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The buccinator originates on the maxilla and mandible gastritis diet 4 life discount 10 mg bentyl free shipping, specifically on the buccal surfaces of the alveolar processes in the vicinity of the three molars, and from the pterygomandibular raphe, a collagenous tendinous inscription attached to the pterygoid hamulus and the mylohyoid line of the mandible. This raphe is interposed between the buccinator and superior pharyngeal constrictor muscles. The buccinator inserts into the fleshy corner of the lip in such a fashion that the upper fascicles and the lower fascicles decussate at the corner of the mouth and insert into the lower and upper lips, respectively, becoming fibers of the orbicularis oris. The highest and lowest fascicles, however, continue without decussation into the upper and lower lips, respectively. The ophthalmic division (V1) of the trigeminal nerve enters the face through the orbit as several branches to provide sensation for the upper eyelid and the region superior and lateral to the orbit. Another branch exits the lower rim of the orbit to serve the eyelids and the area about the face and side of the nose. The lacrimal nerve leaves the superolateral aspect of the orbit as the palpebral branch and enters the upper eyelid to distribute to the lateral half of that structure and the conjunctiva of the eye. The frontal nerve bifurcates in the orbit to form the supraorbital and supratrochlear nerves. The supraobital nerve leaves the orbit via the supraornbital foramen (or notch) after supplying a branch to the frontal sinus. The supratrochlear nerve passes superior to the trochlea and leaves the orbit medial to the supraorbital foramen. These two nerves 146 Chapter 8 Superficial Face supply sensation to the upper eyelid, the conjunctiva, and the medial half of the forehead and scalp. The infratrochlcar nerve, a branch of the nasociliary nerve, leaves the orbit by passing between the middle palpebral ligament of the eye and trochlea to innervate the medial half of the eyelids, the medial angle of the eye, and the side of the nose. The external nasal nerve, a branch of the anterior ethmoidal branch of the nasociliary nerve, leaves the nasal cavity at the distal end of the nasal bone. This nerve provides sensation to the middle of the bridge and part of the ala of the nose. The maxillary division (V2) of the trigeminal nerve enters the face via the infraorbital foramen, providing sensation to the skin of the lower eyelid, nose, upper lip, and mucosa of the labial vestibule. The buccal nerve lies on the surface of the buccinator muscle as it emerges from beneath the masseter muscle. The buccal nerve provides sensation to the cheek and, on piercing the buccinator muscle, supplies sensation to the mucosa of the buccal vestibule and buccal surfaces of the gingivae as far anteriorly as the corner of the mouth. The mental nerve enters the superficial face via the mental foramen of the mandible to serve the chin, the lower lip, and the surrounding mucosa of the oral vestibule. The infraorbital nerve is a continuation of the maxillary division of the trigeminal nerve. After coursing through the floor of the orbit, the infraorbital nerve enters the face via the infraorbital foramen, where it forms a tuft of nerves that may be categorized into three groups: inferior palpebral branches, serving the skin of the lower eyelid and conjunctiva; external nasal branches, providing sensory innervation to the side and mobile septum of the nose; and superior labial branches, supplying the upper lip and mucosa of the superior labial vestibule. The zygomatic branch of the maxillary division of the trigeminal nerve bifurcates to form the zygomaticotemporal and zygomaticofacial nerves. The former enters the superficial face a little superior to the zygomatic arch and supplies sensation to the region of the temple. The latter emerges in the superficial face by way of the zygomaticofacial foramen to serve the skin over the zygomatic bone. The mandibular division (V3) of the trigeminal nerve provides sensation via several branches to the temporomandibular articulation, the anterior aspect of and about the ear, skin of the temple, skin over the cheek, buccal vestibule and gingival to the corner of the mouth, chin, lower lip and oral vestibule, and the mandibular teeth and supporting tissues. The auriculotemporal nerve is a branch of the posterior trunk of the mandibular division of the trigeminal nerve. After separating from the vestibulocochlear nerve and giving several branches within the temporal bone, it emerges through the stylomastoid foramen. A posterior auricular branch arises from the trunk, then passes posterior to the ear on its way to innervate the occipitalis and posterior auricular muscles. The main stem of the facial nerve then supplies fibers to the stylohyoid muscle and the posterior belly of the digastric muscle before entering the deep aspect of the parotid gland. Here it subdivides into the temporofacial and cervicofacial divisions, which combine to form a loop within the substance of the parotid gland.

