ABNORMALITIES OF TEETH Environmental Alterations of Teeth Developmental Alterations of Teeth...
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Transcript of ABNORMALITIES OF TEETH Environmental Alterations of Teeth Developmental Alterations of Teeth...
ABNORMALITIES OF TEETH
Environmental Alterations of Teeth
Developmental Alterations of Teeth
牙齒的異常 - 環境與發育的影響
王文岑 高雄醫學大學 牙醫學系[email protected]
Wen-Chen Wang
ENVIRONMENTAL ALTERATIONS OF TEETH
Developmental tooth defectsTurner’s toothHypoplasia caused by antineoplastic therapyFluorosisSyphilitic hypoplasia
Postdevelopmental structure lossTooth wearInternal and external resorption
Discolorations of teethIntrinsic stainsExtrinsic stains
Localized disturbances in eruption Primary impactionAnkylosis
Wen-Chen Wang
Enamel development Three stages:
1. Matrix formation: protein laid down
2. Mineralization: minerals deposition, majority of original prot. removed-- diffuse, opaque white, soft enamel
3. Maturation: final mineralization-- translucent, hard enamel
Amelogenesis imperfecta Enamel hypoplasia
Wen-Chen Wang
Enamel development
No remodeling after initial formation Timing of ameloblastic damage has a
great impact on location & appearance of the defect
Development of crown : from 14th week of gestation to 12 months of age in deciduous dentition; 6 months to 15 y/o in permanent dentition
Neonatal ring on deciduous enamel and deposition with a rate of 0.023mm/day
Wen-Chen Wang
Factors associated with enamel defects
Systemic-1. Birth-related trauma: premature birth 2. Chemicals: antineoplastic C/T, fluoride,
tetracycline 3. Chromosomal abnormalities: trisomy 214. Infections: chicken pox, CMV, syphilis5. Inherited diseases: Vit.D-dependent rickets 6. Malnutrition: Vit. A deficiency 7. Metabolic disorders: hypoparathyroidism,
maternal diabetes8. Neurologic disorders: cerebral palsy
See Box 2-2
Factors associated with enamel defects
Local-1.Local acute mechanical trauma 2. Electric burn3. Irradiation4. Local infection: periapical inflammatory
disease
See Box 2-2
Wen-Chen Wang
Clinical and Radiographic Features
Environmental enamel defects:1.Hypoplasia: pits, grooves or
large area of missing enamel
2. Diffuse opacities: variation in translucency, normal thickness, white opacity without clear boundary
3. Demarcated opacities: increased opacity, a sharp boundary with adjacent normal enamel, normal thickness
Wen-Chen Wang
Turner’s hypoplasia, Turner’s tooth
Permanent teeth
Periapical inflammatory disease of the overlying deciduous tooth, less frequently in anterior teeth
Traumatic injury- not rare -45% children sustain injury to
their deciduous teeth, 23% permanent teeth development disturbed
Turner’s hypoplasia secondary to previous trauma
Wen-Chen Wang
Turner’s teeth
Wen-Chen Wang
Hypoplasia caused by antineoplastic therapy
Under 12 y/o, esp. under 5y/o Age at treatment, forms of therapy
Chemotherapy-Chemotherapy- Less alteration than radiation Increased number of enamel hypoplasia
and discolorations, slight smaller tooth size, radicular hypoplasia
Wen-Chen Wang
Radiotherapy-Radiotherapy- 0.72 Gy related to mild defects in enamel,
dentin ( 一般成人頭頸癌照射一次約為 2Gy)
Dose, radiation field
Wen-Chen Wang
Developmental radicular hypoplasia and microdontia caused by radiotherapy
Wen-Chen Wang
Hypodontia, microdontia, radicular hypoplasia, enamel hypoplasia, mandibular hypoplpasia, reduced in vertical development of lower 1/3 of face
Mandibular hypoplpasia may caused by Radiation →impaired root development →reduced alveolar bone growth
Cranial radiation→ altered pituitary gland function→ growth failed
Wen-Chen Wang
*Dental fluorosis 1901, Dr. Frederick S. McKay: Colorado brown stain 1909, Dr. F.L. Robertson in Bauxite, Arkansas 1930, H.V. Churchill: high concentration of fluoride of
Bauxite(13.7ppm) and Colorado 1931, Dr. H. Trendley Dean: association between
fluoride, dental fluorosis and prevalence of caries among children
1.0 ppm reduced caries by 50~70% and associated with low and mild mottled enamel
