Eruptive disorders of permanent teeth:

1. Chronological eruption disorders

2. Topographic eruption disorders

3. Disruption of eruption dynamics. Dental inclusion

1. Chronological:
LOCAL FACTORS: • superficial position of the dental bud;
• early extraction of the temporary tooth sometimes accelerates the eruption of the permanent successive tooth;
• periapical inflammatory processes of the temporary teeth, with accentuated risalysis;
• excess space on the arch.

GENERAL FACTORS: • endocrinopathies: hyperthyroidism, hypergonadism, hyperpituitarism;

• febrile diseases.
-late eruption causes:

2. Topographic:

3. Disorders of dynamics in tooth eruption ; inclusion

-Dental inclusion is the intraosseous or submucosal retention of a fully developed tooth beyond its normal eruption period, without
the possibility or tendency to erupt.
-In the literature there are various definitions:
I etiology:

A number of authors argue that local factors and general factors are incriminated in the etiopathogenesis of dental inclusion.

 According to Berger, local factors would be:

• irregularity of the position and pressure of the adjacent tooth;
• surrounding bone density;
• long-term chronic inflammation that results in increased density of the covering mucosa;
• lack of space on the arch due to underdevelopment of the mandible or maxilla;
• long-term persistence of temporary teeth
• necrosis due to local infectious processes.

 Among the general factors, Berger points out:

a) pre- and postnatal causes: • rickets; • anemia; • congenital syphilis; • tuberculosis; • endocrine dysfunctions;
• malnutrition.

b) rare causes: • cleidocranial dysostosis; • oxycephaly; • cleft lip and palate.

 According to Archer, the most logical explanation in dental inclusion is the gradual reduction of the evolutionary process of
dental arches with the lack of space on the arch for certain teeth. In maintaining this theory, the author notes the
congenital absence of the mandibular or maxillary wisdom tooth or their presence on the arch in a form often dwarfed,
rudimentary, at the eruption site.

 Brabant and Meyer consider as general causes including: • endocrine diseases; • dystrophic diseases; • avitaminosis.

Etiopathogenic factors also differ depending on the tooth interested in inclusion - for example, there are differences in the
etiopathogenesis of the inclusion of the lower wisdom tooth compared to the inclusion of the upper canine.

I local factors:
1. Disorders affecting the tooth during the period of development in bone thickness
• plication or elongation of the dental blade that places the tooth in depth (Brabant); • ectopic position of the tooth germ;
• modification of the tooth development axis;• coronary, radicular or corono-radicular malformations (fused teeth, recurved
• traumas or infections of the dental germ (fractures of the maxillary bones, spread of the infection from the temporary teeth).

2. Obstacles to tooth eruption:

• persistence on the arch, above the normal chronological limit, of the temporary tooth; • malposition of neighboring teeth;
• persistence of supernumerary teeth, erupted or included, on the eruption site of the permanent tooth;
• the presence of tumor formations in the way of tooth eruption (osteomas, odontomas, etc.);
• dense and recurrent fibro mucosa, gingival hyperplasia,

3. Reducing the space on the arch, through various mechanisms:

• primary dento-alveolar incongruity (macrodontia); • secondary dento-alveolar incongruity (by cross-inheritance);
• dental migrations secondary to early extractions of temporary teeth;
• skeletal growth deficits in dento-maxillary anomalies (maxillary compression syndrome, maxillary retrognathia, micrognathion
• the phylogenetic tendency of dimensional reduction of the skeletal bone structure,

4. Osteosclerosis of the alveolar process

• trauma; • inflammatory processes, especially at the level of the corresponding temporary tooth; • deforming osteitis,

II General factors:
• endocrine dysfunctions: hypothyroidism, pituitary dwarfism; • avitaminosis (especially avitaminosis D);
• metabolic disorders (rickets, anemia); • hereditary factors; • toxic causes (X-rays);
• chromosomal abnormalities (Down syndrome, Turner syndrome); • cleidocranial dysostosis;
• processes of osteosclerosis secondary to hypocalcemia and hyper fluorosis of the maxillary bones,

III frequency of inclusion: more common for permanent teeth (reinclusion of temporary)
1st Inferior molars, Upper canines,  Upper molars, The upper and lower two premolars.
 Inclusion may also be of interest to: Upper central incisors,Supernumerary teeth and, quite exceptionally, the lower canine, the 6-
year-old molar, the 12-year-old molar or other teeth,

III classification of inclusion

1. According to the morphological criterion, it is described:
• teeth included with crown and root shape abnormalities; • teeth included with corono-radicular angulation;
• inclusions of permanent, temporary or supernumerary teeth; • dental ankylosis of unerupted teeth.

