TOOTH ERUPTION

&
SHEDDING
 CONTENTS
Introduction
Definition
Pattern of tooth movement
Preeruptive tooth movement
Eruptive tooth movement
Posteruptive tooth movement
Theories of tooth eruption
Clinical considerations
 Shedding
Definition
Pattern
Histology
Mechanism
Clinical considerations
Chronology of human dentition
References
 INTRODUCTION

The word eruption properly refers to the cutting of the tooth

through the gum.

It is derived from the Latin word erumpere, meaningto

breakout.

The emergence of the tooth through the gingiva is the first

clinical sign of eruption.
 DEFINITION

Maury Massler and Schour (1941) defined eruption as a

process whereby the forming tooth migrates from its
intraosseous location in the jaw to its functional position
within the oral cavity.
Osborne concluded that eruptive movement is defined as
the axial movement of the tooth which brings the crown of
the tooth from its developmental position within the bone of
the jaw to its functional position in the occlusal plane.
James K Avery defined eruption as the movement of the
teeth through the bone of the jaws and the overlying mucosa
to appear and function in the oral cavity.
 Pattern of tooth movement

Phase 1: The pre-eruptive phase.

Phase 2: The prefunctional eruptive or eruptive phase.

Phase 3: The functional eruptive or posteruptive phase.

 Pre-eruptive phase.

The pre-eruptive phase of tooth movement is preparatory to the

eruptive phase.

It consists of the movement of the developing tooth germs

within the alveolar processes prior to root formation.

During this phase, the growing tooth moves in two directions

to maintain its position in the expanding jaws viz. bodily
movement and eccentric movement.
 Bodily movement, which occurs continuously as the jaw grows,
is a movement of the entire tooth germ.
This causes bone resorption in the direction of tooth movement
and bone apposition behind it .
 Eccentric growth refers to relative growth in one part of the
tooth while the rest of the tooth remains constant.
 During the early pre-eruptive phase, the successional permanent teeth
develop lingual and near to occlusal level of their primary
predecessor.

But at the end of this phase, the teeth are positioned lingually and
near the apical third of the primary anterior teeth.

The change in the position of the permanent tooth germ is mainly

due to the eruption of the primary teeth and the coincident increase in
the height of the supporting tissues.
 Eruptive Phase

The eruptive phase begins with the initiation of the root

formation and ends when the teeth reach occlusal contact.

Anatomic stages of tooth eruption: Given by Noyes and

Schour -
 Changes in Tissues Overlying Teeth
The initial changes seen in the tissues overlying the teeth,
prior to clinical emergence of the crown is the alteration of
the connective tissue of the dental follicle to form pathway
for the erupting teeth.

Histologically, the future eruption pathway appears as a

zone with decreased and degenerated connective tissue
fibers, cells, blood vessels and terminal nerves. These
changes are probably due to the loss of blood supply to this
area, as well as the release of enzymes that aid in
degradation of these tissues.
 An altered tissue space overlying the tooth becomes visible as an
inverted funnel shaped area with the follicle fibers directed towards
the mucosa. This is called the gubernacular cord .

This structure guides the tooth in its eruptive movements

 For successful tooth eruption, there must be some resorption of
the overlying bony crypt so that the tooth can erupt. This can be
considered as a part of remodeling growth.

Osteoclasts differentiate and resorb a portion of the bony crypt

overlying the erupting tooth.

The eruption pathway, which is at first small, increases in

dimension thus allowing movement of the tooth.

When the tooth nears the oral mucosa, the reduced enamel
epithelium comes into contact with the overlying mucosa.
 Simultaneously, the oral epithelial cells proliferate and fuse into one
membrane.

Further movement of the tooth stretches and thins the membrane over the
crown tip.

supply
At this stage, the mucosa becomes blanched because of the lack of blood
to the area.

The tooth that will erupt slightly remain stationary for few days and then
again erupt. In this manner, the supporting tissues are able to make
adjustment to the eruptive movement.

Each eruption movement result in more of the crown appearing in

the cavity and further separation of the attachment epithelium from
the enamel surface.
 Changes in Tissues around the Teeth
Initially the dental follicle is composed of delicate connective
tissue.

Gradually as eruptive movement commences, collagen fibers

become prominent, extending between the forming knot and the
alveolar bone surface.

