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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 4  |  Page : 320-326

Conservative management of molar incisor hypomineralization using biomimetic material in a 9-year-old boy

Department of Pediatric and Preventive Dentistry, Bharati Vidyapeeth Deemed to be University Dental College and Hospital, Navi Mumbai, Maharashtra, India

Date of Submission01-Aug-2022
Date of Decision27-Sep-2022
Date of Acceptance10-Oct-2022
Date of Web Publication12-Feb-2023

Correspondence Address:
Ashwin Jawdekar
Department of Pediatric and Preventive Dentistry, Bharati Vidyapeeth Deemed to be University Dental College and Hospital, Navi Mumbai, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_114_22

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Comprehensive management of severe molar incisor hypomineralization with dental caries in a 9-year-old boy is reported. After the consultation, diagnosis and treatment planning; upon obtaining the consent from parents, and behavior modification of the child over a preparatory visit, three of the four permanent first molars (PFMs) were treated: two with indirect pulp therapy and one with direct pulp capping using tricalcium silicate cement. After observation of 1 month for each tooth, preformed stainless steel crowns (SSCs) were placed on all three PFMs in a diagonal manner for minimizing occlusal discomfort. The remaining PFM (36), restored earlier by another dentist, developed a dentoalveolar abscess during the course; the same was treated endodontically and a coronal seal was established with an SSC. A quadrant approach was adopted to complete extractions of all carious primary teeth along with the treatments of PFMs during the same appointments to minimize the number of visits. Local anesthesia with 4% articaine with adrenaline infiltrations was used for all quadrants except for the third where an inferior alveolar nerve block with 2% lignocaine with adrenaline was given. Follow-up of all PFMs, over a period of over 9 months, was uneventful. The endodontically treated PFM, too, showed satisfactory recovery, posttreatment.

Keywords: Direct pulp capping, first permanent molar, indirect pulp therapy, mineral trioxide aggregate, molar incisor hypomineralization, stainless steel crown, tricalcium silicate cement

How to cite this article:
Mungekar- Markandey S, Jawdekar A. Conservative management of molar incisor hypomineralization using biomimetic material in a 9-year-old boy. J Dent Res Rev 2022;9:320-6

How to cite this URL:
Mungekar- Markandey S, Jawdekar A. Conservative management of molar incisor hypomineralization using biomimetic material in a 9-year-old boy. J Dent Res Rev [serial online] 2022 [cited 2023 Apr 1];9:320-6. Available from: https://www.jdrr.org/text.asp?2022/9/4/320/369581

  Introduction Top

Developmental defects of enamel are common in both deciduous and permanent dentition.[1] These may be of two types – hypomineralization (defect in mineralization) and hypoplasia (defect in organic matrix formation). The term "molar incisor hypomineralization (MIH)" was first introduced in 2001 by Weerheijm et al. at the European Academy of Paediatric Dentistry Congress in Bergen.[2] MIH is defined as "a qualitative developmental defect of enamel in children and adolescents, affecting at least one permanent first molar with or without the involvement of the incisors."[3] Earlier these lesions were described with various terms: nonendemic mottling of enamel, internal enamel hypoplasia, cheese molars, nonfluoride enamel opacities, and idiopathic enamel spots or opacities.[4] The worldwide prevalence of MIH has been reported to be 14.2%[5] and it ranges from 2.4% to 40.2%.[2]

The exact cause and pathogenesis of MIH still remain unclear despite 100 years of investigation into "chalky enamel," making it a challenging etiological problem. The etiology could be related to prenatal, natal, and postnatal effects on developing enamel[6] [Table 1]. Clinically, the hypo-mineralized enamel can be soft, and porous and look like discolored chalk or old Dutch cheese. The enamel defects can vary from white to yellow or brownish but they always show a sharp demarcation between the affected and sound enamel. The porous, brittle enamel can easily chip off under the masticatory forces, the posteruptive breakdown being rapid in some cases[7]. Mathu-Muju and Wright have classified MIH into mild, moderate and severe[8] [Table 2].
Table 1: Causes of molar incisor hypomineralization[6]

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Table 2: Diagnosis of molar incisor hypomineralization (Mathu -Muju and Wright)

