European Archives of Paediatric Dentistry (2023) 24:807–813
[Link]
SHORT COMMUNICATION
Update of the molar incisor hypomineralization: Würzburg concept
K. Bekes1 · R. Steffen2 · N. Krämer3
Received: 21 August 2023 / Accepted: 15 September 2023 / Published online: 19 October 2023
© The Author(s) 2023
Abstract
Purpose Molar incisor hypomineralization (MIH) is playing an increasingly important role in dental practice. MIH is defined
as hypomineralization of systemic origin of one to four permanent first molars, often associated with affected incisors.
Affected teeth are more susceptible to caries and post-eruptive enamel loss and should be diagnosed and treated as early as
possible. In 2016, the Würzburg concept was developed for German-speaking countries including a classification index—the
MIH Treatment Need Index (MIH-TNI)—and a treatment plan based on it for the use in daily practice. In the meantime, the
concept has also gained international recognition. The aim of this paper is to update part 2 of the Würzburg concept, the
treatment plan, as knowledge about MIH has increased and the disease has been studied more extensively in the last years.
Other treatment approaches are now available and therefore need to be included in the concept. Although, the evidence of
the different treatment options is still weak, practitioners need guidance in their daily practice.
Methods The authors reviewed the available literature, including clinical and laboratory studies and published guidelines.
Results The updated version of the Würzburg concept includes additional non-invasive strategies and temporary therapy
options, as well as treatment approaches for incisors. It therefore covers currently available treatment modalities for MIH-
affected teeth, ranging from prophylaxis, non-invasive treatment to restorative approaches and possibly even extraction.
Conclusions This is intended to help guide the practitioner and will need to be further validated by clinical trials.
Keywords Molar incisor hypomineralization · MIH · Würzburg concept · MIH Treatment Need Index · MIH-TNI ·
Treatment plan
Introduction still remains unclear although several systemic and genetic
and/or epigenetic factors acting synergistically or additively
Molar incisor hypomineralization (MIH) stands as a per- seem to be associated with MIH, revealing a multifactorial
plexing and increasingly prevalent dental condition that aetiology model (Garot et al. 2022). The average prevalence
has gained significant attention within the field of (paedi- worldwide is 13.1–14.2% (Schwendicke et al. 2018; Zhao
atric) dentistry and oral health research. First described in et al. 2018; Schwendicke et al. 2019).
the 1980s (Koch et al. 1987), the term was coined in 2001 MIH presents a considerable clinical challenge due to its
by Weerheijm et al. (Weerheijm et al. 2001). MIH is char- diverse clinical spectrum. The severity of enamel defects can
acterised by a qualitative deficiency in enamel mineraliza- range from mild opacities with minimal functional impact to
tion, predominantly affecting the permanent first molars extensive post-eruptive breakdown, and increased sensitivity
with or without the involvement of incisors. The aetiology leading to structural compromise and significant discomfort
and making affected teeth susceptible to caries and dental
pain (Weerheijm 2004; Lygidakis 2010). In general, the
* K. Bekes darker the colour of the opacity, the softer and more porous
[Link]@[Link]
the enamel (Marouane and Manton 2022), and the greater
1
Department of Paediatric Dentistry, University Clinic the risk of posterior substance loss (usually at the cusps)
of Dentistry, Medical University of Vienna, 1090 Vienna, with exposure of dentin (Weerheijm et al. 2003).
Austria For the diagnosis of MIH, the criteria proposed by the
2
Private Practice, Weinfelden, Switzerland EAPD are internationally well known and established. They
3
Department of Paediatric Dentistry, Justus Liebig University, take into account the specific clinical signs and symptoms
Giessen, Germany
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808 European Archives of Paediatric Dentistry (2023) 24:807–813
of the disease: demarcated opacities, post-eruptive enamel Table 1 MIH Treatment Need Index (MIH-TNI)
breakdowns, atypical restorations and extractions of molars Index Definition
(Weerheijm 2003; Lygidakis et al. 2022; Somani et al. 2022).
