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Dental Tribune Middle East & Africa Edition | January-February 2016 23 paediatric Tribune < Page 22 developmentally absent teeth. Consultation with an orthodon- tist is advised. According to the Royal College of Surgeons of England Guide- lines for the Extraction of First Permanent Molars in Chil- dren, the ideal timing of first permanent molar extraction is between 8-10 years of age after the eruption of the lateral inci- sors but before the eruption of the second permanent molars and second premolars. Tradi- tionally, for the most optimum mesial movement of the second permanent molar to occupy the place of the extracted FPM and produce the best occlusal posi- tion, t it has been suggested that the second permanent molar is demonstrating radiographic evidence of calcification in the root bifurcation. (7) Case report A ten-year-old patient (S.S) with no significant medical history or allergies presented to the Department of Paediat- ric Dentistry at Hamdan Bin Mohammed College of Dental Medicine (HBMCDM) in Dubai Healthcare City, Dubai (UAE). Complaining of slight pain due to a dislodged filling in her up- per left region. Presently the tooth is asymptomatic. The pain is described as intermit- tent during the day, lasts for a while (hour or less), does not stop her playing or affect her sleep. Detailed history was taken from the father. The father reported that (S.S) had a sig- nificant number of upper respi- ratory tract infections and ton- sillitis during early years of life. Clinical and radiographic ex- amination of (S.S) revealed yellowish discoloration of the enamel on the occlusal sur- faces of 16 and 26. 26 presented with a dislodged filling, 36 and 46 had big composite fillings. The presentation of the FPM is consistent with the diagnosis of molar incisor hypomineralisa- tion (MIH) without incisor in- volvement. The oral soft tissue appeared healthy with fair oral hygiene, microdontia of upper lateral incisors (peg shaped), with Stained fissures of lower primary molars. Radiographic investigations were done including (OPT and PA radiographs) to assess the proximity of the coronal defect to the pulp and to evaluate the periapical region and to ascer- tain the presence and stage of development of remaining per- manent dentition (especially lower 7s, 5s and 8s). MIH was diagnosed based on clinical appearance. See Fig- ures 1 (a, b, c, d & e) for clinical features. Figures 2 (a, b & c) for radiographic findings. A diagnostic list and treatment plan was formulated by a spe- cialist of Paediatric dentist as well as orthodontist and ex- plained in detailed to the father. Diagnostic Summary A fit and healthy 10-year-old girl in the late mixed dentition with molar incisor hypominer- alisation (MIH). MIH was diag- nosed based on clinical appear- ance. Aims and objectives of treat- ment • To alleviate the pain and sensitivity. • To preserve the structure of the weakened FPMs. • To formulate an individu- alized realistic preventive scheme and reinforce it regu- larly. • To monitor the occlusion of developing dentition and treat as necessary. • Maintain good oral health in the long term. Treatment Plan Short /medium term • Emergency phase o Sedative filling of 26 • Preventive care phase o Oral hygiene instructions o Diet analysis and advice o Plaque score o Fluoride advice •Restorativetreatmentphase o Stainless steel crowns for all permanent first molars • Recall and reviews o Regular recall 3 months, ra- diographs every 6 months and fluoride varnish application ev- ery 3 months Medium / long term • Monitor the eruption of per- manent dentition • Interdisciplinary manage- ment Treatment The treatment plan was set in two phases including Short/ Medium term and long term. The short term will start with Emergency phase for restoring the 26 with GI as a temporary filling. An extensive preventive programme was implemented to improve SS’s oral hygiene in addition to diet assessment, analysis, and advice and fluo- ride application. In several visit crown preparation was done under local anesthesia for 36, 46, 16, and 26 followed by stain- less steel crown placement. Pa- tient’s occlusion was checked for any discrepancy in each visit. As S.S’s is considered to be of high caries risk status .She was kept on regular recall programme including recall visits and fluoride varnish ap- plication every 3 months, ra- diographs every 6 months. See Figures 3 (a, b, c, d & e). Long Term Treatment Plan and Future Considerations • Regular long-term diet monitoring and reinforcement of oral hygiene practices. • Periodic review of the res- torations with radiographic as- sessment. • Review the first permanent molars status. • Monitor eruption and devel- opment of dentition. • Educate patient and parents about the poor long-term prog- nosis of first permanent molars these teeth and available future treatment options. Discussion Children with MIH have higher treatment needs and signifi- cant challenges in behaviour management than other chil- dren. S.S was a quiet girl who was apprehensive in the begin- ning of the dental treatment but willing to have the treatment. S.S was diagnosed as MIH in first permanent molars. Using non-pharmacological behav- iour management techniques including tell-show-do, dis- traction helped to acclimatize S.S to dental treatment. These techniques are widely used in children’s dentistry and well accepted by parents. The tech- nique works well combined with behaviour shaping. S.S was rewarded with a gift after each appointment as positive reinforcement for her good be- haviour and cooperation. 