REVIEW

Stomatologija, Baltic Dental and Maxillofacial Journal, 12: 67-72, 2010

Factors influencing permanent teeth eruption.

Part one – general factors
Ruta Almonaitiene, Irena Balciuniene, Janina Tutkuviene

SUMMARY

Variation in the normal eruption of teeth is a common finding, but significant deviation from
established norms should alert the clinician to take some diagnostic procedures in order to evaluate
patient health and development. Disturbance in tooth eruption time could be a symptom of general
condition or indication of altered physiology and craniofacial development.
The aim of this review is to analyze general factors that could influence permanent teeth erup-
tion. The articles from 1965 to 2009 in English related to topic were identified. 84 articles were
selected for data collection.
Although permanent teeth eruption is under significant genetic control, various general factors
such as gender, socioeconomic status, craniofacial morphology, body composition can influence
this process. Most significant disturbance in teeth emergence is caused by systemic diseases and
syndromes.

Key words: permanent teeth eruption, general factors, influence.

IntRoDUctIon

Tooth eruption is defined as the movement of the osteoclasts in alveolar bone must be formed. In suc-
tooth from its site of development in alveolar bone to cedeaneous dentition, this pathway follows the guber-
the occlusal plane in the oral cavity. The tooth erup- nacular canal above each tooth; i.e., bone resorption
tion is a complex and tightly regulated process which widens the canal to allow the crown to move through
is divided into five stages: preeruptive movements, it and exit the alveolar bone [3]. From studies with
intraosseous stage, mucosal penetration, preocclusal the dogs it was shown that dental follicle (DF) plays
and postocclusal stages. Preeruptive movements major role during intraosseous stage of eruption as
occur during crown formation and are so small that teeth didn’t erupt if the DF had been removed. Si-
they could only be observed by vital staining experi- multaneously when the tooth in the DF was replaced
ments [1]. Active eruption movements occur when with dental amalgam but the DF had been left intact,
root formation begins and therefore it was believed artificial tooth erupted [4]. Osteoclasts which create
that eruptive force comes from periodontal ligament. eruption pathway are formed from mononuclear cells
Although tooth eruption mechanisms are still under which in turn are recruited to the DF by chemokines
debate, it was suggested that periodontal ligament CSF-1 (functional colony-stimulating factor–1) and
provides eruption force after the tooth has pierced MCP-1 (monocyte chemotactic protein-1). Osteo-
gingiva but not during intraosseous stage [2]. For blasts might also influence the process of eruption
active tooth eruption to begin eruption pathway by by activating osteoclasts. Formation of the tooth
eruption pathway is a localized, genetically pro-
1
Institute of Odontology, Faculty of Medicine, Vilnius University
2
Vilnius University Hospital, Zalgiris Clinic grammed event that does not require pressure from
3
Department of Anatomy, Histology and Anthropology, Faculty of the erupting tooth. Putative eruption genes and their
Medicine, Vilnius University products are localized primarily in either the DF or
Ruta Almonaitiene1 – PhD student stellate reticulum [5,6]. During intraosseous stage
Irena Balciuniene2 – D.D.S, PhD. Hab. Dr., prof. there is a coordinated translocation of the tooth into
Janina Tutkuviene3 – M.D. PhD Hab. Dr., prof., Head of Depart-
ment of Anatomy, Histology and Anthropology; resorbed space, bone apposition at the DF fundus
Faculty of Medicine, Vilnius University and simultaneous root elongation. Formation of the
Address correspondence to: Dr. Ruta Almonaitiene, Institute of eruption pathway is completed soon after the cusps
Odontology, Faculty of Medicine, Vilnius University, Zalgirio str. reach the alveolar crest and at this point the rate of
115, 08217 Vilnius, Lithuania.
E-mail address: rutaalmonaitiene@hotmail.com eruption accelerates [7].

