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A Seminar On Eruption & Shedding of Teeth

Guided by : Dr. Mrs. Anuradha Pathak Professor and H.O.D.

Submitted by: Dr. Mahesh Jingarwar (MDS Ist year)

Deptt of Pedodontics and preventive Dentistry, Govt. Dental College and hospital,Patiala

i) INTRODUCTION ii) DEFINITION iii) PATTERN OF TOOTH MOVEMENT (a) pre eruptive tooth movement (b) eruptive tooth movement (c) post eruptive tooth movement iv) HISTOLOGICAL CHANGES IN TISSUES OVERLYING ERUPTING TEETH v) HISTOLOGY OF SURROUNDING TISSUES vi) HISTOLOGY OF UNDERLYING TISSUES vii) THEORIES OF ERUPTION (a) pulp theory (b) vascular theory (c) root elongation theory (d) alveolar bone growth (e) periodontal ligament theory (f) genetic input (g) hydrostatic pressure theory (h) follicular theory viii) ix) x) xi) xii) xiii) xiv) xv) xvi) xvii) PATTERN OF ERUPTION OF TEETH ACTIVE AND PASSIVE ERUPTION SEQUENCE OF ERUPTION CHRONOLOGY OF HUMAN DENTITION FACTORS AFFECTING TOOTH ERUPTION DISORDERS OF ERUPTION TEETHING SHEDDING OF TEETH CLINICAL IMPLICATIONS REFERENCES

ERUPTION Derived from LATIN WORD erumpere , to break out

INTRODUCTION The timely initiation and their eruption into oral cavity is very important for healthy dentition . it is the process by which tooth moves within the jaw bone ,comes out into the oral cavity and comes up to the occlusal contact and maintains its clinical position.Generally, tooth eruption occurs premolars . DEFINITION The axial or occlusal movement of the tooth from its developmental position within the jaw to its functional position in the occlusal plane is called as eruption.(Massler M ,Schour I). Dentition: Diphodont: two sets of dentition is present in humans. Primary vs Secondary dentition Deciduous vs Permanent dentition Mixed dentition: presence of two dentition Teeth in primary dentition are smaller and fewer in number than dentition to conform to the smaller jaw size: Primary dentition: ~ 2 to 6 years of age Mixed dentition: ~ 6 to 12 years Permanent dentition: > 12 years permanent earlier in females than in males, and the

mandibular teeth tend to erupt earlier than their maxillary counterparts except the

PATTERN OF TOOTH MOVEMENT Has been divided into: 1 2 3 PRE ERUPTIVE TOOTH MOVEMENT. ERUPTIVE TOOTH MOVEMENT. POST ERUPTIVE TOOTH MOVEMENT.

during all these 3 stages is the progression that happens from primary to permanent dentition which involves the shedding (exfoliation) of primary teeth. PRE ERUPTIVE TOOTH MOVEMENT Made by deciduous and permanent tooth germs within tissues of jaw before they begin to erupt. When deciduous tooth germ first differentiate they are very small and a good deal of space is present between them ,this space is soon used because rapid growth of the tooth germs and a crowding result in incisor and canine region .This crowding is then relieved by growth of jaws in length which permits drifting of tooth germs . Bone remodelling of crypt wall occurs to facilitate movements of growing tooth and its movement.in bodily movement in a mesial direction ,bone resorbs on mesial side and forms on distal side of crypt, the permanent tooth with its deciduous predecessors also move before they reach the position from which they will erupt. The permanent molars ,which have no deciduous predecessors ,also exhibit movement .for eg upper permanent molars ,which develop in tuberosity of maxilla ,at first have their occlusal surface facing distally and swing around only when maxilla has grown sufficiently to provide the necessary space.

Why do developing crowns move constantly in the jaws during the preeruptive phase? To place teeth in position for eruptive tooth movement To alleviate the problems of jaw growth which allows second molar to move backward and anterior teeth to move forward.

Developing crown move constantly during the preeruptive phase as they respond to positional changes of the neighbouring crowns and to changes in the mandible and maxilla. Permanent teeth develop lingual to the incisal level of the primary anterior teeth and later as primary teeth erupt, the permanent primary roots . Permanent premolars move from occlusal level of primary molars to a position enclosed within the primary tooth roots.All movements in the preruptive phase occur within the crypts of the developing crowns . Two types of tooth movement in pre-eruptive phase: 1 2 Total bodily movement Movement where one part remains fixed while the rest continues to grow crowns are lingual to the apical 3rd of

leading to change in the center of the tooth germ. ERUPTIVE TOOTH MOVEMENT Made by a tooth to move from its position within the bone to its functional position in occlusion, this phase is sometimes subdivided into intraosseous and extraosseous components and the principal direction of movement is occlusal or axial..the term prefunctional eruptive tooth movement is used to describe the movement of the tooth after its appearance in the oral cavity till it attains the functional position. major events takes place in eruptive tooth movement 1.Root formation: it is initiated by growth of hertwigs epithelial root sheath which initiates the differentiation of odontoblasts from dental paplla,the odontoblasts then form root dentin ,bringing about an overall increase in length of the tooth that is largely accommodated by eruptive tooth movement,which begins at the same time as root formation is initiated. Shortly after the onset of root formation cementum,periodontal ligament,and the bone lining the crypt wall are formed.

