DEVELOPMENT AND ERUPTION OF TEETH, ABNORMALITIES

OF DEVELOPMENT

Introduction:

• Birth is an unmatched marvel of nature, as every big happening has a humble of

beginning-So too the growth and development of a teeth.
• “Study the past to know the future”. The journey of the tooth from its inception to
its complete development is one such study.
• The term dentition is used to describe the natural teeth in the jaw bones. There are
two dentitions; the primary and the permanent dentition. A child’s primary dentition
develops during the prenatal period and consists of 20 teeth which erupt and later shed or
lost.
• As the primary teeth are shed and the jaws grow and mature , the permanent
dentition, consisting of 32 teeth, gradually erupts and replaces the primary dentition
• Tooth development, or odontogenesis, takes place in many stages. Odontogenesis
is a continuous process, and there is no clear-cut beginning or end point between these
stages
Not all the teeth in each dentition begin to develop at the same time. The initial teeth for
both dentitions develop in the anterior mandibular region, followed later by the anterior
maxillary region, and then development progress posteriorly in both jaws
• The primary dentition develops during both the embryonic and fetal periods. Most
of the permanent dentition is formed during fetal period. Tooth development continues
for years after birth, however, especially considering the formation of the permanent
second and third molars. Thus, teeth have the longest developmental period of any set of
organs in the body.
Stomodeum or primitive oral cavity
• The primitive oral cavity, or stomodeum, is lined by stratified squamous
epithelium called the oral ectoderm. The oral ectoderm contacts the endoderm of the
foregut to form the buccopharyngeal membrane. At about 27th day of gestation this
membrane ruptures and the primitive oral cavity establishes a connection with the
foregut.

Primary Epithelial Band

• After 37 days of development, a continuous band of thickened epithelium forms

around the mouth in the presumptive upper and lower jaws from the fusion of separate
plates of thickened epithelium.
• These bands are roughly horse-shoe shaped and correspond in position to the
future dental arches of the upper and lower jaws.
• Each band of epithelium, called the primary epithelial band which gives rise to
the dental lamina and vestibular lamina
•
Dental lamina
• Two or three weeks after the rupture of the buccopharyngeal membrane, when the
embryo is about is about 6 weeks old, certain areas of basal cells of oral ectoderm
proliferate at more rapid rate than do the cells of adjacent areas. This leads to the
formation of dental lamina, which is a band of epithelium that has invaded the underlying
ectomesenchyme along each of horse shoe shaped future dental arches
• It serves as the primodium for ectodermal portion of decidious teeth. The
permanent molars arise directly from distal extension of dental lamina. The successor of
decidious teeth develop from a lingual extension of free end of dental lamina.

• Fate of dental lamina:

• The total activity extends over a period of atleast 5 years. However,the dental
lamina may be still be active in the 3rd molar region after it had dissappeared elsewhere.
• Remnants of dental lamina persist as epithelial pearls or islands within the jaws as
well in the gingiva.
Vestibular lamina

• Labial and buccal to the dental lamina in each dental arch, another epithelial
thickening develops independtly and some what later. It is the vestibular lamina, also
termed as lip furrow band. It subsequently hollows and forms the oral vestibule between
the alveolar portion of the jaws and the lips and cheeks.

Stages of tooth development

• Initiation stage.
• Bud stage.
• Cap stage.
• Bell stage.
• Advanced bell stage.
•
Initiation of tooth development

• The odontogenesis is first initiated by factors resident in the first arch epithelium
influencing ectomesenchyme. The bone morphogenic protein(BMP) are specifically and
transiently expressed in the epithelium at sites where teeth will form.

• Odontogenesis of the primary dentition begins between the sixth and seventh
week of prenatal development, during the embryonic period.
• The initiation stage, involves the physiological process of induction, which is an
interaction between the embryological tissues

Bud stage
• The second stage of odontogenesis is called the bud stage and occurs at the
beginning of the eighth week of prenatal development for primary dentition.
• This stage is named for an extensive proliferation.

• The epithelium of the dental laminae is separated from the underlying

ectomesenchyme by a basement membrane.

• Simultaneous with the differentiation of each dental lamina, round or ovoid

swellings arise from the basement membrane at 10 different points, corresponding to
future positions of deciduous teeth. These are the primordia of the enamel organs, the
tooth buds

• In the bud stage, the enamel organ consists of peripherally located low columnar
cells and centrally located polygonal cells. Many cells of the tooth bud and the
surrounding mesenchyme undergo mitosis.
• As a result of increased mitotic activity and the migration of neural crest cells
into the area the ectomesenchymal cells surrounding the tooth bud condense. The
ectomesenchymal condensation immediately subjacent to enamel organ is the dental
papilla.and that surrounds the tooth bud and the dental papilla is the dental sac

Cap stage

• The third stage of odontogenesis is called the cap stage and occurs for the primary
dentition between the ninth and tenth week of prenatal development. This stage not only
involves the proliferation stage, but various levels of differentiation (cytodifferentiation,
histodifferentiation,and morphodifferentiation)

• As the tooth bud continues to proliferate, it does not expand uniformly into a
larger sphere. Instead, unequal growth in different parts of the tooth bud leads to the cap
stage, which is characterized by a shallow invagination on the deep surface of the bud.

Bell stage

• The fourth stage of odontogenesis is the bell stage which occurs between the
eleventh and twelfth week of prenatal development. It is characterized by continuation of
the ongoing process of proliferation, differentiation, and morphogenesis.

