworthy to state that problematic because of the micromorphological
changes found in the hard tissues, which may
the mineralization of the first permanent molars
adversely affect the adhesion between the restor-
usually starts at birth and is fully completed at four to
ative materials and these substrates.24,25 A signifi-
five years of age.50 The early use of those drugs may
cantly higher bond strength to sound enamel when
have a negative influence on the amelogenesis
compared with MIH-affected enamel has been
process. Many of those factors may have influenced
reported, regardless of the type of adhesive system
or increased the odds of MIH development for the
used (total-etch or self-etch systems).23,25 The expla-
patient presented in this case report, including low
nation is that a conventional phosphoric etching
birth weight, bronchitis, anemia, and antibiotic
pattern on MIH enamel is much less pronounced,
intake. and this etching also exposes porosities and voids
The human dental enamel, in its normal state, has resulting in a ‘‘weak link for enamel-resin bond.’’25
a mineral content of 95%, which leads to a high An abnormal etching pattern in MIH-affected enam-
 Sundfeld & Others: Molar Incisor Hypomineralization Treatment

el compared with sound enamel was found in other in order to avoid PED, development of caries lesions
studies.54,61 Moreover, total-etch adhesive systems and pain, and, consequently, invasive treatments
demonstrated higher bond strength to MIH-affected such as root canal treatments or extractions.
enamel when compared with self-etch adhesive
systems.25 On the other hand, dentin adhesion Regulatory Statement
beneath hypomineralized enamel seems not to be
This study was conducted in accordance with all the
negatively affected and may be performed using provisions of the local human subjects oversight committee
either total-etch or self-etch adhesive systems.25 guidelines and policies of the Ingá University Center–
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UNINGÁ, Brazil.
Considering all of this information, all MIH-
affected enamel was removed so as not to jeopardize Conflict of Interest
the bonding quality between the adhesive system
The authors of this article certify that they have no
and enamel. This procedure ensured that margins proprietary, financial, or other personal interest of any nature
were in sound enamel since the cavosurface margins or kind in any product, service, and/or company that is
in hypomineralized enamel show less bonding presented in this article.
capability16 and may be more susceptible to margin-
(Accepted 31 August 2019)
al breakdown. An in vivo study26 found increased
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Operative Dentistry

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