2.Movement : occur incisally or occlusally ..main reason for the movement is so that the root formation can take place normally ,reduced enamel epithelium fuses and contacts the oral epithelium. 3.Penetration of tooth crown tip through the fused epithelial layers allowing the entrance of crown into the oral cavity 4.Intraoral incisal or occlusal movement of the erupting tooth continues until clinical contact with opposing crowns occur. Histology changes that occur in tissues overlying erupting teeth 1 2 3 Degeneration of connective tissue (decrease in blood vessels and degeneration Eruption pathway altered tissue area overlying the teeth Macrophages destroy cells and fibers by secreting hydrolytic enzymes The connective tissue overlying a successional tooth that

of nerves) immediately overlying the erupting teeth

Gubernacular cord:

connects with the lamina propria of the oral mucosa by means of a strand of fibrous connective tissue that contains remnants of dental lamina. Gubernacular canal: Holes noted in a dry skull noted lingual to primary teeth in jaws that represent openings of gubernacular cord . As the successional teeth erupt, gubernacular canal widens enabling tooth to erupt.

HISTOLOGY OF SURROUNDING TISSUES The surrounding fibers change from being parallel to the tooth surface to bundles that are attached to the tooth surface and extending towards the periodontium (bone).The periodontal ligament have contractile properties and changes drastically during eruption. During eruption, collagen fiber formation and turnover are rapid fibers to attach and release and attach in rapid succession. Some fibers may attach and reattach later while the tooth moves occlusally as new bone forms around it and the fibers will organize and increase in number and density as the tooth erupts .

HISTOLOGY OF UNDERLYING TISSUES 1 2 3 4 As the tooth moves occlusally , it creates space underneath the tooth to

accommodate root formation. Fibroblasts around the root apex form collagen that attach to the newly Bone trabeculae fill in the space left behind as the tooth erupts in the pattern After tooth reaches functional occlusion periodontal fibers attach to the apical formed cementum of a ladder which gets denser as the tooth erupts. cementum and extend into the adjacent alveolar bone The rate of tooth eruption depends on the phase of movement Intraosseous phase: 1 to 10 m/day Extraosseous phase: 75 m/day Environmental factors affecting the final position of the tooth: Muscular forces Thumb-sucking POST ERUPTIVE TOOTH MOVEMENT Movements to accommodate the growing jaws. Mostly occursbetween 14 and 18 years by formation of new bone at the alveolar crest and base of socket to keep pace with increasing height of jaws. Movements to compensate for continued occlusal wear. Compensation Similar to primarily occurs by continuous deposition of cementum around the apex of the occurs only after tooth moves.

tooth. However, this deposition eruptive tooth movement

Movements to accommodate interproximal wear. Compensatedby mesial or approximal drift. Mesial drift is the lateral bodily movement of teeth on both sides of the mouth. Very important in orthodontics.

Several factors control mesial drift: A. Contraction of the transseptal fibers: As the proximal tooth tooth surfaces of

adjacent teeth become worn from functional thereby maintain tooth contact .

movement, the transseptal

fibers of the periodontal ligament become shorter (due to contraction) and B. Adaptability of bone tissue: The side of pressure on PDL fibers causes bone resorption, whereas pull on the fibers causes bone apposition (formation). crowns wear, the teeth tend to move An anteriorly directed force is Therefore, as the contact areas of the mesially, thereby maintaining contact C. Anterior compartment of occlusal force: generated when teeth and the Eliminating teeth are forward-directed teeth results force clenched, due to the mesial inclination of most generated from inter-cuspal forces. in elimination of biting forces, causing a

opposing

slowing down of the mesial migration . D. Pressure from soft tissues: Buccal mucosa and tongue push teeth mesially Active eruption: to compensate incisal and occlusal wear Passive eruption: gradual recession of the gingiva and the underlying alveolar

bone.Both active and passive eruption leads to lengthening of clinical crown.