• As the invagination of the epithelium deepens and its margins continue to grow,
the enamel organ assumes a bell shape. Four different types of cells are found within the
enamel organ-
• Inner enamel epithelium
• Outer enamel epithelium
• Stratum intermedium
• Stellate reticulum

• Inner enamel epithelium;

• The cells immediately adjacent to the dental papilla assume a short columnar
shape and are characterized by high glycogen content. These cells are known as IEE. The
IEE consists of a single layer of cells that differentiate prior to amelogenesis into tall
columnar cells called ameloblasts.

• These cells are 4to 5 um in diameter and about 40um height. These elongated
cells are attached to one another by junctional complexes laterally and to cells in the
stratum intermedium by desmosomes.
• The cells of IEE exert an organizing influence on the underlying mesenchymal
cells in the dental papilla, which later differentiate into odontoblasts.

• Outer enamel epithelium.

• At the periphery of dental organ, cells assume cuboidal shape and form the
external or outer enamel epithelium. At the end of the bell stage, preparatory to and
during formation of enamel, the smooth surface of OEE is laid in folds. Between the
folds the adjacent mesenchyme of the dental sac forms papillae that contain capillary
loops and thus provide a rich nutritional supply for the intense metabolic activity of the
avascular enamel organ.

• Stellate Reticulum (Enamel pulp);

• The cells in the center of dental organ synthesize and secrete glycosaminoglycans
which pulls water into the dental organ. So as the fluid increases, the volume of
extracellular components of dental organ increases and therefore the cells are forced
apart. Cells retain connections with each other through their desmosomal contacts and
they become star shaped. These cells are known as stellate reticulum.

• Before enamel formation begins,the stellate reticulum collapses, reducing the

distance between the centrally situated ameloblasts and the nutrient capillaries near the
OEE.

• Stratum Intermedium;

• Between the IEE and the newly differentiated stellate reticulum some epithelial
cells proliferate into layer called stratum intermedium. These cells are closely attached by
desmosomes and gap junctions. This layer seems to be essential for enamel formation.
• Dental Papilla;

• The dental papilla is enclosed in the invaginated portion of enamel organ. Before
the IEE begins to produce enamel, the peripheral cells of mesenchymal dental papilla
differentiate into odontoblasts under the organizing influence of the epithelium to form
pulp and dentin.
• The basement membrane that separates the enamel organ and the dental papilla
just before dentin formation is called the membrana performativa.

• Dental Sac;

• Before formation of dental tissues begins, the dental sac shows a circular
arrangement of fibres and resembles a capsular structure.
• With the development of roots, the fibres of dental sac differentiate into
periodontal ligament that become embedded in the developing cementum and alveolar
bone.

Advanced Bell Stage

• During this stage,the boundary between IEE and odontoblasts outlines the future
dentino-enamel junction. In addition, the cervical portion of the enamel organ gives rise
to the epithelial root sheath of Hertwig.

Enamel knot, Enamel cord, Enamel niche

• During the stages of tooth development some transient structures occurs that are
not necessarily present in every tooth germ or present at the same time.

• Enamel Knot: is a localized thickening in the internal dental epithelium at the

center of the tooth germ.
• The knot is always continuous with the enamel cord or septum, which is a strand
of cells running from the knot to the external dental epithelium,that divides the dental
organ into two.
• These two structures determine the initial position of first cusp of the tooth during
crown pattern formation.
• Enamel Niche: is an apparent structure, created because the dental lamina is a
sheet rather than a single strand and often contains a concavity filled with connective
tissue.

Epithelial Mesenchymal Interactions during tooth development

• During the tooth development,’’messages” pass between the epithelium and
mesenchyme to produce changes of increasing complexity (I.e differentiation) within
the cell layers. The term induction is used to describe the effect that one cell layer
has on another.

• Three main hypothesis have been put forward to explain how information leading
to induction may be transferred between epithelium and mesenchyme.
• 1.A chemical substance (short –range hormone) is produced by one cell layer and
diffuses across the narrow intervening space to be taken up and cause induction in the
other cell layer.

• 2. Induction is triggered by direct cell-to cell contact and does not involve a
diffusible molecule.
• 3. Induction is due to the presence of the initial extracellular matrix, a thin layer
situated between the epithelium and mesenchyme and comprising the basal lamina and
adjacent region. The extracellular matrix has a complex composition, consisting of
collagen(mainly type 4 but possibly some type 1& 3), proteoglycans and glycoproteins.
Break up dental lamina crown pattern determination
• Two other important events take place during the bell stage. First, the dental
lamina joining the tooth germ to the oral epithelium breaks up into discrete islands of
epithelial cells, thus separating the developing tooth from oral epithelium.

• Second, the IEE folds, making it possible to recognize the shape of the future
crown pattern of the tooth.
• If any remnant of dental lamina persist they may form small cysts (eruption cysts)
over the developing teeth and delay eruption.
Vascular supply during early tooth development
• Clusters of blood vessels are found ramifying around the tooth germ in the dental
follicle and entering the dental papilla ( or pulp) during cap stage.
• Their number in the papilla increases during histodifferentiation reaching a
maximum at the onset of crown stage of tooth development.
• With age, the volume of pulp tissue diminishes and the blood supply becomes
progressively reduced, affecting the tissue’s viability.
• The dental organ- Avascular
Nerve supply
• Nerve fibers approach the developing tooth during the bud-cap stage of
development.
• Nerve fibers ramify and form a rich plexus around tooth germ. Initial innervations
of the developing teeth is concerned with the sensory innervations of the future PDL and
pulp.
Enamelogenesis and Dentinogenesis

