CHAPTER 2

LITERATURE REVIEW

.1 DENTAL GROWTH PROCESS

Human teeth consists of special structures which are classified in 3 groups:

propiodontal structure consisting of enamel and dentin, endodontal structure is pulp
and periodontal structure consisting of cementum, alveolar bone, periodontal
membrane, and gingiva. Ectodermal cells will form enamel, stimulate odontoblast
formation and the determination of the shape of the crown and root of the tooth.
Mesodermal cells will form dentine, pulp tissue, cementum, periodontal membrane
and alveolar bone.The physiological stage of the tooth starts from growth,
calcification, eruption, attrition, root resorption and exfoliation. Dental growth
consists of several stages, namely initiation (bud stage), proliferation (cap stage),
histodiferentiation (bell stage), morphodiferensiation and apposition. Calcification
consists of mineralization, namely hardening of the matrix caused by deposition of
inorganic calcium salts and maturation, namely maturation until tooth eruption occurs.
Eruption is the movement of a developing tooth in the axial axis, from its
original location in the jawbone to the functional position in the oral cavity. This
process continues until the surface of the upper teeth meets the surface of the lower
teeth. Atrition is the reduction of the normal layer of teeth so that occlusion occurs.
Root resorption is associated with the growth of permanent teeth replacing deciduous
teeth. Exfoliation is the shaky position of deciduous teeth in the alveolar bone (the
process of resorption of deciduous roots) (UI Lecture Material, Dental Growth and
Development, drg. Taty Zubaidah, Sp.KGA).

2.1.1 THAT STAGE OF GROWTH TEETH

That stage of growth teeth is as follows (McDonald dan Avery, 2000; Finn,
2003).
a. Bud Stage
Initiation was the beginning to the establishment of the seed the
teeth of epithelium of the mouth. Certain cells in the basal layer of began
to proliferate improperly faster than surrounding cells. The result is the
epithelial lining of who buccal regio thicken in a rounded tooth and
 extends up to the entire parts of the upper and lower jaws. At this stage
there has been no differentiation of cells.

Picture 1. Bud Stage

b. Cap Stage

A layer of sel-sel mesenkim which are at a layer of deeply

experience, proliferation, solidifies and bervaskularisasi form papil teeth
that then forms dentin and pulpa at this stage. Mesenkim cells located
around the organs of the teeth and a papilla teeth, solidifies and fibrous
called the bag teeth that would be sementum, the membrane, periodontal
and the bones of the alveolar.

Picture 2. Cap Stage

c. Bell Stage

Happened differentiation cellular at this stage. Epithelial cells

email in the onto inner email epithelium to continues to be long and
astigmatism, called as ameloblas that will differentiate toward in being
enamel and cells part edge of papillæ teeth into odontoblas that will
differentiate toward out into dentine.

Picture 3. Bell Stage

d. Late Bell Stage

Cells in the form of teeth so constituted a way and prepared to

produce the shape and size of teeth next. The morphology of teeth can be
determined if epithelial email part in so constituted a way that the
boundary between epithelial email and odontoblas was an image of
dentinoenamel junction who is to be formed. Dentinoenamel junction
have the special property that act as a pattern in the form of all kinds of
teeth. There are deposit email and matrix dentine in region where
ameloblas cells and odontoblas who will give teeth according to the forms
it measured the.

Picture 4. Late Bell Stage

e. Aposisi

Has be formed the matrix hard fine teeth in email, dentine and
sementum. Email matrix formed of cells ameloblas moving toward the
edge and there has been about the calcified 25 % -30 %. Consisting of 2
stage :

1. Amelogenesis

Preameloblasts differentiate into ameloblasts were probably

crushed to be mendepositkan enamel. Ameloblas able to build many
tome' s these common quickly after amelogenesis starts to be carried
out. The process of are responsible for the production of enamel rods.
After ameloblast finished mendepositkan enamel, tome' s have gone
away into idolatry these common field and was replaced by striated
border. Striated border is responsible for bone resorption components a
matrix. Ameloblas play a critical role in reduced production by
minerals and to the destruction of organic material.

Picture 5. Amelogenesis

2. Dentinogenesis

Connective tissue cells dental papilla near ameloblas

berdifferensiasi into odontoblast, because ameloblast influence
odontoblas berdifferensiasi into dentine. The cell shape : astigmatism
short. Arrayed in one layer all membrana. Ganglia where the core more
towards basal. Long odontoblast couple of times its original length, the
diameter of stay. Changes in the cytoplasm with an increase in :
 organel, components and
elements of globular.

Picture 6. Dentinogenesis

2.1.2 PRIMARY TEETH

Normally children have 20 teeth milk consisting of 10 teeth in the

upper jaw and 10 teeth in the lower jaw. Basically eruption sites teeth milk
first one took place in age 6-8 months. Generally preceded by the teeth insisiv
central bottom, and respectively teeth insisiv above middle, teeth insisiv lateral
over and teeth insisiv lateral bottom, molar first milk, teeth caninus and molar
milk second. But the
eruption process
is not at once, but one by
one and sometimes also a
pair of.

Picture 7. Primary Teeth

2.1.1 PERMANENT TEETH
The first permanent teeth to erupt is the mandibular first molar, which
is when the child is 6 years old, but sometimes the mandibular incisor's first
incisor erupts together or even precedes the first molar. After that, the
maxillary first incisors and second mandibular incisors erupted at 7-8 years,
followed by the maxillary incisors at 8-9 years. Lower jaw canines erupted at
9-10 years and maxillary first premolars at 10-11 years, and so on (Bagley,
2006).
The peak of growth in each person occurs in different times. This is
due to factors that can affect during the growth and development period, such
as endocrine conditions, nutrition, and systemic diseases. Some indicators of
peak growth can be used as a reference, as in this study used dental age by
looking at the eruption of canines, premolars, and permanent second molars.
The teeth are then grouped according to the period of the teeth according to
Lorenzo et al (2008) namely the final period of mixed teeth (eruption of
canines and premolars) and the initial period of permanent teeth (eruption of
permanent second molars). The speed and slow eruption of teeth can be
influenced by several factors such as ankylosis, premature loss, persistence of
deciduous teeth, impact and crowding. In addition, the presence of nutritional
disorders such as vitamins A and D and disorders of growth hormone can also
affect tooth eruption.

