Developmental disturbances

Disturbances of the shape

Disturbance in the shape of the teeth is a change in the root , as you see in the figure bellow there is a curve/ anglulation that is called dilaceration . In dilaceration there is usually a trauma that occurs before mineralization of the root , because if it occurs after mineralization the root will fracture ( something hard and brittle if it had trauma , then it will be fractured) but if it occurred before mineralization , bending of the root will occur then the root will continue growth and mineralization later on .

What is the significance of this curve ?Do we have to treat this tooth ? No, it is a normal tooth, but the significance is when this tooth need RCT (root canal treatment ) it will be difficult which need a specialist to deal with it , because of the curve instruments will not go down to the apex easily. Maybe there is difficulty also in extraction of this tooth . P.S : It maybe idiopathic, sometimes we cant find the cause of dilacerations (it occurs without history of trauma). Another disturbance in shape is :

Taurodontism :
Is that when the furcation area in molar teeth moves more apically so that have elongated pulp chamber in apical occlusal direction . If you compare the two teeth in the radiograph, look at the furcation site; in the normal tooth there is furcation site then two roots, but in the other tooth there are two short roots, so the problem here is
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apical placement (the furcation site is downward to the apex).

Complications: - RCT : difficulty in finding the orifices of the canals and to remove all the pulp chamber tissues . - Surgical extraction: it is difficult to place the forceps at the furcation area which moved apically , so it may need other means to extract the tooth . This developmental change maybe associated with : Amelogenesis imperfect. Down syndrome. Klinefilter syndrome.

P.s : It is most likely to occur in molars but sometimes it may occur in premolars also , deciduous teeth occasionally affected but mainly the permanent teeth which are affected .

Dense invaginatus { Dense in Dente } :

What is the difference between invagination and evagination? In invagination: downward growth occurs , the growth goes inside the tooth toward the pulp. BUT in evagination: it goes outside that when you have an extra cusp (projection on the surface) which usually occurs in premolars especially lower ones between buccal and palatal cusps or more toward the palatal cusps.

 Complications: - It may interfere with occlusion because it's simply extra cusp. Patients with this case ( dense evaginatus) can't be treated by just trimming this projection , because that will expose dentine or the pulp so patient will suffer form sever pulpits and pain etc.. ( so you should take care of the pulp in any treatment ). Dense invaginatus we have invagination at the cingulum pit which found in central and lateral incisors and canines but most likely to occur in lateral incisors, from this pit the enamel invaginates ( goes downward) inside the crown inside the pulp chamber and the root sometimes then it goes up again ; but we cant see it clinically we only see a pit and we may see caries inside this pit . This invagination is variable in length ,it may go just a little bit in the pulp chamber and then go up or all the way down to the apex , so we will have a canal that lined by enamel with variable distances .

How we can decide that the tooth has dense in dente ? We need to see the radio opacity of the tooth , actually we look at the color of the legion, if its look like enamel then its enamel but if its look like dentine then we have to think about other legions . The enamel usually is more radio opaque (chalky white , has more minerals) compare to the dentine .

Dense in dente So dense in dente is a canal or inward growth of enamel through the pulp chamber of variable distances . Dense invaginatus may be severe , dilated , has calcified mass, changing in crown shape and doesn't look as pit or canal this case is called dilated odontume

(so named because it's wide and reaches the pulp and has a collection of enamel , dentine and some pulp). So the most severe form of dense invaginatus is dilated odontome. What is the significance of dense in dente ? By this pit, food and bacteria will be accumulated and caries will occur, then the lining of the pit may be perforated ( perforation due to the analysis of food debris by bacteria so acids will be formed ) and that will cause pulpits (inflammation of the pulp) by the entrance of the bacteria, then the pulp may be necrotic or the products of the bacteria will go in the apical area then form abscess or inflammation in the alveolar bone. If you have abscess and puss in the anterior teeth without caries you should take a radiograph and check dense in dente .

Complications : Pulpal involvement and pre-apical pathosis are expected from untreated dense invaginatus .