• Formation of Preameloblasts:
• After the formation of IEE in the bell shaped enamel organ, these inner most cells
grow even more columnar or elongate as they differentiate into preameloblasts. During
this differentiation, the nucleus in each cell moves away from the center of the cell to a
position farthest away from the basement membrane (repolarization)

• Formation of Odontoblasts and dentin matrix:

•
• After the IEE differentiates into preameloblasts, the outer cells of the dental
papilla are induced by the pre ameloblasts to differentiate into odontoblasts. These cells
undergo repolarization.
• The odontoblasts, now begin dentinogenesis which is the apposition of dentin
matrix, or predentin, on their side of basement membrane.(fig6-13)

• Thus, the odontoblast start their secretory activity some time before enamel
matrix production begins. This explains why dentin layer in any location in a developing
tooth is slightly thicker than the corresponding layer of enamel matrix.

Formation of ameloblasts, dentino enamel junction and enamel matrix:

After the differentiation of odontoblasts from the outer cells of dental papilla and their
formation of predentin, the basement between the pre ameloblasts and the odontoblasts
disintegrates. This disintegration allows the preameloblasts to come into contact with the
newly formed predentin. This induces the pre ameloblasts to differentiate into
ameloblasts.

• Ameloblasts begins amelogenesis, or apposition of enamel matrix, laying it down

on their side of now disintegrating basement membrane. The enamel matrix is secreted
from Tome’s process, a tapered portion of each ameloblast that faces the disintegrating
basement membrane.

• With the enamel matrix in contact with the predentin, mineralization of the
disintegrating basement membrane now occurs, forming the dentino enamel junction.
• The odontoblasts, unlike the ameloblasts, will leave attached cellular extensions
in the length of the predentin called the odontoblastic process. Each odontoblastic process
is contained in the mineralized cylinder, the dentinal tubule.
• The cell bodies of odontoblasts will remain within the pulp tissue. The cell
bodies of ameloblasts will be involved in the eruption and mineralization process but
will be lost after eruption.

Root development

• The process of root development takes place after the crown is completely shaped
and the tooth is starting to erupt into the oral cavity. The structure responsible for root
development is the cervical loop. This is the most cervical portion of enamel organ,a
bilayer rim that consist of IEE and OEE.

• The cervical loop begins to grow deeper into the surrounding mesenchyme of the
dental sac, to enclose more of dental papilla tissue to form Hertwig’s root sheath.
• The function of this sheath or membrane is to shape the roots and induce dentin
formation in root area.

• Root dentin formation:

• Root dentin forms when the outer cells of the dental papilla in the root area are
induced to undergo differentiation and become odontoblasts. After the differentiation,
these cells undergo dentinogenesis and begin to secrete predentin.
• When root dentin formation is completed, this portion of basement membrane
also disintegrates, as does the edntire HERS. After this disintegration of root sheath, its
cells may become the epithelial rests of Malassez.

Cementum and pulp formation

• The apposition of cementum, or cementogenesis, in the root area also occurs

when HERS disintegrates.
• This disintegration of the sheath allows the undifferentiated cells of the dental sac
to come into contact with the newly formed surface of root dentin. This contact of the
dental sac cells with the dentin surface induces these cells to become immature
cementoblasts.
• The cementoblasts move to cover the root dentin area and undergo
cementogenesis, laying down cementum matrix, or cementoid. Many cementoblasts
become entrapped by the cementum they produce and become mature cementocytes.
• As the cementoid surrounding the cementocytes becomes calcified, or matured, it
is then considered cementum. As a result of the apposition of cementum over the dentin,
the dentino cemental junction(DCJ) is formed.
Multirooted teeth

• Like anterior teeth, multirooted premolars and molars originate as a single root on
the base of the crown. This portion on these posterior teeth is called the root trunk. The
cervical cross section of the root trunk initially follows the form of the crown.
• Differential growth of HERS causes the root trunk of the multirooted teeth to
divide into 2 or 3 roots.
• During the formation of the enamel organ on a multirooted tooth, elongation of
cervical loops occurs in such a way that long, tongue like horizontal epithelial extensions
or flaps develop within. Two or three extensions can be present on multirooted teeth,
depending on the similar number of roots on mature tooth.
Primary tooth eruption and shedding
• Eruption of the primary dentition takes place in the chronological order, as does
the permanent dentition later. This process involves active eruption, which is the actual
vertical movement of the tooth.
• After enamel apposition ceases in the crown area of each primary or permanent
tooth, the ameloblasts place an acellular dental cuticle on the new enamel surface. In
addition, the layers of enamel organ are compressed, forming the reduced enamel
epithelium(REE)
• To allow for the eruption process, the REE first fuses with the oral epithelium
lining the oral cavity. Second, enzymes from the REE disintegrate the central portion of
the fused tissue, leaving an epithelial tunnel for the tooth to erupt through into the
surrounding oral epithel;ium of the oral cavity.
• The primary tooth is then lost- exfoliated or shed- as the succedaneous permanent
tooth develops lingual to it. The process consists of differentiation of osteoclasts, which
absorb the alveolar bone between the two teeth, and odontoclasts which causes
resorption.
Permanent tooth eruption
• The succedaneous permanent tooth erupts into the oral cavity in a portion lingual
to the roots of the shedding or shed primary tooth.
The process of eruption for a succedaneous tooth is the same for the primary tooth. A
permanent tooth often starts to erupt before the primary tooth is fully shed.
Developmental Disturbances of Teeth
DISTURBANCES IN SIZE OF TEETH

Microdontia

The term is used to describe teeth which are smaaler than normal.outside the
usual limits of variation.
Three types of Microdontia are recognized:
(1) TRUE GENERALISED MICRODONTIA
(2) RELARIVE GENERALISED MICRODONTIA
(3) MICRODONTIA INVOLVING A SINGLE TOOTH
In true generalized microdontia all the teeth are smaller than normal e.g.Pituatory
dwarfism

Relative Generalised Microdontia Normal or slightly smaller than normal teeth are
present in jaws that are somewhat larger than normal and there is an illusion of true
microdontia.

