Eruption and Shedding of Teeth - 2014

26/12/2014
ERUPTION AND SHEDDING OF

TEETH
Professor Dr. Md Nurul Islam
26/12/2014
Active Tooth Eruption
The term active tooth eruption implies the

emergence of a crown of tooth into the oral cavity.
In general, however, the term refers to the total life
span of the tooth, from the beginning of crown

development until the tooth is lost or the individual
dies.
26/12/2014
Active Tooth Eruption

This eruptive process is usually divided into three
stages, and although there may be some difference
in the terminology, they refer to the same
mechanism.
Preeruptive Stage
The preeruptive stage begins as the crown starts to
develop.
26/12/2014
Recall that dental lamina formation - bud, cap, and

bell stages, as well as the calcification of the crown takes place in the connective tissue beneath the oral
epithelium.
During this time the bone of the maxilla or mandible
surrounds the developing primary tooth in a Ushaped crypt or beginning socket.
26/12/2014
26/12/2014
The eruptive movement associated with the

preeruptive stage is of two varieties - spatial and
excentric.
In spatial movement the crown develops while the
bottom of the socket fills in with bone, pushing the
crown toward the surface.
A similar facial movement accompanies jaw growth.
26/12/2014
26/12/2014
In excentric, or off-center growth, the crown of a

tooth does not grow in a perfectly symmetrical
pattern.
As the crown enlarges, it grows more in one area

than in another, and so the tooth seems to be
moving because the center of the tooth is shifting.
26/12/2014
It appears to have moved because the center point
of the developing crown has shifted.

This is the activity of the preeruptive stage.
It involves crown growth and some movement
toward the surface while the crypt is developing.
26/12/2014
Eruptive Stage
The eruptive stage or prefunctional eruptive stage
begins with the development of the root.
The root develops in a crypt of bone.
As it begins forming, osteoclasts temporarily may
deepen the crypt by resorbing bone at the bottom

to accommodate for the increase in root length.
10
26/12/2014
While the root continues to lengthen, the tooth

begins to move toward the surface of the oral cavity.
As it approaches the oral cavity, the alveolar bone is
growing to keep pace with it.
However, in time the tooth moves faster than the
growing alveolar bone and approaches the surface
of the oral epithelium and breaks into the oral cavity.
11
26/12/2014
The crown of the tooth is surrounded by reduced

enamel epithelium.
Around the reduced enamel epithelium there are
cells of the dental sac, or follicle, that covers the
crown.
Cells of the dental follicle form a cord of connective
tissue epithelium.
12
26/12/2014
This fibrous cord is known as the gubernacular cord

and forms a gubernacular canal that leads the way
and, with the help of macrophages and osteoclasts,
breaks down the bone between the tooth and the
surface oral epithelium for the primary tooth to
erupt.
13
26/12/2014
As the tooth moves to the surface, the reduced

enamel epithelium moves with it until it compresses
the connective tissue and causes it to disintegrate.
The reduced enamel epithelium then contacts the
oral epithehlium, and these two layers fuse into one
layerthe united oral epithelium.
14
26/12/2014
The tooth breaks through this layer and emerges

into the oral cavity.
It is believed that this break down of epithelium is
caused by an enzyme probably produced by the
reduced enamel epithelium.
This stage continues until the erupting teeth meet
the opposing teeth.
15
26/12/2014
16
26/12/2014
17
26/12/2014
18
26/12/2014
For both primary and secondary dentition, tooth

movement in the eruptive stage tends to be occlusal
and facial, more facial in the anteriors than in the
posteriors.
When we think about the pathway for the secondary
teeth, we have to consider their mechanism for
development.
19
26/12/2014
The successional lamina buds off the dental lamina

and forms a permanent tooth at its end, still partially
attached by the successional lamina.
As the permanent tooth becomes surrounded by

bone, the attachment of the successional lamina of
the anterior teeth forms a gubernacular canal.
20
26/12/2014
Successional
Lamina
21
26/12/2014
22
26/12/2014
This is the gubernacular canal, and under normal

circumstances the erupting permanent tooth follows
the pathway of the gubernacular canal to reach the
surface.
It is seen only lingual to the anterior teeth because
the permanent anteriors erupt slightly lingual to
their primary counterparts, while the permanent
posterior teeth lie below the primary and erupt
through their established alveolus.
23
26/12/2014
Posteruptive Stage
The posteruptive stage begins when the teeth come
into occlusion and continues until they are lost or
death occurs.
This posteruptive stage functions in several ways.
First, as the mandible continues to grow and
increase the space between the maxilla and
mandible, the teeth will continue to erupt to
maintain a balance in the arches.
24
26/12/2014
Second, as the teeth wear occlusally because of

