clinical considerations in odontogenesis eruption and shedding

1. Clinical Considerations
in
Tooth Development, Eruption and Shedding
PRESENTED BY : Dr. SHASHI BHAL MAURYA
MDS FIRST YEAR
ORAL AND MAXILLOFACIAL
PATHOLOGY AND MICROBIOLOGY

2. CONTENTS
 Introduction
 Classification
 Defects occurring during initiation
 Defects occurring during proliferation
 Defects occurring during morphodiffrentiation
 Defects occurring during apposition
 Defects occurring during eruption and shedding
 Defects of structures due to systemic diseases
 References

3.  Teeth are specialized structural components of the craniofacial skeleton and are
comprised of - enamel, dentin and cementum.
 Developmental defects occur in each of these mineralized tissues, either alone, or in a
combination (syndromic) with defects in other organs or tissues.
INTRODUCTION

4. CLASSIFICATION
Failure of Neural crest cell to migrate Treacher Collins syndrome
Pierre Robin Syndrome
Hemifacial Microsomia
Cranioschiosis,
Achondroplasia
Due to morphodiffrentiation Anodontia, micro/macrodontia
Supernumerary Teeth,
Fusion, Gemination,
Enamel Hypoplasia,
Dense in Dente,Dense Evaginatus,
Talon Cusp, taurodontism
Dilacerations,Concrescence
Amelogenisis imperfecta,
Dentinogenisis imperfecta
Regional odontodysplasia
Dentin dysplasia

5. Systemic diseases Gardner´s syndrome
Ehlers - Danlos syndrome
Fluorosis (mottled enamel)
Tetracycline staining (TTC)
Odontogenic tumors Tumors of odontogenic epithelium or ectomesenchyme
or mixed in origin
Odontogenic cysts OKC, Dentigerous cyst
Endocrinal changes Hypothyroidism, Hypopituitarism
Eruption and Shedding Turner’s hypoplasia
Ankylosis
Eruption cyst
Eruption sequestrum
Retained deciduous

6. ANODONTIA
• Anodontia, also called anodontia vera,
 It can be complete or partial.
COMPLETE
PARTIAL
MUTATION OF PAX9 MSX1 AND AXIN2
Defects occurring during Initiation:
True anodontia
Psuedo anodontia.
False anodontiaForms-

8. A- Multiple developmentally missing permanent teeth and several
retained deciduous teeth in a female adult.
B -The panoramic radiograph shows no unerupted teeth in either jaw.

9. Syndromes Associated with Anodontia
 ● Ankyloglossia superior
 ● Böök
 ● Cockayne
 ● Coffi n-Lowry
 ● Cranio-oculo-dental
 ● Crouzon
 ● Down
 ● Ectodermal dysplasia
 ● Ectodermal dysplasia, cleft lip, cleft palate
 ● Ehlers-Danlos
 ● Ellis-van Creveld
 ● Focal dermal hypoplasia
 ● Freire-Maia
 ● Frontometaphyseal dysplasia
 ● Goldenhar
 ● GorlinGorlin-Chaudhry-Moss
 ● Hallermann-Streiff
 ● Hanhart
 ● Hypoglossia-hypodactylia
 ● Incontinentia pigmenti
 ● Johanson-Blizzard
 ● Lipoid proteinosis
 ● Marshall-White
 ● Melanoleukoderma
 ● Monilethrix-anodontia
 ● Oral-facial-digital type I
 ● Otodental dysplasia
 ● Palmoplantar keratosis, hypotrichosis, cysts of
eyelid
 ● Progeria
 ● Rieger
 ● Robinson
 ● Rothmund-Thomson
 ● Sturge-Weber
 ● Tooth-and-nail
BRAD W. NEVILLE, DOUGLAS D. DAMM, CARL M. ALLEN, JERRY E. BOUQUOT, ORAL AND MAXILLOFACIAL
PATHOLOGY Third Edition

10. SUPERNUMERARY TEETH
OPG OF Patient having numerous Supernumerary
Teeth
 Results from continued proliferation of
permanent or primary dental lamina to
form third tooth germ.
Inactivation of Apc or forced activation of Wnt/β-catenin
Supplemental
Rudimentary
Molariform
Conical
Tuberculate
Type
Defects occurring during Initiation…..