Microdontia involving a single tooth is rare .It affects most often the Maxillary Lateral
Incisor & Third Molar.Supernumerary teeth are frequently smaller in size.One of the
most common microdontia is Peg shaped Lateral.

Macrodontia

Refers to teeth that are larger than normal.

True Generalised macrodontia in which all teeth are larger than normal.e.g. Pituatory
Gigantism.

Relative generalized Microdontia is common & is the presence of normal or slightly

larger than normal teeth in small jaws.

Macrodontia of single tooth is rarher common condition.The tooth is normal in every

respect except size.In hemihypertrophy of face teeth of involved side may be
comparatively laregr than the unaffected side.

DISTURBANCS IN SHAPE OF TEETH

GEMINATION

Is an anomaly that arises from an attempt at division of a single tooth germ by an

invagination ,with resultant incomplete formation of two teeth.The structure is usually
one with two completely or incompletely separated crownsthat have a single root or root
canal.
It is in deciduous as well as permanent dentition.
The term TWINNING is used to designate the production of one normal &one
supernumerary tooth.

FUSION
Fused teeth arise through union of two normally separated tooth germs.Depending on the
stage of development of the teeth at the time of union fusionmay be either complete or
incomplete.Some physical force or pressure produces contact of the developing teeth and
their subsequent fusion.If this contact occurs before before calcification beigns the two
teeth may be completely united to form a single large tooth. If the contact occurs when a
portion of tooth crown has completed its formation there may be union of roots only.The
dentin is confluent in cases of true fusion.Fusion may occur between a normal tooth and a
supernumerary tooth.

CONCRESCENCE

Is a form of fusion which occurs after root formation is completed.In this condition the
teeth are united by cementum only.It is thought to arise as a result of traumatic injury or
crowding of teeth with resorption of the interdental bone so that the two roots are in
approximate contactand become fused by the depositionof cementum only.Diagnosis can
be established by radiographic examination. Extraction of one teeth may result in the
extraction of the other.

DILACERATION

Refers to an angulation or sharp bend or curve in the root or crown of a formed tooth.The
condition is thought to be due to trauma during the period in which the tooth is forming
with the result that the position of the calcified portion of the tooth is changed & the
remainder of the tooth is formed at an angle.The curve or bend may occur anywhere
along the length of the tooth sometimes along the cervical portion of the tooth.at times at
the midway &sometimes at the apex.
Dilacerated teeth frequently present difficult problems at the time of extraction if the
operator is unaware of the condition.

TALON CUSP

Talon cusp is a supernumerary structure projecting from the

dentoenamel
junction to a variable distance towards the incisal edge of an anterior
tooth.
Studies have shown that it consists of enamel, dentine and a variable
amount of pulp tissue. Hyperactivity of the enamel organ during
morphodifferentiation has been attributed to its formation. Most
previous reports have been made concerning the occurrence of this
structure on primary and permanent teeth and mostly on the palatal
aspect. Only few have been reported on the facial aspect of the teeth.
When it occurs, the effects are mainly aesthetic and functional and so
early detection and treatment is essential in its management to avoid
complications.
Background
This unusual dental anomaly showing an accessory cusp-like structure
projecting from the cingulum to the cutting edge was first described by
Mitchell in 1892 . It was thereafter named a Talon cusp by Mellor and
Ripa due to its resemblance to an eagle's talon. Since then, this
odontogenic anomaly has been given several descriptions, such
as,prominent accessory cusp-like structure , exaggerated cingula
additional cusp , cusp-like hyperplasia , accessory cusp and
supernumerary cusp. It has been defined as a supernumerary
accessory talon-shaped cusp projecting from the lingual or facial
surface of the crown of a tooth and extending for at least half the
distance from the
cemento-enamel junction to the incisal edge . There is a wide variation
in the size and shape of this anomaly. Due to this variation, and in
order to have a diagnostic criteria, it has been classified into 3 types
by Hattab et at
:
Type1: Talon - refers to a morphologically well-delineated additional
cusp that
prominently projects from the palatal (or facial) surface of a primary or
permanent
anterior tooth and extends at least half the distance from the cemento-
enamel junction to the incisal edge.

Type 2: Semi talon - refers to an additional cusp of a millimeter or

more extending less than half the distance from the cemento-enamel
junction to the incisal edge. It may blend with the palatal surface or
stand away from the rest of the crown.

