|Year : 2015 | Volume
| Issue : 4 | Page : 559-562
Comprehensive dental management in a Hallermann-Streiff syndrome patient with unusual radiographic appearance of teeth
O Erken Gungor1, B Guzel Nur2, H Yalcin1, H Karayilmaz1, E Mihchi2
1 Department of Pedodontics, Faculty of Dentistry, Akdeniz University, Antalya, Turkey
2 Department of Pediatric Genetics, Faculty of Medicine, Akdeniz University, Antalya, Turkey
|Date of Acceptance||24-Sep-2014|
|Date of Web Publication||13-May-2015|
Department of Pediatric Genetics, Faculty of Medicine, Akdeniz University, Antalya - 07058
Source of Support: None, Conflict of Interest: The authors certify that they
have obtained all appropriate patient consent forms. In the form the patient(s)
has/have given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients understand that
their names and initials will not be published and due efforts will be made to
conceal their identity, but anonymity cannot be guaranteed.
| Abstract|| |
Hallermann-Streiff syndrome (HSS) is a genetic disorder characterized by proportionate dwarfism, birdlike facies, hypotrichosis, skin atrophy, dyscephaly, bilateral microphthalmia, congenital cataracts, a narrow, weak, beaked nose, a hypoplastic mandible, and orodental anomalies. Occurrence is sporadic and distinct patterns of inheritance have not been found. This case report describes the dental management of a 3-year-old girl patient with HSS, who had unusual radiographic appearance of teeth. Furthermore, dental treatments and a 30-month follow-up period of the patient with this rare tooth structure malformation have been presented.
Keywords: Dental anomalies, Hallermann-Streiff syndrome, orofacial characteristics
|How to cite this article:|
Gungor O E, Nur B G, Yalcin H, Karayilmaz H, Mihchi E. Comprehensive dental management in a Hallermann-Streiff syndrome patient with unusual radiographic appearance of teeth. Niger J Clin Pract 2015;18:559-62
|How to cite this URL:|
Gungor O E, Nur B G, Yalcin H, Karayilmaz H, Mihchi E. Comprehensive dental management in a Hallermann-Streiff syndrome patient with unusual radiographic appearance of teeth. Niger J Clin Pract [serial online] 2015 [cited 2019 Nov 15];18:559-62. Available from: http://www.njcponline.com/text.asp?2015/18/4/559/156910
| Introduction|| |
Hallermann-Streiff syndrome (HSS; OMIM 234100) is a genetic disorder characterized by proportionate dwarfism, bird-like facies, hypotrichosis, skin atrophy, dyscephaly (scaphocephaly or brachycephaly with frontal bossing), bilateral microphthalmia, congenital cataracts, a narrow, weak, beaked nose, a hypoplastic mandible, and orodental anomalies.  HSS was first described by Aubry in 1893, Hallermann in 1948, and Streiff in 1950. This syndrome is also called oculomandibulofacial syndrome, Franηois syndrome, oculomandibulodyscephaly with hypotrichosis, Aubry syndrome I, and Ullric-Fremery-Dohna syndrome. ,,
Currently, the etiology of HSS is incompletely elucidated. Sclaroff and Eppley  suggested that it was a developmental disorder in the 5 th -6 th gestational week, correlated to either the first or second branchial arch syndromes, which affect ectodermal- and mesenchymal-derived structures. The incidence of the syndrome has been reported by Higurashi et al.  to be only one case in 27,472 newborn infants. Almost all cases are sporadic, and consequently, distinct patterns of inheritance have not been found.  Both sexes were affected equally. 
There have been more than 180 cases of HSS reported throughout the literature. , However, very few have addressed the orodentofacial features of the syndrome.
This case report describes the unusual radiographic appearance of teeth detected in both dentitions in a 3-year-old girl with HSS. Furthermore, the craniodentofacial findings, dental treatments rendered, and status after a 30-month follow-up period of the patient with this rare tooth structure malformation have been presented. The differential diagnosis of the syndrome and various treatment approaches are also discussed.
| Case Report|| |
A 3-year-old girl with a diagnosis of HSS by the Akdeniz University, Faculty of Medicine Department of Pediatric Genetics, was referred to our clinic for a mastication disorder, pain, and dental bleeding since 2 months.
She was born at the 38 th week of gestation by vaginal delivery, the third child of healthy nonsconsanguineous parents. Her birth weight was 2300 g, birth height was 48 cm, and head circumference was 35 cm (25-50 th centile). Her prenatal ultrasound showed micrognathia and retrognathia by the second trimester. No amniocentesis was performed. The medical history of her family was normal.
