**THE UNIVERSITY OF WESTERN AUSTRALIA** Dental Anomalies Part 1 DENT5312 Dr **Jilen Patel** DENT5312 Dr Jilen Patel **Lecture Outcomes** **(The University of Western Australia logo)** Students should be able to: - Understand the stages of tooth development and the associated anomalies that can occur at different stages - Explain the difference between anomalies and traits - Define anomalies of tooth size and shape - Explain the aetiology, prevalence, clinical characteristics, implications and potential management strategies for anomalies of tooth size and shape - Identify anomalies of tooth size and shape through visual and radiographic examinations Students should be able to: - Understand the stages of tooth development and the associated anomalies that can occur at different stages - Explain the difference between anomalies and traits - Define anomalies of tooth size and shape - Explain the aetiology, prevalence, clinical characteristics, implications and potential management strategies for anomalies of tooth size and shape - Identify anomalies of tooth size and shape through visual and radiographic examinations **The Stages of Tooth Development** **Top:** * **Title:** Stages of tooth development * **Header:** THE UNIVERSITY OF WESTERN AUSTRALIA **Workflow / Legend:** Initiation → Bud stage → Cap stage → Bell stage → Dentinogenesis **Labels (Top Row):** * **Initiation:** * Dental lamina * Jaw mesenchyme (underline text) * Nerve (underline text) * Dental mesenchyme * **Bud stage/Cap stage:** * (Visual diagram of bud structures) * **Bell stage:** * Odontoblasts * Inner dental epithelium * Outer dental epithelium * Dental papilla * **Dentinogenesis:** * Dentin * Dental follicle **Labels (Bottom Section):** * **Continued dentinogenesis/amelogenesis:** (Row below) * **Amelogenesis** (Right column) * **Eruption** (Left column) * **Mature** (Left column, far left) **Amelogenesis Labels (Right side):** * Ameloblasts * Enamel  #### Chronological Workflow Initiation → Bud stage → Cap stage → Bell stage → Dentinogenesis #### Anatomical Structures by Stage - **Initiation** - Dental lamina - Jaw mesenchyme - Nerve - Dental mesenchyme - **Bell Stage** - Odontoblasts - Inner dental epithelium - Outer dental epithelium - Dental papilla - **Dentinogenesis and Amelogenesis** - Dentin - Dental follicle - Ameloblasts - Enamel #### Final Developmental Phases - Continued dentinogenesis/amelogenesis - Eruption - Mature tooth Labelled diagram illustrating the 'Stages of tooth development' as a continuous biological process. The visual is divided into two main sections: an upper row showing early morphological stages (Initiation, Bud stage, Cap stage, Bell stage, Dentinogenesis) and a lower section showing later developmental phases (Amelogenesis, Continued dentinogenesis/amelogenesis, Eruption, Mature). A horizontal arrow at the bottom indicates the temporal progression from right to left for the final stages. Key anatomical labels include Dental lamina, Jaw mesenchyme, Nerve, Dental mesenchyme, Odontoblasts, Inner/Outer dental epithelium, Dental papilla, Dentin, Dental follicle, Ameloblasts, and Enamel. <table> <thead> <tr> <th>Stage</th> <th>Process</th> <th>Activity</th> <th>Associated anomalies</th> </tr> </thead> <tbody> <tr> <td>Bud</td> <td>Initiation</td> <td>Migration of neural crest cells into arches</td> <td>Tooth number<br/>(supernumerary teeth, hypodontia…)</td> </tr> <tr> <td>Cap</td> <td>Proliferation</td> <td>Condensation of ectoderm and formation of dental organ and dental papilla</td> <td>Odontogenic cysts</td> </tr> <tr> <td rowspan="2">Bell</td> <td>Morphodifferentiation</td> <td>Proliferation of inner enamel epithelium to form the shape of the crown</td> <td>Tooth size and shape<br/>(macrodontia, microdontia…)</td> </tr> <tr> <td>Histodifferentiation</td> <td>Differentiation of precursor cells ameloblasts and odontoblasts</td> <td>Regional odontodysplasia</td> </tr> <tr> <td rowspan="4">Crown</td> <td>Apposition</td> <td>Reciprocal induction and laying down of mantle dentine and first enamel</td> <td>Enamel hypoplasia</td> </tr> <tr> <td>Calcification</td> <td></td> <td>Amelogenesis Imperfecta<br/>Dentinogenesis Imperfecta</td> </tr> <tr> <td>Maturation</td> <td>Enamel crystal formation</td> <td>Enamel hypomineralisation</td> </tr> <tr> <td>Eruption</td> <td>Emergence of tooth and continued development of roots</td> <td>Impacted teeth</td> </tr> </tbody> </table>  | Stage | Process | Activity | Associated Anomalies | | :--- | :--- | :--- | :--- | | **Bud** | Initiation | Migration of neural crest cells into arches | Tooth number (supernumerary teeth, hypodontia…) | | **Cap** | Proliferation | Condensation of ectoderm and formation of dental organ and dental papilla | Odontogenic cysts | | **Bell** | Morphodifferentiation | Proliferation of inner enamel epithelium to form the shape of the crown | Tooth size and shape (macrodontia, microdontia…) | | **Bell** | Histodifferentiation | Differentiation of precursor cells ameloblasts and odontoblasts | Regional odontodysplasia | | **Crown** | Apposition | Reciprocal induction and laying down of mantle dentine and first enamel | Enamel hypoplasia | | **Crown** | Calcification | | Amelogenesis Imperfecta, Dentinogenesis Imperfecta | | **Crown** | Maturation | Enamel crystal formation | Enamel hypomineralisation | | **Crown** | Eruption | Emergence of tooth and continued development of roots | Impacted teeth | A structured table titled 'Stages of tooth development' with four columns: Stage, Process, Activity, and Associated anomalies. The rows detail the developmental stages from Bud to Crown, listing processes like Initiation, Proliferation, Morphodifferentiation, Histodifferentiation, Apposition, Calcification, Maturation, and Eruption. Each row describes specific activities (e.g., migration of neural crest cells, condensation of ectoderm) and associated anomalies (e.g., supernumerary teeth, odontogenic cysts, macrodontia). The table is organized with clear headers and alternating row colors for readability. **Stages of tooth development** **Anomaly or trait?