2.1.2 ERUPTION STAGE

Teeth eruption is a continuous process starting from the initial
formation through several stages until the teeth appear into the oral cavity
(Stewart, 1982; Koch, 1991). There are two important phases in the process of
teeth eruption (Proffit and Fields, 1993), namely active and passive eruptions.
Active eruption is tooth movement which is dominated by vertical movement,
since the crown of a tooth moves from its formation in the jaw to reach
functional occlusion in the oral cavity, while passive eruption is the movement
of the gums toward the apex causing the clinical crown to grow longer and
clinical roots to increase short as a result of changes in the attachment of the
epithelium in the apical region. The teeth eruption process consists of 3
stages :
1) Pre Eruption
At this stage the movement of the teeth is the preparation stage for
the eruption stage. At this stage the process of growth and development of
dental seeds in the alveolar bone before the formation of teeth roots.
During this stage the teeth grow in various directions to maintain their
position in the jaw which is also developing. This can occur with eccentric
growth and movement of the whole dental seed (bodily movement).
Bodily movement is a shift in the whole dental seed, where this will result
in bone resorption in the direction the teeth is moving and bone formation
in the previous place.
2) Prefunctional Eruption
This stage begins with the initiation of teeth root formation and
will end when the teeth begin to reach occlusal contact. There are 5 main
events during this stage :
1. The secretory stage of amelogenesis is complete, just before root
formation begins. The intraosseous stage occurs when root formation
begins as a result of the proliferation of protective root epithelium and
mesenchymal tissue from the papillae and dental follicles.
2. The supraoseus stage starts when the occlusal part of the tooth that is
erupting moves through the lower part of the bone and the connective
tissue of the oral mucosa.
3. The crown end passes through the oral cavity by damaging the center
of the double layer of epithelial cells. This breakthrough is then filled
by the crown end.
4. Teeth that are erupted then move to occlusal at maximum distance
and visible exposure gradually from the appearance of clinical
crowns.
3) Functional Eruption
At this stage the crown of the teeth has grown maximally and there
has been an adjustment of maximum contact with the teeth in the opposite
jaw. Teeth have erupted perfectly and can function normally. Functional
eruption of teeth varies greatly between individuals. But as a guide to the
relationship of functional eruption of deciduous teeth with age (Kurniasih,
2006).
Pict 8. Eruption Stage Maxillary Permanent Teeth, Pict 9. Mandibular Teeth
2.1.3 FACTORS THAT AFFECT TEETH ERUPTION
Teeth eruption is a process that varies with each child. This variation
can occur in each period in the process of growth and development of teeth,
especially in the first and second transition periods. This variation is still
considered a normal condition if the length of time difference in tooth eruption
is still in the range of 2 years (Van der Linden, 1985). Variations in teeth
eruption can be caused by many factors. According to Stewart, et al (1982),
these factors are as follows :
a. Genetic
Heredity can affect the speed of time of teeth eruption (Koch, et
al., 1991). Genetic factors have the greatest influence in determining the
timing and sequence of teeth eruptions, including the process of
calcification (Moyers, 2001). The influence of genetic factors on teeth
eruption is around 78% (Stewart, et al., 1982; Moyers, 2001).
b. Race
Race differences can cause differences in the time and sequence of
eruption of permanent teeth. The eruption time of European teeth and the
mixture of Americans and Europeans is slower than the time of eruption
of black Americans and Indian Americans (Moyers, 2001). Americans,
Swiss, French, British, and Swedes belong to the same race, the Caucasoid
and show no difference in eruption time that is too large (Stewart et al.,
1982).
c. Gender
The time of eruption of the maxillary and permanent teeth occurs
varies between individuals. In general, the time of eruption of teeth of
 girls is faster than boys. This difference ranges from 1 to 6 months (Clark,
1994).
d. Environment
Teeth growth and development are influenced by environmental
factors but do not change much which is determined by heredity. The
influence of environmental factors on the time of teeth eruption is around
20% (Moyers, 2001).
Factors included in environmental factors include :
1) Social Economic
The socioeconomic level can influence the nutritional state, one's
health and other related factors (Stewart, et al., 1982). Children with
low economic levels tend to show slower tooth eruption time than
children with middle economic levels (Moyers, 2001).
2) Nutrition
Nutrition fulfillment factors can affect the time of tooth eruption and
jaw development (Djoharnas, 2000). Nutrition as a growth factor can
affect the eruption and calcification process. Delay in tooth eruption
can be influenced by nutritional deficiencies, such as vitamin D and
endocrine disruption. The influence of nutritional factors on tooth
development is around 1% (Moyers, 2001).
e. Diseases
Disorders of permanent teeth eruption can be caused by systemic
diseases and some syndromes, such as Down syndrome, Cleidocranial
dysostosis, Hypothyroidism, Hypopituitarism, several types of
Craniofacial synostosis and Hemifacial atrophy (Stewart, et al., 1982).
f. Local
Local factors that can affect teeth eruption are the distance of the
teeth to the site of the eruption, teeth malformation, the presence of excess
teeth, trauma from the teeth germ, thickened gum mucosa, and deciduous
deciduous teeth (Salzmann, 1975).