THEORIES OF TOOTH ERUPTION The mechanism that brings about tooth movement is debatable. There are numerous theories of tooth eruption which is usually a reflection of incomplete understanding. All these theories have contributed to and provoked research into various aspects, to support or refute hypotheses which are now briefly reviewed. 1 Pulp Theory

This theory suggests that a propulsive force is generated by extrusion of the pulp through three mechanisms; first growth of dentin, secondly, interstitial pulp growth and thirdly, hydraulic effects within the vasculature. Perhaps the most damning

evidence against this theory is the work of Herzberg and Schour (1941) who removed the pulp of rodent incisors and found that its eruption rates were unaffected. 2 Vascular Theory

The mechanisms behind this theory to some extent overlaps the pulp theory. The force of eruption comes from the pressure in the blood vessels within or below the tooth. This theory has been discounted by some for the same reasons as the pulp theory. In addition, use of hypotensive drugs appears to have no effect on the eruption rates. However, a critical review by Moxham suggests that at least part of the eruptive force is generated by a non-functional force. 3 Root elongation theory

This theory attributes tooth eruption to elongation of the roots. It suggests that the tooth erupts as a result of root pushing against an immovable base. Root formation appears to be the obvious cause of tooth eruption, since it undoubtedly causes an overall increase in the length of the tooth which must be accommodated either by the root growing into bone of the jaw, by increase in height of the jaw, or by crown of the tooth moving occlusally. It is the latter movement, of course that occurs but it does not follow that root growth is responsible. At one time, it was proposed that a structure called Cushion hammock ligament was strung across the base of the socket and when the growing root impinged on it. This structure acted as a sling, translating downward root growth into eruptive tooth movement. Careful histologic study has found no such ligament. It must therefore be concluded that some force other than root growth is moving the tooth to provide room for the newly formed root tissue. Furthermore, Marks and Cahill (Arch. Oral Biol.; 1984) using young dogs, took teeth at the beginning of eruption, removed their pulps and killed the periodontal ligament cells by freeze thawing. These inert rootless teeth with no periodontal ligaments were reimplanted and still managed to erupt by compensatory bone growth. Thus, although root growth can produce a force, it cannot be translated into eruptive tooth movement unless there is some structure at the base of the tooth capable of withstanding the force.

4. Alveolar bone growth The importance of bone growth in tooth eruption was demonstrated with a series of classical experiments by Brash (1928) using madder fed pigs. Madder is a dye which binds to newly formed bone and Brash noticed large amounts of bone laid down between the crypts of erupting teeth. These observations have been confirmed (Marks and Cahill 1980), but although bone formation is clearly involved in tooth eruption, cause and effect are still at the phenomenology stage. 5. Periodontal ligament theory This theory suggests that the impetus for tooth eruption is derived from the periodontal ligament. Evidence for this came from some brief observations by Moxham and Berkovitz (Arch. Oral Biol.; 1974) where root transsection failed to prevent the incisor segment superficial to the transsection from erupting. This strongly implicates the periodontal ligament in the eruption process, and suggests that there is little contribution from alveolar bone, root growth and indeed pulp pressure. Evidence against this theory includes studies with lachyritic compounds, such as aminoproprionitrile. They inhibit intermolecular crosslinking of the polypeptide chains in the collagen molecule and should therefore inhibit the teeth from erupting.. In summary, then the force moving the tooth is most likely generated by the contractile property of the ligament fibroblast. The fibronexus and associated fibronectin could transmit this force to the collagen fibre bundles, but a number of other conditions must exist to translate this contraction into tooth movement. Eruption must therefore be considered a multifactorial phenomenon. The periodontal ligament theory has also gained some support from tissue culture experiments. If a fibroblast is cultured on a substrate on which it can move, it vibrates using contractile mechanisms generated by its cytoskeleton. The actin molecule has a particularly prominent role. As the fibroblast moves, it elongates on the leading edge and leaves the trailing end of the cell adherent to the substrate. Eventually the latter edge will detach. This model has been adapted to show that periodontal ligament fibroblasts are capable of generating sufficient contractile force to lift a piece of root, against gravity,

towards the top of a tissue culture well (Arch. Oral Biol.; 1983). Direct evidence of this tractional effect is not available but these models prove that periodontal ligament has some role in the process of eruption. 6.Genetic input If tooth eruption is to be explained at the cellular and molecular level, a degree of genetic control is highly likely in normal development of occlusion. Incisors erupt before premolars and this process of eruption is often disturbed in a number of genetic disorders. A classification of this has been presented by Caulk (1988). These comprise:

inhibited defects, primarily involving enamel - amelogenesis imperfecta. syndromes with enamel involvement. disorders associated with supernumerary teeth and / or crowding of teeth. growth retardation syndromes.
conditions associated with tissue overgrowth of the gingiva and hyperplastic frenula.

miscellaneous

disorders

(these

include

premature

exfoliation

such

as

Hypophosphatasia, Juvenile Periodontosis and Papillon Lefevre Syndrome). There is no simple explanation of tooth eruption and this biological phenomenon is a multifactorial event. Biological sciences are more likely to offer clear, rational approaches to improve our understanding of tooth eruption. 7.Hydrostatic pressure. This theory requires a higher pressure system, either within or around the base of the tooth. It is known that teeth move in their sockets in synchrony with the arterial pulse, so local volume changes can produce limited tooth movement. Ground substance can swell from 30%-50% by retaining additional water, so this too could create pressure. But, since surgical excision of the growing root and associated tissue eliminate the periapical vasculature without stopping eruption, this means that the local vessels are not absolutely necessary for tooth eruption.

