Josievitz Tan-Zafra, DDM, MSD

Outline
I. Phases of Eruption
1. Pre-eruptive Phase/Pre-eruptive Tooth
Movement
2. Eruptive Tooth Movement
3. Post-eruptive Tooth Movement
- Gubernacular Cord
II. Theories on the Mechanism of Tooth Movement
1. Bone Remodelling Theory
2. Theory of Root Growth
3. Vascular Pressure Theory
4. Ligament Traction Theory
III. Odontoclasts
Clear Zone
Ruffled Border

IV. Mechanism of Resorption and Shedding

Pressure
Loss of PDL attachment
Increased Masticatory forces

V. Clinical Considerations
 Jaws of infant can only accommodate few small teeth.
Deciduous teeth once formed cannot increase in size

Adults jaw require more and bigger teeth.

This accommodation is applied to humans in 2

dentitions:
a. Primary or Deciduous Dentition
b. Permanent or Secondary Dentition

For teeth to become functional, movement is required to

bring it into the occlusal plane.
Tooth Eruption
Movement of teeth from its intraosseous position to its
functional position in the occlusal plane
Continuous throughout life
Changes:
1. Development of dentogingival junction
2. Formation of gingival sulcus
3. Development of root of tooth
4. Development of PDL, Cementum & Alveolar bone

Eruption of 1 teeth ends with exfoliation -> Eruption of 2

teeth
Methods of Study of Eruption
1. Observation of human subjects
2. Observation of structures and their behavior
associated with the erupting tooth
3. Creation of special conditions to study their effect on
eruption
Problems inherent in study
1. Difficult to create experimental conditions that will
isolate a single causative agent
ex. Vitamin C experiment affects many processes
in the body
2. Difficult to interpret data
3. Difficult to create experimental conclusion
I. Phases of Eruption
A. Pre-eruptive Phase / Pre-eruptive Tooth Movement
- Movement of developing tooth within the alveolar
bone towards the position to which the tooth will erupt
- starts from tooth formation up to crown completion
A. Pre-eruptive Phase
- involves bone remodelling: Osteoblasts & Osteoclasts
Each tooth have their own space & covered with bone

Rapid growth of deciduous tooth germs & may become

crowded

Alleviated by jaw lengthening

a. Tooth germs of E move backwards
b. Anterior tooth germs move forward
Simultaneous with outward & upward/downward bodily
movement as jaws increase in dimension
 At birth: developing 1 tooth germ
& 2 tooth germ within the jaw of
infant
Crypt space occupied by 1 &
2 tooth germ
Initially, 1 & 2 shares the same bony
crypt
1 & 2 in the same occlusal level
but 2 lingual to 1
 Jaw Growth -> space for pre-
eruptive tooth movement of 1 ->
2 tooth bud moves lingual &
apical to 1 tooth bud
a. 2 PM: Movement in axial plane
& horizontal movement
End of Ph 1: occupy own
crypts found bet roots of
1 molars
b. 2 I: occupy own cypts lingual & apical to roots of
deciduous
c. 2M: no predecessor in 1 tooth -> dental lamina extend
distally
c.1 2 Mx M: develop with occlusal surface facing
bucally & distally within bone
before eruption: rotate mesially & lingually

c.2 2 Md M: develop with occlusal surface facing

mesially

Failure to rotate results in impaction

 Factors that make-up pre-eruptive movement
(explains how tooth maintains their position relative
to oral mucosa as jaws increase in height)
a. Total bodily movement of tooth germ
b. Growth in which one part of tooth germ remains
fixed while rest continues to grow
B. Eruptive Tooth Movement / Active Eruption
- actual axial movement of the tooth into the oral cavity
until it occludes with its antagonist
- starts with onset of root formation & tooth eruption
- ceases when tooth has occluded with its antagonist

- occurs simultaneously with:

