ORIGINAL ARTICLE

Tooth anomalies associated with failure of eruption of first and

second permanent molars

T. Baccetti, DDS, PhDa

Florence, Italy

The occurrence of tooth anomalies in association with failure of the first and second molars to erupt was
assessed in a sample of 1520 nonsyndromic subjects with uncrowded dental arches (mean age, 14 years 4
months) and compared with the prevalence rate calculated in a matched control group of 1000 subjects. The
tooth anomalies examined included infraocclusion of deciduous molars, palatal displacement of maxillary
canines, rotation of maxillary lateral incisors, aplasia of second premolars, and small size of maxillary lateral
incisors. Associations among arrested eruption of first and second permanent molars and anomalies in tooth
eruption and position (infraoccluded deciduous molars, palatally displaced canines, rotated maxillary lateral
incisors) were highly significant (P < .001). No significant association was found among the occurrence of molar
eruption disturbances, aplasia of premolars, and small-sized laterals. These findings point to a common biologic
cause for the appearance of failure of eruption of molar teeth and other disturbances in tooth eruption and posi-
tion, most likely under genetic influence. (Am J Orthod Dentofacial Orthop 2000;118:608-10)

F ailure of eruption of the first and second permanent

molars is not frequent. The prevalence of the anom-
aly in a normal population is about 0.06%.1 Despite the
low prevalence, arrested eruption of posterior teeth
entails a considerable clinical significance. Failure of
eruption of first or second permanent molars has been
documented as a cause of severe posterior open bite.2
Treatment planning can be complicated by the presence
of altered habits in tongue posture and function that
worsen the clinical situation.
Molar impaction is generally the consequence of
mechanical obstacles to tooth eruption, such as supernu-
meraries, odontomas, and cystic formations. A frequent
type of failure of eruption of the first molars is due to
mesial eruption of these teeth, with subsequent reversible
or irreversible impaction into the distal portion of adjacent
second deciduous molars.3 Heredity has been advocated
as a possible feature of impaction of molar teeth, thus sug-
gesting a genetic origin of the anomaly.4,5
From a clinical point of view, the genetic compo-
nent in the cause of an observed tooth disturbance can
be efficiently investigated by evaluating associated
dental anomalies. The hypothesis of a common genetic
background is confirmed when an increased prevalence
of associated tooth anomalies is found in subjects who
are selected for 1 anomaly when compared with the
prevalence recorded in the general population or in an
aPostdoctoral Fellow, Department of Orthodontics, The University of Florence, Italy.
Reprint requests to: Tiziano Baccetti, Via E. Pistelli, 11, 50135 Firenze, Italia;
e-mail, condax@tin.it.
Submitted, September 1998; revised and accepted, February 1999.
Copyright © 2000 by the American Association of Orthodontists.
0889-5406/2000/$12.00 + 0 8/1/97938
doi:10.1067/mod2000.97938
608
adequate control group. A genetic basis for various
types of tooth anomalies (palatally displaced canines,
enamel hypoplasia, tooth aplasia, tooth rotation, small-
sized lateral incisors, infraocclusion of deciduous
molars, maxillary canine-first premolar transposition)
has been demonstrated with this investigative tool.6-10
The aim of the present study was to assess the
prevalence of clinical associations between failure of
eruption of first or second permanent molars and other
types of dental anomalies in order to point to the addi-
tive genetic component that leads to the phenotypic
expression of arrested molar eruption.
MATERIAL AND METHODS
The initial analyzed sample included 3600 orthodon-
tically untreated subjects from the files of the Department
of Orthodontics of the University of Florence. A group of
1080 subjects was excluded from the initial sample
because of the presence of one or more of the following
characteristics: cleft lip and/or palate or craniofacial mal-
formations, sequelae of traumatic injuries on the denti-
tion, familial relationships with other examined subjects,
crowding of the dental arches, nonwhite race.
The remaining sample of 2520 subjects (1223
males, 1297 females; age range, 12-16 years; mean