2. According to the topographic criterion, the inclusions can be:

intraosseous dental inclusions; • submucosal dental inclusions; • symmetrical or asymmetrical dental inclusions

3. According to the etiology criterion, it is described:

• dental inclusion due to local cause; • dental inclusion due to general cause.

IV signs and diagnosis of inclusion:

-not specific signs and symptoms; MOSTLY , the clinical signs of dental inclusion go unnoticed for the individual and his family ;
externalized by the secondary pathological phenomena that it triggers, or the inclusion is discovered accidentally, on the occasion
of a radiological examination of the neighboring regions.
clinical signs:

-To the mentioned clinical signs can be added

added to secondary pathological phenomena
sometimes triggered by the included teeth.casue
complications .

The inclusion is, in many cases, discovered by

chance, most frequently when performing an
overall radiograph of the dento-maxillary
apparatus, the orthopantomogram

The main data on dental inclusion are provided by the radiological investigation

The knowledge of these data is indispensable for

the elaboration of the diagnosis and, depending
on the type of pathology, the choice of the
therapeutic conduct: dental extraction
(extraction technique) or interdisciplinary
surgical-orthodontic treatment of bringing the
included tooth to the arch

Regardless of the type of tooth remaining included, it is preferable that the radiological assessment be made in the whole dento-
maxillary apparatus and not in isolation, not only for a correct diagnosis, but also for establishing the type of therapeutic
intervention.
- Belot incidence was designed to assess the relationship between the upper wisdom and the maxillary sinus. the film is placed in
the occlusal plane and supported by biting by the patient. The beam will be oriented centered on the molar, making a 60° angle with
the film. This incidence introduces a degree of distortion.

- The incidence of Donovan is indicated in the inclusion of the lower wisdom tooth, to evaluate its transverse ratios, especially with
the lingual cortex, which may be fractured in the odontectomy of the lower third molar to obtain a quality occlusive radiograph,
radiological film, which is also relatively large, must be inserted very deeply.

- CBCT provides a high resolution image, in a single plane, the one of interest to the doctor has the advantage that the anatomical
planes do not overlap, so a special accuracy in assessing the position and neighborhood ratios of the included tooth.

-In addition, compared to conventional CT techniques, the degree of irradiation of the patient is much lower: 50 μSv, which is 1/10
of the radiation dose of a classic CT, and is the equivalent of the irradiation to which the patient is exposed when performing the
generalized status also allows 3D reconstruction.

V Disorders associated with eruption and / or dental inclusion

1. SEPTIC COMPLICATIONS: The first and most important septic complication is pericoronitis, caused by infection of the
pericoronary sac. Pericoronitis or operculitis (after Laskin) is the starting point for other septic complications in the soft perimaxillary
parts, in the bone, in the lymph nodes and remote.

2. Mechanical complications:
• complications at the level of neighboring teeth: rotations, torsions, dento-alveolar incongruity, carious lesions, going as far as
mortifications by damaging the vascular-nervous package.
- A classic example is the root risalysis (=root destruction) of the upper lateral incisor and / or its distoinclination, including the
upper canine. Inclusion of the wisdom tooth can cause tipping, carious lesions, or permanent distal root of the second molar;
• mandibular fractures - the inclusion of the lower wisdom tooth can be a favorable factor in the production of mandibular
fractures, because the inclusion is an area of minimal resistance.
• difficulties in prosthetic edentations where the phenomenon of bone resorption can cause the so-called passive eruption of the
included teeth, which leads to tipping of the prostheses or pressure sores caused by them.