Other disturbances of the shape is cusp of carabilli that is additional cusp on mesiolingual surface of the upper 6 , which consider as supernumerary cusp , but this cusp doesnt cause any complications.

There is another type of cusps which called talon cusp , an extra cusp( has enamel, dentine and pulp) that's usually on the upper anterior teeth ( usually central incisors and sometimes lateral incisor) it interferes with the occlusion and it can't be just trimmed ( we should care of the pulp !), RCT could be done.

This cusp could have grooves in either sides or pits so food and bacteria could be accumulated and caries could happen, so fissure sealant should be used to prevent food accumulating. - Dont confuse this with dense in dente in radiograph , both of them has enamel and pulp but one of them goes toward the pulp (dense in dente ) and the other toward the outside surface (talon cusp).

Supernumerary roots are rare, most common on premolars ,canines and 3rd molars, there significance will be in both RCT( we have to find the extra root to treat it because we can't treat infections by treating root and leave others) and in extraction, because if we don't detect it, it may still without removing, so taking radiograph is important in both RCT and extraction even if the tooth is about to be extracted.

Other Disturbances in the shape of the tooth: Gemination Fusion Concrescence Hypercementosis Cervical enamel projection

Fusion:
Occurs when two teeth germs are fused together ( because teeth germs are present close to each other) , so one single big crown will be formed and it could be completely fused roots or not, but at least dentine should be fused in order to consider it fusion. In fusion we usually find a missing tooth in the arch ( two teeth fused together formed one tooth).
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Gemination:
One single tooth germ tries to give two teeth ( but it didnt work), so we will have single root with incomplete formation of two crowns . Gemination looks like fusion clinically but you can differentiate between these two disturbances by counting the teeth ; if you find a missing tooth it will be fusion, if not it will be germination. The significance of gemination and fusion is only esthetics.

Concrescence:
Fusion between two adjacent teeth through cementum which covers the roots , so the fusion will be in the roots (the crown not involved) . It is not only developmental case , it may occur later on due to chronic infection of the bone / trauma/ proximity usually 3rd molars which are usually impacted and mal aligned . Significance : - During Extraction

Hypercementosis:
It is an increase in cementum deposition which located at the root , usually occurs at the pre-apical area . Causes of hypercementosis: - Infection: low grade infection may start to stimulate deposition of cementum when reaching the pulp instead of resorbing it (as a way of defense ). {chronic infection not acute !}

- Hormonal changes: as in hyperpituitarism - Low occlusal load: if the tooth is out occlusion ,so there will be stimulation to the cementum to deposite for a reason or another , as in low filling / the filling is over carped . - High occlusal load: if the tooth is exposed to high occlusal stress it will start to deposit cementum to withstand the forces, as in high filling or by stressing on the teeth , or if we have an extracted tooth the load will be more on the adjacent tooth (hyper functioning) . Significance: Extraction: instead of having taper roots which are easily extracted, there will be bulbous root (rounded).

Cervical enamel projection:

Developmental change causing enamel to deposit over cementum. Normal location of the enamel is on the crown not on the root surfaces the significance is in the periodontal ligament , PDL will be between cementum and alveolar bone and if the enamel covers the cementum there will be no insertion to PDL on the cementum , so we will have pockets and inflammation will occur .

Another abnormal site other than over cementum is furcation area in molars; in which droplet of enamel will be formed either having dentine in it or not and it's called enamel pearl , it has the same complication , abnormal PDL insertion in that site so loss of the PDL could be .

Alteration of the structure of tooth

As you know the structure of the tooth is composed of enamel, dentine, pulp and cementum ; causes of changes in the structure of the teeth could be : hereditary or environmental. Hereditary causes ; some people may get a disease affecting the structure of the teeth and their teeth will erupts with pits , grooves ,irregularities , yellowish color or soft enamel as a hereditary causes (genetic causes). Environmental causes related to environmental changes, like: nutritional deficiency, anemia ,folic acid deficiency; these environmental changes will affect the tooth structure , because the ameloblasts considered as a sensitive cells in the body ; so if there is deficiency in certain element it may disturb the ameloblasts and the end result will be alternation in the tooth structure. Nutritional deficiencies, bacterial and viral infections ,Chemical injuries to the teeth & trauma all of these are environmental causes.