2.2 KELAINAN TUMBUH KEMBANG GIGI SULUNG DAN PERMANEN

2.2.2 DIASTEMA
 Diastema is a space of more than 0.5 mm in size between the
proximal surface of a tooth and its adjacent teeth. A space that occurs
between two adjacent teeth. Diastema is a discrepancy between the dental
arch and the arch. It can occurs in anterior or posteriorit can even affects
both of them (Endang Prawesthi and Moh. Hasan, Journal of Technology
and Health Arts Vol.08 No.1, 2017).
2.2.3 CENTRAL DIASTEMA
The maxillary central diastema, a malocclusion that often arises
with a characteristic that is the gap that exists between the maxillary central
incisors. Factors causing central diastema that occurs in the maxilla are:
1. The size of a small lateral incisor
2. Anomaly incisor teeth
3. Adhesion to the abnormal frenulum
4. Supernumerary teeth in the median line
5. Loss of lateral incisional teeth congenitally
6. Diastema during normal growth
7. Closing the median line that is not perfect
(Rina Sutjiati, Journal of Unej, Vol.8 No.1, 2011).
2.2.4 INTRUSION
Intrusion is a partial shifting or displacement of the place of partial
teeth into the alveolar socket. In intrusive teeth, a small portion of the
crown is visible or even implanted entirely in the socket due to gingival
swelling. This can be detected by radiography. Intrusion causes trauma to
the alveolar bone, periodontal ligament, cementum and pulp. The
consequences that can occur are pulp necrosis, resorption due to
inflammation and external displacement also ankylosis (Andhika
Priyatama, et al. Maj Ked Gi. December 2013 Vol.20 No.2).

2.3 DENTAL TRAUMA

2.3.2 DEFINITION OF DENTAL TRAUMA
Dental trauma can be interpreted as damage that affects the hard
tissue of the teeth and / or periodontal due to mechanical causes. Anterior
tooth trauma can occur directly and indirectly. Dental trauma directly
occurs when hard objects directly hit the teeth, while indirect dental trauma
 when a collision occurs on the chin causing the lower jaw hit the upper jaw
with force or sudden force and great pressure (Andhika Priyatama, et al.
Maj Ked Gi. December 2013 Vol.20 No.2).
2.3.3 CAUSE OF DENTAL TRAUMA
Some of the most common causes of trauma in the 8-12 year period
are accidents on the playground, biking, or while exercising such as martial
arts, soccer, basketball, running, and swimming (Andhika Priyatama, et al.
Maj Ked Gi. December 2013 Vol.20 No.2).
2.3.4 TRAUMA TO DECIDUOUS TEETH
Trauma to deciduous teeth can interfere with the function of speech,
mastication, aesthetics, and permanent tooth eruption so that it interferes
with tooth growth and development. Some reactions that occur in pulp
tissue after trauma to the teeth are pulp hyperemia, discoloration, internal
resorption, external resorption, metamorphosis of dental pulp calcification,
and pulp necrosis (TRAUMA IN TEETH CHILDREN, Dr. Laelia Dwi
Anggraini, SpKGA, Pediatric Dentist)

