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10 Evaluation of Unerupted Teeth: Orthodontic Viewpoint
1® Evaluation of unerupted teeth: orthodontic view point Nicholas A. Di Salvo, DDS, PhD, New Y ork
O rthodontists, in evaluating unerupted teeth, must take into consideration the role o f such teeth in the overall treatm ent o f malocclusions. Such teeth sometimes may be included in a plan fo r too th removal. In certain situations, the possible etiologic factors must be considered, and the treatm ent plan may be either no treatm ent; o rth o d o n tic treatm ent alone; surgical treatm ent alone, or combined orthodontic-surgical management.
An
u n e ru p te d
c o n ta in e d
to o th
w ith in
th e
q u i t e o b v i o u s l y is a n y t o o t h
t is s u e s o f t h e j a w
s u e s o f t h e o r a l c a v i t y . A t s o m e t i m e t h i s is a n o r m a l c o n d it io n
fo r
a ll
t e e t h . H o w e v e r , t h is
p r e s e n ta t io n
w i l l d e a l w i t h th o s e s itu a tio n s in w h ic h th e c o n d it io n p e r s is ts
beyond
th e
tim e
w hen
n o rm a l
e r u p tio n
s h o u l d h a v e o c c u r r e d o n t h e b a s is o f a c c e p t e d c r i t e r i a o f d e n ta l d e v e lo p m e n t. T h e e a s ie r
to
d ea l w ith
e r u p tio n T h e fir s t c o n s id e r a tio n in th e e v a lu a tio n o f u n e r u p t e d
b o n e s , th e
c r o w n o f w h ic h h a s n o t y e t p e n e tr a t e d th e s o ft tis
w e re
i f th e
s u b je c t w o u l d b e m u c h n o rm a l p ro c e s s o f to o th
u n d e rs to o d , b u t
s u c h is n o t y e t t h e
s ta te o f th e a r t . 1
t e e t h b y t h e o r t h o d o n t i s t is t o d e t e r m i n e w h a t r o l e th is c o n d it io n
c a n b e s t p la y in th e o v e r a ll tr e a tm e n t
o f th e m a lo c c lu s io n . S in c e t r e a t m e n t o f t h i s c o n d i t i o n p r e s e n t s c e r t a i n p r o b le m s ,
such
as
th e
p o s s ib ility
o f th e
need
N o rm a l to o th d e ve lo p m e n t
fo r
s u r g ic a l i n t e r v e n t i o n , p r o lo n g a t i o n o f t r e a t m e n t t i m e , u n c e r ta in ty
o f o u t c o m e , a b e r r a tio n s in t o o t h f o r m ,
a n d s o o n , a n a t u r a l i n c l i n a t i o n is t o t r y t o a v o i d t h e is s u e w h e r e v e r e ru p te d to o th w h e re
to o th
t h i s is p o s s ib le b y i n c l u d i n g t h e u n in to
u n it
a p la n c a llin g f o r t o o t h r e m o v a l, r e d u c t io n
is i n d i c a t e d
fo r p ro p e r
t r e a tm e n t o f th e m a lo c c lu s io n .
b irth
s e le c t e d in s t a n c e s
th e
ja w s
o f
th e
hum an
in fa n t n o r m a lly
c o n t a i n a l l 2 0 d e c i d o u s t o o t h c r o w n s i n v a r i o u s s ta g e s of
d e v e lo p m e n t,
as
w e ll
as
th e
buds
o f th e
fir s t
p e r m a n e n t m o la r s . T h e c r o w n s o f th e l a t t e r m a y h a v e begun
to
a lr e a d y
T h i s c a n o f t e n b e d o n e s u c c e s s f u l l y i n in s t a n c e s o f u n e r u p t e d p r e m o la r s , a n d e v e n in
A t
c a lc ify .
