Delayed tooth eruption

Tooth eruption

Tooth eruption is the process by which developing teeth emerge through the soft tissue of the jaws and the overlying mucosa to enter the oral cavity, contact the teeth of the opposing arch, and function in mastication

Phases of tooth eruption

• Preeruptive phase: All movements of primary and permanenttooth germs (crowns) from time of their early initiation and formation to the time of crown completion (ends with early initiationof root formation)

• Eruptive phase: Starts with initiation of root formation and madeby teeth to move from its position within bone of the jaw to itsfunctional position in occlusion. Has an intraosseous and extraosseous

compartments. 4 stages: root formation, movement,penetration and occlusal contact

• Posteruptive phase: Takes place after the teeth are functioning tomaintain the position of the erupted tooth in occlusion while thejaws are continuing to grow and compensate for occlusal and proximal tooth

wear

Delay tooth eruption

A tooth is defined to have delayed eruption when the concurrent tooth in the adjacent quadrant has erupted or when there is a delay of over 6 months after the defined normal eruption time

Causes of delayed eruption

• Local Conditions• Systemic Conditions• Genetic conditions

Local Conditions associated with DTE

• Mucosal barriers-scar tissue: trauma/surgery• Odontogenic tumors (eg, adenomatoid

odontogenic Tumors, odontomas)• Ankylosis of deciduous teeth• Radiation damage• Oral clefts

Mucosal barriers-scar tissue: trauma/surgery

• failure of the follicle of an erupting tooth to unite with the mucosa

• Gingival hyperplasia resulting from variouscauses might cause an abundance of dense connective

• tissue or acellular collagen that can be an impediment to tooth eruption

Odontogenic tumors

ODONTOMA• calcified mass with

radiodensity of tooth structure or tooth like structure surrounded by a narrow radiolucent zone

• maxilla > mandible • asymptomatic• combined with impacted

teeth lead to impaction of the involved tooth

ADENOMATOID ODONTOGENIC TUMOR

• 2/3 case 10 to 19 years of age• Females > males• maxilla > mandible• Radiographic 75% of cases, as

a circumscribed, unilocular radiolucency involves unerupted tooth crown, most often a canine

• may appear completely radiolucent or fine calcifications (snowflake)

Ankylosis of deciduous teeth

• fusion of the cementum or dentin with the alveolar bone

• most common local cause• occurs commonly in the deciduous dentition, • usually affecting the molars• mandible > maxilla• infraocclusion

Radiation damage

• Radiation therapy involves the head and neck affects on the developing permanent teeth in jawbone. These affects include delayed eruption , fusion of the deciduous teeth in the alveolar bone preventing the permanent teeth from erupting.

• Abnormal development in humans has been observed with a total dose as low as 400 cGy

Oral clefts

• CL ± CP occurs in 1 of every 700 to 1000 births. • Frequently in Asian populations (1.5 times

higher than in whites)• more common in males than in females• May associated to Genetic disorder or not

Oral cleft

• GENETIC FACTORS• Gene Locus• SKI/MTHFR 1p36• TGFB2 1q41• TGFA 2p13• MSX1 4p16, 4q31, 6p23• PVRL1 1 1q23• TGFB3 14q24• GABRB3 15q11• RARA 17q21• BCL3 19q13

ENVIRONMENTAL FACTORS● Maternal alcohol consumption● Maternal cigarette smoking● Folic acid defi ciency● Corticosteroid use● Anticonvulsant therapy

Nonsyndromic Orofacial Clefts

Systemic Conditions associated with DTE

• Nutrition• Vitamin D-resistant rickets• Endocrine disorders

(Hypothyroidism ,Hypopitutarism, Hypoparathyroidism, pseudohypoparathyroidism)

• HIV infection• Cerebral palsy• Celiac disease• Ichthyosis

Malnutrition

• Early malnutrition in childhood affects skeletal growth and results in decreased height. Similarly, poor nutrition affects tooth eruption and results in delayed emergence of the deciduous teeth.

Vitamin D-resistant rickets

• a group of metabolic disorders characterized by renal tubular defects in phosphate transport and bone abnormalities resulting in hypophosphatemic ricket

• teeth may not erupt until after one year. When decido re they erupt, they may be smaller than normal.

