Occlusal rehabilitation of a patient with dentinogenesis imperfecta:

A clinical report
Douglas A. Henke, DDS,a Todd A. Fridrich, CDT, FNBC,b and Steven A. Aquilino, DDS, MSc
College of Dentistry, University of Iowa, Iowa City, Iowa

Dentinogenesis imperfecta is one of the most common autosomal dominant traits experienced in
humans. It is equally distributed among sexes and predominantly seen in white persons. There are 3 forms of
dentinogenesis imperfecta that have been classified into
type I (osteogenesis imperfecta associated), type II
(hereditary opalescent dentin), and type III (Brandywine isolate opalescent dentin).1,2 The prevalence for
all types of dentinogenesis imperfecta is approximately
1 per 8000 subjects.3,4
The histologic structure of the mantle dentin appears
relatively normal; however, the characteristic scalloping
at the dentinoenamel junction is decreased or missing.5,6
This scalloping is thought to help mechanically lock the
2 hard tissues together and with its decrease or absence,
the enamel fractures off easily. Therefore treatment of
dentinogenesis imperfecta focuses on protecting the
affected dentin from caries and attrition, abrasion and
erosion. Options for restorative treatment usually
include full coverage crowns. Esthetics may also be of
concern in young patients and should be included in the
plan of treatment. The restorative dentist must be sure
to remove all existing enamel when preparing the tooth
for a crown and be sure to have adequate resistance and
retention form for the restoration. In addition, because
of the brittleness of the dentin, teeth restored with
crowns could be subject to fracture. Some authors recommend splinting the adjacent crowns to give more
support to individual teeth. In addition, some authors
do not recommend using teeth as abutments for fixed
partial dentures or removable partial dentures because of
their brittleness.3,4,7,8
Endodontic procedures are usually unavailable for
patients suffering from dentinogenesis imperfecta, due
to obliteration of the canals by deposition of tertiary/reparative dentin. An exception would be in
dentinogenesis imperfecta type IIIBrandywine isolate
that exhibits abnormally enlarged pulpal chambers.9 If
the canals can be found, endodontic procedures may
proceed normally. However, if the canals are found and
treated, cast post and core restorations have a quesaGraduate

Resident, Department of Prosthodontics.

Instructor and Certified Dental Technician, Department of
Prosthodontics.
cProfessor and Director of Advanced Education Program in Prosthodontics, Department of Prosthodontics.
J Prosthet Dent 1999;81:503-6.
bClinical

MAY 1999

Fig. 1. Frontal view of patient diagnosed with dentinogenesis imperfecta at initial presentation.

tionable prognosis due to morphologic changes of the

dentin and the increased probability of fracture. Short
and spindly roots also make crown lengthening procedures difficult because of poor crown to root ratios.
Other restorative options that should be considered
are the use of overdentures on vital abutments for
extremely worn dentitions or elderly patients. Dental
implants should be explored for these patients if osteogenesis imperfecta has been excluded from the diagnosis. If osteogenesis imperfecta is associated with
dentinogenesis imperfecta (type I), the associated brittleness of the bone in this disease becomes a relative
contraindication to dental implant treatment. In addition to protecting the remaining dentin, the goal of
treatment is to restore lost vertical dimension, function,
esthetics, and phonetics. This clinical report describes a
treatment solution to the problems encountered by a
dentinogenesis imperfecta restorative patient.

CLINICAL REPORT
A 27-year-old man in good general health was seen
at the University of Iowa College of Dentistry for treatment of advanced dental attrition, which resulted from
dentinogenesis imperfecta type II (Fig. 1). Diagnosis
was made from clinical and radiographic features of this
disease (Fig. 2), and osteogenesis imperfecta was
excluded from the differential diagnosis. Complete
rehabilitation of the dentition was planned, and the
patient was informed of the treatment necessary to
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HENKE, FRIDRICH, AND AQUILINO

Fig. 2. Complete mouth series of initial radiographs.

Fig. 3. Mandibular provisional restorations showing screw

access openings.

Fig. 4. Custom implant abutments for cemented implant

restorations.

restore the dentition. Because of the extreme attrition

of the mandibular dentition, the teeth were deemed
nonrestorable, and implant-supported restorations
were planned.
Diagnostic casts were obtained, duplicated, and
mounted on a semiadjustable articulator (Radial Shift,
Teledyne Hanau, Buffalo, N.Y.) at the proposed vertical dimension of occlusion. A diagnostic wax-up and
tooth arrangement was completed on the duplicated
casts to establish the desired tooth contours and positioning for the final restorations. The mandibular tooth
arrangement was used to fabricate a surgical guide for
the ideal placement of the mandibular implants. Maxillary matrices (Sta-Vac, Buffalo Mfg Co, Syosset, N.Y.)
were fabricated for evaluation of tooth reduction and
to serve as a template for fabrication of provisional
restorations.
Disease control procedures were accomplished for
the maxillary dentition. A pin-retained (Minim pin,
Whaledent Intl, New York, N.Y.) and bonded (All