11. Defects occurring during Initiation…..

12. BRAD W. NEVILLE, DOUGLAS D. DAMM, CARL M. ALLEN, JERRY E. BOUQUOT,ORAL AND
MAXILLOFACIAL PATHOLOGY Third Edition
 Syndromes Associated with Hyperdontia
 ● Apert
 ● Angio-osteohypertrophy
 ● Cleidocranial dysplasia
 ● Craniometaphyseal dysplasia
 ● Crouzon
 ● Curtius
 ● Down
 ● Ehlers-Danlos
 ● Ellis-van Creveld
 ● Fabry-Anderson
 ● Fucosidosis
 ● Gardner
 ● Hallermann-Streiff
 ● Incontinentia pigmenti
 ● Klippel-Trénaunay-Weber
 ● Laband
 ● Leopard
 ● Nance-Horan
 ● Oral-facial-digital types I and III
 ● Sturge-Weber
 ● Tricho-rhino-phalangeal

13. MICRODONTIA
(1) True Generalized Microdontia
-all teeth are smaller than normal
(2) Relative Generalized Microdontia
-normal or slightly smaller than normal teeth.
(3) Focal or Localized Microdontia
-common condition
-affects most often maxillary lateral incisor + 3rd molar
-most common form of local microdontia is Peg Lateral
Defects occurring during PROLIFERATION:

14. Kazhila C. Chinsembu ,Teeth are bones: Signature genes and molecules that underwrite odontogenesis
Journal of Medical Genetics and Genomics Vol. 4(2),March 2012
Wnt signaling is required early in tooth germ formation and interference
with signaling via addition of an antagonist results in retarded
development and formation of smaller teeth; mutation of β-catenin
causes formation of larger teeth.

15. MACRODONTIA
(1) True Generalized Macrodontia
-all teeth are larger than normal.
(2) Relative Generalized Macrodontia
-normal or slightly smaller than normal teeth.
(3) Focal or Localized Macrodontia
-the union of one or more teeth results in
single large tooth.
-variant – hemi hypertrophy of face.
Defects occurring during PROLIFERATION……
Kazhila C. Chinsembu ,Teeth are bones: Signature genes and molecules that underwrite odontogenesis Journal of
Medical Genetics and Genomics Vol. 4(2),March 2012
mutation of β-catenin
causes formation of
large teeth

16. GEMINATION
 partial or complete cleavage of
single tooth germ.
 Large single rooted tooth with one pulp cavity
exhibits “twinning” in crown area.
 The etiology of geminated teeth remains unknown.
 Possible cause-nutritional deficiency, endocrinal disturbance,infectious/inflammatory processes,
hereditary or congenital diseases, and local traumas and by ionizing radiation is also considered.
PK RAO et al,Twin Tooth on Either Side: A Case Report of Bilateral Gemination, Ann Med Health Sci Res. 2013 Apr-Jun;
3(2): 271–273
Defects occurring during MORPHODIFFERENTIATION……

17. FUSION
• Either complete or incomplete union of two normally separated tooth germs.
• The dentin always confluent in cases of true fusion.
before calcification begins later, when a portion of
the tooth crown has
completed its formation.
If this contact occurs
the two teeth may be
completely united to form a
single large tooth .
there may be union of the
roots only.
Defects occurring during MORPHODIFFERENTIATION……
Sandhya shrivastava et al, FUSION/DOUBLE TEETH,10.5005 jp journals,10011-1200

18. DENS INVAGINATUS(Dens- In- Dente )
• Represents a defect of tooth in which a focal area on the tooth surface is
folded or invaginated pulpally to a variable extent.
• Dens invaginatus is a malformation of teeth probably resulting from an
infolding of the dental papilla before calcifiaction.
• Maxillary lateral incisors, central incisors, premolars, canines and molars
are affected in the order of fashion.
Defects occurring during APPOSITION:
M. Hülsmann, “Dens invaginatus: aetiology, classification, prevalence, diagnosis, and treatment considerations,” International
Endodontic Journal, vol. 30, no. 2, 79–90, 1997.

