Eruption & Establishment of the Dentition

Oral Histology Dent 206

Tooth Eruption

A process whereby a tooth moves from its developmental position in the jaw into its functional position in the mouth The process by which developing teeth emerge through the overlying bone, soft tissues & oral mucosa No evidence that eruption ceases after occlusal contact

Over-eruption upon removal of antagonist tooth

A continuous process ending only with the loss of the tooth

Purpose of tooth eruption

Entering the oral cavity Contacting teeth of the opposing arch Functioning in occlusion & mastication

Phases of eruption

Pre-eruptive phase

Initiation of tooth development Crown completion Initiation of root development Establishment of occlusal contact Once occlusal contact is established onwards Concerned with development & maintenance of occlusion

Pre-functional eruptive phase

Post-eruptive functional phase protracted phase

Tooth eruption

Pre-eruptive Phase Pre-functional Eruptive Phase Functional Eruptive Phase

Pre-eruptive Phase

Movements in response to positional changes of adjacent developing crowns Movements in response to changes in the maxilla and the mandible as the face grows downwards and forwards Teeth make mesial and distal movements during lengthening of the jaws Movement of successor teeth in relation to their predecessors when they adjust to the roots of the primary dentition

Movement of successors

Movement of

Permanent anterior Premolars

Change in relative position is due to

Eruption of the predecessor tooth Increase in height

Movement of anterior successors

Begin development lingual to the incisal tip of the primary teeth As primary teeth erupt they are lingual to the apical third of the roots

Movement of permanent molars

Maxillary molars

Develop within the tuberosities Occlusal surfaces slanting distally

Develop in the rami Occlusal surfaces slanting mesially

Mandibular molars

First permanent Molar Developing in Tuberosity

Permanent Molars Developing at Angle of Mandible

Movement of teeth

Rates of eruption

A balance between eruptive & resistive force Resistance (factors affecting eruption rate)

Overlying soft tissues & alveolar bone Viscosity of surrounding PDL Occlusal forces TOOTH
Upper central incisors
Lower 2nd premolars 3rd molars Crowded dentition

ERUPTION RATE
1 mm / month
4.5 mm / 14 weeks 1 mm / 3months < 1 mm in 6 months

Rate of eruption

Slow eruption until the tooth reaches the oral mucosa

2 4 years for permanent teeth

2/3s of root length has formed Maximum rate is 1 mm / month

Rapid eruption as the tooth enters the oral cavity

Eruption slows as the tooth approaches the occlusal plane/contact

No sex difference Racial differences may exist

Active eruption vs. passive eruption

Active

Axial movement of the tooth

Retraction of adjacent soft tissues

Passive

Pre-functional Eruptive Phase

Starts with the initiation of root formation Ends when reaching occlusal contact

Pre-functional Eruptive Phase

Root formation
Proliferation of Epithelial Root Sheath Initiation of dentinogenesis in the root Formation of the pulp tissues An increase in follicular fibrous tissue

Movement
Elongating roots need a space Reduced enamel Epithelium fuses with the oral epithelium

Penetration
Entrance into the oral cavity Enamel cuticle covers enamel No bleeding

Intra-oral occlusal/incisal movement

Until contact with opposing crown occurs Clinical crown vs. Anatomical crown

Pre-functional Eruptive Phase

Changes in tissues
Overlying erupting teeth Surrounding erupting teeth Underling erupting teeth

Overlying erupting teeth

Eruption pathway (Inverted

triangular area)

Zone of degeneration

Blood vessel decrease in number Nerves break down and degenerate

Gubernacular cord at the periphery of the degenerative zone

Follicular fibers directed toward the mucosa Gubernacular canal contains the gubernacular cord The cord is composed of a central strand of epithelium surrounded by connective tissue

Overlying erupting teeth

Osteoclasts

Resorption of overlying bone (In successor teeth) resorption of the root of the predecessor
Build up of resorbed areas after tooth movement

Osteoblasts

Permanent incisors Gubernacualr canals

Crypts of second Permanent molars

Resorption of primary teeth

Begins within 1 year of root completion Similar to bone resorption Dentine and cementum are resorbed but not enamel By osteoclasts

Resorption of primary teeth

Resorbtion at apex

Root resorption

May be inherent May be related to pressure from permanent successor against overlying bone or tooth Non-supporting evidences

Surgical removal of permanent tooth germ

Resorption of predecessor root still occurred Resorption is delayed Successor is absent/abnormally positioned shedding still occurs but can be retarded

Clinical evidence

Factors affecting rate of root resorption

Increased masticatory loads

Less resorption when deciduous teeth are splinted after removal of successor germs Resorption is not a continuous process Reparative tissue may be formed Reattachment of PDL Reparative tissue is cemental-like Repair > resorption leads to loss of PDL & ankylosis to surrounding bone

Rest periods

Ankylosed primary teeth

Failure of continuing eruption Position remains constant in the jaw Height of alveolar bone increases Tooth sinks gradually below the levels of adjacent teeth Called submerged teeth Submerging may continue to an extent where teeth become completely buried within bone

Hard tissue resorption

Osteoclasts resorb the minerals at the ruffled border in 2 phases

Extra-cellular phase

Mineral is separated from collagen and broken into small fragments Osteoclasts ingest mineral fragments

Intra-cellular phase

Organic material resorption occurs by Special fibroblast (fibroblast-fibroclast cell)

Osteoclast Activity in Alveolar Bone

Shedding of primary teeth

Primary dentition from about 2 to 7 years Mixed dentition from 7 to 13 years During mixed dentition period nearly 50 teeth are accommodated in the jaw