On physical examination, her weight was 11.6 g (<3 rd percentile), and height was 84 cm (<3 rd percentile). Proportionate short stature, brachycephaly, frontal bossing, microphthalmia, hypotelorism, strabismus, downs landing palpebral fissures, blue sclera, low set ears, long philtrum, small mouth, speech disorder, broad cheeks, hypoplastic nipples, left thumb shortening, and bilateral syndactyly of the 4 th and 5 th fingers were observed. Her face was characterized by a thin, sharp, and hooked nose, with microretrognathia, resulting in a characteristic birdlike appearance [Figure 1]. Furthermore, atrophic skin and sparse hair and eyebrows were noted.
|Figure 1 : Bilateral syndactyly of the 4th and 5th fingers and facial view of the patient|
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Her cranial radiograph revealed thin cranial bones, wormian bones, and microretrognathy. Her echocardiography detected a secundum atrial septal defect. Laryngomalacia, recurrent respiratory distress, and sleep apnea were also described in our patient's medical history. Both her abdominal ultrasonography and ophthalmologic examination were normal.
Her complete blood count and routine biochemistry tests for renal, liver, and thyroid function were within normal limits. Chromosome analysis of peripheral leukocytes using a high-resolution binding technique showed a normal 46, XX karyotype.
On intraoral examination, hypoplasias and attritions connected with hypoplasias were discovered in all of the deciduous teeth. In addition, caries in varying stages, most of them involving the pulp, were detected. Class II malocclusion and a high, narrow palate were revealed during the dental arch relation [Figure 2].
|Figure 3 : Radiographic examination revealed developmental malformations in the hard structures of teeth, causing a "ghost teeth" appearance|
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Radiographic examination revealed developmental malformations in the hard structures of the deciduous and permanent teeth (especially in dentin), causing a "ghost teeth" appearance [Figure 3].
|Figure 4 : Orthopantomographic view of the patient at the beginning of the dental treatment|
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Due to the good psychomotor development of the patient, she was cooperative during her first visit to our dental clinic, although she had a speech disorder. The IQ assessment of the patient was evaluated, and normal values were found. Thereafter, a dental treatment plan was established, and oral hygiene instructions and dietary recommendations were presented to her parents.
Restorative treatment of primary right mandibular first molar (84), endodontic treatments primary maxillary right and left central and lateral incisors (51, 52, 61, 62) and primary mandibular left first molar (74) and pulpotomy of primary maxillary right and left first molars (54, 64) were performed under clinical conditions [Figure 4] and [Figure 5]. Fluoride varnish was applied on the teeth during subsequent appointments; the patient was fully cooperative. Because of the known dental hypoplasia and developmental malformations of her teeth, exceptional care was taken not to damage any dental structures during treatment.
|Figure 5 : Periapical radiographies of the teeth after dental treatments|
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|Figure 6 : Intraoral appearance of the patient after 1 year for control visit|
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During the follow-up period, rapidly progressive root resorption was detected in endodontically-treated primary mandibular left first molar (74) and hence that at the end of 1 year, only some root fragments remained. The following year, an infection was found in primary maxillary right first molar (54) and root canal treatment was performed. Furthermore, progressive root resorption was detected in the primary maxillary anterior incisors (51, 52, 61, 62) that treated endodontically [Figure 6] and [Figure 7].
|Figure 7 : Orthopantomographic view of the patient after a 30 months follow-up|
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The patient, who is now 5 years old, is still followed-up for care of her deciduous teeth and guidance for healthy eruption of her permanent teeth.
| Discussion|| |
Franηois , listed seven positive and five negative findings to note for a diagnosis of HSS after reviewing 22 patients. Positive signs are dyscephaly and bird face appearance, dental abnormalities, hypotrichosis, atrophy of the skin localized to the head and nose, bilateral microphthalmia, bilateral congenital cataracts, and proportionate dwarfism. In addition, it was reported that patients diagnosed with HSS also demonstrate facial dysmorphism, low birth weight, and growth retardation. Our patient showed all the characteristic findings except bilateral congenital cataracts. Five negative signs were also described by Franηois , as differential diagnostic criteria for HSS. These include the absence of (I) auricular anomalies, (II) palpebral anomalies, (III) premature arteriosclerosis, arthrosis, deformities of joints, muscular atrophy, (IV) nail and extremity anomalies, and (V) mental retardation. No negative signs were seen in our patient.
The differential diagnosis of HSS from progeria and progeroid syndromes, mandibulofacial dysostosis, and pseudoprogeria is as follows. Progeria differs from HSS by having premature atherosclerosis, nail dystrophy, chronic deforming arthritis, acromicria, and normal ocular findings. Mandibulofacial dysostosis usually has ear anomalies and lower eyelid colobomas. Pseudoprogeria/HSS syndrome with an autosomal recessive trait shares similar findings, but it has a normal appearance at birth, psychomotor delay, and severe spastic quadriplegia. 
