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Developmental Disorders
Dr. subhadra H. N www.dentistpro.org to find more

Outline
Disorders Of Teeth
Disturbance in Number of Teeth
Hyper/ Hypodontia

Disturbances in Structure

Disturbance in Size of Teeth


Micro/ Macrodontia

Disturbance in Shape of Teeth


Double Teeth Concrescence Dens Evaginatus

of Enamel Disturbances in Structure of Dentin


Dentinogenesis Imperfecta Dentin Dysplasia

Regional Odontodysplasia Localized eruption

Dens Invaginatus
Taurodontism Dilaceration

disturbances

Outline
Hard & Soft Tissue Disorders
Congenital Lip Pits Double Lip Fissured Tongue Lingual Thyroid Lateral Soft Palate Fistulas

Fordyces Granules
Ankyloglossia Microglossia Macroglossia Median Rhomboid Glossitis

Exostoses
Stafne Defect Fissural Cysts

Outline
Other Rare Disorders
Hemifacial Hypertrophy

Progressive Hemifacial Atrophy

Terminologies

Anomaly : deviation from what is regarded as normal.


Malformation : a primary structural defect that results
from a localized error in morphogenesis

Deformation : an alteration is shape, form or structure of


a previously normally formed part

Malformation complex (Anomalad) : a malformation


together with its subsequently derived structure. E.g.:- Pierre-Robin anomalad

Syndrome : a recognized pattern of malformation


presumably having the same etiology & currently not thought to constitute a single localized error in morphogenesis

Association : a recognized pattern of malformation that


currently is not considered to constitute a syndrome
7

Congenital : anomaly or defect present at birth Hereditary : characteristic, condition or disease


transmitted from parent to offspring

Familial :Pertaining to a characteristic, condition or disease


that is present in some families and not others or that occurs in more family members than would be expected by chance. It is usually but not always hereditary.

Acquired : originating after birth, not caused by hereditary


or developmental factors, but by reaction to environmental influence outside the organism
8

Teratogen : any substance, agent or process that


interferes with normal prenatal development resulting in one or more abnormalities in children
Drugs /chemicals Alcohol Androgens Anticoagulants Antithyroid drugs Chemotherapeutics Lead, Lthium, Mercury Phenytoin Streptomycin Thalidomide Valproic acid Infections Cytomegalovirus Rubella Syphilis Toxoplasmosis Varicella Maternalconditions Radiation Age General health DM Phenylketonuria

Developmental Disorders Of Teeth

10

Disturbance In Size Of Teeth


Etiology
Multifactorial

Maxilla CI LI canine I PM II PM
Mandible CI LI canine IPM IIPM

I II III molar
I II III molar

11

Disturbance In Size Of Teeth


Microdontia Classification
Relative Microdontia Diffuse /Generalized Microdontia Regional / Localized Microdontia Frequently Affected Teeth

Treatment
Composite / Porcelain Veneers Autotransplantation / Implants
13

Disturbance In Size Of Teeth


Macrodontia
Synonyms : Megadontia, Megalodontia

Relative Macrodontia

Classification
Diffuse /Generalized Macrodontia Regional / Localized Macrodontia Rhizomegaly / Radiculomegaly

Treatment
14

Disturbance In Number Of Teeth


Anodontia
Oligodontia)

Total Partial (Hypodontia /

Etiology :
Genetic - Autosomal Dominant / Recessive / Sex linked Environment Evolution

15

Disturbance In Number Of Teeth

Anodontia

Quasi continuous trait

16

Disturbance In Number Of Teeth Hypodontia


Syndromes
Ankyloglossia Superior Ectodermal Dysplasia Ehler Danlos Focaldermal Hypoplasia Goldenhar Gorlin Hurler Orofacial Digital - I Progeria Struge- Weber Turner
17

Disturbance In Number Of Teeth Hypodontia


C/F
Prim (<1%) < perm 3.5 8.0% F:M 1.5:1 3rd molar (20-23%) >Max LI > 2nd PM Assoc - Microdontia, alveolar height, retained teeth

18

Disturbance In Number Of Teeth Hypodontia


Solitary median Max central incisor syndrome
Cleft palate, choanal stenosis, umbelical hernia Hypoplasia of Sella turcica, pitutary dysfunction

Treatment
To provide adequate function Maintain the VD Restore esthetics

19

Disturbance In Number Of Teeth Hyperdontia


IJPD2002;12:244-54

Etiology
Hereditary Autosomal dominant/ sex linked Atavism Hyperactivity of dental lamina Environmental factors Dichotomy theory (Taylor 1972)

20

Disturbance In Number Of Teeth Hyperdontia


Syndromes
Apert Cleidocranial Cleft lip & palate Crouzon Chondroectodermal Dysplasia Ehlers Danlos Orofacial Digital- I, III Gardner Trich- Rhino - Phalangeal
21

Disturbance In Number Of Teeth Hyperdontia


Classification:Morphology Conical Tuberculate Supplemental Odontoma Shape (Primosch1981) Supplemental (Eumorphic) Rudimentary (Dysmorphic)
22

Disturbance In Number Of Teeth Hyperdontia


Location Mesiodens Paramolar Distomolar

23

Disturbance In Number Of Teeth Hyperdontia


Prevalence : 0.1-3.8%, > Mongoloid
< Prim dent (0.3- 0.8%) M:F2:1

Clinical Features
Max ant > Max 4th molar > Mand 4th molar > PM > Mand ant & unusual sites Unilateral / Bilateral Erupted -25% (perm),73%(prim) 77.6% -inverted

