R eview Article

DELAYED TOOTH ERUPTION

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Faizal C Peedikayil Professor, Department of Pedodontics Kannur Dental College and Hospital.
Correspondence: Faizal C Peedikayil Professor, Department of Pedodontics Kannur Dental College and Hospital Anjarakandy, Kannur,
Kerala, India. Email: drfaizalcp@gmail.com Received Nov 3,2011; Revised Nov 27, 2011; Accepted Dec 19, 2011

ABSTRACT Eruption is a complex process that can be influenced by number of factors. Significant deviation from the established norms should alert the clinician to make investigations for the evaluating the cause of delayed tooth eruption. This review presents etiology, clinical implications, investigations, and a methodology for diagnosis and treatment of delayed tooth eruption. Key words: eruption of teeth, chronology of eruption

INTRODUCTION Eruption of deciduous teeth, their exfoliation followed by eruption of permanent dentition is an orderly sequential and age specific event 1. But most parents are anxious about the variation in the timing of the eruption, which is considered as an important milestone during childs development. Racial, ethnic, sexual, and individual factors can influence eruption and are usually considered in determining the standards of normal eruption 2,3.Tooth eruption is a complex and tightly regulated process which is divided into five stages namely preeruptive movements, intraosseous stage, mucosal penetration, preocclusal and postocclusal stages3. Significant deviations from accepted norms of eruption time are often observed in clinical practice. Premature eruption has been noted, but delayed tooth eruption (DTE) is the most commonly encountered deviation from normal eruption time.The importance of DTE as a clinical problem is well reflected by the number of published reports on the subject. DTE might be the primary or sole manifestation of local or systemic pathology.4 General considerations Gender Studies on teeth emergence shows that permanent teeth erupt earlier in girls than in boys5. The difference between eruption times on average is from 4 to 6 months, largest difference being for permanent canines. Earlier eruption of permanent teeth in females is attributed to earlier onset of maturation.6

Preterm birth World Health Organization (WHO) defines preterm birth as birth occuring before 37 weeks of gestation or if the birth weight is below 2500g7. Influence of preterm birth on teeth development and eruption has been investigated. Most of the studies reported that preterm babies children have delayed primary and permanent teeth eruption. Some researches reported that the greatest delay was found in children younger than 6 years of age, whereas for those aged 9 years or older, there was no difference, indicating that a catch- up had occurred 8,9. Local factors Physical obstruction is a common local cause of DTE. These obstructions can be because of mucosal barrier, supernumerary teeth, scar tissue, and tumors etc (Table 1). Mucosal barrier has also been suggested as an important etiologic factor in DTE. Any failure of the follicle of an erupting tooth to unite with the mucosa will entail a delay in the breakdown of the mucosa and constitute a barrier to emergence. Gingival hyperplasia resulting from various causes (hormonal or hereditary causes, drugs such as phenytoin) might cause an abundance of dense connective tissue or acellular collagen that can be an impediment to tooth eruption1,5,6,10. Supernumerary teeth can cause crowding, displacement, rotation, impaction, or delayed eruption of the associated teeth. The most common supernumerary tooth is the mesiodens, followed by a fourth molar in the maxillary arch. Odontomas and other have also been occasionally reported to be responsible for DTE. Regional odontodysplasia, (ghost teeth) is an un-usual dental anomaly that might exhibit a delay or total failure in eruption.

