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Eruptive Tooth Movement May Be Prevented Or Modified by a Variety of Clinical Interventions

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Eruptive Tooth Movement May Be Prevented Or Modified by a Variety of Clinical Interventions PRACTICE IN BRIEF ● Eruption is both a developmental and adaptive process, and continues throughout life. ● Overeruption can be expected to occur when an opposing tooth is lost. ● Overeruption of an unopposed tooth may present challenges for restoration. VERIFIABLE ● Eruptive tooth movement may be prevented or modified by a variety of clinical interventions. CPD PAPER ● Considerations of the possible consequence of leaving a tooth unopposed, need to be addressed as part of the general treatment planning. Eruptive tooth movement — the current state of knowledge H. L. Craddock1 and C. C. Youngson2 How the dentition erupts, and what controls it, is fundamental to almost all aspects of clinical dentistry, yet the mechanisms behind this have not yet been fully elucidated. When the process continues into space that has been created through toothwear or tooth loss, problems in placing restorations can be encountered. This review examines the possible mechanisms of tooth eruption. Differences between processes in animals and humans are highlighted. The limitations of conclusions drawn from animal studies are then discussed with reference to human dental conditions. The differing forms of overeruption in humans are described and the treatment options for overerupted teeth, including prevention of the situation arising, are provided with a discussion of the quality of the evidence base behind these. INTRODUCTION by members of several dental disciplines, SELECTION CRITERIA Understanding of eruptive tooth movement and the possible consequences of this A Medline literature search was carried out is not only relevant to orthodontists and must therefore be appreciated by them all, into the mechanisms of eruption, progress paediatric dentists, but should also be to aid in both the decision making throughout adulthood, physiological factors appreciated by all dentists in order to pro- process, and in the planning of future limiting or modifying eruptive movement vide the most appropriate care for some of tooth replacement. and clinical interventions capable of modi- their adult patients. Orthodontists take advantage of this fying or preventing vertical tooth move- Eruptive tooth movements continue physiological movement at certain stages ment. Key search words were: tooth erup- throughout life, and are most conspicuous- in corrective treatment, and in the growing tion — physiology, compensatory eruption, ly seen in the overeruption of unopposed patient the extent of this can be fairly pre- overuption, supereruption, supraeruption, teeth, and in wear cases, where occlusal dictable. They are equally aware that this hypereruption, axial tooth movement, vertical dimension is maintained. In the predictability is far less in adults. Restora- occlusal vertical dimension, correction of Western population, the numbers of these tive dentists regularly see what is some- overeruption and Dahl appliance. A total of types of cases are seen with increasing reg- times a dramatic loss of interocclusal space 433 references were identified from the ularity, and an understanding of the effects following an extraction of an opposing search. of these types of movements is important tooth. However in order to understand why The vast number of papers on eruptive in the management of both the simple and this takes place a knowledge of the mecha- tooth movement that have been published advanced restorative case. nism of eruption is needed. over the previous century necessitates The decision to extract a tooth, which some criteria for inclusion in this review. will render the unopposed tooth at risk of PURPOSE OF THE REVIEW Many theories are not yet fully proven and vertical positional changes, will be made This review of the literature was undertaken commonly held beliefs cannot be dis- with a view to increasing the understand- proved. The review included papers that: ing of vertical positional changes that may 1*Lecturer in Restorative Dentistry, 2Senior Lecturer in Restorative Dentistry, Division of Restorative Dentistry, occur throughout life, including: • Were available in English Leeds Dental Institute, Worsley Building, Clarendon Way, • The mechanisms that occur during • Provide clear contemporary evidence Leeds LS2 9LU *Correspondence to: H. L. Craddock developmental eruption • Form the basis for the commonly taught Email: [email protected] • Eruption in the adult texts on this subject • Factors preventing and limiting erup- • Illustrate limitations of previous studies Refereed Paper on which current belief is based doi:10.1038/sj.bdj.4811712 tion, and Received 20.12.02; Accepted 29.07.03 • Clinical interventions which may