Orodental anomalies reported in the literature (50-85% of the cases) are microstomia, a small and retracted tongue, mandibular hypoplasia, a high arched palate, class II malocclusion, open bite, hypoplasia of deciduous and permanent teeth, absence of teeth, persistence of deciduous teeth, supernumerary teeth, natal teeth, malformed teeth, and severe and premature caries. ,,,, In our case, microstomia, a small and retracted tongue, mandibular hypoplasia, a high arched palate, class II malocclusion, open bite, hypoplasia of deciduous and permanent teeth, malformed teeth, and severe and premature caries were seen.
The hard tissues of the teeth were determined to be developmentally malformed, causing all deciduous and permanent teeth to have a radiological appearance of "ghost teeth." Until now, only one similar case had been reported. A 15-year-old girl had decreased thickness of enamel and dentin, markedly enlarged pulp chambers and stunted root canals, creating a "ghost teeth" view.  In addition, intraoral examination revealed hypoplasic teeth, similar to our case. There should be more case reports to determine the characteristic features of HSS.
In our patient, dental treatments were performed under local anesthesia because, in this syndrome, the greatest anesthetic challenge lies in the maintenance of the airway. Narrow upper airway associated with the craniofacial configuration, narrowing of the posterior oropharynx, and secondary glossoptosis can lead to complete airway obstruction. In addition, microstomia and an undeveloped temporomandibular joint can make laryngoscopy difficult. Severe respiratory embarrassment and obstructive sleep apnea were also noted. ,
Examination of the few publications available in the related dental literature shows that orthodontic/orthognathic, surgical, prosthetic (implants, prostheses, etc.), and conservative approaches are used to treat the patients' dental problems. ,, Each of these therapeutic approaches has its own advantages and disadvantages. Conservative treatment should initially be given preference, considering the multiple systemic abnormalities. Conventional treatments under local anesthesia, as performed in our patient, should be possible in several HSS patients. In the presence of various dental malformations and the high risk of caries, personalized oral health plans, and regular routine follow-up starting at the time of HSS diagnosis are of particular importance.
| References|| |
Sclaroff A, Eppley BL. Evaluation and surgical correction of the facial skeletal deformity in Hallermann-Streiff syndrome. Int J Oral Maxillofac Surg 1987;16:738-44.
Slootweg PJ, Huber J. Dento-alveolar abnormalities in oculomandi-bulodyscephaly (Hallermann-Streiff syndrome). J Oral Pathol 1984;13:147-54.
Parikh S, Gupta S. Orodental findings in Hallermann-Streiff syndrome. Indian J Dent Res 2012;23:124.
Higurashi M, Oda M, Iijima K, Iijima S, Takeshita T, Watanabe N, et al.
Livebirth prevalence and follow-up of malformation syndromes in 27,472 newborns. Brain Dev 1990;12:770-3.
Thomas J, Ragavi BS, Raneesha P, Ahmed NA, Cynthia S, Manoharan D, et al.
Hallermann-Streiff syndrome. Indian J Dermatol 2013;58:383-4.
Barrucand D, Benradi C, Schmitt J. François syndrome: Apropos of 2 cases. Rev Otoneuroophtalmol 1978;50:305-26.
Hennekam RC, Krantz ID, Allanson JE. Gorlin's Syndromes of the Head and Neck. 5 th
ed. New York, USA: Oxford University Press Inc.; 2010. p. 436-40.
Francois J. A new syndrome; dyscephalia with bird face and dental anomalies, nanism, hypotrichosis, cutaneous atrophy, microphthalmia, and congenital cataract. AMA Arch Ophthalmol 1958;60:842-62.
François J, Pierard J. The François dyscephalic syndrome and skin manifestations. Am J Ophthalmol 1971;71:1241-50.
David LR, Finlon M, Genecov D, Argenta LC. Hallermann-Streiff syndrome: Experience with 15 patients and review of the literature. J Craniofac Surg 1999;10:160-8.
Kirzioglu Z, Ceyhan D. Hallermann-Streiff Syndrome: A case report from Turkey. Med Oral Patol Oral Cir Bucal 2009;14:E236-8.
Jain V, Sethi U, Dua S, Ahuja A, Wali BG. Hallermann-Streiff syndrome: A rare case report.
J Indian Acad Oral Med Radiol 2011;23:237-40.
Defraia E, Marinelli A, Alarashi M. Case report: Orofacial characteristics of Hallermann-Streiff Syndrome. Eur J Paediatr Dent 2003;4:155-8.
Chee WW, Lee W. Hallermann-Streiff syndrome patient treated with removable prosthesis: A clinical report. J Prosthet Dent 2011;106:74-7.
Abadi BJ, Van Sickels JE, McConnell TA, Kluemper GT. Implant rehabilitation for a patient with Hallerman-Streiff syndrome: A case report. J Oral Implantol 2009;35:143-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]