20. DENS EVAGINATUS
• Dens evaginatus (central tubercle, tuberculated cusp, accessory
tubercle, occlusal pearl, evaginated odontome,Leong premolar,
tuberculated premolar)
• Dens evaginatus is a cusp like elevation of enamel located in the
central groove or lingual ridge of the buccal cusp of premolar
or molar teeth.
Cusp like elevation located in
the central groove of
mandibular first bicuspid.
Radiographically,
the occlusal surface exhibits
A tuberculated appearance
Defects occurring during APPOSITION….
result of outward folding of
inner enamel epithelial cells and transient focal
hyperplasia of the peripheral cells of mesenchymal
dental papilla.
• Faiez N. Hattab An Unusual Case of Talon Cusp on Geminated Tooth, © J Can Dent Assoc 2001; 67:263-6

21. ENAMEL PEARL

Mass of ectopic enamel located in
the furcation area of a molar tooth.
Radiopaque nodule on the mesial surface of the root of the
maxillary third molar.
Another less distinct enamel pearl is present on the distal root
of the second molar.
The formation of ectopic enamel requires the presence of differentiated ameloblasts apical to the CEJ. In humans,
Hertwig's epithelial root sheath (HERS) or its residues, the epithelial rests of Malassez have been implicated as the
likely sources of ectopic ameloblasts.
Defects occurring during APPOSITION….
Shivani sharma et al Enamel pearl on an unusual location associated with localized periodontal disease: A clinical report, J
Indian Soc Periodontol. 2013 Nov-Dec; 17(6): 796–800

22. • Also known as “Eagle’s talon” is an extra cusp on anterior teeth.
Defects occurring during APPOSITION….

23. TALONS CUSP
 It may occurs, as a result of outward folding of
inner enamel epithelial cells and transient focal
hyperplasia of the cells of mesenchymal
dental papilla.
• Faiez N. Hattab An Unusual Case of Talon Cusp on Geminated Tooth, © J Can Dent Assoc 2001; 67:263-6
Defects occurring during APPOSITION….

24. Hattab FN, Yassin OM, Al-Nimri KS. Talon cusp in the permanent dentition associated with other dental
anomalies: Review of literature and reports of seven cases. J Dent Child 1996;63:368-76.
 Hattab et al classified talons cusps as
 Type 1, major talon: A morphologically well delineated additional cusp that prominently projects from
the facial or palatal/lingual surface of an anterior tooth and extends at least half the distance from the
CEJ to the incisal edge.
 Type 2, minor talon: A morphologically well-defined additional cusp that projects from the facial or
palatal/lingual surface of an anterior tooth and extends more than onefourth, but less than half the
distance from the CEJ to the incisal edge.
 Type 3, trace talon: Enlarged or prominent cingula and their variations, which occupy less than one-
fourth the distance from the CEJ to the incisal edge.
Defects occurring during APPOSITION….

25. TAURODONTISM
 Taurodontism is an enlargement of the body and pulp chamber of a multirooted tooth, with apical
displacement of the pulpal floor and bifurcation of the roots.
 failure of Hertwig's epithelial sheath diaphragm to invaginate at the proper horizontal level.
 Shape of the taurodont resembles that of the molar teeth of cud-chewing animals (tauro = bull;
dont = tooth).
Defects occurring during APPOSITION….
Manjunatha BS, Kovvuru SK. Taurodontism –A Review on its etiology, prevalence and clinical considerations. J Clin Exp
Dent. 2010;2(4):e187- 90

26. Illustration exhibiting the classification of taurodontism according
to the degree of apical displacement of the pulpal floor
Defects occurring during APPOSITION….

27. SUPERNUMERARY ROOT
 The term supernumerary roots refers to the development of an increased number of roots on a
tooth compared with that classically described in dental anatomy.
A, Gross photograph showing a mandibular molar with
a supernumerary root.
B, Periapical radiograph of the extracted tooth.
A B
• These supernumerary roots may be due to the disturbances
of the Hertwig's epithelial root sheath forming the root.
Kannan SK1, Suganya, Santharam HSupernumerary rootsIndian J Dent Res. 2002 Apr-Jun;13(2):116-9

28. ENAMEL HYPOPLASIA
• Enamel hypoplasia occurs in the form of
pits, grooves, or larger areas of missing enamel.
.
Bilaterally symmetrical pattern of horizontal
enamel hypoplasia of the anterior dentition.
Maxillary central incisors have been restored
previously. (From Neville)
Factors producing injury to ameloblasts during tooth
formation:
Nutritional deficiency (vit. A,C,D)
Diseases like measles, chicken pox, scarlet fever
Congenital syphilis
Hypocalcaemia
Birth injury
Local infection or trauma
Ingestion of chemicals
Defects occurring during APPOSITION….