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The clinician faces many challenges in the management of MIH. The challenges could be classified under the following domains: (a) local anesthesia related-difficulty in achieving adequate anesthesia, (b) child related-limited cooperation of young child, limited mouth-opening, (c) development/eruption–related incomplete root development, partial eruption makes it difficult to isolate with a rubber dam, and (d) material-related adhesion of material to hypomineralized enamel due to rapid posteruptive breakdown.[9]

There is a wide array of treatment procedures for the management of MIH from minimal invasive care, to pulp therapy followed by semipermanent restorations, to extensive radicle approach with extractions followed by orthodontic intervention.[4] There has been a paradigm shift in the management of caries from the traditional approach of complete caries removal to ultraconservative partial or step-wise caries removal.[10],[11] Due to the revolutionary evolution of biomimetic materials, the management has become possible in the minimal invasive way.[12]

The aim of the present case report is to describe the management of hypomineralized first permanent molar (MIH) with an ultraconservative approach using biocompatible tricalcium silicate cement (Septodont Biodentine) to preserve the vitality of pulp and mineral trioxide aggregate (MTA) endodontic sealer for root canal treatment (RCT).

  Case Report Top

A 9-year-old boy reported to the outpatient department of Bharati Vidyapeeth Deemed to be University Dental College and Hospital, with grossly decayed teeth. The medical history was noncontributory. The patient had visited a private dental clinic earlier for the restoration of his carious lower left first permanent molar. The patient had a good clinical experience but financial constraints led them to discontinue the remaining treatment. Intraoral examination revealed that teeth, number 16, 26, 46 (According to the Fédération Dentaire Internationale numbering system) presented with deep occlusal caries with extensive enamel damage [Figure 1]. Orthopantamogram showed occlusal radiolucency due to caries involving enamel dentin and approaching pulp in 16, 26, and 46 [Figure 2].
Figure 1: Preoperative intra-oral photograph of maxillary and mandibular arch

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Figure 2: Preoperative OPG. OPG: Orthopantamogram

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The spot diagnosis for the first permanent molars was severe MIH with dental caries. After a thorough evaluation of clinical and radiographic findings, the diagnosis of 16, 26, and 46 was made as asymptomatic reversible pulpitis [Table 3]. After discussion with parent, vital pulp therapy approach was chosen and the parents were explained about the possibility of RCT at the time or later if conservative management approach fails. After obtaining a written parental consent, the treatment was started. A quadrant dentistry approach was followed to carry out the procedures in a step-wise manner. A protocol was followed to carry out selective excavation and restoration of each tooth as mentioned [Table 4].
Table 3: Examination of teeth

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Table 4: Step-by-Step protocol for carious or traumatized teeth with questionable pulp status

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In the second visit, local anesthesia, articaine with 2% adrenaline was administered, while performing partial caries excavation in 16, a pin-point exposure of the pulp became visible we placed tricalcium silicate cement (Septodont Biodentine) on the floor covering the exposure site, and restored the tooth with Resin modified glass ionomer cement (RMGIC) [Figure 3]. Extractions of 53, 54, 55 were carried out in the same visit as they were nonrestorable.
Figure 3: Photographs showing preoperative condition of 16, pin-point pulp exposure, Biodentine pulp capping, and RMGIC restoration. RMGIC: Resin-modified glass ionomer cement

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In the third visit, we followed a similar clinical protocol for the 2nd quadrant. The indirect pulp therapy (IPT) was carried out in 26 and extractions of 63, 65 as they were nonrestorable [Figure 4].
Figure 4: Photographs showing the partial excavation of 26 followed by Biodentine IPT and RMGIC restoration. RMGIC: Resin-modified glass ionomer cement, IPT: Indirect pulp therapy

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In the fourth visit, extractions of 73, 74, and 75 were carried out as they were nonrestorable. In the fifth visit, 4th quadrant was treated with a similar clinical protocol of partial caries excavation with RMGIC restoration in 46 and extractions of 83, 84, 85 [Figure 5].
Figure 5: Photographs showing partial excavation of 46 followed by biodentine and RMGIC restoration. RMGIC: Resin-modified glass ionomer cement

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After a clinical and radiographic follow-up period of 4 weeks post-RMGIC restoration for 16, 26, and 46, a definitive coronal seal was achieved with a preformed stainless steel crown (SSC) for each tooth in the 6th, 7th, and 8th visit.