8. Follicular Theory This theory attributes a critical role to the dental follicle for the eruption of teeth. It seems unlikely that the dental follicle provides the eruptive force since fibre transsection fails to prevent eruptive movement. It seems more probable that the loose connective tissue of the dental follicle is a rich source of factors which are responsible for bone formation and resorption. Because of the pioneering experiments of Marks and Cahill, it was established that, in teeth of limited eruption, a tissue required for eruption is the dental follicle, a loose connective tissue sac that surrounds the tooth prior to eruption. Their studies showed that surgical removal of the follicle prevents eruption whereas leaving the follicle intact but substituting an inert object for the tooth results in eruption of the inert object (Marks & Cahill; 1984). At the cellular level there is an influx of mononuclear cells (monocytes) in the dental follicle which is the onset of active eruption (Marks et al.; 1983 Wise et al.; 1985). At least 4 molecular signal(s) ultimately initiate the onset of tooth eruption because of their ability to accelerate eruption, their immuno localization, their gene expression or a combination of these. Perhaps the molecule that plays the most direct role in initiating the cellular events of eruption is colony stimulating factor one (CSF-1). When these were injected into osteopetrotic (toothless) rats, the incisors erupted (Ilizuka et al.; 1992) and injection of CSF-1 in normal rats lead to eruption of first molars with increase in numbers of monocytes and osteoclasts (Cielinski et al.; 1995). A cascade of molecular signals is probably involved in stimulating the expression of CSF-1 for the onset of eruption. In particular, interleukin-1 (1L-1 ) enhances the transcription of CSF-1 gene in rat dental follicle cells (Wise and Lin; 1994). Immunolocalization studies have shown that 1L-1 is present in the stellate reticulum (Wise et al.; 1995), the portion of enamel organ that is immediately adjacent to the dental follicle. Thus the 1L-1 might diffuse into the dental follicle to stimulate the dental follicle cells to express the CSF-1 gene.

The expression of the 1L-1 gene may be regulated by epidermal growth factor (EGF). EGF, long known for its ability to stimulate precocious eruption of incisors in rodents (Cohen;1962), also increases the amount of following injection into rats (Wise et al.; 1995). Another molecule that might be involved in a cascade of signals leading to tooth eruption is transforming growth factor 1 (TGF-1). Like 1L-1 , TGF 1 immunolocalizes to the stellate reticulum and in vitro, its mRNA expression is enhanced by incubation with EGF. Because TGF 1 is a chemo attractant for monocytes, it is possible that TGF 1 could enter the capillaries adjacent to the dental follicle and attract monocytes to the follicle. Based on these above studies, a hypothesis of the molecular events of tooth eruption can be presented: If EGF were the first signal there are at least three ways it could initiate eruption. If EGF were not required, however, eruption could begin with a signal from TGF1. Should EGF and TGF 1 both not be required, eruption could begin with 1L-1 enhancing CSF-1 mRNA expression. PATTERN OF ERUPTION OF TEETH The teeth of the deciduous dentition begin to appear in the mouth at about 6 months of age and the dentition is complete by 3 years. A majority of the permanent teeth appear in the mouth between 6 and 12 years of age, during this time teeth from both dentitions are present in the mouth, a phase known as mixed dentition. In the deciduous dentition, calcification of the crowns commences about a month after the completion of cytodifferentiation of the tooth germ. Calcification of all deciduous teeth begins before birth. Crown formation takes about 6 months to complete and the tooth appears in the mouth some 6 months after crown formation is achieved. When the teeth first appear, their roots are incomplete and are not fully formed until 18 months later. In the permanent dentition, the tooth germs are fully formed before birth for all but the second and third molars. Crown formation begins at varying times thereafter. In general, for the teeth of the permanent dentition, crown formation takes 3 years and the 1L-1 in the stellate reticulum