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Development of the Female Genital Ducts and Glands In female embryos gastritis diet during pregnancy order bentyl 10 mg mastercard, the mesonephric ducts regress because of the absence of testosterone and only a few nonfunctional remnants persist (see. The uterine tubes develop from the unfused cranial parts of these ducts. As the name of this structure indicates, it gives rise to the uterus and vagina (superior part). Fusion of the paramesonephric ducts also brings together a peritoneal fold that forms the broad ligament, and two peritoneal compartments-the rectouterine pouch and the vesicouterine pouch. Along the sides of the uterus, between the layers of the broad ligament, the mesenchyme proliferates and differentiates into cellular tissue-the parametrium, -which is composed of loose connective tissue and smooth muscle. Outgrowths from the urogenital sinus form the greater vestibular glands in the lower third of the labia majora. These tubuloalveolar glands also secrete mucus and are homologous to the bulbourethral glands in the male (see Table 12-1). Development of the Uterus and Vagina page 269 page 270 Figure 12-35 A, Dorsal view of the developing prostate in an 11-week fetus. B, Sketch of a median section of the developing urethra and prostate showing numerous endodermal outgrowths from the prostatic urethra. Contact of the uterovaginal primordium with the urogenital sinus, forming the sinus tubercle (see. They extend from the urogenital sinus to the caudal end of the uterovaginal primordium. Later the central cells of this plate break down, forming the lumen of the vagina. The epithelium of the vagina is derived from the peripheral cells of the vaginal plate (see. Until late fetal life, the lumen of the vagina is separated from the cavity of the urogenital sinus by a membrane-the hymen. The membrane is formed by invagination of the posterior wall of the urogenital sinus, resulting from expansion of the caudal end of the vagina. The hymen usually ruptures during the perinatal period and remains as a thin fold of mucous membrane just within the vaginal orifice. Mesonephric Duct Remnants in Males the cranial end of the mesonephric duct may persist as an appendix of the epididymis, which is usually attached to the head of the epididymis (see. Caudal to the efferent ductules, some mesonephric tubules may persist as a small body, the paradidymis. Mesonephric Duct Remnants in Females the cranial end of the mesonephric duct may persist as an appendix vesiculosa (see. A few blind tubules and a duct, the epoophoron, correspond to the efferent ductules and duct of the epididymis in the male. The epoophoron may persist in the mesovarium between the ovary and uterine tube (see. Paramesonephric Duct Remnants in Males the cranial end of the paramesonephric duct may persist as a vesicular appendix of the testis, which is attached to the superior pole of the testis (see. The prostatic utricle, a small saclike structure that opens into the prostatic urethra, is homologous to the vagina. The lining of the prostatic utricle is derived from the epithelium of the urogenital sinus. Within its epithelium, endocrine cells containing neuron-specific enolase and serotonin have been detected. The seminal colliculus, a small elevation in the posterior wall of the prostatic urethra, is the adult derivative of the sinus tubercle (see. Paramesonephric Duct Remnants in Females Part of the cranial end of the paramesonephric duct that does not contribute to the infundibulum of the uterine tube may persist as a vesicular appendage (see. A, Schematic drawing of a sagittal section of the caudal region of an 8-week female embryo. C, Similar section at a more caudal level illustrating fusion of the paramesonephric ducts. D, Similar section showing the uterovaginal primordium, broad ligament, and pouches in the pelvic cavity. Distinguishing sexual characteristics begin to appear during the 9th week, but the external genitalia are not fully differentiated until the 12th week. Early in the fourth week, proliferating mesenchyme produces a genital tubercle in both sexes at the cranial end of the cloacal membrane.

