Abnormalities of the Teeth

Steven Chussid D.D.S.

Director, Division of Pediatric Dentistry

Abnomalities of teeth

Environmental alterations

Developmental alterations

Environmental alterations

Effects on tooth structure development

Localized

Systemic

Postdevelopmental structure loss

Discoloration of teeth

Localized disturbances of eruption

Local factors associated with enamel defects

Trauma

Local infection

Irradiation

Enamel hypoplasia

Enamel hypocalcification

Systemic factors associated with enamel defects

Infections

Medications

Inherited diseases

Metabolic disorders

Malnutrition

Birth-related trauma

Enamel hypoplasia

Enamel hypoplasia-Rickets

Fluorosis

Postdevelopmental tooth loss

Tooth wear

Attrition

Caused by tooth to tooth contact

Abrasion

Caused by external agent

Erosion

Caused by chemical process

Internal resorption

External resorption

Attrition

Erosion-Bulemia

Internal resorption

External resorption

Environmental discoloration

Extrinsic

Bacteria

Iron

Tobacco

Food and beverage

Restorative materials

Medications

Iron stain

Environmental discoloration

Intrinsic

Erythropoietic porphyria

Hyperbilirubinemia

Trauma

Medications

Erythropoietic porphyria

Autosomal recessive disorder of porphyrin metabolism that results in increased synthesis and excretion of porphyrins

Diffuse discoloration of dentition results

Teeth appear red-brown and exhibit a red fluorescence when exposed to UV light

Prophyrin present in enamel and dentin of deciduous teeth so discoloration worse

Only dentin of permanent teeth affected

Erythropoietic porphyria

Hyperbilirubinemia

Excess levels of bilirubin in blood

Bilirubin can accumulate in interstitial fluid, mucosa, skin and developing teeth

Causes include-

Erythroblastosis fetalis

A hemolytic anemia of newborns secondary to blood incompatibility

Biliary atresia

A sclerosing process of the biliary tree

Premature birth

Internal hemorrhage

Hyperbilirubinemia

Trauma

Tetracycline stain

Fluorosis

Localized disturbances of eruption

Ankylosis

Natal teeth

Ankylosis

Cessation of eruption after emergence occuring from an anatomic fusion of tooth cementum or dentin to alveolar bone

Etiology unknown-trauma, local change of metabolism, thermal irritation, and genetic predisposition have been suggested

Can occur at any age but is clinically most evident when it develops during first two decades of life

Peak prevalence- 8-9 years of age

Ankylosis

Reported prevalence of clinically detectable ankylosis- 1.5% to 9%

Primary molars are most commonly involved teeth with most cases in mandible

Radiographic findings

Sound on percussion

Treatment considerations

Ankylosis

Natal teeth

Usually prematurely erupted primary teeth

Present at birth

Prevalence- 1 in 2000

Neonatal teeth erupt within first month

85% are lower incisors, 11% maxillary incisors

Treatment

Natal teeth

Developmental alterations

Number

Size

Shape

Structure

Developmental alterations

Number

Hypodontia

Lack of development of one or more teeth

Anodontia

Total lack of tooth development

Hyperdontia

Development of an increased number of teeth

Hypodontia

Common dental anomaly

3.5%-8% (excluding third molars)

Female predominance about 1.5:1

Uncommon in primary dentition (<1%)

About 20-23% of population missing third molars

After third molars, second premolars and laterals most frequent

Syndromes associated with hypodontia

Ectodermal dysplasia

Chondroectodermal dysplasia (Ellis-van Creveld)

Incontinentia pigmenti

Progeria

Down

Hallermann-Streiff

Rieger

Crouzons

Albright hereditary osteodystrophy

Hypodontia

Hypodontia-Ectodermal dysplasia

Hyperdontia

Prevalence of supernumerary teeth is about 1%-3% (higher rate in Asians)

Single tooth hyperdontia represent 75%-85% of cases

More common in permanent dentition

Almost 90% in maxilla

Maxillary incisor region most common site then 4th molars,premolars and canines

If multiples, usually in mandibular premolar region

Syndromes associated with hyperdontia

Cleidocranial dysplasia

Oral-Facial-Digital

Craniometaphyseal dysplasia

Apert

Hyperdontia

Mesiodens

Hyperdontia

Cleidocranial dysplasia

Paramolar

Developmental alterations

Size

Microdontia

Macrodontia

Microdontia

Teeth are smaller that usual

Relative microdontia=macrognathia

Diffuse true microdontia is uncommon but may occur in Down syndome and pituitary dwarfism