teeth appear in the oral cavity about 3 years after the crown is complete. Root completion is achieved about 3 years after eruption. The sequence of eruption is an important aide memoire; the first permanent molars erupt first at 6 years of age. The other teeth appear at approximately yearly intervals corresponding to their sequence of eruption. If the sequence and dates of eruption are remembered, the timing of other events may be calculated by simple addition or subtraction. BIRTH TO TWO YEARS The permanent incisors and canines first develop lingual to the deciduous tooth germs at the level of their occlusal surfaces and in the same bony crypt. As their deciduous predecessors erupt, they move to a more apical position and occupy their own bony crypts. First teeth to erupt are the mandibular central incisors. The usual eruption sequence in the primary dentition is as follows. First the central incisors, followed in order by the lateral incisors, first molars, canines and second molars. Mandibular teeth usually precede the maxillary teeth. This sequence is not always followed. Time of eruption is usually stated as 6 months of age for the maxillary primary centrals, 7-8 months for the mandibular primary laterals and 8 or 9 months for the maxillary primary laterals. At about 1 year, the first primary molars erupt. At around 16 months, the primary cuspids appear. Two years is usually given as the age for the second primary molars to appear. TWO YEARS TO SIX YEARS By two and a half years of age, the deciduous dentition is usually complete and in full function. By three years of age, the roots of all deciduous teeth are complete. First permanent molar crowns are fully developed and the roots are starting to form. The crypts of the developing permanent second molars are now definite and can be seen in the space formerly occupied by the developing first permanent molars. Between three and six years of age, the development of the permanent teeth continues, with the maxillary and mandibular incisor teeth more advanced. From five to

six years, just before the shedding of the deciduous incisors, there are more teeth in the jaws than at any other time. Space is quite critical within both the alveolar process and the deciduous dental arches themselves. Developing permanent teeth are shifting close to the alveolar border, the apices of the deciduous incisors are being resorbed; the first permanent molars are about ready to erupt. Very little bone exists between the permanent teeth and their crypts and the front line of deciduous teeth. [A cross section of the maxilla and mandible illustrates this remarkable phenomenon]. The complex interplay of forces makes it imperative that the integrity of the dental arch be maintained at this time. Loss of arch length through caries may make the difference between normal occlusion and malocclusion. It does not take very much to upset the delicate timetable of tooth formation, eruption and resorption within a viable osseous medium. SIX YEARS TO TEN YEARS Between six and seven years of age, the first permanent molars erupt into the mouth. As the upper and lower first permanent molars erupt, a pad of tissue overlying them creates a premature contact. Proprioceptive response conditions the patient against biting on this natural bite opener and thus the deciduous teeth anterior to the first permanent molar area erupt, reducing the overbite. About this time, the deciduous central incisors are lost and their permanent successors start their eruptive path toward contact with the incisors of the opposing arch. Usually the mandibular central incisors erupt first, followed by the maxillary permanent central incisors. These teeth frequently erupt lingual to their deciduous counterparts and move forward under the influence of tongue pressure as they erupt. The maxillary central incisors appear as large bulges in the mucobuccal vestibule above the deciduous incisors before they erupt. The period from eruption of the lateral incisors to the eruption of canine is termed by Broadbent as the ugly duckling stage. It is an apt term, implying an unaesthetic metamorphosis leading to an esthetic result. During this period parents become worried. A space may develop between the maxillary central crowns. The lateral crowns may flare. Frenums are often sacrificed in an effort to remove the cause of the space between the centrals. Margolis has called the alveolar process the servant of the tooth. At this stage the maxilla is bulging in the canine region as the alveolar process

develops around the forming canine. With the further migration of the canine occlusally, with its servant the alveolar process, the point of influence of the canine on the laterals shifts incisally so that eventually, the lateral crowns are driven medially, also effecting closure of the space between the centrals. Eruption of the incisors is usually completed by eight and a half years of age. Even though the central and lateral incisors erupt into the normal position, root formation is not complete. The apices are wide open and do not close for at least another year. Between nine and ten years of age, the apices in the deciduous canines and molars begin to resorb. Individual variation is great here. Girls are usually a year to a year and a half ahead of boys. AFTER TEN YEARS Between 10 and 12 years of age, there is considerable variability in the sequence of eruption of the canines and premolars. In about half the cases, the mandibular canines erupt ahead of the mandibular first and second premolars. In the maxilla, the first premolar usually erupts before the canine. The first premolar usually erupts before the canine. The maxillary second premolar and the maxillary canine erupt at about the same time. At times, deciduous teeth are retained beyond the time that they should normally be shed. Eruption of the second molar teeth usually occur shortly after the appearance of the second premolars. Since the second premolar and second molar teeth show the greatest variability in order of eruption of any of the teeth (third molars excepted), the second molar teeth may be expected to erupt before the second premolar teeth in 17% of cases in CaucasiansBoth maxillary and mandibular second molars erupt at about the same time. If the second molars exfoliate before the second premolars, occasionally the first permanent molars may tip to the mesial. Radiographs taken shortly after eruption of second molar teeth often show an image of the developing third molar teeth that are difficult to interpret. This is especially true of the mandibular third molars. (which are seen to be in the ramus but actually present lingual to the ramus). Although maxillary second molars erupt in a downward and forward direction, the maxillary third molars erupt downward and backwards. To this might be added the term outward.