2.4 BROWN TEETH

2.4.1 DISCOLORATION
Discoloration is a condition in which the color of a tooth changes
due to various causes both physiological and pathological or exogenous and
endogenous.
Tooth discoloration occurs during or after the formation of enamel
and dentine. Some discoloration occurs after tooth eruption. Natural
discoloration of teeth on a surface or changes into tooth structure.
Sometimes this results from enamel weakness or traumatic injury.
1) Etiology of Discoloration
a. Pulp Necrosis
Pulp necrosis can cause discoloration of the teeth because
the blood vessels in the capillaries in the pulp chamber are
damaged, causing hemolysis of red blood cells to release iron cells
(Fe). Fe then compounds with the hydrogen sulfide produced by
bacteria to form a black ferric sulphide which is black and
penetrates into the dentinal tubules, trapped in the pulp horn so as
 to give a gray color to the necrotizing teeth (Guldener &
Langeland 1993).
b. Intrapulpa Bleeding
Intrapulpa bleeding and erythrocyte lysis are common
results of traumatic injuries to the teeth. Products in the blood
disintegration, especially iron sulfide, flow in the tubules and
blacken the surrounding dentin. If the pulp becomes necrotic, the
discoloration continues and usually gets worse with time.
c. Dentine Hypercalcification
Excessive formation of irregular dentin in the pulp chamber
and along the canal wall can occur after certain traumatic injuries.
In such cases, a temporary disruption in blood supply occurs,
followed by the destruction of odontoblasts which will be replaced
by undifferentiated mesenchymal cells. As a result, the
transparency of the crown of the tooth as gradually decreases,
giving rise to a yellowish or yellow-brown discoloration.
d. Age
In old age, color changes in the crown occur physiologically
as a result of excessive dentination, thinning of the enamel, and
optical changes. Food and drinks also have a cumulative
discoloration effect.
e. Growth Abnormalities
1. Enamel Hypocalcification
Enamel hypocalcification is a different brown or whitish area,
it can also cause red or brown discoloration in primary and
permanent teeth.
2. Thalassemia and Sickle Cell Anemia
Thalassemia and sickle cell anemia can cause intrinsic
changes in blue, brown, or green.
3. Imperfecta Amelogenesis
Imperfecta amelogenesis can cause yellow or brown
discoloration.
4. Dentinogenesis Imperfecta
 Dentinogenesis imperfecta can cause brownish violet,
yellowish, or gray discoloration.
f. Drug Related Abnormalities
1. Tetracycline
Repeated exposure to tetracycline. Changes in the color of
ultraviolet radiation can cause the formation of reddish-purple
oxidation by the product permanently changing the color of
teeth. In children, anterior teeth are often black while posterior
teeth are less exposed so they change color more slowly.
2. Intracanal Drugs
Is one of the main causes of discoloration of the teeth.
Imperfect obturation cleaning and sealer remains in the pulp
chamber, especially those containing metal components, often
result in dark discoloration.
g. Related Restoration
1. Amalgam
Metals have a severe effect on dentin because dark metal
components can turn dentin into dark gray.
2. Composite
Opened margins allow chemicals to enter between the
restoration and tooth structure and blacken the underlying
dentin. In addition, composites can change color over time
affecting the color of the crown.
h. Endemic Fluorosis
Excessive ingestion of fluoride during tooth formation can
produce defects in the mineral structure, especially in the enamel
matrix, causing hypoplasia.
i. Idiopathic
Whitish spots in enamel are unusual and may be idiopathic,
but both in primary and permanent teeth these whitish spots often
represent mild fluorosis.
j. Jaundice
Jaundice can cause hypoplastic enamel, usually on
permanent teeth, but primary teeth can have a green-gray color that
 tends to fade over time (Uce Ayuandyka, Thesis FKG Unhas,
2016).
2) Discoloration Factors
a. Extrinsic Factors of Discoloration
The most common discoloration of teeth is the result of
highly colored drinks or foods. Tobacco produces a yellowish-
brown color to turn black, usually in the cervical part of the teeth
and especially on the lingual surface. Coffee and tea can worsen
the color change to become black with a long consumption time
(Uce Ayuandyka, Thesis FKG Unhas, 2016).
b. Local Factors of Discoloration
Local factors can be caused by bleeding due to trauma,
errors in dental care procedures, decomposition of pulp tissue, the
influence of drugs and paste canals filling the root canal, and the
influence of restoration materials. Color changes that occur on the
inside of the tooth structure during the period of tooth growth and
color changes generally occur in the dentin (Uce Ayuandyka,
Thesis FKG Unhas, 2016).
1. Dental Trauma
When the primary teeth collide, the nerve of the tooth known
as the pulp occurs bleeding into the dentin, so that the crown
becomes dark gray. Stronger trauma can break the
neurovascular bundle that supplies the pulp so that the pulp
becomes necrotic and changes in crown color.
2. Dental Trauma and Tooth Nekrosis
Dental trauma and necrosis are included in the intrinsic
discoloration resulting from deposits of products causing
bleeding into the dentinal tubules after trauma to the pulp or
necrosis. The appearance of this change produces red, yellow,
yellow-brown, brown, gray, or black.
3. Trauma Pre-Eruption
In areas of deciduous tooth trauma, blood can seep or sink into
the developing enamel during the calcification stage. Tooth
discoloration that occurs is white or yellow-brown.
 c. Intrinsic Factors of Discoloration
1. Calcification Metamorphosis
Calcification metamorphosis is seen most often in anterior
teeth, and is a pulmonary trauma response characterized by
rapid deposition of hard tissue in the root canal. During the
odontogenesis process, teeth can change color due to the
quality and quantity of enamel and dentine. After tooth
eruption, discoloration can originate from tooth tissue or pulp
tissue (Uce Ayuandyka, Thesis FKG Unhas, 2016).
3) Enamel Hypoplasia
Enamel hypoplasia or often also called hypoplastic enamel is a
disorder of the enamel that is characterized by incomplete or
incomplete enamel formation. It can occurs in deciduous or permanent
teeth. Clinically a typical feature is that the surface of the tooth is not
smooth, thin, there is a structural deficiency in the form of a pit or
groove on the enamel surface, and on the surface of the tooth
experiences discoloration from white to brown (Ike Siti Indiarti,
Journal of Dentistry UI, Vol.7, Special Edition).
a. Local Factors of Enamel Hypoplasia
Local factors include trauma and apical infection of
deciduous teeth which affect the formation of enamel of permanent
teeth. Trauma that occurs in primary teeth can cause changes in the
location of apex of primary teeth, especially if it occurs in anterior
teeth and will affect the placement of the enamel matrix.
Hypoplasia caused by email and infection is called turner
hypoplasia (Ike Siti Indiarti, Journal of Dentistry UI, Vol.7,
Special Edition).

2.5 ABNORMALITIES OF GROWTH AND DEVELOPMENT DECIDUOUS

TEETH AND PERMANENT TEETH
2.5.1 ABNORMALITIES BASED ON THE AMOUNT OF TEETH
2.5.1.1 ANODONTIA, HYPODONTIA, OLIGODONTIA
Anodontia, hypodontia, and oligodontia are terms that
indicate the degree of missing teeth, but the term hypodontia is more
 often used because it shows every number of missing teeth.
Oligodontia shows the absence of more than six teeth and anodontia
shows the absence of all teeth in the oral cavity (Pertiwi, A. S. P.
2009).
Teeth that are usually absent are the last teeth in each series
(lateral incisors, second premolars and third molars). Clinically, the
most important thing is not the number of teeth lost, but the type of
teeth lost. Loss of central incisors, canines, or first permanent
molars is rare (Pertiwi, A. S. P. 2009).
Multiple missing teeth are often manifestations of a number
of congenital abnormalities, including ectodermal dysplasia (ED),
cleft palate, trisomy 21, William's syndrome, Rieger's syndrome,
and craniosynostosis syndrome (Pertiwi, A. S. P. 2009).
2.5.1.2 SUPERNUMERARY TEETH

