tooth anomalies in dental practise .pptx

tooth anomalies

1. Abnormality of tooth size

2. Abnormality of tooth form Fusion partial or complete union of dentine and/or enamel of two or more separate tooth germs at some stage of development Gemination attempted separation of a single tooth germ to form 2 separate teeth Two crowns or attempted separation with single root. B oth called as double teeth

3. prevalance primary dentition - 0.5% to 1.6% of Caucasian populations The permanent dentition - 0.1–0.2%. Males and females are affected equally. A genetic basis has been suggested not confirm. Trauma also suggested as a reason The most typical areas affected are the anterior region in the primary dentition, with the mandible more commonly affected than the maxilla. Gemination however, is most often seen in the maxillary primary incisors and the canines

4. presentation Gemination partially or totally separated crowns with enlarged pulp chamber and one root normal number of teeth are maintained bifid crown and is usually found as an isolated trait, not associated with any syndrome.

5. P roblems with gemination tooth malalignment spacing problems arch asymmetry unacceptable appearance periodontal involvement impedes the eruption of the adjacent tooth Increase caries risk

6. Concrescence Concrescence is defined as the cemental union of two adjacent teeth without confluence of the underlying dentin showing independent pulp chambers and root canals It may occur during or after the completion of root formation it is called true/developmental concrescence and acquired/post inflammatory concrescence Concrescence is seen frequently in the posterior maxillary region

7. Etieologies could be Restriction during development local trauma excessive occlusal force local infection after development Radiographic examination is required when concrescence is suspected clinically

8. problems It may affect the extraction of an adjacent tooth and may fracture the tuberosity or floor of the maxillary sinus Orthodontic tooth movement could affect Good for anchorage planning

9. Dilaceration deviation or bend in the linear relationship of crown of a tooth to its root Dilaceration may appear in both permanent and primary teeth but incidence in the latter is very low The term dilaceration was first used by Tomes in 1848. Dilacerations usually occur in the apical third of the root when the anterior teeth are involved, middle third when first molars are involved and coronal third when third molars are involved

10. Root dilacerations are common than crown dilacerations However crown dilacerations are commonly observed in the permanent maxillary incisors followed by mandibular incisors. Pulp necrosis and periapical inflammation may be a common finding even in the absence of decay because the bent portion acts as a nidus for bacterial entry due to defective enamel and dentin

11. A ssociated syndromes Smith Magenis syndrome hypermobility type of Ehlers-Danlos syndrome Axenfeld -Rieger syndrome

12. etiologies 1. Mechanical trauma to the primary predecessor The calcified portion of the permanent tooth germ is displaced in such a way that the remainder of the tooth germ forms at an angle In 1978, Stewart studied the phenomenon in 41 cases of dilacerated incisors and found that only in 22% (nine patients) of the cases, this was due to injury. Therefore, he concluded that the cause lay in the ectopic development of the tooth germ.

13. 2. idiopathic developmental disturbance especially in cases that have no clear evidence of traumatic injury. This theory is more acceptable because dilaceration is observed more frequently in posterior teeth, which are less susceptible to traumatic injury.

14. O ther suggested etiologies advanced infection of root canals ectopic tooth germ development and lack of space the effect of anatomical structures e.g., the cortical bone of the maxillary sinus, the mandibular canal and the nasal fossa mechanical interference during eruption, such as an ankylotic primary tooth

15. RADIOGRAPHIC FEATURES If the roots bend mesially or distally, the dilaceration is clearly apparent on a periapical radiograph. However, when the dilaceration is toward the labial/buccal or palatal/lingual, the central X-ray beam passes almost parallel to the deviating part of the root.  Gives bulls eye or target appearance

16. treatment Surgical exposure with orthodontic traction extraction which may be followed by (a) space closure  surgical repositioning   autotransplantation Apicectomies

17. Dens invaginatus occurs as a consequence of an invagination on the external surface of the tooth crown before calcification The invagination ranges from a short pit confined to the crown to a deep invagination into the root, at times extending to or beyond the root apex. reported in both dentitions. dens in dente ( Busch (1897))

18. Majority of the cases are encountered in maxilla with the maxillary lateral incisors being commonly affected radiographic appearance of coronal DI is a pear shaped invagination of enamel and dentin with a narrow constriction at the opening on the surface of the tooth. The infolding of the enamel lining is more radio-opaque than the surrounding tooth structure aiding easy identification Oehlers et al grouped coronal DI into three types

19. Type I : Invagination limited to the crown Type II : Invagination below the Cementoenamel Junction (CEJ) Type III : Invagination fully extended to the apex of the tooth A radicular form of dens invaginatus has also been described by Oehlers which is thought to arise due to the proliferation of Hertwig’s root sheath.