* The lower molar of the mind erupting or remaining in the intraosseous inclusion can cause a series of disorders and accidents at
the dental level, at the level of the jugal mucosa or at the level of the tongue, which we will group according to the type of induced
pathology. At the level of neighboring teeth, we can find dental pathology:
• due to the pressure exerted -> carious lesions may appear;
• pulpal mortifications and root resorptions of the 12-year-old molar by the same mechanism.

3. Trophic disorders : are vasomotor disorders related to reflex nerve irritation - caused by a difficult eruption of an included
tooth.
These disorders are odontiasis or neurotrophic gingival stomatitis.
It appears suddenly in the absence of any pericoronal suppuration, highlighted by the part of the erupting wisdom tooth.
It is painful and characterized by the appearance of ulcers covered by white-yellow deposits, little adherent, consisting of
remnants of shattered mucosa. When they are detached, a slight hemorrhage occurs.
The ulcers are found on the mucous membrane, but also on the mucosa of the cheek and the pillars of the palatal veil, the lesion
being strictly unilateral.
This gingiva-stomatitis can take a simple congestive form, but can go as far as an ulcerative-membranous gingiva-stomatitis or even
ulcer necrotic. Dental gingiva-stomatitis is caused by a vasomotor disorder of a neuro-reflex nature related to the irritation caused
by the difficult eruption of the lower wisdom tooth, which alters the trophicity of the mucosa.

4. Nervous disorders: most frequently in the eruption or inclusion of the wisdom tooth, there may be sensitive manifestations
such as dental neuralgia, cervico-facial pain, or motor, such as trismus and muscle contracture.
Various nervous disorders may occur during the difficult eruption of the lower molar, an eruption accompanied or not by
inflammatory reactions. The region where the molar evolves, through its contiguity with the lower alveolar nerve, is a reflexogenic
area.
-Sensitive disorders, such as: • dental neuralgia; • dento-cutaneous synalges; • otalgia; • cervico-facial pain.
-Motor disorders: • trismus; • muscle contractions of the facial muscles; • facial paralysis.
-Salivary disorders through the participation of the sympathetic system: • sialorrhea; • asialia.
5. Tumor complications: dental inclusion can be incriminated in the appearance of tumor formations: mandibular cysts, follicular
cysts, marginal cysts or adamantinomas.

The inclusion of the lower wisdom tooth is sometimes associated with or favors the appearance of cysts or benign odontogenic
tumor formations, frequently located at the level of the mandibular angle and branch:
• follicular cyst; • keratocyst; • ameloblastoma; • odontoma, etc.
-The existence of these cysts or odontogenic tumor formations can cause complications, such as:
• suppurations of the fascial spaces and fistulas by infecting the cyst;
• tumor ulceration by trauma caused by antagonistic teeth;
• mandibular angle fractures (pathological bone fractures) due to extensive bone demineralization.

VI ETIOPATHOGENESIS OF ACCIDENTS AND COMPLICATIONS OF ERUPTION / INCLUSION OF THE LOWER WISDOM TOOTH

a) Topography of the eruption site and molar morphology included:

• inclusion at the normal place of eruption; • ectopic inclusion with eruption in the angle of the mandible, ascending branch, etc.;
• eruption in abnormal position with inclinations in the axis (mesial, distal) with lingual or vestibular deviation;
• globular crowns associated with lack of space and eruption in abnormal position; • the relationship with the second molar.

b) The existence of the pericoronal space, virtual cavity, around the crown of the tooth, which, under the action of various
factors, can turn into a real cavity.

c) The mucosal cap (operculum) which represents the main favoring element, in the occurrence of accidents and septic
complications of the inclusion of the lower wisdom tooth. This cap makes a "pocket", and in the space between the occlusal surface
of the included molar and the mucosa, by retaining food debris, optimal conditions for the development of pathogens (especially
anaerobes) are created, favoring the appearance of septic complications. The mucous membrane cap may be thin, stretched,
covering the occlusal surface as a "table face" or may be thick, covering the occlusal face as a "curtain".

d) Opening the follicular sac in the oral environment and grafting the septic process from the 12-year-old molar.