** **Anomaly**: when a variant occurs *rarely* in a given population eg anomalies in tooth number, size, shape, structure **Trait**: when a variant is exhibited by a significant number of people in a population such that it is considered a trait for the dentition of that population eg incisor shovelling, cusp of Carabelli, protostyloid    #### Definitions of Variation - **Anomaly** - Occurs when a variant occurs *rarely* in a given population. - Examples: Anomalies in tooth number, size, shape, and structure. - **Trait** - Occurs when a variant is exhibited by a significant number of people in a population such that it is considered a trait for the dentition of that population. - Examples: Incisor shovelling, cusp of Carabelli, and protostyloid. Clinical photo showing the maxillary anterior teeth with a prominent midline diastema (gap) between the central incisors. Clinical photo of the upper dental arch showing the cusps of Carabelli on the palatal surface of the upper molars, indicated by blue arrows. Clinical photo of the lower dental arch demonstrating protostyloid features (small pointed cusp-like structures) on the lateral incisors, indicated by orange arrows. THE UNIVERSITY OF WESTERN AUSTRALIA ANOMALIES OF TOOTH NUMBER Anomalies of tooth number. # Hyperdonta ## Definition Any tooth or structure formed from a tooth germ **that is in excess** of the **usual number** for any given region of the dental arch ## Terminology * Supernumerary * Polyphodontism (Gibbs, 1913) * Third dentition, superdentition (Gissen, 1935) * Duplicate teeth (Werther & Rothenberg, 1939) * Supplemental (Glassington, 1893) * Aberrant (Nodine, 1943) * Conoidal (Fashlich, 1943)  #### Definition Any tooth or structure formed from a tooth germ that is in excess of the usual number for any given region of the dental arch. #### Terminology - Supernumerary - Polyphodontism (Gibbs, 1913) - Third dentition, superdentition (Gissen, 1935) - Duplicate teeth (Werther & Rothenberg, 1939) - Supplemental (Glassington, 1893) - Aberrant (Nodine, 1943) - Conoidal (Fashlich, 1943) A text-based table listing terminology associated with Hyperdontia. The table contains two columns: the left column lists terms (Supernumerary, Polyphodontism, Third dentition/superdentition, Duplicate teeth, Supplemental, Aberrant, Conoidal) and the right column lists corresponding historical citations (Gibbs, 1913; Gissen, 1935; Werther & Rothenberg, 1939; Glassington, 1893; Nodine, 1943; Fashlich, 1943). ## Etiology * Remains unclear * Various theories have been postulated: * Result of hyperactivity of the dental lamina (Black, 1909) * Tooth germ dichotomy (split of tooth germ): an imbalance between molecules can cause the tooth germ to divide into two parts, of equal or different size (Gardiner, 1961) * Genetic predisposition * Environmental factors * Multifactorial, a combination of environmental and genetic factors (Brook, 1984) THE UNIVERSITY OF WESTERN AUSTRALIA The etiology remains unclear, but various theories have been postulated: - Result of hyperactivity of the dental lamina (Black, 1909) - Tooth germ dichotomy (split of tooth germ): an imbalance between molecules can cause the tooth germ to divide into two parts, of equal or different size (Gardiner, 1961) - Genetic predisposition - Environmental factors - Multifactorial: a combination of environmental and genetic factors (Brook, 1984) # **Hyperdontia** ## **The University of Western Australia** ## **Prevalence** * **Permanent dentition > primary dentition** (Clayton, 1956) * **Primary dentition:** 0.2-0.8% * **Permanent dentition:** 0.5-3.5% (Garvey et al. 1999; Sasaki et al. 2007; Ferrés-Padró et al. 2009; Kaya et al. 2011) * **Male > Females** * **Male : Female = 1.18 : 1.0** (Brook, 1984; Fernandez Montenegro et al. 2006; Liu et al. 2007; Ferres-Padro et al. 2009) * **Maxillary incisor region > mandibular premolar > maxillary molar region** (Grahnen and Lindalh, 1961; King et al. 1993) #### Prevalence Rates - Permanent dentition > primary dentition (Clayton, 1956) - Primary dentition: 0.2-0.8% - Permanent dentition: 0.5-3.5% (Garvey et al. 1999; Sasaki et al. 2007; Ferrés-Padró et al. 2009; Kaya et al. 2011) #### Demographic and Regional Distribution - Male > Females - Male : Female ratio = 1.18 : 1.0 (Brook, 1984; Fernandez Montenegro et al. 2006; Liu et al. 2007; Ferres-Padro et al. 2009) - Maxillary incisor region > mandibular premolar > maxillary molar region (Grahnen and Lindalh, 1961; King et al. 1993) **Supernumerary** **Supernumerary teeth** * Definition: any tooth or odontogenic structure that is formed from a tooth germ in excess of the usual number for any given region of the dental arch (Shafer, 1983) * The term "hyperdontia" is preferred by some authors to describe the dentition which contains one or more supernumerary teeth #### Supernumerary Teeth Definition Any tooth or odontogenic structure that is formed from a tooth germ in excess of the usual number for any given region of the dental arch (Shafer, 1983). #### Preferred Terminology The term "hyperdontia" is preferred by some authors to describe the dentition which contains one or more supernumerary teeth. **Classification of Supernumerary** | Category | Classification Details | Author(s) | |------------------------|----------------------------------------------------------------------------------------|----------------------------------------| | Location | • Mesiodens<br>• Paramolar<br>• Distomolar<br>• Parapremolar | Bolk, 1914; 1917 | | Morphology | • Conical<br>• Tuberculate<br>• Supplemental (or eumorphic)<br>• Odontome | Di Biase, 1969; Foster and Taylor, 1969 | | | - Complex<br> - Compound | | | Orientation | • Vertical or normal<br>• Inverted<br>• Horizontal | | | Position | • Buccal<br>• Palatal<br>• Transverse | | *Primosch, 1981; Garvey, 1989; Beach and Hensman, 2002*  #### Categorization of Supernumerary Teeth - **Location** (Bolk, 1914; 1917) - Mesiodens - Paramolar - Distomolar - Parapremolar - **Morphology** (Di Biase, 1969; Foster and Taylor, 1969) - Conical - Tuberculate - Supplemental (or eumorphic) - Odontome (Complex or Compound) - **Orientation** - Vertical or normal - Inverted - Horizontal - **Position** - Buccal - Palatal - Transverse *(Primosch, 1981; Garvey, 1989; Beach and Hensman, 2002)* A hierarchical classification diagram titled 'Classification of Supernumerary' (rotated vertically on the left). The central node 'Supernumerary' branches into four categories: Location, Morphology, Orientation, and Position. Each category lists