0.7~1.2 ppm water fluoridation was recommended after 1962, currently 0.7ppm is recommended due to increased dental fluorosis
Wen-Chen Wang
Dental fluorosis Retention of the amelogenin protein in enamel
structure→ hypomineralized enamel→ permanent hypomaturation→ increased surface and subsurface porosity→ alters light reflection and create white, chalky area
Wen-Chen Wang
Dental fluorosis Critical period for clinical dental fluorosis is
the 2nd and 3rd year of life, dose dependent Caries resistant
Wen-Chen Wang
Syphilitic hypoplasia •Congenital syphilis •Hutchinson’s incisors & mulberry molars
Wen-Chen Wang
POSTDEVELOPMENTAL LOSS OF TOOTH STRUCTURE
Begin from enamel surface (tooth wear):
Attrition, abrasion, erosion, abfraction
Begin from dentin, cemental surface: internal or external resorption
Wen-Chen Wang
Attrition Tooth to tooth contact during occlusion and
mastication, some are physiologic Accelerated by: poor quality or absent enamel,
premature contact, intraoral abrasives, erosion, grinding habits
Incisal, occlusal and interproximal surfaces
Wen-Chen Wang
Abrasion Pathologic loss of tooth structure or restoration
secondary to the action of an external agent (ex. Toothbrush, hair grips, toothpicks, chewing tobacco, biting thread, dental flossing…)
Toothbrush abrasion: horizontal buccal cervical notches of exposed radicular cementum and dentin with smooth surface.
Greater on prominent teeth ( canines, premolars , and teeth adjacent to edentulous area) and side of the arch opposite to the dominant hand
Demastication- when tooth wear is accelerated by chewing an abrasive substance between opposing teeth (both attrition and abrasion)
Wen-Chen Wang
Abrasion
Wen-Chen Wang
Abrasion
Long-term use of tobacco pipe
Improper use of hair grips
Wen-Chen Wang
Erosion Chemical process, exposure to acidic foods or
drinks, medications (chewable Vit. C, aspirin), involuntary regurgitation (ex. esophagitis, pregnancy), voluntary regurgitation (ex. psychologic problems, bulimia)
Perimolysis- dental erosion from gastric secretion Facial surface of maxillary anteriors affected-
dietary source Posterior teeth extensive loss of occlusal surface,
and palatal surface concave dentin surrounded by an elevated enamel rim- regurgitation of gastric secretion
Wen-Chen Wang
Erosion
concave dentin surrounded by an elevated enamel rim
Wen-Chen Wang
A bulimia patient
Erosion
Wen-Chen Wang
Abfraction Repeated tooth flexure caused by occlusal stresses
(tensile stress)
→ concentrate at the cervical fulcrum
→ may produce disruption in the chemical bonds of enamel crystal
→cracked enamel can be lost or removed by erosion or abrasion
Wedge-shaped cervical defects, deep, narrow V-shaped, not allow toothbrush to contact base; if the defect, often affect a single tooth
Almost exclusively on facial surface and more often in bruxism, higher in mandibular dentition
Wen-Chen Wang
Abfraction
Wen-Chen Wang
Treatment and prognosis of tooth wear
Resolve pain and sensitivity Identify the cause of tooth
structure loss Protection
Wen-Chen Wang
INTERNAL & EXTERNAL RESORPTION Internal resorption- by cells located in pulp, rare Follows injury to pulp tissues, physical trauma
or caries, continue as long as vital pulp remains, may result in communication of the pulp and PDL
External resorption- by cells in PDL, common
Wen-Chen Wang
Factors associated with external resorption
Wen-Chen Wang
Clinical and Radiographic Features
Internal resorption- Inflammatory resorption-
dentin replaced by inflamed granulation tissue Pink tooth of Mummery:
internal resorption involved coronal pulp Balloonlike enlargement of the canal
Replacement, or metaplastic absorption- pulpal dentinal walls are replaced by bone or cementum-like bone
Wen-Chen Wang
Clinical and Radiographic Features
External resorption- Moth-eaten loss of tooth
structure, less well-defined and variation in density in radiography
Most involved apical or midportions of root, occasionally, begin from cervical (invasive cervical resorption)
Wen-Chen Wang
Histopathologic Feature
