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1. I. INTRODUCTION
Tooth eruption is an essential process for the survival of many species
and although the movement of teeth into function has been the subject of
extensive research, there is no consensus as to the mechanisms involved.
The term tooth “tooth eruption” generally refers to the appearance of
some part of the tooth above the surface of the gingiva. However, eruption
actually includes the entire embryological process from the formation of the
tooth germs, in the mandible and maxilla, to calcification, crown formation and
root formation. The root is only about 1/3rd
formed when the crown begins to
erupt into the oral cavity. Not only is this embryological process a part of the
eruption, so is the long process of occlusal development. Thus, the emergence
of teeth into the oral cavity is only a part of the total eruption process.
I. TOOTH MOVEMENTS
The teeth develop within the tissues of the jaw. Thus for the teeth to
become functional, considerable movement is required to bring them into the
occlusal plane. The movements teeth make, are complex and may be described
in general terms under the following headings:
1. Pre-eruptive tooth movement - which is made by both the deciduous and
permanent tooth germs within the tissues of the jaw before they begin to
erupt.
2. Eruptive tooth movement - made by a tooth to move from its position
within the bone of the jaw to its functional position in occlusion.
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2. 3. Post-eruptive tooth movement - those which maintains the position of
the erupted tooth in occlusion while the jaws continue to grow and to
compensate for occlusal and proximal wear of the tooth.
Although this categorization of tooth movement is convenient for
descriptive purposes, it must be recognized that, what is being described is a
complex series of events occurring in a continuous process. As a result, other
categorizations exist. For instance, some describe tooth movement as having
pre-functional and functional phases.
1. Pre-Eruptive Tooth Movements
When the deciduous tooth germs first differentiate, they are extremely
small and there is a good deal of space for them in the developing jaw. Because
the tooth germs grow rapidly, however they become crowded together,
particularly in the anterior region of the jaw. This crowding is gradually
alleviated by the lengthening of the jaws, which permits the second deciduous
molar tooth to move backward and the anterior tooth germs to move forward.
At the same time, the tooth germs are also moving bodily outward and upward
or downward as the case may be, as the jaws increase in length as well as in
width and height.
The permanent tooth germs develop on the lingual aspect of their
deciduous predecessors in the same bony crypt. From this position, the tooth
germs shift considerably as the jaws develop. For example, the incisors and the
canines eventually come to occupy a position, in their own bony crypts, on the
lingual of the roots of their deciduous predecessors, while the premolar tooth
germs, also in their own crypts, are finally positioned between the divergent
roots of the deciduous molars.
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3. The permanent molar tooth germs which have no predecessors, develop
from the backward extension of the dental lamina. At first there is little room in
the jaws to accommodate those tooth germs, so that in the upper jaw the molar
tooth germs first develop with their occlusal surfaces facing distally and can
swing into position only when the maxilla has grown sufficiently to provide
room for such movement. In the mandible, the permanent molars develop with
their axis showing a mesial inclination which becomes vertical only when
sufficient jaw growth has occurred.
These pre-eruptive movements of both deciduous and permanent tooth
germs are best thought of as the movements required to place the teeth within
the jaw in a position for eruptive tooth movement. Analysis has shown that
these pre-eruptive movements of the tooth are a combination of two factors.
The first factor is the total bodily movement of the tooth germs and the
second factor is growth, in which one part of the tooth germ remains fixed
while the rest continues to grow, leading to a change in the centre of the tooth
germ. This growth explains, for example, how the deciduous incisors maintain
their position relative to the oral mucosa as the jaws increase in height.
As pre-eruptive movement occur in an intraosseous location, such
movement is reflected in the patterns of bony remodeling within the crypt wall.
For example during bodily movements in a mesial direction, bone resorption
occurs on the mesial surface of the crypt wall and bone deposition occurs on
the distal wall as a filling in process. During eccentric growth, only bony
resorption occurs, thus altering the shape of the crypt to accommodate the
altering shape of the tooth germ.
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4. 2. Eruptive Tooth Movement
During the eruptive phase of physiologic tooth movement, significant
developmental changes occur, including the formation of roots, periodontal
ligament and dentogingival junction of the tooth.
Root formation is initiated by the proliferation of Hertwig’s epithelial
root sheath. The forming root first grows toward the floor of the bony crypt and
as a result, there is resorption of bone in this location to provide room for the
advancing root tip. However, with the onset of eruptive tooth movement,
(probably coincident with the periodontal ligament formation) space is created
for the forming root and resorption no longer occurs on the floor of the crypt.
Indeed, in some instances the distance moved by the tooth outstrips the rate of
root formation and bone deposition occurs on the crypt floor.
As the roots of the tooth form, important changes associated with the
development of the supporting apparatus of the tooth occur in the dental
follicle.
- There is bone deposition on the crypt wall.
- Cement deposition on the newly formed root surface.
- Organization of a periodontal ligament from the dental
follicle.
These changes lag behind root formation. There are a number of
important histologic features in the periodontal ligament that are important in
explaining eruptive tooth movement. First, is the occurrence of cell to cell
contacts of the adherens type between periodontal ligament fibroblasts. Second,
is the demonstrated presence of contractile elements in ligament fibroblasts.
Third, is the occurrence of a structure called fibronexus. This describes a
morphologic relationship between intracellular microfilaments in the fibroblast,
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5. a corresponding increased density of fibroblast cell membrane, extracellular
filaments and fibronectin.
Fibronectin is a sticky glycoprotein which sticks to a number of
extracellular components including collagen. Fourth, is the active ingestion and
degradation of old collagen fibrils by many of the fibroblasts of the ligament
and the convenient formation of new collagen fibrils. Thus the continual
degradation and synthesis of collagen by fibroblasts permit the remodeling of
the principal fibre bundles of the periodontal ligament.
Significant changes occur within the tissues that cover the erupting
tooth. There is a loss of intervening connective tissue between the reduced
enamel epithelium covering the crown of the tooth and the overlying oral
epithelium. Because of this loss, the two epithelia proliferate and form a solid
plug of cells in advance of the erupting tooth. The central cells of this epithelial
mass degenerate and form an epithelium lined canal through which the tooth
erupts without any haemorrhage. This epithelial cell mass is also involved in
the formation of the dentogingival junction.
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6. Interestingly, once the tooth erupts into the oral cavity, it continues to
erupt at the same rate of about 1mm every 3 months, only slowing as it meets
its antagonist in the opposing arch. This suggests that the resistance to the force
of tooth eruption provided by the overlying connective tissue is minimal. Root
formation, however, is not yet complete, and because further occlusal
movement is restricted, additional root growth is accommodated by removal of
bone on the socket floor.
The above description generally applies to all the teeth. Successional
teeth, however possess an additional anatomic feature, the gubernacular canal
and its contents, the gubernacular cord which may have an influence on
eruptive tooth movement. When the successional tooth germ first develops
within the same crypt as its deciduous predecessor, bone surrounds both tooth
germs but does not complete close over them. As the deciduous tooth erupts,
the permanent tooth germ becomes situated apically and entirely enclosed by
bone, except for a small canal that is filled with connective tissue and often
contains epithelial remnants of the dental lamina. This connective tissue mass
is termed the ‘gubernacular cord’ and it may have a function in guiding the
permanent tooth as it erupts.
Once the erupting tooth appears in the oral cavity, it is subjected to
environmental factors that help determine its final position in the dental arch.
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7. Muscle forces from the tongue, the cheeks, and the lips play on the tooth, as do
the forces of contact of the erupting tooth with other erupted teeth. A sustained
muscular force of only 4 to 5 grams is sufficient to move a tooth. The
childhood habit of thumb sucking is an obvious example of environmental
determination of tooth position.
3. Post Eruptive Movement
Post eruptive movements are those made by the tooth after it has
reached its functional position in the occlusal plane. They may be divided into
three categories:
1. movements made to accommodate the growing jaws.
2. those made to compensate for continued occlusal wear.
3. those made to accommodate interproximal wear.
a. Accommodation for growth
They are seen histologically as a readjustment of the position of the
tooth socket, achieved by the formation of new bone at the alveolar crest and
on the socket floor to keep pace with the increasing height of the jaws. Recent
studies have shown that this readjustment occurs between the ages of 14 to 18,
when active movement of the tooth takes place. The apices of the teeth move 2
to 3 mm away from the inferior dental canal (regarded as a relatively fixed
reference point). This movement occurs earlier in girls than in boys and is
related to the burst of condylar growth that separates the jaws and teeth,
permitting further eruptive movement. Although this movement is seen as
remodeling of the socket, it must not be assumed that this bony remodeling
brings about tooth movement.
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8. b. Compensation for occlusal wear
The axial movement a tooth makes to compensate for occlusal wear is
most likely achieved by the same mechanism as eruptive tooth movement. It is
often stated that the compensation for occlusal wear is achieved by continued
cementum deposition around the apex of the tooth, but the deposition of
cementum in this location occurs only after the tooth has moved.
c. Accommodation for interproximal wear
Wear also occurs at the contact points between teeth on their proximal
surfaces the extent of this wear can be considerable (more than 7 mm in the
mandible). This interproximal wear is compensated for, by a process known as
mesial or approximal drift. There are two, possibly three factors that bring
about mesial drift. They are: i. occlusal force ii. ligament contraction and
possibly iii. soft tissue pressures.
i. Anterior component of occlusal force
When the teeth are brought into contact, for example, when the jaws are
clenched, a forwardly directed force is generated. That this is so can be easily
demonstrated by placing a steel strip between the teeth and showing that more
force is required to remove it when the jaws are clenched. The anterior force is
the result of the mesial inclination of most teeth and the summation of the
intercuspal planes producing a forwardly directed force. In the case of incisors
which are inclined labially, it would be expected that any anterior component
of force would move them in the same direction. Incisors in fact moves
mesially but this can be explained by the billiard ball analogy.
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9. That cuspal inclination is a significant factor can be demonstrated by
selectively grinding cusps in such a way so as to either enhance or reverse the
direction of the occlusal force.
When opposing teeth were removed thereby eliminating the biting force,
the mesial migration of teeth were slowed but not halted indicating the
presence of some other force, and here the transseptal fibres of the periodontal
ligament have been implicated.
ii. Contraction of transseptal fibres
The periodontal ligament has an important role in maintaining tooth
position, and it is suggested that its transseptal fibres running between adjacent
teeth across the alveolar process draw neighbouring teeth together and maintain
them in contact. There is some evidence to support this. For example, it is
known that relapse of orthodontically moved teeth is much reduced if
gingivectomy is done, that is the transseptal ligament is removed. It has been
demonstrated experimentally that in bisected teeth, the two halves separate
from each other. If however, the transseptal ligaments are previously cut, this
separation does not occur. By disking away proximal contacts, room is
provided for the tooth to move to reestablish contact.
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10. iii. Soft tissue pressures
It does not have a major role in tooth movement. The pressures
generated influence tooth position, even if it does not cause tooth movement.
III. THEORIES OF TOOTH ERUPTION
The mechanism that brings about tooth movement is debatable. There
are numerous theories of tooth eruption which is usually a reflection of
incomplete understanding. All these theories have contributed to and provoked
research into various aspects, to support or refute hypotheses which are now
briefly reviewed.
1. Pulp Theory
This theory suggests that a propulsive force is generated by extrusion of
the pulp through three mechanisms; first growth of dentin, secondly, interstitial
pulp growth and thirdly, hydraulic effects within the vasculature. Perhaps the
most damning evidence against this theory is the work of Herzberg and Schour
(1941) who removed the pulp of rodent incisors and found that its eruption
rates were unaffected.
2. Vascular Theory
The mechanisms behind this theory to some extent overlaps the pulp
theory. The force of eruption comes from the pressure in the blood vessels
within or below the tooth. This theory has been discounted by some for the
same reasons as the pulp theory. In addition, use of hypotensive drugs appears
to have no effect on the eruption rates. However, a critical review by Moxham
suggests that at least part of the eruptive force is generated by a non-functional
force.
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11. 3. Root elongation theory
This theory attributes tooth eruption to elongation of the roots. It
suggests that the tooth erupts as a result of root pushing against an immovable
base. Root formation appears to be the obvious cause of tooth eruption, since it
undoubtedly causes an overall increase in the length of the tooth which must be
accommodated either by the root growing into bone of the jaw, by increase in
height of the jaw, or by crown of the tooth moving occlusally. It is the latter
movement, of course that occurs but it does not follow that root growth is
responsible. If a continuously erupting tooth, such as a rodent incisor or a
guinea pig molar is prevented from erupting by pinning the tooth to the bone,
root growth continues and is accommondated by resorption of some bone at the
base of the socket and a buckling of the newly formed root. Such a simple
experiment yields two conclusions: first, that root growth produces a force;
second, that this force is sufficient to produce bone resorption.
At one time, it was proposed that a structure called “Cushion hammock”
ligament was strung across the base of the socket and when the growing root
impinged on it. This structure acted as a sling, translating downward root
growth into eruptive tooth movement. Careful histologic study has found no
such ligament. It must therefore be concluded that some force other than root
growth is moving the tooth to provide room for the newly formed root tissue.
Furthermore, Marks and Cahill (Arch. Oral Biol.; 1984) using young
dogs, took teeth at the beginning of eruption, removed their pulps and killed the
periodontal ligament cells by freeze thawing. These inert rootless teeth with no
periodontal ligaments were reimplanted and still managed to erupt by
compensatory bone growth. Thus, although root growth can produce a force, it
cannot be translated into eruptive tooth movement unless there is some
structure at the base of the tooth capable of withstanding the force.
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12. 4. Alveolar bone growth
The importance of bone growth in tooth eruption was demonstrated with
a series of classical experiments by Brash (1928) using madder fed pigs.
Madder is a dye which binds to newly formed bone and Brash noticed large
amounts of bone laid down between the crypts of erupting teeth. These
observations have been confirmed (Marks and Cahill 1980), but although bone
formation is clearly involved in tooth eruption, cause and effect are still at the
phenomenology stage.
5. Periodontal ligament theory
This theory suggests that the impetus for tooth eruption is derived from
the periodontal ligament. Evidence for this came from some brief observations
by Moxham and Berkovitz (Arch. Oral Biol.; 1974) where root transsection
failed to prevent the incisor segment superfacial to the transsection from
erupting. This strongly implicates the periodontal ligament in the eruption
process, and suggests that there is little contribution from alveolar bone, root
growth and indeed pulp pressure. Evidence against this theory includes studies
with lachyritic compounds, such as β-aminoproprionitrile. They inhibit
intermolecular crosslinking of the polypeptide chains in the collagen molecule
and should therefore inhibit the teeth from erupting. Despite adminstration of
these drugs, rat incisors continue to erupt normally.
It has already been indicated that fibroblasts have the ability to contract,
but for such contractions to bring about tooth movement, a number of other
conditions must be met. There must be some mechanism to summate the
contractile forces of a number of fibroblasts; the fibroblasts must have
something to pull on (collagen fibre bundles?) which must also be firmly
attached to the tooth and be correctly oriented. The numerous cell to cell
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13. contact between fibroblasts could be involved in summating contractile force.
The fibronexus and associated fibronectin could transmit this force to the
collagen fibre bundles. These bundles in turn are firmly attached to the bone
and the tooth in the correct position to bring about tooth movement. Finally,
they have the ability to remodel after the tooth moves.
In summary, then the force moving the tooth is most likely generated by
the contractile property of the ligament fibroblast, but a number of other
conditions must exist to translate this contraction into tooth movement.
Eruption must therefore be considered a multifactorial phenomenon.
The periodontal ligament theory has also gained some support from
tissue culture experiments. If a fibroblast is cultured on a substrate on which it
can move, it vibrates using contractile mechanisms generated by its
cytoskeleton. The actin molecule has a particularly prominent role. As the
fibroblast moves, it elongates on the leading edge and leaves the trailing end of
the cell adherent to the substrate. Eventually the latter edge will detach. If these
cells are cultured on thin silicon sheets, then as they move, the contractile
element is sufficiently strong to cause the rubber to wrinkle. This effect can
also be demonstrated when these cells are embedded in three dimensional gels
and this is true for fibroblasts derived from the periodontal ligament. This
model has been adapted to show that periodontal ligament fibroblasts are
capable of generating sufficient contractile force to lift a piece of root, against
gravity, towards the top of a tissue culture well (Arch. Oral Biol.; 1983). Direct
evidence of this tractional effect is not available but these models prove that
periodontal ligament has some role in the process of eruption.
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14. 6. Genetic input
If tooth eruption is to be explained at the cellular and molecular level, a
degree of genetic control is highly likely in normal development of occlusion.
Incisors erupt before premolars and this process of eruption is often disturbed
in a number of genetic disorders. A classification of this has been presented by
Caulk (1988). These comprise:
a. inhibited defects, primarily involving enamel - amelogenesis
imperfecta.
b. syndromes with enamel involvement.
c. disorders associated with supernumerary teeth and / or crowding of
teeth.
d. growth retardation syndromes.
e. conditions associated with tissue overgrowth of the gingiva and
hyperplastic frenula.
f. miscellaneous disorders (these include premature exfoliation such as
Hypophosphatasia, Juvenile Periodontosis and Papillon Lefevre
Syndrome).
There is no simple explanation of tooth eruption and this biological
phenomenon is a multifactorial event. Biological sciences are more likely to
offer clear, rational approaches to improve our understanding of tooth eruption.
7. Hydrostatic pressure.
This theory requires a higher pressure system, either within or around
the base of the tooth. It is known that teeth move in their sockets in synchrony
with the arterial pulse, so local volume changes can produce limited tooth
14