Supernumerary teeth or additional teeth is a disorder in

which the number of teeth is more than normal. Supernumerary
teeth problems that can affect normal occlusion because the amount
of the teeth is more than it should, so that the impact on the
occurrence of crowded teeth and oral abnormalities. Crowded teeth
are conditions where there is a difference between the space needed
in the dental arch and the space available in the dental arch (Lubis,
H. F. 2016). 
If the supernumerary teeth erupts outside the arch, normal
occlusion may not be disturbed, but if the eruption in the arch where
the permanent tooth is supposed to erupt it can cause malocclusion,
in the form of central diastema, crowding, rotation, etc.
Supernumerary teeth can be single, multiple, and unilateral or
bilateral eruptions and may be present in one or both jaws (Lubis, H.
F. 2016). 
Crowded teeth occur due to disharmony in the size and
length of the arch. For example, tooth size that is too large, jaw
arches that are too short or the number of teeth is more than normal.
Supernumerary teeth are one of the etiologies of crowded teeth. For
example, the presence of lateral incisor supplemental teeth, can
cause teeth in the maxillary anterior region to burst due to lack of
space with the growth of additional teeth (Lubis, H. F. 2016).
The prevalence of supernumerary teeth in the period of
permanent teeth is from 0.1% to 3.8% and from 0.3% to 0.6% in the
period of deciduous teeth. In permanent teeth, supernumerary teeth
are more common in men than in women with a ratio of 2 : 1. The
most common location for supernumerary teeth is the maxillary
(mesiodens), where 80% of all supernumerary teeth are found in the
maxillary incisors, rarely found in the distomolar regions of the
maxilla, mandibular premolars, maxillary premolars, distomolar
jaws, canines, and mandibular incisors (Lubis, H. F. 2016).
Supernumerary teeth can be classified into (Ria, F. D. 2014) :
1) Supernumerary teeth based on location
a. Mesiodens

Mesiodens are supernumerary teeth that are in the

midline / midline between the central incisors. Mesiodens
can occur single or multiple. Mesiodens are usually found
in a state of eruption in the form of conical (cone) and a
single root and often in a divergent position. Mesiodens can
cause delayed eruption of permanent teeth which will
change occlusion or displacement of neighboring teeth can
cause diastema and can also affect the aesthetics and
formation of dentigerous cysts.
b. Paramolar

Paramolar is a supernumerary teeth usually small

and simple, located palatal to one of the maxillary molars
or most commonly occurs in the interproximal buccal space
with upper second and third molars.
c. Distomolar
Distomolar is the fourth permanent molar which is
supernumerary teeth, which are usually located in the
distolingual third molar.
 d. Parapremolar
Parapremolar is supernumerary teeth in the
premolar area usually in the form of supplemental and most
often occurs in the interproximal buccal space above the
first and second premolars.
e. Lateral

Lateral supernumerary teeth are located in the

central incisor area and are usually located in the palatal
area.
2) Supernumerary teeth based on morphology
a. Conical
Usually peg-shaped supernumerary teeth are often
found between permanent teeth. These teeth develop with
the formation of roots that are earlier or the same as the
formation of permanent incisor roots. Conical
supernumerary teeth more often cause displacement of
adjacent teeth, failure to erupt or have no effect on other
teeth.
b. Tuberculate
Usually this type of tooth has more than one cusp or
tubercle and is often described as barrel-shape. Late root
formation compared with permanent incisors. Tuberculates
often form in pairs and are usually located next to the palate
of the central incisors. These supernumerary teeth often do
not erupt and are associated with tooth eruption failure.
c. Supplemental
It is a duplication of normal teeth and is found at the
end of a tooth structure. Clinically, this type of tooth
resembles normal teeth. Supplemental teeth commonly
found are lateral maxillary incisors, premolars and
permanent molars. Supernumerary teeth which are often
found in the period of deciduous teeth are supplemental and
rarely impacted.
 d. Odontome
Usually associated with odontogenic tumors. But
this is not universally accepted. It is widely accepted that
odontom is a hamartomatous malformation of neoplasms.
This lesion is formed by more than one type of tissue and is
called a composite odontome.

2.5.2
TEETH SIZE
2.5.2.1 MACR
ODON
tIA

Macrodontia is a condition that shows the size of teeth larger

than normal, almost 80% larger (can reach 7.7-9.2 mm).  This situation
is rarely found, often in DD (Differential Diagnosis / Comparative
Diagnosis) with fusion teeth. The teeth that often occur in the upper
incisors.

Pict 10. Macrodontia

2.5.2.2 MICRODONTIA
 Microdontia is a condition that shows the size of teeth smaller
than normal.  The shape of the corona (crown) is like conical or peg
shaped. Often assumpted as additional teeth and often found in the
upper two incisors or third molars.  This small tooth size can cause
diastema.

2.5.3 TEETH SHAPE

2.5.3.1 DOUBLED TEETH
Doubled teeth are the fusion of two developing or partially split
seeds (partial dichotomy or gemination) of the tooth seed, so that there
are two teeth that are united. Because it is difficult to determine
whether teeth are large due to fusion or gemination, the term doubled
teeth is used. Can occur in primary and permanent teeth.
Clinical overview :

Large and abnormal tooth shapes are indicated by the presence

of longitudinal grooves on the crown or the curve of the incisal edge.
The roots can be separated in whole or in part. Malformation of the
upper two incisors often has an abnormal shape and size called a Peg
Shaped. Clinical Overview:
There is a deep curve in the palatal part, the crown is small,
conical and resembles an excess tooth. The curve in the palatal part
sometimes forms so deep and forms a cavity. This cavity is formed due
to invagination of a developing tooth seed, this condition is known as
dens in dens. This area is an area that is susceptible to caries, x-rays
need to be taken to ensure it.

2.5.3.2 DILASERASI
Forms of tooth roots or crowns that have sharp curves (forming
angles / curves) that occur during the formation and development of
tooth calcification stages. Curves / bending can occur along the teeth
 depending on how far the teeth are formed when interference occurs.
Etiology : Suspected to occur due to trauma during tooth formation.

2.6 ERUPTION TEETH ABNORMALITIES

2.6.1 ANKYLOSIS
Tooth ankylosis, the fusion of bone and cementum, is a progressive
anomaly of tooth eruption which usually has a profound effect on the
occlusion. Deciduous teeth become ankylosed far more frequently than do
permanent teeth, the ratio being better than 10 to 1, and lower teeth are
ankylosed more than twice as often as upper teeth. Tooth ankylosis exhibits
selectivity as to site (nearly all ankylosed teeth are molars, deciduous or
permanent) and selectivity as to physiologic time (nearly all ankyloses
occur in the deciduous or mixed dentitions). Tooth ankylosis is not likely to
be of random or accidental origin; nor is excessive or traumatic pressure a
probable cause, although the latter enjoys wide acceptance as a possible
explanation. Tooth ankylosis may be due to a disturbed metabolism.
Ankylosis can trigger the occurrence of (a) loss of arch length, (b)
extrusion of teeth in opposite arches, (c) disruption of the tooth eruption
sequence.