• Increased cellularity, vascularity and collagenization • Numerous multinucleated dentinoclasts• Inflammatory cells infiltration
Wen-Chen Wang
Treatment and prognosis Internal resorption-
Removal of all soft tissue from site of resorption Endodontic treatment before perforation in internal
resorption Placement of calcium hydroxide paste for
remineralization Surgical exposure and restoration Extraction
External resorption- Identification and elimination the accelerating factor
Wen-Chen Wang
ENVIRONMENTAL DISCOLORATION OF TEETH
Extrinsic- surface accumulation of exogenous pigment
Intrinsic-secondary to endogenous factors that result in discoloration of underlying dentin
Wen-Chen Wang
Extrinsic stains Bacterial- Chromogenic bacteria, green, black-brown,
orange coloration Frequently in children, labial surface of maxillary ant. in gingival third
Iron- formation of ferric sulfide Tobacco Food and beverage- chlorophyll Gingival hemorrhage- Hb. breakdown to biliverdin Restorative material – ex. Amalgam Medications- iron, iodine, silver nitrate, chlorhexidine,
stannous fluoride
Wen-Chen Wang
Intrinsic stains Amelogenesis imperfecta Dentinogenesis imperfecta Dental fluorosis Erythropoietic porphyria –
autosomatic recessive disorder of porphyrin metabolism, increased synthesis and excretion of porphyrins and their related precursors
Porphyrin deposition in teeth, reddish-brown coloration, red fluorescence when exposed to a Wood’s UV light
Present both in dentin and enamel in deciduous teeth, but only dentin affected in permanent teeth
Wen-Chen Wang
Erythropoietic porphyria
Hyperbilirubinemia
Wen-Chen Wang
Intrinsic stains Hyperbilirubinemia- bilirubin, breakdown product
of RBC, jaundance (yellow-green discoloration), erythroblastosis fetalis, biliary atresia Biliverdin deposition, green discoloration of teeth
(chlorodontia)
Ochronosis-alkaptonuria, blue-black discoloration
Trauma- coronal discoloration, pulp necrosis
Localized RBC breakdown
Wen-Chen Wang
Intrinsic stains Medications-
Tetracycline (bright yellow to dark brown), chlortetracycline (gray-brown), oxytetracycline (yellow) , minocycline hydrochloride
Time of administration dose, duration Avoid from pregnancy up to 8 yrs of age
Wen-Chen Wang
Minocycline hydrochloride Tx for Acne
Blue-gray from incisal 3/4,
to dark green or black in
roots, also affect developed
teeth
Skin, nail, sclera,
conjunctiva, thyroid, bone
discoloration in susceptible
individuals Stained alveolar bone
Wen-Chen Wang
Treatment and prognosis
Extrinsic stains- polishing
Intrinsic stains- bleaching, bonded restoration, crowns
Wen-Chen Wang
LOCALIZED DISTURBANCES IN ERUPTION
PRIMARY IMPACTION- Teeth cease to eruption before emergence
ANKYLOSIS -Cease of eruption after emergence and anatomic fusion of tooth cementum or dentin with alveolar bone
Wen-Chen Wang
Impaction 3rd molars, maxillary canines, mandibular premolars,
mandibular canines, maxillary premolars, maxillary central incisors, maxillary lateral incisors, and mandibular second molars; usually angulated or diverted
Factors associated with impaction: Crowding and deficient maxillofacial development Overlying cysts or tumors Trauma Reconstructive surgery Thickened overlying bone or soft tissue A host of systemic disorders, diseases or syndromes
Wen-Chen Wang
Classification : Partially erupted or full bony impaction according to angulation: Mesioangular,
distoangular, vertical, horizontal or inverted
Eruption sequestrum
Wen-Chen Wang
Treatment and PrognosisChoice of treatment: Long-term observation Orthodontically assisted eruption Transplantation Surgical removal
The risks associated with nonintervention: Crowding dentition Resorption and worsening of the periodontal
status of adjacent teeth Development of pathologic conditions, ex
infections, cysts or tumors
Wen-Chen Wang
The risks associated with intervention:
Transient or permanent sensory loss Alveolitis Trismus Infection Fracture TMJ injury Periodontal injury Injury to adjacent teeth
Wen-Chen Wang
ANKYLOSIS
Infraocclusion, secondary retention, submergence, reimpaction, reinclusion
Wen-Chen Wang
