Anomalies of Tooth

Formation and Eruption

Dr. Samira Adnan
Assistant Professor, Operative Dentistry
SIOHS
Learning Objectives
At the end of this lecture, you should be able to;

 Discuss prevalence, etiology and management of variation in number of

teeth, tooth size and tooth form and their management.

 Describe disturbances in eruption and exfoliation and its clinical

significance.

 Diagnose anomalies of tooth size and form and disturbances in eruption and
exfoliation based on history, clinical and radiographic examination.
Anomalies of Tooth
 Affecting formation
 Affection eruption and exfoliation
Why to learn about them?
 Seen in patients commonly
 Proper diagnosis leads to proper management
 Educate the patient
ANOMALIES OF TOOTH
FORMATION
Classification of Anomalies of tooth formation
 Number
 Size
 Shape/form
 Structural defects
Classification of Anomalies of tooth formation
Small root
 Number 

 Missing teeth  Shape/form

 Anodontia  Fusion
Hypodontia Gemination

 Oligodontia
  Defects in structure
 Concresence  Amelogenesis Imperfecta
 Extra teeth
 Dilaceration  Dentinogenesis Imperfecta
 Supplemental/Supernumerary
 Accessory cusps Molar incisor hypoplasia
 Size 
 Dens invaginatus  Dentinal dysplasia
 Crown size
 Dens evaginatus  Regional Odontodysplasia
 Macrodont
 Microdont  Taurodontism
 Root size  Supernumerary roots
 Large root
 Esthetics
Impaction
Malocclusion
Anomalies of Tooth
Number
MISSING TEETH
 Anodontia: total lack of teeth of one or both
dentitions.

 Hypodontia: less than six teeth missing

 Oligodontia: multiple ⎯usually more than six teeth

are missing
MISSING TEETH
Causes:
 MISSING TEETH
 Hypodontia occur of 0.1-0.9% in the primary dentition,

 3.5-6.5% in the permanent dentition,

 Missing permanent are seen in 30-50% of patients who have missing primary teeth.

Treatment:
 Cases of anodontia, full dentures are required

 Replacement of missing teeth

EXTRA TEETH
 Supplemental teeth: resemble normal teeth

 Accessory/supernumerary teeth: less typical,

often reduced form-sometimes further described as
tuberculate or conical
EXTRA TEETH
 Supernumerary teeth 0.2-0.8% of primary dentition;
 1.5-3.5% of permanent dentition

 2 : 1 M:F
 5 : 1 Max:Mand
 Common in maxillary anterior region

Causes:
 Disturbance during bud stage of tooth development
 Syndromes like cleft palate and cleidocranial dysplasia
EXTRA TEETH
EXTRA TEETH
Mesiodens:
 Most common supernumerary tooth is mesiodens

 mal-formed, peg-like tooth that occurs between

maxillary central incisors
EXTRA TEETH
EXTRA TEETH
Treatment:
Indications for Supernumerary Removal
• Central incisor eruption has been delayed or inhibited;
• Altered eruption or displacement of central incisors is evident;
• There is associated pathology;
• Active orthodontic alignment of an incisor in close proximity to the supernumerary is
envisaged;
• Its presence would compromise secondary alveolar bone grafting in cleft lip and palate
patients;
• The tooth is present in bone designated for implant placement;
• Spontaneous eruption of the supernumerary has occurred.


Indications for Monitoring Without Supernumerary Removal

 Extraction is not always the treatment of choice for supernumerary

teeth. Do monitoring where:

• Satisfactory eruption of related teeth

• No active orthodontic treatment planned
• No associated pathology;
• Removal would prejudice vitality of related teeth.
EXTRA TEETH
Anomalies of Tooth
Size
CROWN SIZE
 Megadont /Macrodont: teeth larger than normal.

 Cause:
 fusion of adjacent tooth germs
 an attempt at separation of a single tooth germ to form two separate teeth.

