Eruption Considerations

Chapter 9, pp 184-201; Chapter 27, pp 627669; McDonald

Overview
Review of spacing Review of space maintenance Local and systemic factors that influence eruption: Habits Ectopic Eruption Impacted and Supernumerary teeth Abnormal Labial Frenum Agenesis of Teeth Ankylosed Teeth

Ectodermal dysplasia Other causes: Clefts, Cherubism, hypophosphatemia, acrodynia, Achondroplastic dwarfism,Cleidocranial
dysplasia, Hypothyroidism, Hypopituitarism, Down, genetics, post natal environment/nutrition, trauma, abcesses, early losses, etc.

Review of spacing: Primary dentition

Interdental spacing-spacing between mesial of canines (across labial surfaces of anterior teeth) Accommodates larger permanent teeth Primate space-between Mx canine and lateral Md canine and 1st molar Closed primate space-no space available Secondary incisor space-created by Md laterals forcing primary Md canines laterally, which forces Mx canines laterally and widens the Mx intercanine arch length. Premature loss Md canines/caries/diskingborderline cases become extraction cases. Leeway space(Primary canines+ Primary molars widths)(Permanent canines+Premolars widths) in each arch Mx-3.4 mm/arch Md 0.9 mm/arch (large primaries)
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Review of space maintenance

Band and Loopunilateral/bilateral Bilateral-appliance of choice mixed dentition need 4 Md incisors/1st molars saves leeway space Distal shoe (contraindicated for poor oral hygiene, blood dyscrasias, immunosuppressed, congenital heart defects, rheumatic fever history, diabetes, debilitation) chronic inflammation with it --may want to regain space later, instead RPD/fixed appliancesanterior collapse/space loss prevention reestablish anterior function/speech
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Habit considerations
0-1 yoclinging and oral habits Compulsive habitsfixated insecure/threatened Damage from habits-duration frequency intensity

Thumbsucking
Incidence47% no residual effects if eliminated before mixed dentition (6yo/school age) Removable digital sucking appliance resembles a Hawley If pt presents with thumbsucking habit, open bite/posterior X-bite refer for orthodontics (treatment may include Quad hexix)
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Tongue Thrust/Infantile/Juvenile swallow

Infantile swallowsuckling associated with nursing, training cups Usually adult swallow by age 6 The tongue can malpose teeth if the swallowing involves the tongue touching the Mx incisors *Try muscle retraining firstpractice placing tongue on incisive papilla and swallow A tongue thrust appliance helps train the tongue to its proper position 7

Activity: Evaluate space maintenance/guidance/habit sample appliances brought to class

Ectopic eruption
Abnormal eruption position Incidence: 3%, (boys more often) Common Sites: Permanent Mx 1st molars Permanent Md laterals Self corrects: 66% of molars DX: evaluate radiographs closely TX for molars: 1. Monitor (usually lack of tuberosity development) 2. Determine it is reversible (selfcorrecting)/irreversible between 7-8y 3. If it is irreversible: orthodontic consult stating concerns/distally reposition it

McDonald 663 27-47

Ectopic eruption
Higher incidence-pts with Cleft lip and palate Self correction rate-22% with a cleft

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Ectopic eruption
Location: more frequently Mx Refer for orthodontic consult for an ectopic molar to distalize it Include your evaluation of dental age, eruption problems, anomalies, concerns, copy of radiographs

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Treatment of Ectopic eruption of a permanent first molar

Kesling spring (separator) Prepare brass wire with double helix bend. Place active spring below contact of the primary 2nd molar and ectopic permanent molar. TX time3-4 weeks

McDonald 665 27-48

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Treatment of Ectopic eruption of a permanent first molar with Kesling spring

Personal collection of Dr. Mike Bagby

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Alternate Treatments of Ectopic eruption of permanent first molar

Pulpotomy on 2nd primary molar Reshape 2nd primary molar Place small SSC on 2nd primary molar which will direct the permanent molar into position
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Ectopic eruption of permanent laterals