Diagnosis
24

Disturbance In Number Of Teeth Hyperdontia


Clinical significance
Failure of eruption Displacement or rotation Crowding Abnormal diastema /Premature space closure Dental caries Dilaceration , root resorption Cystic formation Eruption into the nasal cavity

Treatment
Extraction / Surgical removal
25

Disturbance In Shape Of Teeth Double Teeth


ASDC2000;67:313-25

Synonyms : Double Formations, Joined Teeth, Bifid Teeth, Connation

Classification:
Fusion (syndopdontia) Gemination Schizodontia

Etiology
Evolution C. Rose & W. Kukenthal- Multicusped Teeth - Fusion of Haplodont Trauma Crowding
26

Disturbance In Shape Of Teeth Double Teeth


Diagnosis
Coronal morphology Pupal & root anatomy Location in the jaw Crowding Number of teeth

27

Disturbance In Shape Of Teeth Double Teeth


Clinical importance
Crowding / spacing Periodontal problem Caries Eruption disturbance Aesthetics

Treatment
Hemi section & Endodontic treatment & reshaping OR Surgical removal & prosthetic replacement
28

Disturbance In Shape Of Teeth Concrescence


Etiology
Developmental Post inflammatory

Clinical features
Clinical importance
Extraction difficulty

Treatment
No treatment
29

Accessory / Supernumerary Cusp Cusp Of Carabelli


Pathogenesis : Evagination of IEE
Protostylid Perm mand, Dec molars

Prevalence 90% (whites)

30

Disturbance In Shape Of Teeth Accessory / Supernumerary Cusp


Dens Evaginatus
Talon Cusp

31

Accessory / Supernumerary Cusp Dens Evaginatus


Synonyms : occlusal tubercle, Leongs PM, dilated
composite odontoma, tuberculated PM, occlusal enamel pearl, evaginated odontoma Definition: tubercle or protuberance on posterior teeth

Pathogenesis :
Proliferation & evagination of IEE (Tartman)

Etiology
Hereditary Autosomal dominant

Prevalence: 1.09- 4.3%


> mongoloid
32

Accessory / Supernumerary Cusp Dens Evaginatus


Clinical Features
Bilateral Assoc - Shovel shaped incisor

Clinical significance
Fracture / Wear Pulpal pathosis Eruption interference Malocclusion Dilaceration Caries
33

Accessory / Supernumerary Cusp Dens Evaginatus


Treatment Vital teeth
Selective grinding
Hill & Bellis(1984)

Nonvital teeth
Apexification followed endodontic treatment

34

Accessory / Supernumerary Cusp Talon Cusp


Mellor & Ripa Stewart

Definition: an additional cusp that projects from the lingual


surface of primary or permanent anterior teeth , is morphologically well delineated & extends at least half the distance from the cement enamel junction to the incisal edge - Davis & Brook

Pathogenesis :
Proliferation & evagination of IEE
35

Accessory / Supernumerary Cusp Talon Cusp


Prevalence: 0.17- 7.7%
> Chinese, Caucasians, African Americans M : F 3.2 : 1.8

Clinical Features
LI (55%)>CI(33%)> Mand incisors(6%)>

Max canine(4%)
Deciduous rare (Max CI) Conical, Bifid and talon-like.
36

Accessory / Supernumerary Cusp Talon Cusp


Radiographic Features
Normal tooth structure

syndromes
Rubinstein Taybi, Struge Weber Orofacialdigital syndrome II

D/D :
Supernumerary tooth

37

Accessory / Supernumerary Cusp Talon Cusp


Clinical significance
Unwarranted surgical procedure Fracture / Wear Pulpal pathosis Eruption interference Malocclusion Dilaceration Tongue irritation Caries

Treatment
38

Disturbance In Shape Of Teeth Dens Invaginatus


Int Endod J 1997;79- 90

Synonyms : Dens in Dente Dilated Odontome


Tooth Inclusion.

Ploquel (1794) - Whales tooth Socrates (1856) - Human tooth Definition : is a deep surface invagination of the crown / root that
is lined by enamel

Classification
Coronal Radicular
39

Disturbance In Shape Of Teeth Dens Invaginatus


Coronal
Oehlers (1957)

Radicular - rare

40

Disturbance In Shape Of Teeth Dens Invaginatus


Pathogenesis Coronal
Growth pressure (Euler 1939 & Atkinson1943) Focal failure of the IEE (Kronfeld 1934) Rapid & aggressive proliferation of IEE (Rushton1937) Benign neoplasm of limited growth Twin theory (Bruszt 1950) Infection (Fischer 1936)

Trauma (Gustafson & Sundberg 1950)


Invagination of foramen coecum

Radicular
Infolding of HERS
41

Disturbance In Shape Of Teeth Dens Invaginatus


Prevalence - 0.04 10%
Clinical Features
>Max LI, Bilateral Coronal morphology dilated, peg shaped, barrel shaped/ deep faramen coecum

Radiographic features

42

Disturbance In Shape Of Teeth Dens Invaginatus


Histological Features
Diagnosis
Thorough examination of Max LI Deep pit at foramen coecum

Clinical significance
Predisposition to caries Pulpal pathology Periapical pathology (Type III) Early diagnosis mandatory
43

Disturbance In Shape Of Teeth Dens Invaginatus


Treatment
Vital teeth - Preventive & restorative treatment Fissure sealing Composite restoration & periodic review Nonvital teeth Apexification followed by endodontic treatment Endodontic treatment
Cleaning & shaping irrigation with ultrasonic cleaning Obturation thermoplastic technique Type III treat separately

Surgical treatment
Intentional replantation & retrograde surgery Extraction
44

Disturbance In Shape Of Teeth Ectopic Enamel


Enamel in unusual locations
1. Enamel pearl
2. Cervical enamel extensions
J Clin Peridontol 1990;275-81

