22.03.

2020

DENTAL ANOMALIES AND

ENDODONTICS
DENTAL  Genetic Factors

ANOMALIES AND Poligenic

More than 300 genes have been identified to be
expressed in teeth that are responsible for
odontogenesis. Defects in these genes have been
ENDODONTICS found to be one of the reasons for variation of the
morphology of tooth
 Local Factors
ASSOC.PROF.DR. UMUT AKSOY Trauma
NEAR EAST UNIVERSITY, FACULTY OF DENTISTRY, Infection
DEPARTMENT OF ENDODONTICS Chemical
Nutritional

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Why is diagnosis important DENTAL

in dental anomalies?
ANOMALIES
 Early prophylactic treatment
 Elimination of aesthetic concerns •Number • Size
 Different treatment options in pulpal complications
•Structure • Shape
 To diagnose some syndromes and diseases through
tooth anomalies

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Hypodontia
I.Number anomalies
• The most common dental anomaly
• Absence of normal dentition
Missing teeth (Hypodontia)
Supernumerary teeth (Hyperdontia) Usually missing 1 or 2 permanent teeth
 HYPODONTIA

In the case where there are 6 or more missing permanent teeth

 OLIGODONTIA

Absence of all primary or permanent teeth

 ANODONTIA

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Hypodontia

• Third molars are most commonly affected

• Followed by
Mandibular second premolars,
Maxillary lateral incisors and
Mandibular central incisors.

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Congenital absence of 25, 35 and 45; 65, 75 and 85 are retained

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Hypodontia
May be seen in:

Ectodermal Dysplasia
Down Syndrome
Rieger’s Syndrome
Book’s Syndrome

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Hypodontia Hyperdontia
Clinical Significance
• Unfavourable positions of remaining present teeth Supernumerary teeth
Teeth developing in addition to the normal 32 permanent and
• Common issues faced in treating hypodontia patients 20 deciduous teeth.
include space management, uprighting and aligning teeth,
management of the deep overbite, and retention  90% Maxillary area
 Single or Multiple
• Long-term multidisciplinary management from pedodontics
to orthodontics, prosthodontics, implantology and so on.  Erupted or Impacted
Genetic counselling is important.  The Anterior Maxilla and Mandibular Premolar regions are
quite common locations.

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Hyperdontia
• The most common supernumerary tooth is a
MESIODENS, which is a malformed, peg-like tooth that
occurs between the maxillary central incisors.

• Fourth and fifth molars that form behind the third

molars are another kind of supernumerary teeth.

PARAMOLARBuccally or lingually located 4. molar

DISTOMOLARDistally located 4. molar

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Multiple supernumerary teeth

may be associated with
some syndromes.
 Cleidocranial Dysplasia
 Gardner’s Syndrome
 Sturge-Weber Syndrome

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Hyperdontia
Clinical Significance

 Crowding
 Displacement of a permanent tooth
 Failure to erupt
 Esthetic problem
 Dentigerous cyst formation

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Hyperdontia II.Size Anomalies

Clinical Significance
Treatment decision may affected from several factors, such as
 Microdontia

the ST are erupted or nonerupted, stage of the crown and root
development, the distance between the Supernumerary Teeth
and root of the adjacent teeth and the condition of the
dentition (malocclusion, crowding, missing teeth)  Macrodontia
 If ST do not cause any discernable adverse effect on adjacent
teeth and if no future orthodontic treatment foreseen, surgical
intervention is not essential

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Microdontia

• Smaller than normal teeth

• Most commonly affecting third molars and
maxillary lateral incisors.
• Often demonstrates altered morphology, e.g. a
microdontic lateral incisor often has a conical
(peg-shaped) crown.

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Macrodontia

• Larger than normal teeth.

• Maxillary incisors and third molars
• True generalized macrodontia is very rare.
Macrodontia of a single tooth is more
common.
• May contribute to impactions and crowding.

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III.Shape Anomalies Dens evaginatus

 Dens evaginatus  Gemination  Small focal enamel prominence at the occlusal surfaces of
posterior teeth or lingual surfaces of anterior teeth.
 Talon Cusps  Concresence  Often demonstrates dentin centrally and there may be an
 Dens invaginatus associated pulp horn.
 Palatogingival
(Dens In Dente)  More commonly affecting mandibular premolars and maxillary
 Fusion
groove lateral incisors.