Type 3: Trace talon - an enlarged or prominent cingula and their

variations, i.e. conical,bifid or tubercle-like. Radiographically, it may
appear typically as a v-shaped radiopaque structure, as in true talon or
semi- talon, or be tubercle-like, as in trace talon, originating from the
cervical third of the root. The radiopaque v-shaped structure is
superimposed over the normal image of the crown of the tooth. The
point of the 'V' is inverted in mandibular cases. This appearance varies
with the shape and size of the cusp, and the angle at which the
radiograph is taken. It is composed of enamel, dentine and a varying
amount of pulp tissue . The extent of pulp extension into the cusp is
however difficult to determine because of its superimposition over the
main pulp chamber. While some indicated that talon cusps contain
pulp tissue , some found no evidence of pulp extension into the cusp.
However, it has been suggested that large talon cusps, especially
those that stand away from the tooth crown are more likely to contain
pulp tissue. A review of the literature showed that over the last two
decades, increasing reports have been made of the occurrence of the
condition. The reported prevalence outside Africa is between 0.06% in
Mexicans and 7.7% in a northern Indian population. It has also been
found to be relatively common in the Chinese and Arab , and
predominantly in the male population . These wide variations in
prevalence could be due to individual differences in definitions of
observation, from enlarged cingula to semi- or true talons . If data is
taken from those who reported for treatment only, a high prevalence
might be observed. Patients may seek treatment when there is a
problem, usually with large cusps. No prevalence data was been found
in the literature for Africans.

Aetiology

The exact aetiology is not known, but it is suggested to be a

combination of genetic and environmental factors . It is thought to
arise during the morphodifferentiation stage of tooth development, as
a result of outfolding of the enamel organ or hyperproductivity of the
dental lamina. It is suggested that disturbances during
morphodifferentiation such as altered endocrine function might affect
the shape and size of the tooth without impairing the function of
ameloblasts and odontoblasts . There is also a suggestion of a strong
genetic influence in its formation as evidenced by its occurrence in
close family members. Talon cusp may occur in isolation or with other
dental anomalies such as mesiodens , odontome, unerupted or
impacted teeth , peg-shaped maxillary incisor, dens invaginatus , cleft
lip and distorted nasal alae bilateral gemination , fusion,
supernumerary teeth and enamel clefts.It has also been associated
with some systemic conditions such as Mohr syndrome (oro-facial-
digital II) , Sturge-Weber syndrome (encephalo-trigeminal
angiomatosis, Rubinstein-Taybi syndrome, incontinentia pigmenti
achromians , and Ellis-van Creveld syndrome .

Presentation

It is more common in the permanent dentition (75%) than in the

primary dentition, while 92% affect the maxillary teeth . The maxillary
lateral incisor is the most frequently affected in the permanent
dentition while the maxillary central incisor is the most affected in the
primary dentition . Most times it occurs unilaterally but bilateral
cases ,including multiple talon cusps have also been reported In a
particular case, talon cusps have occurred on both maxillary and
mandibular teeth in the same patient . Rarely, two talon cusps may
occur on a single tooth. Abbot reported a labial and a palatal talon on a
maxillary right central incisor , while another report from Nigeria
presented two palatal talons on a maxillary left central incisor
Complications and Management

The complications of talon cusp are diagnostic, functional, aesthetic

and pathological A large talon cusp is unaesthetic and presents clinical
problems. It may present diagnostic problems if it is unerupted and
resembles a compound odontome or a supernumerary tooth and so
leads to unnecessary surgical procedure. Functional complications
include occlusal interference, trauma to the lip and tongue, speech
problems and displacement of teeth. The deep grooves which join the
cusp to the tooth may also act as stagnation areas for plaque and
debris, become carious and cause subsequent periapical pathology.
Management will depend on individual presentation and complications.
Small talon cusps are asymptomatic and need no treatment. Where
there are deep developmental grooves, simple prophylactic measures
such as fissure sealing and composite resin restoration can be carried
out. An essential step, especially in case of occlusal interference, is to
reduce the bulk of the cusp gradually and periodically and application
of topical fluoride such as Duraphat ® or Acidulated Phosphate
Fluoride (APF) gel to reduce sensitivity and stimulate reparative
dentine formation for pulp protection, or outright total reduction of the
cusp and calcium hydroxide pulpotomy. It may also become necessary
sometimes, to fully reduce the cusp, extirpate the pulp and carry out
root canal therapy . Orthodontic correction may become necessary
when there is tooth displacement or malalignment of affected or
opposing teeth.
This is a report of an unusual case of talon cusp which presented on
the facialspect of a mandibular central incisor.

DENS IN DENTE(Dens Invaginatus ,Dilated composite Odontome)

Is a developmental variation which is thought to arise as a

result of invagination in the surface of a tooth crown before
calcification has occurred .Causes of this condition include an
increased localized external pressure,focal growth
retardation,&focal growth stimulation in certain areas of tooth
bud.The maxillary permanent lateral incisor are most frequently
involved.

Roentgenographic Examination

It is recognized as a Pear shaped invagination of enamel &

dentin with a narrow constriction at the opening on the surface
of the tooth & closely approximating the pulp in its depth. Food
debris may be packed in this area with resultant caries &
 infection of pulp,occasionally even before the tooth has
completely erupted.
To prevent caries ,pulp infection,&premature loss of the
toothjthe condition must be recognized early &the tooth
prophylactically restored.

TAURODONTISM

The term was originated by Sir Artur keith in 1913 to describe a

peculiar dental anomaly in which the body of the tooth is
enlarged at the expense of the roots.The term means “BULL
LIKE TEETH”

Shaw classified taurodont into

1) Hypotaurodont
2) Mesotaurodont
3) Hypertaurodont

Possible causes enumerated by Mangion

1) Specialised or retrograde character
2) A primitive paterrn
3) A mendellian recessive trait
4) An Atavistic feature
5) A Mutation resulting form Odontoblastic deficiency

Taurodont is caused by the failure of Hertwig’s epithelial sheath to

invaginate at the proper horizontal level. It is observed in klinefelter
syndrome (extra X chromosome in males)

C/F

May affect Deciduous or Permanent teeth

Teeth are invariably Molars
Condition may be unilateral or bilateral
R/F

Frequently tend to be Rectangle in shape rather taper towards

roots.the pulp chamber is extremely large with a much greater
apico-occlusal height than normal.The roots are extremely short.The
bifurcation may be only a few mm above the apices of the roots.