Enamel pearl
Synonyms : Enamel droplet, Enamel nodule, Enamel globules, Enamel exostoses, Enameloma

True enamel pearl Entirely enamel Composite enamel pearl Enamel + Dentin

Pathogenesis
Bulging of odontoblastic layer - Prolonged contact b/w HERS & dentin
45

Disturbance In Shape Of Teeth Ectopic Enamel


Prevalence -1.1 5.7%
Eskimos 9.7%

Clinical Features
Max 3rd molar > Mand 3rd & Max 2nd molar > Max 1st molar 1- 4 / tooth

Radiographic Features

46

Disturbance In Shape Of Teeth Ectopic Enamel


Cervical enamel extension
8.6 32.6 % >Asians Mand molars > Max molars

47

Disturbance In Shape Of Teeth Ectopic Enamel


Clinical significance
Furcation involvement Buccal bifurcation cysts

Treatment
Meticulous oral hygiene Flattening & removal with furcation plasty

48

Disturbance In Shape Of Teeth Taurodontism


1913, Keith Tauro - Bull, dont tooth

Pathogenesis
Failure of HERS to invaginate at the proper horizontal level

Etiology :
1. Mendelian recessive trait 2. Atavistic feature

3. Component of various syndromes

Prevalence : 0.5 4%
no sex predilection
49

Disturbance In Shape Of Teeth Taurodontism


Clinical Features
Unilateral /Bilateral Permanent > primary teeth 3rd > 2nd > 1st molar (Field effect)

Radiographic Features

50

Disturbance In Shape Of Teeth Taurodontism


Classification

51

Disturbance In Shape Of Teeth Taurodontism


Clinical significance
Endodontic therapy difficult Furcation involvement Stability & strength as abutment

Treatment
No specific therapy

52

Disturbance In Shape Of Teeth Dilaceration


Abnormal angulation/ bend in the root or less frequently the crown of a tooth

Etiology
Trauma Avulsion / Intrusion Neonatal laryngoscopy & endotracheal intubation Cyst, tumor, odontogenic hamartoma Idiopathic

53

Disturbance In Shape Of Teeth Dilaceration


Clinical Features
Perm teeth > deciduous teeth >Max Incisor Altered path of eruption Posterior teeth apical

Treatment
Deciduous teeth extraction Permanent teeth
Minor no treatment Delayed / abnormal eruption surgical exposure/orthodontic intervention Nonvital teeth endodontic treatment Extensive - extraction , orthodontic movement CI
54

Disturbance In Shape Of Teeth Supernumerary Roots


C/F
>Permanent molars(3rd molar) Root may be divergent

Treatment
No treatment

55

Developmental Alteration In The Structure Of Teeth


Enamel
Hereditary type
Amelogenesis Imperfecta Inherited systemic conditions with enamel defects

Acquired Enamel Defect

56

Amelogenesis Imperfecta
Definitions
A group of disfiguring hereditary conditions which affect the clinical appearance of enamel of all or nearly all teeth which occur in kindred show essentially the same defect & which are unassociated with known morphologic or biochemical changes elsewhere in the body - Witkop & Rao 1971

57

Classification: Witkop, 1988


Type
IA IB IC ID IE IF IG IIA IIB IIC IID IIIA IIIB IV A IVB

Pattern
HYPOPLASTIC ------HYPOMATURATION ---HYPOCALCIFIED -HYPOMATURATION-HYPOPLASTIC HYPOPLASTIC-HYPOMATURATION

Features
Generalized pitted Localized pitted -Diffuse smooth -Diffuse rough Enamel agenesis Diffuse pigmented Diffuse Snow capped -Diffuse -Associated taurodontism --

Inheritance
AD -AR AD X AD AR AR X X AD -AR AD -59

Amelogenesis Imperfecta
Prevalence :
1: 718 1: 14,000

Hypoplastic Pitted form

60

Amelogenesis Imperfecta
Hypoplastic Smooth pattern (AD)

61

Amelogenesis Imperfecta
Hypoplastic Smooth pattern (X -Linked) Lyonization

62

Amelogenesis Imperfecta
Hypoplastic Rough pattern

63

Amelogenesis Imperfecta
Hypoplastic
Enamel Agenesis
Color / shape dentin R/ F no peripheral enamel

64

Amelogenesis Imperfecta
Hypocalcified

65

Amelogenesis Imperfecta
Hypomaturation
Pigmented pattern Snow capped pattern

66

Amelogenesis Imperfecta
Hypomaturation - Hypoplastic

67

Amelogenesis Imperfecta
Clinical significance
Aestheticcs VD Caries

Treatment
Appropriate diagnosis Genetic counseling Early orthodontic assessment Preservation of VD Aesthetics
68

Inherited Systemic Conditions With Enamel Defects


Ectodermal / Ectodermal Mesodermal disorders
Ectodermal disorders Ectodermal dysplasia, Epidermolysis bullosa Tricho dento osseous syndrome Occulo dento osseous syndrome

Ectodermal Mesodermal disorder Incontenentia pigmenti Ehlers Danlos syndrome


69

Inherited Systemic Conditions With Enamel Defects


Multiple systemic malformation / dysmorphic syndrome
Cleidocranial dysplasia Tuberous sclerosis Prader Willi syndrome

Acrocephalosyndactly
Palmoplantar hyperkeratosis syndrome

Inherited disorders of calcium metabolism


Idiopathic & familial hypothyroidism Hypophosphatasia
70

Non-inherited Enamel Structural Defects


Synonym- Chronologic enamel hypoplasia

Infections
Direct cellular damage ameloblastic derangement
eg:- Syphilis, Rubella, Cytomegalovirus