Problem: ectopic permanent Mx/Md lateral can cause premature primary canine loss (7y) Serious problem: ectopic permanent Mn lateral can cause premature primary canine and 1st primary molar loss with transposition of permanent lateral/canine DX: Obtain/review appropriate radiographs TX: Unilateral condition, no midline shift: space maintenance Unilateral condition, midline shift, crowding, loss of 1 primary canine: orthodontic consult extract contralateral canine passive lingual arch

McDonald 666 27-50

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Delayed eruption/ectopic/impacted Permanent canines Prevalence: 3rd molars most commonly impacted Mx canines-2nd most commonly impacted Cause: long development dubious course easily deflected Dx: evaluate canine crypt; radiographs (8y) Tx: orthodontic consultation and surgical intervention

McDonald 666 27-50

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Supernumerary teeth causing ectopic eruption

Cause: Continued budding of enamel organ; familial Incidence: 1/110 Prevalence:Mx:Md 8:1 Most common: mesiodens Problem: ectopic eruption or prevention of eruption of adjacent teeth

McDonald 667 27-54

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Supernumerary: Mesiodens
Location: most are palatal
(von Arx et al., 1992) DX: review radiographs (occlusal) at age 5-6

PresentationAbnormal central diastema Abnormal tooth eruption Abnormal occlusion Cystic degeneration (Huang
et al, 1992)
Supernumerary primaries McDonald 667 27-52

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Supernumerary:Mesiodens
Treatment: If no interference with other teeth and no indication of cyst: Delay extraction until permanent teeth erupt and root closure is complete/child is older If delayed eruption of incisor: Extract mesiodens Remove bone & soft tissue from incisal 1/3 of delayed teeth unless the teeth are very highwatch/wait Maintain/open pathway if possible Scar tissue can halt eruption

McDonald 667 27-54

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Multiple mesiodens in a 3yo at 4yo no tx

Surgery indicated

From Creighton University

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Multiple wisdom teeth

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Anterior Diastema
Postpone until complete eruption of canines unless: 1. laterals are erupting lingually and do not have space to be moved labially; 2. heavy labial frenumclose the space, then do surgery; 3. Other valid reason

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Abnormal labial frenum

Labial frenum: 2 layers of epithelium with a loose vascular connective tissue and muscle fibers from the orbicularis oris Origin: midline on inner lip (wide) Insertion: midline in outer layer periosteum and CT of internal MX suture and alveolar process to: above the crest of the ridge, or at ridge, or through centrals to palatine papilla

McDonald 142 7-49

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Abnormal labial frenum

WNL (within normal limits): midline diastema in pre-school children. Diastema usually closes when canines erupt. Diagnostic test in mid-late mixed dentition: Press on frenum then identify location of alveolar attachmenta blanching of the palatine papilla indicates abnormality. Other concerns: Interference with speech Interference with eating Difficulty brushing

McDonald 142 7-49

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Abnormal labial frenum

Frenectomy: Orthodontic consult Evaluate esthetics/function Possible laser surgery Traditional surgery: Do not disturb mesial of free marginal tissue of incisors. Remove wedge section of tissue between incisors to nasal palatine papilla (transeptal fibers). Lateral incisions on either side of frenum to bone.

cont

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Abnormal labial frenum

Frenectomy cont: Excise the tissue. Recontour labial and/or palatal gingival papilla if there is excessive tissue Do not remove mesial free gingiva Suture inside the lip to approximate free tissue margins

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Agenesis of Teeth-failure of teeth to form

Anodontia all teeth fail to develop Hypodontia1 or more teeth fail to form Older term: Oligodontia oligo-few; few teeth present Inaccurate older terms: Congenitally absent-permanent teeth are not expected at birth Partial anodontia-anodontia is complete absence; how does one have a partial complete absence?

