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Year : 2020  |  Volume : 12  |  Issue : 4  |  Page : 248-250

A conservative approach in management of a molar incisor hypomineralization: Report of a case

1 Department of Pediatric and Preventive Dentistry, Yamuna Institute of Dental Sciences and Research (YIDSR), Village Gadholi, Yamauna Nagar, Haryana, India
2 Department of Pediatric and Preventive Dentistry, Himachal Dental College, Sundernagar, Himachal Pradesh, India
3 Department of Pediatric and Preventive Dentistry, Christian Dental College, Ludhiana, Punjab, India

Date of Submission23-Jan-2020
Date of Decision04-Aug-2020
Date of Acceptance25-Aug-2020
Date of Web Publication13-Oct-2020

Correspondence Address:
Ramneet Kaur
Department of Pediatric and Preventive Dentistry, Yamuna Institute of Dental Sciences & Research (YIDSR), Village Gadholi, Yamuna Nagar, 133 103, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJDS.IJDS_11_20

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Enamel hypomineralization is a developmental defect of enamel occurs due to disturbances in early calcification or maturation during amelogenesis. It can be seen in both the primary and permanent dentitions. These defects usually involves permanent molars and incisors presenting as well demarcated, asymmetrical opaque lesions varying from white to yellow or brown in color. Partial or complete loss of enamel in these soft, porous, and hypomineralized teeth leads to hypersensitivity, impaired masticatory functions, and esthetics. Difficulty in achieving local anesthesia and managing behavior of a young and fearful child makes it even more challenging to the clinicians that necessitate the use of a more conservative approach during the dental treatment. Therefore, we are presenting here a case of diagnosis, restorative, and esthetic correction of molar incisor hypomineralization in a 12-year-old child with least invasive clinical procedures.

Keywords: Developmental defects, enamel hypoplasia, molar incisor hypomineralization

How to cite this article:
Kaur R, Sharma A, Pathania V, Kundra R. A conservative approach in management of a molar incisor hypomineralization: Report of a case. Indian J Dent Sci 2020;12:248-50

How to cite this URL:
Kaur R, Sharma A, Pathania V, Kundra R. A conservative approach in management of a molar incisor hypomineralization: Report of a case. Indian J Dent Sci [serial online] 2020 [cited 2022 Aug 15];12:248-50. Available from: http://www.ijds.in/text.asp?2020/12/4/248/298025

  Introduction Top

According to Weerheijm et al. (2001), molar incisor hypomineralization (MIH) is defined as the hypomineralization of systemic origin that affects one to four permanent first molars (usually affecting the cuspal areas of molars) that is frequently associated with permanent incisors.[1] Earlier in dental history, these kind of developmental defects of enamel in molars were also termed as cheese molars, hypomineralized Permanent first molars (PFM) or idiopathic enamel hypomineralization in PFM.[2],[3],[4] Posteruptive enamel breakdown (PEB) in hypomineralized teeth occurs shortly after tooth eruption leading to the increased tooth sensitivity and rapid progression of caries.[3],[5]

  Case Report Top

A 12-year-old male child reported to the Department of Pediatric and Preventive Dentistry with a chief complaint of decayed teeth in upper front tooth region with increased sensitivity to hot and cold. His parents gave a medical history of repeated episodes of fever during 1st year of life. There was no history of oral or dental trauma. During intraoral examination, dental caries with demarcated opacities at borders in hypomineralized defects were observed in teeth. 11, 21, 22 revealed atypical cavities on the labial surfaces with irregular margins having yellowish opacities. 16, 26, 36, 46 revealed large atypical cavities mainly involving the cuspal areas and sparing the cervical margins [Figure 1]. In the present case, Scoring was done based on EAPD criteria (2003)[6] and Severity was recorded according to Mathu-Muju and Wright[7] criteria of hypomineralized permanent incisors and permanent first molars [Table 1]. Intraoral periapical revealed deep caries involving pulp in immature young permanent teeth with open apex w.r.t 36, 46 [Figure 2]. Treatment modalities based on the best clinical practice guidance developed by EAPD[8] including preventive measures to functional rehabilitation. Preventive protocol included diet counseling as child taking diet with increased amount of sweets. The use of fluoridated toothpaste and mouthwash was recommended. Oral prophylaxis was carried out and topical fluoride applications were scheduled twice in a year. The child had increased tooth sensitivity, therefore, excavation of caries was carried out under local anesthesia in maxillary permanent molars and incisors. Tooth sensibility test was carried out to check the vitality of 36, 46. Thermal testing revealed that the teeth were vital. Mineral trioxide aggregate (MTA) pulpotomy was carried out in 36 and 46 to allow the continuation of apex formation [Figure 3]. Stainless steel crowns were placed on maxillary permanent first molars after excavation of dental caries to prevent their further breakdown [Figure 4]. The caries removal and crown preparation in permanent first molars required lot of patience and constant reassurances to patient as even after anesthesia, he still had some sensitivity while treatment. Esthetic correction was carried out conservatively by treating the permanent upper incisors by composite resin restorations [Figure 4]. The follow up appointments were scheduled to check the root formation in 36 and 46. Single tooth crossbite was seen in 11, the child was referred to orthodontic department for its correction.
Figure 1: Atypical cavities seen in permanent first molars and incisors