specific sub-types (e.g., Mesiodens for Location; Conical, Tuberculate, Supplemental, Odontome for Morphology) and cites associated authors (e.g., Bolk, Di Biase, Foster and Taylor). Mesiodens - Mesiodens: the most “mesially invested tooth”…”the lost incisor” (Bolk,1917) - Most common type of supernumerary Supernumerary tooth in the primary dentition   #### Mesiodens - Defined as the most “mesially invested tooth” or “the lost incisor” (Bolk, 1917). - This is the most common type of supernumerary tooth. #### Primary Dentition Supernumerary tooth in the primary dentition. Clinical photo showing the anterior view of a patient's mouth. The image displays a supernumerary tooth (mesiodens) located in the primary dentition, positioned between the central incisors. The surrounding teeth and gums are also visible. Radiograph (X-ray) of the maxillary anterior region in the primary dentition. It shows the presence of a mesiodens, which appears as an extra tooth structure located between the roots or crowns of the central incisors. The radiograph provides a clear view of the bone structure and root development of the teeth involved. # Supernumerary Supernumerary tooth in the primary dentition  Supernumerary tooth in the primary dentition. Clinical photograph showing two views of supernumerary teeth in the primary dentition. The left image shows an intraoral view of the upper arch with a red circle highlighting a supernumerary tooth between the central incisors. The right image shows another view of the upper and lower arches with a red circle highlighting a supernumerary tooth in the upper anterior region. Supernumerary The University of Western Australia Supernumerary tooth Supplemental lateral incisor   Supernumerary tooth: Supplemental lateral incisor. Clinical photograph showing a frontal view of the maxillary and mandibular anterior teeth with multiple supernumerary teeth. The image is labeled 'Supernumerary tooth' below. Intraoral clinical photograph of the maxillary arch with a supplemental lateral incisor circled in red between the central and canine regions. The image is labeled 'Supplemental lateral incisor' below. **Hyperdontia** Conditions and syndromes associated with hyperdontia: − Cleft lip and palate − Cleidocranial Dysplasia − Gardner Syndrome (Familial Adenomatous Polypsis) − Nance-Horan Syndrome − Tricho-Rhino-Phalangeal Syndromes − Fabry Anderson’s syndrome − Chondroectodermal dysplasia (Ellis–Van Creveld syndrome) − Ehlers–Danlos syndrome − Incontinentia pigmenti The University of Western Australia Conditions and syndromes associated with hyperdontia: - Cleft lip and palate - Cleidocranial Dysplasia - Gardner Syndrome (Familial Adenomatous Polypsis) - Nance-Horan Syndrome - Tricho-Rhino-Phalangeal Syndromes - Fabry Anderson’s syndrome - Chondroectodermal dysplasia (Ellis–Van Creveld syndrome) - Ehlers–Danlos syndrome - Incontinentia pigmenti   Panoramic dental radiograph (OPG) of a pediatric patient showing mixed dentition with primary and permanent teeth. Notable findings include multiple radiopaque foreign bodies or restorative materials in the lower anterior mandible region. Clinical photograph showing an anterior view and a lateral view of a young child's upper torso and neck. The images appear to document physical characteristics such as short stature or body habitus relevant to the case study. **Hyperdontia** **Odontomes** * Odontomes occur because of disordered differentiation and often present because of failure of eruption of a permanent tooth **Types:** * **Complex:** haphazard arrangement of enamel, dentine and cementum * **Compound:** consists of discrete tooth-like structures **Management** * Surgical enucleation * May require surgical exposure and orthodontic alignment Odontomes occur because of disordered differentiation and often present because of failure of eruption of a permanent tooth. #### Types - **Complex:** Haphazard arrangement of enamel, dentine and cementum. - **Compound:** Consists of discrete tooth-like structures. #### Management - Surgical enucleation. - May require surgical exposure and orthodontic alignment. # Hyperdontia **THE UNIVERSITY OF WESTERN AUSTRALIA** ## Clinical Signs * Spacing e.g midline diastema * **Failure of adjacent teeth to erupt** * Especially with failure of upper incisors to erupt * Also may cause retention of primary incisors * **Displacement** * May cause displacement of permanent tooth from mild rotation to complete displacement * Eruption into mouth * Local crowding or irregularity    - Spacing (e.g., midline diastema) - **Failure of adjacent teeth to erupt** - Especially with failure of upper incisors to erupt - May cause retention of primary incisors - **Displacement** - May cause displacement of permanent tooth ranging from mild rotation to complete displacement - Eruption into mouth - Local crowding or irregularity Clinical photo showing a maxillary occlusal view of the upper dental arch demonstrating hyperdontia. The image displays multiple supernumerary teeth in the anterior region causing spacing and irregular alignment, consistent with the 'Spacing' clinical sign. Clinical photo showing a frontal view of the upper anterior dentition. It demonstrates displacement and crowding of permanent incisors due to the presence of extra teeth (hyperdontia), illustrating the 'Displacement' and 'Local crowding or irregularity' signs. Radiograph (X-ray) of the lower jaw showing multiple impacted supernumerary teeth clustered together. This visual evidence supports the diagnosis of hyperdontia and illustrates potential obstruction to normal eruption pathways. # Hyperdontia THE UNIVERSITY OF WESTERN AUSTRALIA ## Complications * Failure of eruption of permanent teeth * Displacement or rotation or crowding * Ectopic eruption of permanent teeth * Abnormal diastema or premature space closure * Dilaceration, delayed or abnormal root development of permanent teeth * Pathology (dentigerous cyst formation) * Rare complication - root resorption/loss of viability - nasal eruption - Failure of eruption of permanent teeth - Displacement, rotation, or crowding - Ectopic eruption of permanent teeth - Abnormal diastema or premature space closure - Dilaceration, delayed or abnormal root development of permanent teeth - Pathology (dentigerous cyst formation) - Rare complications: - Root resorption/loss of viability - Nasal eruption The Oxford Medical Dictionary on DVD **Endoscopic removal of supernumerary tooth from the nasal cavity of a child: a case report** Clementini et al 201    #### Case Reports Endoscopic removal of supernumerary tooth from the nasal cavity of a child: a case report (Clementini et al. 201). Radiograph (X-ray) of a child's dentition showing the maxillary and mandibular arches. A yellow arrow points to a radiopaque structure in the midline of the anterior maxilla, consistent with a supernumerary tooth located within the nasal cavity. Endoscopic view inside the nasal cavity showing the surgical site. A white, round object (the supernumerary tooth) is visible surrounded by reddish mucosal tissue. Clinical photo showing the external view of a patient's nose during surgery. Surgical instruments are being used at one nostril, which appears open, while the other nostril remains closed. Hyperdontia Diagnosis * Clinical - failed or eruption disturbance of permanent tooth * Routine radiographic finding * As part of a syndrome e.g. cleidocranial dysplasia Treatment * Depends on type and position of supernumerary - Long term monitoring - Extraction - Surgical removal #### Diagnosis - Clinical: Failed or eruption disturbance of permanent tooth - Routine radiographic finding - As part of a syndrome (e.g., cleidocranial dysplasia) #### Treatment Treatment depends on the type and position of the supernumerary tooth: - Long term monitoring - Extraction - Surgical removal The University of Western Australia Dental photographs front and side view showing teeth and inflammation with plaque/calculus build up  Dental photographs (front and side view) showing teeth and inflammation with plaque/calculus build up. Composite clinical dental figure containing three distinct views: (Left) Frontal intraoral view showing significant gingival inflammation and plaque accumulation on anterior teeth; (Top Right) Occlusal view of the maxillary arch demonstrating calculus deposits and carious lesions on molars; (Bottom Right) Occlusal view of the mandibular arch. The images collectively demonstrate periodontal pathology. # Hypodontia **Definition** * Developmental absence of one or more teeth excluding third molars (Gooman, 1994) **Terminology** * Hypodontia: less than six missing teeth * Oligodontia: six or more missing teeth * Anodontia: no teeth present * Agenesis of teeth associated with syndromes or systemic abnormalities (Gorlin et al. 1978) #### Definition Developmental absence of one or more teeth excluding third molars (Gooman, 1994). #### Terminology - **Hypodontia:** less than six missing teeth - **Oligodontia:** six or more missing teeth - **Anodontia:** no teeth present - **Agenesis:** of teeth associated with syndromes or systemic abnormalities (Gorlin et al. 1978) # Hypodontia ## Classification - **Mild** 1-2 missing teeth - **Moderate** 3-5 missing teeth - **Severe** 6 or more missing teeth (oligodontia) (Goodman, 1994, Dhanrajani, 2002; Jones, 2009)  #### Severity Classification - **Mild:** 1-2 missing teeth - **Moderate:** 3-5 missing teeth - **Severe:** 6 or more missing teeth (oligodontia) (Goodman, 1994, Dhanrajani, 2002; Jones, 2009) A classification table for Hypodontia severity levels. It lists three categories: 'Mild' corresponding to '1-2 missing teeth', 'Moderate' corresponding to '3-5 missing teeth', and 'Severe' corresponding to '6 or more missing teeth (oligodontia)'. The table includes citation references below. **Hypodontia** **Prevalence** • Most common congenital malformation **Primary dentition** – Uncommon – 0.1-4.1% (Saito, 1959, Brook, 1974, Tongkoom, 1994) – F = M – Often associated with hypodontia in permanent dentition **Permanent dentition** – 4-6% Caucasian (Niswander and Sujaku, 1983; Brook, 1974; Tsai, 1996) – F > M; F: M = 3:2 (Nunn, 2003; Larmour, 2005) – Variation between continents, racial groups and gender (Polder, 2004) (Brook, 1974; Tongkoom 1994; Tsai, 1996; McKeown et al. 2002: Khalaf et al. 2014) #### General Prevalence Hypodontia is considered the most common congenital malformation. #### Primary Dentition - Uncommon: 0.1-4.1% (Saito, 1959, Brook, 1974, Tongkoom, 1994) - Gender distribution: Female = Male - Often associated with hypodontia in the permanent dentition #### Permanent Dentition - Prevalence: 4-6% in Caucasians (Niswander and Sujaku, 1983; Brook, 1974; Tsai, 1996) - Gender distribution: Female > Male (Ratio 3:2) (Nunn, 2003; Larmour, 2005) - Variation exists between continents, racial groups, and gender (Polder, 2004) (Brook, 1974; Tongkoom 1994; Tsai, 1996; McKeown et al. 2002: Khalaf et al. 2014) Hypodontia The UNIVERSITY OF WESTERN AUSTRALIA **Prevalence by the jaws and type of missing teeth** * **Higher percentage of missing teeth** in the maxilla (53.2%) than in the mandible (46.8%) * The teeth most commonly missing are the last teeth in each series (namely the upper lateral incisors, the second premolars and third molars) * Mandibular second premolars 29.9% * Maxillary lateral incisors 24.3% * Maxillary second premolars 13.7% * Mandibular central incisors 6.1% * Mandibular lateral incisors 4.3% * Maxillary first premolars 3.6% * Mandibular first premolars 2.7% * Maxillary canine 2.5% * Mandibular second molars 1.8% * Maxillary second molars 1.5% * Mandibular canines 1.3% * Maxillary first molars 1.1% * Mandibular first molars 1% Khalaf et al. 2014 * Maxillary central incisors 1% #### Distribution by Jaw and Tooth Type - **Higher percentage of missing teeth:** Maxilla (53.2%) vs. Mandible (46.8%) - **Commonly missing teeth:** Usually the last teeth in each series (upper lateral incisors, second premolars, and third molars) #### Prevalence by Specific Tooth - Mandibular second premolars: 29.9% - Maxillary lateral incisors: 24.3% - Maxillary second premolars: 13.7% - Mandibular central incisors: 6.1% - Mandibular lateral incisors: 4.3% - Maxillary first premolars: 3.6% - Mandibular first premolars: 2.7% - Maxillary canine: 2.5% - Mandibular second molars: 1.8% - Maxillary second molars: 1.5% - Mandibular canines: 1.3% - Maxillary first molars: 1.1% - Mandibular first molars: 1% (Khalaf et al. 2014) - Maxillary central incisors: 1% **Hypodontia** Prevalence by the jaws and type of missing teeth * Higher percentage of missing teeth in the maxilla (53.2%) than in the mandible (46.8%) * The teeth most commonly missing are the last teeth in each series (namely the upper lateral incisors, the second premolars and third molars) <table> <tr> <th colspan="3">Table 5. Sequence of most to least affected teeth, divided in three main groups</th> </tr> <tr> <td></td> <td>Prevalence (%)</td> <td>Sequence</td> </tr> <tr> <td>Common</td> <td>1.5–3.1</td> <td>P2ₑ > I2ₙ > P2ₛ</td> </tr> <tr> <td>Less common</td> <td>0.1–0.3</td> <td>I1ₙ > I2ₙ & P1ₑ > Cr & M2ₙ</td> </tr> <tr> <td>Rare</td> <td>0.01–0.04</td> <td>M2ₑ & M1ₑ > Cr > M1ₙ & I1ₑ</td> </tr> <tr> <td colspan="3"><i>s, maxilla; i, mandible.