Dr.

Ali Z
Syed
Diplomate
American Board of Oral &
Maxillofacial Radiology
Department of OMMDS
Case School of Dental
Medicine azs16@case.edu
• Some important
definitions
 Dental Anomalies
• Anomaly: Oddity;
inconsistency or deviation
from
the norm
• Congenital: A condition that
is present at birth by either
heredity or environmental
influences
• Acquired: Not congenital in
that it develops after birth
and may be environmental in
nature
 Dental
• Anomalies
Dysostosis: defective ossification
of fetal cartilages
• Dysplasia: ill formed
abnormality of development
• Dystrophy: disturbance in
bone growth and modeling
resulting from a disturbance
in osseous nutrition or
metabolism
 Types of Dental
Anomalies
• Number of Teeth: Hyperdontia or Supernumerary
teeth, Mesiodens, Hypodontia, Oligodontia, Anodontia
• Size of Teeth: Macrodontia, Microdontia
• Eruption or Position of Teeth: Impaction,
Transposition, Ankylosis , Ectopia
• Morphology (form) of Teeth: Gemination, Twinning,
Fusion, Concresence, Taurodontism, Dens Invagination,
Dens Evagination, Dilaceration
 Number of
•
Teeth
Hyperdontia: too many teeth aka supernumerary
teeth
Mesiodens –most common
single supernumerary tooth

Premolar – most common in mandible

(peridens)

)
Syndromes with Supernumerary
teeth Gardner’s
Syndrome

Cleidocranial
Dysplasia
Mesiodens in an 11 year old
male
 Number of
• Teeth
Hypodontia: Missing one or a few
teeth

www.dentalvets.com

braces4oxford.co.uk
 Number of
• Oligodontia:teeth
missing numerous teeth
(more than 6)

db.uth.tmc.edu This was published in the January 2000 edition of Nature Genetics
 Number of
Teeth
• Anodontia: Missing all of the www.silverstardental.com/dentalconditions.ph

teeth p

In a child
Missing Teeth
Hypodontia – absence of one or more teeth
- 3-10% of the population.
- missing primary teeth uncommon
Oligodontia – absence of
numerous teeth Anodontia –
failure of all teeth to develop
 Number of
•
Teeth
Most common single missing
tooth:
– maxillary incisor
• Most common missing teeth:
– third molars
– second premolars
– maxillary lateral
– mandibular central incisors

www.gfmer.ch/genetic diseases (case

report)
 Syndromes associated with
Missing teeth
• Ectodermal Dysplasia: Autosomal Dominant
disorder where at least two ectodermal structures
are missing such as hair, nails, sweat glands, skin
and teeth

ispub.com

May also see with:

Down
Syndrome Cleft
Lip/ Palate
Hemifacial Microsomia
Quiz
Time
Name at least three syndromic conditions with
supernumerary teeth

Gardner's syndrome
Pyknodystosis
Cleidocranial dysplasia
 Anomalies of
• Size
MACRODONTIA and
microdontia True
generalized Relatively
generalized Single Tooth
 Size of
Teeth
• Macrodontia: Teeth that are
larger than normal
• Usually affects only one tooth
• May occur with:
– Vascular abnormalities (hemangioma)
– Hemihypertrophy of the face
– Pituitary gigantism (generalized)
• May Cause:
– Crowding
– Impactions
– Malocclusion
»Could be confused with fusion,
gemination and positioning
 Size of
• Teeth
Microdontia: A tooth or several teeth
that are smaller than normal and may
have an abnormal form
• Most commonly localized
– Maxillary incisors – peg lateral
– Third molars
• May be syndromic
– Congenital heart disease
– Progeria (Rapid aging in childhood
and failure to grow)
– Down Syndrome
 http://www.gregnotestine.com/images/PegLateralBe
f ore.jpg

Size of
teeth
Localized

Generalized Microdontia
 Size of
• Ruleteeth
out:
– Positioning errors
(too far forward)

– Supernumerary teeth

– Irradiation to the jaws

causing dwarfing of
the teeth
 Eruption or Position of
• Teeth
Impaction – teeth
incased in bone or soft
tissue
• Transposition –
neighboring teeth
trade positions
• Ankylosis – tooth
becomes fused with the
bone and fails to erupt
properly
• Ectopia – displaced or
incorrectly positioned
 Eruption or Position of
• Teeth
Impactions
• Tooth that “fails” to
erupt
• Evident radiographically
• Canines and Molars
most common
 Eruption or Position of
• Transposition
Teeth
• Teeth switch places
• Most common in permanent canine and
1st premolar
• Easily identified
• Teeth altered prosthetically
Transposition
 Eruption or Position of
• Ankylosis
Teeth
• Common in primary teeth
• Fusion to bone caused by
trauma (avulsion), infection,
absence of permanent tooth
• Can cause the tooth to look
submerged
• Loss of lamina dura and PDL
• Difficult to extract
 Eruption or Position of
• Teeth
Ectopia
• Abnormal position
of tooth/follicle
• Most common in
permanent
Bracesquestions.com

canines incisors

Kidtooth.com
Quiz
Time
Name at least three syndromic conditions with
missing teeth