The parents were informed about the periapical abscess seen on the radiograph at the distal root of 36, but they refused to undergo treatment since it was asymptomatic. Parents were also advised an orthodontic consultation [Figure 6].
Figure 6: Postoperative OPG. OPG: Orthopantamogram

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Although the patient was advised a 3 monthly follow-up, he reported with swelling and pain in the lower left back region of the jaw after 9 months. Intra-oral examination revealed a dentoalveolar abscess related to 36. After a thorough clinical and radiographic examination, diagnosis of 36 was made as chronic dentoalveolar abscess and a RCT was planned. The child was prescribed with analgesic ibuprofen 200 mg SOS up to three times a day with 6 h interval between two doses and a topical application of Metrogyl-DG gel three to four times a day for 3 days.

After obtaining a fresh written parental consent, local anesthesia was administered using 2% lignocaine with 1: 80,000 adrenaline (inferior alveolar nerve block). Access cavity of 36 was made using large round bur (BR 31), the working length was determined [Figure 7] and biomechanical preparation was completed using conventional hand files (#15-35 K-file) and intermittent irrigation with 2.5% sodium hypochlorite and normal saline. Water soluble Calcium hydroxide (RC Cal) was used as an intra-canal medicament for 2 weeks while the tooth was sealed with a temporary restoration.
Figure 7: IOPA showing working length estimation in 36. IOPA: Intraoral periapical

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Two weeks later, 36 was assessed clinically and radiographically and was found to be asymptomatic, therefore, obturation was carried out using endoseal MTA as a sealer and gutta-percha. The access cavity was restored with glass ionomer cement [Figure 8]. One week later a definitive coronal seal was achieved with a preformed SSC [Figure 9].
Figure 8: IOPA showing the obturation and postendo restoration. IOPA: Intraoral periapical

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Figure 9: IOPA showing SSC crown placed on 36. IOPA: Intraoral periapical, SSL: Stainless steel crown

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Follow-up schedule and home care measures

The child was advised to have a 6 monthly follow-up until the complete eruption of teeth. Parents were explained about the possibility of replacing the SSC, once complete occlusion develops. Parents were counseled for dietary habits such as reduction in the consumption of sugary items and increase intake of fruits and vegetables. Furthermore, the child was advised home care measures such as twice-a-day tooth brushing with a fluoride-containing toothpaste and daily mouth rinsing with a fluoride mouthwash [Table 5].
Table 5: Treatment plan/summary of treatment

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  Discussion Top

MIH is a well-known entity since a long time and its frequency of occurrence has also increased. As stated by Jälevick and Klingberg (2002) and Kotsanos et al. (2005), the children with MIH have to undergo more dental treatment as compared to one without MIH.[13],[14] MIH mainly affects the oral and functional domains of oral health-related quality of life of school-going children.[15] There have been diverse approaches for the management of MIH depending on its severity, ranging from minimal invasive method by prevention to conservative and radicle approaches of even extraction in severe cases.[16] Conserving teeth is beneficial in preserving the function as well as psychological trauma of children. We employed the conservative management of MIH by taking into considerations the current based evidence, clinical judgment at the time of excavation, and patient's preference. The current-based evidence supports the partial and step-wise caries removal as it reduces the incidence of pulp exposure by 77%.[11],[12] There is emerging evidence of direct and IPT treated with biomimetic materials yielding satisfying results.[17],[18]

Parents too were in favor of conservative approaches unless it was absolutely a must to carry out treatment like RCT. It was also evident since they refused the treatment of 36 where RCT was necessary. We, pediatric dentists, believe in minimizing the burden of care in terms of number of appointments, use of drill, minimize the number of local anesthesia administrations, hence, we followed a quadrant dentistry approach for the management of MIH as well as extractions.