In addition, affected teeth can be further classified into mild Index 0 No MIH, clinically sound
defects and severe defects (Lygidakis et al. 2022; Somani et al. Index 1 MIH: without breakdown, without hypersensitivity
2022). Index 2 MIH: with breakdown, without hypersensitivity
2a extension of defect < 1/3
2b extension of defect ≥ 1/3 to < 2/3
Development of the Würzburg concept 2c extension of defect ≥ 2/3
or/and defect close to the pulp
In 2016, the Würzburg concept was developed by a working or extraction
or atypical restoration
group with representatives from Germany, Austria and Swit-
Index 3 MIH without breakdown, with hypersensitivity
zerland during the spring conference of the German Society
Index 4 MIH with breakdown, with hypersensitivity
of Paediatric Dentistry (DGKiZ) (Bekes et al. 2016, Bekes 4a extension of defect < 1/3
and Steffen 2016, Steffen et al. 2017) and has since gained 4b extension of defect ≥ 1/3 to < 2/3
increasing international acceptance (Hahn et al. 2020; Butera 4c extension of defect ≥ 2/3
et al. 2022; Joshi et al. 2022; Olczak-Kowalczyk et al. 2023). or/and defect close to the pulp
or extraction
The concept includes a classification index—the MIH Treat- or atypical restoration
ment Need Index (MIH-TNI)—and a treatment plan based
on it. The idea for the concept was based on the fact that at
that time almost all available classifications described in the
literature mostly used the defect as a criterion, ignoring the Clinicians who do not treat MIH everyday are often uncer-
possible combined presence of sensitivity, which is clini- tain how to deal with affected children. However, it is impor-
cally relevant. In addition, most of them were not linked to tant for patients to receive the right comprehensive care at
a specific treatment recommendation (Lygidakis et al. 2010). an early stage. Depending on the severity of the hypominer-
The EAPD's updated 'Best Practice Guidance', published in alization, the therapy to be favoured ranges from intensive
2022, has now also filled this gap (Lygidakis et al. 2022). prophylaxis to restorative measures or even extraction. Of
Overall, the Würzburg concept should help guide practition- course, these available options are well known. Neverthe-
ers in their daily practice, although the evidence for different less, uncertainty in choosing the "right" therapy often causes
treatment options is still weak. problems for general dentists. The choice of treatment option
depends on a number of factors. These include the severity
Part 1: MIH treatment need index (MIH‑TNI) of MIH, the presence of symptoms, the age of the patient,
and the social background and expectations of the child and
The MIH-TNI captures the clinical key symptoms of MIH the parents (Lygidakis et al. 2022; Somani et al. 2022). The
(Bekes and Steffen 2016; Steffen et al. 2017). It includes the first step must always be an early diagnosis, which should be
presence and the extent of the breakdown and the problem accompanied by prophylactic measures as soon as possible.
of hypersensitivity. A total of four different grades of MIH The aim of the treatment plan developed for the Würzburg
can be distinguished (Table 1), depending on the presence/ concept was to guide clinicians in their daily work by pro-
absence of breakdown and hypersensitivity. The index can viding an easy-to-use flow chart. The treatment approaches
be applied to all teeth and is not restricted to permanent included the sections of prophylaxis, regeneration, sealing,
teeth or individual groups of teeth. It is suitable for use and immediate treatment, and long-term planning. Since indi-
study in larger populations as well as for accurate description vidual treatment options must be seen in relation to the car-
of findings in individual patients (Bekes and Steffen 2016; ies risk of the patient, two structurally identical flow charts
Steffen et al. 2017). The MIH-TNI has also been tested for were created: one for patients with low caries risk and one
its psychometric properties. It has been found to be valid for patients with high caries risk.
(Stratigaki et al. 2020; Pflugi 2021). The structure of the flow chart was as follows: In the
first horizontal row, the four indices were shown. In the first
column all available treatment approaches were displayed:
Part 2: treatment plan 1.0 prophylaxis (at home, in office), sealing, temporary restora-
tion (short-term), temporary restoration (long-term), per-
Based on the MIH-TNI, a therapy plan in form of a flow manent restoration and extraction. The flow chart should be
chart was developed in a second step (Bekes et al. 2016). read in such a way that after the diagnosis (MIH-TNI 1-4),
In 2016, this was the first MIH concept to provide both—a the user can find the treatment options in the appropriate
classification index and a therapy plan based on the index. column.
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European Archives of Paediatric Dentistry (2023) 24:807–813 809
Update of the Würzburg concept: version 2.0 (possibly plus TCP) should be used twice a day. This may
be accompanied by the additional use of CPP-ACP in a
MIH has been studied extensively in the last years (Lygida- tray once a day (Baroni and Marchionni 2011). Topical
kis et al. 2022). Since 2016, knowledge about MIH has fluoride varnish can be applied ‘in office’ 2–4 times per
increased due to the availability of more clinical and labo- year depending on caries risk (Toumba et al. 2019). The
ratory studies. Other treatment approaches are now avail- need for prophylaxis is independent of the severity of the
able, have been shown to be useful and therefore need to diagnosed TNI.
be included in an updated version of the Würzburg MIH
concept. Therapy headings have also had to be reworded.