fu lly
The
fo rm e d
d e c id o u s and
in c is o r
c a lc if ie d
c ro w n s
and
a re
th e ir
ro o t
g ro w th
and
f o r m a t io n q u ite a d v a n c e d .2 In
th e
n o rm a l
p ro c e s s e s
of
d e v e lo p m e n t, th e
d o e s n o t w o r k v e r y w e ll in o t h e r s itu a tio n s . W h e re n o
fa c e s o f th e a lv e o la r b o n e as r o o t f o r m a t i o n a d v a n c e s . is b e l i e v e d
c ro w n s m o v e
d e n ta l
o f u n e r u p t e d c a n in e s . H o w e v e r , t h i s a p p r o a c h u s u a l l y
to
be
due
to
to w a rd
th e o ra l s u r
p r a c t ic a l m e a n s c a n b e f o u n d t o e lim in a t e th e p r o b
T h is
l e m , o n e p r o c e e d s w i t h a n a n a ly s i s o f t h e s i t u a t i o n .
p r e s s u r e c r e a t e d b y t h e p r o l i f e r a t i o n o f t h e t is s u e s o f
s lig h t in c r e m e n ts o f
JADA, Vol. 82, April 1971 ■ 829
4
*
F ig 1 • F u ll-m o u t h ra d io g ra p h s o f tw o sisters
s h o w in g
g e n e ra liz e d
d e la y e d
e r u p tio n . M o t h e r sta te s b o t h c h ild re n w e r e " la t e te e t h e r s ." O th e rw is e h is to ry is n e g a tiv e . T o p : O n e ag e d 1 4 y e a rs , 1 0 m o n th s . B o t t o m : O th e r ag e d 1 3 y e a rs , 1 m o n t h . N o t e th e p o o r a x ia l in c lin a tio n o f u p p e r c a n in e s in o ld e r sister. These
te e th
a llo w e d
to
w e r e s u rg ic a lly e x p o s e d , e r u p t,
and
f i n a ll y
p o s i
tio n e d o r th o d o n t ic a lly .
th e p u lp
a n d r o o t a g a in s t a n a p i c a l l y s i t u a t e d , r e s is
t a n t b a n d o f tis s u e , th e “ h a m m o c k lig a m e n t .” s h o u ld
One
p o i n t o u t , h o w e v e r , t h a t t h is v ie w h a s b e e n
s e r io u s ly
c h a lle n g e d
s in c e
e x p e r i m e n t a l e v id e n c e i n
ra c e , a n d o t h e r fa c t o r s .7 N e v e rth e le s s , u s e fu l s ta n d a rd s h a v e
been
fo rm u la te d
w ith
re g a rd
to
age a n d
s e q u e n c e o f e r u p t i o n o f th e t e e t h in b o t h d e c id u o u s a n d p e r m a n e n t d e n titio n s .®
W it h d u e a llo w a n c e f o r
a n i m a l s i n d i c a t e s t h a t e r u p t i o n m a y p r o c e e d i n s p it e
n o r m a l in d iv id u a l v a r ia t io n , w h e n
of
to o th
m a d e its a p p e a ra n c e in to th e o r a l c a v ity b y th e tim e
l ig a -
i t s e r u p t i o n is n o r m a l l y e x p e c t e d o n t h e b a s is o f t h e s e
la c k
of
tis s u e s a n d * 3 -6 m e n t.
p r o life r a t io n in
th e
o f a p ic a l b o n e
absence
of
th e
and
ham m ock
s ta n d a rd s , th e
In d u e t im e , th e f o llic le w h ic h c o n ta in s th e t o o t h
c lin ic ia n p r o p e r ly
a to o th
seeks to
has n o t
d e te r m in e
w hy.
c r o w n r e a c h e s a n d p e r f o r a t e s t h e o r a l s u r fa c e o f a lv e
O fte n
th e re
is
c o n s id e r a b le
v a r ia tio n .
