Teeth eruption

Definition: It is the axial or occlusal movement of the tooth

from its developmental position within the jaw to its
functional position in the occlusal plane, begin in the bell
stage and continue throughout the life span of the tooth.

The developmental processes and factors that are related to the

eruption of teeth include:
• Elongation of the root.
• Forces exerted by the vascular tissues around and
beneath the root.
• Growth of the alveolar bone.
• Growth of dentin.
• Pulpal constriction.
• Growth and pull of the periodontal membrane.
• Pressure from the muscular action.
• Resorption of the alveolar crest.
•
Eruption Knowledge:
• Each tooth starts to move toward occlusion at
approximately the time of crown completion.
• By the time of clinical emergence approximately two
third of root formation had occurred. Teeth reach
occlusion before the root development is completed.
• Complete root formation of the deciduous teeth occurs
after tooth eruption by (1-1 ½years).
• Complete root formation of the permanent teeth occurs
after tooth eruption by 3 years.
• Start of resorption of the root of the primary tooth
usually occurs after complete calcification of the
permanent crown successors. So roots of primary teeth
persist without resorption about 1 ½- 2 years.
• Normal eruption ± 6 months is considered normal
(even if reach 12 months).
• From 6 months to 2½- 3 years all deciduous teeth are
exculpated in arch.
• From 3- 6 years occlusion and normal function are
maintained.
• From 6-12 years the mixed dentition period and the 1st
permanent molar erupt before the process of shedding.

Eruptive movement is divided in to:

A) Pre-eruptive phase:
• Begin in the early bell stage and end at root formation
time.
• Tooth germ moves as the jaw grow.
• During total bodily movement of tooth germ, osteoclastic
bone resorption followed by bone deposition of bone
crypt.
B) Eruptive phase:
• Begin at the time of root formation and end when the
teeth reach the occlusal plane.
• Root formation is initiated by proliferation of epithelial
root sheath of hertwig.
 • During this phase the tooth moves in axial-occlusal,
drifting, bodily movement, tilting or tipping, movement
or rotation movement.
C) Post eruptive phase:
• Begin when the tooth has reached its occlusal plane and
terminates at the end of life span of the tooth.

Sequence of Teeth eruption:

A) Primary dentition as follow:
• A, B, D, C& E
• Mandibular teeth usually proceed maxillary teeth
B) Permanent teeth
• In mandible, 6,1,2,3,4,5,7
• In maxilla 6,1,2,4,5,3 &7
• It is desirable that the mandibular canines erupt before
the first and second premolars. This sequence will:
1-maintain adequate arch length
2-prevent lingual tipping of incisors.

Variations in the Sequence of Eruption:

1- The mandibular first permanent molars are often the first
permanent teeth to erupt. They are quickly followed by the
mandibular central incisors.
2-There is no clinical significance in the eruption of the
incisors before the molars.

3- If the mandibular second permanent molar develops and

erupts before the second premolar, a deficiency in arch
length can occur. Eruption of the second permanent molar
out of sequence will exert a strong force on the first
permanent molar and will cause its mesial migration and
encroachment on the space needed for the second premolar.
4- In the maxillary arch the first premolar ideally should
erupt before the second premolar and the canine should
follow them. The premature loss of primary molars in the
maxillary arch, allowing the first permanent molar to drift
and tip mesially, will result in the permanent canine being
blocked out of the arch, usually to the labial side.
5- The eruption second permanent molar before the
premolars and canine can cause a loss of arch length, just as
in the mandibular arch.
6- The eruption of the maxillary canine is often delayed
because of an abnormal position or devious eruption path.
7- Teeth erupt in girls earlier than boys.

Lingual eruption of mandibular permanent incisors:

It is common for mandibular permanent incisors to erupt
lingually to retained 1ry incisors.
This is a source of concern for the patients as they discover a
double row of teeth.
However, this pattern should be considered essentially
normal
The primary teeth may:
• Have undergone extensive root resorption and may be
held only by soft tissues.
• In other instances, the roots may not have undergone
normal resorption and the teeth remain solidly in
place.
It is seen in both patients with:
• Obvious arch length inadequacy.
• In those with desirable amount of spacing of 1ry
incisors.
Management:

• It is not a role to extract.