The first noticeable periodontal fiber bundles appear at the

cervical area of the root and extend at an angle coronally to the
alveolar process.
 At the same time, the alveolar bone of the crypt is remodeled and
the bone fills into conform the smaller root diameter.

As the eruption proceeds, other collagen fibers bundles become

visible along the forming root.

These are then populated with fibroblasts and myo-fibroblasts,

with contractile capabilities.
 Very early in the eruptive process, periodontal fibers attach on
the root surface and in the alveolar bone as cementogenesis
proceeds.

Some fibers release as the tooth moves, and then reattach to

stabilize the tooth.

Alveolar bone remodeling continues during eruption, as the

tooth moves occlusally, the alveolar bone increases in height and
changes shape to accommodate the crown.
 Changes in Tissues Underlying Teeth

These changes take place in the soft tissue and fundic bone
(bone surrounding the apex of the root).

As the tooth erupts, space is provided for the root to lengthen,

primarily due to the crown moving occlusally and the increase
in the height of the alveolar bone.
 During the pre-eruptive and early eruptive phase, the follicular
fibroblasts and fibers are in a plane parallel to the base of the root.

The tooth moves rapidly in the socket during prefunctional eruption

than at any other period.

Fine bony trabeculae appear in the fundic area.

They compensate for tooth eruption, and provide some support at the
apical tissues.
 At the end of the prefunctional eruptive phase, when the tooth
comes into occlusion, about one-third of the enamel remains
covered by the gingiva, and the root is incomplete.

At this time, the bony ladder is gradually resorbed and one plate at
a time, to make space for the developing root tip.

This process takes place from 1 to 1.5 years in deciduous teeth and
from 2 to 3 years in permanent teeth.
 Posteruptive Phase

The posteruptive phase, begins when the teeth reach

occlusion, and continues for long as each tooth remains in the
oral cavity.

During this phase or process, the alveolar process increases in

height and the roots continue to grow.
 The most marked changes occur as the occlusion is established.
Alveolar bone density increases and the principal fibers of the
periodontal ligament establish themselves into separate groups
orient about the gingival third, the alveolar crest and the alveolar
surface around the root.
 Later in life, attrition may wear down the occlusal surfaces of the
teeth.

The teeth erupt slightly to compensate for loss of tooth structure and
to prevent over closure.

If the occlusal wear is excessive, cementum is deposited on the

apical third of the root.

It is deposited in the furcation region to compensate for the

hypereruption of teeth and some bone apposition occurs at the
alveolar crests.
 In addition to slight occlusal movement the teeth tend to move
anteriorly.

This is termed mesial drift and results in bone resorption on the

mesial wall of the socket and bone apposition on the distal wall.

This phase is characterized by movements of the tooth after it has

reached its functional position in the occlusal plane.
THEORIES OF TOOTH
ERUPTION
 Root elongation theory
According to this theory, the simplest and most obvious
mechanism of eruption would be that the crowns of the
teeth are pushed into the oral cavity by virtue of growth
and elongation of the roots.

Evidence for the theory: Root of tooth elongates as crown

erupts into the oral cavity.

Evidence against the theory: Rootless teeth often erupt

without the concomitant elongation of the root,
submerged teeth often continue the formation of their
roots but do not erupt.
 Pulpal constriction theory
This theory states that the growth of the root dentin and
the subsequent constriction of the pulp may cause
sufficient pressure to move the tooth occlusally.

Evidence for the theory: The pulp is progressively constricted

by growth of root dentine.

Evidence against the theory: Pulpless teeth erupts at the same

rate as the normal teeth, premolar will often jump into
occlusion after the premature extraction of the deciduous
molar without any appreciable growth of dentine or
pulpal constriction.
 Growth of periodontal tissues
Pull by surrounding connective tissue: Underwood suggests
that the connective tissue surrounding the tooth
may function in pulling the tooth into the oral cavity. This
theory is invalidated by histological examination of the
direction of the periodontal fibers during tooth eruption,
which shows that the periodontal fibers are being pulled by
the tooth and not vice versa.