In
d e te r
a n d m a k e s it s
m i n i n g w h e t h e r o r n o t a p a r t i c u l a r i n s t a n c e is s i m p l y
a p p e a r a n c e i n t h e o r a l c a v i t y ; i t is t h e n s a id t o h a v e
n o r m a l in d iv id u a l v a r ia tio n o r a b n o r m a l r e ta r d a t io n ,
o la r b o n e
“ e r u p te d .”
and
its o v e r ly in g
m ucosa
T h e p ro c e s s n o r m a lly c o n tin u e s u n t il th e
o n e s h o u l d f i r s t n o t e i f t h e c o n d i t i o n is g e n e r a l i z e d ,
e n t i r e a n a t o m i c c r o w n is e x p o s e d b y a c o m b i n a t i o n
in v o lv in g
o f t o o t h m o v e m e n t t o w a r d th e lin e o f o c c lu s io n , a n d
t e e t h in a p a r tic u la r a re a .
m any
t e e t h , o r lo c a liz e d
to
o n e o r a fe w
a n a p ic a l m ig r a t io n o f th e g in g iv a l a t t a c h m e n t t o w a r d th e c e rv ic a l lin e o f th e t o o t h . U p p r o c e s s is c a l l e d fro m
“ a c tiv e ”
e r u p tio n
to to
t h is p o i n t th e
■ G e n e r a liz e d
d is t in g u is h i t
c a te s r e t a r d e d
th e la te r e r u p tio n w h ic h c o n tin u e s th r o u g h o u t
re ta r d a t io n
o f
e r u p t io n :
T h is
in d i
d e n ta l age a n d m a y b e a n o r m a l in d i
v i d u a l v a r i a t i o n , e s p e c i a l l y i f t h e h i s t o r y d is c lo s e s t h a t
l i f e , c o m p e n s a t i n g f o r o c c lu s a l w e a r f r o m a t t r i t i o n i n
th e
fu n c t io n .
u s u a l a g e ( t h a t is , l a t e r t h a n 5 t o 7 m o n t h s o f a g e ) .
p a t ie n t’ s fir s t
to o th
w as
“ c u t”
a t a la te r-th a n -
A l s o t h e r e is s o m e e v id e n c e t h a t l a t e e r u p t i o n m a y b e fa m ilia l ( F ig 1 ). T h u s a f a m ily h is to r y m a y b e h e lp f u l.
V a ria tio n s in e ru p tio n
In
such
i n s t a n c e s , t h e p a t i e n t is s i m p l y k e p t u n d e r
p e r i o d i c o b s e r v a t i o n a n d i n t e r v e n t i o n is n o t i n d i c a t e d as l o n g a s p r o g r e s s is e v i d e n t . S e v e ra l s tu d ie s o f t o o t h e r u p t i o n in d ic a t e t h a t t h e r e m a y b e c o n s id e r a b le v a r ia t io n a c c o r d in g t o a g e , s e x ,
830 ■ JADA, Vol. 82, April 1971
On
t h e o t h e r h a n d , o n e s h o u l d a t le a s t c o n s id e r
th e p o s s ib ility o f m e t a b o lic o r e n d o c r in e d is tu rb a n c e .
A
h i s t o r y s h o u ld b e t a k e n w i t h th is in m in d a n d , i f
i n d i c a t e d , t h is s h o u ld b e f o llo w e d b y a m e d ic a l c o n s u lta tio n .2
T re a tm e n t
w o u ld
th e n
depend
on
th e
m e d ic a l fin d in g s . A n o t h e r p o s s i b i l i t y t o b e c o n s id e r e d is h y p o d o n t i a (p a r t ia l a n o d o n t ia ) in v o lv in g th e s e c o n d a ry te e t h . In th e s e
s itu a tio n s
one
u s u a lly
a tte m p ts
to
r e ta in
as
m a n y a s is p o s s ib le o f t h e d e c id u o u s t e e t h , t h e s u c c e s s o rs o f w h ic h a re a b s e n t. H o w e v e r , th e t r e a t m e n t p la n is i n d i v i d u a l i z e d
a c c o r d in g
to
th e
o v e r a ll o c c lu s io n
a n d th e c o n d it io n o f th e d e c id u o u s t o o t h r o o t s . M o s t c o m m o n ly t h e a b s e n c e in v o lv e s lo w e r s e c o n d p r e m o la r s
w ith
W h e re
u p p e r l a t e r a l in c i s o r s n e x t
o n ly
tre a tm e n t
th e s e
m ay
te e th
be
a re
in
fre q u e n c y .