For example, the new version of the flow chart now includes
non-invasive strategies for molars, such as SDF, and treat- Therapy B: non‑invasive therapy
ment approaches for incisors. Furthermore, the two flow
charts (low and high caries risk) have been merged into one This section has been reworded. "Sealing" has been
chart (Fig. 1). replaced by "non-invasive therapy" to also cover the
treatment of incisors. For molars, non-invasive therapy
approaches include sealants (Lygidakis et al. 2022). These
Therapy A: prophylaxis/regeneration can be either a fissure sealant or a flowable (both with
pre-application of an adhesive (Lygidakis et al. 2009) and
Prophylaxis is important as MIH-affected children have a if the tooth is fully erupted) or a glass ionomer cement
higher caries risk (Lygidakis et al. 2022). A recent study (if the tooth is not fully erupted). Incisors can be treated
showed that the presence of MIH was associated with a with bleaching (in adolescents) (B3) (Ghanim et al. 2017),
6.15 times higher prevalence of dental caries in first per- microabrasion (B4) (Bhandari et al. 2019), infiltration (B5)
manent molars (Oreano et al. 2023). Prophylaxis and (Marouane and Manton 2021; Altan and Yilmaz 2023),
regeneration include ´at home´ and ´in office´ approaches. etch-bleach-seal technique (B6) [23] or a combination of
Toothpastes containing fluoride (Ghanim et al. 2017) these options.
Fig. 1 Treatment plan based on the MIH-TNI
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810 European Archives of Paediatric Dentistry (2023) 24:807–813
Therapy C: temporary therapy (short‑term) has not yet fully erupted, a temporary fissure sealant should
be applied using a low viscosity glass ionomer cement.
Therapy C has also been reworded. "Temporary restora-
tion" has been replaced by "temporary therapy" to include MIH‑TNI 2
other treatment modalities. Originally, this section only
included short-term provisional treatment options using If MIH-TNI 2 is diagnosed in posterior teeth, the start of
glass ionomer cement (Fragelli et al. 2015; Linner et al. therapy depends on the location and size of the break-
2020) without/with orthoband (Steffen and van Waes down. If the substance loss is not located in the fissure and
2011). In the updated concept, the use of SDF (Seifo et al. involves < 1/3 of the surface of the tooth, sealing therapy
2019; Ballikaya et al. 2022) without/with GIC has been (B) may be the first step of treatment. However, if the loss
added. of substance is located in the fissure or if the defect is > 1/3
or > 2/3, or if defects are found close to the pulp, the short-
term temporary therapy (C) using a GIC with or without
orthoband (C1, C2) is the therapy of choice, which can be
Therapy D: temporary therapy (long‑term) converted to a definitive restoration (E, direct or indirect
restoration) later (Sonmez and Saat 2017, Linner et al. 2020;
Therapy D has also been revised. The term "temporary res- Lygidakis et al. 2022). Thereby, indirect restorations should
toration" has been replaced with "temporary therapy" as in be considered if the child is older.
Therapy C. In addition to stainless steel crowns (Kotsanos If the patient is non-compliant and caries is present, SDF
et al. 2005; Oh et al. 2020), the option of placing a zirconia can be used with or without the additional placement of
crown (Talekar et al. 2023) has been added, as has the prepa- a GIC (C3, C4) (Seifo et al. 2019; Ballikaya et al. 2022).
ration technique for both crowns. Alternatively, a long-term temporary restoration in the form
of a steel crown or a zirconia crown can be chosen (D) (Kot-
sanos et al. 2005; Oh et al. 2020; Talekar et al. 2023). The
Therapy E: permanent therapy preparation technique can be conventional (both materials)
or Hall (stainless steel crown, (Innes et al. 2007)). In addi-
This part covers permanent restorations in the form of direct tion, extraction should be considered as a long-term solution
(composite) and indirect options (Sonmez and Saat 2017; for TNI 2c at the appropriate time (Lygidakis et al. 2022).