• In cases, the tongue & continued alveolar growth seem
to play an important role in influencing the permanent
incisors into a more normal position with time (several
months)
• Even when mandibular permanent incisors erupt
rotated and staggered in position. The molding action
of the tongue and the lips improves their relationship
within a few months.
• Although there may be insufficient room in the arch
for the newly erupted permanent tooth, its position will
improve over several months
• --In some cases there is justification for removal of the
corresponding primary incisors especially when
lingually erupted permanent mandibular incisors are
seen in an older child and the radiograph shows no
root resorption of the primary teeth.
• If the condition is identified before 7 1/2 years of age
and when the patient is first seen in the dentist office
for this specific problem, it is unnecessary to subject
the child to the trauma of removing the primary teeth
because the problem is almost always self-correcting
within a few months.
• Extraction of other primary teeth is not recommended
because it will temporary relieve crowding & may even
contribute to the development of a more sever arch
length inadequacy
 Abnormalities of tooth eruption:

1) Teething and Difficult eruption:

In most children, the eruption of primary teeth is preceded

by increased salivation & child will want to put his hand &
fingers in mouth
Some young children become restless & fretful during the
time of eruption of the 1ry teeth
It causes
• Daytime restlessness.
• An increase in the amount of finger sucking or rubbing
of the gum.
• An increase in drooling.
• Possibly some loss of appetite.
In the past, many conditions, including croup, diarrhea,
fever, and even convulsions, were incorrectly attributed to
eruption.
The local signs: may be redness or swelling of gingiva over
erupting tooth
Since the eruption is normal physiological process, the
association of fever & systemic disturbance is not justified.
These should be considered coincidal to eruption process
rather than related to it.
Management:

• Inflammation of the gingival tissues before complete

emergence of the crown may cause a temporary painful
condition that subsides within a few days.
• The surgical removal of the tissue covering the tooth to
facilitate eruption is not indicated.
• The eruption process can be hastened by allowing the
child to chew on a piece of toast or clean teething object
• Parents should be discouraged from using proprietary
teething aids that contain mercurial compounds
• If the child is having extreme difficulty, the application
of a nonirritating topical anesthetic may bring
temporary relief.
• Topical anesthesia (equal parts of lidocaine ointment
and orabase) is applied to the affected tissue over the
erupting tooth 3-4 times / day

2) Eruption sequestrum:

Definition: It is a tiny spicule of nonviable bone overlying the

crown of an erupting permanent molar just before or im-
mediately after the emergence of the tips of the cusps
through the oral mucosa.
It is seen in the children at the time of eruption of 1st
permanent molars.
It may be develop from either:
• osteogenic (dentin & cementum)
• or odontogenic tissue (cementum like material within
the follicle)
The hard tissue fragment is generally overlying the central
fossa of the associated tooth, embedded & contoured within
the soft tissue
As the tooth erupts &t he cusps emerge, the fragment
sequestrates. After an eruption sequestrum has surfaced
through the mucosa, it can be easily removed if it causes
local irritation
As the base of the sequestrum is embedded in gingival tissue
when it is discovered, and a topical anesthetic or infiltration
of a few drops of a local anesthetic may be necessary to
avoid discomfort during its removal.

3) Eruption hematoma or cyst:

Definition: A bluish purple elevated area of tissue

occasionally develops a few weeks before eruption of
primary or permanent tooth
The blood-filled cyst is most frequently seen with primary
second molar or first permanent molar region.
Bluish color differs according to:
• Amount of blood present in the cavity.
• Thickness of overlying mucus membrane.