</i></td> </tr> </table> Polder et al 2004  #### Prevalence by Jaw and Tooth Type - Higher percentage of missing teeth in the maxilla (53.2%) than in the mandible (46.8%). - The teeth most commonly missing are the last teeth in each series (upper lateral incisors, second premolars, and third molars). #### Frequency Sequence (Polder et al 2004) **Common (1.5–3.1%)** - Mandibular second premolar > Maxillary lateral incisor > Maxillary second premolar **Less Common (0.1–0.3%)** - Mandibular central incisor > Mandibular lateral incisor & Maxillary first premolar > Mandibular canine & Maxillary second molar **Rare (0.01–0.04%)** - Mandibular second molar & Maxillary first molar > Maxillary canine > Mandibular first molar & Maxillary central incisor *(Note: s = maxilla; i = mandible)* Table 5 titled 'Sequence of most to least affected teeth, divided in three main groups'. Columns are 'Prevalence (%)' and 'Sequence'. Rows categorize missing teeth into 'Common', 'Less common', and 'Rare' with specific prevalence ranges (1.5–3.1%, 0.1–0.3%, 0.01–0.04%) and corresponding dental notation sequences (e.g., P2ᵢ > I2ₛ > P2ₛ). A legend below specifies 's, maxilla; i, mandible.'.  Panoramic dental radiograph (OPG) of the maxilla and mandible. The image shows mixed dentition with primary teeth in eruption alongside developing permanent successors. Notable features include unerupted third molars (wisdom teeth) visible at both posterior ends of the jaws. The image includes orientation markers 'R' (right) and 'L' (left). This is a diagnostic clinical photo used for evaluating dental development and alignment.  Panoramic dental radiograph (orthopantomogram) showing the maxilla and mandible with developing permanent dentition. Visible features include unerupted tooth buds in both arches, including what appear to be third molars bilaterally, and varying stages of root formation for posterior teeth. The image includes a header with 'THE UNIVERSITY OF WESTERN AUSTRALIA' logo and text at the top right.   Dental radiograph (X-ray) showing a maxillary or mandibular arch of teeth. The image displays the crowns and roots of multiple teeth with visible enamel, dentin, and pulp chambers. Some teeth appear to have restorations or caries, indicated by darker areas within the tooth structure. The surrounding bone structure is also visible, providing context for the dental anatomy. Another dental radiograph (X-ray), likely of the same arch as the first image but from a different angle or exposure. This image shows similar features: teeth with varying degrees of translucency, possible restorations, and root structures. The overall appearance suggests it may be part of a comparative study or diagnostic evaluation of dental health.  Clinical radiograph (panoramic X-ray) of the mandible and maxilla showing multiple teeth with varying stages of development and alignment. Visible are several unerupted or partially erupted teeth, some with abnormal positioning. The image includes anatomical structures such as the mandibular canal, temporomandibular joints, and maxillary sinuses. No text annotations or labels are present on the radiograph itself. # Aetiology * Several theories – both genetic and environmental factors * Hypodontia commonly associated with small teeth (Graber, 1978) * It can be an isolated non-syndromic feature or a part of a complex syndrome * Genetic basis in the majority of cases – Homeobox genes involved * MSX1 * PAX9 * AXIN2 (Cobourne, 2007) * Environmental factors * Intra-uterine effects of drugs e.g. Thalidomide * Early radiotherapy & chemotherapy * Trauma e.g. alveolar fracture or jaw fracture, jaw surgery, iatrogenic damage to the permanent tooth germ from traumatic extraction of overlying primary tooth * Infection e.g Rubella (Winter, 1996; Brook et al. 2009) #### Theoretical Basis - Involves both genetic and environmental factors. - Commonly associated with small teeth (Graber, 1978). - Can be an isolated non-syndromic feature or part of a complex syndrome. #### Genetic Factors Genetic basis is present in the majority of cases, involving Homeobox genes: - MSX1 - PAX9 - AXIN2 (Cobourne, 2007) #### Environmental Factors - Intra-uterine effects of drugs (e.g., Thalidomide) - Early radiotherapy and chemotherapy - Trauma: Alveolar or jaw fractures, jaw surgery, or iatrogenic damage to permanent tooth germs during traumatic extraction of primary teeth - Infection (e.g., Rubella) (Winter, 1996; Brook et al. 2009) Hypodontia THE UNIVERSITY OF WESTERN AUSTRALIA Hypodontia is a major clinical feature of over 50 syndromes including: * Hypohidrotic Ectodermal Dysplasia (HED) * Hypohidrotic Ectodermal Dysplasia with Immune Deficiency (HED-ID) * Dento-alveolar clefting * Trisomy 21 (Down syndrome * Oral–Facial–Digital Syndrome Type I (OFDI) * Williams (Beuren) Syndrome (WBS) * Solitary Median Maxillary Central Incisor (SMMCI) * Axenfeld–Rieger Syndrome (Rieger Syndrome) * Oligodontia and Colorectal Cancer Syndrome * Odonto-Onycho-Dermal Dysplasia (OODD) * Incontinentia Pigmenti * Wolf–Hirschhorn Syndrome * Witkop Syndrome Hypodontia is a major clinical feature of over 50 syndromes, including: - Hypohidrotic Ectodermal Dysplasia (HED) - Hypohidrotic Ectodermal Dysplasia with Immune Deficiency (HED-ID) - Dento-alveolar clefting - Trisomy 21 (Down syndrome) - Oral–Facial–Digital Syndrome Type I (OFDI) - Williams (Beuren) Syndrome (WBS) - Solitary Median Maxillary Central Incisor (SMMCI) - Axenfeld–Rieger Syndrome (Rieger Syndrome) - Oligodontia and Colorectal Cancer Syndrome - Odonto-Onycho-Dermal Dysplasia (OODD) - Incontinentia Pigmenti - Wolf–Hirschhorn Syndrome - Witkop Syndrome Hypodontia