Endocrine disorders

• Disturbance of the endocrine glands usually has a profound effect on the entire body, including the dentition. Hypothyroidism, hypopituitarism, hypoparathyroidism, and pseudohypoparathyroidism are the most common endocrine disorders associated with DTE

Hypothyroidism (CRETINISM , MYXEDEMA)

• decreased levels of thyroid hormone • may be classifi ed as either primary or secondary• In primary hypothyroidism > the thyroid

abnormal• in secondary hypothyroidism > the pituitary

gland does not produce thyroid-stimulating hormone (TSH) > thyroid gland not release thyroid hormone.

Hypothyroidism• lethargy, dry and coarse skin• swelling of the face and extremities• huskiness of the voice, constipation,

weakness, and fatigue• Bradycardia• Hypothermia

Hypothyroidism• Oral & Dental manifestations– Delayed eruption – Enamel hypoplasia in both dentitions (being less intense

in the permanent dentition) – Anterior open bite – Macroglossia – Micrognathia – Thick lips – Dysgeusia – Mouth breathing

Hypopituitarism (PITUITARY DWARFISM)

• Affected patients are typically much shorter than normal

• maxilla and mandible smaller than normal• teeth show a delayed pattern of eruption,

delay ranges from 1 to 3 years for teeth that normally erup

• lack of 3rd molars

Hypoparathyroidism

• Hypoparathyroidism is a metabolic disorder characterized by hypocalcemia and hypophosphatemia due to a deficiency or absence of parathyroid hormone secretion

Hypoparathyroidism

• Dental manifestations- Enamel hypoplasia in horizontal lines - Poorly calcified dentin - Widened pulp chambers - Dental pulp calcifications - Shortened roots - Hypodontia - Delay or cessation of dental development

Hypoparathyroidism

• Mandibular tori • Chronic candidiasis • Paresthesia of the tongue or lips • Alteration in facial muscles

Pseudohypoparathyroidism

• Pseudohypoparathyroidism (PHP) is a heterogeneous group of disorders characterized by hypocalcemia, hyperphosphatemia, increased serum concentration of parathyroid hormone (PTH)

• Insensitivity to the biological activity of PTH• may be considered an inborn error of metabolism.• inability of the body to respond appropriately to

parathyroid hormone (PTH)

Pseudohypoparathyroidism

• Dental manifestations – enamel hypoplasia– retarded root development with short blunted

roots – larger root canals and distorted and thick dentin at

the apex– Delayed eruption

HIV infection

• Hauk et al ,2001 found a correlation between progression of HIV infection to pediatric AIDS and delayed dental eruption and this delay is most closely linked to severity of symptom not CD4 depletion

Cerebral palsy

• Cerebral palsy is a disorder of movement and posture caused by nonprogressive abnormality of the immature brain that originates during the prenatal or perinatal period or first few years of life. > significant impairment of functional mobility.

• 4 major subtypes are • Spastic (most common)• dyskinetic/athetoid• ataxic• mixed cerebral palsy

Cerebral palsy

• Clinical Manifestations– Intellectual disability (60% of patients) – Seizure disorder (30-50% of patients) – Delayed motor development – Limb spasticity – Persistent primitive reflexes – Involuntary movements, and ataxia

Cerebral palsy

• Oral Manifestations– risk for dental caries and periodontal disease – Enamel hypoplasia – Dental erosion – Delayed eruption of permanent teeth – Dilantin hyperplasia – Increased incidence of Class II Div I malocclusion – Increased risk for oral trauma and injury

Celiac disease

Celiac disease is a permanent intolerance to gluten that results in damage to the small intestinal mucosa caused by an autoimmune mechanism in those who are genetically susceptible to the disease. The villous atrophy that ensues can lead to malabsorption of a variety of macro- and micronutrients including iron, calcium, folate and fat-soluble vitamins.

Celiac disease

• Oral and dental Manifestations– Enamel defects – Delayed eruption – Recurrent aphthous ulcers – Cheilosis – Oral lichen planus – Atrophic glossitis

Ichthyosis

• Ichthyosis is a heterogeneous family of hereditary disorders mostly characterized by the accumulation of hyperkeratotic scales on the skin surface

Ichthyosis• Oral and dental manifestation – Periodontal disease– Enamel hypoplasia– high caries incidence– delayed deciduous and permanent eruption– bruxism– bifid teeth– irregular morphology of teeth– hyperkeratotic plaques on the tongue.