Malfunction of major organs Body temp,


Measles, Chicken pox, Pneumonia
72

Syphylis

Moon s molar/ Fournier molar


73

Non-inherited Enamel Structural Defects


Nutritional disorders
Vit A & D deficiency General malnutrition

Birth trauma
Prolonged labor Multiple pregnancy

74

Non-inherited Enamel Structural Defects


Metabolic disorders Hyperbillurubinemia
Billiary atresia Erythroblastosis fetalis

Common

Internal hemorrhage
Billiary hypoplasia Neonatal hepatitis

Hypocalcaemia
Hypoparathyroidism Vit D deficiency rickets
75

Non-inherited Enamel Structural Defects


Other metabolic disorders
Provitamin D

Skin

Vit D3 cholecalciferol

Liver

1,25- Dihydroxy cholecalciferol

kidney

25- Hydroxy cholecalciferol


76

Non-inherited Enamel Structural Defects


Birth prematurity & low birth weight
Deficiency of Ca 2+ & Po4Trauma to alveolar ridge

Prevalence
62.3% - < 1500gm 27.3% - 1500- 2000gm 12.7% - > 2500gm

77

Non-inherited Enamel Structural Defects


Chemicals Tetracycline Mechanism
Toxic to ameloblasts Disruption of mineralization Chelating Ca 2+ of hydroxyapatite

Critical period
Teeth Prim incisors Prim canines Perm incisors & canines IU (months) 4 5 3-5 EU 3mnths 9 mnths 7yrs
78

Non-inherited Enamel Structural Defects


Tetracycline

Clinical Features

79

Non-inherited Enamel Structural Defects


Anti-neoplastic therapy
Toxic to ameloblasts

Local factors
Trauma Turners hypoplasia Infection

80

Non-inherited Enamel Structural Defects


Fluorosis
Endemic (>2ppm) Permanent teeth > Deciduous teeth Less susceptible to caries

81

Non-inherited Enamel Structural Defects


Clinical features
Mottled enamel Grade Very mild Mild Moderate Severe Clinical appearence White opaque,< 25% -;;- </=50% -;;-/ brownish Opaque, pitted, brown, brittle
82

Non-inherited Enamel Structural Defects


Pathogenesis
Presecretory stage no effect at physilogically relevant Fl

dose
Secretory stage inhibit protien sythesis at high dose
Maturation stage delayed withdrawl of amelogenin, serine

protien-ases activity Enamel matrix protien tightly bound to flourapatite

83

Non-inherited Enamel Structural Defects


Clinical Significance of chronologic enamel hypoplasia
Esthetics Dental caries Tooth sensitivity Loss of vertical dimension

Treatment
Microabrasion
18% HCL / 37% phosphoric acid

Veneers
84

Dentinogenesis Imperfecta
Synonyms : Hereditary opalecent dentin Definition : Hereditary developmental disturbance of the
dentin in the absence of any systemic disorder

Classification :
Shields
DI - I DI- II DI - III

Clinical presentation
Osteogenesis Imperfecta + Opalescent teeth Isolated opalescent teeth Isolated opalescent teeth

Witkop
DI Hereditary opalescent teeth Brandywine isolate
85

Dentinogenesis Imperfecta
Etiology :
Autosomal dominant (100% penetrance , variable expressivity)

Clinical Features
Deciduous > permanent 1st molar & incisors > PM > 2nd , 3rd molar Blue Brown discoloration Accelerated attrition
86

Dentinogenesis Imperfecta

87

Dentinogenesis Imperfecta
Radiographic Features

DI I, II

DI III (Shell teeth)


88

Dentinogenesis Imperfecta
Treatment
risk of cervical fracture Stainless steel crown vertical dimension Endodontic treatment difficult 30yrs complete denture/ implants

89

Dentin Dysplasia
Normal enamel , atypical dentin with abnormal pulp morphology

Classification Shield
Type I

Witkop
Radicular dentin dysplasia

Type II

Coronal dentin dysplasia

90

Dentin Dysplasia
Etiology
Autosomal dominant

Clinical Features
Deciduous = permanent Type I Radicular Dentin Dysplasia (Rootless teeth) Normal appearance Normal eruption Premature exfoliation Type II coronal dentin dysplasia Blue brown discoloration deciduous teeth Normal appearance permanent teeth
91

Dentin Dysplasia
OOO 1991:119- 25

Radiographic Features
Radicular

Type I a

Type I b

Type I c

Type I d
92

Dentin Dysplasia
Coronal Thistle Tube pulp

Deciduous teeth - complete obliteration


93

Dentin Dysplasia
Differential Diagnosis
Fibrous dysplasia of dentin : Autosomal dominant disorder Pulpal dysplasia

Clinical significance
Premature exfoliation Pulp vascular channels close to DEJ Periapical lesions

94

Dentin Dysplasia
Treatment Type I
Preventive care Periapical lesions guided by root length Moderate -Mechanical creation of canal path Short roots Pulpal ramification Periapical curettage & retrograde filling

Type II
Endodontic therapy - accomplished readily
95

Regional Odontodysplasia
Ped Dent 2005; 34- 39

Synonyms : Ghost teeth, Odontogenesis Imperfecta,

Arrested tooth development

Etiology : Idiopathic
Proposed causes 1. Abnormal migration of neural crest cells 2. Local trauma/ infection 3. Local circulatory deficiency 4. Irradiation 5. Metabolic / nutritional deficiency 6. Hyperpyrexia 7. Rh incompatibility
96

Regional Odontodysplasia
Pathological conditions
1. 2. 3. 4.

Ectodermal dysplasia Hypophosphatasia Neurofibromatosis Ipsilateral facial hypoplasia

5.
6.

