Available treatment modalities for molar incisor hypomineralization (MIH)-affected teeth range from prophylaxis to restorative approaches and possibly even extraction. The choice of treatment option depends on a number of factors. These include the severity of MIH, the presence of symptoms, the age of the patient, and the social background and expectations of the child and the parents.1 The first step must always be an early diagnosis, which should be accompanied by prophylactic measures as soon as possible.
In this chapter, currently available treatment concepts with their advantages and disadvantages are presented and discussed.
8.1 First approaches
An initial treatment approach was published by Williams et al and includes six steps2:
(1) risk identification
(2) early diagnosis
(3) remineralization and desensitization
(4) prevention of caries and posteruption breakdown
(5) restorations and extractions (6) maintenance.
Around the same period, Mathu-Muju and Wright3 developed a concept that takes into account the respective severity of the defect (mild, moderate, or severe) and the planned duration of the treatment period (short or long-term). In severe cases with posteruptive breakdowns and hypersensitivities, for example, glass-ionomer cements or steel crowns serve as short-term solutions, whereas laboratory-fabricated restorations are considered more of a long-term treatment option.
8.2 The European Academy of Paediatric Dentistry (EAPD): Best Clinical Practice Guidance
Just over a decade ago, the EAPD published its Best Clinical Practice Guidance1, which have been recently updated4 (see Chapter 8.4). In the initial version from 2010, both the dentition age (early and late mixed dentition, permanent dentition) and the severity (mild, severe) of the disease were taken into account. Figure 8-1 shows the former treatment approaches. The therapy protocol also addressed in detail, for the first time, the treatment options for affected anterior teeth. However, the authors pointed out that, in addition to the conventional treatment approach, the child’s compliance and ability to be treated must also be taken into account as (socio-psychological) parameters.
Fig 8-1 Therapy recommendations based on the Best Clinical Practice Guidance of the EAPD1 (source: Cornelia Jungwirth, Katrin Bekes).
Treatment options for molars included prevention, sealing, restoration (glass ionomer, composite, steel crown, laboratory-fabricated restoration), and extraction.
In early eruption phases, the authors considered prevention to be a particularly important tool, as MIH teeth are at greater risk of developing carious lesions and posteruptive breakdown due to their increased porosity. When defects are present, provisional glass-ionomer cement restorations were given priority at the first stage. Composite fillings found their main indication later on (late mixed dentition, permanent dentition). The extraction of a tooth, if necessary, was favored in the mixed dentition phase.
8.3 Würzburg concept
In 2016, the Würzburg concept was published for the first time in German-speaking countries and has since gained growing international acceptance. Based on the MIH-TNI presented in Chapter 5, a therapy scheme in form of a flow chart was developed in a second step, which is shown in Figures 8-2 and 8-3.5–7 It is the first MIH concept to provide both a classification index and a therapy plan based on it. The latter comprises the sections of prevention, regeneration, immediate treatment, and long-term planning. Since individual treatment options must be seen in relation to the caries risk of the patient, two structurally identical schemes were created: one for patients with a low caries risk (blue scheme, Fig 8-2), and one for patients with a high caries risk (red scheme, Fig 8-3).
Fig 8-2 Treatment plan based on the MIH-TNI for low caries risk (source: Bekes et al6; courtesy of DGKiZ).
Fig 8-3 Treatment plan based on the MIH-TNI for high caries risk (source: Bekes et al6; courtesy of DGKiZ).
In the horizontal line, the four MIH-TNI indices are found in the first row. When using the therapy scheme, the MIH-TNI is first diagnosed for the affected tooth. In the corresponding column, the dentist will then find the step-by-step therapy plan.
All available treatment options are shown vertically in the first column, starting with prophylaxis, continuing with sealing, restorative approaches, and extraction. The sequence of these options also shows the different levels of invasiveness within the therapy. Thus, prophylaxis is at the beginning of the scheme and extraction at its end.
- Therapy A
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