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This sagittal magnetic resonance image of a 9-month-old infant with a large head shows very large lateral and third ventricles gastritis dieta buy 10mg bentyl with visa. The cerebral aqueduct appears as a dark line of fluid ventral to the tectum of the midbrain. This defect is due to failure of cleavage of the prosencephalon (rostral neural tube) into right and left cerebral hemispheres, telencephalon and diencephalon, and into olfactory bulbs and optic tracts. Del Bigio, Department of Pathology [Neuropathology], University of Manitoba, Winnipeg, Manitoba, Canada). Note the greatly reduced cerebral and displaced cerebral hemispheres and cerebellum. It is a tonguelike projection of the medulla and inferior displacement of the vermis of the cerebellum through the foramen magnum into the vertebral canal. The Arnold-Chiari malformation occurs once in every 1000 births and is frequently associated with spina bifida with meningomyelocele, spina bifida with myeloschisis, and hydrocephaly. The cause of the Arnold-Chiari malformation is uncertain; however, the posterior cranial fossa is abnormally small in these infants. In situ exposure of the hindbrain reveals cerebellar tissue (arrow) well below the foramen magnum. Mental retardation may also result from the action of a mutant gene or from a chromosomal abnormality. The 8- to 16-week period of human development is also the period of greatest sensitivity for fetal brain damage resulting from large doses of radiation. By the end of the 16th week, most neuronal proliferation and cell migration to the cerebral cortex are completed. Cell depletion of sufficient degree in the cerebral cortex results in severe mental retardation. Disorders of protein, carbohydrate, or fat metabolism may also cause mental retardation. Retarded mental development throughout the postnatal growth period can result from birth injuries, toxins. Later, the two processes unite to form a single process with peripheral and central components resulting in a unipolar type of neuron (see. The peripheral process terminates in a sensory ending, whereas the central process enters the spinal cord or brain (see. The cell body of each afferent neuron is closely invested by a capsule of modified Schwann cells-satellite cells (see. This capsule is continuous with the neurolemmal sheath of Schwann cells that surrounds the axons of afferent neurons. External to the satellite cells is a layer of connective tissue that is continuous with the endoneurial sheath of the nerve fibers. Neural crest cells also differentiate into multipolar neurons of the autonomic ganglia (see. The term paraganglia includes several widely scattered groups of cells that are similar in many ways to medullary cells of the suprarenal glands. The cell groups largely lie retroperitoneally, often in association with sympathetic ganglia. The carotid and aortic bodies also have small islands of chromaffin cells associated with them. Neural crest cells also give rise to melanoblasts (the precursors of the melanocytes) and cells of the medulla of the suprarenal gland. Spinal Nerves Motor nerve fibers arising from the spinal cord begin to appear at the end of the fourth week. The nerve fibers arise from cells in the basal plates of the developing spinal cord and emerge as a continuous series of rootlets along its ventrolateral surface. The fibers destined for a particular developing muscle group become arranged in a bundle, forming a ventral nerve root. The nerve fibers of the dorsal nerve root are formed by axons derived from neural crest cells that migrate to the dorsolateral aspect of the spinal cord, where they differentiate into the cells of the spinal ganglion.

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A periodontal probe was used to gastritis with erosion discount 10 mg bentyl overnight delivery establish the depth of the gingival sulcus (B), and the laser was used to recontour the tissue (C, one side done; D, gingival recontouring completed). Because the tissue is ablated (vaporized) and the heat of the laser seals the ablation site, no bleeding occurs and no periodontal dressing is needed. A and B, Progress records at age 14-5 showed good incisor display; and, C and D, a nearly corrected malocclusion. The intraoral views and panoramic radiograph (A to F) show excellent alignment and occlusion, with normal gingival contours. Note (D) the bonded maxillary retainer to maintain the rotation correction and space closure for the maxillary central incisors and (E) the bonded canine-to-canine retainer for the lower arch. In the close-up smile images (G and H), note the consonant smile arc and improved maxillary incisor display. F, the posttreatment cephalometric radiograph and (G) a cephalometric superimposition showing the changes during treatment. In the superimposition tracing, note the improvement in upper incisor angulation through palatal root torque, without intrusion or facial tipping of the incisors that would have elevated their incisal edges. One potential solution to a "gummy smile" is intrusion of the maxillary incisors but in this case that would have flattened the smile arc and decreased incisor display, both of which were undesirable. Downward and forward growth of the mandible relative to the maxilla, while the vertical position of the maxillary molars was maintained, was the desired result from use of high-pull headgear. She had almost no growth after completion of treatment, cooperated with wearing retainers at night to age 18, and had a stable result. Treatment Planning in Special Circumstances Dental Disease Problems At one time there was concern that endodontically treated teeth could not be moved. It is now clear that as long as the periodontal ligament is normal, endodontically treated teeth respond to orthodontic force in the same way as teeth with vital pulps. Although some investigators have suggested that root-filled teeth are more subject to root resorption, the current consensus is that this is