15. movement. Ground substance can swell from 30%-50% by retaining additional
water, so this too could create pressure. But, since surgical excision of the
growing root and associated tissue eliminate the periapical vasculature without
stopping eruption, this means that the local vessels are not absolutely necessary
for tooth eruption.
8. Follicular Theory
This theory attributes a critical role to the dental follicle for the eruption
of teeth. It seems unlikely that the dental follicle provides the eruptive force
since fibre transsection fails to prevent eruptive movement. It seems more
probable that the loose connective tissue of the dental follicle is a rich source of
factors which are responsible for bone formation and resorption. Indeed, the
follicle is capable of releasing cytokines, ericunosoids and growth factors but
as our understanding of these factors increases, we’re likely to explain tooth
eruption in terms of cellular and molecular interactions.
Follicular Theory – Molecular Biology of Initiation of Tooth Eruption
Further studies have been done regarding Follicular Theory through
recent advances in Molecular Biology.
Thanks to the pioneering experiments of Marks and Cahill, it was
established that, in teeth of limited eruption, a tissue required for eruption is the
dental follicle, a loose connective tissue sac that surrounds the tooth prior to
eruption. Their studies showed that surgical removal of the follicle prevents
eruption whereas leaving the follicle intact but substituting an inert object for
the tooth results in eruption of the inert object (Marks & Cahill; 1984).
At the cellular level there is an influx of mononuclear cells (monocytes)
in the dental follicle which is the onset of active eruption (Marks et al.; 1983
15

