Disturbances in the Timing of Disturbances in the Timing of Tooth Eruption in Children with Tooth Eruption in Children with

General DiseasesGeneral Diseases

Sven Kreiborg, DDS, DrOdont, PhDSven Kreiborg, DDS, DrOdont, PhDPediatric Dentistry and Clinical GeneticsPediatric Dentistry and Clinical Genetics

School of Dentistry, Faculty of Health SciencesSchool of Dentistry, Faculty of Health SciencesUniversity of Copenhagen, Copenhagen, DenmarkUniversity of Copenhagen, Copenhagen, Denmark

E-mail: skrei@sund.ku.dkE-mail: skrei@sund.ku.dk

Disturbances in the Timing of Disturbances in the Timing of Tooth EruptionTooth Eruption

Natal/neonatal teethNatal/neonatal teeth

Premature eruptionPremature eruption

Delayed eruptionDelayed eruption

Normal Tooth EruptionNormal Tooth EruptionTimingTiming

In the primary dentition: In the primary dentition: no no significant difference between significant difference between boys and girlsboys and girls

In the permanent dentition: In the permanent dentition: girls girls have significantly earlier tooth have significantly earlier tooth eruption than boys eruption than boys (about 6 (about 6 months)months)

Normal Tooth EruptionNormal Tooth EruptionTimingTiming

There is a There is a weakweak correlation correlation between between tooth eruptiontooth eruption and and chronological agechronological age

There is a There is a weakweak correlation correlation between between tooth eruptiontooth eruption and and skeletal ageskeletal age

Normal Tooth EruptionNormal Tooth EruptionTimingTiming

There is a There is a strongstrong correlation correlation between between tooth eruptiontooth eruption and and dental dental ageage

Demijian et al. Demijian et al.

A new system of dental age assessmentA new system of dental age assessmentHum Biol 1973;45:211-27Hum Biol 1973;45:211-27

Stages of Tooth EruptionStages of Tooth Eruption

Pre-eruptivePre-eruptive Intra-osseousIntra-osseous Mucosal penetrationMucosal penetration Pre-occlusalPre-occlusal Post-occlusalPost-occlusal

TOOTH ERUPTION – DURATIONTOOTH ERUPTION – DURATIONIntra-Osseous MovementIntra-Osseous Movement

2.5 – 6.5 years2.5 – 6.5 years

(shortest for M1; longest for C)(shortest for M1; longest for C)

No significant sex differenceNo significant sex difference

TOOTH ERUPTION – DISTANCETOOTH ERUPTION – DISTANCEIntra-Osseous MovementIntra-Osseous Movement

5 – 20 mm5 – 20 mm

(shortest for M1; longest for C)(shortest for M1; longest for C)

TOOTH ERUPTION – VELOCITYTOOTH ERUPTION – VELOCITYIntra-Osseous MovementIntra-Osseous Movement

1-101-10m/day m/day

(10(10m=0.01mm; 100 days=1mm)m=0.01mm; 100 days=1mm)

No significant sex differenceNo significant sex difference

TOOTH ERUPTION – VELOCITYTOOTH ERUPTION – VELOCITYPre-Occlusal MovementPre-Occlusal Movement

10-7510-75m/daym/day

(100(100m=0.1mm; 100 days=10mm)m=0.1mm; 100 days=10mm)

No significant sex difference

TOOTH ERUPTION – VELOCITYTOOTH ERUPTION – VELOCITYPost-Occlusal MovementPost-Occlusal Movement

Magnitude and velocity of tooth movement Magnitude and velocity of tooth movement

depend on depend on

magnitude, velocity, and direction of jaw growth magnitude, velocity, and direction of jaw growth

Significant sex differenceSignificant sex difference

Disturbances in the Timing of Disturbances in the Timing of Tooth EruptionTooth Eruption

Natal/neonatal teeth (1:2,000-3,000 Natal/neonatal teeth (1:2,000-3,000 births) births)