Prevalence of isolated microdontia is between 1% and 8%

Maxillary lateral incisor most frequently affected

Microdont- peg lateral

Microdont

Macrodontia

Teeth are larger than usual

Relative macrodontia=micrognathia

Diffuse involvement very rare

Has been noted in association with pituitary gigantism and hemifacial hyperplasia

Macrodontia

Developmental alterations

Shape

Gemination

Fusion

Concrescence

Talon cusp

Dens evaginatus

Dens invaginatus

Taurodontism

Dilaceration

Double teeth

Gemination and fusion

May have very similar clinical appearance

Higher frequency in anterior and maxillary regions

Rate is about 0.1% in permanent dentition and 0.5% in deciduous

Bilateral cases more infrequent

Etiology unknown but trauma has been suggested

Treatment considerations

Gemination

Single joined or enlarged tooth in which tooth count is normal when anomalous tooth is counted as one

Result from single tooth bud????

Gemination

Fusion

Single joined or enlarged tooth in which tooth count reveals missing tooth when anomalous tooth is counted as one

Union of two separate tooth buds?

Fusion

Concrescence

Union of two adjacent teeth by cementum alone

May occur before or after eruption

Seen most commonly posterior and maxillary regions

Etiology believed to be trauma or overcrowding

Treatment considerations

Concrescence

Talon cusp

Well-delineated additional cusp on the surface of an anterior tooth and extends 1/2 the distance from CEJ to incisal edge

Vast majority on lingual surface

Prevalence studies vary from <1% to 8%

3/4 found in permanent dentition, most commonly maxillary lateral then central

In deciduous dentition, maxillary central most common site

Has been associated with other dental anomalies

Treatment considerations

Talon cusp

Dens evaginatus

Also known as a central tubercle

A cusplike elevation located in the central groove

Typically occurs in permanent mandibular premolars

Usually bilateral

Rare in whites with higher prevalence in Asians, native Americans and Alaskans

Treatment considerations

Dens evaginatus

Dens invaginatus

Dens in dente

Deep surface invagination of crown that is lined by enamel

Represents an accentuation of the lingual pit

Depth varies

Prevalence studies vary from <1% to 10%

Lateral incisors most commonly affected

Bilateral involvement common

Treatment considerations

Dens invaginatus

Taurodontism

Enlargement of the body and pulp chamber of a multirooted tooth with apical displacement of the pulpal floor

More commonly seen in permanent dentition

Prevalence is highly variable

2%-3% in U.S.

Much higher in Eskimos and Middle Eastern populations

Increased frequency in patients with CL and/or CP, Down, Klinefelter,ectodermal dysplasia, trich-dento-osseous

Taurodontism

Dilaceration

Abnormal angulation or bend in the root

Thought to be related to trauma during root development

Permanent maxillary incisors most commonly affected followed by mandibular incisors

Rare in primary dentition

Treatment depends on severity

Dilaceration

Amelogenesis imperfecta

A heterogeneous group of hereditary disorders that demonstrate developmental alterations in the structure of enamel in the absence of a systemic disorder

Many subtypes

Numerous patterns of inheritance

Wide variety of clinical manifestations

Frequency varies between 1:718 and 1:14,000

Both dentitions involved

Amelogenesis imperfecta

Formation of enamel a multistep process

Formation of enamel matrix

Mineralization of matrix

Maturation of matrix

Hereditary defects of enamel formation usually classified as:

Hypoplastic

Hypocalcified

Hypomaturative

Amelogenesis imperfecta
Witkop classification

Amelogenesis imperfecta

Hypoplastic

Teeth erupt with insufficient amounts of enamel

Amount of enamel varies greatly

Enamel present is mineralized appropriately and contrasts well with dentin on radiographs

Teeth may have abnormal shape and open contacts

Open bite may be present

AI-Hypoplastic smooth

AI-Hypoplastic pitted

AI-Hypoplastic rough

Amelogenesis imperfecta

Hypocalcified

Proper amount of enamel matrix is formed but but it doesn’t mineralize properly

Teeth shaped normally upon eruption but enamel is soft and easily lost

Enamel yellow-brown upon eruption but quickly becomes brown to black

Accumulate calculus

Enamel and dentin have similar density on radiographs

AI-Hypocalcified

Amelogenesis imperfecta

Hypomaturative

Enamel matrix is laid down properly and begins to mineralize but there is a defect in maturation of enamel’s crystal structure