not a major concern. It is perfectly feasible to orthodontically reposition the remaining root of a posterior tooth, should this be necessary, after the endodontics is completed. In general, prior endodontic treatment does not contraindicate orthodontic tooth movement, but teeth with a history of severe trauma may be at greater risk of root resorption, whether they have received endodontic treatment or not. Essentially all periodontal treatment procedures may be used in bringing a pre-orthodontic patient to the point of satisfactory maintenance, with the exception of osseous surgery. Scaling, curettage, flap procedures, and gingival grafts should be employed as appropriate before orthodontic treatment so that progression of periodontal problems during orthodontic treatment can be avoided. Children or adults with a lack of adequate attached gingiva in the mandibular anterior region should have free gingival grafts to create attached gingiva before the beginning of orthodontics. This is especially true if tooth movement would place the teeth in a more facial position. Further details in the sequencing of treatment for adults with multiple problems are provided in Chapter 18. During the year of active treatment, the patient had great difficulty in controlling her diabetes and was hospitalized for related problems on two occasions. In adults or children, the most common systemic problem that may complicate orthodontic treatment is diabetes or a prediabetic state. If the diabetes is under good control, periodontal responses to orthodontic force are essentially normal and successful orthodontic treatment, particularly the adjunctive procedures most often desired for adult diabetics, can be carried out successfully. The rapid progression of alveolar bone loss in patients with diabetes is well recognized, however, and if diabetes is not under good control, there is a real risk of accelerated periodontal breakdown (Figure 7-45). Prolonged comprehensive orthodontic treatment should be avoided in these patients if at all possible. Keep in mind that children on steroids may also be taking bisphosphonates, which make orthodontic tooth movement almost impossible. Prolonged orthodontic treatment should be avoided in patients with either type of rheumatoid arthritis because the potential for harm is at least as great as the potential benefit.

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Figure 19-4 Illustrations of the successive stages of the development of a sweat gland gastritis symptoms tongue trusted bentyl 10mg. A and B, the cellular buds of the glands develop at approximately 20 weeks as a solid growth of epidermal cells into the mesenchyme. D, the peripheral cells differentiate into secretory cells and contractile myoepithelial cells. B, A child with severe keratinization of the skin (ichthyosis) from the time of birth. Mario Joao Branco Ferreira, Servico de Dermatologia, Hospital de Desterro, Lisbon, Portugal. Joao Carlos Fernandes Rodrigues, Servico de Dermatologia, Hospital de Desterro, Lisbon, Portugal. Ectrodactyly-Ectodermal Dysplasia-Clefting Syndrome Ectrodactyly-ectodermal dysplasia-clefting syndrome is a congenital skin condition that is inherited as an autosomal dominant trait. It involves both ectodermal and mesodermal tissues, consisting of ectodermal dysplasia associated with hypopigmentation of skin and hair, scanty hair and eyebrows, absence of eyelashes, nail dystrophy, hypodontia and microdontia, ectrodactyly, and cleft lip and palate. Angiomas of Skin these vascular anomalies are developmental defects in which some transitory and/or surplus primitive blood or lymphatic vessels persist. Those composed of blood vessels may be mainly arterial, venous, or cavernous angiomas, but they are often of a mixed type. Angiomas composed of lymphatics are called cystic lymphangiomas or cystic hygromas (see Chapter 13). True angiomas are benign tumors of endothelial cells, usually composed of solid or hollow cords; the hollow cords contain blood. Nevus flammeus denotes a flat, pink or red, flamelike blotch that often appears on the posterior surface of the neck. A portwine stain hemangioma is a larger and darker angioma than a nevus flammeus and is nearly always anterior or lateral on the face and/or neck. It is sharply demarcated when it is near the median plane, whereas the common angioma (pinkish-red blotch) may cross the median plane. A port-wine stain in the area of distribution of the trigeminal nerve is sometimes associated with a similar type of angioma of the meninges of the brain (Sturge-Weber syndrome). Albinism occurs when the melanocytes fail to produce melanin because of the lack of the enzyme tyrosinase. In localized albinism-piebaldism-an autosomal dominant trait, there is a lack of melanin in patches of skin and/or hair. Absence of Skin In rare cases, small areas of skin fail to form, giving the appearance of ulcers. Mammary Glands Mammary glands are a modified and highly specialized type of sweat glands. Mammary buds begin to develop during the sixth week as solid downgrowths of the epidermis into the underlying mesenchyme. The mammary buds develop as downgrowths from thickened mammary crests, which are thickened strips of ectoderm extending from the axillary to the inguinal regions (see. The mammary crests (ridges) appear during the fourth week but normally persist in humans only in the pectoral area, where the breasts develop (see. Each primary bud soon gives rise to several secondary mammary buds that develop into lactiferous ducts and their branches (see. Canalization of these buds is induced by placental sex hormones entering the fetal circulation. This process continues until late gestation, and by term, 15 to 19 lactiferous ducts are formed. The fibrous connective tissue and fat of the mammary gland develop from the surrounding mesenchyme. C, Transverse section of a mammary crest at the site of a developing mammary gland. D to F, Similar sections showing successive stages of breast development between the 12th week and birth.