Reiger syndrome
Trisomy 21
Ectodermal dysplasia
 Morphology of teeth: Form
• Fusion – “missing tooth” when teeth are
counted- Two teeth fused into one and joined
by dentin
• Gemination – normal number of teeth
when counted – tooth bud tries to divide,
twinning
• Concrescence – teeth fused by cementum
• Taurodontism – tooth “trunk” is elongated
and the roots are short, bull like appearance
• Dilacerations – extreme root or tooth
curvature
• Dens in dente (tooth within a tooth)
 Morphology of teeth:
• Form
Geminatio
☻Clefting or
n invagination of the
crown
☻single pulp chamber
may be enlarged or
partially divided

☻Normal number of
teeth
☻Most common in
primary teeth but also
in permanent teeth

☻Most common in
incisor and canines,
rarely in premolar
 Morphology of teeth:
•
Form
Gemination aka
Twinning
☻Complete division of the tooth bud
= twinning

☻Can be confused with

fusion – remember to
count teeth!
 Morphology of teeth:
Form
• Fusion
(synodontia)

Dentin Two pulp

fused chamber
togethe s No PDL space
r between, one
Differentiate less tooth in arch
from:
☺Gemination
☺Macrodontia
☺Concrescence
 Morphology of teeth:
Form
• Concrescence
• Teeth fused by cementum
• Maxillary molars most
often involved
• True concrescence – occurs
during development by
space restriction
• Acquired concrescence – Rare in more than two
teeth!
local trauma, excessive
occlusal force or local
infection after development
 Morphology of teeth:
• Form
Concrescence
• Radiograph shows
– No alveolar bone
or PDL between
teeth
– Roots connected
– by
PDLcementum
and Lamina Differential
Dura surround Diagnosis:
☻Superimposed teeth
roots of both ☻Fusion
teeth ☻Hypercementosis
– Hypercementosis
surrounding roots
of both teeth With
Extractions!!!!
 Morphology of teeth:
Form
• Taurodontism
• Molars are shaped like a “bull”
• Large “trunk” – extension of
pulp
• Short roots
• Normal crown
• Noted on radiographs
• May see with Down’s
Syndrome or Amelogenesis
Imperfecta
 Morphology of teeth:
• Form
Dilaceration
• Extreme root or
tooth curvature
• Noted radiographically
• Most common in
premolars and incisors
maxillary Bull’s
• Result of mechanical Eye
trauma or developmental
• B/L placed roots
appear circular (bull’s
eye)
Differential
Diagnosis:
☻Fused roots
☻Sclerosing osteitis
Bull’s
Eye
 Morphology of teeth:
• Form
Dens in Dente
• Invagination, evagination, dilated odontome
• coronal type -Folding inward of the
enamel organ and is lined by epithelium
• Radicular type caused by folding of Hertwig’s
epithelial root sheath and is lined by
cementum
–mand 1st premolars and 2nd molars - RARE
• Communication with oral cavity
• 5% of Caucasian and Asian population
• Possibly hereditary
• Clinical Importance:
• Pulpal necrosis and ARO
 Morphology of teeth:
• DensForm
in Dente
• Invagination
• lateral incisors, max
centrals, premolars
and canines
 Morphology of teeth:
• DensForm
Evaginatus
(Leong’s
premolar)
• Folding outward of
the enamel organ
www1.umn.edu

• covered tubercle
Evagination – enamel
may chip resulting
in oral
communication
• Most common in
lateral incisors and
premolars
 Morphology of teeth:
Form
Enamel
Pearl Talon
Cusp
Turner’s
Hypoplasia
Congenital Syphilis
Enamel Hypoplasia
 Enamel
Pearl

❖ Small globule of enamel that forms on

the roots of molars

❖ Apical to the CEJ, often in the furcation

❖ Usually not clinically detectable

❖ Differential Dx: calculus, pulp stone

 Talon
• Definition Cusp Eagle
– Accessory cusp located talon

on the lingual surface

of maxillary or
mandibular incisor
• Pathogenesis
– Developmental anomaly
– Frequently in cleft
palate syndrome
 Turner’s
a permanent tooth
Hypoplasia
❖ Local hypoplastic defect in the crown of