Fusion of Reduced Enamel Epithelium & Oral Epithelium

Penetration

Development of dentogingival junction

Tooth approaches oral epithelium Proliferation and union between

Outer layer of REE Basal layer of oral epithelium

Degeneration of epithelium covering the incisal edges/cusp tips Crown emerges through an epithelial-lined pathway Passive separation of oral epithelium from the crown Emergence without bleeding

Development of dentogingival junction

REE is retained as the junctional epithelium

Junctional epithelium acts as an epithelial seal Attached to the unerupted part of the crown

Reduced enamel component is believed to be replaced eventually by oral epithelium Gingival crevice forms when more of the crown is exposed

Development of dentogingival junction

Infant mandible 18 months

Eruption vs. root completion

Eruption is complete before root formation is complete Root is completed

Primary teeth

1-1.5 yrs post-eruption 2-3 yrs post-eruption

Permanent teeth

Eruption of permanent molars

Permanent molars do not have primary precursors Permanent molars erupt through alveolar bone Bone loss occurs before approaching the oral epithelium Tooth organ epithelium makes contact with oral mucosa Causes stretching and thinning of the oral mucosa Rupture of oral epithelium Tooth emerges until clinical contact with the opposing tooth is made

Eruption of permanent Molar

Surrounding erupting teeth

Formation begins with root formation From delicate fibers parallel to the surface of the tooth into well-organized fibrous bundles Blood vessels become more dominant As root elongates more fibrous bundles appear Fibres increase in density and number as the tooth erupts Fibers attach and release and re-attach rapidly as the root elongates Alveolar bone increases in height accordingly After functional occlusion fibers gain their mature orientation

Periodontal Ligament

Development of Periodontal Ligament

Alveolar Process

The alveolar process develops during the eruption of teeth Grows at a rapid rate at the free border Proliferates at the alveolar crest No distinct boundary exists between the body of the maxilla or mandible and the alveolar process If teeth are lost the alveolar bone disappears

Alveolar Bone

Crypt increases in height to accommodate the root formation Alveolar bone deposited appositionally around emerging crown Increase in height

Development of Bony Crypt

Deciduous tooth & permanent successor initially share crypt Bone subsequently forms to encase the permanent tooth

Development of Bony Crypt

Bony Crypts

Underlying erupting teeth

Occlusal movement provides an underlying space (fundic region) Highly fibroblastic Fine strands of fibers that calcify into bone trabeculae (ladder-like arrangement) As the tooth moves up, bone trabeculae become denser and the spaces are filled with bone

Mechanisms of tooth eruption

Theories of tooth eruption

Tooth is pushed out as a result of forces generated beneath & around it

Alveolar bone growth Root growth Blood pressure/tissue fluid pressures Cell proliferation

Tooth is pulled out as a result of tension within the PDL

No theory is yet supported by sufficient experimental evidence

Eruptive mechanism

A property of the PDL Does not require a tractional force pulling the tooth outwards Multifactorial A combination of

Fibroblast activity Vascular and/or tissue hydrostatic pressures

Role of PDL in eruption

Root resection

Surgical removal of proliferative tissue at the base of a continuously growing incisor Cutting the incisor into proximal & distal portions

Root transection

Resected & transected incisors continue to erupt because their PDL is still intact Tractional pulling forces are unlikely to have a role

Role of PDL in eruption

Eruptive potential is also inherent in the precursor of the PDL dental follicle

Unerupted premolar removed from its follicle & replaced with a metal replica relica erupts because the dental follicle was retained Rootless erupt because they are surrounded by dental follicle

Role of PDL in eruption

Lathyrogens are drugs that inhibit cross-liking of collagen Eruption rates of lathyritic incisors are unaffected No tractional elements in pulling the tooth outwards Teeth erupt in the absence of well-developed PDL Disproving the theory of contraction of PDL collagen

Role of PDL in eruption

Conclusion

Connective tissue surrounding the tooth contains the eruptive elements - 2 views

Force is produced by activity of fibroblasts contractility & motility Vascular/hydrostatic pressure in & around the tooth is responsible for eruption

Role of PDL fibroblast motility/contractility

Cells exert tractional forces via contractility/motility through

Collage network Cell-to-cell contacts

Colchicine is a drug that disturbs intracellular microtubules Colchicine retards eruption

Role of PDL vascular/hydrostatic pressure

Vascular pressure can change the position of a tooth in its socket Tooth moves in synchrony of arterial pulse At death, blood pressure is zero eruption ceases Changes is eruptive behavior upon

Administration of vasoactive drugs Interference with sympathetic vasomotor nerves

Stimulation of cervical sympathetic nerves

Role of PDL vascular/hydrostatic pressure

There should be a pressure differentials along the PDL Proteoglycan is increased during active eruption Increased number of fenestrations on the capillaries during active eruption

Fenestrations are higher near the base & low near the alveolar crest Differential vascular activity across the length of the PDL

Other theories of tooth eruption

Growth of the root Pulpal pressure Detachment & reattachment of PDL fibers Cell proliferation Increased bone formation around the teeth Endocrine Vascular changes Enzymatic degradation

Root elongation

Pulpal Pressure

Many blood vessels in apical region cause tissue fluid to build up Increased vascularity pressure potential between the highly vascular diaphragmatic proliferation zone and the degenerative eruption pathway PT -Tissue pressure PI - Intrapulpal pressure

Periodontal ligament fibers

Attachment release and re-attachment of the PDL fibrous bundles

Functional Eruptive Phase

Continues as long as teeth area present Compensation to

Increase in alveolar process height Attrition/abrasion of incisal/occlusal surfaces Loss of opposing tooth (over eruption) Root apex Furcation areas

Cementum deposited at

Stages in Development