Alveolar bone growth: Herman believed that the growth of the

alveolar bone might push or squeeze the tooth out of its
alveolus and into the oral cavity. However, X-ray and
histological sections show that the bone does not actually
touch the tooth. In addition, this mechanism can operate
only upon single conical roots but not on multirooted teeth.
 Resorption of the alveolar crest
Resorption of the alveolar crest would serve to expose the
crown of the tooth into the oral cavity.

This theory is not tenable since histological examination

shows that the alveolar crest is the site of the most rapid
and continuous growth of bone.
 Cellular proliferation theory
Noyes points out that the tremendous pressure, which is
evolved from cellular proliferation, provides the growing
plant with sufficient force to break through hard obstacles.

Similarly, the osmotic pressure and forces resulting from

cellular proliferation in the pulp and surrounding tissues
may account for the eruption of the teeth.
 Vascularity theory
Constant (1896) points out the fact that the tissues, which
lie between the developing tooth and its bony surrounding
possess a very rich vascular supply.

He said that the blood pressure exerted in the vascular

tissue which lies between the developing tooth and its bony
surroundings is the active mechanical factor in the process
known as eruption of teeth.

Evidence for the theory: Submerged teeth often erupt under

the influence of hyperemia, the hyperemia in periodontitis
causes a supraeruption of teeth.
Periodontal ligament contraction theory

Suggests that the contractile element within the

periodontal ligament, collagen constriction and
constriction due to fibroblasts are responsible.

Furthermore, there is evidence that the actual force

required to move the tooth is linked to the contractility of
fibroblasts.

When fibroblasts are plated onto silicone rubber, they

crawl about and in doing so create wrinkles or folds in the
rubber indicating that tractions forces are associated with
locomotion.
 A model system consisting of a well, lined by a
perforated mesh (mimicking the cryptal bone) and
containing a gel plated with fibroblasts and a slice of
root dentin has shown that not only there is three
dimensional network established but also this network
generates sufficient force to raise the root slice from the
bottom to the top of the well.
 Bony remodeling theory
Bony remodeling of the jaws has been linked to tooth
eruption as in the pre-eruptive phase; the inherent growth
pattern of the mandible or maxilla supposedly moves teeth
by the selective deposition and resorption of the bone in
the immediate surroundings of the tooth.

When the developing premolar is removed without

disturbing the dental follicle, an eruptive pathway still
forms overlying the enucleated tooth.

Whereas, if the dental follicle is removed no eruptive

pathway is formed.
 Furthermore, if the tooth germ is replaced by a metal or
silicone replica, and the dental follicle is retained the
replica will erupt, with the formation of an eruptive
pathway.

These observations clearly demonstrate that

programed bony remodeling can and does occur, i.e.
an eruptive pathway forms in bone without a developing
and growing tooth. Second, they show that the dental
follicle is involved but perhaps only indirectly.
Clinical considerations
 Teething

Natal and neonatal teeth

Eruption cyst/eruption haematoma

Eruption sequestrum

Ectopic eruption

Epstein pearls,Bohn Nodules,and dental Lamina cysts

 Local and systemic factors that influence
eruption
Ankylosed teeth

Trisomy 21 syndrome(Down syndrome)

Cleidocranial Dysplasia

Hypothyroidism

Hypopituitarism

Achondroplastic Dwarfism
 Other causes
Fibromatosis gingivae

Albright hereditary osteodystrophy

Chondroectodermal dysplasia

De Lange syndrome

Frontometaphyseal dysplasia

Gardner syndrome

Goltz syndrome

Hunter syndrome
 Incontinentia pigmenti syndrome

Miller-Dieker syndrome

Progeria syndrome

Maroteaux-Lamy mucopolysaccharidosis

Familial hypophosphatemia

Bisphosphonate therapy on children with osteogenesis

imperfecta.
 TEETHING
A term limited by common usage to eruption of primary dentition

CLINICAL FEATURES OF TEETHING

LOCAL SIGNS

Hyperemia or swelling of the mucosa overlying the erupting teeth

Patches of erythema on the cheeks

Flushing may also occur in the skin of the adjacent cheek

SYSTEMIC SIGNS

General irritability & crying

Loss of appetite

Sleeplessness, restlessness

Increased salivation and drooling

Insanity

Meningitis

Increased thirst

Circumoral rash

Cough
 Natal teeth
These are extra teeth that are present at birth.
The most common natal teeth are lower incisors.