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Table 1: Scoring (the European Academy of Pediatrics. Dentistry criteria, 2003) 7 and Severity (Mathu-Muju and Wright 2006)[7] of hypomineralized permanent incisors and permanent first molars

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Figure 2: Intraoral periapical revealed deep caries involving pulp with immature apex in 36, 46

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Figure 3: Intraoral periapical showing MTA pulpotomy in 36, 46

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Figure 4: Composite restoration on permanent incisors and crowns placed on 16, 26

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  Discussion Top

First evidence of calcification in first permanent molars is seen at birth at the cusp tips that get united around the age of 6 months, any disturbance locally or systemically during this period can cause developmental defects in enamel. Various systemic conditions or environmental factor may contribute to MIH, that mainly includes repeated episodes of high fever during the 1st year of life, ear infections, tonsillitis, respiratory tract infections, allergical reactions, difficult delivery, preterm birth, use of antibiotics during infancy or by mother during pregnancy or breastfeeding have been reported to cause such defects by altering the sensitive ameloblasts in their maturation phase.[2],[4],[5],[9]

The well-established criteria recommended by the EAPD (2003)[6] for the diagnosis of MIH was used: The presence of demarcated opacities-1, PEB-2, atypical restoration-3, extraction due to MIH-4, failure of eruption of a molar or incisor-5. In the present case, all the incisors and molars were scored 2 as they exhibited post eruptive enamel breakdown. In addition, based on severity, the hypomineralized first permanent molars teeth in this report are classified as severe according to Severity criteria given by Mathu-Muju and Wright[7] that indicates widespread PEB/caries involving more than 2 surfaces and tooth hypersensitivity. The permanent incisors were classified as moderate that indicates PEB/caries involving one or two surfaces.

MIH presents as a challenge to the dentists as the post eruptive enamel breakdown of soft, porous hypomineralized teeth leads to the increased sensitivity to hot and cold. Difficulty in achieving local anaesthesia in hypomineralized teeth makes it hard to remove caries completely.[3],[10] Behavior management of a young child while doing the treatment of MIH becomes crucial here. Child compliance is needed to be maintained constantly. In the present case also, the treatment of molars reduced the sensitivity and pain making the child more positive towards the outcome of dental procedure. Even after having difficulty while getting the treatment done, he was willing to cooperate to get the treatment done for other teeth especially for esthetic correction in anterior teeth. Patience and positive reassurances by the dentists helps in making child patient comfortable.

The child being 12 years of age with permanent mandibular first molars erupted 4–5 years earlier resulted large atypical cavities with rapid caries progression involving pulp. Permanent maxillary first molars and incisors were saved from pulpal treatment. Early diagnosis at the age of 6–8 years leads to more of preventive measures than therapeutic treatment. Knowledge of MIH, its diagnosis and appropriate treatment is of high need for dentists to provide early and better dental care to the children.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Weerheijm KL, Jalevik B, Alaluusua S. Molar-incisor hypomineralisation. Caries Res 2001;35:390-1.  Back to cited text no. 1
Koch G, Hallonsten AL, Ludvigsson N, Hansson BO, Holst A, Ullbro C. Epidemiologic study of idiopathic enamel hypomineralization in permanent teeth of Swedish children. Community Dent Oral Epidemiol 1987;15:279-85.  Back to cited text no. 2
Leppaniemi A, Lukinmaa PL, Alaluusua S. Nonfluoride hypomineralisation in the permanent first molars and their impact on treatment need. Caries Res 2001;35:36-40.  Back to cited text no. 3
Van Amerongen WE, Kreulen CM. Cheese molars: A pilot study of the etiology of hypocalcifications in first permanent molars. J Dent Child 1995;62:266-9.  Back to cited text no. 4
Lygidakis NA, Dimou G, Marinou D. Molar-incisor-hypomineralisation (MIH). A retrospective clinical study in Greek children. II. Possible medical aetiological factors. Eur Arch Paediatr Dent 2008;9:207-17.  Back to cited text no. 5
Weerheijm KL, Duggal M, Mejàre I, Papagiannoulis L, Koch G, Martens LC, et al. Judgement criteria for molar incisor hypomineralisation (MIH) in epidemiologic studies: A summary of the European meeting on MIH held in Athens, 2003. Eur J Paediatr Dent 2003;4:110-3.  Back to cited text no. 6
Mathu-Muju K, Wright JT. Diagnosis and treatment of molar incisor hypomineralisation. Compend Contin Educ Dent 2006;27:604-10.  Back to cited text no. 7
Lygidakis NA, Wong F, Jälevik B, Vierrou AM, Alaluusua S, Espelid I. Best clinical practice guidance for clinicians dealing with children presenting with molar-incisor hypomineralisation (MIH). An EAPD policy document. Eur Arch Paediatr Dent 2010;11:75-81.  Back to cited text no. 8
Jälevik B, Norén JG. Enamel hypomineralization of permanent first molars: A morphological study and survey of possible aetiological factors. Int J Paediatr Dent 2000;10:278-89.  Back to cited text no. 9
Jälevik 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.  Back to cited text no. 10


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1]


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