20. P ossible eatiogies Infection trauma pressure from the growing dental arch A focal failure of growth or a proliferation of a part of the inner enamel epithelium may be involved in the invagination

21. problems E arly caries lead to pulpal pathalogy and peri apical infections. Enamel and dentine that lines the in‐folded areas is very thin and easily breached by early caries. In ortho have to careful about these pathalogies H ave to restor before otho

22. Dens evaginatus developmental aberration of a tooth resulting in formation of an accessory cusp whose morphology has been described as abnormal tubercle, elevation, protuberance, excrescence, extrusion, or a bulge exhibiting enamel covering a dentinal core that usually contains pulp tissue; occasionally having slender pulp horn which extends to various distances within the dentinal core Evaginated odontome is another term used to describe this condition Both primary and permanent dentitions may be involved

23. It occurs during the bell stage and is characterized by abnormal proliferation of inner enamel epithelium into the stellate reticulum of the enamel organ These are usually but not exclusively seen on the occlusal surface of the buccal cusp in premolar tooth, with a high incidence in Asian and Caucasian populations. It is more common in lower premolar

24. Merril has classified dens evaginatus into two groups Originating from the lingual crest of the buccal cusp Originating from the middle of the occlusal surface

25. T alon cusp Incisor teeth may have an additional cusp arising from the cingulum, often referred to as a ‘talon cusp’. . Mitchell introduced the term in 1982, and Mellor and Ripa (1970) later named it “talon cusp” because of its likeness to the talon of an eagle A classification based on size and shape was introduced by Hattab et al. (1996):

26. Type I (talon ) : An extra cusp on the palatal or labial surface of a primary or permanent tooth at half its clinical height. Type II ( semi‐talon ) : An extra cusp of more than 1 mm, but less than half of the clinical crown. This excess part is either isolated or conjoint with the palatal surface of the tooth. Type III ( trace talon ) : A large cingulum with different shapes of conical, bifid, or tubercle like projections.

27. The highest incidence is on primary maxillary lateral incisors and permanent maxillary central incisors. Associated with syndromes such as Rubinstein and Taybi , Berardinelli- Seip , Mohr, Ellis-van Creveld, Sturge-Weber and incontinentia pigmenti achromians usually unilateral, but bilateral cases have been reported.

28. Problems O cclusal interfearances D velopmental grovee between cusp and tooth lead to caries

29. Treatment Selective grinding, repeated over a period of time Fissure sealant or restoration the marging between cusp and tooth S ome times pulp therapy

30. O rthodontic consideration Occlusal interferences Gradual trimming or some time one visit complete removal and pulp therapy may needed

31. C usp of caeabelli   Carabelli cusp is a tubercle or cuspule, or a groove often seen on the palatal surface of the mesiopalatal cusp of maxillary permanent molars and maxillary second deciduous molars. The cusp of Carabelli is an heritable feature. Kraus (1951) proposed that  homozygosity  of a gene is responsible for a pronounced tubercle

32. Taurodontism Witkop defined taurodontism as teeth with large pulp chambers in which the bifurcation or trifurcation are displaced apically This anomaly is detected in radiographs and is seen in both dentitions but is commoner in the permanent dentition.

33. Etiology is still uncertain but it is thought to be caused by the failure of Hertwig's sheath to invaginate at the proper horizontal spontaneous mutation and the influence of additional factors such as infection, on the developing tooth

34. A ssociated syndromes conditions Down syndrome, tricho ‐ dento ‐osseous syndrome hypophosphatemia dentinogenesis imperfecta associated with osteogenesis imperfecta vitamin D resistance

35. PROBLEMS difficulty in endodontic treatment taurodontic molars are suggested to have less resistance to lateral displacing forces compared to cynodont due its smaller surface area and hence are not used as an abutment

