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DELAYED TOOTH ERUPTION

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R eview Article www.ejournalofdentistry.com

DELAYED TOOTH ERUPTION

Faizal C Peedikayil Professor, Department of Pedodontics Kannur Dental College and Hospital.
Correspondence: Faizal C Peedikayil Professor, Department of Pedodontics Kannur Dental College and Hospital Anjarakandy, Kannur,
Kerala, India. Email: drfaizalcp@gmail.com
Received Nov 3,2011; Revised Nov 27, 2011; Accepted Dec 19, 2011

ABSTRACT
Eruption is a complex process that can be influenced by number of factors. Significant deviation from the established
norms should alert the clinician to make investigations for the evaluating the cause of delayed tooth eruption. This
review presents etiology, clinical implications, investigations, and a methodology for diagnosis and treatment of
delayed tooth eruption.
Key words: eruption of teeth, chronology of eruption

INTRODUCTION Preterm birth

Eruption of deciduous teeth, their exfoliation
followed by eruption of permanent dentition is an orderly
sequential and age specific event 1. But most parents are
anxious about the variation in the timing of the eruption,
which is considered as an important milestone during childs
development. Racial, ethnic, sexual, and individual factors
can influence eruption and are usually considered in
determining the standards of normal eruption 2,3.Tooth
eruption is a complex and tightly regulated process which
is divided into five stages namely preeruptive movements,
intraosseous stage, mucosal penetration, preocclusal and
postocclusal stages3.
World Health Organization (WHO) defines
preterm birth as birth occuring before 37 weeks of gestation
or if the birth weight is below 2500g7. Influence of preterm
birth on teeth development and eruption has been
investigated. Most of the studies reported that preterm
babies children have delayed primary and permanent teeth
eruption. Some researches reported that the greatest delay
was found in children younger than 6 years of age, whereas
for those aged 9 years or older, there was no difference,
indicating that a “catch- up” had occurred 8,9.
Local factors

Significant deviations from accepted norms of
eruption time are often observed in clinical practice.
Premature eruption has been noted, but delayed tooth
eruption (DTE) is the most commonly encountered deviation
from normal eruption time.The importance of DTE as a
clinical problem is well reflected by the number of published
reports on the subject. DTE might be the primary or sole
manifestation of local or systemic pathology.4
General considerations
Gender
Studies on teeth emergence shows that permanent
teeth erupt earlier in girls than in boys5. The difference
between eruption times on average is from 4 to 6 months,
largest difference being for permanent canines. Earlier
eruption of permanent teeth in females is attributed to earlier
onset of maturation.6
Physical obstruction is a common local cause of
DTE. These obstructions can be because of mucosal barrier,
supernumerary teeth, scar tissue, and tumors etc (Table 1).
Mucosal barrier has also been suggested as an important
etiologic factor in DTE. Any failure of the follicle of an
erupting tooth to unite with the mucosa will entail a delay
in the breakdown of the mucosa and constitute a barrier to
emergence. Gingival hyperplasia resulting from various
causes (hormonal or hereditary causes, drugs such as
phenytoin) might cause an abundance of dense connective
tissue or acellular collagen that can be an impediment to
tooth eruption1,5,6,10.
Supernumerary teeth can cause crowding,
displacement, rotation, impaction, or delayed eruption of
the associated teeth. The most common supernumerary
tooth is the mesiodens, followed by a fourth molar in the
maxillary arch. Odontomas and other have also been
occasionally reported to be responsible for DTE. Regional
odontodysplasia, (ghost teeth) is an un-usual dental
anomaly that might exhibit a delay or total failure in eruption.