in v o lv e d ,
o r th o d o n tic
e m p lo y e d , a fte r re m o v a l
d e c i d u o u s t e e t h , t o c lo s e
o f th e
sp a c e s a n d a v o id p r o s th e tic
re p la c e m e n t. F ig 2 ■ T o p : B ila te r a l sp a ce d e f ic ie n c y in lo w e r s e c o n d p r e ■
L o c a liz e d
G u n te r ,9
re ta rd e d
fa ilu r e
o f
A c c o r d in g
e r u p t io n :
e r u p tio n
o c c u rs ,
in
to
d e c re a s in g
o r d e r o f f r e q u e n c y , in m a n d ib u la r t h ir d m o la rs ; m a x illa r y
th ir d
m o la rs ;
m a x illa r y
m o la r areas in a g ir l,
c o n d it io n
is l o c a l i z e d
tr e a te d o r th o d o n tic a lly b y re m o v a l o f f o u r p r e m o la rs .
and
in v o lv e s
o n e o r fe w
U n ila t e r a l fa ilu r e
S a l z m a n n 10 e r u p tio n :
of
e r u p tio n
a ffe c tin g
o f e r u p tio n
o f in d iv id u a l te e t h
in d ic a t e s t h a t lo c a l f a c t o r s a r e m o s t l ik e l y t h e c a u s e .
la te ra l o r u n ila te r a l. fa ilu r e
m o n t h s o ld . B o t to m :
c a n in e s ; m a n d i b u l a r
t e e t h , o n e s h o u l d n o t e w h e t h e r t h e c o n d i t i o n is b i
B ila te r a l
y e a rs , 9
o ld g irl. T h e s e g irls h a d a rc h le n g th d e fic ie n c ie s t h a t w e re
s e c o n d p r e m o la r s ; a n d m a x illa r y s e c o n d p r e m o la r s . I f th e
11
B ila te r a l sp a ce d e f ic ie n c y In u p p e r c a n in e areas in a 1 0 y e a r
a n tim e re s
l is t s
th e
fo llo w in g
causes
■ D is ta n c e o f t o o t h f r o m its p la c e o f e r u p t io n .
p le , b ila te r a l im p a c t io n o f lo w e r s e c o n d p r e m o la r s o r
■ M a lfo r m a tio n o f th e to o th .
upper
■ P re s e n c e o f s u p e rn u m e ra ry te e th .
d e f ic ie n c y e ru p t
m ay
s in c e t h e s e
“ w ith in ”
posed
occur
to
th e
th e
a re
in
u s u a lly
r e s p e c tiv e
m o la rs w h ic h
d is ta l t o
th e
th e re fo r e
o fte n
p e rs o n s w ith
an
a rc h
th e la s t t e e t h to
■ T ra u m a o f to o th g e rm .
d e n ta l a rc h e s , as o p
e ru p t
“ o u ts id e
■ In fe c tio n o f to o th g e rm .
o f ’ or
tr a n s it io n a l d e n titio n . T h e s e te e t h
are
■ D is p la c e m e n t o f t o o t h g e r m o r t o o t h b y a n e o p la s m .
