Griffith University Oral Biology 2 1009DOH

Eruption, Shedding and Maxillary Sinus

Dr. Mahmoud Bakr Lecturer in General Dental Practice B.D.S, M.D.S (Cairo University), ADC (Australia) Member of the Australian Dental Association (ADA), the Australian Biology Institute Inc. (ABI) and the Egyptian Dental Union (EDU)

Learning objectives:
After completing this lecture you should be able to: 1- Demonstrate understanding of the processes of tooth eruption and shedding and abnormalities that might be associated with them.

2- Name, classify, identify and describe the structure and function of the components of Maxillary Sinus.

3- By observing the histological details of cells and tissues, you should be able to use a microscope to identify different histological structures of Enamel and understand the histological processes involved in preparing slides.

All Microscopic images and x-rays are taken from the Digital Library of the Oral Biology Department (Cairo University).

Tooth Eruption:
Traditionally considered to be a developmental process whereby the tooth moves in an axial direction from its location within the alveolar crypt of the jaw into a functional position in the oral cavity and continues throughout life.

TERMINOLOGY OF ERUPTION

ACTIVE ERUPTION: It is the actual movement of the tooth from its developmental site to its position in the dental arch. PASSIVE ERUPTION: Does not involve tooth movement but occurs due to apical recession of gingival tissue exposing more tooth structure into the oral cavity. ANATOMICAL CROWN: It is part of the tooth which is covered by enamel. CLINICAL CROWN: is the part of the tooth which is seen in the oral cavity.

Histological phases of eruption:

1) Pre-eruptive phase:

It starts at the beginning of tooth development (early bell stage) and ends when the crown formation is completed (beginning of root formation). It is characterized by:

a) Growth of tooth germ i.e. dental (enamel) organ, dental papilla and dental sac. b) Formation of bony crypt. c) Movement of developing tooth within the growing jaw. Different types of movement occurs: bodily, axial, rotational and eccentric( i.e. shifting the long axis of the developing tooth). This eccentric movement is associated with differential grow.

THE PRE-ERUPTIVE PHASE

In the beginning of this phase the tooth germ of both deciduous and permanent are present in the same bony crypt. Later on each tooth germ is located in a separate bony crypt. In the anterior teeth region the permanent successors are located lingual to the deciduous roots. This will lead to crowding in this area, that is corrected by the increase of the ridge height, length and width .This adjustment is carried by two types of movement.

Movements in the pre-eruptive stage:

1-Bodily movement: There will be bone resorption in the surface toward which tooth moves. While bone deposition occurs on the crypt wall behind it. 2-Eccentric growth: It means that one part of the developing tooth germ remains stationary and the remainder continues to grow leading to shift in its center.

Shedding of Primary Teeth

~2 Years of Age

2) Prefunctional ( Eruptive) phase:

It starts at the beginning of root formation and ends when the tooth reaches occlusion. It is characterized by: a) Formation of the root. b) Bone apposition especially at the fundus of the crypt. c) Initial organization of periodontal ligament. d) Rapid active eruption.

Tooth eruption
ultra-low power section of developing jaw

1 4
4 3

3 2 3 2

1 mm

Key: 1 = milk teeth; 2 = developing adult teeth; 3 = jaw bone; 4 = gum

Tooth eruption

Osteoclasts erode jaw bone to make way for erupting adult tooth

ERUPTIVE PHASE.
Pattern of tooth movement: A- Axial occlusal: in the direction of the long axis .It is the principal one. B-Bodily movement: in distal, mesial, lingual or buccal direction. C-Tilting or tipping movement: around the transverse axis as in case of molars. D- Rotating: around long axisas in case of lower central incisors or canine.

ERUPTIVE PHASE:

Root completion continues for a considerable time after the teeth have been in function.( 1-1.5 y ) for deciduous while in permanent teeth from( 2-3 years). Upper molars occlusal surface face downwards and distally. Lower molars occlusal surface inclined mesially and uppwards. Clinically, tooth eruption may be accompanied by discomfort or pain, irritability and/ or a slight temperature increase. There is also increased salivation but no bleeding.