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Faizal C Peedikayil
Central incisors, lateral incisors, and canines are the most
frequently affected teeth10,11
Injuries to deciduous teeth have also been
implicated as a cause of DTE of the permanent teeth.
Traumatic injuries can lead to disruption in normal
odontogenesis in the form of dilacerations or physical
displacement of the permanent germ 12 . Cystic
transformation of a nonvital deciduous incisors might also
cause delay in the eruption of the permanent successor. In
some instances, the traumatized deciduous incisor might
become ankylosed or delayed in its root resorption .This
also leads to the overretention of the deciduous tooth and
disruption in the eruption of its successor. The eruption of
the succedaneous teeth is often delayed after the premature
loss of deciduous teeth before the beginning of their root
resorption. This can be explained by the abnormal changes
that might occur in the connective tissue overlying the
permanent tooth and the formation of thick, fibrous gingiva.
Ankylosis occurs commonly in the deciduous dentition,
usually affecting the molars, and has been reported in all 4
quadrants, although the mandible is more commonly
affected than the maxilla.10,12
Arch-length deficiency is often mentioned as an
etiologic factor for crowding and impactions. Arch-length
deficiency might lead to DTE, although more frequently
the tooth erupts ectopically.13
X-radiation has also been shown to impair tooth
eruption. Ankylosis of bone to tooth was the most relevant
finding in irradiated animals. Root formation impairment,
periodontal cell damage, and insufficient mandibular growth
also seem to be linked to tooth eruption disturbances due
to x-radiation.14
Systemic conditions
The high metabolic demand on the growing
tissues might influence the eruptive process. delayed
eruption is often reported in patients who are deficient in
some essential nutrient. Agarwal et al15 had reported delayed
deciduous dental eruption in malnourished Indian children.
Chronic malnutrition extending beyond the early childhood
is correlated with delayed teeth eruption. Most of the teeth
showed a one to four month variation around the mean
eruption time16
Table 2 shows various systemic condition which
can lead to DTE. Disturbance of the endocrine glands
usually has a profound effect on the entire body, including
the dentition 10 . Hypothyroidism, Hypopituitarism,
Hypoparathyroidism, and Pseudohypoparathyroidism are
the most common endocrine disorders associated with DTE.
www.ejournalofdentistry.com
in hypopituitarism or pituitary dwarfism, the eruption and
shedding of the teeth are delayed, as is the growth of the
body in general. The dental arch has been reported to be
smaller than normal; thus it cannot accommodate all the
teeth, so a malocclusion develops. The roots of the teeth
are shorter than normal in dwarfism, and the supporting
structures are retarded in growth.17
Other systemic conditions associated with
impairment of growth, such as anemia (hypoxic hypoxia,
histotoxic hypoxia, and anemic hypoxia) and renal failure,
have also been correlated with DTE and other abnormalities
in dentofacial development.10
Genetic disorders
Genetics has an important role in development. A
generalized developmental delay is seen in patients with
syndromes. Table 3 shows various genetic conditions
assosiated with DTE. Various mechanisms have been
suggested to explain DTE in relation to genetic disorders.
Supernumerary teeth have been found to be responsible
for DTE in Apert syndrome, Cleidocranial dysostosis, and
Gardner syndrome. There is considerable evidence to
implicate the periodontal tissues’ development and
assosiated structures of the tooth in DTE. Lack of cellular
cementum has been found in cleidocranial dysplasia,
cementum-like proliferations and obliteration of periodontal-
ligament space with resultant ankylosis have been noted
in Gardner syndrome. In osteopetrosis, sclerosteosis,
Carpenter syndrome, Apert syndrome, cleidocranial
dysplasia, Pyknodysostosis, and others, underlying defects
in bone resorption might be responsible for DTE.10,18,19,20,21
Occasionally, some syndromes or genetic
disorders are associated with multiple tumors or cysts in
the jaws, and these might lead to generalized DTE. Gorlin
syndrome, cherubism, and Gardner syndrome are such
disorders, in which DTE might be the result of interference
to eruption by these lesions20,21,22,23,24. Generalized delay in
the eruption of teeth is noted in some families . Patient
medical history might be totally unremarkable, with DTE as
the only finding. The presence of a gene for tooth eruption
has also been suggested, and its “delayed onset” might be
responsible for DTE in “inherited retarded eruption”.10, 19
CLINICAL IMPLICATIONS (table 4)
Diagnosis of DTE is an important but complicated
process. When teeth do not erupt at the expected age (mean
+_ 2 SD), a careful evaluation should be performed to
establish the etiology and the treatment plan accordingly10.
Various tables and diagrammatic charts of the stages of
