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Eruption Abnormalities in Permanent Molars: Differential Diagnosis and Radiographic Exploration

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Eruption Abnormalities in Permanent Molars: Differential Diagnosis and Radiographic Exploration DOI: 10.1051/odfen/2014054 J Dentofacial Anom Orthod 2015;18:403 © The authors Eruption abnormalities in permanent molars: differential diagnosis and radiographic exploration J. Cohen-Lévy1, N. Cohen2 1 Dental surgeon, DFO specialist 2 Dental surgeon ABSTRACT Abnormalities of permanent molar eruption are relatively rare, and particularly difficult to deal with,. Diagnosis is founded mainly on radiographs, the systematic analysis of which is detailed here. Necessary terms such as non-eruption, impaction, embedding, primary failure of eruption and ankylosis are defined and situated in their clinical context, illustrated by typical cases. KEY WORDS Molars, impaction, primary failure of eruption (PFE), dilaceration, ankylosis INTRODUCTION Dental eruption is a complex developmen- at 0.08% for second maxillary molars and tal process during which the dental germ 0.01% for first mandibular molars. More re- moves in a coordinated fashion through cently, considerably higher prevalence rates time and space as it continues the edifica- were reported in retrospective studies based tion of the root; its 3-dimensional pathway on orthodontic consultation records: 2.3% crosses the alveolar bone up to the oral for second molar eruption abnormalities as epithelium to reach its final position in the a whole, comprising 1.5% ectopic eruption, occlusion plane. This local process is regu- 0.2% impaction and 0.6% primary failure of lated by genes expressing in the dental fol- eruption (PFE) (Bondemark and Tsiopa4), and licle, at critical periods following a precise up to 1.36% permanent second molar iim- chronology, bilaterally coordinated with fa- paction according to Cassetta et al.6. cial growth. However rare, these abnormalities repre- Unlike the third molars, in first and second sent a real therapeutic challenge32: permanent molars eruption abnormalities – situated distally and sometimes deeply, are relatively rare, estimated at 0.06% by they are difficult of access for the sur- Prece25; Grover17 reported similar prevalence, geon and orthodontist; Address for correspondence: Article received: 30-10-2014. Julia Cohen-Lévy Accepted for publication: 27-11-2014. 255, Rue Saint-Honoré 75001 Paris This is an Open Access article distributed under the terms of the Creative Commons Attribution E-mail: [email protected] License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1 Article available at https://www.jdao-journal.org or https://doi.org/10.1051/odfen/2014054 J. COHEN-LÉVY, N. COHEN – as anchorage is strong, movement or not, but in which eruption is ar- is difficult to control without impact rested by an obstacle. Once the on proximal teeth; obstacle has been lifted, the tooth – they may fail to respond to ortho- conserves evolutive potential and dontic treatment, and may show can resume eruption; ankylosis, to the frustration of both – a “disinvested tooth” is a tooth that patient and care team5,22,23. had been impacted but becomes The present article defines termi- exposed to the oral cavity. nology in eruption abnormality (non- The World Health Organization eruption, retention, embedding and (WHO) drew up its Classification of impaction, ankylosis, and failure Diseases and Related Health Prob- of eruption), then analyzes various lems (ICD); ICD-10 is the 10th version. clinical situations and associated ra- It defined “embedded tooth” as a diographic signs. Complementary ex- tooth that has not erupted into the aminations (panoramic X-ray, lateral arcade despite absence of obstacle, teleradiography, CT or cone-beam and “impacted tooth” as a tooth hin- CT cross-sectional imaging) should dered by an obstacle. be systematically analyzed, without Raghoebar27,28 gave definitions overlooking their shortcomings. based on etiology: – “impacted” teeth, blocked in erup- tion by a mechanical obstacle, TERMINOLOGY AND DEFINITIONS without alteration of the eruption process as such, which continues Certain of the definitions used by once the obstacle has been lifted; the French health authority (Haute – teeth in which the eruption process Autorité de Santé, formerly ANAES1) is impaired. Such “retention” may were adopted and explained by Favre be isolated or associated with other de Thierrens et al.13,14: genetic abnormalities. There are 2 – an “unerupted“ tooth is a mature associated clinical entities: ankylo- tooth that has failed to erupt by sis (OMIM #157950) and primary the physiological date, with a peri- failure of eruption (PFE), a genetic coronary follicule lacking commu- disorder (OMIM #125350). nication with the oral cavity. An According to