DELAYED TOOTH ERUPTION - e-Journal of Dentistry

R eview Article www.ejournalofdentistry.com

DELAYED TOOTH ERUPTION

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: [email protected]
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 Preterm birth

Eruption of deciduous teeth, their exfoliation World Health Organization (WHO) defines
followed by eruption of permanent dentition is an orderly preterm birth as birth occuring before 37 weeks of gestation
sequential and age specific event 1. But most parents are or if the birth weight is below 2500g7. Influence of preterm
anxious about the variation in the timing of the eruption, birth on teeth development and eruption has been
which is considered as an important milestone during childs investigated. Most of the studies reported that preterm
development. Racial, ethnic, sexual, and individual factors babies children have delayed primary and permanent teeth
can influence eruption and are usually considered in eruption. Some researches reported that the greatest delay
determining the standards of normal eruption2,3.Tooth was found in children younger than 6 years of age, whereas
eruption is a complex and tightly regulated process which for those aged 9 years or older, there was no difference,
is divided into five stages namely preeruptive movements, indicating that a “catch- up” had occurred 8,9.
intraosseous stage, mucosal penetration, preocclusal and
postocclusal stages3. Local factors

Significant deviations from accepted norms of Physical obstruction is a common local cause of
eruption time are often observed in clinical practice. DTE. These obstructions can be because of mucosal barrier,
Premature eruption has been noted, but delayed tooth supernumerary teeth, scar tissue, and tumors etc (Table 1).
eruption (DTE) is the most commonly encountered deviation Mucosal barrier has also been suggested as an important
from normal eruption time.The importance of DTE as a etiologic factor in DTE. Any failure of the follicle of an
clinical problem is well reflected by the number of published erupting tooth to unite with the mucosa will entail a delay
reports on the subject. DTE might be the primary or sole in the breakdown of the mucosa and constitute a barrier to
manifestation of local or systemic pathology.4 emergence. Gingival hyperplasia resulting from various
causes (hormonal or hereditary causes, drugs such as
General considerations phenytoin) might cause an abundance of dense connective
tissue or acellular collagen that can be an impediment to
Gender tooth eruption1,5,6,10.

Studies on teeth emergence shows that permanent Supernumerary teeth can cause crowding,
teeth erupt earlier in girls than in boys5. The difference displacement, rotation, impaction, or delayed eruption of
between eruption times on average is from 4 to 6 months, the associated teeth. The most common supernumerary
largest difference being for permanent canines. Earlier tooth is the mesiodens, followed by a fourth molar in the
eruption of permanent teeth in females is attributed to earlier maxillary arch. Odontomas and other have also been
onset of maturation.6 occasionally reported to be responsible for DTE. Regional
odontodysplasia, (ghost teeth) is an un-usual dental
anomalythat might exhibit a delayor total failure in eruption.

