Heimler Syndrome.

Heimler syndrome is a rare syndrome associating sensorineural hearing loss with retinal dystrophy and amelogenesis imperfecta due to PEX1 or PEX6 biallelic pathogenic variations. This syndrome is one of the less severe forms of peroxisome biogenesis disorders. In this chapter, we will review clinical, biological, and genetic knowledges about the Heimler syndrome.

Dental and extra-oral clinical features in 41 patients with WNT10A gene mutations: A multicentric genotype-phenotype study.

WNT10A gene encodes a canonical wingless pathway signaling molecule involved in cell fate specification as well as morphogenetic patterning of the developing ectoderm, nervous system, skeleton, and tooth. In patients, WNT10A mutations are responsible for ectodermal-derived pathologies including isolated hypo-oligodontia, tricho-odonto-onycho-dermal dysplasia and Schöpf-Schulz-Passarge syndrome (SSPS). Here we describe the dental, ectodermal, and extra-ectodermal phenotypic features of a cohort of 41 patients from 32 unrelated families. Correlations with WNT10A molecular status (heterozygous carrier, compound heterozygous, homozygous) and patient's phenotypes were performed. Mild to severe oligodontia was observed in all patients bearing biallelic WNT10A mutations. However, patients with compound heterozygous mutations presented no significant difference in phenotypes compared with homozygous individuals. Anomalies in tooth morphology were frequently observed with heterozygous patients displaying hypodontia. No signs of SSPS, especially eyelids cysts, were detected in our cohort. Interestingly, extra-ectodermal signs consisted of skeletal, neurological and vascular anomalies, the latter suggesting a wider phenotypic spectrum associated with WNT10A mutations. Indeed, the Wnt pathway plays a crucial role in skeletal development, lipid metabolism, and neurogenesis, potentially explaining patient's clinical manifestations.

Delayed osteoprogenitor differentiation in cleft-palate models.

Failure of palatal shelf fusion results in cleft palate (CP) and may lead to malformation of palatal bones and undergrowth of the maxilla. It is not known whether defects in bone formation may contribute to this phenotype. We tested the hypothesis that impaired fusion of developing palatal shelves affects palatal bone development using palate organotypic cultures. Using two different approaches, we show that induction of cleft results in increased expression of pre-osteoblast and early osteoblast markers, Twist1, Snai1 and Runx2, and decreased expression of more mature markers of bone differentiation, collagen-1 and osteopontin, indicating delayed osteoblast differentiation in CPs. This, together with the increase in immature osteoblasts and proliferation observed in non-fused palatal shelves, suggests that palatal osteoblast differentiation is at least partly modulated by shelf fusion. Delayed osteoblast differentiation may therefore contribute to defects in gross morphology and function of the maxilla in CP patients.

Hypophosphatasia: oral cavity and dental disorders.

Dental anomalies exist in every subtype of hypophosphatasia (HPP), from the most severe to the most moderate, called odontohypophosphatasia. The forms are defined by the age at onset of the initial symptoms. These anomalies affect all dental mineralized tissues from enamel, dentin and cementum to alveolar bone in a gradient proportional to the severity of the disease. Early loss of the deciduous teeth, before 3 years of age, and then possibly of the permanent teeth, is due to an abnormality of the cementum, the tissue attaching the teeth to alveolar bone, and is the most frequent abnormality. Tooth loss is a very important diagnostic sign and needs to be recognized. Patients with HPP need specialized oral and dental care in coordination with the reference and expert centers. The oral and dental signs and their treatment remain poorly known. The recording of the abnormalities and their treatment in a registry is indispensable in order to enhance patient management and oral and dental health.

Amelogenesis Imperfecta: 1 Family, 2 Phenotypes, and 2 Mutated Genes.

Amelogenesis imperfecta (AI) is a clinically and genetically heterogeneous group of diseases characterized by enamel defects. The authors have identified a large consanguineous Moroccan family segregating different clinical subtypes of hypoplastic and hypomineralized AI in different individuals within the family. Using targeted next-generation sequencing, the authors identified a novel heterozygous nonsense mutation in COL17A1 (c.1873C>T, p.R625*) segregating with hypoplastic AI and a novel homozygous 8-bp deletion in C4orf26 (c.39_46del, p.Cys14Glyfs*18) segregating with hypomineralized-hypoplastic AI in this family. This study highlights the phenotypic and genotypic heterogeneity of AI that can exist even within a single consanguineous family. Furthermore, the identification of novel mutations in COL17A1 and C4orf26 and their correlation with distinct AI phenotypes can contribute to a better understanding of the pathophysiology of AI and the contribution of these genes to amelogenesis.

Gene expression during palate fusion in vivo and in vitro.