prolonged masticatory stress and wear, they will
continue to erupt to maintain tooth contact.
Third, because there is slight interproximal wear, a

slight mesial eruptive force will keep the teeth in
contact.
25
26/12/2014
This mesial drifting can be caused, particularly in

the mandible, by unerupted third molars that are
pushing against the second molars; however, there is
a physiologic mesial drift inherent to teeth.
Both of these circumstances are referred to as

mesial drift.
Finally, if an opposing tooth is lost, the tooth may
continue to erupt in what is generally referred to as

supraeruption, or hypereruption.
26
26/12/2014
Supra eruption can cause serious problems in the

replacement of the missing tooth because it makes it
difficult to reestablish the normal occlusal plane.
27
26/12/2014
Causes of Eruption
What causes tooth eruption? What are the forces
involved? Much research has been done concerning
this question, but much more still needs to be done.
Following are some of the discussions and thoughts.
Root Growth. It has been said that the increase in
root length, or root elongation, forces the tooth into
the oral cavity.
28
26/12/2014
However, several things would tend to disprove this.

Experiments have been done in which Hertwigs root
sheath has been destroyed and root growth has

been stopped or inhibited, yet the tooth has still
erupted.
Teeth have had their roots cut and a pin placed

through the apical section, but the occlusal portion
continues to erupt.
29
26/12/2014
On the other hand, third molars have grown roots to

full length, but the teeth have not erupted.
It seems that root elongation by itself is not required
for tooth eruption, but probably has a relationship to

the process.
30
26/12/2014
Alveolar Bone Formation and Changes. It has been

said that alveolar bone growth, tooth development,
and eruption are interdependent mechanisms.
The alveolar process forms in areas where teeth are

developing and is deficient in areas where teeth fail
to develop.
31
26/12/2014
Alveolar bone changes involve both formation and

resorption, and these metabolic events are
dependent on the presence of the various parts of
the dental sac or dental follicle.
The dental sac plays a role in the formation of
cementum of the root, the periodontal ligament, and
alveolar bone.
32
26/12/2014
The presence of the outer layers of the enamel organ

also is important in assisting with the osteoclastic
activity and soft tissue destruction necessary for the

crown to move up through the bone and soft tissue.
This cycle of bone development is rhythmic both in
the crest and crypt of the alveolar bone - instances

of osteoblastic activity followed by osteoclastic
activity or inactivity.
33
26/12/2014
In multirooted teeth the interradicular bone seems
to have a fairly significant role in the eruptive

process, according to some researchers.
Periodontal Ligament. Even though the periodontal
ligament is less involved in tooth eruption than was

once believed, it still has a role to play, probably
more so toward the end of eruption than at the
beginning.
34
26/12/2014
Earlier theories of the periodontal ligament having

contractile properties in some of its fibers is now a
thing of the past in most of the literature.
There does still appear to be a remodeling of the

intertwining of periodontal fibers in later tooth
eruption that is part of the process, but teeth
without roots have been shown to erupt in the
absence of the periodontal ligament.
35
26/12/2014
Vascular Pressure in Dental Tissues. It has been

known for a long time that there are vascular
pressures present in pulpal tissues as well as in the
periodontal ligament.
There is also reasonable agreement that the function
of the periodontal ligament as a shock absorber
for teeth is a result of these vascular pressures.
36
26/12/2014
These pulsating blood pressures not only enhance

cellular activity but seem to have a direct eruptive
role.
However, it is difficult to assess because removal of

all fluid pressures would mean the elimination of
oxygen and other nutrients from the developing
teeth.
37
26/12/2014
The role of the tooth itself. The tooth plays little if

any role in eruption because developing teeth have
been surgically removed and replaced by metal or
silicone implants into the dental sac, and these
implants have erupted.
The question is yet to be answered as to the actual
factors in tooth eruption.
38
26/12/2014
It is obvious from the information presented above

that tooth eruption is definitely multifactorial.
Much research is being focused on the biochemistry
and cell and molecular biology aspects of the

subject, and it seems that these disciplines will begin
to provide more and more answers.
39
26/12/2014
Shedding of Primary Dentition

As mentioned, the 20 permanent teeth that follow
the primary teeth develop as off shoots of the
primary dental lamina.
Recall that the anterior permanent teeth develop
apically and lingually to the primary teeth, whereas
the permanent premolars develop between the roots
of the primary molars.
40
26/12/2014
Regardless of its position, the fact that the

permanent tooth is present and is in the eruptive
stage means that the permanent tooth is moving
toward the surface and putting pressure on the root
of the primary tooth.
It is believed that this pressure causes osteoclasts to
form and begin resorbing the primary tooth root.
41
26/12/2014
42
26/12/2014
43
26/12/2014
44
26/12/2014
45
26/12/2014
This resorption is intermittent and not constant.