16. Wise et al.; 1985). Concurrent with the monocyte influx is an increase in the
number of osteoclasts on the coronal positions of the bony crypt followed by a
decrease that parallels monocyte decrease. Studies by Wise and Lan (1989)
suggests that the influx of the monocytes contributes to the formation of
osteoclasts to resorb alveolar bone for the tooth to escape its bony crypt.
What is / are the molecular signal(s) that ultimately initiate the onset of
tooth eruption as seen by the above cellular changes?. At least 4 molecules
emerge as potential candidates because of their ability to accelerate eruption,
their immuno localization, their gene expression or a combination of these.
Perhaps the molecule that plays the most direct role in initating the
cellular events of eruption is colony stimulating factor one (CSF-1). When
these were injected into osteopetrotic (toothless) rats, the incisors erupted
(Ilizuka et al.; 1992) and injection of CSF-1 in normal rats lead to eruption of
first molars with increase in numbers of monocytes and osteoclasts (Cielinski
et al.; 1995).
A cascade of molecular signals is probably involved in stimulating the
expression of CSF-1 for the onset of eruption. In particular, interleukin-1α
(1L-1α) enhances the transcription of CSF-1 gene in rat dental follicle cells
(Wise and Lin; 1994). Immunolocalization studies have shown that 1L-1α is
present in the stellate reticulum (Wise et al.; 1995), the portion of enamel organ
that is immediately adjacent to the dental follicle. Thus the 1L-1α might diffuse
into the dental follicle to stimulate the dental follicle cells to express the CSF-1
gene.
The expression of the 1L-1α gene may be regulated by epidermal
growth factor (EGF). EGF, long known for its ability to stimulate precocious
16