“ lo c k e d o u t ” b e c a u s e o f in s u f fic ie n t
■ A n k y lo s is o f th e t o o t h w i t h t h e j a w b o n e .
s p a c e in w h ic h t o e r u p t as a re s u lt o f in a d e q u a te b a s a l a rc h le n g th d e v e lo p m e n t ( F ig 2 ) . ( T h e te r m
“ im p a c
d e la y e d
■ E c t o p ic p o s it io n o f th e t o o t h .
m a y b e a n in d ic a t io n o f g r o w th d e f ic ie n c y . F o r e x a m
c a n in e s
of
■
S y s t e m i c d is e a s e s s u c h a s d i e t a r y , m e t a b o l i c a n d
e n d o c r in e d is tu rb a n c e s .
t i o n ” is u s e d t o r e f e r t o s i t u a t i o n s i n w h i c h f a i l u r e o f
T o th e s e m a y b e a d d e d :
e r u p t i o n is a p p a r e n t l y d u e t o a m e c h a n i c a l b l o c k i n g ,
■ O v e r - r e t e n t io n o f d e c id u o u s p r e d e c e s s o r .
such
■ L a c k o f sp a c e fo r th e t o o t h in th e d e n ta l a rc h .
as b y th e p r e s e n c e o f a d ja c e n t te e t h o r o t h e r
s tr u c tu r e in th e p a th o f e r u p t io n .) A n o th e r tio n ”
e x a m p le
is t h e
■ M u c o s a l b a r r ie r d u e t o g in g iv a l fib r o s is .
s o -c a lle d “ e c t o p ic e r u p
A n a ly s is o f a p r o b le m o f la c k o f e r u p t i o n in v o lv e s
o f f i r s t m o l a r s w h e r e e r u p t i o n o f t h i s t o o t h is
e x a m in a t io n o f th e t o o t h w i t h r e s p e c t t o : its p re s e n c e
b lo c k e d b e c a u s e o f a b n o r m a l re s o r p tio n o f th e d is ta l
in
s u rfa c e
n a tu re
o f th e
d is ta l
r o o t o f th e d e c id u o u s s e c o n d
th e j a w ; its p o s it io n
m o la r , le a v in g a n o v e r h a n g in g c r o w n u n d e r w h i c h th e
tio n s
p e rm a n e n t
a lr e a d y lis te d ).
m ay
m o la r b e c o m e s
tr a p p e d . T h is
c o n d it io n
b e a n in d ic a t io n o f in s u f fic ie n t a r c h le n g th to
a c c o m o d a te th e f u ll a d u lt d e n titio n w it h o u t c r o w d
th a t m a y
To
e v a lu a te
it
le m s .
based on
e v a lu a tio n
and
in v o lv e s
u s u a lly
a
c o m p le te
o r th o d o n tic
in c lu d e s r e m o v a l o f t w o
or
be
an
in te r fe r in g
u n e ru p te d
w ith
to o th
its e r u p t io n
an
(a s
in it ia l ju d g
m e n t is r e q u i r e d r e g a r d i n g t h e p r o g n o s i s f o r b r i n g i n g
in g .2 T h e s e s itu a tio n s a re p r im a r ily o r t h o d o n t ic p r o b T re a tm e n t
a n d a t t i t u d e ; t h e s ta g e a n d
o f it s d e v e lo p m e n t ; a n d o b v io u s lo c a l c o n d i
in to
good its
assessed fr o m
f u n c t i o n a l p o s i t i o n . T h i s e v a l u a t i o n is m o r p h o lo g y , p o s it io n , a n d a t t it u d e
as
g o o d r a d i o g r a p h s . T h e f i l m s w i l l a ls o
fo u r p e r m a n e n t te e th in o r d e r to a c c o m m o d a te th e
in d ic a t e w h e t h e r t h e r e a r e a n y o b v io u s f a c t o r s im p e d
d e n t it io n to th e d e f ic ie n t s k e le ta l b as es.
in g e r u p t io n .