❖ Caused by infectious or mechanical

trauma

❖ Alteration in normal contours of

affected tooth

❖ Differential Dx: High dose of therapeutic

radiation, caries
Hutchinson’s Teeth
(Congenital
Syphilis)
Developmental and
Congenital Anomalies:
Part 2
 Anomalies Of
Form
Amelogenesis Imperfecta
Dentinogenesis
Imperfecta Dentin
Dysplasia
Regional Odontodysplasia
 Amelogenesis
– An Imperfecta
ectodermal disturbance
– Hereditary defect of enamel
– Enamel hypoplasia due to an incomplete or
defective formation of the enamel matrix
of primary and permanent teeth
 Amelogenesis Imperfecta (AI)

• Features
– Tendency toward impaction
– Normal dentin structure
– Resistance to caries
– Four general types (White and
Pharoah)
• Hypoplastic
• Hypomaturation
• Hypocalcification
• Hypomaturation/hypocalcification
 Hypoplastic
Enamel fails to develop to normal thickness
✔Color of underlying dentin is yellowish-brown
✔Enamel –rough, pitted, smooth or glossy
✔Crowns – undersized, roughly square shape
Reduced enamel thickness → loss of interproximal
contact
✔Occlusal surfaces – flat with low cusps, not fully formed

“Picket-
fence”
Amelogenesis
Imperfecta Hypoplastic
Type
Enamel - mottled appearance, normal
thickness

✔Softer with density similar to dentin

✔Enamel may break away from crown
✔Color – clear to cloudy, white, yellow or brown
✔“Snow-capped” – white, opaque enamel
 Hypocalcification
Crowns – normal in size and shape, enamel is regular
thickness
✔Enamel – poorly mineralized (less dense than dentin)
✔Fractures under function
✔Enamel and dentin abrade away glossy, worn tooth
✔Explorer can penetrate yet caries is unusual
✔Increased permeability → staining, dark brown
Amelogenesis Imperfecta
Hypocalcified Type
Amelogenesis Imperfecta
Hypocalcified Type
 Hypomaturation with Taurodontism
Combination: hypomaturation with taudontism.

Radiographic
✔Identification primarily by clinical examination
✔Radiographic features substantiate the clinical
impression
✔Square crown, thin radiopaque layer of enamel,
low or absent cusps, multiple open contacts.
✔Hypo maturation the density is same as dentin.
✔Hypo calcified more radiolucent than the dentin.
Management
✔Restoration of esthetics and function
 Dentinogenesis Imperfecta
• (DIB) opalescent dentin”
“hereditary
• Hereditary condition affecting primary and
permanent dentition where dentin is
defective
• More prevalent than amelogenesis
imperfecta
• Three types
• DEJ is smooth
• Bulbous crowns
• Constricted necks
• Shortened roots
• Imperfect formation of dentin
 Dentinogenesis
Imperfecta Type 1

With Osteogenesis Imperfecta, Blue

sclera Multiple Fractures and Scars
 Dentinogenesis
Imperfecta Type 2

Does not occur in association with osteogenesis

imperfecta. Most frequently referred to as hereditary
opalescent dentin.
Dentinogenesis
Imperfecta Type 2
Dentinogenesis
Imperfecta What
type??
 Dentin Dysplasia
• Rare occurrence
•
(DDR)
“rootless teeth”
• Autosomal dominant
• Two types
– Type I: Radicular – short roots, conical in shape and
sometimes known as “rootless teeth”, Molar will have
a shallow W shape, 20% assoc. with periapical lesions
• Four variations
– Type II: Coronal – Normally shaped roots, normal
length, Pulp chambers become flame or thistle shaped
with multiple pulp stones
Dentin Dysplasia Type I
(Radicular)
Dentin Dysplasia Type
I