TREATMENT

No special treatment.
 SUPERNUMERARY ROOTS

The developmental condition is not uncommon & may involve any

tooth. Teeth that are normally single rooted ,particularly the
mandibular bicuspids & cuspids often have two roots.Both maxillary
&mandibular molars particularly third molars , may exhibit one or
more supernumerary roots.
The significance in Exodontia is one of these roots may be broken
off during Extraction & if unrecognized & left in the Alveolus may be
a source of infection.

DEVELOPMENTAL DISTURBANCES IN NUMBER OF TEETH

ANODONTIA

True anodontia or congenital absence of teeth are of two types

1)Total
2)Partial

TOTAL ANODONTIA

In which all teeth are missing,may involve both the deciduous and permanent
dentition.Rare condition associated with Hereditary Ectodermal Dysplasia.

TRUE PARTIAL ANODONTIA

Involves one or more teeth & is a common condition.Although any tooth may be
missing ,there is a tendency for certain teeth to be missing more frequently than
others.There is an increasing tendency for 3rd molars ,maxillary lateral incisors,
maxillary or mandibular 2nd premolars are commonly missing often bilaterally.In
severe partial anodontia ,the bilateral absence of corresponding teeth may be
striking.Congenital absence of deciduous teeth are uncommon but may involve
maxillary lateral incisor.Hereditary Ectodermal Dysplasia may be associated with
partial Anodontia the teeth being misshapen and cone shaped.Tooth buds are
extremely sensitive to radiation and may be destroyed completelyby relatively small
doses.
 Supernumerary Teeth

S upernumerary teeth may be encountered by the general dental practitioner as a

chance finding on a radiograph or as the cause of an impacted central incisor. They may
also be found intraorally following spontaneous eruption. The most common
supernumerary tooth which appears in the maxillary midline is called a mesiodens.
Treatment depends on the type and position of the supernumerary tooth and on its effect
on adjacent teeth.

Definition

A supernumerary tooth is one that is additional to the normal series and can be found in
almost any region of the dental arch.

Etiology

The etiology of supernumerary teeth is not completely understood. Various theories exist
for the different types of supernumerary. One theory suggests that the supernumerary
tooth is created as a result of a dichotomy of the tooth bud.1 Another theory, well
supported in the literature, is the hyperactivity theory, which suggests that
supernumeraries are formed as a result of local, independent, conditioned hyperactivity of
the dental lamina.1,2 Heredity may also play a role in the occurrence of this anomaly, as
supernumeraries are more common in the relatives of affected children than in the
general population. However, the anomaly does not follow a simple Mendelian pattern.

Prevalence

In a survey of 2,000 schoolchildren, Brook found that supernumerary teeth were present
in 0.8% of primary dentitions and in 2.1% of permanent dentitions.3

Occurrence may be single or multiple, unilateral or bilateral, erupted or impacted, and in

one or both jaws. Multiple supernumerary teeth are rare in individuals with no other
associated diseases or syndromes.The conditions commonly associated with an increased
prevalence of supernumerary teeth include cleft lip and palate, cleidocranial dysplasia
and Gardner syndrome. Supernumerary teeth associated with cleft lip and palate result
from fragmentation of the dental lamina during cleft formation. The frequency of
supernumerary permanent teeth in the cleft area in children with unilateral cleft lip or
palate or both was found to be 22.2%.5 The frequency of supernumeraries in patients with
cleidocranial dysplasia ranged from 22% in the maxillary incisor region to 5% in the
molar region.6 While there is no significant sex distribution in primary supernumerary
teeth, males are affected approximately twice as frequently as females in the permanent
dentition.7

Classification

Supernumerary teeth are classified according to morphology and location In the primary
dentition, morphology is usually normal or conical. There is a greater variety of forms
presenting in the permanent dentition. Four different morphological types of
supernumerary teeth have been described:8,9

• conical

• tuberculate

• supplemental

• odontome.

Conical

This small peg-shaped conical tooth is the supernumerary most commonly found in the
permanent dentition. It develops with root formation ahead of or at an equivalent stage to
that of permanent incisors and usually presents as a mesiodens. It may occasionally be
found high and inverted into the palate or in a horizontal position. In most cases,
however, the long axis of the tooth is normally inclined. The conical supernumerary can
result in rotation or displacement of the permanent incisor, but rarely delays eruption.

Tuberculate

The tuberculate type of supernumerary possesses more than one cusp or tubercle. It is
frequently described as barrel-shaped and may be invaginated. Root formation is delayed
compared to that of the permanent incisors. Tuberculate supernumeraries are often paired
and are commonly located on the palatal aspect of the central incisors. They rarely erupt
and are frequently associated with delayed eruption of the incisors .

Supplemental

The supplemental supernumerary refers to a duplication of teeth in the normal series and
is found at the end of a tooth series The most common supplemental tooth is the
permanent maxillary lateral incisor, but supplemental premolars and molars also occur.
The majority of supernumeraries found in the primary dentition are of the supplemental
type and seldom remain impacted.