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Central incisors, lateral incisors, and canines are the most frequently affected teeth10,11 Injuries to deciduous teeth have also been implicated as a cause of DTE of the permanent teeth. Traumatic injuries can lead to disruption in normal odontogenesis in the form of dilacerations or physical displacement of the permanent germ 12 . Cystic transformation of a nonvital deciduous incisors might also cause delay in the eruption of the permanent successor. In some instances, the traumatized deciduous incisor might become ankylosed or delayed in its root resorption .This also leads to the overretention of the deciduous tooth and disruption in the eruption of its successor. The eruption of the succedaneous teeth is often delayed after the premature loss of deciduous teeth before the beginning of their root resorption. This can be explained by the abnormal changes that might occur in the connective tissue overlying the permanent tooth and the formation of thick, fibrous gingiva. Ankylosis occurs commonly in the deciduous dentition, usually affecting the molars, and has been reported in all 4 quadrants, although the mandible is more commonly affected than the maxilla.10,12 Arch-length deficiency is often mentioned as an etiologic factor for crowding and impactions. Arch-length deficiency might lead to DTE, although more frequently the tooth erupts ectopically.13 X-radiation has also been shown to impair tooth eruption. Ankylosis of bone to tooth was the most relevant finding in irradiated animals. Root formation impairment, periodontal cell damage, and insufficient mandibular growth also seem to be linked to tooth eruption disturbances due to x-radiation.14 Systemic conditions The high metabolic demand on the growing tissues might influence the eruptive process. delayed eruption is often reported in patients who are deficient in some essential nutrient. Agarwal et al15 had reported delayed deciduous dental eruption in malnourished Indian children. Chronic malnutrition extending beyond the early childhood is correlated with delayed teeth eruption. Most of the teeth showed a one to four month variation around the mean eruption time16 Table 2 shows various systemic condition which can lead to DTE. Disturbance of the endocrine glands usually has a profound effect on the entire body, including the dentition 10 . Hypothyroidism, Hypopituitarism, Hypoparathyroidism, and Pseudohypoparathyroidism are the most common endocrine disorders associated with DTE.

in hypopituitarism or pituitary dwarfism, the eruption and shedding of the teeth are delayed, as is the growth of the body in general. The dental arch has been reported to be smaller than normal; thus it cannot accommodate all the teeth, so a malocclusion develops. The roots of the teeth are shorter than normal in dwarfism, and the supporting structures are retarded in growth.17 Other systemic conditions associated with impairment of growth, such as anemia (hypoxic hypoxia, histotoxic hypoxia, and anemic hypoxia) and renal failure, have also been correlated with DTE and other abnormalities in dentofacial development.10 Genetic disorders Genetics has an important role in development. A generalized developmental delay is seen in patients with syndromes. Table 3 shows various genetic conditions assosiated with DTE. Various mechanisms have been suggested to explain DTE in relation to genetic disorders. Supernumerary teeth have been found to be responsible for DTE in Apert syndrome, Cleidocranial dysostosis, and Gardner syndrome. There is considerable evidence to implicate the periodontal tissues development and assosiated structures of the tooth in DTE. Lack of cellular cementum has been found in cleidocranial dysplasia, cementum-like proliferations and obliteration of periodontalligament space with resultant ankylosis have been noted in Gardner syndrome. In osteopetrosis, sclerosteosis, Carpenter syndrome, Apert syndrome, cleidocranial dysplasia, Pyknodysostosis, and others, underlying defects in bone resorption might be responsible for DTE.10,18,19,20,21 Occasionally, some syndromes or genetic disorders are associated with multiple tumors or cysts in the jaws, and these might lead to generalized DTE. Gorlin syndrome, cherubism, and Gardner syndrome are such disorders, in which DTE might be the result of interference to eruption by these lesions20,21,22,23,24. Generalized delay in the eruption of teeth is noted in some families . Patient medical history might be totally unremarkable, with DTE as the only finding. The presence of a gene for tooth eruption has also been suggested, and its delayed onset might be responsible for DTE in inherited retarded eruption.10, 19 CLINICAL IMPLICATIONS (table 4) Diagnosis of DTE is an important but complicated process. When teeth do not erupt at the expected age (mean +_ 2 SD), a careful evaluation should be performed to establish the etiology and the treatment plan accordingly10. Various tables and diagrammatic charts of the stages of tooth development, starting from the initiation of the