ANKYLOSISClinical And Radiographic Features Pathogenesis is unknown, may be secondary to
many factors and result in PDL barrier deficiency. May occur at any age, any tooth Most affect 8~9yr-old children and D , E , D , E PDL absent Occlusal, periodontal problems, impaction of the
underlying teeth
Treatment and Prognosis Variable : extraction, orthodontics, segmental
osteotomy
Wen-Chen Wang
DEVELOPMENTAL ALTERATIONS OF TEETH
SHAPE Gemination, Fusion, Concrescence
Accessary cusps Dense in dente Ectopic Enamel Taurodontism Dilaceration Hypercementosis Supernumerary roots
NUMBER Hypodontia Hyperdontia
SIZE Microdontia Macrodontia
STRUCTURE Amelogenesis imperfecta Dentinogenesis imperfecta Dentin dysplasia I & II Regional odontodysplasia
Wen-Chen Wang
Missing teeth 1.6-9.6% , excluding 3rd molars, female predominance Hypodontia: missing one or more teeth Oligodontia: missing 6 or more teeth Anodontia: total missing 8 > 5 > 2 > 1 Deciduous mandibular incisors Gene mutation, ex: PAX9, MSX1, AXIN2 gene, He-Zhao
deficiency, maps to chromosome 10q11.2 AXIN2 mutation: associated with the development of
adenomatous polyps of colon, and colorectal carcinoma
Ectodermal dysplasiaorofaciodigital syndrome
Wen-Chen Wang
Hypodontia
Wen-Chen Wang
Ectodermal dysplasia
Kaohsiung Medical University, Oral Pathology and image Diagnosis Dept.
Wen-Chen Wang
Supernumerary teeth, hyperdontia
Mesiodens 4th molar Paramolar Distomolar, distodens deciduous - lat. incisors 86% single supernumerary multiple & impaction
cleidocranial dysostosis Gardner’s syndrome
Wen-Chen Wang
Mesiodens
The most common in supernumerary.Premaxillary area , usually between upper central incisorsCone-shaped crown & short rootOne or two in number
Wen-Chen WangKaohsiung Medical University, Oral Pathology and image Diagnosis Dept.
Wen-Chen Wang
Cleidocranial dysostosis
1.Skull: flat appearance, sutures remain open
2.Jaws: underdeveloped, high narrow palate
3.Teeth: prolonged retained deciduous teeth,
delayed eruption of permanent teeth
4.Clavicles: complete or partial absent
Wen-Chen WangKaohsiung Medical University, Oral Pathology and image Diagnosis Dept.
Wen-Chen WangKaohsiung Medical University, Oral Pathology and image Diagnosis Dept.
Wen-Chen WangKaohsiung Medical University, Oral Pathology and image Diagnosis Dept.
Wen-Chen WangKaohsiung Medical University, Oral Pathology and image Diagnosis Dept.
Wen-Chen Wang
Wen-Chen Wang
Gardner’s syndrome
1.multiple polyposis of the large intestine2.osteoma of the bone3.multiple epidermoid cysts or sebaceous cysts
of the skin4.desmoid tumors5.impacted supernumerary & permanent teeth
Wen-Chen Wang
Predeciduous dentition
Neonatal teeth: within 30 days Natal teeth: newborns Most are prematurely erupted deciduous teeth Removal only if mobile and at risk of aspiration
Wen-Chen Wang
Wen-Chen Wang
Microdontia True: 1.General -pituitary dwarfism 2. Single -peg lat., 3rd molar Relative microdontia
Wen-Chen Wang
Macrodontia
True macrodontia :
1. Generalized-pituitary gigantism
2. Localized- single, hemifacial hypertrophy Relative macrodontia: small jaw, child
Wen-Chen Wang
Wen-Chen Wang
Gemination, Fusion, Concrescence
Wen-Chen Wang
Gemination
single tooth germ division
single root & root canal + 2 complete or incomplete separated crowns
tooth no.: normal twinning
Wen-Chen Wang
Fusion
Union of 2 separate tooth germsContact of tooth germ before calcifiedConfluent of the dentinComplete- form a single tooth Incomplete- after calcified beginsTooth no. : less one
Wen-Chen Wang
Concrescence
Fusion after root formationCementun unitedTraumatic injury or crowdingPre-extraction x-ray check
Wen-Chen Wang
Talon cusp
Eagle’s talonLingual projection from the cingulum area of ant. teethMost contain a pulp hornBoth in deciduous & permanent dentition
Wen-Chen Wang
Dens evaginatus
( central tubercle, occlusal tuberculated premolar; Leong’s premolar; evaginated odontome; occlusal enamel pearl )
An accessory cusp or a globule of enamel on central groove or buccal cusp of premolars or molars; unilateral or bilateral.