Affected teeth normal in shape

Mottled appearance-white, brown or yellow

Enamel soft and chips away from dentin

Enamel has similar radiodensity to dentin

AI-Hypomaturative

AI-Hypomaturative, snowcapped

Dentinogenesis imperfecta

Hereditary developmental disturbance of dentin

Autosomal dominant

Also known as hereditary opalescent dentin

Shields classification

Prevalence is about 1:8000

Most cases in whites of English or French ancestry from communities near English Channel

Dentinogenesis imperfecta

All teeth in both dentitions affected

Deciduous teeth affected most severely followed by permanent incisors and first molars

Yellow-brown to blue-gray translucent, opalescent appearance

Enamel frequently separates easily from dentin

Once exposed, dentin exhibits rapid attrition

Bulbous crowns with cervical constriction

Thin roots

Early obliteration of pulp chambers and root canals

Dentinogenesis imperfecta

Dentin dysplasia

Rare autosomal-dominant condition that affects dentin

Prevalence about 1:100,000

Dentin dysplasia

Type I

Radicular type or ‘rootless teeth’

Roots short and pulps almost obliterated

Periapical radiolucencies

More common type

Enamel and coronal dentin are normal

Wide variation in root formation because dentinal disorganization may occur at different stages of tooth development

Color is normal in both dentitions

Radiographically, deciduous teeth more severly affected

Dentin dysplasia type I

Dentin dysplasia

Dentin dysplasia

Type II

Coronal type

Root length normal in both dentitions

Primary teeth

Clinically resemble dentinogenesis imperfecta

Radiographically have similar appearance to Type I

Permanent teeth

Normal coloration

Pulp chambers enlarged with apical extension-thistle-tube-shaped or flame-shaped

Dentin dyplasia type II

Regional odontodysplasia

‘Ghost teeth’

Localized, non-hereditary developmental abnormality of teeth with extensive adverse effects on formation of enamel, dentin and pulp

Occurs in region or quadrant

Etiology unknown

Occurs in both dentitions and if present in primary dentition,permanent teeth in area usually affected

Maxillary predominance- 2.5:1

Many affected teeth fail to erupt

Erupted teeth have small irregular yellow-brown crowns

Short roots, enlarged pulp and open apical foramina

Regional odontodysplasia

References

Oral & Maxillofacial Pathology-Second Edition

Neville, Damm, Allen and Bouquot

Oral Pathology-Clinical Pathologic Correlations

Regezi, Sciubba and Jordan

Thank you!




	Steven Chussid D.D.S.
	Director, Division of Pediatric Dentistry


	Effects on tooth structure development
		Localized
		Systemic
	Postdevelopmental structure loss
	Discoloration of teeth
	Localized disturbances of eruption


	Infections
	Medications
	Inherited diseases
	Metabolic disorders
	Malnutrition
	Birth-related trauma


Tooth wear
	Attrition
		Caused by tooth to tooth contact
	Abrasion
		Caused by external agent
	Erosion
		Caused by chemical process
Internal resorption
External resorption


	Extrinsic
		Bacteria
		Iron
		Tobacco
		Food and beverage
		Restorative materials
		Medications


	Intrinsic
		Erythropoietic porphyria
		Hyperbilirubinemia
		Trauma
		Medications


	Autosomal recessive disorder of porphyrin metabolism that results in increased synthesis and excretion of porphyrins
	Diffuse discoloration of dentition results
	Teeth appear red-brown and exhibit a red fluorescence when exposed to UV light
	Prophyrin present in enamel and dentin of deciduous teeth so discoloration worse
	Only dentin of permanent teeth affected


Excess levels of bilirubin in blood
Bilirubin can accumulate in interstitial fluid, mucosa, skin and developing teeth
Causes include-
	Erythroblastosis fetalis
		A hemolytic anemia of newborns secondary to blood incompatibility
	Biliary atresia
		A sclerosing process of the biliary tree
	Premature birth
	Internal hemorrhage


	Cessation of eruption after emergence occuring from an anatomic fusion of tooth cementum or dentin to alveolar bone
	Etiology unknown-trauma, local change of metabolism, thermal irritation, and genetic predisposition have been suggested
	Can occur at any age but is clinically most evident when it develops during first two decades of life
	Peak prevalence- 8-9 years of age


	Reported prevalence of clinically detectable ankylosis- 1.5% to 9%
	Primary molars are most commonly involved teeth with most cases in mandible
	Radiographic findings
	Sound on percussion
	Treatment considerations


	Usually prematurely erupted primary teeth
	Present at birth
	Prevalence- 1 in 2000
	Neonatal teeth erupt within first month
	85% are lower incisors, 11% maxillary incisors
	Treatment