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Delayed Tooth Eruption

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calcification process to the completion of the root apex of each tooth are part of dental education. Norms with the average chronologic ages at which each stage occurs should be compared3 Medical history, family information and information from affected patients about unusual variations in eruption patterns should be investigated. Clinical examination must begin with the overall physical evaluation of the patient. Significant right-left variations in eruption timings might be associated with tumors and should alert the clinician to perform further investigation.10 Intraoral examination should include inspection, palpation, percussion, and radiographic examination. The clinician should inspect for gross soft tissue pathology, scars, swellings, and fibrous or dense frenal attachments. Careful observation and palpation of the alveolar ridges buccally and lingually usually shows the characteristics bulge of a tooth in the process of eruption. Palpation producing pain, crackling, or other symptoms should be further evaluated for pathology. Overretained deciduous tooth and the supporting structures should be thoroughly examined. Ankylosed teeth also interfere with the vertical development of the alveolus.10 INVESTIGATIONS A panoramic radiograph is ideal for evaluating the position of teeth and the extent of tooth development, estimating the time of emergence of the tooth into the oral cavity, and screening for pathology. IOPA with the image/ tube shift method, Clarks rule, buccal object rule are suggested for radiographic localization of tumors, supernumerary teeth, and displaced teeth, which require surgical correction. Computed tomography can be used as the most precise method of radiographic localization 25,26,27 TREATMENT CONSIDERATIONS The treatment of DTE depends on the etiology. A number of techniques have been suggested for treating DTE. The treatment plan should also consider 10 (1) The decision to remove or retain the tooth or teeth affected by DTE (2) The use of surgery to remove obstructions,

(6) Diagnosis and treatment of systemic disease that causes DTE. The treatment flowchart (table 5) can serve as a guideline for addressing the most important treatment options in DTE. Once the clinical determination of chronologic DTE (>2 SD) has been established, a panoramic radiograph should be obtained. The screening radiograph can be used to rule out tooth agenesis and assess the developmental state of the tooth25,28 If there is defective tooth formation, the first step should be to assess whether the defect is localized or generalized. Unerupted deciduous teeth with serious defects should be extracted, but the time of extraction should be defined carefully by considering the development of the succedaneous teeth and the space relationships in the permanent dentition. In the permanent dentition, unerupted teeth are normally closely observed until the skeletal growth period necessary for appropriate development and preservation of the surrounding alveolar ridge has been attained.In DTE with no obvious developmental defect in the affected tooth or teeth on the radiograph, root development (biologic eruption status), tooth position and physical obstruction should be evaluated. For a succedaneous tooth if root formation is inadequate, extraction of the deciduous tooth or exposure to apply active orthodontic treatment is not justified. If the tooth is lagging in its eruption status, active treatment is recommended when more than 2/3 of the root has developed 25 . Radiographic examination might also show an ectopic position of the developing tooth. Often, some deviations self-correct, but significant migration of the tooth usually requires extraction. If self-correction is not observed over time, active treatment should begin. Exposure accompanied by orthodontic traction has been shown to be successful. In patients in whom the ectopic teeth deviate more than 90 from the normal eruptive path, autotransplantation might be an effective alternative.10,23,24,25 An obstruction causing delayed eruption might or might not be obvious on the radiographic survey. A soft tissue barrier to eruption is not seen on the radiograph, but the obstruction should be treated with an uncovering procedure that includes enamel exposure. Supernumerary teeth, tumors, cysts, and bony sequestra are physical obstructions visible on the radiographic survey. Their removal usually will permit the affected tooth to erupt29 In the deciduous dentition, DTE due to obstruction is uncommon, but scar tissue (due to trauma) and pericoronal odontogenic cysts or neoplasms are the usual culprits in cases of obstruction. Trauma is more

(3) Surgical exposure of teeth affected by DTE, (4) The application of orthodontic traction, (5) The need for space creation and maintenance, and