Odontoma

Howard lists odontoma as the fourth category of supernumerary tooth. However, this
category is not universally accepted. The term “odontoma” refers to any tumor of
odontogenic origin. Most authorities, however, accept the view that the odontoma
represents a hamartomatous malformation rather than a neoplasm. The lesion is
composed of more than one type of tissue and consequently has been called a composite
odontoma.Two separate types have been described: the diffuse mass of dental tissue
which is totally disorganized is known as a complex composite odontoma whereas the
malformation which bears some superficial anatomical similarity to a normal tooth is
referred to as a compound composite odontoma.

Problems Associated with Supernumerary Teeth

Failure of Eruption

The presence of a supernumerary tooth is the most common cause for the failure of
eruption of a maxillary central incisor. It may also cause retention of the primary incisor.
The problem is usually noticed with the eruption of the maxillary lateral incisors together
with the failure of eruption of one or both central incisors . Supernumerary teeth in other
locations may also cause failure of eruption of adjacent teeth.

Displacement
The presence of a supernumerary tooth may cause displacement of a permanent tooth.
The degree of displacement may vary from a mild rotation to complete displacement.
Displacement of the crowns of the incisor teeth is a common feature in the majority of
cases associated with delayed eruption.

Crowding

Erupted supplemental teeth most often cause crowding. A supplemental lateral incisor
may cause crowding in the upper anterior region. The problem may be resolved by
extracting the most displaced or deformed tooth.

Pathology

Dentigerous cyst formation is another problem that may be associated with

supernumerary teeth Primosch reported an enlarged follicular sac in 30% of cases, but
histological evidence of cyst formation was found in only 4 to 9% of cases.Resorption of
roots adjacent to a supernumerary may occur but it is extremely rare.

Alveolar Bone Grafting

Supernumerary teeth may compromise secondary alveolar bone grafting in patients with
cleft lip and palate. Erupted supernumeraries are usually removed and the socket site
allowed to heal prior to bone grafting. Supernumeraries should not be extracted without
consultation with the cleft team. Cooperation between the general dental practitioner and
the cleft team is essential. Unerupted supernumeraries in the cleft site are generally
removed at the time of bone grafting.

Implant Site Preparation

The presence of an unerupted supernumerary in a potential implant site may compromise

implant placement. The supernumerary may require removal prior to implant placement.
If removed at the time of implant placement, bone grafting may be required.

Asymptomatic

Occasionally, supernumerary teeth are not associated with any adverse effects and may
be detected as a chance finding during radiographic examination.

Radiographic Examination
A radiographic examination is indicated if abnormal clinical signs are found. An anterior
occlusal or periapical radiograph is useful to show the incisor region in detail. The bucco-
lingual position of unerupted supernumeraries can be determined using the parallax
radiographic principle:the horizontal tube shift method utilizes two periapical radiographs
taken with different horizontal tube positions, whereas an occlusal film together with a
panorex view are routinely used for vertical parallax. If the supernumerary moves in the
same direction as the tube shift it lies in a palatal position, but if it moves in the opposite
direction then it lies buccally. Intraoral views may give a misleading impression of the
depth of the tooth. A true lateral radiograph of the incisor region assists in locating the
supernumeraries that are lying deeply in the palate and enables the practitioner to decide
whether a buccal rather than a palatal approach should be used to remove them.

Management of Supernumeraries

Treatment depends on the type and position of the supernumerary tooth and on its effect
or potential effect on adjacent teeth. The management of a supernumerary tooth should
form part of a comprehensive treatment plan and should not be considered in isolation.

Indications for Supernumerary Removal

Removal of the supernumerary tooth is recommended where:

• 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. They may be
monitored without removal where:

• satisfactory eruption of related teeth has occurred;

• no active orthodontic treatment is envisaged;

• there is no associated pathology;

• removal would prejudice the vitality of the related teeth.

Recommendations Following Supernumerary Removal

Three factors influence the time it takes for an impacted tooth to erupt following removal
of the supernumerary:

• the type of supernumerary tooth;

• the distance the unerupted permanent tooth was displaced;

• the space available within the arch for the unerupted tooth.

Removal of a supernumerary tooth preventing permanent tooth eruption usually results in

the eruption of the tooth, provided adequate space is available in the arch to
accommodate it. Di Biase found 75% of incisors erupted spontaneously after removal of
the supernumerary.Eruption occurred on average within 18 months, provided that the
incisor was not too far displaced and that sufficient space was available.

Although the majority of authors recommend exposure of the unerupted tooth when the
supernumerary is removed, Di Biase advocates conservative management without
exposure.

A lower spontaneous eruption rate of 54% following supernumerary removal was

reported by Witsenburg and Boering, who recommend the routine bonding of an
attachment and gold chain for orthodontic traction at the time of surgery.19 However, the
time and expense involved in this technique may not be justified if the rates of
spontaneous incisor eruption are found to be in the region of 75 to 78%, as reported by
both Di Biase and Mitchell and Bennett.

If there is adequate space in the arch for the unerupted incisor following supernumerary
removal, space maintenance can be ensured by fitting a simple removable appliance. If
the space is inadequate, the adjacent teeth will need to be moved distally to create space
for incisor eruption. In that case, the primary canines may need to be extracted at the
same time as the supernumerary tooth. Where there is adequate space and the incisor
tooth fails to erupt, surgical exposure of the incisor and orthodontic traction is usually
required.