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These light final arches must include any firstor second-order bends used in the rectangular finishing arches gastritis and nausea order 10mg bentyl with mastercard. It is usually unnecessary for the patient to wear light posterior vertical elastics during this settling, but they can be used if needed. These light arches will quickly settle the teeth into final occlusion and should remain in place for only a few weeks at most. The difficulty with undersized round wires at the end of treatment is that some freedom of movement for settling of posterior teeth is desired, but precise control of anterior teeth is lost as well. It was not until the 1980s that orthodontists realized the advantage of removing only the posterior part of the rectangular finishing wire, leaving the anterior segment (typically canine-to-canine) in place, and using laced elastics to bring the posterior teeth into tight occlusion (Figure 16-12). For the majority of patients who had well-aligned posterior teeth from the beginning, however, this is a remarkably simple and effective way to settle the teeth into their final occlusion. An alternative is to use a pair of or inch elastics on both sides in a vertical triangle. These elastics should not remain in place for more than 2 weeks, and 1 week usually is enough to accomplish the desired settling. Because it is used after the orthodontic appliance has been removed, the use of a tooth positioner for final settling is discussed after the section below on removing bands and bonded brackets. The elastics can be used either with light round archwires or (usually preferred) with rectangular segments in the anterior brackets and no wire at all posteriorly. The last step in treatment then becomes cutting the rectangular finishing archwires distal to the lateral incisors or canines and removing the posterior segments. Because of this, it is important to slightly overcorrect the occlusal relationships. This provides some latitude for the teeth to rebound before final settling is accomplished. Rebound is a 1 to 2 mm phenomenon; posturing can lead to 4 to 5 mm relapse, and obviously it is important to detect it and continue treatment to a true correction. These considerations lead to the guidelines for finishing treatment when interarch elastics have been used: 1When an appropriate degree of overcorrection has been achieved, the force used with the elastics should be decreased while the light elastics are continued full time for another appointment interval; 2At that point, interarch elastics should be discontinued, 4 to 8 weeks before the orthodontic appliances are to be removed, so that changes due to rebound or posturing can be observed. It is better to tell the patient that he or she is getting a vacation from the elastics and that some further elastic wear may be necessary if changes are observed, rather than saying that elastics are no longer needed. If changes do occur, that makes it easier for patients to accept that the vacation is over and another period of elastics is needed. Removal of Bands and Bonded Attachments Removal of bands is accomplished by breaking the cement attachment and then lifting the band off the tooth, which sounds simpler than it is in some instances. For upper molar and premolar teeth, a band-removing instrument is placed so that first the lingual, then the buccal surface is elevated (Figure 16-13). A welded lingual bar is needed on these bands to provide a point of attachment for the pliers if lingual hooks or cleats are not a part of the appliance. For the lower posterior teeth, the sequence of force is just the reverse: the band remover is applied first on the buccal, then the lingual surface. Bonded brackets must be removed, insofar as possible, without damaging the enamel surface. This is done by creating a fracture within the resin bonding material or between the bracket and the resin and then removing the residual resin from the enamel surface. With metal brackets, applying a cutting pliers to the base of the bracket so that the bracket bends (Figure 16-14) is the safest method. This has the disadvantage of destroying the bracket, which otherwise could be reused, but protecting the enamel usually is a more important consideration. Enamel damage from debonding metal brackets is rare, but there have been a number of reports of enamel fractures and removal of chunks of enamel when ceramic brackets are debonded (see Chapter 10 for a more detailed discussion). It also is easy to fracture a ceramic bracket while attempting to remove it, and if that happens, large pieces of the bracket must be ground away with a diamond stone in a handpiece. These problems arise because ceramic brackets have little or no ability to deform-they are either intact or broken.