26 was temporized with glass ionomer to relief discomfort, stabilize the situation and to re- duce bacterial count present in the oral cavity. Failure of achieving complete anaesthesia of first perma- nent molars was related to the nature of MIH. S.S received supplemental intralegmental infiltration. The innervations density in the pulp of hypomin- eralised molars is significantly greater than of normal molars. This can explain why lower left 6 was hard to be anaesthetised. Due to poor quality of the FPM teeth of S.S and significant tooth break down full cover- age by preformed metal crowns was done. Preformed metal crowns prevent further tooth loss, control sensitivity, estab- lish correct interproximal and proper occlusal contacts, are not costly and require little time to prepare and insert. Conclusions • The presence of MIH mo- lars not only requires the den- tist to identify problems at the earliest opportunity, but also to clarify the problem thoroughly and explain the treatment op- tions to the parents and child. • It is advisable to consider children with a poor general health in the first four years af- ter birth at risk for MIH. These children should be monitored more frequently during erup- tion of the first permanent mo- lars. • Whilst many potential ap- proaches exist for the restor- ative management of molar incisor hypomineralisation, few are yet supported by good quality clinical research data. Preformed Metal crowns have been recommended as the prosthesis of choice in MIH afflicted posterior teeth with post-eruptive enamel break- down in majority of the litera- ture available. • The use of nitrous oxide inhalation sedation can be a useful adjunct in obtaining satisfactory analgesia in MIH patients. Nitrous oxide was not used in the case of S.S. due to parental refusal because of limited financial resources. • Had this patient presented earlier, consideration for en- forced extraction of FPM would have been considered. References 1. Weerheijm KL. Molar inci- sor hypomineralization (MIH): clinical presentation, aetiology and management. Dent Up- date. 2004;31(1):9–12. 2. Weerheijm KL, Duggal M, Mejàre I, Papagiannoulis L, Koch G, Martens LC, et al. Judgement criteria for molar incisor hypomineralisation (MIH) in epidemiologic stud- ies: a summary of the Europe- an meeting on MIH held in Ath- ens, 2003. Eur J Paediatr Dent. 2003;(4):110–3. 3. Beentjes V, Weerheijm KL, Groen HJ. Factors involved in the aetiology of molar-incisor hypomineralisation (MIH). Eur J Paediatr Dent. 2002;3:9–13. 4. Willmott NS, Bryan RAE, Duggal MS. Molar-incisor- hypomineralisation: a litera- ture review. Eur Arch Paediatr Dent. 2008;9(4):172–9. 5. Seale NS, Randall R. The Use of Stainless Steel Crowns: A Systematic Literature Review. Pediatr Dent. American Acad- emy of Pediatric Dentistry; 2015;37(2):145–60. 6. Lygidakis NA. Treatment modalities in children with teeth affected by molar-inci- sor enamel hypomineralisa- tion (MIH): a systematic re- view. Eur Arch Paediatr Dent. 2010;11(2):65–74. 7. Cobourne MT, Williams A MRA. Guideline for the Extrac- tion of First Permanent Molar In Children. (revised 2014). www.rcseng.ac.uk/fds/pub- lications-clinical guidelines/ clinical_guidelines. 2014. Dr. Shaikha Alraeesi DDS (AUST) Postgraduate Resident in Paediat- ric Dentistry. HamdanBinMohammedCollege of Dental Medicine (HBMCDM). Mohamed Bin Rashid University of Medical and Healthcare Sci- ences. Dubai, United Arab Emirates (UAE). Contact email: shaikha.alraeesi@hbmcdm.ac.ae Dr. Manal Al Halabi Program Director and Associate Professor Paediatric Dentistry. MSc, BDS, Diplomate, American Board of Pediatric Dentistry. HamdanBinMohammedCollege of Dental Medicine (HBMCDM). Mohamed Bin Rashid University of Medical and Healthcare Sci- ences Dubai, United Arab Emir- ates (UAE). Contact email: manal.alhalabi @hbmcdm.ac.ae About the Authors Fig. 3 (a, b, c, d & e). Immediate post- treatment completion images. All first permanents molar were restored with SSCs. Good gingival health and oral hygiene were noted. Fig. 4 (a & b). Bitewing radiographs taken 6 months post treatment completion .Radiographic finding, fully seated crowns of all first permant molars with no progression of any pathological lesion underneath the SSC. Dental Tribune Middle East & Africa Edition | January-February 201623