Molar Incisor

Hypomineralization (MIH)

Presented by:

Dr/ Christeen Azer

Dr/ Reem Ahmed
Dr/ Wardshah Raafat
 Table of contents
1 2 3
Definition Etiology Clinical
picture

4 5 6
Differential Treatment
diagnosis Classification modalities &
preventive
measures
 Definition
Molar incisor hypomineralization (MIH)
refers to a systemic-origin hypomineralization
that primarily affects one to four permanent
first molars and is often accompanied by
permanent incisors
The European Academy of Paediatric Dentistry
first defined MIH as a qualitative defect in
enamel formation . This
condition typically presents as distinct
white-yellow or yellow-brown opacities
 Etiology
•MIH is believed to arise from a complex interaction
of systemic, environmental, and possibly genetic
factors that disrupt amelogenesis (enamel
formation) in developing teeth, especially first
permanent molars (FPMs) and incisors.
•The critical window for disturbance is between 28
weeks in utero and the first 10 days after birth,
when ameloblasts are active
Prenatal Factors (Before Birth)
Maternal pyrexia (fever):
→ Can impair ameloblast function or even cause cellular
degeneration.
Maternal diabetes:
→ Leads to maternal hypocalcemia and reduced oxygen for the
infant, disrupting enamel formation.
Prolonged maternal nausea, vomiting:
→ Leads to fluid, electrolyte, and nutritional disturbances,
causing fetal biochemical imbalance.
Use of myometrium spasmolytics
→ Side effects (nausea, vomiting, fetal hypocalcemia) can
impair amelogenesis.
•Perinatal Factors (Around Birth)
Low birth weight / preterm birth:
→ Miss out on last-trimester calcium and phosphorus accumulation → mineral
deficiency.

Neonatal hypocalcemia:
→ Common in premature infants, especially with respiratory distress or birth asphyxia.
Complicated or prolonged delivery:
→ Can cause birth asphyxia (oxygen shortage).
Cesarean delivery (especially elective):
→ Increased risk of neonatal respiratory problems and hypoxia.
Spinal anesthesia during cesarean:
→ Can cause maternal hypotension → nausea/vomiting → occasional infant hypoxia.
•Postnatal Factors (After Birth)

Infectious illnesses (associated with fever):

Otitis media (ear infections), pneumonia, asthma, urinary tract infections,
chickenpox.

Antibiotic use:
→ Particularly amoxicillin in the first year, associated with MIH and enamel defects.
Environmental toxicants:
→ Dioxins, PCBs (from environmental exposure or breast milk) linked to enamel
defects
 Clinical picture
• Disruption during enamel mineralization
• FIRST molars, permanent incisors
• Asymmetrical
•(molars/incisors, random pattern White,
yellow, or brown demarcated opacities
• Soft, porous, prone to post-eruptive
breakdown Post-eruptive breakdown (PEB)
Common, especially on molars Pattern
• Demarcated (clear borders
 Differential diagnosis
•White spot lesion
•This is the earliest clinical sign of caries. The lesions
appear chalkier, matt or more opaque than the
adjacent sound enamel. They can be distinguished
from MIH because they occur in areas of plaque
stagnation, such as the cervical margin of the tooth.
•Traumatic hypomineralisation
•This is associated with a history of dental
trauma to the primary predecessor tooth.
Periapical infection of the primary tooth can
disturb mineralisation of the underlying tooth
germ. It has a wide variety of clinical
presentations differing in shape, outline,
localisation and colour. It is often limited to one
tooth and asymmetrical
•Enamel hypoplasia
•This is a quantitative defect with reduced enamel
thickness. The borders of hypoplastic enamel lesions are
mostly regular and smooth, indicating developmental and
pre-eruptive lack of enamel. The margins in MIH with
post-eruptive enamel breakdown are sharp and irregular
due to post-eruptive shearing of weakened enamel.
•Amelogenesis imperfecta
This is a genetic condition which results in enamel
that is hypoplastic, hypomature, or
hypomineralized. In this condition, all teeth in both
dentitions are affected and a familial history is
often present.
Classification of MIH
16
Treatment
modalities
 Wurzburg
concept
( MIH - TNI )
Bekes K, Steffen R, Krämer N. Update of the molar incisor hypomineralization: Würzburg concept.
Eur Arch Paediatr Dent. 2023;24(6):807-813. doi:10.1007/s40368-023-00848-5
 Wurzburg
concept
( MIH - TNI ) The MIH- TNI captures the
clinical key symptoms of
MIH , It includes the
presence and the extent
of the breakdown and
the problem of
hypersensitivity .
 Treatment
Approaches
 Treatment Approaches
Therapy A = Prevention .
Therapy B = Non - invasive Therapy .
Therapy C = Short Term Temporary .
Therapy D = Long term Temporary .
Therapy E = Permanent Therapy .
Therapy F = Extraction .
Therapy A
Prophylaxis -
Regeneration
A1 = At home
Toothpaste containing Fluoride 2 / day .