 Treatment:
 Acceptance
 Remodeling of the tooth
 Extraction of the tooth with orthodontic treatment if necessary, &
subsequent masking of the space with a bridge, denture, or implant
CROWN SIZE
 Microdont: teeth smaller than normal

 Treatment :
 Modified by acid-etch composite material

 In adult life, use porcelain based restorations

ROOT SIZE
Large root size: permanent maxillary central incisors
affected
 prevalence 2.3%
 4:1 M:F

Small root size:

 In the primary dentition may be associated with other
dental abnormalities,
 affecting the permanent maxillary central incisors

Cause: Irradiation of the jaws, or chemotherapy during the

period of root formation
Anomalies of Tooth
Shape/Form
FUSION AND GEMINATION
 The term 'double teeth' has been
applied to cover both situations

 0.1-1.6% in primary dentition

 0.1-0.2% in permanent dentition
 No sex predilection

 Fusion: two developing teeth merge

into one tooth

 Gemination: where a developing

tooth splits into two separate teeth
FUSION AND GEMINATION
Treatment:
 No treatment in the primary dentition

 In the permanent dentition, the final decision on whether to retain, extract,

surgically divide or otherwise treat such teeth depends:
 Space available within the arch,
 The morphology of the pulp chambers and/or root canals
 Degree of attachment between the two parts of the tooth or teeth

 A groove in the teeth is prone to caries and may need filling

CONCRESCENCE
 Cementum overlying roots of two teeth
joins together
 May occur before or after eruption
 Most commonly in post maxilla

Cause:
 Trauma or crowding of teeth

Treatment:
 Surgical separation of teeth may be necessary
if one is to be extracted
DILACERATION
 Angulation, or a sharp bend or curve in the root or
crown of a formed tooth
 Permanent maxillary incisors most commonly
affected followed by mandibular incisors
 Rare in primary dentition

 Cause:
 Thought to be related to trauma during root
development
 Treatment:
 Pose difficulty during extraction hence pre-operative
radiograph important
 Endodontics difficult
ACCESSORY CUSPS
 Talon cusp: an extra cusp that resembles an eagle's
talon (a talon is the claw of a bird of prey), projection
from the cingulum of incisor teeth.
 They are found rarely in primary teeth
Cause:
 Genetics or a disruption of the tooth during formation
Treatment:
 Observe
 If lingual pit present, seal
 If interferes with occlusal, only grinding may lead to
pulp exposure, therefore RCT and restore
DENS INVAGINATUS or dens in dente
 Presence of an invagination in crown of
tooth, forming an in-folding lined by enamel
within crown of tooth, sometimes extending
into root

 Due to invagination of enamel

epithelium into dental papilla during
development

 Maxillary lateral incisor most commonly

affected
DENS INVAGINATUS or dens in dente
DENS INVAGINATUS or dens in dente
EVAGINATED TEETH OR DENS EVAGINATUS
 Most commonly affect the premolar teeth or
permanent molar teeth

 Small tubercule on occlusal surface of

premolar in central part of fissure pattern
EVAGINATED TEETH OR DENS EVAGINATUS
Treatment:
 Careful radiographic evaluation----pulpal extension into evagination

 Restricted and repeated grinding of tubercule can be undertaken to promote

reactionary dentine deposition on pulpal aspect of evagination

 Removal of tubercule and a limited pulpotomy are required

TAURODONTISM
 Late invagination (or failure) of Hertwig's root sheath,
which maps out the shape of root formation

 The furcation is displaced apically

 Conditions associated with taurodontism:

 Oral-facial-digital Syndrome
 Amelogenesis Imperfecta- Type IV
 Down Syndrome

Treatment: Challenging if endodontic treatment

required as difficult to locate canals
ACCESSORY ROOTS
 May occur in almost any tooth

 Cause: Pressure, trauma or metabolic disease

affection the HERS

 1-9% primary dentition,1%-45% of permanent

dentition
 In primary dentition---molars
 In permanent dentition----max incisors, mand
canines, premolars, and molars, situated on the
distolingual aspect of the tooth.
Anomalies of Tooth Structure
Causes of Anomalies of tooth formation
DENTINAL DYSPLASIA
 Dentin dysplasia is a genetic disorder of teeth, commonly exhibiting an
autosomal dominant inheritance.
 Presence of normal enamel but atypical dentin with abnormal pulpal
morphology.