tooth development, starting from the initiation of the
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Delayed Tooth Eruption
calcification process to the completion of the root apex of
each tooth are part of dental education. Norms with the
average chronologic ages at which each stage occurs should
be compared3
Medical history, family information and
information from affected patients about unusual variations
in eruption patterns should be investigated. Clinical
examination must begin with the overall physical evaluation
of the patient. Significant right-left variations in eruption
timings might be associated with tumors and should alert
the clinician to perform further investigation.10
Intraoral examination should include inspection,
palpation, percussion, and radiographic examination. The
clinician should inspect for gross soft tissue pathology,
scars, swellings, and fibrous or dense frenal attachments.
Careful observation and palpation of the alveolar ridges
buccally and lingually usually shows the characteristics
bulge of a tooth in the process of eruption. Palpation
producing pain, crackling, or other symptoms should be
further evaluated for pathology. Overretained deciduous
tooth and the supporting structures should be thoroughly
examined. Ankylosed teeth also interfere with the vertical
development of the alveolus.10
INVESTIGATIONS
A panoramic radiograph is ideal for evaluating the
position of teeth and the extent of tooth development,
estimating the time of emergence of the tooth into the oral
cavity, and screening for pathology. IOPA with the image/
tube shift method, Clark’s rule, buccal object rule are
suggested for radiographic localization of tumors,
supernumerary teeth, and displaced teeth, which require
surgical correction. Computed tomography can be used as
the most precise method of radiographic localization 25,26,27
TREATMENT CONSIDERATIONS
The treatment of DTE depends on the etiology. A
number of techniques have been suggested for treating
DTE. The treatment plan should also consider 10
(1) The decision to remove or retain the tooth or teeth
affected by DTE
(2) The use of surgery to remove obstructions,
(3) Surgical exposure of teeth affected by DTE,
(4) The application of orthodontic traction,
(5) The need for space creation and maintenance, and
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(6) Diagnosis and treatment of systemic disease that
causes DTE.
The treatment flowchart (table 5) can serve as a
guideline for addressing the most important treatment
options in DTE. Once the clinical determination of
chronologic DTE (>2 SD) has been established, a panoramic
radiograph should be obtained. The screening radiograph
can be used to rule out tooth agenesis and assess the
developmental state of the tooth25,28
If there is defective tooth formation, the first step
should be to assess whether the defect is localized or
generalized. Unerupted deciduous teeth with serious
defects should be extracted, but the time of extraction should
be defined carefully by considering the development of
the succedaneous teeth and the space relationships in the
permanent dentition. In the permanent dentition, unerupted
teeth are normally closely observed until the skeletal growth
period necessary for appropriate development and
preservation of the surrounding alveolar ridge has been
attained.In DTE with no obvious developmental defect in
the affected tooth or teeth on the radiograph, root
development (biologic eruption status), tooth position and
physical obstruction should be evaluated. For a
succedaneous tooth if root formation is inadequate,
extraction of the deciduous tooth or exposure to apply active
orthodontic treatment is not justified. If the tooth is lagging
in its eruption status, active treatment is recommended
when more than 2/3 of the root has developed 25 .
Radiographic examination might also show an ectopic
position of the developing tooth. Often, some deviations
self-correct, but significant migration of the tooth usually
requires extraction. If self-correction is not observed over
time, active treatment should begin. Exposure accompanied
by orthodontic traction has been shown to be successful.
In patients in whom the ectopic teeth deviate more than 90°
from the normal eruptive path, autotransplantation might
be an effective alternative.10,23,24,25
An obstruction causing delayed eruption might
or might not be obvious on the radiographic survey. A soft
tissue barrier to eruption is not seen on the radiograph, but
the obstruction should be treated with an uncovering
procedure that includes enamel exposure. Supernumerary
teeth, tumors, cysts, and bony sequestra are physical
obstructions visible on the radiographic survey. Their
removal usually will permit the affected tooth to erupt29
In the deciduous dentition, DTE due to
obstruction is uncommon, but scar tissue (due to trauma)
and pericoronal odontogenic cysts or neoplasms are the
usual culprits in cases of obstruction. Trauma is more
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Faizal C Peedikayil www.ejournalofdentistry.com