Premature eruptionPremature eruption

Delayed eruptionDelayed eruption

Disturbances of Tooth EruptionDisturbances of Tooth EruptionPOSSUM-DatabasePOSSUM-Database

Natal/Neonatal TeethNatal/Neonatal Teeth

62 Syndromes62 Syndromes(e.g. Ellis-vanCreveld Syndrome and (e.g. Ellis-vanCreveld Syndrome and

Hallermann-Streiff Syndrome)Hallermann-Streiff Syndrome)

Disturbances of Tooth EruptionDisturbances of Tooth EruptionPOSSUM-DatabasePOSSUM-Database

Premature EruptionPremature Eruption

51 Syndromes51 Syndromes(e.g. Soto syndrome)(e.g. Soto syndrome)

Soto SyndromeSoto SyndromePremature Tooth EruptionPremature Tooth Eruption

Tall statureTall stature Cerebral gigantismCerebral gigantism MacrocephalyMacrocephaly Large mandibleLarge mandible

Cause of premature tooth eruptionCause of premature tooth eruption::accelerated general growthaccelerated general growth

Klippel-Trenaunay-Weber Syndrome Klippel-Trenaunay-Weber Syndrome Premature Tooth EruptionPremature Tooth Eruption

Generalized unilateral hypertrophyGeneralized unilateral hypertrophy Cutaneous angiomatosisCutaneous angiomatosis Varicose veinsVaricose veins

Cause of premature tooth eruptionCause of premature tooth eruption::

accelerated general growth unilaterallyaccelerated general growth unilaterally

TOOTH ERUPTION - DELAYEDTOOTH ERUPTION - DELAYED

Genetic factorsGenetic factors Chronic diseasesChronic diseases Chromosomal aberrationsChromosomal aberrations Endocrine disordersEndocrine disorders

- Hypopituitarism- Hypopituitarism

- Hypothyroidism- Hypothyroidism

- Hypoparathyroidism- Hypoparathyroidism SyndromesSyndromes

TOOTH ERUPTION TOOTH ERUPTION DELAYING/HINDERING FACTORSDELAYING/HINDERING FACTORS

Intra-Osseous MovementIntra-Osseous Movement

Dental follicleDental follicle Tooth/root formationTooth/root formation Alveolar bone Alveolar bone

Space conditions Space conditions Obstacles Obstacles Bone metabolismBone metabolism

TOOTH ERUPTION – DELAYEDTOOTH ERUPTION – DELAYEDPhysical FactorsPhysical Factors

CrowdingCrowding Supernumerary teethSupernumerary teeth Odontomas/osteomasOdontomas/osteomas CystsCysts Gingival fibromatosisGingival fibromatosis OtherOther

Disturbances of Tooth EruptionDisturbances of Tooth EruptionPOSSUM-DatabasePOSSUM-Database

Delayed EruptionDelayed Eruption

180 Syndromes180 Syndromese.g. Apert syndrome, Cherubism, cleidocranial e.g. Apert syndrome, Cherubism, cleidocranial

dysplasia, dysplasia, ectodermal dysplasias, Ellis-vanCreveld ectodermal dysplasias, Ellis-vanCreveld syndrome, GAPO syndrome, GAPO syndrome, Hurler syndrome, syndrome, Hurler syndrome, Incontinentia Pigmenti syndrome, McCune Albright syndrome, Incontinentia Pigmenti syndrome, McCune Albright syndrome, Pycnodysostosis, Tricho-Dento-Osseous syndrome, etc. …. Pycnodysostosis, Tricho-Dento-Osseous syndrome, etc. ….