1. Root formation
2. PDL development & remodeling by fibroblast (dual
function) to permit continued eruptive movement
3. Alveolar bone development
4. Dentogingival junction formation
5. Cementum formation
 Reduced Enamel Epithelium covering of crown that
separates tooth from oral epithelium
When tooth begins to erupt:
1. Collagen fibers of CT will degenerate
2. Decrease in # of BV & nerves
Connection or fusion between REE & OE forms a pathway
called Gubernacular Cord (guides the tooth when it erupts)
 Gubernacular cord strands of fibrous tissue
containing remnants of the dental lamina which
connects dental follicle of succedaneous tooth with
lamina propria of oral mucosa
 Gubernacular canal holes in jaws on lingual aspect of
deciduous teeth;
- pathway for succedaneous tooth; contains the cord;
widened by osteoclasts as succesional tooth erupts,
delineating its eruptive pathway
C. Post-eruptive Tooth Movement
- Movement of tooth after it has reached its functional
position in the OC
Types:
1. Movement which maintains the position of erupted
tooth while the jaw continues to grow /
Accomodation for jaw growth
growth in condyle area will cause a downward and
forward growth of mandible; teeth are also
included
1. Accomodation for jaw growth
- completed after 20 years
- achieved by formation of bone at alveolar crest &
socket floor to keep pace with increasing height of jaws
- apices of teeth move away from inferior dental canal
(fixed reference point)
- occurs earlier in girls & is related to bursts of condylar
growth that separates the jaws & teeth
2. Movement that compensates for occlusal attrition /
Compensation for occlusal wear
- axial post-eruptive movements made when the apices
of permanent lower molars are fully formed and apices
of 2nd premolar and molar are almost complete.
- indicates that root growth is not a factor for axial
movement and emphasizes the PDLs role
- achieved by continued cementum deposition around
apex of tooth
3. Accomodation for interproximal wear / lateral tooth
movement
- occurs in proximal spaces and is known as mesial or
approximal drift
- important for orthodontics because maintenance of
tooth position after treatment depends on such a drift.
 Forces that bring about mesial drift
1. Anterior component of occlusal force
- produced when teeth are brought into contact
- result of
a. mesial inclination of most teeth
b. summation of intercuspal planes produces a
forward-directed force
2. Contraction of transseptal ligament
- ligament between adjacent teeth across alveolar
process draws neighboring teeth together and maintain
them in contact
- evidence: relapse of orthodontically moved teeth is
much reduced if gingivectomy (removal of transseptal
ligament) is done
3. Soft tissue pressure
- caused by cheek and tongue, may push mesially and
influences tooth position and not tooth movement.
II. Theories on the Mechanism of
Tooth Movement
A. Bone Remodelling Theory
- suggests that the growth of alveolar bone will pull the
tooth into the OC
ANTI: Tetracycline antibx when taken may result to
gray/brown teeth; used as a marker that is deposited in
calcified tissue
1. Initial axial movement: resorption at base of alveolus;
thus, cannot cause tooth eruption
2. After initial resorption -> deposition
However, still cannot push because resorption still took
place
3. Bone grows by apposition (not interstitially).
Addition of bone in alveolar crest wont have any effect in
eruption of the teeth
 PRO:
1. Researcher removed a developing tooth and left
behind a dental follicle. The gubernacular cord still
formed
2. Substitution of tooth with silicone : it erupted
Remove everything including the dental follicle: no
eruption
Thus, dental follicle is important in eruption
Bone comes from dental follicle
Bone has a role in eruption
B. Theory of Root Growth
- An increase in the length of root will provide the eruptive
force by pushing the structure called Cushion Hammock
Ligament

Increase in length of root -> push this ligament to cause axial

movement of teeth
Root pushes bone -> cause resorption
-> pushes against the ligament
 ANTI:
1. There is no such thing! It does not exist!
Pulp limiting / delineating membrane
- delineates DP from surrounding cells
If root apex is not yet formed -> wide open apex
2. If root growth is responsible for eruption, then end of
eruption should coincide with end of root formation
However, root growth stops 3 yrs after eruption
Eruption continues throughout life
Thus, root growth alone will not cause tooth eruption
 Berkovitz & Thomas, 1969: Removed the growing part
of the root but distal part still continued. Thus, root
growth contributes to eruption but is not the only
driving force
C. Vascular Pressure Theory
- Numerous BV in apical region causes a local increase
in tissue fluid pressure and the only way to release this
pressure is through tooth eruption

PRO: Amount of tissue fluid P was measured incisal &

apical to developing tooth. They found out that the P
apically is greater by 15 mmHg than incisally. This is
sufficient to cause tooth eruption
PRO
1. When researchers measured the amount of tissue
fluid pressure, they found out that pressure apically
is greater by 15 mmHg than incisally.
2. They tried to control constriction of BV by giving
drugs that promote vasodilation (more tissue fluid in
apical part. Greater pressure causes an increase in
rate of eruption
 Teeth move in their sockets in synchrony with the
arterial pulse thus local volume changes can produce
limited movement.

Ground substance can swell up to 30-50% by retaining

additional water.
Fenestrated capillaries in PDL suggest capability for
rapid fluid adjustment
ANTI
Berkovitz & Thomas, 1969: Researchers removed growth
center of incisor in rats (apical part of root). In removing
it, there is no tissue fluid. If theory is correct, it should
not erupt. But, the distal part erupted so tissue fluid
cannot be the cause of tooth eruption.
This experiment also disproved theory of root growth
D. Periodontal Ligament Traction Theory
- Eruptive force comes from periodontal ligament either
from fibroblasts or collagen fibers of PDL

PRO
1. Expt #3 tissue responsible for its eruption is PDL
2. Another study fed the rats with aminoacetonitrile, a
lathyrogen (drug that interferes with formation of
collagen fibers). When given to rats, it interrupts
the formation of collagen fibers of PDL; thus, rate of
eruption decreases
ANTI
1. Another group performed the experiment. However,
their result was that there was no effect on the rate of
eruption. The tooth was just easier to extract.