29. AMELOGENESIS IMPERFECTA
Definition:
 Amelogenesis imperfecta is an abnormal formation of the enamel .
 color: yellow, brown or grey.
CAUSE: Amelogenesis Imperfecta is due to the malfunction of the proteins in the enamel.
Related gene Protein Variants
AMLEX AMELOGENIN smooth hypoplastic and hypomaturation
ENAM ENAMELIN Hypoplastic (minor pitting to diffuse generalized thin
enamel)
MMP-20 ENAMELYSIN pigmented hypomaturation
KLK4 KALLIKREIN Hypomaturation
DLX3 hypoplastic-hypomaturation
Defects occurring during APPOSITION….

30. Hypoplastic amelogenesis imperfecta, generalized pitted pattern.
A B
Defects occurring during APPOSITION….

31. DENTINOGENESIS IMPERFECTA(CAPDEPONT’S TEETH)
 Dentinogenesis imperfecta (hereditary Opalescent Dentin)
 Causes- discoloration (most often a blue-gray or yellow-brown color) and translucent.
 Teeth are weaker, prone to rapid wear, breakage, caries and loss.
A B
Defects occurring during APPOSITION….

32. Genes, locus, proteins and associated defects seen in Hereditary Dentinal defects
Aswathy Raj,Deepa.M.S, Ahmed Hasan Farooqi GENETICS AND TOOTH ANOMALIES - AN UPDATE
Oral & Maxillofacial Pathology Journal Vol. 4 No. 1 Jan - June 2013

33.  Classified into three basic types:
Shields Type I (associated with Osteogenesis Imperfecta)-
Features- periapical radiolucencies, bulbous crowns, obliteration of pulp chambers, root fractures and amber
translucent tooth color.
Shields Type II (Hereditary Opalescent Dentin)
Features are same as Shields Type I apart from Osteogenesis Imperfecta.
Shields Type III (Brandywine Type)
Teeth have a shell-like appearance with bell-shaped crowns.
Occurs exclusively in a isolated group in Maryland called Brandywine population
Defects occurring during APPOSITION….

34. SHELL TEETH NORMAL TEETH
Defects occurring during APPOSITION….

35. REGIONAL ODONTODYSPLASIA(ghost teeth)
 Regional odontodysplasia is a localized, nonhereditary developmental abnormality of
teeth with extensive adverse effects on the formation of enamel, dentin, and pulp.
Posterior mandibular dentition exhibiting enlarged
pulps and extremely thin enamel and dentin.
Defects occurring during APPOSITION….

36. DENTIN DYSPLASIA
Defects occurring during APPOSITION….
type II (coronal dentin dysplasia)
type I (radicular dentin dysplasia)
Two type –

37. 1. Dentin dysplasia type I (radicular dentin dysplasia)
 has been referred to as rootless teeth, because the loss of organization of the root dentin often leads to a
shortened root length.
Posterior dentition exhibiting shortened roots, absence of
pulp canals, and small, crescent-shaped pulp chambers.
FEATURES-Because of the shortened roots, the initial clinical signs
are extreme tooth mobility and premature exfoliation, spontaneously or
secondary to minor trauma. Less frequently, delayed eruption is the
presenting symptom.
Defects occurring during APPOSITION….

38. Defects occurring during APPOSITION….

39.  Dentin dysplasia type II (coronal dentin dysplasia)
 The root length is normal in both dentitions.
 Radiographically, the dental changes include bulbous crowns, cervical constriction, thin roots, and early
obliteration of the pulp.
 the pulp chamber exhibit significant enlargement and apical extension which is described as thistle tube–
shaped or flame-shaped.
Permanent dentition that does not exhibit translucence,
as noted in the deciduous teeth.
The patient also exhibits mild fluorosis of the enamel.
Radiographic appearance of the dentition thistle tube
shaped enlargements of the pulp chambers
Defects occurring during APPOSITION….