Hypohidrotic Ectodermal Dysplasia   #### Hypohidrotic Ectodermal Dysplasia Clinical photo labeled (A) showing an intraoral view of a patient with hypodontia associated with Hypohidrotic Ectodermal Dysplasia. The image reveals multiple missing teeth in both the upper and lower anterior regions, conical-shaped remaining teeth, and inflamed gingival tissue. Panoramic radiograph labeled (B) demonstrating severe hypodontia consistent with Hypohidrotic Ectodermal Dysplasia. The X-ray shows significant agenesis of permanent teeth in both arches, particularly in the anterior region, along with retained primary teeth and developing permanent successors. # Hypodontia **THE UNIVERSITY OF WESTERN AUSTRALIA** Hypodontia associated with syndromes * Ectrodactyly, Ectodermal Dysplasia and Clefing (EEC) * Ellis-van Creveld Syndrome (EVC) * Weyers Acrofacial Dysostosis Syndrome (Curry-Hall Syndrome) * Van der Woude Syndrome (VWS) * Angel-Shaped Phalango Epiphyseal Dysplasia (ASPED) * Lacrimoauriculodentodigital Syndrome (LADD) * Kallmann Syndrome (KS; KAL2) * Bloom Syndrome (BS, BLS) * Rothmund–Thomson Syndrome * Diastrophic Dysplasia Syndrome * Johanson–Blizzard Syndrome * Kabuki Syndrome #### Additional Syndromic Associations - Ectrodactyly, Ectodermal Dysplasia and Clefting (EEC) - Ellis-van Creveld Syndrome (EVC) - Weyers Acrofacial Dysostosis Syndrome (Curry-Hall Syndrome) - Van der Woude Syndrome (VWS) - Angel-Shaped Phalango Epiphyseal Dysplasia (ASPED) - Lacrimoauriculodentodigital Syndrome (LADD) - Kallmann Syndrome (KS; KAL2) - Bloom Syndrome (BS, BLS) - Rothmund–Thomson Syndrome - Diastrophic Dysplasia Syndrome - Johanson–Blizzard Syndrome - Kabuki Syndrome THE UNIVERSITY OF WESTERN AUSTRALIA (A) (B) Solitary Median Maxillary Central Incisor syndrome ⏰⏰🚩!   Solitary Median Maxillary Central Incisor syndrome Radiograph (Panel A) showing multiple supernumerary teeth in the maxillary anterior region, consistent with a dental anomaly. Clinical photo (Panel B) of the maxillary anterior dentition showing a single large median central incisor and adjacent smaller lateral incisors. Associated text reads 'Solitary Median Maxillary Central Incisor syndrome'. **Clinical Features** - Delayed/asymmetric eruption of permanent teeth - Retained or infraoccluded deciduous teeth - Absent deciduous teeth - Can be associated with short root anomaly - Patients with hypodontia often present a tendency to - Lip protrusion (Chung, 2000) - Increased overbite - Increased rotations of teeth (Bacetti, 1998) - Increased prevalence of ectopic maxillary canines - Reduced mandibular plane angle #### Dental Manifestations - Delayed or asymmetric eruption of permanent teeth - Retained or infraoccluded deciduous teeth - Absent deciduous teeth - Association with short root anomaly #### Associated Clinical Tendencies - Lip protrusion (Chung, 2000) - Increased overbite - Increased rotations of teeth (Bacetti, 1998) - Increased prevalence of ectopic maxillary canines - Reduced mandibular plane angle **Hypodontia** Treatment - Acid-etch retained, composite resin build-ups of conical teeth - Orthodontic management of spaces - Removable prosthesis - Partial dentures - conventional dentures - overdentures - Fixed prostheesis - composite resin veneers - crowns - bridges - Autotransplantation - Osseointegrated implants (usually after the cessation of growth). #### Restorative and Orthodontic Options - Acid-etch retained, composite resin build-ups of conical teeth - Orthodontic management of spaces #### Prosthetic Management - **Removable prosthesis:** - Partial dentures - Conventional dentures - Overdentures - **Fixed prosthesis:** - Composite resin veneers - Crowns - Bridges #### Surgical and Advanced Options - Autotransplantation - Osseointegrated implants (usually after the cessation of growth) THE UNIVERSITY OF WESTERN AUSTRALIA  Panoramic dental radiograph (OPG) displaying the maxillary and mandibular arches. The image shows mixed dentition with both primary and permanent teeth visible. Notable features include developing permanent molars in the posterior regions and a circular radiopaque object located centrally between the anterior upper incisors. THE UNIVERSITY OF WESTERN AUSTRALIA # ANOMALIES OF TOOTH SIZE Anomalies of tooth size. **Microdontia** **Definition:** It is described as teeth which are smaller than normal and outside the usual limits of variation (Rushton, 1948) * In general microdontia, the teeth are small, the crowns short, and normal contact areas between the teeth are frequently missing (Boyle, 1955) * Alternative terminology (Shafer et al. 1974) – Microdentism – Microdontism #### Terminology and Description **Microdontia** is described as teeth which are smaller than normal and outside the usual limits of variation (Rushton, 1948). - In general microdontia, the teeth are small, the crowns short, and normal contact areas between the teeth are frequently missing (Boyle, 1955). - Alternative terminology (Shafer et al. 1974): - Microdentism - Microdontism # Microdontia **THE UNIVERSITY OF WESTERN AUSTRALIA** **Prevalence** * Permanent dentition > primary dentition (Shafer, 1974) * Female > male (Brook, 1974, Tongkoom, 1994; Tsia, 1996) * More frequently in the maxillary teeth than the mandibular teeth * Most prevalence data are available only for maxillary lateral incisors **Primary dentition** * 0.5- 6.3% (Brook, 1974; Tongkoom, 1994; Ooshima et al. 1996) **Permanent dentition** * 1.9- 6.9% (Brook, 1974; Ooshima et al. 1996; Tsai, 1996; Aldred et al. 2012) #### Prevalence Data - Permanent dentition > primary dentition (Shafer, 1974) - Female > male (Brook, 1974, Tongkoom, 1994; Tsia, 1996) - More frequently in the maxillary teeth than the mandibular teeth - Most prevalence data are available only for maxillary lateral incisors **Primary dentition** - 0.5- 6.3% (Brook, 1974; Tongkoom, 1994; Ooshima et al. 1996) **Permanent dentition** - 1.9- 6.9% (Brook, 1974; Ooshima et al. 1996; Tsai, 1996; Aldred et al. 2012) # Microdontia The University of Western Australia ## Classification * True generalised microdontia * Generalised relative Microdontia * Localised microdontia (Shafer et al. 1958) According to Shafer et al. (1958), microdontia is classified into: - True generalised microdontia - Generalised relative Microdontia - Localised microdontia **Microdontia** **True generalised type** * All the teeth are smaller than normal * All of the teeth are of a normal morphological form * Exceedingly rare * Reported in * radiation or chemotherapeutic treatment during the developmental stage of the teeth (Van der waal, 1988) * pituitary dwarfism (Shafer, 1958) * fanconi's anemia (Opinya et al. 1988) </img> #### True Generalised Microdontia - All the teeth are smaller than normal - All of the teeth are of a normal morphological form - Exceedingly rare - Reported in: - Radiation or chemotherapeutic treatment during the developmental stage of the teeth (Van der waal, 1988) - Pituitary dwarfism (Shafer, 1958) - Fanconi's anemia (Opinya et al. 1988) Microdontia **THE UNIVERSITY OF WESTERN AUSTRALIA**  Microdontia Clinical intraoral photograph demonstrating microdontia. The image shows the maxillary and mandibular anterior dentition with a distinct discrepancy in tooth size between the arches. The upper (maxillary) incisors are visibly smaller and more conical than the lower (mandibular) incisors, which appear normal in proportion relative to each other. This visual evidence supports the diagnosis of microdontia as indicated by the OCR text. ## **Microdontia** ### **Generalised relative Microdontia** * Normal or slightly smaller than normal teeth but the jaws are somewhat larger than normal – impression of microdontia #### Generalised Relative Microdontia - Normal or slightly smaller than normal teeth but the jaws are somewhat larger than normal – impression of microdontia # Microdontia **THE UNIVERSITY OF WESTERN AUSTRALIA** ## Localised microdontia Involving a single tooth & further subdivided into: 1. Microdontia of the whole tooth 2. Microdontia of the crown of the tooth 3. Microdontia of the root alone (Ufomata, 1988) - Rather common - Affects mostly the maxillary lateral incisor (Peg-shaped laterals) - Supernumerary teeth are frequently small in size #### Localised Microdontia Involving a single tooth and further subdivided into (Ufomata, 1988): 1. Microdontia of the whole tooth 2. Microdontia of the crown of the tooth 3. Microdontia of the root alone **Clinical Observations** - Rather common - Affects mostly the maxillary lateral incisor (Peg-shaped laterals) - Supernumerary teeth are frequently small in size The UNIVERSITY of WESTERN AUSTRALIA  Dental radiograph showing multiple posterior teeth with radiopaque restorations (fillings). The image includes the University of Western Australia logo in the top right corner. This is a clinical diagnostic image used to visualize internal tooth structure and restoration placement. **Microdantia** (University of Western Australia logo) * Common form in lateral incisors – PEG laterals * The mesial and distal surfaces converge or taper incisally forming a peg-shaped or cone-shaped crown * The roots are frequently shorter than normal   #### Peg Laterals Common form in lateral incisors: - The mesial and distal surfaces converge or taper incisally forming a peg-shaped or cone-shaped crown - The roots are frequently shorter than normal Clinical photo showing the upper anterior dentition. The image demonstrates microdontia in the lateral incisors (labeled as 'PEG laterals' in the OCR context). The central incisors appear normal in size, while the adjacent lateral incisors are significantly smaller, exhibiting a peg-shaped or cone-shaped crown where mesial and distal surfaces converge incisally. Clinical photo of an occlusal view of the maxillary arch. This image illustrates severe microdontia and crowding. The central incisors are small with visible diastemas (gaps), and the lateral incisors are extremely reduced in size (peg-shaped) or potentially missing/impacted, contributing to the overall malalignment. # Microdontia Conditions and syndromes associated with microdontia * Patients with ectodermal dysplasia often present with microdontia * Pituitary dwarfism * Down syndrome * Facial Hemiatrophy * Gorlin-Chaudhry-Moss syndrome * Williams's syndrome * Chromosome d/u, 45X [Ullrich-Turner syndrome] * Chromosome 13 [trisomy 13] * Rothmund-Thomson syndrome * Hallermann-Streiff * Orofaciodigital syndrome (type 3) * Oculo-mandibulo-facial syndrome * Tricho-Rhino-Phalangeal * type1 Branchiooculo- facial syndrome THE UNIVERSITY OF WESTERN AUSTRALIA #### Conditions and Syndromes - Patients with ectodermal dysplasia often present with microdontia - Pituitary dwarfism - Down syndrome - Facial Hemiatrophy - Gorlin-Chaudhry-Moss syndrome - Williams's syndrome - Chromosome d/u, 45X [Ullrich-Turner syndrome] - Chromosome 13 [trisomy 13] - Rothmund-Thomson syndrome - Hallermann-Streiff - Orofaciodigital syndrome (type 3) - Oculo-mandibulo-facial syndrome - Tricho-Rhino-Phalangeal type 1 - Branchiooculo-facial syndrome **Microdontia** **Treatment** • Composite resin build-up • Porcelain veneers • Ceramic crown • Cast restoration • Orthodontic alignment and extraction of the tooth • Autotransplantation • Extraction and implants #### Clinical Management - Composite resin build-up - Porcelain veneers - Ceramic crown - Cast restoration - Orthodontic alignment and extraction of the tooth - Autotransplantation - Extraction and implants **Macrodontia** **Definition** • Tooth size that is outside the usual limits of variation for that type (Shafer et al. 1974) **Terminology:** – Megalodontia – Megadontia – Gigantism (Shafer et al. 1974; Dugmore, 2001) • For practical purpose this is a tooth that is 1 mm larger than their antimeres or the mean dimension of the tooth, and exhibits normal crown, root and pulp morphology (Chaudhary et al. 1997) • The affected teeth may be of normal or abnormal morphology #### Clinical Definition - Tooth size that is outside the usual limits of variation for that type (Shafer et al. 1974). - For practical purposes, this is a tooth that is 1 mm larger than its antimere or the mean dimension of the tooth, and exhibits normal crown, root, and pulp morphology (Chaudhary et al. 1997). - The affected teeth may be of normal or abnormal morphology. #### Terminology Alternative terms include: - Megalodontia - Megadontia - Gigantism (Shafer et al. 1974; Dugmore, 2001) **Macrodontia** | The University of<br>Western Australia | **Prevalence** - Male > Female (Brook, 1974; Tonghkoom, 1994; Oashima et al. 1996; Tsai, 1996) - Primary dentition: 