An Interdisciplinary Approach for Rehabilitation of a Patient with Amelogenesis Imperfecta: A Case Report

An interdisciplinary approach can be used to treat the uncommon hereditary defect known as amelogenesis imperfecta, which is characterised by insufficient crown length, hypersensitivity, dental caries, and decreased vertical dimension. The present case report describes a successfully managed case of amelogenesis imperfecta with full mouth rehabilitation using implant supported prosthesis. This interdisciplinary approach helped to restore the function and aesthetic of an adult patient, which was followed up for six years without any complications.

Based on the clinical and radiographic findings, the patient was diagnosed with hypoplastic amelogenesis imperfecta with chronic generalised marginal gingivitis.
Based on his desire to restore the aesthetic and function of the dentition, a full mouth rehabilitation was planned involving the department of periodontics, oral surgery, endodontics, and prosthodontics.The entire treatment plan was explained to the patient, and informed consent was obtained.A complete haemogram was advised, which depicted values within normal limits.Diagnostic impressions and study casts were prepared, and ridge mapping was done to determine the size of the implant (Figure 3).Initially, the patient underwent scaling and root planing with oral hygiene instructions.The patient was advised to have hopeless teeth extracted (#18, #17, #16, #11, #34, #45, #46, and #47) and root canal treatment for all remaining teeth.Furthermore, implant surgery for replacement of missing teeth followed by insertion of fixed prosthesis was planned.
After a month, surgical therapy was scheduled.The patient was instructed to use a 0.2% chlorhexidine mouth rinse prior to surgery.Left inferior alveolar and long buccal nerve block was administered using 0.2% Lignocaine with adrenaline.A crestal incision extending from #34 to #36 tooth regions was given with the help of #15 surgical blade, followed by reflection of the mucoperiosteal flap using Molt's #9 periosteal elevator (Figure 4a).Osteotomy site preparation in relation to 34 was carried out initially with a Tri-step drill at a speed of 800 rpm, along with saline irrigation.Further, the preparation was followed by pilot drills with a diameter of 2.8 mm and 3.5 mm in a sequential manner (Figure 4b).
An implant depth gauge and parallel pin were used to ensure the depth and angulation for implant placement (Figure 4c).In regard to #34, the ADIN Touareg Close Fit TM Dental Implant (AFULA, Israel) sized 3.75 mm x 13 mm was inserted.Torque was applied using a hand wrench at a rate of 35 N/cm.Simultaneously, the osteotomy site was prepared at #36, and implant of size 5*10 mm 2 was inserted.After the insertion, cover screws were secured, and the sites were thoroughly irrigated.In addition, flaps were approximated, sutured with 4-0 silk sutures using the interrupted loop suturing technique (Figure 4d).Then, the operated site was protected using periodontal dressing (COE-PAK TM GC America).
The patient was prescribed capsule amoxicillin with a dosage of 500 mg three times daily for a week and tablet ibuprofen 400 mg three times daily for three days.Chlorhexidine mouth rinse 0.2% (10 mL) was also prescribed twice daily for two weeks.Periodontal dressing and suture removal were done two weeks postoperatively.Likewise, implant placement was completed sequentially in relation to #16, #26, #42, #44, and #46 at a two-week gap for each quadrant (Figure 5).During the maintenance phase, satisfactory healing was observed.
After four months, the patient was recalled.The implants were exposed, and cover screws were replaced with

DISCUSSION
Patients with AI often experience impaired aesthetics and problems in mastication, leading to early tooth loss. 5Various treatment modalities can be opted by such patients to optimise the longevity, such as orthognathic surgery, prosthetic crowns, veneers, etc.For the replacement of missing teeth, dental implants provide promising treatment alternatives.The alveolar ridge and neighboring natural tooth structure are preserved. 6e restrictions include a lack of accessible space, a thin enough alveolar ridge, and insufficient alveolar bone support for the gingival papilla. 7Implant surgery to replace missing teeth was planned for our patient, followed by the insertion of a fixed prosthesis.Therefore, a multidisciplinary strategy requiring the roles of a prosthodontist, maxillofacial surgeon, endodontist, and periodontist was required for long-term success in the present case.Other clinicians also successfully applied this strategy. 1,5 patients with AI, Ameri et al. 8 recommended extractions of all unrestorable teeth and rehabilitation with implant-supported prosthesis as the most effective choice, which was also carried out in the present case.
Previous literature revealed that fixed implant-supported prosthesis achieved high cumulative survival rates. 9Full mouth rehabilitation was done with zirconia crowns in the anterior segment to restore the patient's esthetic and porcelain fused to metal crowns in the remaining posterior teeth.The benefit of using a zirconia crown has been evidenced in various studies as its low weight reduces the gravity-induced loading stress. 8 addition, crown lengthening was performed in anterior teeth in the patient to increase the extent of supragingival tooth structure and to allow a healthy, optimal relationship between the restoration and the periodontium.It is also a viable option for improving aesthetics, as suggested by previous report. 10As a result, clinicians must consider treatment options that balance the aesthetics and functional needs of the patient for their overall well-being and long-term prognosis.

SUMMARY
Complete rehabilitation of an AI patient is a constant challenge to the clinician which necessitate an interdisciplinary approach with active involvement of various branches of dentistry.This approach should be oriented towards sustaining the functional, aesthetic and physical well-being of the patient.

ACKNOWLEGEMENT
The authors would like to acknowledge and thank Dr. Devendra Mandhyan from the Department of Prosthodontics and Maxillofacial Prosthetics for his insightful advice regarding the management of the present case.Additionally, the authors would also like to acknowledge the patient for his good compliance and cooperation during the treatment.

Figure 4 :
Figure 4: A) Full thickness flap reflection with exposure of alveolar ridge of the third quadrant.B) Osteotomy sites were prepared in relation to #34 and #36.C) Parallel pins placed within osteotomy sites.D) Interrupted loop suturing done.

Figure 6 :
Figure 6: Surgical crown lengthening done.Figure 7: Post-operative clinical view after placement of implant supported fixed prosthesis.

Figure 7 :
Figure 6: Surgical crown lengthening done.Figure 7: Post-operative clinical view after placement of implant supported fixed prosthesis.

Figure 8 :
Figure 8: A) Post-operative radiographic view after one year of full mouth rehabilitation.B) Post-operative radiographic view after six years of full mouth rehabilitation.