During the procedures, we had used the articaine infiltration technique. Articaine is reportedly superior to that lidocaine in achieving anesthesia with an odds ratio of 2.44.[19] During the excavation of 16, there was a pulpal exposure evident; however, since the size of the exposure was <1 mm with no profuse bleeding, we placed tricalcium silicate cement (Septodont Biodentine) on the pulpal floor and completed the treatment. With the advent of such materials, the management of 26 and 46 in a conservative manner became possible.

For 36, the patient was explained about the periapical lesion at the apex of the distal root but since the tooth was asymptomatic the parent did not agree for the treatment initially. After 9 months, the patient reported for the same tooth with symptoms, and root canal therapy was completed for 36 using Endoseal MTA and gutta-percha. The use of MTA sealer has benefits in terms of sealing ability, biocompatibility, and inductive properties. Endoseal MTA used in the present case has superior handling characteristics since it is syringe-loaded and injectable. Restoring occlusion is a challenge while placing performed SSC.[20],[21] We placed the SSC in diagonal manner, i.e., 46 first followed by 26 and then 16 for allowing the occlusal adjustment.[22]

There is no one size that fits all in the management of MIH. It depends on many factors such as parent's willingness, age, severity of MIH, restorability, and long-term prognosis [Figure 10].[13]
Figure 10: Postoperative intraoral photograph of maxillary and mandibular arch

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We were unable to place a rubber dam for isolation on molars due to severe mutilation of the coronal structure of 16, 26, and 46.

  Conclusion Top

Conservative management of MIH consequences with selective caries removal and use of tricalcium silicate cement for indirect and direct pulp therapy, restorations with full coverage using preformed SSCs for first permanent molars, led to successful outcomes. Endodontic treatment with MTA sealer and gutta-percha obturation of a molar with dentoalveolar abscess led to a successful outcome, too.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their 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.


A longer follow-up, good preventive care, and age-appropriate replacement of interim restorations are recommended.


Materials used in the present case report were procured at no cost from Septodont, India, and Yogi Enterprises. However, we acknowledge their contributions with gratitude.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Jälevik B. Prevalence and diagnosis of molar-incisor- hypomineralisation (MIH): A systematic review. Eur Arch Paediatr Dent 2010;11:59-64.  Back to cited text no. 2
Wu X, Wang J, Li YH, Yang ZY, Zhou Z. Association of molar incisor hypomineralization with premature birth or low birth weight: Systematic review and meta-analysis. J Matern Fetal Neonatal Med 2020;33:1700-8.  Back to cited text no. 3
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Schwendicke F, Walsh T, Lamont T, Al-Yaseen W, Bjørndal L, Clarkson JE, et al. Interventions for treating cavitated or dentine carious lesion ns. Cochrane Database Syst Rev 2021;7:CD013039.  Back to cited text no. 12
Sauro S, Comisi J. Overview On Molar-Incisor Hypo-Mineralisation (MIH): Treatment And Preventive Approaches. Dental Biomaterials Sci-Res. 2016;1 (06).  Back to cited text no. 13
Kotsanos N, Kaklamanos EG, Arapostathis K. Treatment management of first permanent molars in children with molar-incisor hypomineralisation. Eur J Paediatr Dent 2005;6:179-84.  Back to cited text no. 14
Dantas-Neta NB, Moura LF, Cruz PF, Moura MS, Paiva SM, Martins CC, et al. Impact of molar-incisor hypomineralization on oral health-related quality of life in schoolchildren. Braz Oral Res 2016;30:e117.  Back to cited text no. 15
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. 16
Brizuela C, Ormeño A, Cabrera C, Cabezas R, Silva CI, Ramírez V, et al. Direct Pulp capping with calcium hydroxide, mineral trioxide aggregate, and biodentine in permanent young teeth with caries: A randomized clinical trial. J Endod 2017;43:1776-80.  Back to cited text no. 17
Tomás-Catalá CJ, Collado-González M, García-Bernal D, Oñate-Sánchez RE, Forner L, Llena C, et al. Biocompatibility of new pulp-capping materials NeoMTA Plus, MTA repair HP, and biodentine on human dental pulp stem cells. J Endod 2018;44:126-32.  Back to cited text no. 18
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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