e-Journal of Dentistry Oct - Dec 2011 Vol 1 Issue 4 81

Faizal C Peedikayil www.ejournalofdentistry.com

Central incisors, lateral incisors, and canines are the most in hypopituitarism or pituitary dwarfism, the eruption and
frequently affected teeth10,11 shedding of the teeth are delayed, as is the growth of the
body in general. The dental arch has been reported to be
Injuries to deciduous teeth have also been smaller than normal; thus it cannot accommodate all the
implicated as a cause of DTE of the permanent teeth. teeth, so a malocclusion develops. The roots of the teeth
Traumatic injuries can lead to disruption in normal are shorter than normal in dwarfism, and the supporting
odontogenesis in the form of dilacerations or physical structures are retarded in growth.17
displacement of the permanent germ12. Cystic
transformation of a nonvital deciduous incisors might also Other systemic conditions associated with
cause delay in the eruption of the permanent successor. In impairment of growth, such as anemia (hypoxic hypoxia,
some instances, the traumatized deciduous incisor might histotoxic hypoxia, and anemic hypoxia) and renal failure,
become ankylosed or delayed in its root resorption .This have also been correlated with DTE and other abnormalities
also leads to the overretention of the deciduous tooth and in dentofacial development.10
disruption in the eruption of its successor. The eruption of
the succedaneous teeth is often delayed after the premature Genetic disorders
loss of deciduous teeth before the beginning of their root
resorption. This can be explained by the abnormal changes Genetics has an important role in development. A
that might occur in the connective tissue overlying the generalized developmental delay is seen in patients with
permanent tooth and the formation of thick, fibrous gingiva. syndromes. Table 3 shows various genetic conditions
Ankylosis occurs commonly in the deciduous dentition, assosiated with DTE. Various mechanisms have been
usually affecting the molars, and has been reported in all 4 suggested to explain DTE in relation to genetic disorders.
quadrants, although the mandible is more commonly Supernumerary teeth have been found to be responsible
affected than the maxilla.10,12 for DTE in Apert syndrome, Cleidocranial dysostosis, and
Gardner syndrome. There is considerable evidence to
Arch-length deficiency is often mentioned as an implicate the periodontal tissues’ development and
etiologic factor for crowding and impactions. Arch-length assosiated structures of the tooth in DTE. Lack of cellular
deficiency might lead to DTE, although more frequently cementum has been found in cleidocranial dysplasia,
the tooth erupts ectopically.13 cementum-like proliferations and obliteration of periodontal-
ligament space with resultant ankylosis have been noted
X-radiation has also been shown to impair tooth in Gardner syndrome. In osteopetrosis, sclerosteosis,
eruption. Ankylosis of bone to tooth was the most relevant Carpenter syndrome, Apert syndrome, cleidocranial
finding in irradiated animals. Root formation impairment, dysplasia, Pyknodysostosis, and others, underlying defects
periodontal cell damage, and insufficient mandibular growth in bone resorption might be responsible for DTE.10,18,19,20,21
also seem to be linked to tooth eruption disturbances due
to x-radiation.14 Occasionally, some syndromes or genetic
disorders are associated with multiple tumors or cysts in
Systemic conditions the jaws, and these might lead to generalized DTE. Gorlin
syndrome, cherubism, and Gardner syndrome are such
The high metabolic demand on the growing disorders, in which DTE might be the result of interference
tissues might influence the eruptive process. delayed to eruption by these lesions20,21,22,23,24. Generalized delay in
eruption is often reported in patients who are deficient in the eruption of teeth is noted in some families . Patient
some essential nutrient. Agarwal et al15 had reported delayed medical history might be totally unremarkable, with DTE as
deciduous dental eruption in malnourished Indian children. the only finding. The presence of a gene for tooth eruption
Chronic malnutrition extending beyond the early childhood has also been suggested, and its “delayed onset” might be
is correlated with delayed teeth eruption. Most of the teeth responsible for DTE in “inherited retarded eruption”.10,19
showed a one to four month variation around the mean
eruption time16 CLINICALIMPLICATIONS (table 4)

Table 2 shows various systemic condition which Diagnosis of DTE is an important but complicated
can lead to DTE. Disturbance of the endocrine glands process. When teeth do not erupt at the expected age (mean
usually has a profound effect on the entire body, including +_ 2 SD), a careful evaluation should be performed to
the dentition10. Hypothyroidism, Hypopituitarism, establish the etiology and the treatment plan accordingly10.
Hypoparathyroidism, and Pseudohypoparathyroidism are Various tables and diagrammatic charts of the stages of
the most common endocrine disorders associated with DTE. tooth development, starting from the initiation of the

82

Delayed Tooth Eruption www.ejournalofdentistry.com

calcification process to the completion of the root apex of (6) Diagnosis and treatment of systemic disease that
each tooth are part of dental education. Norms with the causes DTE.
average chronologic ages at which each stage occurs should
be compared3 The treatment flowchart (table 5) can serve as a
guideline for addressing the most important treatment
Medical history, family information and options in DTE. Once the clinical determination of
information from affected patients about unusual variations chronologic DTE (>2 SD) has been established, a panoramic
in eruption patterns should be investigated. Clinical radiograph should be obtained. The screening radiograph
examination must begin with the overall physical evaluation can be used to rule out tooth agenesis and assess the
of the patient. Significant right-left variations in eruption developmental state of the tooth25,28
timings might be associated with tumors and should alert
the clinician to perform further investigation.10 If there is defective tooth formation, the first step
should be to assess whether the defect is localized or
Intraoral examination should include inspection, generalized. Unerupted deciduous teeth with serious
palpation, percussion, and radiographic examination. The defects should be extracted, but the time of extraction should
clinician should inspect for gross soft tissue pathology, be defined carefully by considering the development of
scars, swellings, and fibrous or dense frenal attachments. the succedaneous teeth and the space relationships in the
Careful observation and palpation of the alveolar ridges permanent dentition. In the permanent dentition, unerupted
buccally and lingually usually shows the characteristics teeth are normally closely observed until the skeletal growth
bulge of a tooth in the process of eruption. Palpation period necessary for appropriate development and
producing pain, crackling, or other symptoms should be preservation of the surrounding alveolar ridge has been
further evaluated for pathology. Overretained deciduous attained.In DTE with no obvious developmental defect in
tooth and the supporting structures should be thoroughly the affected tooth or teeth on the radiograph, root
examined. Ankylosed teeth also interfere with the vertical development (biologic eruption status), tooth position and
development of the alveolus.10 physical obstruction should be evaluated. For a
succedaneous tooth if root formation is inadequate,
INVESTIGATIONS extraction of the deciduous tooth or exposure to apply active
orthodontic treatment is not justified. If the tooth is lagging
A panoramic radiograph is ideal for evaluating the in its eruption status, active treatment is recommended
position of teeth and the extent of tooth development, when more than 2/3 of the root has developed25.
estimating the time of emergence of the tooth into the oral Radiographic examination might also show an ectopic
cavity, and screening for pathology. IOPA with the image/ position of the developing tooth. Often, some deviations
tube shift method, Clark’s rule, buccal object rule are self-correct, but significant migration of the tooth usually
suggested for radiographic localization of tumors, requires extraction. If self-correction is not observed over
supernumerary teeth, and displaced teeth, which require time, active treatment should begin. Exposure accompanied
surgical correction. Computed tomography can be used as by orthodontic traction has been shown to be successful.
the most precise method of radiographic localization 25,26,27 In patients in whom the ectopic teeth deviate more than 90°
from the normal eruptive path, autotransplantation might
TREATMENT CONSIDERATIONS be an effective alternative.10,23,24,25