 Dilaseration  Taurodontism  Associated with increased risk of pulpal and periapical

inflammatory disease.
 Enamel pearl
 Often causing occlusal interference

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Dens evaginatus
 Early detection of these conditions is important so that
preventive management can be started as early as possible
 Selective reduction of the opposing occluding teeth can be
done
 In a situation where the tubercle has fractured, it can be
sealed with resin.
 In the case of pulp exposure during the early phase of root
development, pulpotomy is suggested.
 If the pulp is necrotic root canal treatment should be
performed

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Talon Cusps

 An additional cusp of an incisor, thought to be related to an

extremely prominent cingulum.
 More commonly affecting maxillary lateral incisor

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Talon Cusps - syndromes

 Rubinstein-Taybi Syndrome
 Mohr Syndrome
 Ellis-vanCreveld Syndrome

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Talon cusp Talon cusp

complications
 May contribute to impactions
 Susceptible to dental caries
 Susceptible to Endodontic infections
 Occlusal trauma, esthetic problems
 Irritation of soft tissues and tongue during
mastication and speech
complications
 May contribute to impactions
 Susceptible to dental caries
 Susceptible to Endodontic infections
 Occlusal trauma, esthetic problems
 Irritation of soft tissues and tongue

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Talon Cusps
Treatment
Some common treatments include:

 Fissure sealing

 Composite resin restoration

 Reduction of cusp

 Pulpotomy

 Root canal treatment

 Extraction

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Dens invaginatus
dens in dente

 Invagination of enamel into the crown, to varying

extents.
 Occurs most frequently in the maxillary lateral
incisors.
 Associated with increased risk of pulpal and
periapical inflammatory disease:
◦ Infolded enamel is often defective, including
canals which lead to the pulp.
◦ Usually, a deep pit connects this with the oral
cavity, withresultant increased caries risk.

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Oehler’s Classification
 Type I: the invagination is confined to within the crown of the
tooth and does not extend beyond the level of the amelo-
cemental junction.

 Type II: the invagination extends into the pulp chamber but
remains within the root canal with no communication with the
periodontal ligament.

 Type IIIA: the invagination extends through the root and

communicates laterally with the periodontal ligament space
through a pseudo-foramen.

 Type IIIB: the invagination extends through the root and

communicates with the periodontal ligament at the apical
foramen

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Dens invaginatus - treatment

Type I
• Preventative treatment - e.g. Type III
oral hygiene instructions, fissure  Preventative treatment -
sealant e.g. oral hygiene
instructions, fissure sealant
• Restorations
 Restorations
• Endodontic treatment
 Endodontic treatment
Type II  Endo-surgery
• Preventative treatment -
 Intentional Reimplantation
e.g. oral hygiene
instructions, fissure sealant  Extraction
• Restorations
To be continued…
• Endodontic treatment
• Endo-surgery

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Dens invaginatus - treatment

Type I
DENTAL • Preventative treatment - e.g.
oral hygiene instructions, fissure
Type III
 Preventative treatment -
sealant e.g. oral hygiene
ANOMALIES AND • Restorations

instructions, fissure sealant
Restorations
• Endodontic treatment
ENDODONTICS II Type II



Endodontic treatment
Endo-surgery
• Preventative treatment -
 Intentional Reimplantation
ASSOC.PROF.DR. UMUT AKSOY e.g. oral hygiene
instructions, fissure sealant  Extraction
NEAR EAST UNIVERSITY, FACULTY OF DENTISTRY,
DEPARTMENT OF ENDODONTICS • Restorations
• Endodontic treatment
• Endo-surgery

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Dens invaginatus
Endodontic management
 The anatomy of DI lesions can be
extremely complex. Therefore,
adequate chemomechanical
debridement and obturation of
these malformations can be
challenging

 The invagination can be

removed with high-speed
carbide or diamond burs (long
shanked).