Absence of teeth may be: Nonsyndromic/syndromic One syndrome is Ectodermal Dysplasias

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Anodontia
Autosomal recessive No permanent dentition The primary dentition is usually not affected Treatment : Overlay denture
McDonald 130 7-37

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Hypodontia
Most common: 3rd molars
Most common in children: Md 2nd premolars Mx lateral incisors Mx 2nd premolars Most common primary: Mx lateral Several genes may be involved PAX9 gene produces DNA binding protein that controls other genes in tooth development and was mutated in one family with hypodontia
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Hypodontia-7 yo female
When reviewing a radiograph, count the teeth

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Panograph of 10 year old male with history of premature birth and delayed development

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Ankylosed teeth
Description: Fusion of cementum and alveolar bone Improper terms: submerged tooth infraocclusion Use ankylosed instead Cause: unknown Possible causes: 1.familial pattern, probably non-sex linked trait 2. no permanent successor researchers disagree if ankylosis is associated/not 3. intermittent resorption and repair (increased repair)

Ankylosed teeth are often below occlusal table McDonald 186 9-12

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Ankylosed teeth
Other possible causes Inadequate Arch space Pre-eruptive proximity of permanent molars Ectopic eruption of permanent molars Caries Occurrence: usually after root resorption begins or after trauma (anterior teeth) Highest Incidence- Md primary molars Diagnosing: Tooth appears depressed Tapping - solid sound (normal teeth have a cushioned sound) Tooth not mobile PDL on radiograph is discontinuous

McDonald 186 9-12

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Ankylosed tooth with permanent successor

Treatment: Watchful waiting for normal exfoliation or Extraction and placement of any needed space maintainers

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Ankylosed tooth with no permanent successor

If there is adequate crown exposure and sufficient root length, no successor and ankylosis occurs late:
Keep as a functional unit Restore proximal and occlusal contacts Restore with SSC, composite resin, crown, gold casting crown, etc. Assess perio periodically on adjacent teeth

If ankylosed tooth is extracted:

Orthodontic referral/therapy or Prepare for prosthodontics with space maintainance

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All the primary molars are ankylosed

Permanent molars are tipping mesially It is time to extract and provide space maintenance

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Ankylosed permanent teeth

The incomplete eruption of a permanent molar may be related to a small area of root ankylosis TX: Remove soft tissue and bone covering the occlusal of the tooth for a path for eruption If unsuccessful: Surgical consult to luxate and break the ankylosis A delay in treatment may result in permanent ankylosis
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Ectodermal Dysplasias-100 types

Presentation: Ectodermally derived structures are altered: Anodontia or hypodontia of primary/permanent teeth Retained primary teeth Hair-hypotrichosis absent/lanugo (fine) Sweat glands-hypohydrosis deficient uncomfortable in warm weather Xerostomia Fissuring at corners of mouth Skeletal structuresnormal with normal jaw development
McDonald 133 7-39

Types: 1. XLHED-X-linked recessive hypohidrotic ectodermal dysplasia also called anhidrotic ectodermal dysplasia and Christ-Siemens-Touraine syndrome 2. Autosomal recessive ectodermal dysplasia

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Ectodermal Dysplasias in children

Lack of teeth

Primary anterior teeth are conical

Primary molars tend to ankylosis without permanent successors Difficult case to treat-overdentures
McDonald 133 7-39

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Next week
Continuation of eruption considerations

McDonald 133 7-39

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Objectives
Describe the dx/tx for: Define primate, leeway, secondary and closed Ectopic/impacted teeth spaces; agenesis, Superrnumeraries anodontia, hypodontia, Ankylosed teeth oligodontia, and ankylosis. Anterior diastema List when the distal shoe is Abnormal labial frenum not indicated. Explain why these terms are State when an RPD may be inaccurate indicated to replace D, E, congenitally absent F, or G. permanent teeth Identify sites with frequent partial anodontia ectopic/missing teeth. Describe the consequences submerged teeth of ectopically positioned infra-occlusion teeth Describe ectodermal dysplasia.
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