17. eruption of incisors in rodents (Cohen; 1962), also increases the amount of
1L-1α in the stellate reticulum following injection into rats (Wise et al.; 1995).
Another molecule that might be
involved in a cascade of signals leading to
tooth eruption is transforming growth
factor β1 (TGF- β1). Like 1L-1α TGF β1
immunolocalizes to the stellate reticulum
and in vitro, its mRNA expression is
enhanced by incubation with EGF.
Because TGF- β1 is a chemoattractant for
monocytes, it is possible that TGF- β1
could enter the capillaries adjacent to the
dental follicle and attract monocytes to the
follicle.
Based on these above studies, a
hypothesis of the molecular events of tooth
eruption can be presented:
1. If EGF were the first signal there are at least three ways it could initiate
eruption.
2. If EGF were not required, however, eruption could begin with a signal
from TGF- β1.
3. Should EGF and TGF-β1 both not be required, eruption could begin
with 1L-1α enhancing CSF-1 mRNA expression.
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18. IV. PATTERN OF ERUPTION OF TEETH
The teeth of the deciduous dentition begin to appear in the mouth at
about 6 months of age and the dentition is complete by 3 years. A majority of
the permanent teeth appear in the mouth between 6 and 12 years of age, during
this time teeth from both dentitions are present in the mouth, a phase known as
mixed dentition.
The teeth of both dentitions develop initially within the bones of the
jaws and have to move bodily through the jaws to reach the oral cavity by the
process of eruption. In addition, the deciduous teeth have to be shed or
exfoliated to make room for their permanent successors.
In the deciduous dentition, calcification of the crowns commences about
a month after the completion of cytodifferentiation of the tooth germ.
Calcification of all deciduous teeth begins before birth. Crown formation takes
about 6 months to complete and the tooth appears in the mouth some 6 months
after crown formation is achieved. When the teeth first appear, their roots are
incomplete and are not fully formed until 18 months later.
In the permanent dentition, the tooth germs are fully formed before birth
for all but the second and third molars. Crown formation begins at varying
times thereafter. In general, for the teeth of the permanent dentition, crown
formation takes 3 years and the teeth appear in the oral cavity about 3 years
after the crown is complete. Root completion is achieved about 3 years after
eruption.
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19. The sequence of eruption is an important aide memoire; the first
permanent molars erupt first at 6 years of age. The other teeth appear at
approximately yearly intervals corresponding to their sequence of eruption. If
the sequence and dates of eruption are remembered, the timing of other events
may be calculated by simple addition or subtraction.
Birth to Two Years
The permanent incisors and canines first develop lingual to the
deciduous tooth germs at the level of their occlusal surfaces and in the same
bony crypt. As their deciduous predecessors erupt, they move to a more apical
position and occupy their own bony crypts. First teeth to erupt are the
mandibular central incisors.
The usual eruption sequence in the primary dentition is as follows. First
the central incisors, followed in order by the lateral incisors, first molars,
canines and second molars. Mandibular teeth usually precede the maxillary
teeth. This sequence is not always followed.
Time of eruption is usually stated as 6 months of age for the maxillary
primary centrals, 7-8 months for the mandibular primary laterals and 8 or 9
months for the maxillary primary laterals. At about 1 year, the first primary
molars erupt. At around 16 months, the primary cuspids appear. Two years is
usually given as the age for the second primary molars to appear.
Two Years to Six Years
By two and a half years of age, the deciduous dentition is usually
complete and in full function. By three years of age, the roots of all deciduous
teeth are complete. First permanent molar crowns are fully developed and the
roots are starting to form. The crypts of the developing permanent second
19