15% in Asians, rare in whites
Wen-Chen Wang
Dens evaginatus
Kaohsiung Medical University, Oral Pathology and image Diagnosis Dept.
Wen-Chen Wang
Shovel-shaped incisors
Wen-Chen Wang
Dens in dente(Dens invaginatus; Dilated composite odontome)
Tooth within a tooth, incidence 5% Invagination of the enamel organ into
dental papilla before calcification
Coronal type: 3 types maxillary lateral incisors are common
Wen-Chen Wang
Dens invaginatus, coronal type II
Wen-Chen Wang
Dens invaginatus Radicular type
Hertwig’s sheath invagination
Food deposition→ caries → pulp infection Restorated as soon as possible
Wen-Chen Wang
Taurodontism
“Bull-like “ teethBi- or trifurcation near the apexPulp chamber : greater apico-occlusal height and no constriction at the cervical of the tooth
Wen-Chen Wang
Syndromes associated with taurodontism
Wen-Chen Wang
Hypercementosis
Wen-Chen Wang
Supernumerary roots Any tooth may develop accessary roots No tx required, but critical important in
endodontic procedure
Wen-Chen Wang
Dilaceration
Angulation, sharp bend of root or crownTrauma during tooth is formingPre-extraction x-ray check
Wen-Chen Wang
Amelogenesis imperfecta (Hereditary enamel dysplasia; Hereditary brown
enamel; Hereditary brown opalescent teeth)
Defects in-- Formative stage→hypoplastic type → defective
formation of matrix Calcification stage →hypocalified → defective
mineralization of formed matrix Maturation stage → hypomaturation → enamel
crystallites remain immature Genes mutation : AMELX, ENAM, MMP-20, KLK4,
DLX3
Wen-Chen Wang
Amelogenesis imperfecta
Wen-Chen Wang
Thin enamel with pitted, rough or smooth & glossy surface; yellowish to brown
undersized, squared crown, lack of contact
flat occlusal surface & low cusps, attrition
1.Hypoplastic type
Wen-Chen Wang
Hypoplastic type
Kaohsiung Medical University, Oral Pathology and image Diagnosis Dept.
Wen-Chen Wang
Hypoplastic type
Wen-Chen Wang
2.Hypomaturation
normal thickness of enamel, but mottled surface; cloudy white, yellow or brown, opaque in color
softer than normal same density as dentin
Wen-Chen Wang
Hypomaturation type
Kaohsiung Medical University, Oral Pathology and image Diagnosis Dept.
Wen-Chen Wang
normal thickness of enamel, density less than dentin
normal size & shape when erupt, abrade or fracture away rapidly
permeability increase, darkened & stained
3.Hypocalcified type
4.Hypomaturation-hypocalcified with taurodontism
Wen-Chen Wang
Hypocalcified type
Wen-Chen Wang
Tricho-dento-osseous syndrome
Hypoplastic-Hypomaturation type
Wen-Chen Wang
Dentinogenesis imperfecta
(Hereditary opalescent dentin)
Classification of DI : (Shields)
Type I : DI + OI (osteogenesis imperfecta) COL1A1,
COL1A2 Type II : Isolated DI. (1/8000) DSPP Type III: DI of the Brandywine type * DSPP
A racial isolate in Maryland, DI + multiple pulp exposures in deciduous teeth
Wen-Chen Wang
Osteosclerosis imperfecta
Blue sclera
M Greenwood, J G Meechan,:General medicine and surgery for dental practitioners Part 8: Musculoskeletal system. British Dental Journal 2003 (195) 243 - 248 ,
Wen-Chen Wang
Clinical features type I : deciduous severe than permanent teeth; type II: equally affected; type III: both dentitions affected. Gray to brownish violet or yellowish brown
color, with translucent or opalescent hue. Enamel lost early through fracture, esp. on the
incisal & occlusal surface, and dentin attrition rapidly.