This is the usual manner in which resorption occurs,
but other factors may be involved.
Although most primary teeth would be retained if a
permanent tooth did not develop, it is still possible
to see a primary tooth undergo root resorption in
the absence of a permanent tooth and a primary
tooth retained in the presence of a permanent tooth.
46
26/12/2014
Therefore, although the pressure of a developing

tooth is a major factor in resorption of primary teeth,
it is not the only factor; there is a focus on the role
of the enamel organ of the erupting tooth in the
whole process.
47
26/12/2014
Retained Primary Teeth

There are several reasons why primary teeth are
retained beyond their normal time for exfoliation.
Here we are not really considering a general delayed
eruption of retarded growth patterns, but rather the
cases in which one or two teeth are retained well
beyond the expected period of time for them to be
lost.
The reasons for this are several. First, there may be
no permanent successor, and the tooth remains.
48
26/12/2014
Second, there may be ankylosis of the primary

tooth, a condition in which the alveolar crest of bone
fuses in the cervical area with the cementum of a
resorbing root.
Although virtually all the root may have been
resorbed, the tooth remains firmly in place,
preventing the permanent tooth below from
erupting.
49
26/12/2014
This may remain that way for years, and yet when
the ankylosed tooth is removed the permanent
tooth will generally begin to erupt.

The last reason for a retained primary tooth is that
the permanent tooth does not erupt in its normal
position and therefore does not cause resorption of

the primary tooth root or roots, and the tooth
remains.
50
26/12/2014
This is frequently seen in the anterior mandibular

area, where the permanent teeth erupt apically,
rather than apically and labially.
In these cases, both sets of anterior teeth will be
seen.
Another problem associated with the shedding of
primary teeth is unresorbed root fragments.
51
26/12/2014
This condition is usually but not always associated

with a malaligned primary or permanent tooth.
If the root tip of a primary tooth is not in the path of
eruption of a permanent tooth, the cervical portion
of the root may be resorbed, leaving the apical part
still embedded in the jaw.

The fragments may remain there for some time and
eventually may work their way to the surface and be
removed.
52
26/12/2014
These retained root tips are seen in radiographs

from time to time.
The time schedule of eruption and shedding is
varied.
In general, the posterior teeth go through a slower

process than the anterior teeth do.
53
26/12/2014
Not only does the length of time for eruption vary,

but also its beginning or ending time varies from
one person to another.
There is a range for normal eruption time, and only
when this period is exceeded is there cause for
concern.
54
26/12/2014
Development Disturbances
During Eruption
55
26/12/2014
Developmental Disturbances During Eruption
An odontogenic cyst that forms from the REE after
the crown has completely formed and matured is the

dentigerous cyst, or follicular cyst.
56
26/12/2014
Dentigerous Cyst
Elsevier, Imaging Consult, imaging.consult.com, 2009
57
26/12/2014
Dentigerous Cyst
Elsevier, Imaging Consult, imaging.consult.com, 2009
58
26/12/2014
Developmental Disturbances During Eruption

If a dentigerous cyst
appears on a partially
erupted tooth, it is
considered an eruption
cyst and appears as

fluctuant, blue,
vesicle-like gingival
lesion.
59
26/12/2014
Clinical Considerations for

Tooth Development
60
26/12/2014
Nasmyth's Membrane
A residue may form on newly
erupted teeth of both dentitions

that may leave the teeth
extrinsically stained.
This residue, Nasmyth's

membrane, consists of the fused
tissue of the REE and oral
epithelium as well as the dental cuticle placed by the

ameloblasts on the new enamel surface.
61
26/12/2014
Bohn's Nodules
The white bumps present on the maxillary alveolar

ridge are Bohn's nodules.
62
26/12/2014
Problems in Spacing
A permanent tooth often starts to erupt before the
primary tooth is fully shed, possibly creating
problems in spacing.
Interceptive orthodontic therapy can prevent some
of these situations.
Thus it is important for children with prolonged
retention of any primary teeth to seek early dental
consultation.
63
26/12/2014
Root Fragments
Root fragments from primary molars may be left
from the process and create periodontal

complications for the permanent dentition;
Panoramic radiographs of the mixed dentition are
important in order to monitor tooth development.
64
26/12/2014
RETAINED
RadiopaqueROOT
area of
the
TIP
alveolar ridge with the
structural appearance of the
apical part of a tooth root.
A thin periodontal ligament
space is visible on the distal.
Note the similarity of the
radiodensity of the root tip
and the adjacent premolar
root.
65
26/12/2014
Traumatic Injury Prevention