ACTIVE AND PASSIVE ERUPTION According to the concept of continuous eruption (Orbans, Gottlieb J. Dent. Res. 13 ; 214 ; 1933), eruption does not cease when the teeth meet their functional antagonists but continues throughout life. It consists of an active and passive phase. Active eruption is the movement of the teeth in the direction of the occlusal plane. Passive eruption is the exposure of the teeth by the apical migration of the gingiva.Passive eruption is divided into four stages although this was originally thought to be a normal physiologic process ,it is currently considered a pathologic process: Stage one: The teeth reach the line of occlusion. The junctional epithelium and the base of the gingival sulcus are one the enamel. Stage two: The junctional epithelium proliferates so that part is on the enamel. The base of the sulcus is still on the enamel. Stage three: The entire junctional epithelium is on the cementum, and the base of the sulcus is at the cementoenamel junction. As the junctional epithelium proliferates from the crown onto the root, it remains at the CEJ no longer than any other area on the tooth. Stage four: The junctional epithelium has proliferated further on the cementum. The base of the sulcus is on the cementum, a portion of which is exposed. Proliferation of the junctional epithelium onto the root is accompanied by degeneration of gingival and periodontal ligament fibres and thin detachment from the tooth.

The six/four rule for primary tooth emergence four teeth emerge for each 6 months of age 1. 6 months: 4 teeth (lower centrals & upper centrals) 2. 12 months: 8 teeth (1. + upper laterals & lower laterals) 3. 18 months: 12 teeth (2. + upper 1st molars & lower 1st molars) 4. 24 months: 16 teeth (3. + upper canines & lower canines) 5. 30 months: 20 teeth (4. + lower 2nd molars & upper 2nd molars) SUMMARY 1 2 3 4 By 5 months in utero, all crowns started calcification By 1 year old, all crowns completed formation By 2.5 years, all primary teeth erupted By 4 years old, all primary teeth completed root formation

Chronology of Human Permanent Dentition

The rules of Fours for permanent tooth development (3rd molars not included)

At birth, four 1st molars have initiated calcification At 4 years of age, all crowns have initiated calcification At 8 years, all crowns are completed At 12 years, all crowns emerge At 16 years, all roots are complete Rules of sixes in dental development 6 weeks old in utero: beginning of dental development 6 months old: emergence of the first primary tooth 6 years old: emergence of first permanent tooth

FACTORS AFFECTING TOOTH ERUPTION 1. Age 2. Genetics 3. Race:- eruption timing seems to be earlier in the American black and Indian population than in American whites of European origin 4. Sex :- Except for the 3rd molar Females tend to calcify and erupt their permanent teeth about five month earlier than males. 5. Height and Weight :- Taller and heavier have greater number of erupted teeth then shorter and lighter children 6. Environment :1. Socio economic group 2.Climate 7. General Factors :1.Disease 2.Hormones 3.Metabolism 4.Vit- C deficiency Local Factors :1.Pathology, trauma, ankylosis 2.Early Loss of Primary teeth 3.Delayed Loss of Primary teeth 4.Impaction / Crowding 5.Supernumerary teeth 6.Space Available 7.Degree of Root Formation 8.Growth Factor

DISORDERS OF ERUPTION Premature & Accelerated Tooth Eruption All these Conditions are Attributed to a superficial position of forming tooth germ These may be:1.Natal Teeth :-Present at the time of birth. 2.Neo Natal Teeth:-Erupts with in 30 days after birth. 3.Preerupted Teeth :-Appear in 2nd or 3rd Month after birth. Delayed Tooth Eruption Situation in which it occurs: 1 2 3 4 5 6 7 8 9 10 11 Ankylosis Congenital hypothyroidism Juvenile acquired hypothyroidism Cleidocranial dysplasia Down syndrome Gingival fibromatosis Amelogenesis imperfecta Epidermolysis bullosa Mucopolysaccaroidosis Acondroplasia Regional odontodysplasia

TEETHING Physiological process of eruption of primary dentition through the gingiva . Clinical features:A) Local signs-

1.Hyperemia or swelling of the mucosa overlying the erupting teeth 2. Patches of erythema on the cheeks 3. Flushing in the skin of adjacent cheek

B) Systemic signs:1. General irritability & crying 2. Loss of appetite 3. Sleeplessness, restlessness 4. Increase salivation & drooling 5. Insanity 6. Increase thirst 7. Circumoral rash