Stomatologija, Baltic Dental and Maxillofacial Journal, 2010, Vol. 12, No. 3 67
R. Almonaitiene, et al. REVIEW

The outer enamel epithelium of the tooth bud tooth eruption”. The articles from 1965 to 2009
proliferates and fuses with oral epithelium creat- in English related to subject were identified. 84
ing the junctional epithelium on the tooth surface. articles were selected and analyzed. Most of the
Erupting tooth penetrates mucosa and preeoclusal articles were case-control studies except for gender
eruption stage begins. As the root grows and bone influence (longitudinal and cross-sectional popula-
forms at the base of the crypt, tooth reaches func- tion studies) and syndromes, which are so rare that
tional occlusion plane. Most of the postemerged the only information available is case reports.
eruption proceeds during night [1]. Once the occlu-
sion is reached, tooth eruption speed drops dramati- RESUltS
cally but continues at a slow rate during life thus
compensating tooth wear. If the antagonist tooth is Genetics
lost, eruption rate increases. Genetic factors definitely controls tooth emer-
Normal permanent teeth eruption into oral gence as studies with monozygotic twins shows a
cavity occurs over a broad chronological age range concordance rate of 0.9 [8]. Dizygotic twins and
and can be influenced by number of factors. These siblings show a lower concordance rate but it is still
factors can be classified into local and general. higher than in unrelated individuals. Some authors
stated that heritability is higher for tooth develop-
MAtERIAlS AnD MEthoDS ment then for tooth eruption [9,10].
Both longitudinal and cross-sectional studies
To identify all studies that examined the re- reported differences in teeth emergence time among
lationship between general factors and permanent different races [11-16]. Permanent teeth emerge con-
teeth eruption, a literature survey was performed siderably earlier in African and American-African
using Medline database. Free text terms or in com- children than in Asians and Caucasians [12].
bination with controlled vocabulary were used for There are certain genetic disorders that affect
a search. Key words used in the search included teeth eruption. Most of them are reported to delay
“permanent teeth emergence”, “impaired tooth permanent teeth eruption, others are associated with
eruption”, “delayed tooth eruption”, accelerated complete failure teeth to erupt. Genetic disorders

table 1. Genetic disorders influencing permanent teeth eruption

Amelogenesis imperfecta [43] Gorlin syndrome [61]
Aarskog syndrome [44] Hallermann-Streiff syndrome [62]
Acrodysostosis [6] Hyperimmunoglobulinemia (Buckley syndrome) [53]
Albright Hereditary Osteodystrophy [6] I-cell disease (mucolipidosis II) [63]
Apert syndrome [45] Incontinentia pigmenti (Bloch-Sulzberger syndrome)
Carpenter syndrome [46] [64]
Cherubism [47] Mc-Cune-Albright syndrome (polyostotic fibrous
Chondroectodermal dysplasia [48] dysplasia) [48]
Cleidocranial dysplasia [1] Menkes’ kinky hair syndrome [65]
Cockayne syndrome [6] Neurofibromatoses [66]
Congenital hypertrichosis lanuginosa [49] Oculoauriculo vertebral spectrum (Goldenhar syn-
Dentin dysplasia [50] drome/hemifacial microsomia) [67]
Mucopolysaccharidosis (MPS) [48] Osteoglophonic dyspalsia [68]
Down syndrome [51] Osteopathia striata with cranial stenosis [68]
Dyskeratosis congenita [52] Osteopetrosis (marble bone disease) Osteogenesis
Ectodermal dysplasia [53] imperfecta [69]
Ekman-Westborg-Julin syndrome [54] Otodental dysplasia [70]
Epidermolysis bullosa [55] Parry-Romberg syndrome (progressive hemifacial
GAPO syndrome (growth retardation, alopecia, pseu- atrophy) [71]
doanodontia, and optic atrophy) [56] Progeria (Hutchinson-Gilford syndrome) [68]
Gardner syndrome [57] Rothmund-Thompson syndrome [68]
Gaucher disease [58] Sclerosteosis [72]
Gingival fibromatosis associated syndromes [59] Shokier syndrome (hereditary anodontia spuria) [60]
Laband syndrome [60] SHORT syndrome [68]
Murray-Puretic-Drescher syndrome [60] Singleton-Merten syndrome [73]
Rutherford syndrome [60] VonRecklinghausen neurofibromatosis [74]
Cross syndrome [60] 22q11 deletion syndrome [75]