Di Salvo: EVALUATION OF UNERUPTED TEETH ■ 831
F ig 4 ■ E r u p tio n o f u p p e r s e c o n d p r e m o la r a f t e r o r th o d o n tic re c re a tio n o f space in a 1 0 y e a r o ld g irl. F ig 3 ■ S p o n ta n e o u s u n a id e d e r u p tio n o f p a r tia lly b lo c k e d o u t u p p e r s e c o n d p r e m o la rs in a g irl b e tw e e n th e ages o f 1 V A (t o p ) a n d
1 2 ( b o t t o m ) . H o w e v e r, lo w e r r ig h t s e c o n d p r e
m o la r , m o r e c o m p le t e ly b lo c k e d , d id n o t e r u p t, a lth o u g h s o m e In c re a s e in sp a ce d id d e v e lo p .
lo s s o f t h e p r o b le m tio n .
d e c id u o u s
The
p ro c e d u re
o r th o d o n tic
C linical m anagem ent
second
m o la r .
H o w e v e r , th e
m a y a r is e i n a l m o s t a n y p a r t o f t h e d e n t i is
to
r e - e s t a b li s h t h e s p a c e b y
m o v e m e n t o f th e a d ja c e n t te e th
w h ic h
h a v e p r e -e m p te d i t , a n d to a llo w th e u n e ru p te d to o th t o m o v e in t o p o s it io n . P e r io d ic r a d io g r a p h s a re ta k e n t o d e te r m in e w h e t h e r e r u p tiv e m o v e m e n ts a re o c c u r
In
th e c lin ic a l m a n a g e m e n t o f u n e r u p t e d t e e t h , f o u r
r in g . I f
th e y
a r e , i t is s i m p l y a m a t t e r o f w a t c h f u l
p o s s ib ilitie s m a y b e c o n s id e r e d : n o t r e a t m e n t ; o r t h o
w a itin g . W h e n e r u p tio n o c c u rs , th e t o o t h m a y o r m a y
d o n t i c t r e a t m e n t a lo n e ; s u r g ic a l t r e a t m e n t a lo n e ; o r
not
c o m b in e d o r th o d o n tic - s u r g ic a l m a n a g e m e n t.
n e e d s o f th e case (F ig 4 ) .
■ N o th e
In
tre a tm e n t:
p o s it io n
g r o w in g
o r a ttitu d e
in d iv id u a ls in
o f th e
to o th
w hom
is s u c h
be
d ir e c te d
o r th o d o n tic a lly
■ S u rg ic a l tre a tm e n t a lo n e :
d e p e n d in g
on
th e
T h is a p p r o a c h le n d s i t
th a t
s e lf b e s t to s itu a tio n s in w h ic h t h e b lo c k t o e r u p tio n
s u r g i c a l a c c e s s is h a z a r d o u s t o t h e s u r r o u n d i n g s t r u c
i n v o l v e s t is s u e w h i c h is e i t h e r e x p e n d a b l e o r i n d i c a t e d
t u r e s , s u c h a s o t h e r t e e t h , s in u s c a v i t i e s , m a j o r b l o o d
fo r
v e s s e ls o r n e r v e s , a n d s o o n , a n d w h e r e
r e t a in e d d e c id u o u s t e e t h , o r p a t h o lo g y in v o lv in g b o n e
t h e r e is n o
re m o v a l
(s u c h
as, s u p e rn u m e ra ry
t e e t h , o v e r ly -
im m e d ia te n e e d to in te rv e n e b e c a u s e o f a p a th o lo g ic
or
c o n d it io n , t r e a t m e n t s h o u ld b e d e f e r r e d a n d th e p a
a t t i t u d e o f t h e t o o t h is f a v o r a b l e f o r e r u p t i o n .
t i e n t k e p t u n d e r p e r io d ic r a d io g r a p h ic e x a m in a t io n .