40. CONCRESCENCE
• Two fully formed teeth, adhered along the root surface by cementum.
• 2nd molar is frequently involved.
• Clinically radiographic diagnosis is mandatory before attempting tooth extraction.
• Deciduous dentition can result in crowding, abnormal spacing, and delayed or ectopic eruption of the
underlying permanent teeth.
Concrescence. Union by cementum of adjacent
Molars and it’s Radiograph.
Defects occurring during ROOT FORMATION……
The space restriction during development, local trauma,
excessive occlusal force or local infection after development
may be the suspected causative factors.
Dr. Jyoti S. Khedgikar, Dr. Shirish B. Khedgikar Concrescence of a Maxillary First and Second Molar: A Case Report,
Journal of Medical and Dental Science Research Volume 2 Issue 1 (2015)

41. DILACERATION
• Dilaceration refers to an abnormal angulation or a sharp
bend or curve anywhere along the root portion of a tooth
• Occurs due to trauma that displaces the calcified portion
of the tooth germ which alters the angulation of the tooth
during root formation
Root angulation of a mandibular
cuspid. Development has been altered by the presence of an
adjacent compound odontoma.(NEVILLE) (NEVILLE)
Defects occurring during ROOT FORMATION……

42. NATAL TEETH
 These are extra teeth that are present at birth.
 The most common natal teeth are lower incisors.
 Treatment:
 These teeth are defective and their removal is
generally recommended, particularly if mobility
poses a threat of aspiration.
 These teeth also make feeding difficult.
Disorders of ERUPTION………..

43. NEONATAL TEETH
 These are primary teeth that erupt prematurely
(during the first few weeks of life).
 Treatment:
 These teeth are usually normal primary teeth and
should be retained. An x-ray will be taken if
possible to confirm that these are not extra
teeth.
Disorders of ERUPTION………..

44. ERUPTION CYST (ERUPTION HEMATOMA)
 The cyst develops as a result of separation of the dental follicle from around the crown of an
erupting tooth that is within the soft tissues overlying the alveolar bone.
 The epithelial lining of eruption cyst is similar to that of the dentigerous cyst (non-
keratinized stratified squamous epithelium), so the eruption cyst is considered a superficial
dentigerous cyst.
This soft gingival swelling contains considerable blood
and can also be designated as an eruption hematoma
Disorders of ERUPTION………..
Preeti Dhawan et al Eruption cysts: A series of two cases Dent Res J (Isfahan). 2012 Sep-Oct; 9(5): 647–650

45. ERUPTION SEQUESTRUM
 A small spicule of nonvital bone may be seen radiographically or clinically overlying the crown
of partially erupted permanent posterior tooth.
 The process is termed an eruption sequestrum
 It’s occurs when the osseous fragment becomes separated from the contiguous bone during
eruption of the associated tooth.
A radiopaque fragment of sequestrating bone
can be seen overlying an impacted third molar.
Disorders of ERUPTION………..

46. Turner’s Hypoplasia
 Enamel defects seen in permanent teeth is caused by periapical inflammatory disease of the
overlying deciduous tooth. The altered tooth is called a Turner’s tooth.
 Anterior teeth are involved less frequently because crown formation is usually complete before
the development of any apical inflammatory disease.
Extensive enamel hypoplasia of mandibular first bicuspid secondary
to previous inflammatory process associated with overlying first
deciduous molar.
Radiograph of the same
tooth
Disorders of ERUPTION………..

47. ODONTOGENIC TUMORS
I. Tumors of odontogenic epithelium
 A. Ameloblastoma
 1. Malignant ameloblastoma
 2. Ameloblastic carcinoma
 B. Clear cell odontogenic carcinoma
 C. Adenomatoid odontogenic tumor
 D. Calcifying epithelial odontogenic
tumor
 E. Squamous odontogenic tumor
II. Mixed odontogenic
tumors
A. Ameloblastic fibroma
B. Ameloblastic fibro-
odontoma
C. Ameloblastic fibrosarcoma
D. Odontoameloblastoma
E. Compound odontoma
F. Complex odontoma
III. Tumors of odontogenic
ectomesenchyme
A. Odontogenic fibroma
B. Granular cell Odontogenic tumor
C. Odontogenic myxoma
D. Cementoblastoma

48. ODONTOGENIC KERATOCYST
 odontogenic keratocyst arises from cell rests of the dental lamina.
 Multiple odontogenic keratocysts sometimes associated with
nevoid basal cell carcinoma (Gorlin) syndrome
associated with mutations in the gene PTCH, which is part of
the Hedgehog signaling pathway
A
B
ODONTOGENIC CYST
Paul J.W. Stoelinga, Etiology and pathogenesis of keratocysts oral and maxillofacial surgery clinics am 15 (2003) 317-324