2.6.2 ERUPTION CYST

 Is a variation of a dentigerous cyst that surrounds an erupted tooth. 
This cyst is often seen clinically as a bluish, translucent, elevated,
compressible, asymptomatic, dome-shaped lesion of the alveolar ridge
associated with a permanent tooth eruption or deciduous tooth eruption. 
Eruptive cysts show a smooth swelling covering the erupted teeth, with a
different color from normal gingival. sometimes the pain is not infected,
soft and fluctuating. Cysts can often burst spontaneously during tooth
eruption, but trauma to these cysts can produce bleeding resulting in
discoloration and pain.

Pict. 11 Eruption
Cyst

2.6.3

ERUPTION HEMATOMA
Is a bluish, opaque, asymptomatic lesion covering an erupted
tooth Swelling occurs in relation to the accumulation of blood,
 tissue fluid, which occurs in follicular pockets that expand around
the crown eruption.

Pict 12.
Eruption Hematoma

2.6.4 ECTOPIC ERUPTION

A condition that usually shows when permanent teeth begin to replace
deciduous teeth at around 6 years of age.  Is an abnormal eruption of a
permanent tooth in this case the tooth out of the normal path and causes
abnormal resorption of a deciduous tooth to be replaced.  There are often two
dental lines in the anterior region of the lower jaw. Permanent incisors grow
behind deciduous incisors. Ectopic Eruption may be related to one of three
different processes of developmental disruption, pathological processes, and
iatrogenic activity.  The etiology of ectopic teeth is unknown. Abnormal
tissue interactions during development may potentially result in the
development of teeth with ectopic eruption. The etiology of ectopic eruption
of a first permanent maxillary molars is not clearly understood even though
one or more of the following
conditions may be related to it :
 Pict 13. Ectopic Eruption

a) As a result of the size of permanent first molars and or deciduous

second molars larger than normal.
b) Teeth erupt at an abnormal angle to the occlusal lane.
c) Growth of late tuberosity, resulting in abnormal arch length.
d) Morphology of the distal surface of the crown of the second molar 
decidui and roots provide eruption barriers resulting in abnormalities
of the first molar permanent teeth.  sometimes it is done to ease the
eruption.
Ectopic eruption Self-corrective (Jump-type), 66% of cases of ectopic
eruption of molar teeth can eventually erupt in their proper position without
going through corrective treatment.  Treatment methods can vary based on
clinical examination, depending on the obstacle and space analysis. The
treatment of ectopic eruption of permanent molar teeth aims to free
permanent molar teeth from obstructions and provide eruption guidance for
these teeth.  In some cases, the deciduous second molars were extracted;
permanent molar teeth can erupt and then move distally to the normal
position. Some of the methods used are beass ligatie stainless steel stainless
steel.

2.6.5 ODONTOMA
It is the most common type of odontogenic tumor and is
usually not accompanied by complaints for sufferers. Odontomas
are formed due to abnormal growth of the epithelium and
mesenchymal cells that form ameloblasts and odontoblasts. This
type of tumor basically contains a layer of enamel and dentin, but
can also contain a number of cementum and pulp tissue components.
Odontomas are classified into two groups, namely compound and
complex. Compound odontomas consist of the formation of several
structures resembling small teeth and groups, while complex
odontomas appear as the distribution of enamel and dentin with
anatomical forms that do not resemble teeth. Compound odontomas
are more commonly found than complex odontomas. Odontoma is a
 type of odontogenic tumor that can form anywhere, both in the
maxillary arch and the lower arch. Most odontomas that form in the
anterior region of the maxilla are odontoma compound types,
whereas odontoma complexes are most commonly found in the
posterior region of the lower jaw. On radiographic examination,
odontoma compounds appear as radiopaque images of a group of
structures resembling teeth and surrounded by a narrow radiolucent
zone. While the odontoma complex will appear as a picture of the
period authenticated with radiodensity resembling tooth structure,
and is surrounded by radiolucent ring formations. Odontoma images

often accompany unerupted teeth and usually obstruct the eruption

of these teeth. The characteristics of compound odontomas and
complex odontomas are described in table 1.
Table 1. Characteristics of Odontoma

2.7 DENTOKRANIOFACIAL
Growth is defined as an increase in the physical size of cells, tissue organs,
or organisms as a whole, accompanied by differentiation and form changes. The
 changes occur as a function of time, which includes modification of the physical
size, shape, or position of a structure. Any changes in a section should be
proportionate to the rest of the section. The goal is to maintain and achieve a
overall functional and structural balance through appropriate growth and
adjustment.
The growth of dentokraniofacial is related to the structure and function of
craniofacial complexes. The growth and adaptation of Craniofasial skeletal covers
all aspects of bone biology, neurophysiology, and anthropology. The process of
growing flowers is a complex phenomenon of life. Taking place since the prenatal
from conception to birth continued postwar period in newborns to adulthood.
Dentokraniofacial growth encompasses the growth of occlusion, curved curvature,
as well as the jaw and upper bones. 
The components of the facial vertical dimension are the growth of Macsila
and mandible as well as the development of the Alveolaris Batrachus as a result of
the eruption of the volcanic growth. The face growth factor is influenced by the
following things; Genetic race, gender, age, nutritional status and disease.
Dentokraniofacial growth can be evaluated using a description of a cephalometric.
Other indicators can use somatic, sexual, skeletal and dental maturity. Dentofacial
abnormalities are an imbalance of facial proportions as well as unwell dental
relationships that interfere with facial aesthetics. Such abnormalities may cause
impaired jaw function, dental intercourse and facial aesthetics. Causes of
dentokraniofacial abnormalities can be metabolic disorders and genetic disorders.
Examples of disorders caused by metabolic disorder are acromegali, Caffey
disease, Osteitis deformas, and Hypophosphatasia. Examples of genetic disorders
are Atrophy, hemifacial, hypertrophy, Marfan's syndrome, and so on.