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common in the anterior region, but cysts or neoplasms are more likely to result in DTE in the canine and molar regions. Odontomas are reported to be the most common of the odontogenic lesions associated with DTE 30. Treatment options for deciduous DTE range from observation, removal of physical obstruction with and without exposure of the affected tooth, orthodontic traction on rare occasions, and extraction of the involved tooth28,31. In the permanent dentition, removal of the physical obstruction from the path of eruption is recommended. When neoplasms (odontogenic or nonodontogenic) cause obstruction, the surgical approach is dictated by the biologic behavior of the lesion. If the affected tooth is deep in the bone, the follicle around it should be left intact. When the affected tooth is in a superficial position, exposure of the enamel is done at tumor removal. Occasionally, the affected tooth must be removed. McDonald and Avery32 recommend exposure of the tooth delayed in eruption at the surgical removal of the barrier, but Houston and Tulley 33 advocate removing the obstruction and providing sufficient space for the unerupted tooth to erupt spontaneously. If the tooth is exposed at the time of surgery, it might or might not be subjected to orthodontic traction to accelerate and guide its eruption into the arch. The decision to use orthodontic traction in most case reports seems to be a judgment call for the clinician. Occasionally, a deciduous tooth can be a physical barrier to the eruption of the succedaneous tooth. In most cases, removing the deciduous tooth will allow for spontaneous eruption of the successor4. When arch length deficiency creates a physical obstruction, either expansion of the dental arches or extraction might be necessary to obtain the required space.
10,13

Table 1: Local Conditions associated with DTE *(10,11,12)

Mucosal barriers-scar tissue: trauma/surgery Supernumerary teeth Odontogenic tumors (eg, adenomatoid odontogenic Tumors, odontomas) Nonodontogenic tumors Enamel pearls Injuries to primary teeth Ankylosis of deciduous teeth Premature loss of primary tooth Lack of resorption of deciduous tooth Apical periodontitis of deciduous teeth Regional odontodysplasia Drugs -Phenytoin Ectopic eruption Arch-length deficiency and skeletal pattern Radiation damage Oral clefts Segmental odontomaxillary dysplasia

Table 2: Systemic Conditions associated with DTE * (10,

15,16,17)
Nutrition Vitam in D-resistant rickets Endocrine disorders (H ypothyroidism ,H ypopitutarism, hypoparathyroidism, pseudohypoparathyroidism) Long-term chemotherapy HIV infection Cerebral palsy Dysosteosclerosis Anemia Celiac disease Prem aturity/low birth weight Ichthyosis renal failure

Table 3: Genetic conditions associated with DTE*(10,18-24)

A m e lo g e ne sis im p e rfe ct an d a sso cia te d d is ord ers E n a m e l a g e n es is a n d n ep h ro ca lc ino sis A m e lo -o n ych oh yp o h ydro tic d ysp la sia d e nto -os seo u s s yn d rom e (typ e s I an d II) A p e rt syn d ro m e C arp e nte r s ynd rom e C he ru bism C ho n d ro e cto d erm al dysp la sia (Ellis-va n C re ve ld s yn d rom e C le id oc ra n ia l d ysp las ia C on g e n ita l h ype rtric ho sis lan u g in o sa D en tin d ysp la sia M u co p o lysa cc ha rid os is D eL a n g e s yn d rom e H urle r syn dro m e H un te r s yn d rom e P yk no d yso sto sis (M a rote a ux-L am y syn d ro m e ) (M P S IV ) D ow n s yn dro m e E cto d e rm a l d ys plas ia E p id e rm o lysis bu llo sa G ard ne r synd rom e G au ch e r d ise a se R uth e rford syn d ro m e C ro ss synd rom e R am o n s ynd rom e G ing iva l fibro m a tos es w ith se ns orin e ura l h e a rin g lo ss G ing iva l fibro m a tos es w ith gro w th ho rm o n e d e ific ie ncy G orlin syn d ro m e N eu rofib ro m a to se s O ste op e tro sis (m a rb le b on e d ise a se ) O ste og e n esis im p erfecta O tod e nta l d ysp la sia P a rry-R o m be rg syn d ro m e P rog eria (H utch in so n -G ilfo rd syn dro m e ) R oth m u n d-T h o m p so n synd ro m e V o n R e ck lin g h au se n ne u ro fib rom a tosis

Whenever DTE is generalized, the patient should be examined for systemic diseases affecting eruption, such as endocrine disorders, organ failures, metabolic disorders, drugs, and inherited and genetic disorders. Various methods have been suggested for treating eruption disorders in these conditions. These include no treatment (observation), elimination of obstacles to eruption (eg, cysts, soft tissue overgrowths), exposure of affected teeth with and without orthodontic traction, autotransplantation, and control of the systemic disease.1,4,10,11,12,17,19