Vascular nevi
Hydrocephalus
97

Regional Odontodysplasia
Prevalence : Uncommon
F: M = 1.4 : 1

Clinical Features
Permanent = Deciduous Max > Mand, Unilateral, Anteriors > Posteriors Yellow Brown discoloration Delay / failure of eruption Rough surface Deficient enamel & dentin Premature exfoliated
98

Regional Odontodysplasia
Radiographic Features

Short roots Pulp stones


99

Regional Odontodysplasia
Clinical Significance
Predisposition to caries Pupal necrosis Premature exfoliation

Treatment
Erupted teeth Intermediate restoration - etched retained restoration / SS crown Tooth preparation CI Nonvital endodontic therapy/ extraction
100

Regional Odontodysplasia
Treatment
Unerupted teeth Undisturbed Premature exfoliation Removable prosthesis Auto transplantation

101

102

103

Disturbances in Eruption
Premature Eruption
Delayed Eruption

Ankylosed Deciduous Teeth


Impacted Teeth

104

Premature Eruption

Premature loss of primary teeth Hyperthyroidism

105

Disturbances in Eruption Natal & Neonatal Teeth


Definition :
Natal teeth observable at birth Neonatal teeth erupt during the first 30 days

Ped Dent 2001: 23158 -62

Synonyms : Congenital teeth, Fetal teeth, Predecidual teeth,

-Massler & Savara

Etiology : unknown
Superficial positioning of the germ Infection Malnutrition Febrile state Hormonal stimulation Hereditary (AD)

Osteoblastic activity, Hypovitaminosis

106

Disturbances in Eruption Natal & Neonatal Teeth


Syndromes
Hallerman Streiff,
Craniofacial dysostosis, Congenital pachyonychia

Fauconnier & Gerardy


Early eruption Endocrine disturbance
Solidity , normal path of eruption, integrity of gingiva

Premature eruption (expulsive folliculitis) - Pathological


Rapid tooth eruption, rootless,extreme mobility, inflamed gingiva
107

Disturbances in Eruption Natal & Neonatal Teeth


Clinical Features
Conical / normal shaped Yellow brownish

Classification
Spouge & Feasby (1960) Mature Immature Hebling (997) Shell shaped crowns, poorly fixed, absence of root Solid crown, poorly fixed, little/ no root Incisal margin observable Unerupted ,palpable tooth, edema of gingiva,
108

Disturbances in Eruption Natal & Neonatal Teeth


Primary teeth -95%, Supernumerary 5% Lower incisor (85%) > upper incisor (11%) > lower canines & molars (3%) > upper canines & molars(1%)

Histological Features
Enamel hypoplasia Irregular dentin Absence of cementum Highly vascularized pulp

109

Disturbances in Eruption Natal & Neonatal Teeth


Differential Diagnosis
Cysts of dental lamina Bohn nodule

Clinical Significance
Dislocation & aspiration
Traumatic injury Caldarelli (1857)

Riga & Fede

Treatment
Normal / supernumerary Mobility Inconvenience during suckling
110

Disturbances in Eruption Natal & Neonatal Teeth


Incisal margin smoothening
Extraction

Only after 10days Or Administer vit K (0.5- 1.0mg), IM


Prevention of caries
Control plaque accumulation
Periodic Fl application

111

Disturbances in Eruption Delayed Eruption


Etiology
Systemic disease Rickets, Cleidocranial dysplasia,

Cretinism
Trauma Fibrous tissue Supernumerary teeeth, cysts, odontoma, Retained / prematurely lost deciduous teeth Arch length deficiency Delayed tooth development

Treatment
112

Disturbances in Eruption Submerged Teeth


Synonyms : Ankylosed teeth, Infraocclusion, Secondary retention, Reimpaction, Reinclusion

Etiology
Ankylosis

Pathogenesis
Disturbances in local metabolism 2. Trauma 3. Local infection 4. Chemical / Thermal irritation
1.

113

Disturbances in Eruption Submerged Teeth


Prevalence
1.3 8.9 % 7-18 yrs (8-9 yrs) Mand > Max 1st molar > 2nd molar

Clinical Features
Sharp, solid sound (> 20% root ankylosed)

Radiographic Features

114

Disturbances in Eruption Submerged Teeth


Clinical significance
Occlusal & periodontal problem Supraeruption Impaction of underlying permanent teeth

Treatment
extraction Prosthetic build up Luxation

115

Disturbances in Eruption Impacted Teeth


Embedded lack of eruptive force Impacted prevented from eruption by physical barrier Etiology
Lack of space Deviated path of eruption Retained dec teeth

Other factors
Overlying cyst / tumor Trauma Reconstructive surgery Thickened overlying bone/ soft tissue
116

Disturbances in Eruption Impacted Teeth


Prevalence
Mand & Max 3rd molar > Max cuspid > Bicuspids, supernumerary teeth Mand 3rd molar 22% Max 3rd molar 18% Max cuspid 0.9%

117

Disturbances in Eruption Impacted Teeth


Impacted mandibular 3rd molar
Winters classification Mesioangular Distoangular Vertical Horizontal

Impacted maxillary 3rd molar

Impacted maxillary cuspid


Horizontal / Vertical Labial / Palatal
118

Disturbances in Eruption Impacted Teeth


Clinical Significance
Partially Impacted tooth Infection Dental caries Root resorption Dentigerous cyst/ Ameloblastoma

Treatment
Molar Extraction Cuspid Extract Deciduous canine Surgical exposure & orthodontic traction
119

Disturbances in Eruption Impacted Teeth


Treatment (contd)
Achieve adequate space expansion, molar distalization / incisor advancement Unfavorable position extraction & positioning of 1st bicuspid Or Periodic observation