20. molars are now definite and can be seen in the space formerly occupied by the
developing first permanent molars.
Between three and six years of age, the development of the permanent
teeth continues, with the maxillary and mandibular incisor teeth more
advanced. From five to six years, just before the shedding of the deciduous
incisors, there are more teeth in the jaws than at any other time. Space is quite
critical within both the alveolar process and the deciduous dental arches
themselves. Developing permanent teeth are shifting close to the alveolar
border, the apices of the deciduous incisors are being resorbed; the first
permanent molars are about ready to erupt.
Very little bone exists between the permanent teeth and their crypts and
the “front line” of deciduous teeth. [A cross section of the maxilla and
mandible illustrates this remarkable phenomenon]. The complex interplay of
forces makes it imperative that the integrity of the dental arch be maintained at
this time. Loss of arch length through caries may make the difference between
normal occlusion and malocclusion. It does not take very much to upset the
delicate timetable of tooth formation, eruption and resorption within a viable
osseous medium.
Six Years to Ten Years
Between six and seven years of age, the first permanent molars erupt
into the mouth. As the upper and lower first permanent molars erupt, a pad of
tissue overlying them creates a premature contact. Proprioceptive response
conditions the patient against biting on this natural “bite opener” and thus the
deciduous teeth anterior to the first permanent molar area erupt, reducing the
overbite. About this time, the deciduous central incisors are lost and their
permanent successors start their eruptive path toward contact with the incisors
20

21. of the opposing arch. Usually the mandibular central incisors erupt first,
followed by the maxillary permanent central incisors. These teeth frequently
erupt lingual to their deciduous counterparts and move forward under the
influence of tongue pressure as they erupt. The maxillary central incisors
appear as large bulges in the mucobuccal vestibule above the deciduous
incisors before they erupt.
Calendric age is even less
reliable as a bases for projection
of eruption of maxillary and
mandibular incisors. More
sophisticated research and the
accumulation of precise
developmental data from several
“growth centres” has indicated
that the physiologic age provides
a better yard stick. Those neat and
simplified “tooth eruption charts”
based on specific ages, posted in
schools, physicians offices etc.
with no indication of range,
standard deviation or standard
error provide little useful
information. By themselves, these
charts are often misleading and
can delude an inquiring parent
into a sense of false security.
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22. The period from eruption of the lateral incisors to the eruption of canine
is termed by Broadbent as the “ugly duckling stage”. It is an apt term, implying
an unaesthetic metamorphosis leading to an esthetic result. During this period
parents become worried. A space may develop between the maxillary central
crowns. The lateral crowns may flare. Frenums are often sacrificed in an effort
to remove the cause of the space between the centrals.
Actually, the crowns of the cuspids in the young jaw impinge as the
developing roots of the lateral incisors, driving the roots medially and causing
the crowns to flare laterally. The roots of the centrals are also forced towards
each other. As the laterals erupt further, narrower portions of their roots are in
proximity to the developing canines. Margolis has called the alveolar process
“the servant of the tooth”. At this stage the maxilla is bulging in the canine
region as the alveolar process develops around the forming canine. With the
further migration of the canine occlusally, with its servant the alveolar process,
the point of influence of the canine on the laterals shifts incisally so that
eventually, the lateral crowns are driven medially, also effecting closure of the
space between the centrals.
Eruption of the incisors is usually completed by eight and a half years of
age. Even though the central and lateral incisors erupt into the normal position,
root formation is not complete. The apices are wide open and do not close for
at least another year. Between nine and ten years of age, the apices in the
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23. deciduous canines and molars begin to resorb. Individual variation is great
here. Girls are usually a year to a year and a half ahead of boys.
After Ten Years
Between 10 and 12 years of age, there is considerable variability in the
sequence of eruption of the canines and premolars. In about half the cases, the
mandibular canines erupt ahead of the mandibular first and second premolars.
In the maxilla, the first premolar usually erupts before the canine. The first
premolar usually erupts before the canine. The maxillary second premolar and
the maxillary canine erupt at about the same time. At times, deciduous teeth are
retained beyond the time that they should normally be shed. A good rule of
thumb is to try and maintain the left and right sides on approximately the same
schedule. If the upper left deciduous molar is lost naturally and the upper right
first deciduous molar is still firm, radiographic evidence may show that the
mesial or distal root has not resorbed properly. It is then advisable to assist the
removal of the tooth.
Eruption of the second molar teeth usually occur shortly after the
appearance of the second premolars. Since the second premolar and second
molar teeth show the greatest variability in order of eruption of any of the teeth
(third molars excepted), the second molar teeth may be expected to erupt
before the second premolar teeth in 17% of cases in Caucasians.
Both maxillary and mandibular second molars erupt at about the same
time. Here again, we are confronted with the raising of the bite that is the
gingival pads overlying the upper second molars contact prematurely, blocking
open the bite anteriorly allowing eruption of teeth anterior to second molar, for
a couple of weeks.
23