SHEDDING OF TEETH The physiologic process resulting in the elimination of the deciduous dentition is called shedding or exfoliation. The eruptive pathway of the permanent teeth is very much related to the shedding or exfoliation of the deciduous teeth as pressure from the erupting successional tooth helps to determine the pattern of deciduous tooth resorption. 1. Osteoclast/bone remodeling 2. Odontoclast (cementoclast; dentinoclast) 3. Resorption of soft tissues 4. Pressure from successional teeth Osteoclasts are bone resorbing cells derived form monocyte-macrophage lineage they are giant multinuclear cells with 4-20 nuclei. Osteoclasts resorb hard tissue by separating mineral from the collagen matrix through the action of hydrolytic enzymes...Resorption occurs at the ruffled border which greatly increases the surface area of the osteoclast in contact with bone . Hard Tissue resorption: 1. Extracellular phase 2. Intracellular phase

Shedding of teeth can occur due to two factors: Odontoclasts.: The resorption of the hard tissues of the tooth is achieved by cells that have an identical histology to osteoclasts but which, because they are involved in the removal of dental tissue, are sometimes called odontoclasts. The odontoclasts are capable of resorbing all dental hard tissues, including enamel, but it is most commonly found on the surface of roots, where it resorbs cementum and dentin. It is also found on occasion within the pulp chamber, resorbing coronal dentin. This variation in the pattern of the deciduous tooth resorption depends very much on the position of the successional tooth in relation to the deciduous tooth. Thus, since the permanent incisors and canine develop lingually to the deciduous teeth and erupt in an occlusal and vestibular direction, resorption occurs at the lingual surface of the root and the tooth is shed with much of its pulp chamber intact. Permanent premolars, however, develop between the divergent roots of the deciduous molars and erupt in an occlusal direction. Hence the resorption of interradicular dentin occurs with the resorption of the pulp chamber and coronal dentin. While little is known about resorption of the dental hard tissues, even less is known about the resorption of the soft tissues associated with them; such as dental pulp and periodontal ligament. Simple observation of histological sections shows that the loss of periodontal ligament is abrupt. absence of inflammation. Pressure : Obviously, pressure from the erupting successional tooth plays a role in the shedding of the deciduous dentition. For instance, if a successional tooth germ is congenitally missing or occupies an aberrant position in the jaw, shedding of the deciduous tooth is delayed. Yet the tooth is eventually shed. Growth of the jaws and also the muscles of mastication also aid in resorption of deciduous teeth. PATTERN OF SHEDDING It has been seen that the pattern of exfoliation is symmetrical for the right and left sides of the mouth. Girls exfoliate their teeth before boys. The greatest discrepancy between the sexes is observed for the mandibular canines, the least for the maxillary central incisors.. Electron microscopic examination confirms this finding and also shows that cell death occurs in this region in the

TISSUE CHANGES PRODUCED BY ERRUPTIVE GROWTH Effect of coronal growth on adjacent tissue :-The developing component of the growing crown and its associated dental sac tissue are protected by compressing forces. This protection is offered by the tissue of the surrounding dental sac which is abundantly supplied with intercellular fluid ,thus the growth pressure of the crown are transmitted through the tissue of dental sac to the peripheral bony wall. For this reason neither the developing germ nor its adjacent soft tissue is affected. The crypt changes: developing crowns produced osteoclastic activity which was restricted to the lateral walls and the ceiling of bony the crypt .Because of the high fluid content of the dental sac , the hydraulic phenomenon limit bone resorption.to the sides and top of the crypt. Resorption of the roots:- In general the pressure generated by the growing and erupting permanent tooth dectates the pattern of deciduous tooth resorption. At first this pressure is directed against the root surface of deciduos teeth itelf ,because of the developmental position of the permanent incisor and canine tooth germs and their subsequent physiologic movement in an occlusal and vestibular direction .Resorption of the roots of the deciduous incisors and canine begins on their lingual surfaces .Resorption of the of deciduos molars often first begins on their inner surface because the early developing bicuspids are found between them. Resorption occurs on the surface of cementum and dentine . Resorption involves a loss of the organic as well as the mineral constituent of the matrix . during resorption the process of disorganisation relative to the mineral and the organic components occurs more or less concomitantly. Resorption of cementum and dentine of deciduous teeth is characterized by the presence of osteoclasts. Changes in the Dental pulp:-Dramatic changes in the organization of the near the

fibrous and the cellular components are not evidenced ,nor are there conspicuous indication of degeneration. In fact , the dentinogenic layer located ceiling of the pulp chamber may remain active up to the period immediately preceding exfoliation. Because the integrity of the dental pulp with the subjacent connective tissue is maintained long after much of the efficacy of the suspensory

apparatus is negated and precocious exfoliation is avoided, In fact ,belated shedding may be a result of the tenacious connection between the dental pulp and the underlying connective tissue. Exfoliation proper:-with progressive resorption of the root and even the crown and with disorganization of the structural and functional features of the adnexal tissue , the temporary of primary tooth is loosened more and more until tooth can be removed from its shallow alveolus with little efforts.