120

Eruption Sequestrum
Clinical Feature
Tiny irregular spicule of bone, overlying the occlusal fossa

R/F
Tiny irregular opacity, overlying the occlusal fossa

Etiology

Clinical Significance
Soreness in the area

Treatment
121

Developmental Disturbances of Soft Tissues

122

Developmental Disturbance of Lip Commissural Lip Pits


Etiology : Autosomal dominant Pathogenesis: Prevalence:
Adults - 12-20% Children -0.2- 0.7%

Clinical Features
Unilateral / Bilateral Depth 1-4 mm Fluid can be expreesed Not assoc with facial / palatal clefts Preauricular pits
123

Developmental Disturbance of Lip Commissural Lip Pits


Histological Features
Str sq epithelial lining Ducts of minor salivary glands

Clinical significance
Cystic formation/ Secondary infection

Treatment
Asymptomatic no treatment Surgical excision

124

Developmental Disturbance of Lip Paramedian Lip Pits


Synonyms : Congenital fistulas of lower lip

Etiology :
Persistent lateral sulci

Clinical Features
Bilateral Depth 1.5 cm Express salivary secretions

Clinical significance
Autosomal dominant + cleft lip / palate (Van der woude

syndrome)
125

Developmental Disturbance of Lip Paramedian Lip Pits


Cystic formation/ secondary infection

Histological Features Treatment


Surgical excision

126

Developmental Disturbance of Lip Double Lip JADA 1990:193- 2


Redundant fold of noninflammatory, hypertrophic tissue on the mucosal side of the lip

Etiology: not clear Congenital


Persistence of sulcus b/w pars glabrosa & pars villosa

Acquired
Oral habit / trauma

Ascher syndrome
Double lip + blepharoclasis + non toxic thyroid enlargement
127

Developmental Disturbance of Lip Double Lip


Causes
Heredity Endocrine dysfunction Allergic reaction Rheumatoid disease

Clinical Features
Bilateral , > upper lip Cupids Bow appearance

128

Developmental Disturbance of Lip Double Lip


Differential diagnosis
Hemangioma, Lymphangioma , Mucocele, Angioedema, Cheilitis glandularis & Cheilitis granulomatosa

Treatment
Not indicated

129

Developmental Disturbance of Tongue - Microglossia


Synonym: Hypoglossia Aglossia Entire tongue missing
Mandibular Limb hypogenesis Cleft palate

Clinical Features

Treatment
Orthognathic correction Speech & language development normal
130

Developmental Disturbance of Tongue - Macroglossia


Etiology True Macroglossia
Plast & reconstr surg 1986; 715-23

Congenital 1. Vascular malformation, (lymphatic, venous, capillary ) 2. Muscular enlargement (Hemi hypertrophy, Beckwith Weidmann syndrome) 3. Systemic disorder (mucopolysaccharide storage disorder) 4. Tumor / Cyst (Rhabdomyoma, dermoid cyst)

131

Developmental Disturbance of Tongue - Macroglossia


Acquired
1. Tumor (lymphoma, epidermoid carcinoma) 2. Systemic disorder (amyloidosis , gigantism) 3. Local reactive change (edema, vascular congestion)

Relative macroglossia
Congenital
Systemic disorder (downs, cretinism)

Acquired
1. Functional (post op maladaptation) 2. Elevation (ludwig s angina,) 3. Systemic disorder (myxedema)

132

Developmental Disturbance of Tongue - Macroglossia


Clinical Features
Noisy breathing Difficulty with chewing/ swallowing Drooling Slurred speech Widened interdental space Scalloping/ crenations

Open bite/ mandibular prognathism


Dry/ cracked tongue Ulceration/ secondary infection/

hemorrhage
133

Developmental Disturbance of Tongue - Macroglossia


Treatment
Mild no treatment speech therapy Severe reduction glossectomy

134

Developmental Disturbance of Tongue Ankyloglossia Ped dent 2005; 40-6


Synonym : tongue tie

Etiology : abnormally short lingual frenum Classification : Kotlow,1999


Normal range of free tongue = > 16mm Class I : mild ankyloglossia =12-16mm Class II : moderate ankyloglossia =8-11 mm Class III : severe ankyloglossia = 3-7mm Class IV : complete ankyloglosia = < 3mm

Prevalence : 0.02- 5%
M: F = 3: 1 Orofacialdigital syndrome, Beckwith Wiedemann , X-linked Cleft palate

135

Developmental Disturbance of Tongue - Ankyloglossia


Clinical significance
Feeding difficulties Does not delay speech, Interference with articulation Malocclusion Gingival recession Dyspnea Social issues

136

Developmental Disturbance of Tongue - Ankyloglossia


Clinical assessment
Ability to produce tongue sounds t , d , i, s Kotlows classification Lingual mobility & tongue elevation (Lalakea 2002)
Normal 20-25mm AG 15mm/ less

Treatment
Early intervention Frenotomy should not be performed before 4-5 yrs
137

Developmental Disturbance of Tongue - Lingual Thyroid


Etiology :
Inability of primitive gland to descend normally Prevalence : 10% M: F = 1: 4

Clinical Features
Site b/w foramen caecum epiglottis Asymptomatic Small nodular lesion large mass Dysphagia, Dysphonia, Dyspnea Hypothyroidism (33%)

138

Developmental Disturbance of Tongue - Lingual Thyroid


Diagnosis
Thyroid scan (Iodine Isotope/ Technetium 99) C T scan & MRI Biopsy avoided

Treatment
Asymptomatic periodic follow up Symptomatic

Suppressive therapy with supplemental thyriod harmone Surgical removal autotransplantation