Genetic conditions• Amelogenesis imperfect• Cherubism• Cleidocranial dysplasia• Cornelia de Lange Syndrome• Down s yndrome• Hurler syndrome• Gorlin syndrome• Osteopetrosis (marble bone disease)

Amelogenesis imperfect

• Amelogenesis imperfecta (AI) is a genetically and clinically heterogeneous group of inherited dental enamel defects.

• hypoplastic enamel• Hypomineralised• Eruption of permanent teeth is often delayed

and sometimes completely impaired

Cherubism• autosomal dominant

disorder and with 100% penetrance in males and 50 to 75% penetrance in females, with 2:1 male predominance

• Cystic, fibrous jaw lesions

• Bilateral symmetric jaw expansion

• Exposure of sclera below the iris

• Aplasia of teeth

Cleidocranial dysplasia

• Caused by a defect in the CBFA1 gene

• Large head with prominent frontal bones

• Wide sutures and fontanelles

• Small face• Aplasia/hypoplasia of

clavicles• Supernumerary teeth• Delayed eruption

tooth

Cornelia de Lange Syndrome

• General features: – microbrachycephaly – synophrys/long eyelashes – hand and limb anomalies – delayed bone age – abnormal speech pattern – frequently do not express facial

expression – low hairline on forehead and neck

R short, thick neck R pigmented nevi on ski

• Oral manifestation :– micrognathia – down turned, thin lips – cleft palate in 20% – delayed tooth eruption and widely spaced teeth – microdontia – often severe dental behavior problem

Down s yndrome• Incidence 1 in 600-700. • Most cases of trisomy 21 are caused by non disjunction, resulting in an

extra chromosome• General feature :

– brachycephaly/flat occiput– upward slanting palpebral fissures/epicanthal folds– brachydactyly/clinodactyly/simian crease

• Note: Aatlantoaxial instability (10-20%) and• occipitoatlantal instability is seen in these• patients. These features are important• particularly in relation to cervical extension• during OR procedures or during full restraint• procedures.

Down s yndrome• Oral manifestration

– Enamel hypoplasia (primary dentition)– Periodontal disease (90%) and NUG (30%)– Narrow and short palate– Irregular and delayed dental eruption– missing– teeth (3rd M, 2nd M, Lat. Incisors) decreased– calculus formation

• caries• rate is low hypodontia• taurodontism• Malocclusion (crossbites and openbites common)• Parotid salivary flow rate is decreased and increase Na+, Ca 2+, HCO -, and

uric acid

Down s yndrome• caries• rate is low hypodontia• taurodontism• Malocclusion (crossbites

and openbites common)• Parotid salivary flow rate is

decreased and• increase Na+, Ca 2+, HCO

-, and uric acid

Down s yndrome• cardiac• defect may be present requiring SBE• prophylaxis• lingual• papillae are large protruding,• large and fissured tongue• Lips are broad, irregular fissured, and dry

Open mouth

Hurler syndrome

• Autosomal Recessiv (MPS I)• (Mucopolysaccharidosis I-H)• General features: – macrocephaly/frontal bossing – course facies/thick ear lobes

and lips– hepatosplenomegaly – chest and spine deformities

• Oral manifastration: – flattened philtrum – Lip patulous – widely spaced teeth – lip and tongue enlargement after 5 years old -

incisors somewhat conical – anterior open bite due to macroglossia - ectopic

molars in mandibular rami

Oral manifastration : (con)– delayed eruption – TMJ may exhibit limited motion – dentigerous cysts – airway obstruction – sleep apnea reported – mandible short and broad – wide bigonial distance

Gorlin syndrome

• Gorlin syndrome is inherited as an autosomal dominant trait with a high degree ofpenetrance and variable expressivity.

• The disorder has a population prevalence of 1 per 57,000 people

• Male < female 3:1• multiple odontogenic keratocysts• mandibular prognathism• and/or cleft lip and palate• Delayed tooth eruprion

Osteopetrosis (marble bone disease)

• Rare hereditary bone disorder characterized by increase in bone density due to defect in bone remodeling caused by failure of normal osteoclast function.

• Oral manifestations: – Facial deformity leading to hypertelorism, – snub nose, frontal bossing etc. – Delayed tooth eruption and osteomyelitis of jaws. – Sclerosis of skull bones leads to narrowing of foramina

which causes compression of various cranial nerves – blindness, deafness, facial paralysis etc.

– The medullary spaces of the jaws are reduced. – Fracture of jaws during extraction procedure can occur

without undue force, due to fragility of the bone