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Delayed Tooth Eruption

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Table 4: Etiology and Diagnosis of Chronological delayed tooth eruption(>2SD)

Normal tooth development

Abnormal tooth development( defect in shape , size, structure, colour)

Normal biologic eruption: root length< 2/3

Delayed biologic eruption: root length>2/3 -Amelogenisis imperfecta - Dentinogenesis imperfecta - Regional odontodysplasia

than two years should be investigated. eventhough genetics has an important role in the eruptuin process other factors such as gender, body composition, local disturbances,nutritional factors, systemic diseases etc can influence the process. But significant cause may be due to systemic conditions and syndromes associated with orofacial structures. Timely diagnosis of DTE is necessary for selecting the right treatment modality.
REFERENCES 1. Pahkala R, Pahkala A, Laine T. Eruption pattern of permanent teeth in a rural community in northeastern Finland. Acta Odontol Scand. 1991; 49:341-9. 2. Proffit WR, Fields HW. Contemporary orthodontics. 3 rd ed. Mosby Inc.; 2000. 3. Nolla CM. The development of the human dentition. ASDC J Dent Child 1960; 27: 254-66. 4. Kochhar R, Richardson A. The chronology and sequence of eruption of human permanent teeth in Northern Ireland. Int J Paediatr Dent 1998;8: 243-52

preterm birth/ low birth weight nutrition vit D resistant rickets downs syndrome Hypopitutarism

-Dilacerations - Dentin dysplasia

Physical obstruction

Radiographycally evident -supernumerary tooth - tumor - cyst -eruption sequestrum -ectopic eruption

Not evident radiographically -Scar from trauma -Scar from surgery -Ankylosis -Gingival hyperplasia -Premature loss of primary teeth OTHERS -Nutritional deficiency -Radiation damage -traumatic displacement of tooth germ -cleidocranial dysplasia -arch length deficiency -Scleroosteosis -HIV infection -Genetic predisposition

5. Nystrom M, Kleemola-Kujala E, Evalahti M, Peck L, Kataja M. Emergence of permanent teeth and dental age in a series of Finns. Acta Odontol Scand 2001; 59: 49-56. 6. Ekstrand KR, Christiansen J, Christiansen ME. Time and duration of eruption of first and second permanent molars: a longitudinal investigation. Community Dent Oral Epidemiol 2003;31: 344-50. 7. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of preterm birth. Lancet 2008;371: 75-84 . 8. Seow WK, Humphrys C, Mahanonda R, Tudehope DI. Dental eruption in low birth-weight prematurely born children: a controlled study. Pediatr Dent 1988;10: 39-42. 9. Harila-Kaera V, Heikkinen T, Alvesalo L. The eruption of permanent incisors and first molars in prematurely born children. Eur J Orthod 2003;25: 293-9. 10. Suri l, Gagari E, Vastardis H. Delayed tooth eruption:Pathogenesis,diagnosis and treatment. A literature review. Am J Dentofacial Orthop 2004;126;432-45 11. Cunha RF, Boer FA, Torriani DD, Frossard WT. Natal and neonatal teeth: review of the literature. Pediatr Dent 2001;23: 158-62 12. Brin I, Ben-Bassat Y, Zilberman Y, Fuks A. Effect of trauma to the primary incisors on the alignment of their permanent successors in Israelis. Community Dent Oral Epidemiol 1988;16: 104-8.
No

Table 5: Chart of treatment options of DTE affecting permanent teeth

Chronological delayed tooth eruption Radiographic examination Evaluate for tooth agenesis Tooth present Evaluate systemic influences observation Observation Diagnosis &control of diagnosis systemic disease Yes Is DTE generalized? No Tooth development normal on radiographic survey Yes Root development ? 2/3 ? Yes Observation Physical obstruction yes Evaluate tooth position Observation Extraction of affected teeth+ replacement (implant,fixed, removable prosthesis, autotransplantation ofhealthy tooth bud ) . Exposure of affected tooth exposure +orthodontic traction -Removal of obstruction , Removal of obstuction + exposure of affected teeth , Removal of obstruction+ exposure + orthodontic traction , Removal of obstruction + removal of affected teeth +replacement of tooth (implant, removable or fixed prosthesis,autotransplantation), Removal of obstruction+ removal of affected tooth +orthodontic space closure , Extraction of neighboring tooth to create space , Expansion of arches if ectopic No tooth missing Space closure, Restorative options