Bond, Bisco Inc, Itasca, Ill.) amalgam foundation

(Tytin alloy, Kerr Mfg Co, Romulus, Mich.) was placed
in the maxillary left first molar because of the inability
to perform endodontics. All mandibular teeth were
extracted to allow healing for implant placement. Full
arch maxillary crown lengthening procedures were
then performed before tooth preparation because of
the short clinical crown height that would have made
provisional crown retention impossible. After adequate
gingival healing, all maxillary teeth were prepared for
full veneer restorations and acrylic resin ( L.D. Caulk
Division, Dentsply International Inc, Milford, Del.)
provisional restorations were placed.
Four months after extraction of the mandibular dentition, 6 endosseous implants (Nobel Biocare USA,
Inc, Westmont, Ill.) were placed and allowed to integrate for 6 months before stage II surgery. Final
implant impressions (Impregum, ESPE America, Norristown, Pa.) were made at the implant hex level to
select appropriate abutments for restoration.

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Fig. 5. Definitive mandibular implant restorations.

Fig. 7. Definitive maxillary fixed restorations.

Fig. 6. Jaw relationship records for maxillary fixed restoration fabrication.

Fig. 8. Frontal view of completed restorations.

The proper sequencing of treatment is extremely

important to achieve the desired functional and esthetic result. For this patient, the decision was made to
complete the definitive mandibular restorations and
deliver them before the maxillary restorations were
finalized. A diagnostic mounting was made for the
maxillary provisional restorations opposing the implant
master cast at the determined vertical dimension of
occlusion. During the diagnostic waxing and processing of the provisional restorations (Biolon Crown and
Bridge Resin, Dentsply/York Division, Dentsply International Inc, York, Pa.), it was determined that the
position and angulation of the implants would require
custom-fabricated abutments to eliminate screw access
openings from the functional cusps of the mandibular
molars and the incisal edges of the anterior teeth
(Fig. 3). Custom abutments were waxed and cast to
allow the final restorations to be cemented over the top
of these copings (Fig. 4).
The mandibular restorations were completed and
cemented provisionally (Temp Bond, Kerr Mfg Co) to

evaluate occlusion and tissue response and to allow

access to the abutment screws, if needed (Fig. 5). Maxillary tooth preparations were finalized and jaw relationship records were made with autopolymerizing
acrylic resin copings (GC Resin, GC America Inc)
(Fig. 6). Because of the short maxillary preparations
and the questionable dentin strength, the final restorations were splinted in segments, No. 3-4, No. 6-7-8,
and No. 9-10-11 (Fig. 7).
A canine-protected occlusion was developed in the
final restorations to decrease lateral forces on the posterior dentition. Protrusive guidance was evenly distributed
across the maxillary incisors opposing the incisors and first
premolars of the mandibular implant-supported prostheses. Completed maxillary restorations were provisionally
cemented to evaluate tissue response, esthetics, function,
and phonetics before permanent cementation (Fig. 8).
Maxillary restorations were permanently cemented with a
resin-modified glass ionomer cement (Vitremer, 3M Dental Products, St. Paul, Minn.). The mandibular implant
prostheses were left provisionally cemented.

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DISCUSSION
This clinical report illustrates 1 solution to the problems encountered when restoring a patient with a congenital abnormality such as dentinogenesis imperfecta.
The inability to perform such routine procedures as
endodontic therapy makes the treatment planning of
this type of patient all the more critical. Because of the
short root structure of this congenital defect, crown
lengthening procedures should be seen as a relative
contraindication. The final crown-to-root ratio in the
maxillary dentition of this patient was approximately
1:1, which is acceptable but not optimal. In addition,
crown lengthening before tooth preparation in a
patient with teeth that lack clinical height for provisional crown retention must be recognized and
sequenced properly.
With the introduction of mandibular implants in this
patient, and because of the lack of a periodontal ligament surrounding the implants, the possibility of
increased forces on the maxillary dentition could be
introduced. The lack of a periodontal ligament in
implant restorations deprives the patient of the majority of the periodontal mechanoreceptors that signal
occlusal overload.10 Therefore mandibular implant
restorations could possibly overload the maxillary
toothsupported restorations because of their compromised length and altered anatomic structure. This is a
concern that must be monitored closely.
The occlusion on implant restorations is one of
much interest and opinion.11-13 The development of
canine guidance on an implant restoration may transfer
a nonaxial load to the implant-abutment interface and
cause screw loosening or screw fracture. However,
because the mandibular canines were splinted to 2
other implants with fixed restorations, support for this
type of occlusion was believed to be the best option to
relieve lateral forces on the posterior dentition.

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Reprint requests to:

DR STEVEN A. AQUILINO
DEPARTMENT OF PROSTHODONTICS
414 DENTAL SCIENCE BLDG. S
COLLEGE OF DENTISTRY
UNIVERSITY OF IOWA
IOWA CITY, IA 52242-1001
E-MAIL: steve-aquilino@uiowa.edu
Copyright 1999 by The Editorial Council of The Journal of Prosthetic
Dentistry.
0022-3913/99/$8.00 + 0. 10/1/97146

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