68 Stomatologija, Baltic Dental and Maxillofacial Journal, 2010, Vol. 12, No. 3
REVIEW R. Almonaitiene, et al.

can be divided into disorders that affect enamel eruption of permanent first molars and incisors in
formation and/or the tooth follicle (e.g. amelogen- 6 year old group of children with early childhood
esis imperfecta, Hurler’s syndrome, mucopolysac- protein- energy malnutrition, but their sample was
charidosis VI) and disorders that interfere with small and they failed to report nutritional status at
osteoclastic activity (e.g. Cleidocranial dysplasia, the time of examination [23].
osteopetrosis). Other syndromes are associated with
deficient growth or teeth eruption can be delayed by Preterm birth
multiple supernumerary teeth or gingival hyperpla- According to World Health Organization
sia [7]. Genetic syndromes that affect teeth eruption (WHO) preterm birth is defined as birth occuring
are listed in Table 1. before 37 weeks of gestation or if the birth weight
is below 2500 g. The incidence of preterm birth
Gender (PT) varies between populations and is reported to
There is an agreement from studies on teeth be from 5 to 13% in developed countries [24-27].
emergence that in girls permanent teeth erupt earlier The weight of an infant at birth is usually ac-
than in boys [13,17-20]. Significant differences cepted as the best index of prematurity.
has been found for maxillary lateral incisors and Influence of preterm birth on teeth develop-
canines [15,18,19] and mandibular canine [15,17- ment and eruption has been investigated [28-30].
19]. The difference between eruption times on Most of the studies reported oral findings during
average is from 4 to 6 months, largest difference primary dentition stage, while data on permanent
being for permanent canines. Earlier eruption of dentition development, especially on permanent
permanent teeth in females is attributed to earlier teeth eruption, is rare. Most of the studies re-
onset of maturation. Only one study reported earlier ported that PT children have delayed primary and
emergence of second molars in boys than in girls permanent teeth eruption, if emergence time was
and explained this phenomenon as a catch-up de- compared to chronological age. However some
velopment by the age of eruption of second molars researches showed that if eruption time was related
because of later onset of puberty in the males [15]. to corrected age (i.e. chronological age in weeks
Eruption sequence, especially during the second minus gestational age 40 weeks), no difference has
eruption phase, differs among genders: the clas- been found between dental maturation and eruption
sical orders of eruption appeared more frequently times of PT and control children [28-30]. Some re-
in males (20% upper, 17% lower) as compared to searches reported that the greatest delay was found
females (12% upper, 8% lower) [15,17,20,21]. In in children younger than 6 years of age, whereas
girls the maxillary canine can be expected before for those aged 9 years or older, there was no dif-
the second premolar, and the mandibular second ference, indicating that a ‘‘catch-up’’ had occurred
premolar can be expected before second molar; in [29]. Results of another study showed that matura-
boys both orders are reversed [21]. tion of permanent dentition evaluated according
Demirjan methodology did not differ among PT
nutrition born children and controls [28]. One study even
Although data on nutrition influence on perma- reported earlier eruption of permanent first molar
nent teeth emergence is scarce, there is evidence that and incisors in PT black and white children when
chronic malnutrition extending beyond the early compared to controls, although group of white
childhood is correlated with delayed teeth erup- children was small [31]. The authors suggested
tion [22]. Although one study reported accelerated that various post-natal factors and an accelerated

table 2. Systemic diseases associated with impaired dental eruption

Vitamin D-resistant rickets [48] Renal failure [79]
Endocrine disorders [76] Exposure to hypobaria [80]
Hypothyroidism (cretinism) Idiopathic [1]
Hypopituitarism Radiation damage
Hypoparathyroidism Celiac disease [81]
Pseudohypoparathyroidism Anemia [79]
Drugs: phenytoin [77] Dysosteosclerosis [82]
Long-term chemotherapy [78] Cerebral palsy [1]
Ichthyosis [53] HIV infection [83]
Oral clefts [1] Heavy metal intoxication [84]