2.8 Factors Causing Delayed Eruption

2.8.1 Delayed eruption that occurs locally
Delay in eruption of permanent teeth locally is a form of eruption
abnormality that only involves one or several teeth. Things that can cause
delays in eruption of permanent teeth locally, include trauma and dental
abnormalities.
 Trauma to primary teeth can cause eruption disorders locally on
permanent teeth. Trauma causes abnormalities that can effect the delay in
tooth eruption. These disorders include (1) ankylosis. Permanent teeth that
are not fully erupted or erupted late may have ankylosis. The cause of
ankylosis is preceded by a trauma or chronic infection which further
irritates the periodontal tissue in the root area. As a result of infection (or
trauma), the periodontal tissue and epithelium around the tooth are
damaged. Then, cementum in the area of the damaged root is deposited and
then fixed in the alveolar bone. In addition to these conditions, ankylosis of
primary teeth caused by delayed root resorption can also cause delayed
eruption of permanent teeth. (2) Dilationation. Dilationation can be
interpreted as a deviation that occurs when the development and growth of
teeth that cause changes in the axial relationship between the crown and
roots. Dilation can be caused by trauma during the process of growth and
development of teeth. In some cases, due to trauma in the form of blows,
deciduous incisors are pushed inward and press the seeds of permanent
incisors that are in the process of growth. The disorder can change the axial
direction of the tooth so that it can inhibit tooth eruption. In addition, it can
also be caused by the continued growth of the root formation while on the
winding eruption road. Although in some cases it is still idiopathic. (3)
concurrency. This condition can occur as a result of trauma to the area of
interseptal bone loss accompanied by crowding. In addition, concretions
can also occur due to the influence of pathological stimuli such as chronic
periapical inflammation. As a result of the cementum casing that is fused, it
can cause both teeth to be retained in the alveolar bone, which can cause
delay in eruption of permanent teeth. Concretions can occur before or after
an erupted tooth, usually occurring in the permanent maxillary permanent
molar. (4) erupted cyst. Clinically, cysts can be proven by the swelling of
the mucosa in the alveolar ridge as a result of the development of fibrotic
tissue resulting in thickening. This situation is believed to be the result of
trauma to the soft tissue as long as the oral cavity carries out its function
(mastication). Changes that appear on the mucosa as a result of fibrotic
tissue that is getting thicker, can result in delayed eruption. (5) Premature
exfoliation of primary teeth. Exfoliation or loss of primary teeth that are too
 early, can be caused by various reasons including trauma, extraction as a
result of caries, or because of the location of the wrong seeds. If primary
teeth undergo early exfoliation before their replacement teeth enter the pre-
eruption stage, it can cause delays in eruption of permanent teeth.

Tooth abnormalities can occur in number, size, and color.

Abnormalities in the number and size can cause delayed eruption of
replacement teeth. Tooth abnormalities in question are (1) supernumerary
teeth that indicate the presence of one or more teeth that exceeds the
number of normal teeth. Supernumerary teeth can be caused by continued
growth of organ enamel seeds or due to excessive cell proliferation.
Supernumerary teeth can be single or multiple, besides that some cases can
erupt but some are impacted. This can prevent the eruption of neighboring
teeth; (2) regional odontodysplasia (ROD) that occurs due to a disruption in
the process of growth and development of teeth. Inadequate formation of
enamel and dentin is accompanied by imperfect calcification of follicles
and pulp. This causes reduced tooth density due to thin enamel and dentin
and pulp space that is too large. This situation can cause teeth to experience
delays or not even eruption; (3) fusion, the shape of which can vary
depending on the stage that is experiencing interference. If the disturbance
starts before the calcification stage, then the fusion covers all the dental
components including enamel, dentin, cementum and pulp. However, if the
new disturbance occurs at the final stage of tooth development, the effect
can be in the form of fusion in the root area without the unification of the
crown. The clinical implication of fusion is that in addition to disrupting
aesthetics, it can also result in crowding so as to prevent the eruption of
neighboring teeth.

2.8.2 Delayed eruption that occurs systemically

Delay in eruption of permanent teeth locally is a form of eruption
abnormality that involves many teeth or even as a whole. Things that can
cause delays in overall eruption of permanent teeth include endocrine
disorders, nutritional disorders and systemic diseases. The endocrine system
is one of the important components for human survival besides the central
nervous system. Some conditions in endocrine disorders associated with
delayed eruption of teeth are hypothyroidism, hypoparathyroidism, and
hypoptituarism.
Hypothyroidism; disorders of the thyroid gland can be divided into
two kinds, namely congenital hypothyroidism (cretinism) and juvenile
hypothyroidism. Congenital hypothyroidism results from a disruption of the
growth of the thyroid gland which causes hereditary thyroid hormone
deficiency. Thyroid hormone is a growth hormone, so that this patient has a
deformity in the form of short arms and legs so that it looks stunted
(cretinism), disproportionate head growth due to its larger size, and is
usually obese. Manifestations in the oral cavity, namely a delay in all stages
including eruption of deciduous teeth, exfoliation of deciduous teeth, and
finally the impact on the delay of eruption of permanent teeth.
Hypoparathyroid; parathyroid is four small glands which are usually
located behind the thyroid gland. The four glands produce parathyroid
hormone (PTH, parathyroid hormone). One of the functions of this
hormone is to maintain the balance of calcium ions in body fluids that work
on bones by stimulating osteoclast resorption. One result if PTH production
is inadequate is a decrease in calcium ions. If the calcium level decreases, it
can interfere with the process of calcification of the teeth so that it can
result in delayed tooth eruption.
Hipoptituarism; the pituitary gland (ptituary) in relation to the
hypothalamus of the brain, plays an important role in controlling the
endocrine system. Reported slowing of bone and soft tissue growth in a
person's body as a manifestation of growth hormone secretion deficiency.
One of the diseases associated with hypoptituarism is ptituary dwarfism,
which can result in delayed tooth eruption as its characteristic. In severe
cases, deciduous teeth do not undergo resorption and it is possible to remain
stuck in the gingiva for the rest of his life. As a result, permanent teeth
underneath still experience growth and development even though they
cannot erupt.