s o ft
t is s u e s ) a n d
T h e p ro c e d u re
a g a in , w h e r e
th e
p o s itio n
and
is t o r e m o v e t h e i m p e d i m e n t , a n d
O f t e n th e p o s it io n s o f th e s e te e t h w i l l c h a n g e , m a k in g
t o a s s is t e r u p t i o n b y e x p o s i n g t h e c r o w n a s m u c h a s is
th e
m o r e fa v o r a b le . A ls o
p o s s ib le . I d e a l l y
in
th a t
c e r v ix , o r a t le a s t b e l o w t h e h e ig h t o f c r o w n c o n t o u r ,
s e e m e d h o p e le s s ly s it u a t e d , o r b lo c k e d o u t b e c a u s e o f
so t h a t a p la s t ic o r m e t a l c r o w n f o r m m a y b e c e m e n t
p r o g n o s is f o r in t e r v e n t i o n
in s ta n c e s
have
been
re p o rte d
w h ic h
te e th
th e
bone
is r e m o v e d t o
th e to o t h
s p a c e lo s s h a v e e v e n t u a l l y e r u p t e d u n a i d e d i n t o g o o d
e d a n d th e t o o t h a llo w e d to e r u p t o n its o w n (F ig 5 ) .
p o s it io n . S o m e h o w
The
c re a te d as th e
th e sp a ce w a s s p o n ta n e o u s ly re
b l o c k e d - o u t t o o t h e r u p t e d . 11
U n fo r
p r im a r y
c o n s id e r a tio n
h e re
is t o
p re v e n t co m
p le t e c lo s u r e o f th e s u r g ic a l w o u n d , w i t h e p i t h e l ia liz a -
t u n a t e l y t h is h a p p y r e s u lt c a n n o t b e e x p e c t e d w i t h
tio n
a n y re a s o n a b le d e g re e o f fr e q u e n c y ( F ig 3 ) .
w o u l d r e c r e a t e t h e b a r r i e r t o e r u p t i o n . O n e s t u d y 12 of
■ O r th o d o n tic
tre a tm e n t
a lo n e :
T h is m e t h o d
m ay
and
over
a lo n e
subsequent
200
w ith
re fo r m a tio n
cases in d ic a te s
p a c k in g
th a t
o f
bone,
w h ic h
s u r g ic a l e x p o s u r e
w a s a lm o s t a lw a y s f o llo w e d b y
b e u s e d w h e r e l a c k o f e r u p t i o n is d u e t o s p a c e d e f i
t o o t h e r u p t i o n . W h e r e a n o v e r l y i n g o b s t r u c t i o n is t o
c i e n c y t h a t is n o t r e l a t e d t o b a s a l a r c h s iz e d e f i c i e n c y ,
b e r e m o v e d , b u t t h e t o o t h b u d is t o o d e e p , o r i n a c
a n d w h e r e t h e p o s it io n a n d a t t it u d e o f th e u n e r u p t e d
c e s s ib le w i t h o u t d a m a g in g s u r r o u n d i n g s t r u c t u r e s , t h e
to o th
bone
is f a v o r a b l e .
T y p ic a l in s ta n c e s
in v o lv e
lo w e r
s e c o n d p r e m o la r s w h ic h b e c o m e b lo c k e d o u t b e c a u s e o f fo rw a rd
d r ift
o f th e fir s t m o la r a f te r p r e m a tu r e
832 ■ JADA, Vol. 82, April 1971
in
th e
e r u p tio n
p a th
s h o u ld b e c h a n n e le d to
f a c ilita te e r u p tio n . A n o t h e r p r o c e d u r e t h a t h a s b e e n d e s c r i b e d is s u r -
F i g 6 « T o p : B ila te r a l h o r iz o n t a lly d e v e lo p in g lo w e r s e co n d p re m o la rs . C e n te r : D e c id u o u s s e c o n d m o la rs w e r e re m o v e d a n d th e s e c o n d p r e m o la r b u d s s u rg ic a lly re p o s itio n e d . B o t t o m : T e e t h e r u p te d in to p o s itio n b u t r o o t a p e x e s d id n o t d e v e lo p n o r m a lly . (C o u rte s y , D r . A . S m i t h ) . F ig 5 ■ T o p , C e n t e r : F a ilu r e o f e r u p tio n o f u p p e r rig h t c e n tr a l in c is o r, a s s o c ia te d w it h p re s e n c e o f s u p e rn u m e ra rie s , in a 1 0 y e a r o ld b o y w h o h a d c le id o c r a n ia l d ys o sto sis. P a t ie n t h ad
n o s is m a y s o m e t i m e s b e m a d e r a d i o g r a p h i c a l l y i f t h e
m a n y o t h e r e x t r a te e t h . B o t t o m : E r u p tio n o f th e to o t h 6
la m in a
w e e k s a f t e r re m o v a l o f th e a s s o c ia te d s u p e rn u m e ra r y to o th ,
t i n u o u s o r n o t e v i d e n t . H o w e v e r , i t is u s u a l l y a f t e r a ll
e x p o s u re o f th e c r o w n , a n d c e m e n ta tio n o f a c e llu lo id c r o w n
a t te m p t s to e n c o u ra g e e r u p tio n p r o v e fr u itle s s th a t a
fo r m .