Prognosis
Malignancy 1%, > males
139

Fissured Tongue
Synonym : Scrotal tongue

Etiology :not certain


Genetic polygenic / Autosomal dominant Chronic trauma

Prevalence 2-5%
M>F

Clinical Features
Grooves / furrows 2-6mm Asymptomatic / mild burning sensation rarely Melkerson Rosenthal syndrome Chelitis granulomatosa, facial paralysis, scrotal tongue
140

Fissured Tongue
Treatment
No specific treatment Encouraged to brush the tongue

141

Median Rhomboid Glossitis


Synonym : central papillary atrophy of the tongue

Etiology :controversial
Persistence of tuberculum impar

Baughman 10, 000 school children no cases Localized chronic fungal infection C. Albicans

Prevalence : < 1%
Common in adults M>F

142

Median Rhomboid Glossitis


Clinical Features
Ovoid / diamond / rhomboid shaped Reddish patch Lack of filiform papillae

Treatment : No specific treatment


Antifungal therapy Lesions regress spontaneously

143

Lateral Soft Palate Fistulas


Etiology :
Defect in the development of the 2nd pharyngeal pouch Infection / Surgery

Clinical Features
Common on ant tonsillar pillar

Bilateral
Asymptomatic Associated with Hypoplasia of palatine tonsil Hearing loss Preauricular fistula

Treatment
Innocuous- No treatment
144

Developmental Disturbance of Oral Mucosa - Fordyce's granules


Synonym :Fordyces spot, Fordyces disease

Fordyce 1896

Etiology
Inclusion of ectoderm

Prevalence
95% - adults

Clinical Features
Bilateral Sites BM, Lips Batsaki & E L Nagar - Normal (BM) Heterotopic anomalous (other sites)
145

Developmental Disturbance of Oral Mucosa Fordyces granules


Clinical Significance
Benign sebaceous adenoma rarely Keratin filled Pseudocyst

Treatment
No treatment required

146

Peutz Jeghers Syndrome


Clinical Features
Orally 1 to 4 mm brown to blue grey macules- Labial & buccal mucosa

Face nose, eyes , lips


Small intestine polyps

148

Fibromatous Gingiva
Synonym : Elephantiasis Gingivae ,Hereditary Gingival Fibromatosis , Congenital Macrogingivae.

Familial / sporadic

Clinical Features
Dense, Diffuse, Smooth, or Nodular overgrowth , Non painful, No Hemorrhage One / both arches, Time of eruption of Permanent incisor, Few instances even at birth ,

Clinical significance
Prevent eruption of teeth ,

Treatment
Gingivectomy, Reccuence - common
149

Exostoses
Localized bony protuberance from cortical plate Common Torus palatinus Torus mandibularis Others Buccal exostoses Palatal exostoses (Palatine tubercle) Solitary exostoses Reactive subpontine exostoses (Subpontic osseous proliferation, Subpontic osseous hyperplasia)

150

Exostoses

Buccal exostoses

Palatal exostoses

subpontine exostoses
151

Torus Palatinus
Etiology :
Genetic Autosomal Dominant Environmental factors- masticatory stress Prevalence -9-60%, High in Asians F>M with age

Clinical Features
Flat torus

152

Torus Palatinus

Lobular torus < 2 cms Asymptomatic

Nodular torus

153

Torus Palatinus
Radiographic Features
Not routinely found on IOPAR

Histological Features
Dense , lamellar ,cortical bone with inner trabecular bone

154

Torus Mandibularis
Etiology :
Multifactorial

Prevalence
5-40% M>F early adult hood

Clinical Features
Above Mylohyoid line Bilateral (90%) Asymptomatic
155

Torus Mandibularis
Radiographic Features

Histological Features D/D


Cementifying fibroma, ossified subperiossteal hematoma, early osteosarcoma,

Treatment
156

Developmental Lingual Mandibular Salivary Gland Depression


Synonym : stafne cyst, static bone cavity/ cyst, Latent bone cyst, lingual mandibular bone cavity

Stafne 1942

Clinical & Radiographic Features

158

Developmental Lingual Mandibular Salivary Gland Depression


Rare children, most middle aged Stable in size

Diagnosis
Radographically - location Lack symptoms C T scan / MRI/ Sialograph

Histological Features
Normal submandibular gland/ muscle, blood vessels, CT, lymphoid

Treatment
159

Developmental Cysts / Fissural Cysts


Int J oral Surg1982, 351-59

Nasolabial cyst
Synonyms : Nasoalveolar cyst / Kelstadts cyst Rare

Pathogenesis not clear


1. Fissural cyst Kelstadt 2. Degenerated nasolacrimal duct Bruggemann 3. Retention cyst of nasal mucous gland

160

Nasolabial Cyst
Clinical Features

Radiographic Features

161

Nasolabial Cyst
Histological Features
Ciliated pseudo stratified columnar/ str sq epethilium Fibrous CT wall

D/D
Nasal furunculous Periapical abscess Dentigerous & Odontogenic Cyst

Treatment
Surgical excision Recurrence - rare
162

Nasopalatine Duct Cyst


Int J oral surg; 1981: 441-61

Synonyms :Median anterior maxillary cyst, Incisive canal cyst

common

Etiology
1. Proliferation of epithelial remnants of the nasopalatine duct

Congdon (1920)
Trauma Infection

2. Mucous retention phenomenon 3. Epithelium of vomeronasal organ of Jacobson

Prevalence 1%
M>F Rare in children
163

Nasopalatine Duct Cyst


Clinical Features

Asymptomatic Loss of smell Spontaneous drainage


164

Nasopalatine Duct Cyst


Radiographic Features

Histological Features
Respiratory epithelium/ str sq epithelium
165

Nasopalatine Duct Cyst


D/D
Incessive fossa 6 mm Periapcal pathology

Treatment
Surgical excision - via palatal flap

166

Median Palatal Cyst


Rare

Pathogenesis
Epithelium entraped b/w palatal shelves

Clinical Features
Firm , fluctuant, swelling Frequent in young adults Asymptomatic