age, 14 years and 2 months) was randomly divided into
two groups: (1) experimental group (1520 subjects, 698
males, 822 females, mean age, 14 years 4 months); and
(2) control group (1000 subjects, 478 males, 522
females; mean age, 14 years 1 month).
Experimental and control groups were therefore
matched as to origin, age, and gender distribution. Most
of the subjects in both groups were of Italian ancestry.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 118, Number 6
Table I. Prevalence
rates of tooth anomalies associated with failure of eruption of first and second permanent molars
compared with reference values
Group with failure of eruption of first
and second permanent molars (n = 26)
Tooth anomaly Ratio
Infraocclusion of deciduous molars 10/26
Palatal displacement of maxillary canines 8/26
Rotation of maxillary lateral incisors 6/26
Aplasia of second premolars 4/26
Small size of maxillary lateral incisors 1/26
NS, Not significant.
In the experimental group, 26 subjects were found
with a failure of eruption of first and second permanent
molars (prevalence rate of 1.7%). Failure of tooth erup-
tion was defined as complete retention of the tooth in the
alveolar bone under the oral mucosa. The diagnosis was
made on the basis of both clinical inspection of the den-
tal casts and radiographic examination. Failure of molar
eruption was diagnosed in the presence of fully erupted
homologous teeth on the dental arches and in the absence
of any discernible cause of tooth impaction. Subjects
with failure of molar eruption because of mechanical
obstacles to eruption were therefore not considered. Fol-
low-up radiographs were also examined to confirm
arrested eruption of the molar teeth. Second permanent
molars failed to erupt in 16 subjects, and eruption of first
permanent molars was arrested in 10. Molar eruption dis-
turbances were located at the upper arch in 12 subjects
and at the lower arch in 14. Four subjects presented with
bilateral failure of eruption of permanent second molars.
Male-to-female ratio was M1:F2.25.
The following dental anomalies were assessed both
by clinical inspection and radiographically in the group
of 26 subjects with failure of first and second molar
eruption: infraocclusion of deciduous molars, palatal
displacement of maxillary permanent canines, rotation
of maxillary permanent lateral incisors, aplasia of sec-
ond premolars, and the small size of maxillary perma-
nent lateral incisors. The definitions of these tooth
anomalies were given in previous articles.9,10
The reference prevalence rates for these dental anom-
alies were calculated in the control group. (Fourteen indi-
viduals with failure of first and second molar eruption
were present in control group, with a prevalence rate of
1.4%). The assessment of all dental anomalies was per-
formed twice with an interval period of 3 months. Repro-
ducibility of assessment ranged from 97% to 100%.
The prevalence rates of the dental anomalies in asso-
ciation with failure of eruption of first and second molars
were compared to the reference prevalence rates in the
control group by means of χ2 tests.
Baccetti 609
Prevalence rate
reference value
Prevalence rate (%) (control group) (%) χ2 P
38.46 4.9 46.65 .000
30.76 4.8 28.27 .000
23.07 4.4 15.25 .000
15.38 6.2 NS NS
3.84 4.1 NS NS
RESULTS
The prevalence rates of tooth anomalies associated with
unerupted first and second permanent molars are shown in
Table I, with the prevalence rates of the tooth anomalies in
the control group and the results of χ2 tests.
Infraocclusion of deciduous molars, palatally dis-
placed maxillary canines, and rotation of maxillary lat-
eral incisors showed a significantly higher prevalence
rate (P < .001) in the subjects with concomitant failure
of eruption of molar teeth than in the control group. No
significant association was found for aplasia of second
premolars and small-sized maxillary lateral incisors.
Nine of the 26 subjects with molar impaction did not
show any associated tooth anomaly. Eight subjects had
molar impaction concomitant with a single associated
tooth anomaly, 6 subjects had 2 associated tooth anom-
alies, and 3 subjects had 3 associated tooth anomalies.
DISCUSSION
The present study provides evidence that several
different types of dental anomalies can be significantly
associated with the failure of eruption of first and sec-