4 Years of Age

~5 Years of Age

7 Years of Age

9 Years of Age

ERUPTION PATH:
GUBERNACULAR CORD AND CANAL: The fibrocellular follicle surrounding the permanent tooth retains its connection with the lamina propria of the oral mucous membrane by means of a stand of fibrous tissue containing remnants of the dental lamina, known as the GUBERNACULAR CORD. It is contained in a bony canal known as GUBERNACULAR CANAL. In the anterior teeth ,these canals are seen in the lingual plate of bone ,while in premolars the canals are present in the corresponding deciduous molars.

At a given time, bone resorption by osteoclasts will occur in this GUBRNACULAR CANAL even if the tooth is stationary. Consequently, formation of the tooth eruption pathway is a localized, genetically programmed event that does not require pressure from the erupting tooth. During the intraosseous phase, the rate averages 1-10 um per day, it increases to about 75 um per day once the tooth escapes from its bony cell . When erupting tooth is subjected to environmental factors that help determine its final position in the dental arch. Muscle forces from the tongue, and lips on the tooth, as do the forces of contact of the erupting tooth with other erupting teeth. The childhood habit of thumb-sucking is an obvious example of environmental determination of tooth position.

3) Functional ( Posteruptive ) phase:

It starts when the erupting tooth reaches occlusion with its antagonists and lasts throughout the life of the tooth. It is characterized by:

a) Occlusal active eruption (more cementum and alveolar bone apposition). b) Occlusomesial physiological drift ( alveolar bone remodeling ). c) Organization of periodontal ligament principal fibers

POST ERUPTIVE PHASE

These movements continue throughout the life span of the tooth and could be divided into three categories: 1- Movements made to accommodate the growing jaws. 2- Those made to compensate for continued occlusal wear and 3-Those made to accommodate interproximal wear.

Accommodation for growth Movements.

Completed at the end of the second decade when the jaw growth cease. Achieved by the formation of new bone at the alveolar crest and at the socket floor to keep pace with the increasing height of the jaws. This readjustment occurs between 14-18y. The apices of the teeth move 2-3 mm away from the inferior dental canal .This movement occurs earlier in girls than in boys.

Compensation for Occlusal wear:

These axial posteruptive movements are made when apices of the lower permanent molars are formed fully. Compensation for occlusal wear often is stated to be achieved by continuous cementum deposition around the apex of the tooth, however , deposition of cementum in this location occurs only after the tooth has moved.

Accommodation for Interproximal wear.

It is compensated for by a process known as MESIAL DRIFT. The forces causing mesial drift are multifactorial and include an anterior component of occlusal force, contraction of the transseptal ligament between teeth, and soft tissue pressure.

In order to be clinically valid, a theory of tooth eruption must accommodate the following observations about the eruptive process: (1) teeth are moved in three dimensions of space, (2) teeth arrive at a functional position that is heritable, and (3) teeth erupt at varying, characteristic stage-specific speeds.

-Mechanism(s) of Tooth Eruption:

The nature of the intrinsic forces involved in active tooth eruption is not fully understood. Available experimental evidence seems to support factors related to tissue tension theories. Experiments where an erupting tooth is wired to the lower border of the mandible show that in spite of immobilizing the tooth, an eruptive path is formed by resorption of the overlying bone. However, if the dental follicle associated with an erupting tooth is removed, no such pathway in bone is formed. This finding coupled with the fact that human teeth erupt according to a specific chronology imply the presence of a programmed mechanism that leads to tooth eruption. Such mechanism is probably a multifactorial one that includes control by specific gene(s), hormones as well as several growth factors.

Tissue tension theories:

Role of dental follicle, periodontal ligament and contraction of periodontal fibroblasts: Experimental evidence points out the existence of factors other than pressure by the erupting tooth that leads to bone resorption . Such factors either reside and/or act on components of the dental follicle.
In addition to the essential roles of the dental follicle and one of its derivatives, namely the periodontal ligament, the contractile potential of the fibroblasts was proposed as a contributing factor. In an in vitro experimental model, fibroblasts were cultured in a cylindrical well lined by a perforated mesh simulating the bony wall of a crypt.