The treatment of DTE depends on the etiology. A An obstruction causing delayed eruption might
number of techniques have been suggested for treating or might not be obvious on the radiographic survey. A soft
DTE. The treatment plan should also consider10 tissue barrier to eruption is not seen on the radiograph, but
the obstruction should be treated with an uncovering
(1) The decision to remove or retain the tooth or teeth procedure that includes enamel exposure. Supernumerary
affected by DTE teeth, tumors, cysts, and bony sequestra are physical
obstructions visible on the radiographic survey. Their
(2) The use of surgery to remove obstructions, removal usually will permit the affected tooth to erupt29

(3) Surgical exposure of teeth affected by DTE, In the deciduous dentition, DTE due to
obstruction is uncommon, but scar tissue (due to trauma)
(4) The application of orthodontic traction, and pericoronal odontogenic cysts or neoplasms are the
usual culprits in cases of obstruction. Trauma is more
(5) The need for space creation and maintenance, and

e-Journal of Dentistry Oct - Dec 2011 Vol 1 Issue 4 83

Faizal C Peedikayil www.ejournalofdentistry.com

common in the anterior region, but cysts or neoplasms are Table 1: Local Conditions associated with DTE *(10,11,12)
more likely to result in DTE in the canine and molar regions.
Odontomas are reported to be the most common of the  Mucosal barriers-scar tissue: trauma/surgery
odontogenic lesions associated with DTE30. Treatment
options for deciduous DTE range from observation,  Supernumerary teeth
removal of physical obstruction with and without exposure
of the affected tooth, orthodontic traction on rare  Odontogenic tumors (eg, adenomatoid odontogenic Tumors, odontomas)
occasions, and extraction of the involved tooth28,31.
 Nonodontogenic tumors
In the permanent dentition, removal of the physical
obstruction from the path of eruption is recommended.  Enamel pearls
When neoplasms (odontogenic or nonodontogenic) cause
obstruction, the surgical approach is dictated by the  Injuries to primary teeth
biologic behavior of the lesion. If the affected tooth is deep
in the bone, the follicle around it should be left intact. When  Ankylosis of deciduous teeth
the affected tooth is in a superficial position, exposure of  Premature loss of primary tooth
the enamel is done at tumor removal. Occasionally, the
affected tooth must be removed. McDonald and Avery32  Lack of resorption of deciduous tooth
recommend exposure of the tooth delayed in eruption at
the surgical removal of the barrier, but Houston and Tulley  Apical periodontitis of deciduous teeth
33advocate removing the obstruction and providing
sufficient space for the unerupted tooth to erupt  Regional odontodysplasia
spontaneously. If the tooth is exposed at the time of surgery,
it might or might not be subjected to orthodontic traction  Drugs -Phenytoin
to accelerate and guide its eruption into the arch. The  Ectopic eruption
decision to use orthodontic traction in most case reports
seems to be a judgment call for the clinician. Occasionally,  Arch-length deficiency and skeletal pattern
a deciduous tooth can be a physical barrier to the eruption
of the succedaneous tooth. In most cases, removing the  Radiation damage
deciduous tooth will allow for spontaneous eruption of the
successor4. When arch length deficiency creates a physical  Oral clefts Segmental odontomaxillary dysplasia
obstruction, either expansion of the dental arches or
extraction might be necessary to obtain the required space. Table 2: Systemic Conditions associated with DTE * (10,