24. If the second molars exfoliate before the second premolars, occasionally
the first permanent molars may tip to the mesial. This is especially true in
patients with premature loss of second deciduous molars. If the molars are
tipped mesially, the eruption of the second premolar is further delayed, it may
erupt lingually or may not erupt at all.
Radiographs taken shortly after
eruption of second molar teeth often show
an image of the developing third molar
teeth that are difficult to interpret. This is
especially true of the mandibular third
molars. Since the alveolar process curves
lingually at the point of juncture with the
anterior border of the ramus, the 3rd
molars (which are seen to be in the ramus
but actually present lingual to the ramus)
may erupt lingually. Although maxillary
second molars erupt in a downward and
forward direction, the maxillary third
molars erupt downward and backwards.
To this might be added the term
‘outward’. It is not possible to estimate a
definite time of eruption of third molars.
Hume estimates the median time of
eruption of 20.5 yrs. Eruption of 3rd
molars is seen more rapidly in girls than
in boys. By 20 yrs of age must females
have their 3rd
molars if they have going to
have them. This is not true for males.
24

25. It is easy to understand that problems arise frequently in the third molar
area considering the initial deficiency in arch length, the tendencies for the
maxillary and mandibular molars to bypass each other, their varying axial
inclination and the unpredictable timing of eruption of these teeth. The 3rd
molar problem can be not only be a painful experience but can cause functional
disturbance which can affect longevity of the dentition and create and
aggravate TMJ pathology.
Chronology of the human dentition
Teeth Hard tissue
formation begins
Amount of enamel
formed at birth
Enamel
completed
Eruption Root
completed
Deciduous dentition
Maxillary
Central incisor
Lateral incisor
Cuspid
First molar
Second molar
Mandibular
Central incisor
Lateral incisor
Cuspid
First molar
Second molar
Permanent dentition
Maxillary
Central incisor
Lateral incisor
Cuspid
First bicuspid
Second bicuspid
First molar
Second molar
Third molar
Mandibular
Central incisor
Lateral incisor
Cuspid
First bicuspid
Second bicuspid
First molar
Second molar
Third molar
4 mo in utero
4 ½ mo in utero
5 mo in utero
5 mo in utero
6 mo in utero
4 ½ mo in utero
4 ½ mo in utero
5 mo in utero
5 mo in utero
6 mo in utero
3-4 mo
10-12 mo
4-5 mo
1 ½ - 1 ¼ yr
2-2 ¼ yr
At birth
2 ½ - 3 yr
7-9 yr
3-4 mo
3-4 mo
4-5 mo
1 ¼-2 yr
2 ¼ - 1 ½ yr
At birth
2 ½-3 yr
8-10 yr
Five sixths
Two thirds
One third
Cusps united
Cusp tips still isolated
Three fifths
Three fifths
One third
Cusps united
Cusp tips still isolated
Sometimes a trace
Sometimes a trace
1 ½ mo
2 ½ mo
9 mo
6 mo
11 mo
2 ½ mo
3 mo
9 mo
5 ½ mo
10 mo
4-5 yr
4-5 yr
6-7 yr
5-6 yr
6-7 yr
2 ½ - 3 yr
7-8 yr
12-16 yr
4-5 yr
4-5 yr
6-7 yr
5-6 yr
6-7 yr
2 ½-3 yr
7-8 yr
12-16 yr
7 ½ mo
9 mo
18 mo
14 mo
24 mo
6 mo
7 mo
16 mo
12 mo
20 mo
7-8 yr
8-9 yr
11-12 yr
10-11 yr
10-12 yr
6-7 yr
12-13 yr
17-21 yr
6-7 yr
7-8 yr
9-10 yr
10-12 yr
11-12 yr
6-7 yr
11-13 yr
17-21 yr
1 ½ yr
2 yr
3 ¼ yr
2 ½ yr
3 yr
1 ½ yr
1 ½ yr
3 ¼ yr
2 ¼ yr
3 yr
10 yr
11 yr
13-15 yr
12-13 yr
12-14 yr
9-10 yr
14-16 yr
18-25 yr
9 yr
10 yr
12-14 yr
12-13 yr
13-14 yr
9-10 yr
14-15 yr
18-25 yr
25

26. V. ACTIVE AND PASSIVE ERUPTION
According to the concept of continuous eruption (Orbans, Gottlieb J.
Dent. Res. 13 ; 214 ; 1933), eruption does not cease when the teeth meet their
functional antagonists but continues throughout life. It consists of an active and
passive phase.
Active eruption – is the movement of the teeth in the direction of the occlusal
plane.
Passive eruption – is the exposure of the teeth by the apical migration of the
gingiva.
This concept distinguishes between the:
Anatomic crown - the portion of the tooth covered by enamel.
Anatomic root - the portion of tooth covered by cementum.
Clinical crown - the part of the tooth that has been derived of its gingiva and
projects into the oral cavity.
Clinical root - that portion of the tooth covered by periodontal tissues.
When the teeth reach their functional antagonists, the gingival sulcus
and junctional epithelium are still on the enamel, and the clinical crown is
approximately two thirds of the anatomic crown.
Active and passive eruption were believed by Gottlieb to proceed
together. Active eruption is coordinated with attrition. The teeth erupt to
compensate for tooth substance worn away by attrition. Attrition reduces the
clinical crown and prevents it from being disproportionately long in relation to
the clinical root, thus avoiding excess leverage in the periodontal tissues.
26