E ) General factors: include the infection of the follicular sac, which can occur in a general, endogenous way, especially during
diseases that lower the immune threshold.
*septic: These have as a starting point the infection of the included pericoronary sac of the included molar causing pericoronitis
(operculitis), a mild septic suppuration that can be complicated or aggravated leading to septic complications, some very serious.
- The first and most important septic complication caused by the eruption of the lower wisdom tooth is pericoronitis called Laskin
and operculitis.
- is a septic process of the pericoronal sac that is the starting point of other septic complications in the soft perimaxillary parts, in
the bone, in the ganglia and remote.
*how septic complication occurs: :
• through a trauma that produces a solution of continuity and a communication of the coronary sac with the oral cavity;
• from a complicated gangrene of the neighboring teeth; • from a periodontal bag in the vicinity;
• from an outbreak of osteomyelitis; • by a decubitus injury caused by a mobile prosthesis; • in the blood in infectious diseases.
• by a large atrophy of the alveolar process in edentulous, which can lead to the opening of the coronary sac;

*what is participating in septic complication:

From a microbiological point of view, the germs that cause pericoronaritis are saprophytes, the same ones found in the gingival
sulcus. They are species of gram-positive aerobic cocci and gram-negative anaerobic cocci. Because the oral flora is a combination
of aerobic and anaerobic bacteria, it is not surprising to find in both odontogenic infections both aerobic and anaerobic flora.
Peterson shows in a statistical study that infections caused by aerobic germs account for about 5% of all odontogenic infections,
those with anaerobic germs 35%, and mixed infections 60%.
- Pericoronaritis forms: congestive & suppurative

A. MILD SEPTIC COMPLICATIONS 1. congestive pericoronitis : between 18-25 years old, “alarm”, spontaneus pain, variable
intensity, serum bloodu mucus membrne cup, swollen mucosa, hyperemic, may evolve to supprative
2. suppurative pericoronitis (*it can be complicated leading to severe septic complications)-
febrile ,loss of appetite, embarrassment in swallowing and trismus., The crown can be palpated with a dental probe. By spontaneous
evacuation of purulent secretion, complications in the soft perimaxillary parts, in the maxillary bones, in the lymph nodes or remote.

* complications of pericoronitis: The particularities of location, onset and evolution of suppurative processes due to suppurative
pericoronitis of the lower wisdom tooth are determined by:
• morphological characteristics of the region - the orientation of the roots in relation to the bone plates, the existence of lodges
that communicate with each other;
• type and virulence of causal germs;
• the patient's reactivity and terrain.
* Pericoronaritis, through the septic process it maintains, can be the starting point of osteitis and / or mandibular osteomyelitis.
However, these bone complications remain quite rare.
The septic process can spread to the bone by:
• periosteal - following infections of the peri mandibular tissues;
• ligamentary, the infection spreading along the roots, through the dissociated alveolo-dental ligaments;
• directly through the pericoronary sac into the deep inclusions.
Under the incidence of the chronic infectious process, hypertrophic osteitis with bone proliferative reaction or even osteomyelitis
can occur.

 Frequent involvement of the submandibular lymph nodes, geniuses and sometimes pretragians in the septic process due to
suppurative pericoronitis causes the appearance of acute or chronic adenitis.

 In addition to regional infectious complications in which infection spreads from close to close, many remote septic
complications can occur, such as cavernous sinus thrombophlebitis, septic pulmonary complications, or sepsis.

B. SEVERE SEPTIC COMPLICATIONS 1. soft parts - infections of the primary and secondary fascial spaces;
2. bone complications - osteitis, osteomyelitis;
3. lymph node complications - acute and chronic adenitis;
4. remote septic complications - cavernous sinus thrombophlebitis, pulmonary, septicemia

f. orthodontic pathology: • dento-alveolar incongruity with crowding in the region of the lower frontals;
• dental movements with lingual or vestibular rotation;
• factor blocking the evolution of the second molar;
• malocclusions due to dento-alveolar incongruity;
• proalveolar recurrence factor.

 To these are added the secondary complications, represented by periodontopathies due to the dento-alveolar incongruity
and / or disturbances in the ATM dynamics.

 At the level of the jugal mucosa and tongue, through chronic irritation, ulcerative lesions may appear, either at the level of
the jugal mucosa or at the level of the presulcal region of the tongue.

 These ulcerative lesions often lend themselves to confusion with various types of malignancies during the onset.