10,13 15,16,17)
 Nutrition
Whenever DTE is generalized, the patient should
be examined for systemic diseases affecting eruption, such  Vitam in D-resistant rickets
as endocrine disorders, organ failures, metabolic disorders,
drugs, and inherited and genetic disorders. Various methods  Endocrine disorders (H ypothyroidism ,H ypopitutarism, hypoparathyroidism,
have been suggested for treating eruption disorders in pse udo hypo par athyroi dis m )
these conditions. These include no treatment (observation),
elimination of obstacles to eruption (eg, cysts, soft tissue  Long-term chemotherapy
overgrowths), exposure of affected teeth with and without
orthodontic traction, autotransplantation, and control of  HIV infection
the systemic disease.1,4,10,11,12,17,19
 Cerebral palsy

 Dysosteosclerosis

 Anemia

 Celiac disease

 Prem aturity/low birth weight

 Ichthyosis

 renal failure

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

 Am elogenesis imperfect and associated disorders
 Enamel agenesis and nephrocalcinosis
 Am elo-onychohypohydrotic dysplasia dento-osseous

s yndrom e (types I and II)
 Apert syndrom e
 Carpenter syndrom e
 Cherubism
 C hondroectoderm al dysplasia (Ellis-van C reveld

syndrom e
 C leidocranial dysplasia
 C ongenital hypertrichosis lanuginosa
 D entin dysplasia
 Mucopolysaccharidosis
 D eLange syndrom e
 H urler syndrome
 H unter syndrom e
 Pyknodysostosis (Maroteaux-Lam y syndrom e) (M PS IV)
 Down syndrome
 Ectoderm al dysplasia
 Epiderm olysis bullosa
 G ardner syndrome
 G aucher disease
 R utherford syndrom e
 C ross syndrom e

Ramon syndrome
G ingival fibromatoses with sensorineural hearing loss
G ingival fibromatoses with growth ho rmone deificiency
 G orlin syndrom e
 N eurofibromatoses
 O steopetrosis (marble bone disease)
 O steogenesis im perfecta
 O todental dysplasia
 Parry-Rom berg syndrom e
 Prog eria (H utchinson-G ilford syndrome)
 R othm und-Thompson syndrome
 VonRecklinghausen neurofibrom atosis

84

Delayed Tooth Eruption www.ejournalofdentistry.com

Table 4: Etiology and Diagnosis of Chronological than two years should be investigated. eventhough
delayed tooth eruption(>2SD) genetics has an important role in the eruptuin process other
factors such as gender, body composition, local
Normal tooth development Abnormal tooth development( defect in shape , size, disturbances,nutritional factors, systemic diseases etc can
structure, colour) influence the process. But significant cause may be due to
systemic conditions and syndromes associated with
Normal biologic Delayed biologic eruption: root orofacial structures. Timely diagnosis of DTE is necessary
eruption: root length< length>2/3 for selecting the right treatment modality.

2/3 REFERENCES

- preterm birth/ low birth -Amelogenisis imperfecta 1. Pahkala R, Pahkala A, Laine T. Eruption pattern of permanent teeth in a rural
weight - Dentinogenesis imperfecta community in northeastern Finland. Acta Odontol Scand. 1991; 49:341-9.
- Regional odontodysplasia
- nutrition -Dilacerations 2. Proffit WR, Fields HW. Contemporary orthodontics. 3 rd ed. Mosby Inc.; 2000.
- vit D resistant rickets - Dentin dysplasia
- down’s syndrome 3. Nolla CM. The development of the human dentition. ASDC J Dent Child 1960;
- Hypopitutarism 27: 254-66.