The well was filled with a collagen gel which contained a slice of radicular dentin. The fibroblasts were able to organize into a three dimensional network that was attached to both the dentin slice and the mesh lining the well. Further, a force was generated that caused the movement of the radicular dentin slice from the bottom of the well to its surface. Significantly, when chemicals were used to disrupt the cytoskeleton of the fibroblasts, the movement of the dentin slice was significantly inhibited. It should be emphasized that no such action was demonstrated in vivo. The movement is probably caused by contractile elements in fibroblasts such as specialized junctions between fibroblasts, fibronexal connections between fibroblasts and collagenous fiber bundles ( a fibronexus is a specialized structure involving attachment between cytoplasmic filaments, fibroblast plasma membrane and extracellular matrix elements including fibers).

Fibronexus:
It is a term used to describe the relationship between fibroblasts and external environment. 1- There is a direct cell to cell connection between adjacent Fibroblasts along PDL. 2- Presence of contractile elements in each Fibroblast was demonstrated. 3- Fibroblasts are connected to the external environment via Tonofilaments and a sticky glycoprotein called FIBRONECTIN. 4- If a wave of contraction is initiated on one side of the PDL it will be transmitted to the other side and external environment (Bone and Cementum) via Fibronexus,

Other theories proposed but proven wrong or lacking any supporting evidence include: 1- Root growth ( increase in root length ):

Root growth seems to generate a force but it does not cause eruptive tooth movement. Teeth without roots erupt, also some human teeth during eruption move a greater distance than the length of their fully formed roots. Further, teeth continue to erupt after root formation is completed and when root forming tissues were surgically removed in experimental animals, those teeth continued to erupt. 2- Dentin growth and pulpal constriction:
This theory was based on the assumption that since the developing roots taper towards their apical ends and thus this constriction may compress the pulpal tissues in the area generating force that may propel the tooth occlusally. This assumption ignore the fact that the pulpal tissue in the wide apical area of an erupting tooth is not in a static condition but undergoes remodeling coordinated with apposition of radicular dentin. 3- Bone growth: Studies using bone markers clearly showed that bone apposition at the bottom of the bony crypt housing an erupting tooth is a result of the occlusal movement of the tooth not a cause for eruption.

 In

conclusion, it appears that there is no single cause of tooth eruption. Experimental evidence clearly suggest that the dental follicle is an important element in tooth eruption. Study--and debate continue.

Clinical considerations

Disturbances in tooth eruption:

Disturbances in tooth eruption are most commonly attributed to mechanical interferences caused by supernumerary teeth, crowding, and soft-tissue impaction as well as by odontogenic tumors and cysts. For example: Ankylosis typically occurs after partial eruption of the tooth into the oral cavity and is defined as fusion of cementum or dentin to alveolar bone due to cellular changes in the periodontal ligament caused by trauma and other pathologies. When the tooth becomes ankylosed, it appears to submerge in relation to adjacent teeth that continue to erupt.

Eruption Problems
Impaction
Ankylosis Misdirected Teeth (Ectoped eruption) Eruption Haematoma Eruption Cyst

Impaction is defined as a cessation of eruption of a tooth caused by a clinically or radiographically detectable physical barrier in the eruption path or by an ectopic position of the tooth. Primary retention (unerupted and embedded teeth) is defined as a cessation of eruption before gingival emergence without a recognizable physical barrier in the eruption path or ectopic eruption. Secondary retention is termed as cessation of eruption after emergence, without evidence of a physical barrier either in the eruption path or as a result of an abnormal position.

Ankylosis is caused by the fusion of the cementum of the root to the bone and accompanying loss of periodontal ligament attachment. Prevalence is between 7-14% in the primary dentition. The most commonly affected teeth are mandibular primary first molar, mandibular primary second molar, maxillary first molar and maxillary primary second molar in that order

Ankylosis can lead to: Loss of arch length Extrusion of teeth of the opposite arch Interference with the eruption of succedaneous teeth

Ankylosed third molar. Ankylosis is the union of cementum to the surrounding bone without the intervening periodontal ligament space.

Ankylosis typically occurs after partial eruption of the tooth into the oral cavity and is defined as fusion of cementum or dentin to alveolar bone due to cellular changes in the periodontal ligament caused by trauma and other pathologies. When the tooth becomes ankylosed, it appears to submerge in relation to adjacent teeth that continue to erupt, therefore ankylosed teeth are also known as Submerged teeth.