Raghoebar27,28, in PFE unerupted tooth may or may not be the tooth remains in an infracrestal covered by bone tissue, but is to- position, never penetrating the oral tally covered by the oral mucosa; cavity; in secondary failure of eruption – a “retained” tooth is an immature (SFE), eruption is interrupted suprac- tooth in which eruption is hindered restally, after penetration into the cav- but evolutive potential is conserved. ity. In recent publications, the terms Radicular edification is not arrested “primary” and “secondary” have (open apex). With maturation, “re- given way to “infra-/supra-crestal”, tention” becomes inclusion or em- which are more descriptive, free of bedding; etiological presuppositions31. – an “impacted” tooth is a mature In French, however, we feel that the tooth, which may be unerupted term “rétention” may be confusing 2 Cohen-Lévy J., Cohen N. Eruption abnormalities in permanent molars: differential diagnosis and radiographic exploration ERUPTION ABNORMALITIES IN PERMANENT MOLARS: DIFFERENTIAL DIAGNOSIS AND RADIOGRAPHIC EXPLORATION and should not be used for an erup- PFE is that all the teeth distal to the tion abnormality: treatment is quite first to be affected are also involved; different if the tooth is “retained” by they do not respond to orthodontic an obstacle, as could quite naturally treatment, and undergo secondary be said in French, whereas the Eng- ankylosis15,16,26,31. lish term “retention” specifically im- Isolated ankylosis and PFE are plies the absence of any obstacle and very difficult to differentiate, espe- rather an impaired eruption process. cially in young patients31-33, but every Ankylosis is defined histologically effort should be made to do so, as as fusion of the cementum with the treatment is radically different31,34, alveolar bone in at least 1 zone, which despite the similar clinical aspect thus lacks any ligament space. Etiol- of infra-occlusion. In PFE, all the ogy is generally traumatic and anky- distal teeth are affected, cannot be losis in a tooth thus tends to be iso- mobilized, and undergo secondary lated. ankylosis; in isolated ankylosis, by In PFE, there is no primary ankylo- contrast, the distal teeth respond to sis, but rather a disorder of the erup- orthodontic displacement, and ortho- tion mechanism, totally or partially dontic treatment is feasible (perhaps preventing tooth progression. In case with extraction of the ankylosed of early extraction, PFE teeth show tooth, or mobilizing only the adjacent normal mobility. The specificity of teeth)15,16,26,31. GENERAL HISTORY Eruption abnormalities may be isolat- and optic atrophy)9 (OMIM ed or associated with other disorders, #230740); explored by the medical questionnaire – osteopetrosis or osteosclerosis and history-taking, looking for endocrine (also known as marble bone dis- disorders (hypopituitarism, hypothyroid- ease: OMIM #259700 #259710 ism, parathyroid pathology), phospho- #259730 for recessive forms, and calcic metabolism disorder (rickets, Al- #166600 #607634 for dominant bright’s disease), and signs of genetic forms). abnormalities that may be associated Familial history of posterior with generalized dental retardation: tooth eruption disorder should – cleidocranial dysplasia (sequela of be investigated (siblings6,7,12, cleidocranial dysostosis or Marie- parents6,7,19,29-31), as PFE is often Sainton syndrome, now classified associated with non-syndromic as OMIM #119600); genetic abnormalities (familial in – mucopolysaccharidosis; 10-40% of cases4). Mutations or – Gorlin-Goltz syndrome (OMIM single nucleotide non-function- #109400); al polymorphisms of the gene – GAPO syndrome (growth retarda- coding for parathyroid hor- tion, alopecia, pseudo-anodontia mone 1 receptor24 (PTH1R, on J Dentofacial Anom Orthod 2015;18:403 3 J. COHEN-LÉVY, N. COHEN chromosome 310,15,16,31) have been Other associated dental abnormali- reported31. Transmission is auto- ties (class-III malocclusion, decidu- somal-dominant with incomplete ous molar ankylosis) have also been penetrance2,4. reported in PFE3,31,36. SYSTEMATIC RADIOGRAPHY ANALYSIS In a clinical situation with missing – Germ orientation (coronary mesio- molars, various diagnoses are to be version or straight axis), project- excluded: general retardation of den- ing the eruption pathway to check tal age, locally retarded eruption (due for obstacles. The developmental to an obstacle, or not) or one or more axis of the mandibular molars is ageneses (fig. 1). determined by the inclination of Panoramic radiography is essential, the dental lamina, which curves in- to inventory dental abnormalities (of ward at the mandibular angle dur- form, position and structure), com- ing growth: PFE or ankylosis may pare progression between left and often be suspected is eruption is right sides, and give a general im- arrested despite a
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