 Affects both primary and permanent dentition

Types:
 Type I radicular type
 Type II coronal type
 Shell teeth?
DENTINAL DYSPLASIA
Cheese molars?
Features:
 Type I:
 Clinically normal teeth but root affected
(rootless teeth)
 Teeth may be extremely mobile and exfoliate
prematurely
 Roots of teeth are shorter than normal, pulp
chamber may be nearly gone in primary teeth
 Pulp chamber sometimes described as having
"crescent shaped“ appearance in permanent
teeth
 Multiple periapical radiolucencies
DENTINAL DYSPLASIA
Features
 Type II:
Primary teeth
 Clinical crowns an amber or brown/opalescent blue hue;
 Pulp chambers become completely obliterated.
Secondary teeth
 Crowns are largely unaffected or may have an amber/translucent appearance;
 Roots are of normal shape and contour;
 Abnormal pulp chamber shapes seen; (thistle shaped)
 Intra-pulpal calcifications may be present;
 Partial pulp obliteration is common
DENTINAL DYSPLASIA
DENTINAL DYSPLASIA
 Aim of treatment
Remove the sources of infection/pain;
Retain teeth for as long as possible;
Protect teeth from non-carious tooth surface loss;
Restore function and appearance when teeth are lost.

 Important foci for treatment

Promote and reinforce oral hygiene practices throughout childhood into adulthood;
Dietary advice to prevent primary dental disease;
Educate and counsel the patient and family on expected dental outcomes and
prognosis of dentition in the long term;
Provide dental interventions when necessary in the most conservative way.
REGIONAL ODONTODYSPLASIA (RO)
 Developmental abnormality of teeth, usually localized to a certain area and
nonhereditary.
 Enamel, dentin, and pulp of teeth are affected, and on radiographs the teeth
are described as "ghost teeth".
 Localised arrest in tooth development
 All the elements of tooth are hypocalcified and hypoplastic
 Maxillary anterior teeth of both the permanent and
primary dentitions. (primary teeth more severely affected)
REGIONAL ODONTODYSPLASIA (RO)
Cause:
The etiology is uncertain;
 Local trauma,
 Irradiation,
 Hypophosphatasia,
 Hypocalcemia,
 Hyperpyrexia.
REGIONAL ODONTODYSPLASIA (RO)
Clinical features:
 Small and mottled brown teeth
 Susceptible to caries
 Either delay or total failure of eruption
 Gingival swelling adjacent to the tooth surface is common
REGIONAL ODONTODYSPLASIA (RO)
Radiographic features:
 Ghost teeth – marked reduction in density, so that the teeth assume ghost
appearance.
 Ghost teeth that do not erupt are so hypomineralized and hypoplastic that
they appear to be resorbing
 Shell teeth – sometimes only the shell of enamel remain on the tooth
 Pulp chamber is very large with wide root canals and open apices

Treatment:
Variable., may require extraction of affected teeth followed by replacement
ANOMALIES OF TOOTH ERUPTION
AND EXFOLIATION
DEFECTS OF ERUPTION
Anomalies of Tooth
Eruption
PREMATURE ERUPTION
 Natal teeth: Extra teeth present at birth

 Neonatal teeth: Teeth that emerge through

the gingiva during the first month (30 days) of
life (the neonatal period)

 Maybe considered an example of pre

deciduous dentition

 Most common natal teeth are lower incisors

NATAL AND NEONATAL TEETH
 Associated syndromes
• Chondroectodermal dysplasia
• Pierre- Robin syndrome
• Ellis van creveld syndrome
• Sotos syndrome
• Rigafede disease

 Clinical aspects :
 Small immature conical dental structures, of a brown yellowish color, with an
undeveloped root

 Great mobility, facilitating spontaneous loss or exfoliation, with gingival

edema and inflammation, and some bleeding areas
NATAL AND NEONATAL TEETH
Considerations prior to extraction:
 Radiographic evaluation to determine supplemental tooth or normal dentition
 Mobility and feeding difficulties
 Vit K status of baby
 Checking medical history for infantile jaundice
 Hypo-prothrombinemia contraindicates extraction
 Mandatory protection of airways by placing a gauze on the back of mouth

 Treatment:
 These teeth are defective and their removal is generally recommended, particularly
if mobility poses a threat of aspiration.