Physical obstruction 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
Radiographycally evident Not evident OTHERS
radiographically -Nutritional deficiency 5. Nystrom M, Kleemola-Kujala E, Evalahti M, Peck L, Kataja M. Emergence of
-supernumerary tooth -Scar from trauma -Radiation damage permanent teeth and dental age in a series of Finns. Acta Odontol Scand 2001; 59:
- tumor -Scar from surgery -traumatic displacement of tooth germ 49-56.
- cyst -Ankylosis -cleidocranial dysplasia
-eruption sequestrum -Gingival hyperplasia -arch length deficiency 6. Ekstrand KR, Christiansen J, Christiansen ME. Time and duration of eruption
-ectopic eruption -Premature loss of -Scleroosteosis of first and second permanent molars: a longitudinal investigation. Community
-HIV infection Dent Oral Epidemiol 2003;31: 344-50.
primary teeth -Genetic predisposition
7. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of
Table 5: Chart of treatment options of DTE affecting preterm birth. Lancet 2008;371: 75-84 .
permanent teeth
8. Seow WK, Humphrys C, Mahanonda R, Tudehope DI. Dental eruption in low
Chronological delayed tooth eruption birth-weight prematurely born children: a controlled study. Pediatr Dent 1988;10:
39-42.
Radiographic examination Space closure,
Evaluate for tooth agenesis tooth missing Restorative options 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.
Tooth present
10. Suri l, Gagari E, Vastardis H. Delayed tooth eruption:Pathogenesis,diagnosis
Evaluate systemic influences Yes Is DTE generalized? and treatment. A literature review. Am J Dentofacial Orthop 2004;126;432-45

Observoabtsioernvation No 11. Cunha RF, Boer FA, Torriani DD, Frossard WT. Natal and neonatal teeth: review
Diagnodsiiasg&ncoosinstrol of of the literature. Pediatr Dent 2001;23: 158-62
systemic disease Tooth development Yes Root development ? 2/3 ? No
normal on 12. Brin I, Ben-Bassat Y, Zilberman Y, Fuks A. Effect of trauma to the primary
No radiographic survey Yes incisors on the alignment of their permanent successors in Israelis. Community
Dent Oral Epidemiol 1988;16: 104-8.
Observation Physical obstruction
13. Suda N, Hiyama S, Kuroda T. Relationship between formation/ eruption of
yes No maxillary teeth and skeletal pattern of maxilla. Am J Orthod Dentofacial Orthop
2002;121: 46-52.
Evaluate tooth position
14. Piloni MJ, Ubios AM. Impairment of molar tooth eruption caused by x-
Observation -Removal of obstruction , if ectopic radiation. Acta Odontol Latinoam 1996;9: 87-92.
Extraction of affected teeth+ Removal of obstuction + exposure of
replacement (implant,fixed, 15. Agarwal KN, Narula S, Faridi MM, Kalra N. Deciduous dentition and enamel
removable prosthesis, affected teeth , defects. Indian Pediatr. 2003;40: 124-9.
autotransplantation ofhealthy
tooth bud ) . Removal of obstruction+ exposure + 16. Psoter W, Gebrian B, Prophete S, Reid B, Katz R. Effect of early childhood
Exposure of affected tooth malnutrition on tooth eruption in Haitian adolescents. Community Dent Oral
exposure +orthodontic orthodontic traction , Observation Epidemiol 2008;36: 179-89.
traction
Removal of obstruction + removal of Exposure+orthodontic 17 Shaw L, Foster TD. Size and development of the dentition in endocrine
deficiency. J Pedod 1989;13: 155-60.
affected teeth +replacement of traction
18.Kaloust S, Ishii K, Vargervik K. Dental development in Apert syndrome. Cleft
tooth (implant, removable or fixed Extraction +replacement Palate Craniofac J 1997;34: 117-21.
prosthesis,autotransplantation), (implant, fixed removable
Removal of obstruction+ removal of prosthesis, 19. Blankenstein R, Brook AH, Smith RN, Patrick D, Russell JM. Oral findings in
affected tooth +orthodontic space Carpenter syndrome. Int J PaediatrDent 2001;11:352-60.

closure , Autotransplantation ) 20.Franklin DL, Roberts GJ. Delayed tooth eruption in congenital hypertrichosis
Extraction of neighboring tooth to lanuginosa. Pediatr Dent 1998;20:192-4.

create space , 21.Gorlin RJ, Cohen MMJ, Hennekam RCM. Syndromes ofthe head and neck. New
York: Oxford University Press; 2001.
Expansion of arches
22.Buch B, Noffke C, de KS. Gardner’s syndrome—the importance of early
CONCLUSION diagnosis: a case report and a review. SADJ 2001;56:242-5

The sequential and timely eruption of teeth is 23. Rasmussen P, Kotsaki A. Inherited retarded eruption in the permanent
critical in overall development of the child. Variations can dentition. J Clin Pediatr Dent 1997;21: 205-11.
occur due to various reasons, but eruption delay of more
24. Pulse CL, Moses MS, Greenman D, Rosenberg SN, Zegarelli DJ. Cherubism:
case reports and literature review. Dent Today 2001; 20: 100-3.

e-Journal of Dentistry Oct - Dec 2011 Vol 1 Issue 4 85

Faizal C Peedikayil www.ejournalofdentistry.com

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

86