27. Ideally, the rate of active eruption keeps pace with tooth wear, preserving the
vertical dimension of the dentition.
As the teeth erupt, cementum is deposited at the apices and furcations of
the roots, and bone is formed along the fundus of the alveolus and at the crest
of the alveolar bone.
In this way, part of the tooth substance lost by attrition is replaced by
lengthening of the root and socket depth is maintained to support the root.
Passive eruption is divided
into four stages. Although this
was originally thought to be a
normal physiologic process, it is
currently considered a pathologic
process.
1. Stage one: The teeth reach the line of occlusion. The junctional
epithelium and the base of the gingival sulcus are one the
enamel.
2. Stage two: The junctional epithelium proliferates so that part is on
the enamel. The base of the sulcus is still on the enamel.
3. Stage three: The entire junctional epithelium is on the cementum, and
the base of the sulcus is at the cementoenamel junction.
As the junctional epithelium proliferates from the crown
onto the root, it remains at the CEJ no longer than any
other area on the tooth.
4. Stage four: The junctional epithelium has proliferated further on the
cementum. The base of the sulcus is on the cementum, a
27

28. portion of which is exposed. Proliferation of the
junctional epithelium onto the root is accompanied by
degeneration of gingival and periodontal ligament fibres
and thin detachment from the tooth. The cause of this
degeneration is not understood. At present however, it is
believed to be the result of chronic inflammation and
therefore a pathologic process.
The distance between the apical end of the junctional epithelium and the
crest of the alveolus remains constant throughout continuous tooth eruption
(1.07mm).
Exposure of the tooth by the apical migration of the gingiva is called
gingival recession or atrophy. According to the concept of continuous eruption,
the gingival sulcus may be located on the crown, CEJ, or root depending on the
age of the patient and the stage of eruption. Therefore some root exposure with
age is considered normal and referred to as physiologic recession. As
mentioned previously, this concept is not accepted at present. Excessive
exposure is termed pathologic recession.
VI. SHEDDING OF DECIDUOUS TEETH
The physiologic process resulting in the elimination of the deciduous
dentition is called shedding or exfoliation. The eruptive pathway of the
permanent teeth is very much related to the shedding or exfoliation of the
deciduous teeth as pressure from the erupting successional tooth helps to
determine the pattern of deciduous tooth resorption.
Shedding of teeth can occur due to two factors:
1) Odontoclasts.
28

29. The resorption of the hard tissues of the tooth is achieved by cells that
have an identical histology to osteoclasts but which, because they are involved
in the removal of dental tissue, are sometimes called odontoclasts. The
odontoclasts are capable of resorbing all dental hard tissues, including enamel,
but it is most commonly found on the surface of roots, where it resorbs
cementum and dentin. It is also found on occasion within the pulp chamber,
resorbing coronal dentin. This variation in the pattern of the deciduous tooth
resorption depends very much on the position of the successional tooth in
relation to the deciduous tooth. Thus, since the permanent incisors and canine
develop lingually to the deciduous teeth and erupt in an occlusal and vestibular
direction, resorption occurs at the lingual surface of the root and the tooth is
shed with much of its pulp chamber intact. Permanent premolars, however,
develop between the divergent roots of the deciduous molars and erupt in an
occlusal direction. Hence the resorption of the with interradicular dentin occurs
with the resorption of the pulp chamber and coronal dentin.
While little is known about resorption of the dental hard tissues, even
less is known about the resorption of the soft tissues associated with them; such
as dental pulp and periodontal ligament.
Simple observation of histological sections shows that the loss of
periodontal ligament is abrupt. Electron microscopic examination confirms this
finding and also shows that cell death occurs in this region in the absence of
inflammation.
2) Pressure
Obviously, pressure from the erupting successional tooth plays a role in
the shedding of the deciduous dentition. For instance, if a successional tooth
germ is congenitally missing or occupies an aberrant position in the jaw,
29

30. shedding of the deciduous tooth is delayed. Yet the tooth is eventually shed.
Growth of the jaws and also the muscles of mastication also aid in resorption of
deciduous teeth.
Pattern of shedding
It has been seen that the pattern of exfoliation is symmetrical for the
right and left sides of the mouth. Girls exfoliate their teeth before boys. The
greatest discrepancy between the sexes is observed for the mandibular canines,
the least for the maxillary central incisors.
Clinically it has been noticed that human deciduous teeth are shed with
little bleeding, when the teeth naturally exfoliate. Immediately after teeth are
shed, stratified squamous epithelium present in the dentogingival junction
(DGJ) and gingiva were found in the underlying tissue indicating that DGJ
epithelium and gingival epithelium play an important role in the process of
exfoliation. Furthermore, wound healing after exfoliation is usually more rapid
than after eruption. A study by N. Sahara et al. showed migration appeared to
be further stimulated as a result of chronic inflammation by microorganisms
present adjacent to the DGJ. The most interesting finding of the study was the
evidence of the stratified squamous epithelium of the DGJ and gingiva
proliferated and migrated towards the inside of the crown and eventually ended
up under the deciduous crown.
VII. CLINICAL SIGNIFICANCE
1. Caries during Tooth Eruption (Particularly in First Molars)
Caries is a disease with many causal factors. It is known to occur very
often in the occlusal surfaces of the first molars. The risk of caries is highest
during the first two years after the eruption of the first molars (i.e. the first
30

31. molars’ first two years), which roughly corresponds to the one to three year
period during which the first molars complete their eruption.
Survey studies revealed that, during the first 12 months after the first
molars had started erupting, caries was found on 6% of the maxillary first
molars and almost 20% of the mandibular first molars. During the first 24
months this percentage jumped to 37% of the maxillary first molars and 62% of
mandibular first molars.
The four major types of caries causal factors are:
a. The susceptible tooth.
b. Cariogenic bacteria in plaque.
c. Substrates.
d. Time (long term accumulation of plaque etc.)
Let us briefly examine each of these 4 factors:
a. Susceptible tooth : susceptibility to caries is largely determined by
hereditary and environmental factors, and in the first molars is also
caused by such anatomical factors as the large occlusal surface and the
numerous deep sulci, grooves and fissures. In addition, a long period is
required for eruption and during this period, the tooth substance is still
young.
b. Cariogenic bacteria are also part of oral microbiota. Cariogenic bacteria
known to the present time are Streptococcus Mutans, Streptococcus
Sanguis, Lactobacillus Acidophilus, Actinomyces Viscosus and
Actinomyces Naeslundii.
31