Nutritional disorders as a cause of delays in tooth eruption that

occur as a whole, among others caused by protein deficiency, vitamin D
deficiency, and calcium and phosphorus deficiency. Protein deficiency;
besides carbohydrates, protein is also needed by our body to produce
energy. The presence of protein in the body plays an important role
especially during the developmental stages including the prenatal and
postnatal periods. During tooth growth, protein deficiency, especially in
large amounts can cause smaller molar teeth size, delayed mandibular
development, and marked delay in eruption.

Vitamin D deficiency; vitamin D helps the body in the absorption

and regulation of calcium. Its main function is bone and tooth
mineralization. Vitamin D is very closely related to calcium and
phosphorus. Vitamin D regulates calcium and phosphorus levels in the
blood. In addition, another function of vitamin D which is assisted by
thyroid and parathyroid hormones is to regulate the absorption and supply
of calcium and phosphorus in bones including alveolar bone. Trabeculae in
the alveolar bone become weak due to decreased function of vitamin D
which interacts with osteoblasts (cells forming new bone tissue). Vitamin D
deficiency results in a disruption in bone structure, namely imperfect
calcification due to inadequate absorption of calcium and phosphorus,
thereby causing delays in eruption, both in children and in adults.

Calcium and phosphorus deficiency; calcium and phosphorus

function to store and maintain serum levels in the amount needed. Serum
calcium and phosphorus levels have a reciprocal relationship. The point is
that if the level of calcium increases, the level of phosphorus decreases, and
vice versa. This relationship acts as a protection mechanism to prevent the
high concentration of the combination of the two which can further affect
the calcification of soft tissue and hard tissue formation. When calcium
deficiency occurs, it can affect the amount of calcium contained in the
alveolar bone which in turn affects the process of replacing deciduous teeth
and delays the eruption of permanent teeth. Similarly, when phosphorus
deficiency occurs during tooth development, the calcification process is not
perfect and can have an impact on the eruption delay.

Systemic disease also plays a role in causing a delay in overall tooth

eruption. There are several known diseases.
 Hemifacial hyperthropy and odontomaxillary dysplasia; People with
hemifacial hyperthropy and odontomaxillary dysplasia have manifestations
in the oral cavity in the form of relative generalized macrodontia, which
shows a condition of the upper jaw, lower jaw, or both are smaller while
normal sized teeth, so that the teeth appear larger and cause crammed teeth
both locally and regionally. . Relatively generalized macrodontia can cause
a lack of space in the arch, so that teeth that have an eruption sequence
later, can erupt late, erupt in the wrong place, or even not erupt.

Cleidocranial dysplasia; in patients with cleidocranial dysplasia,

eruption of deciduous teeth is complete at around 15 years of age. This
happens because of the delay in the process of growth and development of
the teeth so that it causes delays in the resorption of deciduous teeth and can
subsequently result in delayed eruption of permanent teeth. Impaired tooth
eruption associated with skeletal pathology accompanied by late
differentiation of osteoblasts, osteoclasts, and odontoblasts, and the
formation of supernumerary teeth. Although there are no supernumerary
teeth, replacement of deciduous teeth and eruption of permanent teeth can
also experience eruption delays.

Down's syndrome; Trisomy 21 syndrome (Down syndrome [DS]) is

one of the most common congenital abnormalities and is well known
among the general public. Diagnosis of DS in children is not too difficult
due to the typical face shape in this patient. Chromosome abnormalities
manifest in complex developmental abnormalities of the body. These
chromosomal abnormalities usually occur when the fetus is still in the
womb during the embryonic development process, during the initial stages
of cell division. Disturbances at this stage can affect the process of growth
and development of teeth which are also inhibited, so that it can cause
delays in eruption in both primary and permanent teeth. In addition, as a
result of growth disorders in the upper jaw and lower jaw so that the shape
of the small jaw can contribute in the form of crammed teeth and can also
inhibit tooth eruption.
 Achondroplastic dwarfism; is a type of syndrome whose etiology is
not known with certainty, but clearly there is interference with autosomal
cells and rarely caused by spontaneous mutations. Manifestations in the oral
cavity in the form of a small upper jaw, which results in crowding and there
is a tendency for open bite. In addition, tooth growth is also experiencing
delays which can have an impact on the delay in eruption of permanent
teeth.

Tricho-Dento-Osseus-Syndrome (TDO); TDO sufferers have the

characteristics of a disturbance that occurs in the process of the
development of hair, teeth, and bones. Patients have normal body height,
but bone remodeling disorders occur due to decreased osteoclast activity.
This causes delays in eruption in both primary and permanent teeth.

Pycnodisostosis; characteristics of patients with pycnodisostosis are

short body caused by limb development which is also not perfect as a result
of the process of osteoporosis with increasing bone fragility. This also
applies to the jawbone, which when accompanied by crowding can cause
delay in eruption of deciduous and permanent teeth.

Ptituitary gigantism; true generalized macrodontia is a manifestation

of the oral cavity of patients with pituitary gigantism. Makrodonsia is a
term used to indicate one or several teeth that have a size larger than
normal. In this patient, all teeth have a size larger than normal in both the
upper and lower jaw. True generalized macrodontia can cause a lack of
space in the arch, so that teeth that have an eruption sequence later, can
erupt late, erupt in the wrong place, or even not erupt.