Short, poorly developed roots, obliterated pulp

chambers, ARO associate with type I dentin dysplasia,
“half-moon” or “demilune” shape of pulp chambers
Type 1
(radicular)
Type II – Coronal form
✔Obliteration of pulp chamber, reduction in caliber
of root canals after eruption. (5 or 6 years)
✔Flame or thistle shaped pulp chambers
✔Pulp stones - multiple
✔Roots – normal in size, shape
Management
✔Crowned – normal root size
Dentin Dysplasia Type 2
(Coronal)
 Regional
Odontodysplasia
• Large pulp chambers
• Thin enamel
• Hypocalcified, thin dentin
• Usually restricted to a region such as
a single quadrant
• Also known as “ghost teeth”
Regional
Odontodysplasia
 Acquired Pathologic Conditions
Attrition
✔Physiologic wearing of the dentition from occlusal
contacts
✔Occurs in 90% of young adults, > men
✔Extent - abrasiveness of diet, salivary factors,
mineralization of the teeth, emotional tension
✔Aging process
✔Pathologic - Bruxism
Clinical
✔Wear facets – cusps, incisal edges,
✔Molars – Max. –lingual cusps Mand. – buccal cusps
✔Dentin – exposure results in staining and pitting
Radiographic
✔Height – shortened, secondary dentin, widened pdl,
hypercementosis occasionally
 Abrasion
Nonphysiologic wearing of teeth in contact with foreign substances. Result of
friction induced by factitious habits or occupational hazards
Most common: Improper tooth brushing and flossing, pipe smoking, hairpins,
toothpicks, denture clasps
Toothbrush Injury
✔Most frequent injury to dental hard tissue
✔Improper “back-and-forth” movement
✔V-shaped notch at cervical area – enamel + root
surface
✔Maxillary premolars, canines, incisors
✔Left side for right-handed person and vice versa
Radiographic y
✔Semi circular shape with increasing radiopacit
Dental Floss Injury
Cervical portion of the proximal surface just above the gingiva
Radiographic
✔Radiolucent grooves on distal surface of tooth deeper than
mesial – pulling force >pushing force
✔Deep → obliteration of pulp chamber with secondary dentin

Floss abrasion Dental clasp

 Erosion
Chemical destruction not involving bacteria
✔Chronic vomiting or acid reflux
✔Diet rich in citrus fruits, carbonated beverages
✔Found on incisors, multiple teeth
✔Regurgitated acids → lingual and palatal surface
✔Dietary Acids → demineralize labial surface
✔Edges of lesions caused by erosion are more
rounded
✔Lesions are smooth glistening depressions in the
enamel
 Resorption
Removal of tooth structure by osteoclasts (odontoclasts)
Internal Resorption
✔Occurs within the pulp chamber or canal
✔Dentin
✔Etiology – unknown, inflammation?
✔Permanent teeth - centrals, 1st- 2nd molars
✔4th and 5th decades, males
Radiographic
✔Localized, RL, round, oval, elongated
✔Outline – sharply defined, smooth
✔Expansion of pulp canal or chamber
Management
✔Endodontic treatment halts the resorption
External Resorption
Odontoclasts resorb outer surface of the tooth
✔Root surface, involves cementum and dentin
✔Intact blood supply – soft tissue coverage necessary
✔Single or multiple teeth – centrals, canines, premolars
✔Resorption of entire tooth if impacted – 3rd molar,
canine
✔Most common – apical or cervical regions
✔Apex – smooth resorption, bone and lamina dura
follow the resorbing root
Management
✔Remove etiologic factor – excessive mechanical forces,
impacted tooth, cyst, tumor, source of inflammation
External Resorption Resorption of impacted tooth

Loss of tooth structure from the

apex

Lateral surface of
root
Secondary Dentin
Secondary dentin is deposited in the pulp chamber
and canal after primary dentin has been completed.
✔Physiologic aging
✔Response from pathologic conditions – progressive
caries, trauma, erosion, abrasion, attrition,
restorative procedure
✔Produce by odontoblasts
✔Reduces the sensitivity of the teeth to external
stimuli

Obliterates pulp chamber and narrows canal – due to caries or

attrition
Quiz:
Ghost teeth are noted in which
condition?
 Pulp Stones
Foci of calcification in the dental pulp
✔Occur in almost all people over age 50
✔Most are microscopic some reach 2-3mm
✔Cause: Unknown
✔No treatment
 Pulpal Sclerosis
Calcification in the pulp chamber and canals
✔Diffuse process, unknown etiology
✔Correlates strongly with age - 90% of all teeth in
people ages 50-70 show histologic evidence
✔Amorphous and unorganized
✔Linear strands of calcified material paralleling
blood vessels and nerves in the
pulp

Diffuse calcification of pulp chamber

and canals
 Hypercementosis
Excessive deposition of cementum on the tooth
roots
✔Cause is unknown
✔Appears on supraerupted tooth root, inflammation
from rarefying or sclerosing osteitis, teeth in
hyperocclusion
✔Deposited on root surface adjacent to apex
✔Paget’s disease,Hyperpituitarism (Gigantism)
Radiographic
✔Bulbous enlargement of irregular
accumulation of cementum at
apical one third of the root
 DEVELOPMENTAL AND
CONGENITAL
ANOMALIES: PART THREE

