Case 5

Our patient is a 16-year-old male; he came into our clinic for an initial examination.
During an oral examination, it was revealed that he had a generalized brown-colored dentition.
Examination of the oral soft tissues showed no unusual finding and no bony abnormalities. The
patient's radiograph revealed teeth with thin amounts of enamel, with areas where the enamel
had fractured away. Upon further questionings, our patient stated that his teeth had appeared
brown for as long as he could remember. The patient stated that his father also has browncolored teeth similar to his. The patient appeared to be in an overall good state of health at the
time of his dental visit. No significant problems were noted during the medical history and the
patient is not currently on any type of medications. The patient had no unusual or abnormal
finding.
The first diagnosis is regional odontodysplasia or (odontogenesis imperfecta). This is an
uncommon developmental abnormality of teeth, usually localized to a certain area of mouth. It
is neither hereditary nor connected to a certain race. Females are more prone to regional
odotodysplasia. The enamel, dentin, and pulp of the teeth are all affected and do not
developed properly, resulting in brittle teeth. Radiographically, the regional odontodysplasia
affected teeth are more radiolucent than normal and are described as "ghost teeth".
Symptoms are idiopathic, with some cases associated with syndromes, growth abnormalities,
neural disorders, and vascular malformations.
The second diagnosis is dentin dysplasia; a genetic disorder of teeth. Dentin dysplasia is
characterized by presence of normal enamel but an absence of roots, atypical dentin, and
abnormal pulpal morphology. The pulp of dentin dysplasia can have short roots with a nearly
obliterated pulp chamber or an enlarged "thistle tube" shaped chamber with pulp stones.
Radiographic diagnosis can reveal periapical radiolucencies.
The third diagnosis is amelogenesis imperfecta; a rare heredity disorder of abnormal
enamel formation. The external layers of the teeth are affected due to the malfunction of the
proteins in the enamel. Individuals with amelogenesis imperfecta can have abnormal teeth
color (yellow, brown, and grey), fracturing of enamel, rapid attrition of teeth, and extreme
sensitivity to temperature changes, excessive calculus formation, and gingival hyperplasia.
Radiographic finding will reveal normal dentins and pulps with thin layer of enamels. This
disorder can affect any number of teeth, and can increase risk for dental caries.
The fourth diagnosis is dentinogenesis imperfecta; a heredity disorder of abnormal
dentin formation. Dentinogenesis imperfecta affect both primary and permanent dentition. The
color of affect teeth can be brown to blue with an opalescent sheen. Enamel may show a
hypoplastic or hypocalcified defect. The enamel frequently fractures away from the defective
dentin due to lack of support of the demineralized dentin; leading to rapid wear and attrition of
teeth. Radiographically the teeth have bulbous crowns with constricted short roots. The pulp
chambers may be abnormally wide but will progressively obliterate. Although the enamel
seems to be normal in structure, it tends to crack.
The fifth diagnosis is internal resorption. Internal resorption is an unusual condition
where the dentin and pulpal walls begin to resorb centrally within the root canal. The first
evidence of the lesion may be the appearance of a pink-hue on the crown of the tooth. Main
causes of internal resorption are inflammatory response in the pulp, trauma to the tooth, its
usually idiopathic. Radiographically, the enamel and dentin look normal and the root surface is
lost.
Based on the information provided, we concluded that the most likely diagnosis is amelogensis
imperfecta. The patient has had brown teeth for as long as he could remember with no other
unusual findings or abnormal health complications, giving us information that it could be
genetic related. Radiographic and clinical diagnosis further reveals that the patient has a thin
layer of enamel that is fracturing with a normal dentin and pulp formation.
It is not regional odontodysplasia because it is not associated with heredity, and affects the
entire teeth. The patient stated his dad also has the same condition, which gives us an idea
that his disorder might be inherited. Only the patient's enamel was affected.

It is not dentin dysplasia because it involved the root and pulp chamber of the teeth . The
patient's enamels was affected while his roots and dentins were normal.
It is not dentinogenesis imperfecta because it is associated with abnormal dentin formation
and affects the pulp. The healthy enamel cracks due to the lack of support of the defective
dentin. The patient's dentin and pulp are normal radiographically, but his enamel seems to be
thin and fracturing.
It is not internal resorption because it affects the root of tooth and has evidence of a pink-hue
on the crown. The patient's root does not seem to be affected, and his teeth color is brown.

Common odontogenic cysts in order of frequency are

1. Radicular cyst
5. Lateral periodontal
2. Dentigerous cyst
6. Gingival cysts
3. Primorial cyst
7. Odontogenic keratocyst
4. Residual cyst cysts
8. Traumatic bone cyst
Odontogenic keratocyst are aggressive, difficult to remove and commonly
recur. They commonly give rise to daughter cysts - must be completely
removed to prevent recurrence. Histologically these cysts are lined by
stratified squamous epithelium which is capable of producing orthokeratin
and parakeratin. The lumen of these cysts is filled with foul smelling cheesy
material - collected degenerated keratin. OKCs may be associated with
Basal Cell Nevus Syndrome (hypertelorism, midface hypoplasia, relative
frontal bossing and prognathism, mental retardation, schizophrenia, multiple
basal cell carcinomas, calcification of the falx cerebri, bifid ribs, palmar
pitting)
Traumatic Bone Cyst occurs following Bleeding within the bone caused by
trauma. Defect in organisation of a blood clot which liquefactively
necrotises. The bone is destroyed by enzymatic activity. The bone cavity
enlarges by the increased pressure of its content.
Radicular cyst (Synonyms - Periapical cyst, DENTAL cyst) is commonest of
all odontogenic cysts. Palpation egg shell crackling may be felt in the
anterior wall of the maxilla over the canine fossa. Microscopically, the
epithelium is a stratified squamous epithelium without keratin formation.
Management is for small tumor endodontic therapy of the involved tooth
and for large tumor excision or marsupialisation by Caldwell Luc surgery.

Dentigerous cyst is second commonest always associated with unerupted

tooth 4. Most are asymptomatic incidental discoveries. Radiology - a welldemarcated radiolucent lesion attached at an acute angle to the cervical
area of an unerupted tooth Histologically a normal dental follicle is lined by
enamel epithelium, but dentigerous cyst is lined by non keratinising
stratified squamous epithelium. It may give rise to mucoepidermoid
carcinoma or pathological fractures. Management is by Caldwell Luc
approach.

 Primodial cyst develops in place of tooth. The formed dental follicle

undergoing cystic degeneration. It is lined by stratified squamous
epithelium.

Residual cyst is caused by retained periapical cysts after the tooth is

removed. The cyst wall is formed by stratified squamous epithelium.

Lateral periodontal cysts are associated with lateral canals within the tooth
structure. The lining epithelium is made of thin cuboidal cells.

Gingival cysts are small cysts located in the alveolar ridges

OKCs of maxilla have diagnostic difficulties due to lack of specific clinical

and radiographic characteristics. They are less common in maxilla than
mandible with only 31.3% in maxilla. But then they do occur, they are more
common in the canine