Histologically:

Ankylosis appears as a series of Howships lacunae filled with newly formed bone.
That is explained by the fact that Ankylosis ocurrs a result of PDL injury (Trauma or Infection) which results in bone resorption and osteoclastic activity.

What type of incremental lines would you expect to see around an ankylosed tooth?

Submerged deciduous second molar undergoing resorption of the crown. A submerged tooth is a retained deciduous tooth with its occlusal surface at a lower level than the adjoining permanent teeth. Mesial to the submerged molar is an impacted second premolar in the transverse position.

Ectopic eruption:
Diverse oral anatomical locations can infrequently be the site of an ectopic tooth eruption. 3 Such locations include the nasal cavity, chin, mandibular condyle, coronoid process, and palate. One of the sites for an ectopic tooth in a nondental location is the maxillary sinus. Impaction of a tooth in the maxillary sinus can be asymptomatic. Such teeth are often discovered serendipitously on radiographs of the skull or teeth.

Slide 9 of 75

Eruption Hematoma is a bluish, opaque, asymptomatic lesion

which overlays an erupting tooth. The swelling is due to the accumulation of blood, tissue fluid, or both in the dilated follicular sac around the erupting crown. It can be differentiated from an eruption cyst by transillumination. Treatment is not indicated, although incision is sometimes performed to facilitate eruption

Eruption Cyst is a bluish, translucent, elevated, compressible, asymptomatic, dome-shaped lesion of the alveolar ridge associated with an erupting primary or permanent tooth. If left untreated, the cyst will spontaneously rupture. The cyst may be marsupialized or punctured to facilitate eruption.

Sequence of Eruption
For Deciduous teeth: A-B-D-C-E For Permanent teeth: 6-1-2-4-5-3-7 (mostly in upper teeth) Or 6-1-2-4-5-7-3 (mostly in lower teeth).

Shedding

Definition: Shedding is a natural physiological elimination of the deciduous teeth as a result of the resorbtion of their roots prior to the eruption of their permanent successors. Contributing factors: 1- Increased masticatory forces. 2- Weakened supporting structures e. g. loss of cementum, alveolar bone and periodontal attachment. 3- Pressure due to erupting successor.

Pattern:
Resorption of the roots of primary teeth starts at the lingual apical areas in the anterior teeth and in the interradicular areas of molars. It is related to where the erupting permanent successors are located.

Histological

features of teeth shedding:

undergoing

Root surfaces exhibit resorption lacunae and clast cells are often associated with these concavities. It is significant that periodontal fibroblasts in the area show signs of impaired function. The fact that programmed cell death is seen during shedding that occurs at specific ages is consistent with the concept that shedding is a genetically determined process. It should be emphasized that the pulp tissue in teeth undergoing shedding appears histologically normal except that neural elements seem to be missing. Thus the pulp does not contribute to the process of shedding and plays a passive role in this process.

The cell responsible for Shedding is Odontoclast.

Clast cells: Cytological features: Clast cells have certain characters: 1- Multinucleated cells 2- Acidophilic foamy cytoplasm 3- Ruffled border 4- Clear zone for attachment 5- numerous mitochondria 6- numerous lysosomes 7- High Acid-Phosphatase activity

Osteoclasts and odontoclasts are morphologically similar and seem to have the same origin and mechanism of action. The rationale for using different names for these cells is to reflect the specific tissue that is being resorbed.

They both rest a bay-like depression called Howships lacuna.

Mechanism of action during resorption of mineralized tissues:

1- Attachment to the surface: by clear zone. 2-Demineraliztion of the tissue: removal of the inorganic component takes place as the ruffled border acts as a proton pump releasing acids such as citric acid and lactic acid. 3- Degradation of organic matrix: through enzymes as Acid-Phosphatase and Collagenase. 4- PDL cells: attached to the tissue undergo Apoptosis (preprogrammed cell death) which suggests that there is a genetic role associated with Shedding. 5- Pulp: plays a passive role during the process of shedding. 6- Removal of debri: takes place mechanically through the ruffled border or through Endocytosis.