 The invagination should be

thoroughly debrided using
ultrasonic instruments and
hypochlorite

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Dens invaginatus Dens invaginatus

Endodontic management Clinical Tips
 Irregular internal
morphology  Irrigation is  Lateral-vertical
important
 Calcium Hydroxide Dressing condensation

 Thermoplastic
gutta-percha

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Double teeth Gemination

a) geminasyon  Gemination is a partial cleavage of a single tooth germ
resulting in 2 partially or totally separated crowns with
b) şizodonti enlarged pulp chamber and one root.

c) fusion (sinodonti)  Normal number of teeth are maintained. The anomalous tooth
has a large bifid crown

d) concresens  Most often seen in the maxillary primary incisors and the
canines.
 The anomaly causes tooth malalignment, spacing problems,
arch asymmetry, unacceptable appearance, periodontal
involvement and impedes the eruption of the adjacent tooth.
 If geminated tooth is present in anterior region, then it gives
unaesthetic appearance.
Gemination
(Partial Schizodontia) Schizodontia Fusion Concrescence

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Schizodontia
 The term schizodontia would only fit complete
splitting, which results in “twinning” and thus
leading to hyperdontia.

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Gemination
Endodontic management

 It is important to create or achieve functional and esthetic

success in these cases.

 Several treatment methods have been described with respect

to the different types and morphological variations of
geminated teeth, including endodontic, restorative, surgical
and periodontal treatment.

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Fusion  Complete fusion

 Partial fusion
 Union of two normally separate tooth germs,
to varying extents.
 More common in the deciduous dentition.
 One tooth is absent. Rarely, there may be fusion
of a normal tooth with a supernumerary tooth.
 More common in the deciduous dentition. More
commonly associated with anterior teeth

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Fusion
Endodontic Management
 Teeth are joined by the dentine; pulp chambers and canals
may be linked or separated depending on the developmental
stage when the union occurs.
 In the anterior region this anomaly also causes an unpleasant
aesthetic tooth shape due to the irregular morphology.
 Presence of fissures or grooves at the union between fused
teeth predisposes it to caries and periodontal disease.
 Restorative treatment
 Endodontic treatment
 Endodontic surgery
 Reimplantation

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Concrescence
 The joining of roots of normally separate teeth with
cementum

 Concrescence is most frequently noted in maxillary

molars, especially a third molar and a supernumerary
tooth.

 Concrescence may occur during root formation or after

the radicular phase of development is complete. If the
condition occurs during development, it is called true
concrescence; if it occurs later, it is acquired
concrescence.

 When developmental, it might be associated with failed

eruption of one or more teeth.

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Concrescence
 If the union does not affect aesthetics or cause eruption
pathologies, no treatment is required.

 Concrescence should be carefully identified to reduce

the risk of complications associated with surgical
procedures. It may affect the extraction of an adjacent
tooth and may fracture the tuberosity or floor of the
maxillary sinus.

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Palatogingival grooves

 A type of invagination, is a sharp,

somewhat irregular, funnel-like groove,
running from the palatal enamel of the
crown and extending along the root.
 This particularly occurs in the permanent
maxillary lateral incisors.
 The groove commonly starts at the
junction of the marginal ridge and the
cingulum, and then continues along the
proximal surface of the root, extending to
the apical third of the root or to the apex
itself.

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Palatogingival groove

• Endo + Perio
*Flap reflection
*Removal of
granulation tissue
*Grinding and
flattening of the
groove
• Odontoplasty
• Restorations
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Taurodontism Taurodontism

 Longer body of the tooth with shorter roots.

 Pulp chamber is extremely large with a greater apico-occlusal height

 Radiological appearance of a longer body with short roots, and a normal

crown.

 The molars are the mostly affected, followed by the premolars.

 Occurs in the deciduous and the permanent dentitions

 Can occur uni- or bilaterally

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Taurodontism Taurodontism

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 Hipotaurodontism

 Mezotaurodontism

 Hipertaurodontism

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Taurodontism
may be associated with some syndromes.

 Klinefelter’s Syndrome
 Down Syndrome
 Ectodermal Dysplasia
 Mohr Syndrome

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Taurodontism Taurodontism
Clinical Management Clinical Management
 Size and shape of the  Because the pulp of a
pulp chamber  taurodont is usually voluminous,
Hemostasis in order to ensure complete
removal of the necrotic pulp,
 Apically positioned sodium hypochlorite has been
canal orifices  suggested initially as an irrigant
Locating to digest pulp tissue

 Application of final ultrasonic

 Extraordinary root irrigation may ensure that no
canals in terms of pulp tissue remains
shape and number

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Dilaceration

 A distinct bend of a tooth crown or root. Root

dilacerations are much more common.
 Most are likely to be developmental in
nature. Some may be related to trauma
during tooth development.
 Dilacerated roots interfere with endodontic
treatment, orthodontics and extraction.