 Feeding difficult
ERUPTION CYST / HEMATOMA
 Develops as a result of separation of dental follicle from around crown of an erupting tooth
that is within the soft tissues overlying the alveolar bone

 Considered a superficial dentigerous cyst

 Appears as a soft, often translucent swelling in the gingival mucosa overlying crown of an
erupting deciduous or permanent tooth

 Deciduous mandibular centrals, 1st permanent molars and the deciduous maxillary incisors

 Soft gingival swelling contains considerable blood and can also be designated as an eruption
hematoma
ERUPTION CYST / HEMATOMA
Treatment
 Usually asymptomatic and does not require treatment
 If symptomatic, should be treated with simple surgical excision
DELAYED ERUPTION
 Difficult to assess unless gross variation present
Etiology:
 Systemic conditions:
 Rickets
 Cretinism
 Cleidocranial dysplasia
 Local factors;
 Fibromatosis gingivae

 Treatment of primary condition may lead to eruption of teeth

IMPACTION
 Teeth that cease to erupt before emergence are impacted
 Causes:
– Crowding
– Insufficient maxillofacial development
– Overlying cysts and tumours
– Trauma
– Reconstructive surgery
– Systemic disorders and syndromes
 Treatment:
 Observation
 Intervention
 Relocation
 Extraction
ANKYLOSIS
 Cessation of eruption after emergence
 Occurs from anatomic fusion of tooth cementum or dentin with alveolar
bone
 Causes :
– Trauma
– Local failure from bone growth
– Abnormal pressure form the tongue

 PDL acts as a barrier preventing osteoblasts from applying bone directly into
the cementum
 Deficiency of this natural barrier causes ankylosis
ANKYLOSIS
 Treatment:
 If a primary tooth was ankylosed and no permanent teeth
 If onset early -> extraction, space maintainer.
 If the onset is late , can build up with composite to occlusal plane & maintain contacts
appropriately
 If permanent teeth is present
 Surgical extraction
 If a permanent tooth is ankylosed
 Itself is not a reason to remove a permanent tooth
 Build up with restorative material to maintain contacts
ERUPTION SEQUESTRUM
 Small spicule of non-vital bone may be seen
radiographically or clinically overlying crown of
partially erupted permanent posterior tooth

 Osseous fragment becomes separated from

contiguous bone during eruption of the associated
tooth

 Clinical features: child may complain of soreness in

that area

 Treatment: Usually none, bone fragment sequesters

through mucosa as tooth erupts and is lost
Anomalies of Tooth Exfoliation
PRE-MATURE EXFOLIATION
 Always warrants investigation

 Causes:
 Hypophosphatia
 Severe congenital neutropenia
 Cyclic neutropenia
 Chediak–higashi syndrome
 The langerhans cell histiocytoses
 Papillon–lefèvre syndrome
DELAYED EXFOLIATION
 Primary teeth not exfoliated with normal age range

1% to 39%, in primary molars, when one or more premolar is missing, but can
occur when there is a permanent successor.
Causes:
Local causes;
Fused/geminated primary teeth
Ectopically developing permanent teeth
Trauma
Severe infection of primary teeth
DELAYED EXFOLIATION
Treatment:
 If no permanent teeth
 Tooth may be retained, if orthodontic space closure not possible
 Build up with composite
 Onlay or preformed metal crowns
 Extract, space closure
DELAYED EXFOLIATION
 If permanent teeth is present
 Usually spontaneously exfoliated
 Conservative monitoring for 6-12 months
 Crown built up with composite to maintain occulsal contact and
prevent tipping of adjacent teeth

If significantly delayed or permanent premolar ectopic or excessive

tipping of adjacent teeth ---extraction
Quick Recap!
 In which conditions will you observe greater than normal number of teeth?

 In which conditions will you observe lesser than normal number of teeth?

 Condition with more than 6 teeth missing?

Quick Recap!
 Condition where teeth attached with cementum?

 Condition where tooth is bent?

 Condition where the tooth completely fails to erupt?

 Condition where the tooth does not reach its actual occlusal position?

 Condition where the tooth is present at the time of birth?

Summary
 Be vigilant when encountering dental anomalies
 If in primary teeth may be associated with permanent teeth
 One dental anomaly may be associated with another
 Anomalies may be multi-factorial
 Treatment based on severity and symptoms
Thank you
DELAYED EXFOLIATION
EXTRA TEETH
FUSION AND GEMINATION