Management:
• The condition is self-limited & treatment is rarely
necessary
• However, surgical uncovering the crown may be
justified. Unless it might delay eruption or if there is a
trauma.
N.B: When the parents discover an eruption hematoma, they
may fear that the child has a serious disease such as a
malignant tumor. The dentist must reassure the parent that
the lesion is not serious.
4) Ectopic eruption:
Definition: Tooth erupt or try to erupt in abnormal position.
Causes:
• Arch length inadequacy.
• Tooth mass redundancy (large tooth and small jaws).
• Abnormal angulations of eruption path.
• Delayed calcification of first permanent molar.
• Or variety of local factors.
Frequently first permanent molar, in instances of otherwise
ideal occlusion may be positioned too far mesially in its
eruption with resultant resorption of distal root of second
primary molar
The permanent tooth may become completely locked & may
cause premature loss of second primary molar or make it
necessary to extract the affected tooth
Complication:

• Asymptomatic and discovered in radiographic

examination.
• The child may complain occasionally from neuralgic
pain in the area of impaction. Due to either break down
in epithelial attachment with ingress of oral fluid, pulp
infection, or resorption of adjacent roots.

5) Natal & neonatal teeth:

• The prevalence of natal teeth (teeth present at birth)
and neonatal teeth (teeth that erupt during the first 30
days) is low
• Occasionally one or more teeth are erupted at birth
and are described as natal teeth.
• The cause is often obscure but seems to be familial.
• They are usually members of normal series & not
supernumerary elements and found most commonly in
the mandibular incisor region.
 • The enamel is hypoplastic and since there is no root
formation at birth & the teeth are only loosely
attached

Management:
1. Since a natal tooth is a part of the normal dentition, it
should be retained unless it cause discomfort to mother
(if the baby is breast fed) or if it is so loose that it may
become dislodged & inhaled or the sharp incisal edge
of the tooth causes laceration of the lingual surface of
the tongue.
2. A radiograph should be made to determine the amount
of root development and the relationship of a
prematurely erupted tooth to its adjacent teeth. One of
the parents can hold the x-ray film in the infant's
mouth during the exposure
3. Root growth takes place normally after birth & the
attachment of the tooth improves gradually
5-Epstein pearls, Bohn Nodules & Dental Lamina
cysts
It is Small, white or grayish white lesions on the alveolar
mucosa of the newborn & may on rare occasions be
incorrectly diagnosed as natal teeth. -The lesions are usually
multiple but do not increase in size
No treatment is indicated, since the lesions are
spontaneously shed a few weeks after birth.
1. Epstein pearls are formed along the midpalatine
raphe. They are remnants of epithelial tissue
trapped along the raphe as the fetus grew.
2. Bohn nodules are formed along the buccal and
lingual aspects of the dental ridges and on the palate
away from the raphe. The nodules are remnants of
mucous gland tissue
3. Dental lamina cysts are found on the crest of the
maxillary and mandibular dental ridges. The cysts
originated from remnants of the dental lamina.
Epstein pearls are formed along the
midpalatine raphe.

Bohn nodules are formed along the buccal

and lingual aspects of the dental ridges
and on the palate away from the raphe.
 Factors influencing tooth eruption:

Local & systemic factors that influence eruption:

(A) Local factors:

1) Localized eruption delay:

It is more common in permanent than primary dentition
and some of its causes are:
1. Delayed resorption of primary incisors following
trauma & pulp death
2. Dilaceration of permanent incisors
3. Supernumerary teeth
4. Very early loss of primary tooth followed by formation
of bone in the tooth socket
5. Arch length defficency
6. Abnormal eruption path of maxillary canine
7.Impaction against other teeth due to abnormal
angulations or crowding
8.Retarded resorption of primary molar that has been
treated by pulpotomy
9.Ankylosed teeth

Ankylosed teeth:

Definition: Are in a state of static retention, whereas in the

adjacent area eruption & alveolar growth continue (this
gives it the picture of submerged tooth)
However the term submerged molar or infraocclusion is not
preferable to ankylosis.
The mandibular primary molars are teeth most observed to
be ankylosed -Ankylosis of the anterior primary teeth does
not occur unless there has been a trauma.
Causes:
• The cause of ankylosis in the primary molar areas is
unknown.
• But it follows a familial pattern.
 • There is a relation between it & congenital absence of
permanent teeth.
• Truma.
Mechanism:

A solid union develops between the bone & primary tooth

because normal root resorption of primary molars (which
begins on the inner surface or the lingual surface of the
roots) is not continuous but interrupted by periods of
inactivity in which repair takes place
This intermittent resorption and repair may explain the
varying degrees of firmness of the primary teeth before their
exfoliation
The ankylosed teeth are not mobile even in cases of
advanced root resorption
Ankylosis of the primary molar to the alveolar bone does not
occur until its root resorption begins.
• If ankylosis occurs early, eruption of adjacent teeth
progress while the ankylosed tooth is far below the
normal plane of occlusion and may be partially covered
with soft tissue.
•
• General Factors :- Ankylosis may occur before the
eruption and complete root formation of the primary
tooth.
• Ankylosis can also occur late in the resorption of the
primary roots and then can interfere with the eruption
of the underlying permanent tooth.

Diagnosis of an ankylosed tooth:

Is not difficult to make:
1. The opposing molars in the area are out of occlusion.
2. The ankylosed tooth is not mobile, even in cases of
advanced root resorption.
3. When taping on ankylosed tooth with a blunt
instrument it will have a solid sound whereas adjacent
normal tooth have a cushioned sound because it has an
 intact periodontal membrane that absorbs some of the
shock of the blow.
4. X-ray is a valid aid in its diagnosis (a break in the
continuity of periodontal membrane indicating an area
of ankylosis is evident in x-ray)

Treatment:
1. The eventual treatment may involve surgical removal
2. However, unless the caries problem is unusual, loss of
arch length is evident or interference with eruption of
premolars is evident, the dentist may choose to keep
the tooth under observation (a watchful waiting
approach).

N.B:
A tooth that is definitely ankylosed may at some future time
undergoes normal root resorption & become normally
exfoliated
Ankylosis of Primary Molars with Absence of Permanent
Successors
• Attempts are made to establish functional occlusion
with stainless steel crowns, overlays, or bonded
composite resins on the affected primary molars.
• This treatment is successful only if maximum eruption
of permanent teeth in the arch has occurred.
• If adjacent teeth are still in a state of active eruption,
they will soon bypass the ankylosed tooth
Ankylosed Permanent Teeth
 • The incomplete eruption of a permanent molar may be
related to a small area of root ankylosis.
• The removal of soft tissue and bone covering the
occlusal aspect of the crown is attempted first and the
area is packed with surgical cement to provide a
pathway for the developing permanent tooth.
• If the permanent tooth is exposed in the oral cavity and
at a lower occlusal plane than the adjacent teeth,
ankylosis is the probable cause. – --The luxation
technique is effective in breaking the bony ankylosis. If
the rocking technique is not immediately successful, it
should be repeated in 6 months.
• In the unerupted tooth, enamel is protected by enamel
epithelium. The enamel epithelium may disintegrate as
a result of infection (or trauma), the enamel may
subsequently be resorbed, and bone or coronal
cementum may be deposited in its place. The result is
solid fixation of the tooth in its unerupted position

2) Generalized eruption delay:

As in fibromatosis gingiva in which the thick coarse gingival

tissue interfere with teeth eruption.
 (B) Systemic factors:

1) 21-trisomy syndrome (mongolism or Down syndrome):

Definition: It is one of the congenital anomaly in which
delayed eruption of teeth frequently occurs
The first primary tooth may not appear until 2 years of age
& dentition may be not completed until 4-5 years of age
The eruption follows an abnormal sequence & some primary
teeth may be retained until 14 –15 year of age
The cause is Trisomy 21(3 number 21 chromosomes rather
than the normal 2 (diploid)).
The diagnosis of a child with Down syndrome is not usually
difficult to make because of the characteristic facial pattern:
1. The orbits are small, the eyes slope upward, and
depressed bridge of the nose.
2. Mental retardation is another characteristic finding,
with most children in the mild-to-moderate range of
disability
3. Smaller upper facial height.
4. Retardation in the growth of the maxillae and
mandible.
5. The smaller jaws contribute to protrusion of the tongue
and dental crowding (both of which may compromise
occlusion development). Their tongues tend to be
larger than normal.
6. High prevalence and severity of periodontal disease
Management:
They can be managed in the dental office in the same way
as other children but reduced resistance to infection
should be considered in the dental management of the
child with Down syndrome.