Treatment:
These teeth are defective and their removal is
generally recommended, particularly if mobility
poses a threat of aspiration.
These teeth also make feeding difficult.
 NEONATAL TEETH
These are primary teeth that erupt prematurely
(during the first few weeks of life).

Treatment:
These teeth are usually normal primary teeth and
should be retained. An x-ray will be taken if
possible to confirm that these are not extra
teeth.
 ERUPTION CYST (ERUPTION
HEMATOMA)
A bluish purple,elevated area of tissue,commonly calles an
eruption hematoma,occasionally develops a few weeks before
the eruption of primary or permanent tooth.
The blood-filled cyst is most frequently seen in primary
second molar or first permanent molar region.

This soft gingival swelling contains

considerable blood and can also be
designated as an eruption hematoma
 This condition develops as a result of trauma to soft tissue
during function.

Usually within a few days the tooth breaks through the

tissue,and hematoma subsides.

Because the condition is almost always self-limited,treatment

of an eruption hematoma is rarely necessary.

However, surgically uncovering the crown may occasionally

be done.
 ERUPTION SEQUESTRUM
A small spicule of nonvital bone may be seen
radiographically or clinically overlying the
crown of partially erupted permanent posterior
tooth.
The process is termed an eruption
sequestrum
Its occurs when the osseous fragment
becomes separated from the contiguous bone
during eruption of the associated tooth.

A radiopaque fragment of sequestrating bone

can be seen overlying an impacted third molar.
 ETOPIC TOOTH ERUPTION
Refers to the eruption of tooth in a position that is not its
normal position in the dental arch.
Prevalence - 5.6% & majority are permanent central incisors.
- In maxilla-often unilateral & mandibles it is bilateral.
TREATMENT
minimal deviation - extract the corresponding teeth allow
it to its normal position.
extensive deviation - an appliance can be used.
 Epstein pearls,Bohn Nodules,and dental
Lamina cysts
Fromm divided benign lesions into 3types on the basis of their
histopathology and position in oral cavity:
Epstein pearls are formed along the midpalatine raphe.They are
considered remnants of epithelial tissue trapped along the raphe as
the fetus grew.

Bohn nodules are formed along the buccal and lingual aspects of
dental ridges and on palate away from the raphe.The nodules are
considered remnants of mucous gland tissue and are histologically
different from Epstein pearls.
 Dental lamina cysts are found on crest of maxillary and
mandibular dental ridges.
The cysts apparently originated from remnants of dental
lamina.
 Paula et al made a simple classification which was
based on the location of these cysts in the oral cavity.

Palatal cyst located in the mid-palatine raphe.

Alveolar cysts located on buccal, lingual or crest

of alveolar ridge.

Dental Lamina Cyst in a Newborn Infant -A Rare Case

Report

Vasanthakumari A et al., Sch. J. Dent. Sci., Vol-3, Iss-2 (Feb,

2016), pp-71-73
 SHEDDING OF
DECIDUOUS TEETH
 Definition
The human dentition like those of most
mammals consists of two generations.

The first generation is known as the

deciduous dentition and the second as the
permanent dentition.

The necessity of two dentitions exists because

infant jaws are small and the size and number
of teeth they can support is limited.

The physiologic process resulting in the

elimination of the deciduous dentition is
called shedding or exfoliation.
 Pattern of Shedding

The shedding of deciduous teeth is the result of progressive

resorption of the roots of teeth and their supporting tissues.
 Resorption of Anterior Teeth
The position of the permanent anterior tooth germ is lingual to the
apical third of the roots of primary tooth hence the resorption is in
the occluso-labial direction, which corresponds to the movements
of the permanent tooth germ .
 Later the crown of the permanent tooth lies directly apical to
the root of primary tooth, which causes resorption to proceed
horizontally.

This horizontal resorption allows the permanent tooth to erupt

into the position of the primary tooth.
 Resorption of Posterior Teeth
The growing crowns of the premolars initially are situated
between the roots of the primary molars.
The initiation is by the resorption of the inter-radicular bone
followed by resorption of the adjacent surfaces of the root of
primary tooth .
 Meanwhile, the alveolar process is growing to compensate for
lengthening roots of the permanent tooth.
As this occurs, the primary molars move occlusally, this
allows the premolar crowns to be more apical.

