PERIMEMBRANOUS VENTRICULAR SEPTAL DEFECT WITH TWO DIFFERENT PATTERNS OF MOLAR INCISAL HYPOMINERALIZATION.
Perimembranous ventricular septal defects (VSD) are chromosomal abnormality of trisomy18 21. It usually affects the new born. The prevalence of this disease is low in Pakistan population. This case presents with two different patterns of Molar/Incisal hypoplasia which is not common. Treatment plan includes restoration of deciduous teeth with Glass Inomer cement and permanent teeth with direct composite veneers. All procedures were performed under the direct supervision of restorative consultant of deMontmorency College of Dentistry Lahore Pakistan.
Key Words: Ventricular septal defects Molar Incisal hypomineralization.
Perimembranous ventricular septal defect is one of the congenital heart defects which affect the new born. Perimembranous ventricular septal defects are located in the left ventricle usually the aortic valve. Normal closure of ventricular septum occurs during embryonic phase by downward movement of membranous walls to form the outlet.1 Other methods involve septum of inlet formed by cushions of endocardium.2 Such tissue serves as a mechanism of spontaneous closure. Apical and middle portion of septum is formed by muscles.3
Epidemiology shows that the defects presents as 4 in 1000.4 Ventricular septal defects show 55% prevalence in females. VSDs are classified according to the Jacobs in 7 types according to location.6
Perimembranous VSDs are caused due to various reasons but predominantly as a result of spontaneous abnormalities in development. The precise etiology is unknown. VSDs are most commonly associated with Down syndrome.7 However many of these are not associated with chromosomal defects. Frequent maternal cannabis intake slightly increases the incidence.8
During pregnancy the use of medications like selective serotonin reuptake inhibitors (SSRIs) may contribute to the etiology.9 Amoxicillin causes the 16.3% MIH while erythromycin causes 4.14% of the disease.10
The results of a literature showed that many conditions contribute to the Molar/Incisal hypoplasia like asthma pneumonia upper respiratory tract infections otitis media antibiotics dioxins in mother's milk tonsillitis tonsillectomy and exanthamatous fevers of childhood.11
The conditions that are associated with the defects are Edward syndrome Patau syndrome and recurrent illness of child.12 Pregnancy if encountered with diabetes mellitus is also associated.13 Eisemenger syndrome also frequently presents with the defects.14
A 10 year old male child came to the restorative department with the complain of esthetically compromised teeth. After taking the written consent he was examined. Oral examination revealed he had mixed dentition. The diagnosis confirmed the Molar/ Incisal hypoplasia with two different patterns. His mother informed that the child is suffering from perimembranous ventricular septal defects. The history record of cardiology department showed that the boy suffered from meningitis pneumonias and repeated chest infection since birth till 6 years. Drug profile showed that he had taken medicines which included amoxicillin erythromycin and metronidazole for septal defects since birth till he was 9 years old. He often had to be hospitalized due to the medical illness up to the age of 5 years. Due to the use of certain medications and illness it affected the tooth buds during development which resulted in Molar/incisal hypoplasia.
For further investigation orthomopantogram was taken. The teeth showed pitted enamel with spots of brown discoloration. Treatment plan for anterior teeth was direct composite veneering. Deciduous teeth were restored with Glass Inomer cements.
Perimembranous VSD are the most common among all congenital heart abnormalities.15 The first case was documented in early 2000 which was limited to a muscular one.16 The defect may involve any part of the left ventricle depending on the location and size of defect.17 The defect can be closed by many proposed treatment options. Many clinicians proposed the surgical and transcathereal procedures as safe closure.181920
The molar/Incisal hypoplasia has no direct correlation with the (PMVSD). The use of certain medications may cause disturbance during the development of dental tissues. The precise etiology of MIH is unclear but the children born with some congenital defects or if any systematically compromised condition may encounter such situation.212223
There are many treatment options for restoring the esthetically compromised teeth depending up-on the age and systemic/dental health. Direct composites veneering is an affordable option for the hypoplastic teeth.24 Restoring the anterior teeth with composites require certain expertise as many variables are involved.
Proper shade matching for composites keeping hue chrome and value in consideration is essential.25 Opacifier usage before composite placement masks the dark effect of restorations and makes it more acceptable.2627
Different other treatment modalities for the restoration of molar/incisal hypolplasia depending on the severity of the disease. These approaches include the microabration esthetic restorations and tooth whitening.2829 Direct composite restorations give the acceptable outcomes as the main goal is to restore compromised teeth with proper function and in harmony with occlusion.28
Children with cardiac history may suffer from the developmental dental disorders. Following the proper protocol for the treatment of molar/Incisal hypoplasia with direct composites veneering seems to have a good outcome.
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22 Reston E Corba D Ruschel K Tovo M Barbosa A. Conservative approach for esthetic treatment of enamel hypoplasia. Oper Dent. 2011; 36: 340-43.
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25 Heller A. Clinical procedures to avoid the dark halo' in restorations with direct composite resins. (309-10 312). Dent Update. 2011; 38: 304-06.
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|Publication:||Pakistan Oral and Dental Journal|
|Date:||Dec 31, 2014|
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