2) Cleidocranial dysotosis or dysplasia :

Definition: A rare congenital syndrome diagnosed by

absence of clavicle although there may be remnants of the
clavicles.
 • The fontanels are large, and radiographs of the head
show open sutures, even late in the child's life. The
sinuses, particularly the frontal sinus, are usually
small
• Real maxillary prominence or mandibular
prognathism.
• Development of dentition is delayed
• Complete primary dentition at 15 years of age due to
delayed resorption of deciduous teeth & delayed
eruption of permanent teeth is common
• Presence of supernumerary teeth in varying number
• Even with the removal of primary & supernumerary
teeth, the eruption of permanent teeth is often delayed
& irregular.

3) Hypothyroidism

a) Congenital hypothyroidism (cretinism):

Causes: It is the result of the absence or under development
of thyroid gland insufficient thyroid hormone.
Clinically:
• The child is a small and disproportionate person, with
abnormally short arms and legs. The head is
disproportionately large.
 • Obesity is common.
• Some disability is invariably associated with cretinism.
• The dentition is delayed in all stages including eruption
of primary teeth, exfoliation of primary teeth &
eruption of permanent teeth
• Teeth are normal in size but crowded in the jaws that
are smaller than normal
• The tongue is large and protrudes from the mouth. The
abnormal size of the tongue and its position cause an
anterior open bite and flaring of the anterior teeth.
• The crowding of the teeth( malocclusion) and mouth
breathing cause a chronic hyperplastic type of
gingivitis.
b) Juvenile or acquired hypothyroidism:
Causes: Results from malfunction of thyroid gland, usually
between 6-12 years of age
Since the deficiency occurs after the period of rapid growth,
there is not the unusual facial and body pattern that is
characteristic of a person with congenital hypothyroidism.

Clinically:

• However, obesity is evident to a lesser degree.

• Characterized by delayed exfoliation of primary teeth
& delayed eruption of permanent teeth
• A child with a chronologic age of 14 years may have a
dentition in a stage of development comparable with
that of a child 9 or 10 years of age.

4) Hypopituitarism (dwarfism)

Causes: Is the result of an early hypofunction of pituitary

gland.

Clinically:
 • The pituitary dwarf is a well-proportioned individual
but resembles a child of considerably lower chronologic
age.
• Some degree of cognitive disability often occurs.
• The dentition is essentially normal in size.
• Delayed eruption of dentition is characteristic
• In sever cases, the primary teeth do not undergo
resorption but instead may be retained through the life
of person
• The underlying permanent teeth continue to develop
but do not erupt
• Extraction of primary teeth is not indicated because
eruption of permanent teeth can not be assured.

5) Achondroplastic dwarfism
Etiology: is unknown, but may be an autosomal dominant
disorder
Clinically:
• Growth of extremities is limited due to lack of
calcification in cartilage of long bones
• The head is disproportionately large, though the trunk
is normal in size. The fingers may be of almost equal
length, and the hands are plump.
• Underdeveloped upper face &depressed bridge of the
nose
• Deficient growth in the cranial base.
• The maxilla may be small, with resultant crowding of
the teeth and a tendency for open bite.
• A chronic gingivitis is usually present. However, this
condition may be related to the malocclusion and
crowding of the teeth.
• The development of the dentition was slightly delayed.
•
6) Chondroectodermal dysplasia

Definition: It is an autosomal recessive disorder

characterized by short stature, skeletal abnormalities,
congenital heart defect, absence of anterior maxillary
mucobucal fold and notched alveolar ridge

The children have:

• Natal teeth.
• Hypodontia, and retarded eruption of teeth –the teeth,
which erupt, may be small, conical & have unusual
cusp form.