Why there is no pain when deciduous tooth exfoliate? 'spontaneous' degeneration of nerve fibres has been said to occur in the nerves of the papillae of the organ of Eimer in the growing mole (Boeke, 1940).It may be noted that this early terminal and preterminal degeneration in the nerves of deciduous teeth probably accounts for the absence of pain when they are shed. {THE FATE OF THE NERVES OF THE DECIDUOUS TEETH BY A. MOHIUDDIN Department of Anatomy, St Mary's Hospital Medical School *}

Why there is no bleeding/less bleeding when deciduous tooth exfoliate? Clinically it has been noticed that human deciduous teeth are shed with little bleeding, when the teeth naturally exfoliate. Immediately after teeth are shed, stratified squamous epithelium present in the dentogingival junction (DGJ) and gingiva were found in the underlying tissue indicating that DGJ epithelium and gingival epithelium play an important role in the process of exfoliation. Furthermore, wound healing after exfoliation is usually more rapid than after eruption. A study by N. Sahara et al. showed migration appeared to be further stimulated as a result of chronic inflammation by microorganisms present adjacent to the DGJ. The most interesting finding of the study was the evidence of the stratified squamous epithelium of the DGJ and gingiva proliferated and migrated towards the inside of the crown and eventually ended up under the deciduous crown.

Clinical consideration Remnants of deciduous teeth :-sometimes parts of the roots of deciduous teeth are not in the path of erupting permanent teeth and may escape resorption.They are most frequently found in association with the permanent premolars, especially in the region of lower second premolars. The reason is that the roots of lower second deciduous molars are strongly curved or divergent. Retained deciduous teeth:-deciduous teeth may be retained for long time beyond their usual shedding schedule. such teeth are usually without permanent successor, or their successor are impacted. Retained deciduous teeth are most often the upper lateral incisor and rarely lower central incisor. Submerged deciduous teeth:- Trauma may result in damage to either the dental follicle or the developing periodontal ligament. In such case the eruption ceases and it becomes ankylosed to the bone of jaw. Submerged should be removed as early as possible deciduous teeth prevents the eruption of their permanent successor or force them from their position. Such teeth

REFERENCES 1. ORAL HISTOLOGY A.R. TEN CATE, MOSBY PUBLICATIONS (3RD EDITION) 2. ORBANS ORAL HISTOLOGY AND EMBRYOLOGY MOSBY PUBLICATIONS (10TH EDITION). 3. ERUPTION OF PERMANENT TEETH A COLOUR ATLAS SADAKATSU SATO AND PATRICIA PARSONS (ISHIYAKU EURO AMERICA INC.). 4. PRINCIPLES OF ANATOMY AND ORAL ANATOMY FOR DENTAL STUDENTS M.E. ATKINSON AND F.H. PUBLISHERS. 5. 6. ORTHODONTICS, PRINCIPLES AND PRACTICE - T.M. GRABER (3RD EDITION) W.B. SAUNDERS PUBLICATION. CLINICAL PERIODONTOLOGY - CARRANZA AND NEWMAN (8TH EDITION) W.B. SAUNDERS PUBLICATION. 7. MECHANISM OF TOOTH ERUPTION T.B. KANDOS. B.D.J. VOL. 181, NO. 3 AUG. 10 : 1996 (91-95). 8. THE MOLECULAR BIOLOGY OF INITIATION OF TOOTH ERUPTION - G.E. WISE AND F LIN. J. DENT. RES. 74 (1) : 303-306 JAN 95. 9. A HISTOLOGIC STUDY OF THE EXFOLIATION OF HUMAN DECIDUOUS TEETH N. SAHARA, N. OKAFUJI, Y. ASHIZAWA AND K. SUZUKI. J. DENT. RES. 72 (3) : 634-640, MARCH 93. 10. 11. 12. THE DAILY RHYTHM OF TOOTH ERUPTION. AJODO 1995;107: 38-47. ERUPTIVE TOOTH MOVEMENT THE CURRENT STATE OF WHITE (1ST EDITION) CHURCHILL LIVINGSTONE

KNOWLEDGE .BRITISH DENTAL JOURNAL ;197: 385 391,2004. TEETHING AND TOOTH ERUPTION IN INFANTS: A COHORT STUDY. PEDIATRICS; 106( 6) :1374-1379 ,2000.

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