0–2.3% (Brook, 1974; Tonghkoom, 1994; Oashima et al. 1996) - Permanent dentition: 1.1–3.6% (Brook, 1974; Oashima et al. 1996; Tsai, 1996) #### Demographic and Dentition Statistics - **Gender Predilection:** Male > Female (Brook, 1974; Tonghkoom, 1994; Oashima et al. 1996; Tsai, 1996) - **Primary Dentition:** 0–2.3% (Brook, 1974; Tonghkoom, 1994; Oashima et al. 1996) - **Permanent Dentition:** 1.1–3.6% (Brook, 1974; Oashima et al. 1996; Tsai, 1996) **Macrodontia** Classification * True generalised macrodontia * Generalised relative macrodontia * Localised macrodontia (Shafer et al. 1958; Nemes and Alberth, 2006; Dugmore, 2001) Macrodontia is categorized into three main types (Shafer et al. 1958; Nemes and Alberth, 2006; Dugmore, 2001): - True generalised macrodontia - Generalised relative macrodontia - Localised macrodontia # Macrodontia ## True generalized type - Extremely rare - All or at least multiple teeth are larger than normal - Associated with - Pituitary gigantism - Hemifacial hyperplasia - Otodental syndrome - Klinefelter syndrome - KBG syndrome (Herrmann-Pallister-Opitz Syndrome) - Pineal hyperplasia with hyperinsulinism THE UNIVERSITY OF WESTERN AUSTRALIA (logo) #### True Generalized Macrodontia - Extremely rare condition where all or at least multiple teeth are larger than normal. **Associated Conditions:** - Pituitary gigantism - Hemifacial hyperplasia - Otodental syndrome - Klinefelter syndrome - KBG syndrome (Herrmann-Pallister-Opitz Syndrome) - Pineal hyperplasia with hyperinsulinism  Clinical intraoral photograph showing the occlusal view of the maxillary posterior teeth (molars and premolars). The image demonstrates 'Generalised macrodontia,' characterized by abnormally large tooth crowns. The teeth exhibit extensive carious lesions with significant structural loss. The caption below identifies the condition. **THE UNIVERSITY OF WESTERN AUSTRALIA** Generalized macrodontia associated with KBG syndrome  Generalized macrodontia associated with KBG syndrome Clinical dental radiograph (panoramic X-ray) showing generalized macrodontia associated with KBG syndrome. The image displays multiple enlarged teeth within the maxilla and mandible, with visible crowding and overlapping due to increased tooth size. The University of Western Australia Macrodont permanent upper central incisors in KBG syndrome  Macrodont permanent upper central incisors in KBG syndrome Clinical photo showing macrodont permanent upper central incisors in KBG syndrome. The image displays enlarged upper front teeth with visible spacing and yellowish enamel. THE UNIVERSITY OF WESTERN AUSTRALIA Large incisors in a boy with Klinefelter syndrome   Large incisors in a boy with Klinefelter syndrome Clinical intraoral photograph showing a close-up of the anterior teeth. The image demonstrates large incisors in both the maxillary and mandibular arches, with visible crowding and malocclusion. This visual is pertinent to demonstrating the dental phenotype associated with Klinefelter syndrome. Dental panoramic radiograph (orthopantomogram) displaying the dentition and jaws. The image shows developing permanent teeth and bone structure. It serves as a diagnostic tool to visualize the underlying skeletal and dental conditions mentioned in the context of Klinefelter syndrome. **Macrodontia** THE UNIVERSITY OF WESTERN AUSTRALIA * **Generalized relative type** * Some what more common * Normal or slightly larger sized teeth in smaller jaws * An illusion of generalized macrodontia * Hereditary factors #### Generalized Relative Macrodontia - Somewhat more common than the true generalized type. - Characterized by normal or slightly larger sized teeth situated in smaller jaws. - Creates an illusion of generalized macrodontia. - Influenced by hereditary factors. **Macrodontia** ## **Isolated macrodontia** – Involving a single tooth – Relatively uncommon – Unknown etiology – Tooth may appear normal in every aspect except for its size • Frequently reported in – incisors – canines • Can be seen in – second mandibular premolars – mandibular molars or premolars – third molars Dugmore, 2001; Kumar, 2009; Almandey et al. 2010 #### Isolated Macrodontia - Involves a single tooth. - Relatively uncommon with an unknown etiology. - The tooth may appear normal in every aspect except for its size. **Frequently Reported In:** - Incisors - Canines **Also Observed In:** - Second mandibular premolars - Mandibular molars or premolars - Third molars (Dugmore, 2001; Kumar, 2009; Almandey et al. 2010)   Clinical intraoral photograph showing the maxillary anterior dentition. The image displays gingival inflammation and recession around the central incisors, with visible yellowing of the cervical tooth structure. Dental radiograph (periapical view) of the maxillary anterior teeth. The image shows the roots of the central and lateral incisors, including the apices and surrounding bone structure. THE UNIVERSITY OF WESTERN AUSTRALIA Isolated macrodontia in a mandibular second premolar tooth  Isolated macrodontia in a mandibular second premolar tooth Dental radiograph (X-ray) of the maxillofacial region showing teeth in mixed dentition. The image demonstrates 'isolated macrodontia in a mandibular second premolar tooth' as indicated by the caption below. The affected tooth is visibly enlarged compared to adjacent teeth. **Macrodontia** **Complications** * Problems with aesthetics * Arch length discrepancies * Crowding * Disruption of the developing occlusion * Teeth predispose to caries #### Clinical Complications - Problems with aesthetics - Arch length discrepancies - Crowding - Disruption of the developing occlusion - Teeth predispose to caries # Macro prosthodontia ## Treatment - **Stripping** of the macrodont - **Stripping** combined with composite resin build-up of the antimere if only one tooth affected - Extraction and placement by - fixed prosthesis - removable prosthesis - implant - Autotransplantation #### Treatment Options - **Stripping:** Interproximal reduction of the macrodont. - **Stripping and Restoration:** Combined with composite resin build-up of the antimere if only one tooth is affected. - **Extraction and Replacement:** - Fixed prosthesis - Removable prosthesis - Implant - **Autotransplantation** **Thank You** 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