Disturbances of Tooth EruptionDisturbances of Tooth EruptionPOSSUM-DatabasePOSSUM-Database

Delayed eruption in syndromes with:Delayed eruption in syndromes with: General growth disturbancesGeneral growth disturbances Maxillary and mandibular hypoplasiaMaxillary and mandibular hypoplasia Disturbances of tooth formationDisturbances of tooth formation Gingival fibromatosisGingival fibromatosis Disturbances of bone metabolismDisturbances of bone metabolism

Delayed Tooth EruptionDelayed Tooth Eruption

There is a There is a strongstrong correlation correlation between between tooth eruptiontooth eruption and and abnormal tooth developmentabnormal tooth development

TOOTH ERUPTION – DELAYEDTOOTH ERUPTION – DELAYEDSyndromes with Dental AnomaliesSyndromes with Dental Anomalies

Amelogenesis ImperfectaAmelogenesis Imperfecta Ectodermal DysplasiaEctodermal Dysplasia Ekman-Westborg-Julin SyndromeEkman-Westborg-Julin Syndrome Morquio syndromeMorquio syndrome

Ectodermal Dysplasia (X-Linked)Ectodermal Dysplasia (X-Linked)Delayed Tooth EruptionDelayed Tooth Eruption

Sparse scalp hair, eyelashes, eyebrowsSparse scalp hair, eyelashes, eyebrows Inability to sweatInability to sweat High forhead, depressed nasal bridgeHigh forhead, depressed nasal bridge Decreased anterior face heightDecreased anterior face height Dental abnormalities (oligodontia/anodontia)Dental abnormalities (oligodontia/anodontia) Microdontia, tooth shape abnormalitiesMicrodontia, tooth shape abnormalities

Cause of delayed tooth eruptionCause of delayed tooth eruption::

abnormalities of tooth formationabnormalities of tooth formation

Ekman-Westborg-Julin SyndromeEkman-Westborg-Julin SyndromeDelayed Tooth EruptionDelayed Tooth Eruption

MacrodontiaMacrodontia MultituberculismMultituberculism Pulp invaginationsPulp invaginations

Causes of delayed tooth eruptionCauses of delayed tooth eruption::abnormalities of tooth development and crowdingabnormalities of tooth development and crowding

Morquio SyndromeMorquio SyndromeDelayed Tooth EruptionDelayed Tooth Eruption

Short statureShort stature Coarse faciesCoarse facies Short neckShort neck Joint contracturesJoint contractures PrognathismPrognathism Enamel hypoplasiaEnamel hypoplasia

Cause of delayed tooth eruptionCause of delayed tooth eruption::abnormalities of tooth developmentabnormalities of tooth development

TOOTH ERUPTION – DELAYEDTOOTH ERUPTION – DELAYEDSyndromes with hypoplastic jawsSyndromes with hypoplastic jaws

Apert syndromeApert syndrome Crouzon syndromeCrouzon syndrome Cleft palateCleft palate Treacher-Collins syndromeTreacher-Collins syndrome Silver-Russell syndromeSilver-Russell syndrome PycnodysostosisPycnodysostosis

APERT SYNDROMEAPERT SYNDROMEDelayed Tooth EruptionDelayed Tooth Eruption

Premature craniosynostosisPremature craniosynostosis Maxillary hypoplasiaMaxillary hypoplasia Shallow orbitsShallow orbits Small noseSmall nose Syndactyly of hands and feetSyndactyly of hands and feet

Causes of delayed tooth eruptionCauses of delayed tooth eruption::maxillary hypoplasia with severe crowding and maxillary hypoplasia with severe crowding and gingival hyperplasiagingival hyperplasia

PycnodysostosisPycnodysostosisDelayed Tooth EruptionDelayed Tooth Eruption

Short statureShort stature Increased bone density (osteopetrosis)Increased bone density (osteopetrosis) Delayed closure of fontanelles and suturesDelayed closure of fontanelles and sutures Hypoplastic midfaceHypoplastic midface Mandibular retrognathia Mandibular retrognathia Aplasia of teethAplasia of teethCauses of delayed tooth eruptionCauses of delayed tooth eruption::hypoplastic jaws with crowding and abnormal hypoplastic jaws with crowding and abnormal bone metabolism bone metabolism