UNLABELLED: Failure of secondary palate fusion during embryogenesis is a cause of cleft palate. Disappearance of the medial epithelial seam (MES) is required to allow merging of the mesenchyme from both palatal shelves. This involves complex changes of the medial edge epithelial (MEE) cells and surrounding structures that are controlled by several genes whose spatio-temporal expression is tightly regulated. We have carried out morphological analyses and used a semi-quantitative RT-PCR technique to evaluate whether morphological changes and modulation in the expression of putative key genes, such as twist, snail, and E-cadherin, during the fusion process in palate organ culture parallel those observed in vivo, and show that this is indeed the case. We also show, using the organotypic model of palate fusion, that the down-regulation of the transcription factor snail that occurs with the progression of palate development is not dependent on fusion of the palatal shelves. ABBREVIATIONS: dsg1, desmoglein1; EMT, epithelial-mesenchymal transition; MEE, medial edge epithelium; MES, medial epithelial seam; RT-PCR, reverse-transcriptase polymerase chain-reaction.

Effects of retinoids on tooth morphogenesis and cytodifferentiations, in vitro.

The first embryonic lower mouse molar was used as a model system to investigate the effects of two retinoids, retinoic acid (RA) and a synthetic analogue, Ch55, on morphogenesis and cytodifferentiations in vitro. Exogenous retinoids were indispensable for morphogenesis of bud, cap and bell-stage molars in serum-free, chemically-defined, culture media. Transferrin and RA or transferrin and Ch55 acted synergistically in promoting morphogenesis from bud and cap-stage explants. Transferrin, per se, had no morphogenetic effect. Epithelial histogenesis, odontoblast functional differentiation and ameloblast polarization always occurred in RA-depleted explants. Comparison of the distributions of bromodeoxyuridine (BrdU) incorporation between explants cultured in the absence or presence of RA revealed that RA could modify the patterns of cell proliferation in the inner dental epithelium and dental mesenchyme. Inner dental epithelium cell proliferation is regulated by the dental mesenchyme through basement membrane-mediated interactions, and tooth morphogenesis is controlled by the dental mesenchyme. Laminin is a target molecule of retinoid action. Using a monospecific antibody, we immunolocalized laminin and/or structurally-related molecules sharing the laminin B chain in the embryonic dental mesenchyme and in the dental basement membrane and showed that RA could promote the synthesis or secretion of these molecules. Based on previous in situ hybridization data, it was speculated that CRABPs might regulate the effects of RA on embryonic dental cell proliferation. The fact that Ch55, a retinoid which does not bind to CRABPs, is 100 times more potent than RA in promoting tooth morphogenesis in vitro seems to rule out this hypothesis. On the other hand, the stage-specific inhibition of tooth morphogenesis by excess RA is consistent with the hypothesis that CRABPs might protect embryonic tissues against potentially teratogenic concentrations of free retinoids.

R-twist gene expression during rat palatogenesis.

Palatal clefting is often associated with premature fusion of cranial sutures in human craniosynostosis syndromes, many of which are characterised by mutations affecting the fibroblast growth factor receptor (FGFR) gene family. In palatal fusion, epithelio-mesenchymal transition (EMT) contributes to the dispersion of the midline epithelial seam. EMT has also been observed in neoplastic epithelial cells in relation to the acquisition of malignant characteristics where morphological changes are accompanied by rapid switching in the expression of fgfr2 from the epithelial type (kgfr) to the mesenchymal type (bek). The twist gene codes for a basic helix-loop-helix transcription factor putatively involved in regulation of transcription of fgfr2. Mutations in the TWIST gene have been described as being responsible for the Saethre-Chotzen syndrome, an autosomal dominant craniosynostosis associated with cleft palate as well as other disturbances of the facial skeleton. In this study we have analysed the distribution of twist transcripts during rat palatogenesis in vivo from 14.5 to 17.5 days post coitum by in situ hybridisation with digoxygenin-labelled ssDNA probes. twist transcripts were found to be concentrated in mesenchymal cells beneath the epithelium at the tip of the palatal shelves immediately prior to, and during fusion as well as in a localised epithelial area at the tip of the shelves prior to fusion, thereby implicating twist gene expression in the process of palatogenesis. This pattern of expression illuminates the disturbances of maxillary growth that occur in human craniosynostotic syndromes.

Midline fusion in the formation of the secondary palate anticipated by upregulation of keratin K5/6 and localized expression of vimentin mRNA in medial edge epithelium.