36. N umber anomalies H ypodontia S upernumeries

37. hypodontia the developmental absence of one or more teeth, excluding 8s Goodman et al., 1994

38. Overall -6.4% population mild 81.6%, moderate 14.3%, severe 3.1% Africa (13.4%) Europe (7%) Asia (6.3%) North America (5%) Caribbean/Latin America (4.4%) FEMALES > MALES MOST AFFECTED mandibular 5 > maxillary lateral incisors >maxillary 5 premolars . The least affected teeth were found to be the maxillary 1 maxillary and mandibular 6 mandibular 3 Khalaf 2014 Polder et al. (2004) Mattheeuws et al. (2004) S ummerised pevious articles so khalaf summerised 2002 onward

39. The permanent dentition is much more affected than the primary , where hypodontia is reported to be rare ( Cobourne , 2007) similar in max and mand - Polder et al., 2004 gene involved - MSX1 (incisor, premolar), PAX9 (molar) and AXIN2 Cobourne , 2007

40. eatiology

41. T reatment options reopen space close space redistribute space

42. Complications /difficulties with treatment Anchorage necking'/ atropy of bone root parallelism for implants Aesthetics risk of relapse e.g. spaces reopening long treatment time cost

43. M issing maxillary lateral incisor 2% Familial tendency for both peg and missing laterals Zilberman et al., 1990 Anomalous ( microdont) laterals are associated with palatally ectopic canines – Brin 1986 ( Position of maxillary permanent canines in relation to anomalous or missing lateral incisors: a population study, EJO, 8;12-16) impaction in 42.6%

44. Brin 1986 study I srael study S ample 2440 school children Missing, peg or small lateral could be a etiology to the palataly impacted canine B ut if you see a peg small or missing lateral you coulden suspect a palataly impacted canine

45. S pace opening vs closing literature preferred option - space closure if aesthetics will be good (no restorative burden) -McNeil & Joondelph , 1973

46. S pace closing S pace opening McNeil & Joondelph , 1973- space closure if aesthetics will be good (no restorative burden Asher & Lewis, 1986 -space maintenance and redistribution of space to accept a prosthesis may be preferred because of poor aesthetics related to unsuitable colour, position or anatomy of adjacent teeth Qadri et al., 2016 - when bilateral 2 missing slightly increase attractiveness rating for space closure than prosthetic replacement Rosa et al., 2016 -long term periodontal studies suggest that space closure is preferable to space opening S ilveira et al., 2016 – systematic review Gives space closing is better than space opening

47. Conclusions: T ooth-supported dental prostheses of maxillary lateral incisor agenesis had worse scores in the periodontal indexes than did orthodontic space closure. Space closure is evaluated better esthetically than prosthetic replacements the presence or absence of a Class I relationship of the canines showed no relationship with occlusal function or with signs and symptoms of temporomandibular disorders Silveira et al., 2016

48. A dvantages of space opening D isadvatages of space opening may not be possible to close the space completely commits the pt to a permanent prosthesis advantageous both functionally and occlusally, favouring good intercuspation in the buccal segments improved aesthetics

49. T reatment mechanics S pace opening 'push-pull' mechanics - involving open-coil spring in the 2 region (the 'push') and lacebacks /power chain to retract the canine (the 'pull') minimum space requirement for implant retained prosthesis = 6.5mm (3.5mm implant needing 1.5mm space either side once appropriate space has been opened, closed-coil spring or an acrylic denture tooth attached to the orthodontic archwire via a bonded bracket should be placed to maintain space retention - VFRs (can prevent relapse in all 3 dimensions) or Hawley-type retainer incorporating prosthetic teeth and wire stops; definitive restoration should take into account the need for long-term retention

50. options that are available for the definitive restoration: Implant-retained prosthesis Resin-retained bridges Conventional bridges Partial denture Interceptive manegment consider Xtn CIC to encourage 3/3 to erupt into 2 position

51. S pace closure C anine lateralization C hallenges due to canine Greater mesio -distal width Greater bucco -palatal width Greater crown length Higher gingival level Prominent canine eminence Usually darker in shade.

52. E namel reduction of canine do while prior or during ortho M ainly from distaly to reduce bell shape R educe bucco palatal width- will lead to darker the teeth more due to more dentine show.( bleaching will needed) G ingival level reposition the canine bracket to a more gingival position to extrude the canine. The canine tip must be progressively reduced during this process as, otherwise, it will lead to occlusal interferences.