Prevention of traumatic injury to the
permanent teeth before they are
fully anchored into the jaws is very

important.
Sport bite guards are recommended for children active
in all areas of sport and consist of individually formed

plastic coverings for the teeth.
Any injury to a child's dentition needs to be seen
promptly by a dentist.
66
26/12/2014
Traumatic Injury Response

Avulsed tooth, a tooth that is completely removed
from the socket, occurs as a result of trauma and
may involve moderate pain or no pain.
Patient needs immediate examination in a dental
setting or emergency hospital unit by a dental
professional.
67
26/12/2014
Traumatic Injury Response
Ask patient to bring tooth in a wet handkerchief,

milk, or water or in buccal vestibule (preferred mode
of transport because of maintenance of hydration in
saliva);
Purchased transport medium for sport teams is
now available.
68
26/12/2014
RESEARCH UPDATE
SUMMARY: In comparison with the teeth from the
controls, the teeth from preterm children had a higher
relative value of carbon (C), a lower relative value of
calcium (Ca), a lower ratio of calcium/phosphorus
(Ca/P) and a lower ratio of Ca/C throughout the outer
part of the enamel. In dentin, the relative values for P
were higher, and Ca/P ratio was lower, at the dentinpulp junction. The Ca/P ratio indicated normal
hydroxyapatite in the crystals in enamel and dentin.
The lower ratio of Ca/C in the bulk and outer part of the
enamel indicated more porous enamel.
69
26/12/2014
70

Eruption and Shedding of Teeth - 2014

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Eruption and Shedding of Teeth - 2014

Uploaded by

Copyright:

Available Formats

26/12/2014

ERUPTION AND SHEDDING OF

Professor Dr. Md Nurul Islam

Active Tooth Eruption

The term active tooth eruption implies the

span of the tooth, from the beginning of crown

Professor Dr. Md Nurul Islam

Active Tooth Eruption

Recall that dental lamina formation - bud, cap, and

Professor Dr. Md Nurul Islam

Professor Dr. Md Nurul Islam

The eruptive movement associated with the

Professor Dr. Md Nurul Islam

In excentric, or off-center growth, the crown of a

As the crown enlarges, it grows more in one area

Professor Dr. Md Nurul Islam

It appears to have moved because the center point

of the developing crown has shifted.

Professor Dr. Md Nurul Islam

deepen the crypt by resorbing bone at the bottom

While the root continues to lengthen, the tooth

The crown of the tooth is surrounded by reduced

Professor Dr. Md Nurul Islam

This fibrous cord is known as the gubernacular cord

Professor Dr. Md Nurul Islam

As the tooth moves to the surface, the reduced

Professor Dr. Md Nurul Islam

The tooth breaks through this layer and emerges

Professor Dr. Md Nurul Islam

Professor Dr. Md Nurul Islam

Professor Dr. Md Nurul Islam

Professor Dr. Md Nurul Islam

For both primary and secondary dentition, tooth

Professor Dr. Md Nurul Islam

The successional lamina buds off the dental lamina

As the permanent tooth becomes surrounded by

Professor Dr. Md Nurul Islam

Professor Dr. Md Nurul Islam

This is the gubernacular canal, and under normal

Second, as the teeth wear occlusally because of

Third, because there is slight interproximal wear, a

Professor Dr. Md Nurul Islam

This mesial drifting can be caused, particularly in

Both of these circumstances are referred to as

continue to erupt in what is generally referred to as

Supra eruption can cause serious problems in the

Professor Dr. Md Nurul Islam

Professor Dr. Md Nurul Islam

However, several things would tend to disprove this.

sheath has been destroyed and root growth has

Teeth have had their roots cut and a pin placed

On the other hand, third molars have grown roots to

for tooth eruption, but probably has a relationship to

Professor Dr. Md Nurul Islam

Alveolar Bone Formation and Changes. It has been

The alveolar process forms in areas where teeth are

Professor Dr. Md Nurul Islam

Alveolar bone changes involve both formation and

Professor Dr. Md Nurul Islam

The presence of the outer layers of the enamel organ

activity and soft tissue destruction necessary for the

the crest and crypt of the alveolar bone - instances

In multirooted teeth the interradicular bone seems