Secondary palatal fusion is dependent on targeted removal of the epithelium between the palatal shelves. Aseptically delivered rat embryos 15 through 18 days post coitum (dpc) were probed with DIG-labeled antisense and sense ssDNA probes for spliced exon sequences flanking intron E of cytokeratins K5/6 and spliced exon sequences flanking intron F of vimentin. Cytokeratin K5/6 expression was upregulated in the medial edge epithelium (MEE) prior to rotation of the palatal shelves and in the vomerine epithelium in the region of fusion with the palate. K5/6 expression continued in the medial epithelial seam (MES) and in epithelial islands during breakdown of the MES. Vimentin expression was not detected in the MEE prior to rotation but was specifically upregulated in the MEE following rotation and prior to midline contact and continued in the MES and in epithelial cells identifiable during the breakdown of the MES. Initiation of vimentin upregulation in the MEE prior to contact of the palatal shelves was tested by serum-free organ culture of palates from embryos at 15.5 dpc with the shelves separated by a biocompatible membrane. Vimentin upregulation occurred in the epithelium specifically in the region of anticipated contact. These results are interpreted as indicating that i) cytokeratin K5/6 expression may play a critical role in the integration of the epithelial layers of the MES to ensure subsequent merging of the mesenchyme and ii) epithelial cells in the MEE are specifically 'primed' to upregulate expression of mesenchymal genes prior to integration into and breakdown of the MES.

Roles of retinoic acid receptors and of Hox genes in the patterning of the teeth and of the jaw skeleton.

Retinoic acid receptors and transcriptional factors encoded by Hox genes play key roles in vertebrate development and belong to an integrated functional network. To investigate the actual functions of these molecules during ontogenesis and in particular in the patterning of the cranial neural crest cells giving rise to the teeth and to the jaw bones, we have generated null mutant mice lacking functional retinoic acid receptors or Hox genes by gene targeting in embryonic stem cells.

In vitro effects of retinoic acid on mouse incisor development.

The developing dentition is known to express the complete set of retinoic acid (RA) nuclear receptors and cytoplasmic RA-binding proteins (CRABPI and II), and RA is required for in vitro mouse molar morphogenesis, so the role of RA during in vitro mouse incisor development was investigated. Histological procedures, immunocytochemical detection of proliferating cells, immunofluorescence detection of laminin, and in situ hybridization with RNA probes for CRABPI and II were done on the tooth-germ cultures either in the presence or in the absence of RA. RA appeared to control initial morphogenesis, particularly the asymmetrical growth of the cervical loop, and to regulate required differential mitotic activity. RA seemed also to be involved in asymmetrical laminin deposition. The distribution of the CRABP gene transcripts was similar during in vivo and in vitro incisor development. However, CRABPI gene transcript distribution in the labial part of the epithelial loop was detected in vitro only in the presence of RA. A direct role of the CRABPs during tooth development is, however, unlikely because Ch55, a synthetic RA analogue that does not bind to CRABP, had the same effects as RA on in vitro incisor development.

Septo-optic dysplasia, subglottic stenosis and skeletal abnormalities: a case report.

We report a girl with septo-optic dysplasia in association with subglottic stenosis, sagittal craniosynostosis, osteoporosis and dental anomalies. It is uncommon for patients with septo-optic dysplasia to have multiple, extra-cranial malformations. A number of differential diagnoses were considered in this case, including Cole-Carpenter syndrome, Pfeiffer syndrome and osteoglophonic dwarfism. However, none can account for all the abnormalities seen. We therefore believe that this is a previously unreported, but highly distinctive, phenotype.

Galactosylceramide lipidosis (Krabbe's disease) and deciduous dental tissues. A case report.

The deciduous teeth of a 5-year-old girl affected by a protracted type of infantile globoid-cell leukodystrophy or Krabbe's disease, a galactosylceramide lipidosis, were examined with the scanning and transmission electron microscopes. The diagnosis was established on the basis of galactosylceramidase activity (0.04 mu katal/kg proteins versus 0.86 +/- 0.49 in the normal situation) and abnormalities in the white matter and trouble in myelinization assessed by magnetic resonance imaging. In spite of the fact that enamel, dentin and pulp are extraneural tissues, they were also affected by the disease. Ultrastructural observations of dental mineralized tissues revealed enamel hypoplasia as well as abnormal proteinaceous lamina and hypomineralized lines or bands. Inside the mantle dentin, dendritic inclusions of amorphous material were seen. Lysosomal storage inclusions were observed in all the cells of the dental pulp. The myelin sheaths of dental peripheral nerves displayed severe degenerative changes. Proliferation of dentinoclasts contributed to stimulate root resorption.

Case report: Macrodont mandibular second premolars, a hereditary dental anomaly.

BACKGROUND: Macrodontia or megadontia is a rare dental anomaly that refers to teeth that appear larger than normal. Generalised macrodontia may be associated with certain medical conditions and syndromes. Isolated macrodontia involves single teeth, might be the result of teeth fusion and is mainly seen in the incisor area. CASE REPORTS: This paper describes two unrelated cases presenting with bilateral macrodont second lower premolars and the treatment provided. One case demonstrated the anomaly in both the patient and his father. CONCLUSION: This case report suggests for the first time in the literature the genetic aetiology and heritability, as a possible autosomal dominant trait, of this rare dental anomaly.