Radiographic Features Histological Features


Str sq epithelial lining

Treatment
Surgical excision Recurence - rare
167

Globulomaxillary Cyst
Pathogenesis
Epithelium entrapped b/w globular & max process Odontogenic

Clinical & Radiographic Features


Between max lateral & cuspid Inverted Pear appearance

Histological Features Treatment


Surgical removal
168

Median Mandibular Cyst


Pathogenesis
Epithelium entrapped b/w mand processes Odontogenic

Clinical & Radiographic Features


Radiolucency b/w / apical to CI Cortical expansion

Histological Features
Str sq pseudo str ciliated columunar epithelium

Treatment
Surgical excision
169

Palatal Cyst Of The Neonates


Synonym : Epsteins pearls, Bohns nodules

Heinrich Bohn (1866), Alois Epstien (1880)

Pathogenesis
Epithelial remnants of minor salivary gland Bohn nodule Epithelial remnants entrapped b/w palatal shelves Epstien Remnant of dental lamina

Prevalence
Common ,65 % to 85% of Neonates .

Clinical features
1 to 3 mm . White or Yellowish, raised nodule.

Treatment
No tretment
170

Dermoid Cyst
Pathogenesis
Cystic form of teratoma entraped totipotent blastomeres

Prevalence
Common in children & young adults . 15 % - congenital .

Clinical Features
Slow growing , painless , rubbery mass.

Midline of the floor of the mouth. Difficulty in eating , speaking & breathing . Double Chin appearance . Size - few mm to 12 cm .
171

Dermoid Cyst
Histological Features
Orthokeratinized str sq epithelium Lumen- keratin

CT wall skin appendages

Treatment
Surgical removal

Recurrence uncommon
Malignant transformation
172

Thyroglossal Duct Cyst


Pathogenesis
Remnants of thyroglossal duct epithelium.

Prevalence
50 % < 20 yrs , No sex predilection

Clinical Features
Foramen caecum - suprasternal notch . Painless , fluctuant , movable swelling . < 3 cm, occasionally - 10 cms. Maintain contact with hyoid

Treatment
Surgical intervention Sistrunk procedure . Thyroid adenocarcinoma < 1%
173

Cervical Lymphoepithelial Cyst


Synonym Branchial Cleft Cyst

Pathogenesis
Remnants of the branchial clefts , or Parotid gland epithelium entrapped in upper cervical LN

Clinical Features
20 to 40 yrs , Tender , Soft , Fluctuant mass 1 to 10 cm .

Histological Features
Str sq epithelial lining CT wall lymphoid tissue with germinal centers

Treatment
Surgical removal
174

Other Rare Development Anomalies

177

Hemihyperplasia
Synonyms :Hemihypertrophy

Etiology : obscure
Vascular / lymphatic abnormalities Central nervous system disturbances Endocrine dysfunction Aberrant twinning

Syndromes
Beckwith Wiedemann syndrome Neurofibromatosis Epidermal nevus syndrome Multipple exostoses syndrome
178

Hemihyperplasia
Clinical Features
Complex hemihyperplasia Simple hemihyperplasia Hemifacial hyperplasia M : F = 1:2 > Right side Mental retardation (20%) Wilms tumor , Adrenocortical carcinoma (5.9%)

179

Hemihyperplasia
Skin pigmentation, hypertrichosis, telegctasia, Unilateral macroglossia , Macrodontia, premature eruption Malocclusion Mandibular canal size

Histological Features
Thickness of epithelium CT hyperplasia

Treatment :
Periodic ultrasound examination Cosmetic surgery
180

Progressive Hemifacial Atrophy


Synonym Romberg syndrome ; Parry-Romberg syndrome .

Etiology : obscure
Malfunction of cervical sympathetic nervous system , H / O prior trauma , Viral or Borrelia infection , Hereditary .

Clinical Features:
Onset 1st two decades of life . Localized atrophy of skin & subcutaneous str. Hypoplasia of underlying bone . coup de sabre strike of the sword Enophthalmos , Localized Alopecia . Occasionally Trigeminal Neuralgia , Facial Paresthesia , Migraine .
181

Progressive Hemifacial Atrophy


The mouth & nose are deviated Atrophy of upper lip expose max teeth . Unilateral atrophy of tongue . Unilateral posterior open bite . Delayed eruption of teeth , deficient root dev / root resorption.

Histological Features
Atrophy of epidermis , Perivascular infiltrate of lympho cytes & monocytes

Treatment
Plastic surgery cosmetic deformity. Orthodontic therapy malocclusion .
182

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Conclusion

183

References
Oral & maxillofacial pathology Neville, Damm,

Allen, Bouquot A text book of oral pathology Shafer, Hine , Levy Cawsons essential of oral pathology and oral medicine R. A Cawson, E. W. Odell A text book of pediatric dentistry Cameron & Widmer
184

Disturbance In Shape Of Teeth Taurodontism


Syndromes
Amelogenesis imperfecta, hypoplastic, type IE
Amelogenesis imperfecta-taurodontism, type IB Ectodermal dysplasia

Klinefelter
Microcephalic dwarfism-taurodontism Oculo-dento-digital dysplasia Oral-facial-digital, type II Downs syndrome Tricho-dento-osseous, type I, II, and III Tricho-onycho-dental
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