A2 = At Office
Topical Fluoride Varnish 2-4 /Year .
Therapy B
Non- invasive
therapy Molars
B1 = Fissure Sealant Flowable
B2 = GIC
Incisors
B3 = Bleaching (Adolescent Only )
B4= Micro- abrasion
B5= Infiltration
Therapy C
Short -term
Temporary
C1= GIC
C2 = GIC + Orth band
C3 = SDF + GIC
C4= SDF
Therapy D
Long term
Therapy
D = SS crown
Zirconia Crown
Therapy E
Permanent
therapy

E1 = Direct composite
E2 = Indirect option
Therapy F
Extraction

Indication :-
Massive breakdown with
pulp involvement or dental
abscesses
Treatment
Plane
1- Posterior teeth
2- Anterior teeth
Treatment Plan
1- Posterior teeth
2- Anterior teeth
The evidence collected indicates that the treatment
of MIH should be customized according to the
severity of the case, the age of the patient, and other
variables. There is no universal approach that is
effective for all patients with MIH and combined
techniques are recommended.
Denis M, Atlan A, Vennat E, Tirlet G, & Attal JP (2013) White defects on enamel: diagnosis and anatomopathology:two essential factors for proper
treatment (part 1) International Orthodontics 11(2) 139-165.
1) Dental Sealants and Application of
Fluoride Paints and Casein Products
Application of fluoride varnishes (FVs) and casein-based
products has emerged as a pivotal preventive and
therapeutic strategy.
■ Fluoride varnishes function by promoting
remineralization of the affected enamel, thereby
enhancing resistance to dental caries and reducing
dentinal hypersensitivity. They form a temporary
protective layer over the hypomineralized areas,
slowing down enamel demineralization and
enhancing the fluoride uptake by the tooth surface.
1) Dental Sealants and Application of
Fluoride Paints and Casein Products

■ Casein phosphopeptide–amorphous calcium phosphate

(CPP-ACP) based products, derived from casein, have shown
promise in managing MIH. CPP-ACP acts by maintaining a
supersaturated environment of calcium and phosphate ions at
the tooth surface, thus promoting remineralization and
inhibiting further demineralization of the enamel. Together, the
synergistic use of fluoride varnishes and casein-based products
provides a holistic approach to halt the progression of MIH and
restore the structural integrity of the affected teeth.
2) Fluorinated Silver Diamine Therapy
■ Both silver diamine fluoride (SDF)
application alone and SDF followed
by Hybrid Glass Ionomer Cement
(SMART) sealants were effective in
treating MIH-affected molars, by
arresting carious lesions and
desensitization.
■ Marginal discoloration due to SDF
application was a common
drawback in SMART(Silver Modified
Atraumatic Restorative Technique)
sealants.
3) Low-Level Laser Therapy