ond permanent molars. This entails that a common
cause, most likely a shared genetic background, under-
lies the onset of the eruption disturbance.
The association that presents with the highest preva-
lence rate is the concomitance of arrested molar eruption
with infraocclusion of deciduous molars (Fig 1). In 2 of the
examined subjects, infraocclusion of deciduous molars
was so severe that the affected teeth were in a completely
intraosseous position. An interesting suggestion deriving
from these data is that the etiologic anomaly shared by the
2 tooth abnormalities may be connected with some distur-
bance in alveolar bone or periodontal ligament metabo-
lism. It is known that the biologic interactions between
alveolar bone and periodontium are fundamental to tooth
eruption11 and that these interactions are frequently altered
in infraoccluded deciduous molars, leading to tooth anky-
losis.12 Submerged and apparently ankylosed deciduous
molars have been described in the vicinity of a nonerupt-
610 Baccetti
Fig 1. Radiograph of 13-year-old male shows failure of
eruption of (a) 2.6 associated with infraocclusion of (b)
8.5 and rotation of (c) 1.2 (confirmed on dental casts).
ing permanent molar.2 Noteworthy enough, Humerfelt and
Reitan13 and Israel14 reported the arrested eruption of pos-
terior permanent teeth featuring reduction of the periodon-
tal ligamental space and ankylosis in 2 families, with evi-
dence of an autosomal dominant mode of inheritance.
Another tooth disturbance that appears to be signifi-
cantly associated with failure of eruption of posterior teeth
is the palatal displacement of maxillary permanent canines.
The higher prevalence rate of dental anomalies in number,
shape, size, structure, and eruption in subjects with
palatally displaced canines than in reference populations
has been extensively documented in the past, pointing to
the genetic origin of the canine displacement.6,8,9 The
results of this study provide further support to these claims.
As 6 of 8 subjects with palatally displaced canines pre-
sented with arrested eruption of the first permanent molars,
the association between the 2 eruption disturbances may
become evident in the early phases of the transition to the
permanent dentition. Failure of first molar eruption can be
therefore included among those dental anomalies repre-
senting early indicators of the risk of canine displacement.9
Arrested eruption of the first and second molars
also showed a significant association with rotation of
maxillary lateral incisors in the examined sample (Fig
1). It has been recently demonstrated that a significant
increase in the occurrence of tooth rotation has to be
expected in subjects with congenitally missing teeth.10
The findings of this study expand the spectrum of tooth
anomalies possibly associated with rotation of maxil-
lary lateral incisors by taking into account eruption dis-
turbances of first and second molars.
Though anomalies in tooth number and size have
been found in association with several other types of
dental anomalies, including ectopic eruption of first
molars leading to secondary molar impaction, the
prevalence rates for aplasia of second premolars and
for small-sized lateral incisors were not significantly
increased in subjects with failure of molar eruption.
American Journal of Orthodontics and Dentofacial Orthopedics
December 2000
The gender ratio for arrested eruption of first and
second molars (male-to-female prevalence rate ratio of
M1:F2.25) compares favorably with those recorded for
other anomalies in tooth eruption. For instance, gender
ratios range from M1:F1.3 to M1:F3.2 in subjects with
palatally displaced canines.15 These data suggest a pos-
sible involvement of sexual chromosomes in the cause
of tooth eruption disturbances.
CONCLUSIONS
The findings of the present study reveal a possible
additive genetic effect in the phenotypic expression of fail-
ure of first and second molar eruption, which appears to be
a covariant in the pattern of associations among different
anomalies in tooth position and eruption. Further studies
are needed to elucidate the differential contribution of
genetic components and environmental factors (such as
functional influence provided by the tongue and the
cheeks) in the cause of arrested posterior teeth eruption.
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