DEVELOPMENTAL DISTURABNCES IN STRUCTURE OF TEETH

Amelogenesis Imperfecta

Represents a group of hereditary defects of enamel unassociated with any congenital

defects of enamel unassociated with any generalized defects.It is basically an ectodermal
condition since the mesodermal components are normal.
Three basic types of amelogenesis Imperfecta are seen
1) Hypoplastic type
2) Hypoclcific type
3) Hypomaturative type

C/F

Hypoplastic –The enamel is not formed to full normal thickness

Hypocalcific-The enamel is so soft that it can be removed by a prophylaxis
instrument
Hypomaturative –The enamel can be pierced by by an explorer pointunder firm
pressure.

The crowns of teeth may or may not show discoloration.It varies from yellow to
dark.In others it may have a chalky texture or cheesy consistency or be relatively
hard.It may be chipped or show depressions in the base of which dentin may be
formed.contact points between the teeth are often open occlusal or incisal surfaces
may be abraded.

R/F

The overall shape may or maynot be normal,depending on the amount of occlusal

wear.The enamel may be totally absent or when present it is a thin layerchiefly over
the cusps & on the interproximal surfaces.

H/F

There is a disturbance in the differentiation or viability of the ameloblasts in the

hypoplastic type,and this is reflected in defects in matrix formation up to and
including total absence of matrix .In the hypocalcification types there are defects of
matrix structure and of mineral deposition.In the Hypomaturation types there are
alterations in enamel rod or rod sheath structures.

TREATMENT
There is no treatment except for cosmetic appearance.

Dentinogenesis Imperfecta (Hereditary Opalescent dentin)

Shields & his co-workers have given the following classification

Type-1 Dentinogenesis Imperfecta with odontogenesis Imperfecta

Tpye-2 Dentinogenesis Imperfecta without odontogenesis Imperfecta
Type-3 Dentinogenesis Imperfecta of brandywine type

C/F

The deciduous teeth are affected more severely than permanent teeth in type1
whereas in type2 the dentitions are equally affected .both dentitions are affected in
type3 .

The color of teeth may vary from gray to yellowish brown but exhibit a characteristic
unusual translucent or opalescent hue.The enamel may be lost early through
fracturing away ,especially on incisal & occlusal surfaces of teeth.the usual
scalopping of this junction is reportedly absent .With the early of enamel the dentin
undergoes rapid attrition and the occlusal surfaces are usually attrited.

R/F

Partial or total obliteration of the pulp chambers and root canals by continued
formation of dentin .The roots may be short or blunted ,the cementum ,periodontal
membrane ,supporting bone appear normal.The teeth of type3 are characterized as
shell teeth.Enamel is normal ,dentin is extremely thin & the pulp chambers are
extremely enormous . roots of the teeth are extremely short

H/F

It is purely a mesodermal disturbance.Enamel is essentially normal except for its

peculiar shade, the dentin is composed of irregular tubules,often with large areas of
uncalcified matrix.The tubules tend to be larger in diameter & hence less
numerous.The odontoblasts have limited ability to form well-organised dentinal
matrix,& they appear to degenerate easily,becoming entrapted in this matrix.

TREATMENT

Treatment is directed at prevention of enamel and dentin loss through attrition.Cast

metal crowns on the posterior teeth & jacket crowns on the anterior teeth.

DENTIN DYSPLASIA (rootless teeth)

 Is a rare disturbance of dentin formatin characterized by normal enamel but atypical
dentin formation with abnormal pulpal mormphology.The 1st concise description of
the disease was published in 1939 by Rushton .

SHIELDS & ASSOCIATES CLASSIFIED INTO

Type1- Dentin dysplasia

Type2 – Anomalous dysplasia of Dentin

Acc to Witkop

Type1- Radicular denitn dysplasia

Type2- Coronal dentin Dysplasia

ETIOLOGY

A Hereditary disease transmitted as an autosomal dominant characteristic.

CLINICAL FEATURES

Type1(radicular)-

Both dentitions are affected

Teeth appear normal in morphologic appearance &color
Amebr translucency may be present
Teeth exhibit normal eruption pattern
Teeth exhibit extreme mobility & are exfoliated prematurely

Type 2 (coronal)

Both dentitions are affected

Deciduous teeth exhibit yellow ,brown,or bluish-grey opalescent appearance
Permanent dentition is normal

R/F
 Type1

In both dentitions roots are short, blunt,conicalor similarly malformed

Decidous dentition pulp chambers are completely obliterated
Permanent dentition shows crescent shaped pulpal remnant.

Type2

In deciduous teeth pulp chambers are completely obliterated.

The permanent dentition pulp chamber is abnormally large described as a
Thistle tube appearance.

TREATMENT

No treatment ,prognosis depends on occurrence of periapical lesions & upon the

exfoliation of teeth due to inceased mobility.

REGIONAL ODONTODYSPLASIA(GHOST TEETH)

An unusual dental anomaly in which one or several teeth in a localized area are
affected in an unusual manner..Maxillary teeth involved more than mandibular.Maot
frequently involved being maxillary permanent incisor ,lateral incisor & cuspid.the
deciduous & permanent are involved.
C/F

The teeth affected by odontodysplasia exhibit either a delay or a total failure in

eruption. Their shape is markedly altered,being generally very irregular in appearance &
defective mineralization .

R/F

Marked reduction in radiodensity & teeth assume a ghost appearance.Both the

enamel & dentin appear very thin & the pulp chamber is exceedingly large.

TREATMENT

Because of poor cosmetic appearance extraction with restoration using a prosthetic

appliance.