R eview Article

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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: 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

Preterm birth

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.

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.

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

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.

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

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Local factors

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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Faizal C Peedikayil

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.

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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

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,

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(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

(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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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

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Faizal C Peedikayil

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

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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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

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Delayed Tooth Eruption

Table 4: Etiology and Diagnosis of Chronological

delayed tooth eruption(>2SD)

Normal tooth development

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.

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

REFERENCES

- Regional odontodysplasia
-

preterm birth/ low birth

weight
nutrition
vit D resistant rickets
downs syndrome
Hypopitutarism

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.

-Dilacerations
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Physical obstruction

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Radiographycally evident

Not evident
radiographically

-supernumerary tooth

-Scar from trauma

OTHERS

- tumor

-Scar from surgery

-Nutritional deficiency

- cyst

-Ankylosis

-Radiation damage

-eruption sequestrum

-Gingival hyperplasia

-traumatic displacement of tooth germ

-ectopic eruption

-Premature loss of

-cleidocranial dysplasia

primary teeth

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:
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-arch length deficiency

7. Goldenberg RL, Culhane JF, Iams JD, Romero R. Epidemiology and causes of
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Table 5: Chart of treatment options of DTE affecting

permanent teeth
Chronological delayed tooth eruption
Radiographic examination
Evaluate for tooth agenesis

12. Brin I, Ben-Bassat Y, Zilberman Y, Fuks A. Effect of trauma to the primary

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Tooth present
Evaluate systemic influences
observation
Observation
Diagnosis &control of
diagnosis
systemic disease

No

Yes

Is DTE generalized?
No

Tooth development
normal on
radiographic survey

Yes

Root development ? 2/3 ?

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.

No

Yes
Observation

Physical obstruction
yes

No

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

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

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

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21.Gorlin RJ, Cohen MMJ, Hennekam RCM. Syndromes ofthe head and neck. New
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Faizal C Peedikayil

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25. Jacobs SG. Radiographic localization of unerupted teeth: further findings about
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27. Raghoebar GM, Boering G, Vissink A, Stegenga B. Eruption disturbances of
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1992

Source of Support : Nil, Conflict of Interest : Nil

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