TOOTH ERUPTION – DELAYEDTOOTH ERUPTION – DELAYEDSyndromes with Bone DisordersSyndromes with Bone Disorders

OsteopetrosisOsteopetrosis PycnodysostosisPycnodysostosis McCune Albright syndromeMcCune Albright syndrome Tricho-dento-osseous syndromeTricho-dento-osseous syndrome Osteopathia striata with cranial Osteopathia striata with cranial

sclerosissclerosis

McCune-Albright SyndromeMcCune-Albright SyndromeDelayed Tooth EruptionDelayed Tooth Eruption

Endocrine abnormalities (precocious puberty) Endocrine abnormalities (precocious puberty) Fibrous dysplasia of boneFibrous dysplasia of bone ScoliosisScoliosis Patchy/streak-like skin hyperpigmentationPatchy/streak-like skin hyperpigmentation Facial asymmetryFacial asymmetry Sclerotic/dense boneSclerotic/dense bone Dental abnormalitiesDental abnormalitiesCause of delayed tooth eruptionCause of delayed tooth eruption::

abnormal bone metabolismabnormal bone metabolism

Tricho-Dento-Osseous SyndromeTricho-Dento-Osseous SyndromeDelayed Tooth EruptionDelayed Tooth Eruption

Curly/frizzy hairCurly/frizzy hair Increased bone densityIncreased bone density Aplasia of teethAplasia of teeth Amelogenesis imperfectaAmelogenesis imperfecta TaurodontismTaurodontism

Causes of delayed tooth eruptionCauses of delayed tooth eruption::abnormal bone metabolism and abnormalities abnormal bone metabolism and abnormalities of tooth developmentof tooth development

Osteopathia Striata with Cranial SclerosisOsteopathia Striata with Cranial SclerosisDelayed Tooth EruptionDelayed Tooth Eruption

Increased bone densityIncreased bone density Hearing lossHearing loss Linear striations in long bonesLinear striations in long bones Aplasia of teethAplasia of teeth TaurodontismTaurodontism

Cause of delayed tooth eruptionCause of delayed tooth eruption::abnormal bone metabolismabnormal bone metabolism

TOOTH ERUPTION – DELAYEDTOOTH ERUPTION – DELAYEDSyndromes with ObstaclesSyndromes with Obstacles

Cleidocranial dysplasiaCleidocranial dysplasia Kreiborg-Pakistan syndromeKreiborg-Pakistan syndrome Hurler syndromeHurler syndrome CherubismCherubism Gardner syndromeGardner syndrome

Cleidocranial DysplasiaCleidocranial DysplasiaDelayed Tooth EruptionDelayed Tooth Eruption

Large head with prominent frontal bonesLarge head with prominent frontal bones Wide sutures and fontanellesWide sutures and fontanelles Small faceSmall face Aplasia/hypoplasia of claviclesAplasia/hypoplasia of clavicles Supernumerary teethSupernumerary teeth

Causes of delayed tooth eruptionCauses of delayed tooth eruption::supernumerary teeth and abnormal bone metabolismsupernumerary teeth and abnormal bone metabolism

Kreiborg-Pakistan SyndromeKreiborg-Pakistan SyndromeDelayed Tooth EruptionDelayed Tooth Eruption

Premature craniosynostosisPremature craniosynostosis Supernumerary teethSupernumerary teeth

Causes of delayed tooth eruptionCauses of delayed tooth eruption::

supernumerary teeth and abnormal bone metabolismsupernumerary teeth and abnormal bone metabolism

Gardner SyndromeGardner SyndromeDelayed Tooth EruptionDelayed Tooth Eruption

Familial adenomatous polyposis Familial adenomatous polyposis (malignancies)(malignancies)

Osteomas of skull/facial bonesOsteomas of skull/facial bones Epidermoid/sebaceous skin cystsEpidermoid/sebaceous skin cysts