common in the anterior region, but cysts or neoplasms are Table 1: Local Conditions associated with DTE *(10,11,12)
 Mucosal barriers-scar tissue: trauma/surgery
more likely to result in DTE in the canine and molar regions.  Supernumerary teeth
Odontomas are reported to be the most common of the  Odontogenic tumors (eg, adenomatoid odontogenic Tumors, odontomas)
 Nonodontogenic tumors
odontogenic lesions associated with DTE 30. Treatment
 Enamel pearls
options for deciduous DTE range from observation,  Injuries to primary teeth
Ankylosis of deciduous teeth
removal of physical obstruction with and without exposure 
 Premature loss of primary tooth
of the affected tooth, orthodontic traction on rare  Lack of resorption of deciduous tooth

occasions, and extraction of the involved tooth28,31.  Apical periodontitis of deciduous teeth
 Regional odontodysplasia
 Drugs -Phenytoin
In the permanent dentition, removal of the physical  Ectopic eruption

obstruction from the path of eruption is recommended.  Arch-length deficiency and skeletal pattern
 Radiation damage
When neoplasms (odontogenic or nonodontogenic) cause  Oral clefts Segmental odontomaxillary dysplasia

obstruction, the surgical approach is dictated by the

biologic behavior of the lesion. If the affected tooth is deep Table 2: Systemic Conditions associated with DTE * (10,
15,16,17)
in the bone, the follicle around it should be left intact. When  Nutrition
 Vitam in D-resistant rickets
the affected tooth is in a superficial position, exposure of
 Endocrine disorders (H ypothyroidism ,H ypopitutarism, hypoparathyroidism,
the enamel is done at tumor removal. Occasionally, the pseudohypoparathyroidism)
 Long-term chemotherapy
affected tooth must be removed. McDonald and Avery32  HIV infection
recommend exposure of the tooth delayed in eruption at  Cerebral palsy
 Dysosteosclerosis
the surgical removal of the barrier, but Houston and Tulley
 Anemia
33
advocate removing the obstruction and providing  Celiac disease

sufficient space for the unerupted tooth to erupt  Prem aturity/low birth weight
 Ichthyosis
spontaneously. If the tooth is exposed at the time of surgery,  renal failure
it might or might not be subjected to orthodontic traction
Table 3: Genetic conditions associated with DTE*(10,18-24)
to accelerate and guide its eruption into the arch. The
 A m e lo g e ne sis im p e rfe ct an d a sso cia te d d is ord ers
decision to use orthodontic traction in most case reports  E n a m e l a g e n es is a n d n ep h ro ca lc ino sis
 A m e lo -o n ych oh yp o h ydro tic d ysp la sia d e nto -os seo u s
seems to be a judgment call for the clinician. Occasionally, s yn d rom e (typ e s I an d II)
 A p e rt syn d ro m e
a deciduous tooth can be a physical barrier to the eruption  C arp e nte r s ynd rom e
C he ru bism
of the succedaneous tooth. In most cases, removing the 
 C ho n d ro e cto d erm al dysp la sia (Ellis-va n C re ve ld
deciduous tooth will allow for spontaneous eruption of the s yn d rom e
 C le id oc ra n ia l d ysp las ia
successor4. When arch length deficiency creates a physical  C on g e n ita l h ype rtric ho sis lan u g in o sa
 D en tin d ysp la sia
obstruction, either expansion of the dental arches or  M u co p o lysa cc ha rid os is
 D eL a n g e s yn d rom e
extraction might be necessary to obtain the required space.  H urle r syn dro m e
10,13  H un te r s yn d rom e
 P yk no d yso sto sis (M a rote a ux-L am y syn d ro m e ) (M P S IV )
 D ow n s yn dro m e
Whenever DTE is generalized, the patient should  E cto d e rm a l d ys plas ia
 E p id e rm o lysis bu llo sa
be examined for systemic diseases affecting eruption, such  G ard ne r synd rom e
 G au ch e r d ise a se
as endocrine disorders, organ failures, metabolic disorders,  R uth e rford syn d ro m e
 C ro ss synd rom e
drugs, and inherited and genetic disorders. Various methods R am o n s ynd rom e
have been suggested for treating eruption disorders in G ing iva l fibro m a tos es w ith se ns orin e ura l h e a rin g lo ss
G ing iva l fibro m a tos es w ith gro w th ho rm o n e d e ific ie ncy
these conditions. These include no treatment (observation),  G orlin syn d ro m e
 N eu rofib ro m a to se s
elimination of obstacles to eruption (eg, cysts, soft tissue  O ste op e tro sis (m a rb le b on e d ise a se )
 O ste og e n esis im p erfecta
overgrowths), exposure of affected teeth with and without  O tod e nta l d ysp la sia
 P a rry-R o m be rg syn d ro m e
orthodontic traction, autotransplantation, and control of  P rog eria (H utch in so n -G ilfo rd syn dro m e )
the systemic disease.1,4,10,11,12,17,19  R oth m u n d-T h o m p so n synd ro m e
 V o n R e ck lin g h au se n ne u ro fib rom a tosis

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Delayed Tooth Eruption www.ejournalofdentistry.com

Table 4: Etiology and Diagnosis of Chronological than two years should be investigated. eventhough
delayed tooth eruption(>2SD) genetics has an important role in the eruptuin process other
factors such as gender, body composition, local
disturbances,nutritional factors, systemic diseases etc can
Normal tooth development
Abnormal tooth development( defect in shape , size,
structure, colour)
influence the process. But significant cause may be due to
systemic conditions and syndromes associated with
Normal biologic
orofacial structures. Timely diagnosis of DTE is necessary
Delayed biologic eruption: root
eruption: root length<
2/3 length>2/3 for selecting the right treatment modality.
-Amelogenisis imperfecta

- Dentinogenesis imperfecta
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25. Jacobs SG. Radiographic localization of unerupted teeth: further findings about
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