7) Gardner syndrome
It is a heritable disorder complex characterized by:
• Multiple osteoma.
• Multiple polyposis of large intestine.
• Multiple epidermoid &sebaceous cysts.
• Impacted teeth & delayed eruption.

8) Rickets
Causes:
Due to lake intake of ricketic food(vit.D,minerals)sunlight.
there is a delayed bone mineralization & teeth eruption
 Early exfoliation of teeth

Shedding or Exfoliation:

Definition: It is the physiological elimination of the

deciduous teeth as a result of resorption of their root prior
to the eruption of their permanent successors.
• Pressure from the growing and eruption of their
permanent tooth germ, odontoclast cell which
differentiate from loss connective tissue cells causing
root resorption of deciduous teeth mainly from lingual
surface.
• Odntoclast cause removal of minerals
(Demineralization of inorganic part) followed by
organic matrix dissolution (Disintegration of organic
part).

Variation in the time of eruption of the 1ry teeth and in the

time of exfoliation are frequently observed in the children
A variation as much as 18 month in the exfoliation time of
primary teeth is considered normal. However, this pattern
must be consistent with other aspect of the dental
development
The early exfoliation of the teeth merits a special attention
because it can be related to pathologic condition of local and
systemic origin

1) Familial fibrous dysplasia (cherubism):

Definition: A Symmetric or asymmetric enlargement of jaws

may be noted at an early age.
Features:
• Numerous sharp, well defined multilocular areas of
bone destruction & thinning of cortical plate of bone is
evident in x-ray
• Early exfoliation of the teeth in the involved area as a
result of interference in root development.
 • Asymetrical or symmetrical enlargement of jaw.

2) Acrodynia (pink disease):

Caused by: exposure of young children to minute amount of
mercury
Sources: Ointment, medication are the usual sources of the
mercury
Clinical feature: of the disease includes
• Fever,
• Anorexia.
• Desquamation of soles & palms.
• Sweating.
• Tachycardia.
The oral finding: Include
• Inflammation & ulceration of mouth.
• Excessive salivation,
• Loss of alveolar bone.
• Premature exfoliation of teeth

3) Hypophosphatasia:
The clinical dental findings diagnostic: of the disease in
children is
• Premature exfoliation of primary teeth (either
spontaneously or from slight trauma). There will be an
absence of gingival inflammation
• The loss of alveolar bone limited to anterior region
• Diagnostic test should include the determination of
serum alkaline phosphatase (N 13-17 king Armstrong
units)

4) Pseudohypophosphatasia:
Clinically:
• Seems to be hereditary.
• Resemble hypophosphatasia &
• Results in premature loss of primary teeth.
 • However the serum alkaline phosphatase level is
normal
• The patient exhibit Osteopathy of long bone &skull

4) Anomalous dental development

Defective root development as observed in the cases of

dentinal dysplasia and in shell teeth, can cause early
exfoliation of primary & permanent teeth

5) Cyclic neutropenia:

Clinically:
It is characterized by
• Periodic or cyclic diminution in polymorphonuclear
neutrophilic leukocytes
• the conditions spontaneously regress only to recur
subsequently in a in rhythmic pattern
• Children exhibit a sever gingivitis & ulceration with a
return of neutrophil count to normal, the gingiva
assumes a nearly normal clinical appearance
• In children with repeated insults of the infection, there
is a considerable loss of supporting bone around teeth
&this has sometimes been termed prepubertal
periodontitis

6) Acatalasia:

Definition: In acatalasia there is a deficiency of catalase

enzyme which present normally in blood & mucous
membrane.
Clinical consequence
1. The chemical reaction of hydrogen peroxide catalyzed
by catalase enzyme.
2.
 2H2O2 2H2O + O2

3. Thus individuals with abnormal enzyme do not

metabolize peroxides
4. These individuals show sever a gangrenous stomatitis
leading to early exfoliation of teeth

8) Hperpituitarism: Accelerate bone resorption.

9) Juvenile diabetes: Patient liable to infection with gingival

inflammation lead to bone loss and then early exfoliation.