NONODONTOGENIC
 Nonodontogenic Anomalies of the
Jaws

• Stafne Bone Defect

• Exostosis/enostosis
• TMJ Abnormalities
• Incisive canal cyst
• Cleft Palate
• Maxillary Sinus Anomalies
• Craniofacial Developmental Disturbances
of the Face and Skull
 Definitions:

• Hypertrophy: an enlargement of an organ or

tissue due to an increase in the size of the
cells, nontumorous overgrowth
• Hyperplasia: an enlargement of an organ or
tissue due to an abnormal increase in the
number of cells
• Hypoplasia: incomplete or underdevelopment
of an organ or tissue
• Coloboma: a hole in one of the structures of the
eye – congenital defect most commonly of the
iris (keyhole)
 Definitions:

• Brachycephalic: someone who has a short, broad head

• Hypertelorism: abnormal increase between
two organs/parts of the body - eyes
• Wormian bones: extra small, irregular pieces of bone
that occur within a suture of the cranium
• Synostosis: abnormal fusion of neighboring skeletal
bones making one larger bone
• Oxycephaly: congenital abnormality of the skull that
leads to a cone shape appearance of the head. Caused
by premature closure of the lambdoid and coronal
sutures
• Trigonocephaly: congenital abnormality of the skull
Autosomal dominant – an abnormal gene from one
parent is capable of causing the disease
Autosomal recessive – abnormal genes from both
parents must be inherited in order to have the
disease
Microsomia – small body size
 Stafne Bone
Lingual Salivary Gland Depression,
Defect
Dev. Salivary Gland Defect, Latent Bone
Cyst
• Group of concavities on
mandibular lingual surface –
submandibular gland fossa
most common
• Described by Stafne in 1942
• Caused by growth of
salivary gland
• Rarely –medial surface of
ascending ramus from
parotid gland
• Unknown etiology – Pressure
TMJ
Abnormalities
• Condylar
Agenesis
• Condylar
Hyperplasia

• Bifid Condyle
Condylar
Hyperplasia
Bifid
Condyle
CLEFT Can be unilateral
or bilateral
PALATE
 CLEFT
PALATE

5 year old male

Bilateral cleft
palate May 2007

Same patient, 7 yrs

Bilateral cleft palate
August 2009
 CLEFT
PALATE

September
2009
 Maxillary Sinus
Anomalies
• Sinus Pneumatization - expansion of
the

sinus into edentulous spaces

• Sinus Hypoplasia

• Sinus Agenesis-sinus never forms

Sinus
Pneumatization
Sinus
Agenesis
 Craniofacial Developmental
Disturbances
• Cleidocranial Dysplasia

• Craniofacial Dysplasia
– Crouzan’s Syndrome

• Mandibulo-Facial
Dysplasia
– Treacher-Collins Syndrome
 Cleidocranial
• A congenital hereditary condition
•
Dysplasia
Abnormalities of skull, teeth, jaws,
clavicle and some longbones,
• Skull has a flat appearance
• partially or totally missing clavicle
• Retention of decidous teeth
• Delay in eruption
of permanent
teeth
• Supernumerary teeth
• Multiple impactions
• Dentigerous cysts may
Cleidocranial
Dysplasia

13 year old male. October

2005
Cleidocranial
Dysplasia Large head with frontal
and parietal bossing
High arched palate
Small sinuses –
maxillary micrognathia
Hearing loss
Craniofacial Dysplasia- Crouzan’s
•Syndrome
Early closure of all cranial
sutures (radiographic absence
of sutures)
• “Frontal bossing” - Bulging
of frontal bone
• Hypertelorism (eyes are
wide apart)
• “Beaten metal” appearance -
Cranial markings which look
like digital impressions seen in
the cranial vault
• Normal mental capacity
Jenny’s story at:
http://hub.webring.org/hub/craniofacial
Craniofacial
Dysplasia Crouzan’s
Syndrome
 Mandibulofacial Dysplasia
(Treacher - Collins
• Syndrome)
Underdevelopment of the mid-facial
region
– Coloboma of the eyes
– Malformation of the external ear
– Atypical hair growth
– Macrostomia
• Radiographic findings
– Hypoplasia of the facial
bones especially the zygoma
– Facial clefts and other
skeletal deformities
www.radiopaedia.org/cases/treacher-collins-syndrome-
Mandibulofacial
Dysplasia
Questions?
?