Causes of delayed tooth eruptionCauses of delayed tooth eruption::

osteomas in the jawsosteomas in the jaws

Hurler SyndromeHurler SyndromeDelayed Tooth EruptionDelayed Tooth Eruption

Mucopolysaccharidosis 1HMucopolysaccharidosis 1H Growth retardationGrowth retardation Progressive neurological deteriorationProgressive neurological deterioration Coarse faceCoarse face Corneal cloudingCorneal clouding Kyphosis and multiple joint contracturesKyphosis and multiple joint contractures Dental cystsDental cystsCause of delayed tooth eruptionCause of delayed tooth eruption::

dental cysts with accumulation of MPSdental cysts with accumulation of MPS

CherubismCherubismDelayed Tooth EruptionDelayed Tooth Eruption

Cystic, fibrous jaw lesionsCystic, fibrous jaw lesions Bilateral symmetric jaw expansion Bilateral symmetric jaw expansion Exposure of sclera below the irisExposure of sclera below the iris Aplasia of teethAplasia of teeth

Cause of delayed tooth eruptionCause of delayed tooth eruption::

cystic jaw lesions (giant-cell granulomas)cystic jaw lesions (giant-cell granulomas)

TOOTH ERUPTION – DELAYEDTOOTH ERUPTION – DELAYEDSyndromes with Anomalies of Oral MucosaSyndromes with Anomalies of Oral Mucosa

Gingival fibromatosisGingival fibromatosis NeurofibromatosisNeurofibromatosis Apert syndromeApert syndrome

TOOTH ERUPTION – DELAYEDTOOTH ERUPTION – DELAYED

Syndromes but with Unknown Syndromes but with Unknown MechanismMechanism

GAPO syndromeGAPO syndrome Romberg syndromeRomberg syndrome

GAPO syndromeGAPO syndromeDelayed Tooth EruptionDelayed Tooth Eruption

GGrowth retardationrowth retardation AAlopecialopecia PPseudoanodontiaseudoanodontia OOptic atrophyptic atrophy Premature craniosynostosisPremature craniosynostosis Thick lips, thick and fibrous gingivaThick lips, thick and fibrous gingivaCause of delayed tooth eruptionCause of delayed tooth eruption::

unknown, but ossifications in the gingiva have been seenunknown, but ossifications in the gingiva have been seen

Romberg SyndromeRomberg SyndromeDelayed Tooth EruptionDelayed Tooth Eruption

Hemifacial atrophy (skin, fat, cartilage, Hemifacial atrophy (skin, fat, cartilage, bone, and teeth)bone, and teeth)

Cause of delayed tooth eruptionCause of delayed tooth eruption::

unknown but related to the atrophy of tissuesunknown but related to the atrophy of tissues

TOOTH ERUPTIONTOOTH ERUPTION Delay in Intra-Osseous or Delay in Intra-Osseous or

Mucosal Penetration StagesMucosal Penetration Stages

General Treatment PrincipleGeneral Treatment Principle

The tooth should penetrate the The tooth should penetrate the mucosa no later than at mucosa no later than at

developmental developmental stage Gstage G according according to Demirjian et al. (1973)to Demirjian et al. (1973)

TOOTH ERUPTIONTOOTH ERUPTION Delay in Intra-Osseous or Delay in Intra-Osseous or

Mucosal Penetration StagesMucosal Penetration Stages

Treatment Considerations Treatment Considerations

• Extraction of primary tooth/teethExtraction of primary tooth/teeth• Removal of obstaclesRemoval of obstacles• DenudationDenudation• Removal of alveolar bone occlusallyRemoval of alveolar bone occlusally• Orthodontic tractionOrthodontic traction• Bone distractionBone distraction• AutotransplantationAutotransplantation

TOOTH ERUPTIONTOOTH ERUPTION Delay in Intra-Osseous or Delay in Intra-Osseous or

Mucosal Penetration StagesMucosal Penetration Stages

Be observant and alertBe observant and alert

andand

ACT!ACT!