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As the root of the tooth grows gastritis onions buy cheap bentyl 10mg, its crown gradually erupts through the oral epithelium. Usually eruption of the deciduous teeth occurs between the 6th and 24th months after birth (see Table 19-1). The mandibular medial or central incisor teeth usually erupt 6 to 8 months after birth, but this process may not begin until 12 or 13 months in some children. Despite this, all 20 deciduous teeth are usually present by the end of the second year in healthy children. Delayed eruption of all teeth may indicate a systemic or nutritional disturbance such as hypopituitarism or hypothyroidism. The permanent teeth develop in a manner similar to that described for deciduous teeth. As a permanent tooth grows, the root of the corresponding deciduous tooth is gradually resorbed by osteoclasts (odontoclasts). Consequently, when the deciduous tooth is shed, it consists only of the crown and the uppermost part of the root. The shape of the face is affected by the development of the paranasal sinuses and the growth of the maxilla and mandible to accommodate the teeth (see Chapter 9). It is the lengthening of the alveolar processes (bony sockets supporting the teeth) that results in the increase in the depth of the face during childhood. Because these are prematurely erupting decidual teeth, spacers may be required to prevent overcrowding of the other teeth. Enamel Hypoplasia Defective enamel formation causes pits and/or fissures in the enamel of teeth. Rickets occurring during the critical in utero period of tooth development (6-12 weeks) is a common cause of enamel hypoplasia. Rickets, a disease in children who are deficient in vitamin D, is characterized by disturbance of ossification of the epiphysial cartilages and disorientation of cells at the metaphysis (see Chapter 14). Variations of Tooth Shape page 451 page 452 Abnormally shaped teeth are relatively common. Occasionally there are spherical masses of enamel- enamel pearlson the root of a tooth that is separate from the enamel of the crown. In other cases, the maxillary lateral incisor teeth may have a slender, tapering shape (peg-shaped incisors). Congenital syphilis affects the differentiation of the permanent teeth, resulting in screwdriver-shaped incisors, with central notches in their incisive edges. The molars are also affected and are called mulberry molars because of their characteristic features. Supernumerary teeth usually develop in the area of the maxillary incisors and can disrupt the position and eruption of normal teeth. The extra teeth commonly erupt posterior to the normal ones (or can remain unerupted) and are asymptomatic in most cases. In partial anodontia, one or more teeth are absent; this is often a familial trait. Occasionally a tooth bud either partially or completely divides into two separate teeth. The result is a macrodont or megadont (large teeth) with a common root canal system. If the tooth germ completely divides into two separate teeth, the result is twinning with one additional tooth in the dentition. This condition can be differentiated radiographically from gemination by two separate root canal systems found with fusion. Abnormally Sized Teeth Disturbances during the differentiation of teeth may result in gross alterations of dental morphology, such as macrodontia (large teeth) and microdontia (small teeth). The dentigerous (tooth-bearing) cyst develops because of cystic degeneration of the enamel reticulum of the enamel organ of an unerupted tooth. Most cysts are deeply situated in the jaw and are associated with misplaced or malformed secondary teeth that have failed to erupt. Amelogenesis Imperfecta page 452 page 453 Amelogenesis imperfecta is a complex group of at least 14 different clinical entities that involve developmental aberrations in enamel formation in the absence of any systemic disorder. This is a congenital, inherited ectodermal defect that primarily affects the enamel only. Depending on the type of amelogenesis imperfecta, the enamel may be hard or soft, pitted or smooth, and thin or normal in thickness.


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