13. Suda N, Hiyama S, Kuroda T. Relationship between formation/ eruption of maxillary teeth and skeletal pattern of maxilla. Am J Orthod Dentofacial Orthop 2002;121: 46-52. 14. Piloni MJ, Ubios AM. Impairment of molar tooth eruption caused by xradiation. Acta Odontol Latinoam 1996;9: 87-92. 15. Agarwal KN, Narula S, Faridi MM, Kalra N. Deciduous dentition and enamel defects. Indian Pediatr. 2003;40: 124-9. 16. Psoter W, Gebrian B, Prophete S, Reid B, Katz R. Effect of early childhood malnutrition on tooth eruption in Haitian adolescents. Community Dent Oral Epidemiol 2008;36: 179-89. 17 Shaw L, Foster TD. Size and development of the dentition in endocrine deficiency. J Pedod 1989;13: 155-60. 18.Kaloust S, Ishii K, Vargervik K. Dental development in Apert syndrome. Cleft Palate Craniofac J 1997;34: 117-21. 19. Blankenstein R, Brook AH, Smith RN, Patrick D, Russell JM. Oral findings in Carpenter syndrome. Int J PaediatrDent 2001;11:352-60. 20.Franklin DL, Roberts GJ. Delayed tooth eruption in congenital hypertrichosis lanuginosa. Pediatr Dent 1998;20:192-4. 21.Gorlin RJ, Cohen MMJ, Hennekam RCM. Syndromes ofthe head and neck. New York: Oxford University Press; 2001. 22.Buch B, Noffke C, de KS. Gardners syndromethe importance of early diagnosis: a case report and a review. SADJ 2001;56:242-5 23. Rasmussen P, Kotsaki A. Inherited retarded eruption in the permanent dentition. J Clin Pediatr Dent 1997;21: 205-11. 24. Pulse CL, Moses MS, Greenman D, Rosenberg SN, Zegarelli DJ. Cherubism: case reports and literature review. Dent Today 2001; 20: 100-3.

No

Observation Exposure+orthodontic traction Extraction +replacement (implant, fixed removable prosthesis, Autotransplantation )

CONCLUSION The sequential and timely eruption of teeth is critical in overall development of the child. Variations can occur due to various reasons, but eruption delay of more

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25. Jacobs SG. Radiographic localization of unerupted teeth: further findings about the vertical tube shift method and other localization techniques. Am J Orthod Dentofacial Orthop 2000;118: 439-47. 26. Southall PJ, Gravely JF. Radiographic localization of unerupted teeth in the anterior part of the maxilla: a survey of methods currently employed. Br J Orthod 1987;14: 235-42. 27. Raghoebar GM, Boering G, Vissink A, Stegenga B. Eruption disturbances of permanent molars: a review. J Oral Pathol Med 1991;20: 159-66. 28. Rebellato J, Schabel B.Treatment of patient with an impacted transmigrant canine and palatally impacted maxillary canine. Angle Orthod 2003;73:328-336 29. Yeung KH, Cheung RC, Tsang MM. Compound odontoma associated with an unerupted and dilacerated maxillary primary central incisor in a young patient. Int J Paediatr Dent 2003;13: 208-12. 30. Diab M, elBadrawy HE. Intrusion injuries of primary incisors.Part III: Effects on the permanent successors. Quintessence Int 2000;31:377-84. 31. Jarvien SH. Unerupted second primary molars:report of two cases. ASDC J Dent Child 1994;61:397-400 32. McDonald RE, Avery DR, Dentistry for the child and adolescent . St Louis:Mosby 1999 33. Houston WJB, Tulley WJ. A textbook of orthodontics. Bristol, United Kingdom 1992

Source of Support : Nil, Conflict of Interest : Nil

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