After termination of their resorption function, the odontoclasts lost their ruffled borders and became detached from the resorbed surface. Most of the detached odontoclasts had numerous large pale vacuoles and secondary lysosomes and appeared to be in the process of degeneration.

Tissue and cellular changes

Shedding is an intermittent process with periods of resorption involving alveolar bone, cementum and root dentin resorption by clast cells, osteoclasts and odontoclasts, respectively and recovery periods when osteoblasts and cementoblasts replace part of the resorbed tissues with Cementum-like material. Eventually more resorption takes place and when the tooth loses its supporting periodontal tissues, it is shed. During this process the primary teeth become loose during the periods of resorption and tighten during the brief periods of apposition.

A, Reversal line; B, Cementoblasts; C, Cementocyte.

Clinical considerations

Retained deciduous teeth

-A retained

tooth is one that remains in the dental arch beyond the age at which it is supposed to be shed. Many conditions cause primary teeth to be retained for example root ankylosis or the absence of a permanent successor. -An ankylosed tooth is one that have its root( s) fused to the alveolar bone. -A shortened tooth is a retained primary tooth which is smaller than the adjacent larger permanent teeth. -A submerged tooth is a retained tooth that becomes surrounded by alveolar bone. This condition is created by the loss of adjacent primary teeth and the accompanying resorption of their alveolar bone. When the permanent successors erupt they have their own alveolar bone which covers the retained tooth.

Remnants of deciduous teeth

Parts of the roots of deciduous teeth which are not in the path of erupting permanent teeth may escape resorbtion. e.g. The lower E have widely divergent roots, where the mesiodistal diameter of lower 5 is smaller than the distance between the roots of lower E, so part of roots found deep in the bone ,and their fate is; a- Surrounded by cellular cementum. b- Ankylosed to bone. c- Resorbed. d- Exfoliated.

Incomplete physiologic root resorption resulting in retained root tips of deciduous second molar.

Retained deciduous root tips

Physiologic resorption of deciduous second

molar in the absence

of the second

premolar. Resorption
of a deciduous tooth can occur even in the absence of an underlying permanent tooth. However, the resorption may be

delayed.

Congenitally Missing Teeth

Hypodontia - usually a single tooth missing Frequency: 2-9% Usually occurs with lateral incisors, second premolars, and third molars Key to diagnosis - count the teeth!!!

Missing teeth!!!

Pink tooth syndrome

If the root of the primary tooth is resorbed by neighbouring permanent teeth instead of the respective successor, we speak of undermining resorption. This occurs more frequently in the upper than in the lower jaw and more often in boys than in girls. In descending order, this happens to a) the distal roots of the upper second primary molars by the first permanent molars b) the lateral primary incisors by the permanent central incisors c) the primary canines by the lateral incisors, more rarely by the permanent first bicuspids. This is caused mainly by a lack of space, but also by an unfavourable inclination of the erupting teeth. The consequences of undermining resorption are similar to those of premature loss of the primary teeth or breakdown of the buccal segment (Stuetzzone) due to caries (tooth migrations, tipping, rotations), i.e., lack of space in the front teeth segment or in the buccal segment (Stuetzzone).

Maxillary sinus

 It

is the largest bilateral air sinus

It

also known as the Maxillary Antrum or Antrum of Highmore.

Anatomy of Max. Sinus

Pyramidal in shape Base: Lateral wall of the nasal cavity Apex: Towards Zygomatic process Anterior wall: Facial surface of the body of Maxilla Posterior wall: Infra-temporal surface of Maxilla The roof: Floor of the Orbit The floor: The Alveolar process

Drainage of the Max. Sinus

The Max. Sinus opens into the Middle Nasal Meatus by an opening called Ostium Maxillare Ostium Maxillare is found in a recess in the Middle Nasal Meatus called Hiatus Semilunaris.