They continued to study this theory and found

MYOFIBROBLASTS specific cells in PDL
-similar to smooth muscle cell (contract -> tooth erupts)
- existence is not yet proven
 Fibroblasts organize and align collagen fibers via their
cell processes thereby establishing intercellular
contacts & junctional complexes to form a 3D
honeycombed environment
They are responsible for the tractional force since
without the cells no force is generated for eruption
Frequent cell-to-cell junctions allow the summation of
contractile forces
 2 Structural Requirements
1. Collagen fibers must be oriented obliquely
2. This orientation must be maintained. Maintenance
is achieved via rapid remodeling of fiber bundles

Force moving tooth is likely generated by contractile

property of PDL fibroblasts but needs other conditions
such as root growth and bone collagen remodeling.
Thus, it is a multi-faceted phenomenon.
 Primary teeth eruption ends with exfoliation of teeth

Exfoliation / Shedding due to physiologic resorption

of root; gradual loss of PDL attachment
III. Odontoclasts
Cells that resorbs primary teeth
Derived from monocyte & migrate from BV to
resorption site
Similar to osteoclasts: multinucleated
Differences:
1. Ruffled Border contains vacuole filled with acid
phosphates that initiates resorption of primary teeth
2. Clear Attachment Zone -adjacent to RB; mechanism
of attachment of odontoclasts to teeth
IV. Mechanism of Resorption /
Shedding
1. Pressure from growing & erupting permanent
teeth
Pressure -> Resorption

Anterior teeth: resorption begins at lingual surface (shed

with much of pulp chamber intact)

1 molars: resorption begins at interradicular

surface (R: interradicular dentin, pulp chamber, coronal
dentin & sometimes enamel)
Resorption of the roots of
As, Bs and Cs begins on
their lingual surface due to
position of 1s, 2s and 3s
tooth germs
Later, tooth germs
(1s,2s,3s) occupy a
position directly apical to
the primary teeth
Resorption of the roots of
the Ds & Es begins on
their inner surfaces due
to 4s & 5s tooth germs
 Little is known about resorption of soft tissues pulp
& PDL
Loss of PDL fibers is abrupt; there is no inflammation
Cell death occurs in 2 forms:
1. Fibroblasts accumulate intracellular collagen
suggests interference with normal collagen secretory
mechanisms
2. Ligament fibroblasts exhibit morphologic features
characteristic of apoptotic cell death
2. Loss of PDL attachment weakening of supporting
tissue as a result of root resorption

3. Increase in masticatory force exerted on

weakened teeth as a result of muscular growth

ST resorption Apoptotic Cell Death shrinkage of cell

followed by phagocytosis
 Pressure provided by erupting succedaneous tooth
If succedaneous tooth is missing congenitally, shedding
will be delayed. Why?
Increased force applied to deciduous tooth initiates its
resorption.
Growth of face and jaws, increase in size & strength of
muscles increase the force applied so the supporting
apparatus of the tooth is damaged.
Rate of exfoliation is determined by both local
pressure (from succedaneous tooth) & masticatory
forces.
Pattern of Shedding
- Symmetrical for left & right sides of the mouth
- Except for second molars,mandibular is shed before
their maxillary counterparts
- Girls exfoliate before boys
- Greatest discrepancy is observed for mandibular
canines
Sequence of Shedding
- Md: anterior to posterior
- Mx: disrupted by first molar exfoliating before the
canine
 PRIMARY DENTITION

Eruption Sequence & Timing

A---B D C E upper
/ \ /\/\/
A B------D C E lower
________________________

6-7 13 16 18 28 months
 Eruption Times for Primary Teeth
Maxilla Mandible
Central Incisor 10 months 8 months
Lateral Incisor 11 months 13 months
Canine 19 months 20 months
First molar 16 months 16 months
Second molar 29 months 27 months
Permanent Teeth Eruption
Sequence
6 1 2 4 5 3 7 8 upper
/ \ / \ / \ / \ / \ / \ / __/
6 1 2 3 4 5 7 8 lower
_________________________________
6 8.5 10 11.5 12 18+ y.o
 Eruption times (Years) of Permanent Teeth

Tooth Maxilla Mandible

1 7-8 6-7
2 8-9 7-8
3 11-12 9-10
4 10-11 10-12
5 10-12 11-12
6 6-7 6-7
7 12-13 11-13
8 17-21 17-21
V. Clinical Considerations
Teeth usually missing 3rd molars, Mx lateral incisors

Teeth usually impacted 3rd molars, Mx C