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Dilaceration Dilaceration

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Dilaceration Dilaceration

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Enamel Pearls

 An enamel pearl is a small oval to round enamel

bulb, which may or may not have dentine and
pulp tissue.
 It is typically found on/within the root, and
sometimes on the crown.
 A “true pearl” consists of enamel, a “composite
pearl” contains dentine (“enamel-dentine
pearl”), and rarely an “enamel-dentine-pulp
pearl” may also occur.

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Enamel Pearls IV. Structural Anomalies

 Larger pearls may interfere with the removal
• Amelogenesis Imperfecta
of calculus and there is a risk of fracture of
• Dentinogenesis Imperfecta
the tip of the scaler. Small pearls may show
up on radiographs, resembling calculus. • Dentine Dysplasia
Unless the pearls are associated with
localised periodontal destruction, treatment • Odontodysplasia
is not required.

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Amelogenesis Imperfecta Amelogenesis Imperfecta

Amelogenesis imperfecta consists of heterogeneous
structural and morphological enamel defects of
genetic origin occurring in the absence of systemic
disorders.
 Insufficient occlusal enamel leads to reduced
vertical dimension, worsened by chipping and
wear, and a deep overbite.
 The dentine is normal, as is the pulp, although a
considerable amount of secondary and tertiary
dentine is deposited in the hypoplastic rough
form. The hypocalcified subtypes are more
prone to caries than the hypoplastic ones.

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Dentinogenesis Imperfecta
• Dentinogenesis imperfecta is an inherited anomaly of dentinal
structure, which presents with and without osteogenesis
imperfecta, with bulbous crowns of an opalescent (translucent)
soft brown (amber or opal) colour, thin and short, often
transparent, roots, and pulpal obliteration after tooth eruption.
• Early loss and excessive wear of the teeth (attrition)

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Dentinogenesis Imperfecta Dentinogenesis Imperfecta

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Dentinogenesis Imperfecta
Dentinogenezis Imperfecta
Clinical Management

• Objectives of early treatment of the deciduous

dentition are maintenance of the dentition
(vitality, form, size), aesthetics, prevention of
loss of vertical dimension, maintenance of arch
length, and normal growth of facial bones
and the temporomandibular joint.

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Dentinogenezis Imperfecta
Clinical Management
 The use of crowns possibly prevents periapical pathology. However, dental
abscesses are also thought to arise due to disruption of the pulpal vascular
supply in association with the abnormal pulpal calcifications, which leads to
pulp necrosis. Sequential radiographs are therefore desirable. Endodontic
treatment in case of pulpal pathosis is difficult if initiated after pulp canal
obliteration, and may make extraction unavoidable. The outcome of
endodontic treatment may be unfavourable and short roots are
a contraindication for endodontic surgery.
 Root canals are obliterated  Endodontic treatment is difficult
 Selective endodontic treatment is recommended early in strategic teeth.
 Chelating irrigants are not recommended because dentin is hypomineralized
 Vitality tests are unreliable

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Dentin Dysplasia Dentin Dysplasia

Clinical Management
 Hereditary dentin abnormality  In radicular dentine dysplasia, pulp necrosis and
 Similar appearance to dentinogenesis imperfecta but apical granulomas/cysts may be present pre-
rarer eruptively. Posteruption, abscesses are common
because of bacterial ingress into the pulp through
 Two types: type I (radicular) and type II (coronal). the dysplastic dentine after the loss of the enamel.
 Pulp spaces are largely obliterated Surface protection with crowns may prevent pulp
 Higher risk of non‐caries‐related periapical pathosis and excessive wear. Abscesses may also
inflammatory lesions. be the result of endo-perio lesions. Meticulous
oral hygiene has been shown to be effective.

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Odontodysplasia Odontodysplasia
• Regional odontodysplasia is a rare developmental disorder of, in
general, a few teeth, where the enamel and dentine are
hypomineralised, hypoplastic, thin and discoloured, and the
pulp cavity is wide.
• The teeth are seen on radiographs as vague images
the term “ghost teeth” has been generally adopted. The
cementum is involved, and many teeth do not erupt.

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