Homozygous and compound heterozygous MMP20 mutations in amelogenesis imperfecta.

In this article, we focus on hypomaturation autosomal-recessive-type amelogenesis imperfecta (type IIA2) and describe 2 new causal Matrix metalloproteinase 20 (MMP20) mutations validated in two unrelated families: a missense mutation p.T130I at the expected homozygous state, and a compound heterozygous mutation having the same mutation combined with a nucleotide deletion, leading to a premature stop codon (p.N120fz*2). We characterized the enamel structure of the latter case using scanning electron microscopy analysis and microanalysis (Energy-dispersive X-ray Spectroscopy, EDX) and confirmed the hypomaturation-type amelogenesis imperfecta as identified in the clinical diagnosis. The mineralized content was slightly decreased, with magnesium substituting for calcium in the crystal structure. The anomalies affected enamel with minimal inter-rod enamel present and apatite crystals perpendicular to the enamel prisms, suggesting a possible new role for MMP20 in enamel formation.

From the transcription of genes involved in ectodermal dysplasias to the understanding of associated dental anomalies.

Orodental anomalies are one aspect of rare diseases and are increasingly identified as diagnostic and predictive traits. To understand the rationale behind gene expression during tooth or other ectodermal derivative development and the disruption of odontogenesis or hair and salivary gland formation in human syndromes we analyzed the expression patterns of a set of genes (Irf6, Nfkbia, Ercc3, Evc2, Map2k1) involved in human ectodermal dysplasias in mouse by in situ hybridization. The expression patterns of Nfkbia, Ercc3 and Evc2 during odontogenesis had never been reported previously. All genes were indeed transcribed in different tissues/organs of ectodermal origin. However, for Nfkbia, Ercc3, Evc2, and Map2k1, signals were also present in the ectomesenchymal components of the tooth germs. These expression patterns were consistent in timing and localization with the known dental anomalies (tooth agenesis, microdontia, conical shape, enamel hypoplasia) encountered in syndromes resulting from mutations in those genes. They could also explain the similar orodental anomalies encountered in some of the corresponding mutant mouse models. Translational approaches in development and medicine are relevant to gain understanding of the molecular events underlying clinical manifestations.

Oral health of children with intractable epilepsy attending the UK National Centre for Young People with Epilepsy.

AIM: To investigate the oral health of children with intractable epilepsy attending the UK National Centre for Young People with Epilepsy. STUDY DESIGN AND METHODS: 39 children and adolescents with intractable epilepsy at a residential school, the UK National Centre For Young People With Epilepsy (NCYPE) were age, gender and ethnicity matched with 39 healthy children from local schools in Surrey (England). Dental examinations were completed for indices for both the primary and permanent dentitions comprising decayed, missing and filled teeth and surfaces, plaque index, gingivitis index, developmental enamel defects, and incisor tooth trauma. RESULTS: There was no significant difference in the dmfs, dmft, DMFS or DMFT in the children with epilepsy compared with the controls. There was a significantly greater mean plaque score associated with permanent teeth in the children with epilepsy 68.0 SD+/- 31.5, compared with the control children, 142.9 SD+/- 23.2, p<0.0001. The mean +/- SD gingivitis score was significantly greater in the children with epilepsy 47.9+/-33.8, compared with the control children, 15.85+/-21.8, p<0.001. A significantly greater number of children with epilepsy had experienced anterior tooth trauma, 54% in all, compared with the controls, 12.5% p<0.0001. Although children with epilepsy had greater mean plaque and gingivitis scores, the prevalence of dental caries was low. Children and teenagers with intractable epilepsy were more likely to have sustained dental trauma than controls. CONCLUSIONS: A dental service aimed at early attention to anterior tooth trauma is needed. In addition, there is an ongoing need for improving the oral hygiene of these individuals to prevent the development of periodontal disease in later life.

Oro-dental features as useful diagnostic tool in Rubinstein-Taybi syndrome.

Rubinstein-Taybi syndrome (RTS; OMIM # 180849) is a well-known disorder characterized by mental and growth retardation, broad thumbs and great toes, and unusual facial characteristics. We studied oro-dental findings in a group of RTS patients: 12 from the UK, 2 from Greece, and 26 from France. All were examined by two investigators, using the Diagnosing Dental Defects Database record form to document these. Various oro-dental features were found: small mouth, retrognathia, micrognathia, highly arched and narrow palate, talon cusps, expressed crowding, screwdriver incisors, cross bites, and enamel hypoplasia. Eruption was usually normal. Specific attention for these anomalies should facilitate diagnosis and help adequate management.