Linner et al. 2020; Lygidakis et al. 2022). “Permanent res- In this case, it is essential to consult with the orthodontist
toration” has also been changed into “permanent therapy”. to determine the optimal time for extraction. If the time for
extraction has not yet been reached, every effort should be
made (therapy B, C and possibly even D) to preserve the
MIH tooth until then.
Therapy F: extraction
MIH‑TNI 3
The therapy plan is completed with therapy F, extraction.
In severe cases, when molars show massive post-eruptive If there is no breakdown but hypersensitivity, sealing should
breakdowns, the pulp is involved or dental abscesses are be considered as initial therapy in posterior teeth to reduce
present, extraction is the treatment of choice (Lygidakis et al. pain. This can be done with a fissure sealant (B1) (Bekes
2022). et al. 2021, 2022). If the tooth has not fully erupted, sealing
with a low viscosity glass ionomer cement (B2) can also be
performed.
Posterior teeth MIH‑TNI 4
MIH‑TNI 1 If breakdown and hypersensitivity are present in posterior
teeth, the patient follows the same steps as for MIH-TNI
For MIH posterior teeth showing no breakdown and hyper- 2. Again, the size and the location of the defect is impor-
sensitivity (MIH-TNI 1), sealing therapy is considered the tant. If the breakdown is minimal (TNI 2a) and not in
method of choice in addition to prophylaxis. If the tooth is the fissure, sealing can begin. However, if the defect is
fully erupted, this procedure should be carried out with a located in the fissure or if the defect is > 1/3 or > 2/3 in
conventional fissure sealant or a flowable with the pre-appli- its extension or close to the pulp, then—as with MIH-TNI
cation of an adhesive (Lygidakis et al. 2009). If the molar 2—short-term temporary therapy (C) with GIC (Fragelli
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European Archives of Paediatric Dentistry (2023) 24:807–813 811
et al. 2015; Linner et al. 2020) with or without orthoband Conclusions
is the approach of choice. As with TNI 2, if the patient
is non-compliant and caries is present, SDF can be used The severity of hypomineralized MIH teeth and associated
with or without the additional placement of a GIC. (C3, problems can vary widely. The Würzburg concepts provide
C4) (Seifo et al. 2019). This temporary restoration can be an easy-to-use clinical index and a treatment plan based on
converted to a permanent restoration (E) if the patient is it that can be used in daily practice. It also shows how to
compliant and a rubber dam can be achieved. This can be relieve the patient's pain in an emergency situation and how
a direct or indirect restoration (Sonmez and Saat 2017; to implement an individualised long-term solution once the
Linner et al. 2020; Lygidakis et al. 2022). Alternatively, affected teeth have fully erupted. The updated Würzburg
the stainless steel or zircona crown is the temporary long- MIH Concept reaffirms Part 1, the use of the MIH-TNI.
term restoration option (D) (Kotsanos et al. 2005; Oh et al. Part 2, the treatment plan, has been updated to include other
2020; Talekar et al. 2023). In addition, extraction should available treatment approaches and has been expanded to
also be considered as a long-term solution for TNI 2c at include the treatment of anterior hypomineralized teeth.
the appropriate time (Lygidakis et al. 2022). Further clinical studies should demonstrate the evidence of
the concept.
Funding Open access funding provided by Medical University of
Vienna.
Anterior teeth
Data availability The paper does not include additional data.
MIH‑TNI 1–4
Open Access This article is licensed under a Creative Commons Attri-
bution 4.0 International License, which permits use, sharing, adapta-
There are many options, but not every hypomineralized ante- tion, distribution and reproduction in any medium or format, as long
rior tooth needs to be treated from a dental point of view. as you give appropriate credit to the original author(s) and the source,
Parents often want to act early in the interest of the child. provide a link to the Creative Commons licence, and indicate if changes
However, it is not the parents but the child who should be were made. The images or other third party material in this article are
included in the article’s Creative Commons licence, unless indicated
asked about the existing pressure of suffering. Measure- otherwise in a credit line to the material. If material is not included in
ment of oral health-related quality (OHRQoL) might help the article’s Creative Commons licence and your intended use is not
to understand the child´s perspective (Shayestehpour et al. permitted by statutory regulation or exceeds the permitted use, you will
2022) as it is known that anterior teeth affected by MIH need to obtain permission directly from the copyright holder. To view a
copy of this licence, visit [Link]
can have an impact. In particular, problems related to social
and emotional well-being have been described (Reissen-
berger et al. 2022). Treatment can improve the perception
of oral health (Hasmun et al. 2020). However, young patients
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