The premolars continue to erupt until the primary molars

roots are entirely resorbed and the teeth exfoliate.

The premolars then appear in place of the primary molars.

 HISTOLOGY OF SHEDDING

Odontoclasts are resorbing cells

derived from monocyte -
macrophage lineage.

Giant multinuclear cells with 4-20

nuclei.

Resorption occurs at the ruffled

border which greatly increases the
surface area of the odontoclast in
contact with bone.
 Mechanism of Resorption and
Shedding

The exact causes of resorption and shedding of deciduous

teeth cannot be underlined however three main reasons have
been attributed to this which are loss of root, loss of bone and
increased force.

Kronfield was one of the first researchers to suggest role of

stellate reticulum and dental follicle in shedding mechanism.

As permanent teeth grow they exert pressure to induce

differentiation of osteoclasts and odontoclasts, which causes
resorption of hard tissues and supporting structures of root.
 Osteoclasts are bone resorbing cells derived form monocyte-
macrophage lineage with giant multinuclear cells with 4 to 20
nuclei. Osteoclasts cells have striated border and are housed in
Howships lacunae which attach to the resorbing front of hard
tissue and release acid phophatse.
 This disrupts collagen network and releases crystals which are
digested by the vacuoles of osteoclasts.

The disrupted collagen is then destroyed by fibroclasts.

 Resorption occurs at the ruffled border which greatly increases the
surface area where the osteoclasts are in contact with bone.

During the process of resorption the pressure form tooth is first

directed to the bone and following its resorption the forces are
directed to primary tooth.

Forces of mastication are also synergistically involved in the

mechanism of shedding.
 Due to growth and increased loading of jaws these forces far
exceed the limit that the deciduous tooth periodontal ligament can
withstand, thereby causing trauma to the ligament and the initiation
of resorption.

Recently Evlambia HH, 2007 demonstrated a new concept in the

shedding of primary teeth. He explained that this process is
regulated in the same manner as bone remodeling involving
receptor ligand system (RANK), i.e. receptor activator of
nuclear factor of kappa B, which stimulates osteoclast formation.
 CLINICAL CONSIDERATION

Remnants of deciduous tooth

Retained deciduous tooth

Submerged deciduous tooth

 Remnants of deciduous tooth

Sometimes parts of the roots of deciduous teeth are not in the path
of erupting permanent teeth and may escape resorption. Such
remnants may remain embedded in the jaw for a considerable time.

Most frequently -lower second premolars

Root remnants may later be found deep ankylosed to the bone

 Retained deciduous tooth
A deciduous tooth that remains in place beyond its normal
shedding time, owing to absence or retarded development of the
permanent tooth

Altered path of eruption of the permanent tooth

Non-resorption of the root of the

deciduous tooth
 Submerged deciduous tooth
Ankylosis - a dental situation in which the roots of primary teeth lose
their normal attachment to the bone (small ligaments) and
become fused directly to the bone. The cause of this is notknown,
but it is seen fairly often, particularly in lower primary molars.
Consequences-
malpositioning of the teeth on either side
super-eruption of the opposing tooth in the opposite dental arch
Of greater concern
disruption of the usual way that primary teeth lose their roots
CHRONOLOGY OF HUMAN
DENTITION
REFERENCES
 TEXTBOOK OF ORAL PATHOLOGY SHAFER, HINE & LEVY

TEN CATES ORAL HISTOLOGY- TEN CATE 5th EDITION

ORBANS ORAL HISTOLOGY AND EMBRYOLOGY 12th

EDITION

TEXT BOOK OF DENTAL & ORAL HISTOLOGY WITH

EMBRIOLOGY SATHISH CHANDRA 2nd EDITION

TEXT BOOK OF PEDODONTICS- SHOBHA TANDON 2nd

EDITION

Dental Lamina Cyst in a Newborn Infant -A Rare Case Report

Vasanthakumari A et al., Sch. J. Dent. Sci., Vol-3, Iss-2 (Feb, 2016), pp-
71-73

TEXT BOOK OF DENTISTRY FOR CHILD AND

ADOLESCENT_McDonald and Avery