Number
	Hypodontia
		Lack of development of one or more teeth
	Anodontia
		Total lack of tooth development
	Hyperdontia
		Development of an increased number of teeth


	Common dental anomaly
		3.5%-8% (excluding third molars)
	Female predominance about 1.5:1
	Uncommon in primary dentition (<1%)
	About 20-23% of population missing third molars
	After third molars, second premolars and laterals most frequent


	Ectodermal dysplasia
	Chondroectodermal dysplasia (Ellis-van Creveld)
	Incontinentia pigmenti
	Progeria
	Down
	Hallermann-Streiff
	Rieger
	Crouzons
	Albright hereditary osteodystrophy


	Prevalence of supernumerary teeth is about 1%-3% (higher rate in Asians)
	Single tooth hyperdontia represent 75%-85% of cases
	More common in permanent dentition
	Almost 90% in maxilla
	Maxillary incisor region most common site then 4th molars,premolars and canines
	If multiples, usually in mandibular premolar region


	Cleidocranial dysplasia
	Oral-Facial-Digital
	Craniometaphyseal dysplasia
	Apert


	Teeth are smaller that usual
	Relative microdontia=macrognathia
	Diffuse true microdontia is uncommon but may occur in Down syndome and pituitary dwarfism
	Prevalence of isolated microdontia is between 1% and 8%
	Maxillary lateral incisor most frequently affected


	Teeth are larger than usual
	Relative macrodontia=micrognathia
	Diffuse involvement very rare
	Has been noted in association with pituitary gigantism and hemifacial hyperplasia


	Shape
		Gemination
		Fusion
		Concrescence
		Talon cusp
		Dens evaginatus
		Dens invaginatus
		Taurodontism
		Dilaceration


	Gemination and fusion
		May have very similar clinical appearance
	Higher frequency in anterior and maxillary regions
	Rate is about 0.1% in permanent dentition and 0.5% in deciduous
	Bilateral cases more infrequent
	Etiology unknown but trauma has been suggested
	Treatment considerations


	Single joined or enlarged tooth in which tooth count is normal when anomalous tooth is counted as one
	Result from single tooth bud????


	Single joined or enlarged tooth in which tooth count reveals missing tooth when anomalous tooth is counted as one
	Union of two separate tooth buds?


	Union of two adjacent teeth by cementum alone
	May occur before or after eruption
	Seen most commonly posterior and maxillary regions
	Etiology believed to be trauma or overcrowding
	Treatment considerations


	Well-delineated additional cusp on the surface of an anterior tooth and extends 1/2 the distance from CEJ to incisal edge
	Vast majority on lingual surface
	Prevalence studies vary from <1% to 8%
	3/4 found in permanent dentition, most commonly maxillary lateral then central
	In deciduous dentition, maxillary central most common site
	Has been associated with other dental anomalies
	Treatment considerations


	Also known as a central tubercle
	A cusplike elevation located in the central groove
	Typically occurs in permanent mandibular premolars
	Usually bilateral
	Rare in whites with higher prevalence in Asians, native Americans and Alaskans
	Treatment considerations


	Dens in dente
	Deep surface invagination of crown that is lined by enamel
	Represents an accentuation of the lingual pit
	Depth varies
	Prevalence studies vary from <1% to 10%
	Lateral incisors most commonly affected
	Bilateral involvement common
	Treatment considerations


	Enlargement of the body and pulp chamber of a multirooted tooth with apical displacement of the pulpal floor
	More commonly seen in permanent dentition
	Prevalence is highly variable
		2%-3% in U.S.
		Much higher in Eskimos and Middle Eastern populations
	Increased frequency in patients with CL and/or CP, Down, Klinefelter,ectodermal dysplasia, trich-dento-osseous


	Abnormal angulation or bend in the root
	Thought to be related to trauma during root development
	Permanent maxillary incisors most commonly affected followed by mandibular incisors
	Rare in primary dentition
	Treatment depends on severity


	A heterogeneous group of hereditary disorders that demonstrate developmental alterations in the structure of enamel in the absence of a systemic disorder
	Many subtypes
	Numerous patterns of inheritance
	Wide variety of clinical manifestations
	Frequency varies between 1:718 and 1:14,000
	Both dentitions involved


	Formation of enamel a multistep process
		Formation of enamel matrix
		Mineralization of matrix
		Maturation of matrix
	Hereditary defects of enamel formation usually classified as:
		Hypoplastic
		Hypocalcified
		Hypomaturative