pre- • Suggest hypotheses, backed by strong © British Dental Journal 2004; 197: 385–391 vent and reverse eruptive movements. evidence, but not yet proven BRITISH DENTAL JOURNAL VOLUME 197 NO. 7 OCTOBER 9 2004 385 PRACTICE • Suggest clinically useful interventions dogs, showed the tooth itself played no part the dental follicle. These experiments how- and recommendations. in the eruptive process. In this investigation ever, provide no evidence that the follicle is tooth germs were removed and replaced involved in determination of final tooth Whenever possible human studies were with dead crown shells, synthetic substi- position. cited, and when animal studies were used tutes or given no form of replacement. The their limitations were discussed. Using follicular changes and the path of eruption Periodontal ligament these criteria 31 papers were selected and were no different from that seen in normal- Ten Cate1 looked for evidence to support are discussed in the following sections. ly erupting teeth, with the exception of the the theory of the periodontal ligament hav- group which used methyl methacrylate ing a major role in determining tooth erup- MECHANISM OF ERUPTION replica teeth. The methacrylate substitute tion. Strong evidence exists to show that Eruptive tooth movements are involved in group did not erupt, and inflammatory the periodontal ligament, which is derived primary eruption, supraeruption, impaction, changes were seen in the follicle. Although from the dental follicle, provides the force alveolar compensation following wear, as small sample sizes were used in this study, required for eruption. The cells thought to well as failure of eruption. For the purposes the results were nonetheless conclusive, be responsible are the fibroblasts within the of this paper, eruption into an initial func- and also serve to illustrate that inflamma- periodontal ligament, which have contrac- tional position and post-eruptive move- tion and disruption of the follicle may tile potential. An early paper by Ten Cate ment will be considered as two distinct impede eruption. This followed on from the et al.6 discussed the role of fibroblasts in phases of eruptive movement, although earlier study by the same group,3 designed the remodelling of the periodontal liga- some of the mechanisms may be similar. to assess the relative importance of the ment, citing various studies indicating the Meaningful scientific study of erup- gubernaculum dentis, tooth root, tooth role of fibroblasts in phagocytosis during tion is difficult in that tooth structure and crown and the dental follicle in the process re-modelling, increased fibroblastic activi- eruption vary from one species to anoth- of eruption. The dental follicle was found to ty during eruption and the distribution of er, and that histological studies in be the only structure necessary for an erup- fibroblasts within the periodontal ligament humans are rarely possible because of the tive pathway to develop and eruption to as indicators that fibroblasts play a key role inaccessibility of tissue for sampling and proceed. Again, relatively small numbers of in physiologic tooth movement. Although ethical considerations. subjects produced conclusive evidence. informative, this study consisted of histo- Many of our standard undergraduate Tooth morphology in the dog is sufficiently logical observations, and did not provide texts on eruption rely heavily on the evi- similar to that of humans to indicate that sufficient data on the origins of the tissues dence of animal experiments to explain the this study of primary eruption may also be studied (ie species, age, whether eruption mechanisms involved in tooth eruption. applicable to humans. was occurring) to enable the reader to Whilst providing valuable background accurately extrapolate the findings to knowledge of the processes likely to be Hydrostatic pressure eruptive tooth movement in humans. Ten involved in eruptive movement, this can- A number of studies exist to demonstrate Cate's theories have been further studied by not be directly extrapolated to the mecha- that there is a hydrostatic pressure differ- Berkovitz,7 who also agreed that no one nisms involved in humans for reasons that ential between the tissues investing the hypothesis can fully explain the mecha- will be explained. erupting tooth crown and its apical nism of tooth eruption. He proposed a mul- extent. tifactorial concept of tooth eruption, which ERUPTION The hydrostatic theory was investigat- embraces Ten Cate's favoured theory of Tooth eruption is defined as the process ed by Van Hassel and McMinn4 again fibroblast contraction, although recognis- whereby a tooth moves from its develop- using dogs, who found that the tissue ing the limitations of in vitro tissue studies. mental position within the jaws to emerge pressure apical to the erupting tooth was He also noted that there
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