P.S: - Environmental causes affect either the permanent or the deciduous teeth ,
not both of them, but in hereditary causes both dentitions are affected . - Environmental causes affect both types of hard tissues but in hereditary causes either enamel or dentine is affected .

Localized causes :
As we said trauma is one of the environmental causes , if there is a trauma to a deciduous tooth the successor tooth (permanent) will abnormal , it may be yellowish in color , has a groove etc . we call this tooth a turner tooth 1. Turner tooth : is a permanent tooth; But it has enamel hypoplasia ,it's abnormal in shape , has a rough surface , thats mean a problem in the
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structure of the tooth is due to a cause related to the deciduous tooth in that area. For examole , the deciduous lower anterior may have a trauma or perapical infection, that will affect the developing permanent central incisor; So the developing permanent central incisor will have a defect in the enamel & this defect is localized to the anterior region because the problem was infection of the lower anterior deciduous teeth. This localized turner tooth changes will varies in severity from just yellow to brown color , forms grooves , pits and rough surface ; the turner tooth which is a permanent tooth that has defect in dental structure or enamel due to problem to the deciduous teeth . So it's not a primary tooth.

General informations : If we have a groove , pit or depression on the surface of a tooth it means that we have Hypopalasia ,which means decrease in the produced amount of enamel . If the structure of the tooth is soft then we will think about hypocalcification. {maybe both of them (hypopalasia and hypocalcification) either one of them associated with the turner tooth}

2. Enamel opacities Enamel opacity which is very common , there is a little bit hypocalcification in a certain location of the tooth like a spot , the whole tooth will be normal except a white spot for example on the labial surface, this is because the ameloblasts is very sensitive to any stimulus , e.g thermal , chemical, environmental , nutritional etc..{maybe something that happened during the tooth development which cause hypocalcification but thats not enough to cause softness in the enamel } Usually central incisors are affected .

Generalized causes : Chronological hypoplasia: chronological it's time related to disease or

defect happened over a certain period of time, affected a certain area or number of teeth, which were developing at that time. Look at the picture in slide #39 , we have a band or a defect of the middle third of the labial surface of the upper anterior teeth , the incisal edge here & maybe the canine tip, the lower canine & the middle surface of the lower anterior teeth, So this defect here is generalized (several teeth involved ) we can relate it to time related cause , bands of pits & grooves ,and their distribution depend on the enamel developing at time of the disease . What causes generalized hypoplasia ? Generalized environmental hypoplasia caused by nutritional deficiencies like hypocalcimea , you know that calcium is very important for teeth structure; and ameloblasts are one of the most the sensitive cells in the body for nutritional changes .

There is neonatal line, it's affecting deciduous teeth which are developing at the time of birth (negative effect on the ameloblasts) that cause a change in the enamel structure (incisial edges).

Dental fluorosis ,as you took in oral histology increased in fluoride concentration, the fluoride ion will be incorporated in the structure of the tooth, this is abnormal ,it will give us different appearance of the teeth, the advantage of dental fluorosis is that these teeth are caries resistant but the patient doesn't like them for aesthetic reasons. There is a range of changes in dental fluorosis ,something mild just changes in the color of teeth , somthing more severe hypoplasia and change in the structures themselves. * Hypominralization or hypopalasic this is the sever form of fluorosis (the enamel will be soft) .You know that the teeth are affected by dental fluorosis darken in color with time specially the anterior teeth because they are exposed to light .
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If a patient come to your clinic suffer from generalized fluorosis ,you will notice that his upper anterior teeth are brown, because they are exposed to light, while the rest of the teeth just having white flakes .

How does dental fluorosis work? It interferes with ameloblasts function ,white flakes or discoloration could happen .In severe case enamel will be soft .

* You have to read table 1.2 from the book !

Done by : Abeer Dirawi Forgive me for any mistake Good Luck

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