32. c. Substrate (glucides) : adherence of plaque to teeth is a natural
consequence of the teeths’ role in eating.
d. Time : two temporal factors contribute to tooth decay. These are:
i. the time since eruption in which the teeth lay exposed in the
mouth.
ii. the period of time that elapses before the plaque is removed.
Therefore, the environment most conducive to rapid outbreak of caries
is that found during the first molars eruption period.
However, when just about two thirds of occlusal surface has erupted, in
the 1st
and 2nd
molars, although gingiva still covers the crown edges which
makes them extremely conducive to decay and difficult to clean. Caries occur
quite easily during this stage and utmost caution must be taken to achieve
adequate oral hygiene. This can be achieved by fluoride treatment and use of
molar brushes.
It is also common for caries in primary second molars and in
neighbouring primary teeth, to spread to the permanent first molar, which then
leads to problems in the entire permanent dental arch. Therefore, it is very
important to protect the primary teeth from caries thereby allowing the
permanent to develop and erupt normally.
2. It is evident that the principal supporting tissue of the tooth, the periodontal
ligament and the bone of the jaw, possess a remarkable plasticity that
enable the tooth to react favourably or unfavourably to its immediate
environment. This plasticity of the supporting tissue is used by the
orthodontist to achieve a favourable clinical response. By applying forces
to the tooth and by relying on the biologic responses of bone and
periodontal ligament, malalignment of teeth can often be corrected.
32

33. 3. Sometimes when trauma occurs to the tooth especially permanent
anteriors, before the root formation is complete, it results in the formation
of blunderbuss canals. At this time endodontic therapy namely
apexification or apexogenesis is advocated to stimulate completion form of
root apex.
4. Premature eruption of teeth occurs infrequently. Sometimes, infants are
born with “erupted” lower central incisors, but this is an example of gross
maldevelopment. Such teeth need to be extracted as soon as possible
because they prevent suckling. Premature loss of a deciduous tooth without
closure of the gap may lead to early eruption of its successor.
5. Far more common, however is the occurrence of delayed or retarded
eruption. This may be caused by localized or systemic factors. Systemic
factors include nutritional, genetic and endocrine deficiencies. Local
factors include, such situations as loss of a deciduous tooth and drifting of
opposing teeth to block eruptive pathways. Severe trauma may eliminate
the dental follicle and hence periodontal ligament formation is prevented.
When this happens, the bone of the jaw fuses with the tooth, a condition
known as ankylosis, and eruption is not possible.
6. Whites exhibit an evolutionary trend to a diminution in the size of the
jaws. This trend has not been accompanied by a corresponding decrease in
size of teeth and as a result crowding is a common occurrence. The third
molars are the last teeth to erupt and frequently all the available space has
been used. And as a result teeth become impacted. Canines are also often
impacted because of their late eruption time.
7. Finally, it has been shown that the moment a tooth breaks through the
oral epithelium, an acute inflammatory response occurs in the connective
33

34. tissue adjacent to the tooth. This is seen even in the germ-free animals and
is seen in varying degrees around all teeth throughout life. Clinically, as
teeth break through the oral mucosa, there is often some pain, slight fever
and general malaise, all signs of an inflammatory process. In infants, these
symptoms are popularly called “teething”.
34

35. VIII. SUMMARY & CONCLUSION
The mechanism of tooth eruption is an enigma which has perplexed
many investigators. It is a process that has been the subject of scientific enquiry
since 1778 when Hunter attributed the mechanism to root elongation. Recent
reviews have concluded that there is no simple explanation for this biological
phenomenon which is not surprising since most teeth erupt during periods of
active craniofacial growth and therefore eruption should be considered as part
of a multifactorial event. Furthermore, some evidence suggests that different
mechanisms operate during various stages of eruption and for teeth which have
limited or continuous growth. Recent advances in biochemistry, immunology
and structural and molecular biology have renewed interest in understanding
the mechanisms of bone remodeling and tooth eruption because it is now
possible to localize and determine the activity of cytokines, membrane
receptors, signal transduction molecules and post activation intracellular
events.
IX. REFERENCES
1. Eruption of Permanent Teeth – A Colour Atlas – Sadakatsu Sato and
Patricia Parsons (Ishiyaku Euro America Inc.).
2. Oral Histology – A.R. Ten Cate, Mosby Publications (3rd
edition).
3. Orban’s Oral Histology and Embryology – Mosby Publications
(10th
edition).
4. Principles of Anatomy and Oral Anatomy for Dental Students – M.E.
Atkinson and F.H. White (1st
edition) Churchill Livingstone
Publishers.
35

36. 5. Orthodontics, Principles and Practice - T.M. Graber (3rd
edition)
W.B. Saunders Publication.
6. Clinical Periodontology - Carranza and Newman (8th
edition)
W.B. Saunders Publication.
Journals
1. Mechanism of tooth eruption – T.B. Kandos.
B.D.J. Vol. 181, No. 3 Aug. 10 : 1996 (91-95).
2. Tooth eruption and orthodontic movements – J.R. Sandy.
B.D.J. Vol 172, No. 4 : Feb 22, 1992 (141-149).
The Molecular Biology of Initiation of Tooth Eruption - G.E. Wise and
F Lin.
J. Dent. Res. 74 (1) : 303-306 Jan 95.
3. A Histologic study of the Exfoliation of Human Deciduous Teeth
– N. Sahara, N. Okafuji, Y. Ashizawa and K. Suzuki.
J. Dent. Res. 72 (3) : 634-640, March 93.
36