Caries rate is not increased.
Wen-Chen Wang
Dentinogenesis imperfecta
Wen-Chen Wang
Dentinogenesis imperfecta
Histology: 1.pulp chamber obliterated with dentin 2.flatten D-E junction 3.atypical granular dentin, enlarged tubles, poor calcification
water contents: 50% above normal
Wen-Chen Wang
Radiographic featuresPartial or total obliteration of the pulp chamber & root canal by continued formation of dentin, in both dentitions.
Short and blunted roots
Normal cementum, PDL & supporting bone
Wen-Chen Wang
Shell teeth Initial reported in the Brandywine population Normal thickness of enamel associated with extremely thin dentin and dramatically enlarged pulps (due to insufficent and deffective dentin formation) Short roots.
Wen-Chen WangKaohsiung Medical University, Oral Pathology and image Diagnosis Dept.
Wen-Chen Wang
Dentin dysplasia
Hereditary, autosomal dominant. Normal enamel but atypical dentin formation with abnormal pulp morphology
Type I (radicular type): “Rootless teeth”
Type II (coronal) DSPP (dentin sialophosphoprotein) gene mutation
Wen-Chen Wang
Type I (radicular type)Radiographically: deciduous teeth affected more severely, little or no pulp,
short or absent roots. If disorganization late---normal pulp chambers, with a
large pulp stone. periapical lesions (R-L) no obvious cause.
Histologic features Normal coronal enamel& dentin. In root: tubular dentin and atypical osteodentin
surrounded with normal dentin --- appearance of “ Lava flowing around boulders”.
Wen-Chen Wang
Dentin dysplasia, type I
Wen-Chen Wang
Type II (coronal)
Normal root length in both dentitions.
Primary dentition similar to DI:
bulbous crowns, cervical constriction
thin roots , early obliterated pulp.
Permanent teeth : normal coloration, thistle tube-shaped or flame-shaped pulp chamber with pulp stones.
Wen-Chen Wang
Dentin dysplasia, type II (coronal)
Wen-Chen Wang
Dentin dysplasia
“Lava flowing around boulders”.
Large pulp stones
Wen-Chen Wang
Regional odontodysplasia
(odontodysplasia; odontogenic dysplasia; odontogenesis imperfecta; ghost teeth)
One or several teeth in a localized area Maxi. > Mand.; both dentitions most in ant. area Delayed or total failure eruption Irregular appearance Defective mineralization
Wen-Chen Wang
Radiographic features
1. Radiodensity ↓, “ghost appearance”
2. Large pulp, thin enamel & dentin
Histologic features
1. Dentin↓
2.Widening of the predentin layer,
3. Interglobular dentin and an irregular tubular pattern of dentin ↑
4.Calcification of the reduced enamel epi.
Wen-Chen Wang
Regional odontodysplasia
Enameloid conglomerates Odontogenic epithelium
Wen-Chen Wang
ENVIRONMENTAL ALTERATIONS OF TEETH
Developmental tooth defectsTurner’s toothHypoplasia caused by antineoplastic therapyFluorosisSyphilitic hypoplasia
Postdevelopmental structure lossTooth wearInternal and external resorption
Discolorations of teethIntrinsic stainsExtrinsic stains
Localized disturbances in eruption Primary impactionAnkylosis
Summary
Wen-Chen Wang
DEVELOPMENTAL ALTERATIONS OF TEETH
SHAPE Gemination, Fusion, Concrescence
Accessary cusps Dense in dente Ectopic Enamel Taurodontism Dilaceration Hypercementosis Supernumerary roots
NUMBER Hypodontia Hyperdontia
SIZE Microdontia Macrodontia
STRUCTURE Amelogenesis imperfecta Dentinogenesis imperfecta Dentin dysplasia I & II Regional odontodysplasia
Summary