■ Authors suggested that LLLTʼs anti-inflammatory

properties contributed to reducing sensitivity in
teeth affected by MIH.
■ Combination of LLLT and fluoride varnish had a
similar desensitizing effect to fluoride varnish
alone at the end of treatment. However, LLLT
provided immediate relief, while fluoride varnish
had a delayed effect.
3) Low-Level Laser Therapy
4) Tooth bleaching
4) Tooth bleaching
5) Resin infiltration
5) Resin infiltration
Tooth bleaching
Resin infiltration
6) Macroabrasion + composite restoration
7) Combined treatment ( Microabrasion +
Macrosbradion + Deep infiltration + Composite )
7) Combined treatment
7) Combined treatment
8) Direct and Indirect Resin and Composite
Restorations
● In mild and severe cases, molars with
MIH often require restorative
interventions to ensure long-term oral
health and function.
● For direct composite restorations,
researchers concluded that when the
cavity preparation is conservative, both
self-etching adhesives and total-etch
adhesives can be used for restorations
in molars affected by MIH, resulting in
good clinical success rates.
● Indirect resin composite restorations CREDITS: This presentation template was created by Slidesgo, and
includes icons by Flaticon, and infographics & images by Freepik
were particularly advantageous in
terms of child satisfaction due to
shorter treatment sessions
7) Direct and Indirect Resin and Composite
Restorations
8) Full coronal coverage restorations

• All three types of crowns have shown excellent retention over

24 months.
• None of the crowns showed any sign of secondary caries.
• Complete resolution of hypersensitivity
• Parents and children have shown a preference for
tooth-colored crowns i.e., Lithium disilicate and Zirconia.
8) Full coronal coverage restorations
 References
■ Inchingolo AM, Inchingolo AD, Viapiano F, Ciocia AM, Ferrara I, Netti A, Dipalma G, Palermo A, Inchingolo F. Treatment Approaches to
Molar Incisor Hypomineralization: A Systematic Review. J Clin Med. 2023 Nov 20;12(22):7194. doi: 10.3390/jcm12227194. PMID: 38002806;
PMCID: PMC10671994.

■ Enax J, Amaechi BT, Farah R, Liu JA, Schulze Zur Wiesche E, Meyer F. Remineralization Strategies for Teeth with Molar Incisor
Hypomineralization (MIH): A Literature Review. Dent J (Basel). 2023 Mar 13;11(3):80. doi: 10.3390/dj11030080. PMID: 36975577; PMCID:
PMC10047667.

■ Zaghdoudi Hajer*; Douki Nabiha; Ben Amor Faten. Minimally Invasive Therapy for Treating White Spot Lesions on Anterior Teeth in
Molar Incisor Hypomineralization : Case report.Faculty of Dental Medicine, Monastir University,Published: Aug 23, 2023.

■ Bekes K, Steffen R, Krämer N. Update of the molar incisor hypomineralization: Würzburg concept. Eur Arch Paediatr Dent.
2023;24(6):807-813. doi:10.1007/s40368-023-00848-5
■ Z. Almuallem and A. Busuttil-Naudi, Molar incisor hypomineralisation (MIH) – an overview. Official journal of the British Dental
Association. VOLUME 225 NO.7 | OCTOBER 12 2018.
■ S. K. Singh, A. Goyal, K. Gauba. S. Bhandari.S. Kaur.Full coverage crowns for rehabilitation of MIH affected molars:
■ 24 month randomized clinical trial.European Archives of Paediatric Dentistry.August 2021 https://doi.org/10.1007/s40368-021-00657-8
■ Denis M, Atlan A, Vennat E, Tirlet G, & Attal JP (2013) White defects on enamel: diagnosis and anatomopathology:two essential
factors for proper treatment (part 1) International Orthodontics 11(2) 139-165.
Thanks!
CREDITS: This presentation template was created by Slidesgo, and
includes icons by Flaticon, and infographics & images by Freepik