Stomatologija, Baltic Dental and Maxillofacial Journal, 2010, Vol. 12, No. 3 69
R. Almonaitiene, et al. REVIEW

growth period (catch-up growth) with related un- craniofacial morphology

known factors may influence the eruption of teeth Although tooth eruption has a poor correlation
that goes through a sensitive period circumnatally with general body and facial growth, it was specu-
(permanent incisors and first molars). lated that permanent second molar eruption might be
When evaluating factors affecting maturation different in subjects with skeletal Class II and Class
and eruption of permanent dentition, one study con- I malocclusion [36]. The study sample was rather
cluded that neither low birth weight, nor gestational small and they actually look at the eruptive position
age nor pubertal stage had significant influence on on panoramic radiograms but they concluded that in
dentition [28]. Associations has been found between part study results suggests that the maxillary second
maturity of primary dentition and permanent denti- molars may erupt earlier in patients with skeletal
tion in that a small number of primary teeth at 1 maxillary Class II malocclusions.
year of chronological age is associated with less Several studies showed that formation and
mature permanent teeth at 9–11 years of age in eruption of the maxillary teeth, especially molars,
children born preterm. Also positive correlation has are delayed in skeletal Class III patients [37]. One
been reported between PT children body height and study found the only teeth to be influenced by skel-
permanent teeth maturation stage (the taller preterm etal maxillary morphology (in particular maxillary
child was at the time of evaluation, the Demirjan retrusion) are maxillary second molars [38]. Authors
SDS was more advanced). The correlation between concluded that variables influencing delayed erup-
body height and permanent tooth emergence has tion were palatal length and chronological age.
been noted in another study in that stunted children Several studies tried to investigate the influence of
at 6 months of age were more likely to have non- facial type on dental development. The first conducted
emerged first upper left and lower right permanent study in this field concluded that skeletal open bite is
molars at 6 years of age. associated with advanced dental maturity if compared
to skeletal deep bite. The difference between dental
Socioeconomic factors ages was about 6 months [39]. However, the sample
In a number of studies it has been found that included in study was rather small and the two extreme
children from higher socioeconomic backgrounds groups were overlapping each other, which might have
show earlier tooth emergence than children from obscured results. Another study with a larger sample
lower socioeconomic classes [32], while others did group failed to find any significant difference in per-
not supported this theory [33]. manent teeth development between the short face and
It is thought that children from higher socio- the long face skeletal types [40].
economic class get better health care, nutrition
and these factors influence earlier development of hormonal factors
dentition. Disturbance of the endocrine glands usually has
Some researches found that permanent teeth a profound effect on the entire body, including the
eruption sequence is different among children from dentition. Hypothyroidism, hypopituitarism, hypo-
different socioeconomic classes. The first teeth to parathyroidism, and pseudohypoparathyroidism are
erupt in child’s from higher backgrounds oral cavity the most common endocrine disorders associated
is mandibular incisor as opposite to mandibular first with delayed permanent teeth eruption [41,42].
molar in children from lower class [16,33]. Accelerated dental development has been noted
in association with increased adrenal androgen se-
Body height and weight cretion, whereas the effect of an excess of growth
A positive correlation between body height and hormone and thyroid hormones on dental develop-
weight and teeth emergence has been established ment is less clear [8].
in the earlier studies [8,34]. The taller and heavier
children are slightly advanced dentally while it is Systemic diseases
apparent that stunting (retarded linear growth) is Most of the diseases reported in literature are
more strongly associated with delayed tooth erup- associated with delayed tooth eruption, and only
tion. diabetes accelerates tooth eruption [1,7]. There
Research on children obesity and dental devel- are different mechanisms for the delay, usually it
opment also showed a positive correlation: obese is associated with retained primary teeth, gingival
children mature earlier and teeth tend to erupt on hyperplasia, fibromatosis or hormonal changes
average 1.2 to 1.5 year earlier as compared to chil- which influences bone resorption rate. Diseases that
dren with normal body mass index [35]. interfere with tooth eruption are listed in Table 2.

70 Stomatologija, Baltic Dental and Maxillofacial Journal, 2010, Vol. 12, No. 3
REVIEW R. Almonaitiene, et al.

conclUSIon tors: genetics, nutrition, preterm birth, socioeco-

nomic factors, body height and weight, craniofacial
Permanent teeth eruption is a complex process morphology, hormonal factors and various systemic
that can be influenced by a number of general fac- diseases.

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Received: 13 10 2009
Accepted for publishing: 23 09 1010

72 Stomatologija, Baltic Dental and Maxillofacial Journal, 2010, Vol. 12, No. 3