49. DENTIGEROUS CYST
 The dentigerous cyst is defined as a cyst that originates by the separation of the follicle from
around the crown of an unerupted tooth.
 The dentigerous cyst encloses the crown of an unerupted tooth and is attached to the tooth at
the cementoenamel junction.
Central type showing the
crown projecting into the cystic cavity.
Gross specimen of a
dentigerous cyst involving a tooth.
ODONTOGENIC CYST

50. Defects of structure ………….– systemic diseases
 Congenital syphilis –
 dental follicle infection by T. Pallidum
 Diagnostic feature known as Hutchinson Triad
 ● Hutchinson’s teeth
 ● Ocular interstitial keratitis
 ● Eighth nerve deafness
 The infection alters the formation of both the
 Anterior teeth (Hutchinson’s incisors)
 posterior dentition(mulberry molars, Fournier’s molars, Moon’s
 molars).
Systemic disease…

51. Defects of structure …………– systemic diseases
 teeth varying from bright yellow to dark brown and,
in UV light, showing a bright-yellow fluorescence
 TETRACYCLINE
Diffuse brownish discoloration of the permanent dentition.
Systemic disease…

52. Defects of structure………… – systemic diseases
 Fluorosis (mottled enamel)
  fluoride in drinking water
 yellow to dark-brown discoloration
 areas of moderate-to-severe enamel fluorosis were termed mottled enamel.
Dentition exhibiting lusterless, white, and opaque enamel.
Systemic disease…

53. References…
 NEVILLE, ALLEN, BOUQUOT Oral and Maxillofacial Pathology third edition
 Shafer’s text book of oral and maxillofacial pathology seventh edition
 Orban’s oral histology and embryology 13th edition.
 Aswathy Raj,Deepa.M.S, Ahmed Hasan Farooqi GENETICS AND TOOTH ANOMALIES - AN
UPDATEOral & Maxillofacial Pathology Journal Vol. 4 No. 1 Jan - June 2013
 Hattab FN, Yassin OM, Al-Nimri KS. Talon cusp in the permanent dentition associated with
other dental anomalies: Review of literature and reports of seven cases. J Dent Child
1996;63:368-76.
 Danker E, Harari D, Rotstein I. Dens evaginatus of anterior teeth. Literature review and
radiographic survey of 15,000 teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1996;81:472-76
 Jan C-C. Hu, James P.,Developmental biology and genetics of dental malformations Orthod
Craniofacial Res 10, 2007; 45–52
 Thaleia Kouskoura1 Natassa Fragou1 Maria Alexiou1 Nessy John2 Lukas Sommer2,The genetic
basis of craniofacial and dental abnormalities, Schweiz Monatsschr Zahnmed Vol. 121 7/8/2011

54.  Preeti Dhawan et al Eruption cysts: A series of two cases Dent Res J (Isfahan). 2012 Sep-Oct; 9(5):
647–650
 Dr. Jyoti S. Khedgikar, Dr. Shirish B. Khedgikar Concrescence of a Maxillary First and Second
Molar: A Case Report, Journal of Medical and Dental Science Research Volume 2 Issue 1 (2015)
 Aswathy Raj,Deepa.M.S, Ahmed Hasan Farooqi GENETICS AND TOOTH ANOMALIES - AN
UPDATE Oral & Maxillofacial Pathology Journal Vol. 4 No. 1 Jan - June 2013
 Kannan SK1, Suganya, Santharam HSupernumerary rootsIndian J Dent Res. 2002 Apr-Jun;13(2):116-
9
 Shivani sharma et al Enamel pearl on an unusual location associated with localized periodontal
disease: A clinical report, J Indian Soc Periodontol. 2013 Nov-Dec; 17(6): 796–800
 Sandhya shrivastava et al, FUSION/DOUBLE TEETH,10.5005 jp journals,10011-1200
 M. Hülsmann, “Dens invaginatus: aetiology, classification, prevalence, diagnosis, and treatment
considerations,” International Endodontic Journal, vol. 30, no. 2, 79–90, 1997.
 Paul J.W. Stoelinga, Etiology and pathogenesis of keratocysts oral and maxillofacial surgery clinics
am 15 (2003) 317-324