53. torque has a negative (buccal root) torque value, then inverting the bracket introduces palatal root torque which moves the apex of the canine root more palatally , helping to eliminate the canine eminence differential vital bleaching to the desired shade To complete the camouflaging of the canine, composite resin additions or direct composite veneers are placed. Any residual spaces are closed later.

54. Disguising first maxillary premolars as canine Nordquist and McNeill 1975 have shown, here is no long-term occlusal or periodontal damage to a first premolar occupying the canine position or to any of the adjacent teeth, with adequate function being obtained. Bracket position Horizontal Slightly distaly – mesio lingual rotation Hide palatal cusp from view Increase tooth mesio distal width

55. V erticle M ore incisaly C orrect gingival level going up to canine level I ntrude palatal cusp but palatal root torque increase lead to hanging palatal cusp N eed occlusal buidup 2. M ore gingivaly extrude- gingival level wrong N o need of occlusal buildup G reater buccal root torque –hide palatal cusp Greater gingival eminance

56. D epend on patient smile line select PERMENENT RETAINERS

57. Absent premolars premolars can form as late as 9yrs - Wisth et al., 1974 Space opening maintain lower E long-term but reduce mesial-distal width ( premolarise ) - check E's root morpholog Space closing may be incorporated into ' Xtn ' pattern if malocclusion dictates, e.g. crowding present, increase OJ consider controlled sectioning of lower E's to allow bodily space ( hemisectioning ), better success in under 9yr - Valencia et al., 2004

58. Long-term success of replacements Bridges survival 5yrs 91% 10yrs 83% Implants · 5 years - 95.2%, 10yrs 80% but complications in 24 %

59. Supernumeries A 'tooth' or 'tooth-like' structure which develops in addition to the normal series of 32 teeth Prevalance 0.3−0.8% in the primary dentition Shah 2008 review type article 0.1−3.8% in the permanent dentition Males are affected approximately twice as often as female Maxilla> mandible Mostly pre maxilla

60. Spacing often present in the primary dentition may allow supernumerary teeth to erupt into reasonable alignment and remain unnoticed by parents Cases involving one or two supernumerary teeth most commonly affect the anterior maxilla, followed by the mandibular premolar region scheiner MA, Sampson WJ. Supernumerary teeth: a review of the literature and four case reports. Aust Dent J 1997; Cases involving multiple supernumeraries (more than five) tend to involve the mandibular premolar region. yusof WZ. Non-syndrome multiple supernumerary teeth: literature review. J Can Dent Assoc 1990;

61. Etiology Multifactorial, different theories Atavism It was originally suggested that supernumerary teeth were the result of phylogenetic reversion to extinct primates with three pairs of incisors. This theory has been largely discounted. Dichotomy theory This stated that the tooth bud splits into two equal or different-sized parts, resulting in the formation of two teeth of equal size, or one normal and one dysmorphic tooth This also discontinued

62. Dental lamina hyperactivity theory This involves localized, independent, conditioned hyperactivity of the dental lamina. According to this theory, a supplemental form would develop from the lingual extension of an accessory tooth bud whereas a rudimentary form would develop from the proliferation of epithelial remnants of the dental lamina most literature supports the dental lamina hyperactivity theory

63. Genetic factors These are considered important in the occurrence of supernumerary teeth. Many cases have been reported of recurrence within the same family. A sex-linked inheritance has been suggested by the observation that males are affected approximately twice as often as females.

64. Associated syndromes Down's syndrome cleidocranial dysplasia (gene: RUNX2) CLP anomalies Gardner Ellis-van Creveld

65. Classification of supernumerary teeth morphology location Conical most common conical or triangular-shaped crowns and complete root formation onften as isolated single cases and are usually located between the maxillary central incisors ( mesiodens ) they can also occur as bilateral ( mesiodentes ) structures in the premaxilla risk of cystic formation/resorption of incisors is very low Tyrologou et al., 2005 little effect on incisor eruption Mesiodens Tooth located between the maxillary central incisors located palatal to the permanent incisors, with only a few lying in the line of the arch or labially Tuberculate barrel-shaped appearance and a crown consisting of multiple tubercles delays/prevents eruption of central incisors Foster & Taylor, 1969 may be invaginated incomplete or absent root formation They are generally larger than conical supernumerary teeth and are usually found in a palatal position relative to the maxillary incisor tuberculate supernumeraries are often paired and bilateral supernumerary cases have a predominance of tuberculate- shaped teeth – primosh 1981 Paramolar A paramolar is a supernumerary molar, usually rudimentary situated buccally or lingually/ palatally to one of the molars / in the interproximal space buccal to the second and third molar

