Primary Failure Of Eruption

Outline
• Tooth eruption
• Normal eruption process
• Types of failure of eruption
• Causes of eruption failure
• Primary failure of eruption (PFE) – definition, cause
• Clinical features of PFE
• Management of PFE
Tooth Eruption
Axial movement of tooth from developmental position in bone to
functional position in occlusion

Phases of Tooth Eruption:

1. Pre-Eruptive Stage: Movement of teeth within the bone from

early initiation of crown formation to crown completion

2. Eruptive Stage: Movement of teeth from its position in bone to

its functional position in occlusion

3. Post-Eruptive stage: Movement to maintain position of tooth in

function while the vertical growth of jaws continue
Theories of Tooth Eruption

1. Pulp theory

2. Vascular theory

3. Root elongation theory

4. Alveolar bone growth theory

5. Periodontal ligament theory

6. Genetic theory

7. Dental follicular theory

Biology of Tooth Eruption
 Biology of Tooth Eruption

Stellate cells in Induces EGF,

upper part of Secretes PTHrP EGF-R, CSF-1,
dental follicle RANK-L, PTHR1

Differentiates
Bone resorption osteoclasts from
at occlusal end mononuclear
cells
 Biology of Tooth Eruption

Apical part of Expression of

Stimulates
dental follicle genes Cbfa-1
osteogenesis
and BMP

Translocates
tooth germ
Tooth erupts
through eruption
pathway
Etiology of Eruption Failure
Local Factors (Tooth impaction):

a) Mucosal barrier

b) Supernumerary teeth / cysts

c) Arch length deficiency

d) Trauma to primary dentition

e) Radiation

f) CLP

g) Macroglossia
Etiology of Eruption Failure
Other Factors (Tooth Retention):

a) Genetic Disorders:

Cleidocranial dysplasia Cbfa-1/RUNX-2 gene

Osteoporosis

Osteopetrosis TRAF-6 gene

Gardner syndrome APC gene

Osteoglophonic dysplasia FgFR1-3 gene

b) Endocrinal Disorders:

Hypothyroidism

Hypopituitarism

Hypoparathyroidism
Etiology of Eruption Failure

Other Factors (Tooth Retention):

c) Others:

Vitamin D deficiency

Coeliac diseases

d) Idiopathic:

Primary failure of eruption

Primary Failure of Tooth
Eruption
Primary Failure of Tooth Eruption
(PFE)

• Eruption failure of permanent teeth in absence of mechanical

obstruction / syndrome

• Mutation in PTH1R gene

• Estimated prevalence of 0.6%

• Male to female ratio 1:2.25

• Autosomal dominant disorder with high familial occurrence

 Pathogenesis of PFE

Vitamin/mineral
metabolism

Balances bone
Molecular
resorption /
transport
bone formation

VDR/RXR Maintains No.,

quality, function
Cell signaling activation of osteoblast &
pathway osteoclast
Classification of PFE

Primary retention
Based on
eruption defect
Secondary
retention

Type I
Based on
clinical feature
Type II
 Classification of PFE

PRIMARY RETENTION SECONDARY RETENTION

Arrested eruption before tooth penetrates Cessation eruption after tooth emerges
1
oral mucosa in oral cavity
No physical barrier or ectopic tooth
2 No local or systemic involvement
position

3 Equal male to female ratio More in females

4 Prevalent in maxilla Prevalent in mandible

Dentitions with normal / abnormal Dentition with normal development of
5 development of 2nd molar, with / without 2nd molar, without generalized
malocclusion malocclusion

6 Bilateral occurrence = genetic cause Bilateral occurrence = genetic cause

7 Unilateral occurrence = viral infection Unilateral occurrence = viral infection

 Classification of PFE

TYPE I TYPE II

1 Undifferentiated Differentiated

All affected teeth display similar lack of Teeth distal to the first affected tooth
2
eruption potential have more eruptive potential

Progressive open bite from anterior to Progressive open bite from anterior to
3
posterior posterior but of less severity

Varied expression of eruption failures

4 All quadrants equally affected
in quadrants
 Posterior teeth more affected, specially 1st & 2nd molars

Anterior tooth has eruption disturbance, posterior tooth will be

Features of PFE

affected too

Bone resorbs, but tooth erupts partly or incomplete

Primary & secondary dentition affected

Asymmetrical / unilateral

Ankylosed after applying orthodontic forces

 Infraocclusion of affected teeth
Features of PFE

Vertical facial growth might be affected

Posterior open bite malocclusion

Two or more quadrants involved

Characteristic “resorption chimneys” seen on X-rays

Associated with hypodontia / single tooth ankylosis

Ankylosis

• Fusion of cementum to alveolar bone

• Absence of PDL space on radiographs

• Absence of physiological mobility

• Sharp solid sound on tooth percussion

• Clinical appearance of infra-occlusion

 D/D of Ankylosis & PFE
PFE
• Positive family history
• Mutation of PTH1R gene
• Multiple teeth affected
• More than 1 quadrant affected
• Normal PDL space
• Adjacent unerupted teeth don’t
respond to orthodontic forces
ANKYLOSIS
• No family history
• No genetic etiology
• 1-2 teeth affected
• Only 1 quadrant affected
• Absence of PDL space
• Only affected tooth will not
respond to orthodontic forces
Management of PFE
Management of PFE in children:

1. Ensure proper development of stomatognathic system

2. Regain chewing function as early as possible

3. Absence of posterior teeth, patient bites from anterior teeth,

increased attrition, further loss of OVD = restore OVD

4. Removable, tissue supported prosthesis to maintain OVD

5. Give psychosocial boost to such children

6. Replace prosthesis every few months to avoid growth restriction

7. Shift to fixed prosthesis when growth ceases

Management of PFE

Management of PFE in Adults:

1. Do not treat if less severe

2. Provide crowns for partially erupted teeth close to the occlusal plane

3. Avoid continuous arch wire mechanics

4. Attempt extrusion of affected teeth from implants in opposite arch

5. If surrounding bone atrophy, give gingival borne removable prosthesis

6. Tooth extraction followed by bone grafting and implants

7. Segmental osteotomies

8. Distraction osteogenesis of the involved segment

Case Reports on Primary Failure
of Eruption
Case Report 1
Case Report 2 (Type I PFE)
Case Report 3 (Type II PFE)
Case Report 4
(Continous Archwire Mechanics)

PFE of left first molar (Before Treatment)

Intrusion of adjacent teeth (After Treatment)

Case Report 5
Posterior open bite due to PFE

Segmental
Osteotomy
with Elastic
Traction
Conclusion

Primary failure of eruption is a rare disorder requiring specific

management at both the diagnostic and therapeutic levels. Accurate
diagnosis is paramount for adequate PFE treatment, since
conventional methods supporting the eruption of embedded teeth are
ultimately futile or even detrimental for initial occlusion. In such cases,
the only reasonable decision is the abandonment of ineffective
orthodontic therapy and a search for an alternate solution
Conclusion