Capacity of the sinus is about 15 ml

Dimensions: Transversely: 2.3 cm Anteroposteriorly: 3.4 cm Vertically: 3.35 cm

The Maxillary sinus may have septa to divide it partially or completely into compartments that may interfere with drainage

These compartments may have separate openings to the nasal cavity

Development The maxillary sinus (antrum of Highmore) is an air filled cavity. These structures are usually fluid-filled at birth. The growth of these sinuses is biphasic with growth during years 0-3 and 7-12. During the later phase pneumatization spreads more inferiorly as the permanent teeth take their place. Pneumatization can be so extensive as to expose tooth roots with only a thin layer of soft tissue covering them.

facial view

Floor of nasal fossa (red arrows) and anterior border of maxillary sinus (blue arrows), forming the inverted (upside down) Y.

Bony septa dividing the Max. Sinus

Pneumatization
It is the main method of growth of the maxillary sinus and contributes to the growth of the Maxilla.

It occurs by hollowing out of the air sinus by resorption on the inner side of the sinus and bone deposition on the facial surface of the Maxilla.

The greater the pneumatization the thinner the walls of the sinus.

This film shows the expansion of the borders of the maxillary sinus through pneumatization (red arrows). This expansion increases with age and it may be accelerated as a result of chronic sinus infections. It is most commonly seen when the first molar is extracted prematurely, as in the film at right (the second and third molars have migrated anteriorly to close the space). The coronoid process is seen in the lower left-hand corner of each film. The green arrow identifies a sinus recess.

Pneumatization. Expansion of sinus wall into surrounding bone, usually in areas where teeth have been lost prematurely. Increases with age.

Vascular supply Branches of the internal maxillary artery supply this sinus. These include the infraorbital (as it runs with the infraorbital nerve), lateral branches of the sphenopalatine, greater palatine, and the alveolar arteries. Venous drainage runs anteriorly into the facial vein and posteriorly into the maxillary vein and jugular vs. dural sinus systems.

Innervation The maxillary sinus is innervated by branches of V2. Specifically, the greater palatine nerve and the branches of the infraorbital nerve.

Histology of the Max. Sinus

It is lined by pseudostratified columnar ciliated epithelium with Goblet cells (Respiratory epithelium).

Cilia is not controlled by the nervous system but it beats automatically toward the nasal cavity to get rid of foreign bodies. Although the ostium is located at a higher level than the floor of the maxillary sinus, the normal sinus drains satisfactorily because of the action of the cilia of the pseudostratified columnar epithelium.

Cilia are formed of 20 microtubules arranged in a (9 + 1) arrangement.

Maxillary Sinus Physiology & function

1- Provides resonance to the voice. 2- Humidifying and warming inspired air, pressure dampening. 3- Increasing olfactory surface area, absorption and heat insulation of the brain. 4- Mechanical rigidity and lightens the weight of the craniofacial complex. 5- Antibacterial activity as the sinus produces mucous containing lysosome and immunoglobulins

Clinical considerations

Relation between teeth and the sinus Maxillary teeth are closely related to the sinus in this order 6,7,5,4,8,3 especially the palatal root of upper 6.

Sinus floor is found not between the roots of adjacent teeth but also sometimes between the roots of all individual teeth, so that the root apices protrude into the sinus cavity.

This close relation results in:

1- Referred pain from an inflammed sinus may affect maxillary teeth and should not be mistaken with dental pain. 2- Infection around the roots of Maxillary teeth may spread to the sinus. 3- When extracting Maxillary teeth, a forceful extraction of a closely related tooth may result in pushing the tooth into the sinus or result in an Oroantral communication.

Oro-antral communication
Tooth extraction, and developmental clefts may cause oral antral fistula. The most common cause of oral antral fistulas is tooth extraction. Maxillary first molars account for 50% of oral antral fistulas caused by extractions. Maxillary second and third molar extractions account for the other 50%. Prior to extraction, infection of these teeth may create a communication with the antrum. Approximately 10% of all sinusitis cases have a dental origin.

The maxillary sinus surrounds the root of the canine, which may be misinterpreted as pathology.

facial view

Maxillary sinus. As seen in the above film, the floor of the maxillary sinus flows around the roots of the maxillary molars and premolars. The walls of the sinus may become very thin. As a result, sinusitis may put pressure on the superior alveolar nerves resulting in apparent tooth pain, even though the tooth is perfectly healthy. Note coronoid process (green arrow), sinus septum (yellow arrow) and neurovascular canal (orange arrows).