66. Supplemental resemble their respective normal teeth. They form at the end of a tooth series. Common supplemental tooth is the permanent maxillary lateral incisor supplemental premolars and molars also occur The majority of supernumerary teeth in the primary dentition are supplemental and rarely remain unerupted. Liu 1995 most common in primary dentition Distomolar A distomolar is a supernumerary tooth located distal to a third molar and is usually rudimentary Odontomes These are hamartomas two different types of odontome : compound and complex Compound odontomes comprise many separate, small tooth-like structur A complex odontome is a single, irregular mass of dental tissue that has no morphological resemblance to a tooth. 50% impede eruption of teeth compounds are 4x more common than complex Parapremolar This is a supernumerary that forms in the premolar region and resembles a premola

67. investigations R/Gs to localise teeth using parallax (if under 30% calcified will not show on R/G)- Southall & Gravely, 1989 supernumerary premolars commonly occur in several regions of the same mouth, so the finding of one indicates radiographic examination of the other premolar regions SolaresR,RomeroMI.Supernumerarypremolars:a literature review. Pediatr Dent 2004; 26 : 450−458.

68. Clinical features of supernumerary teeth Supernumerary teeth with a normal orientation will usually erupt. However, only 13−34% of all permanent supernumerary teeth are erupted, compared with 73% of primary supernumerary teeth – Rajab 2002 a review Prevention or delay of eruption of associated permanent teeth Displacement or rotation of permanent teeth Crowding Incomplete space closure during orthodontic treatment Dilaceration, delayed or abnormal root development of associated permanent teeth Root resorption of adjacent teeth

69. Tuberculate supernumeraries are the main cause for failure of eruption of maxillary permanent incisor - Welbury RR, Duggal MS, Hosey M-T. Paediatric Dentistry 3rd edn . Oxford: Oxford University Press, 2005.

70. Manegment I dentification of problems associated with supernumerary N o complications no ortho obstruction – leave with yearly assesments C yst formation risk is however there. 4−9 % of unerupted supernumeraries Primosh RE 1981 If they are associated with the roots of permanent teeth, it may be sensible to await full root development before surgical extraction to minimize the chances of root damage.

71. I f suprenumerary causes obstruction of permenant to erapt E arly extraction- --1.perman e nt have eraption potential. 2.minimise centerline displacements 3. correction of rotation E.g : 1.tuberculate supernumeraries need to be removed to allow incisor eruption, but only 50% of previously impacted incisors will then erupt spontaneously yaqoob et al., 2016 2.Xtn of Cs and space maintenance/creation to allow eruption of impacted 1; 89% erupt in 9mths; Bryan et al., 2005 Following removal of supernumerary teeth, the time taken for the unerupted tooth to erupt can vary between six months and three years

72. Factors affecting delay in self eraption the distance unerupted tooth was displaced the space available in the dental arch the stage of root development of the permanent tooth The patient’s age

73. Recommend attaching a bracket at time of supernumerary Xtn or exposure depending on position but Exposure of the unerupted tooth (with or without a bonded attachment) may result in poor gingival aesthetics, with less attached gingivae between the exposed tooth and neighbouring teeth. MitchellL,BennettTG.Supernumerary teeth causing delayed eruption − a retrospective study. Br J Orthod 1992; 19 : 41−46

74. If supernumerary teeth are likely to interfere with orthodontic tooth movement, they should be removed prior to the commencement of treatment S upplimental tooth- assuming both teeth are healthy, it is logical to extract the tooth most displaced from the line of the arch for the relief of crowding. development of late forming supernumerary teeth , especially in the lower premolar region. It has been reported that up to 24% of patients with an anterior maxillary supernumerary may later develop supplemental premolars. SolaresR,RomeroMI.Supernumerarypremolars:a literature review. Pediatr Dent 2004; 26 : 450−458.