d u ra
d e f in it e
g ic a l r e p o s i t i o n i n g . 13
T h is h a s b e e n u s e d w h e r e th e
t o o t h b u d is e i t h e r o u t o f i t s n o r m a l e r u p t i v e p o s i t i o n o r in a b n o r m a l in c lin a t io n
s u c h as i n a n i n v e r t e d o r
h o r iz o n ta l a t t it u d e . H e r e th e ra te d fr o m e d tim e
b u d is p h y s i c a l l y s e p a
its b o n y c r y p t , r e lo c a t e d , a n d th e n a llo w
t o d e v e l o p a n d e r u p t . T h e p r o c e d u r e is n o t
or
d i a g n o s is
p e r io d o n ta l
of
m e m b ra n e
a n k y lo s is
is
is
d is c o n
m ade. T he
o n ly
t r e a t m e n t t h e n is r e m o v a l . 1 4 ’ 15 In
a ll
of
th e
f o r e g o in g
m e th o d s ,
r e lia n c e
is o n
n a t u r a l e r u p t i v e f o r c e s . I t is i m p o r t a n t , t h e r e f o r e , t o r e a liz e t h a t th e s e m e t h o d s s u c c e e d b e s t w h e n a p p lie d w ith in
tw o
to
th re e y e a rs o f th e n o r m a lly e x p e c te d
t i m e o f e r u p t i o n , a n d t h a t e r u p t i o n is m o r e l i k e l y t o
w i d e l y p r a c t i c e d b e c a u s e i t is p o t e n t i a l l y d a m a g i n g t o
occur
th e d e v e lo p m e n ta l p ro c e s s o f th e t o o t h ( F ig 6 ) .
e d . 1 2 ’ 16 H o w e v e r , i t is d o u b t f u l i f e r u p t i v e f o r c e s a r e
A
v a r ia tio n
o f
th e
re p o s itio n in g
te c h n iq u e
has
ever
b e fo re
th e
c o m p le te ly
ro o t
lo s t
apex
is
s in c e t h e r e
c o m p le te ly
a re
fo rm
n u m e ro u s
in
b e e n u s e d w h e r e la c k o f e r u p t io n w a s b e lie v e d d u e to
s ta n c e s r e c o r d e d o f e r u p t io n o c c u r r in g w e ll in t o la te r
a n k y lo s is . T h is m e t h o d in v o lv e s l u x a t io n o f th e t o o t h
a d u lt lif e .
to fr e e it f r o m
th e b o n e a n d th e n a llo w in g tim e f o r
e r u p t i o n . I t s h o u ld b e m e n t io n e d h e r e t h a t a n k y lo s is
■ C o m b in e d o r th o d o n t ic -s u r g ic a l m a n a g e m e n t:
p r e s e n t s o n e o f t h e m o r e d i f f i c u l t p r o b l e m s t o r e s o lv e
is t h e
s a tis fa c t o r ily .
e r u p tio n
s c u re , a n d
its
The
e t io lo g y
o f th e
c o n d it io n
is o b
t r e a t m e n t u s u a l l y u n s u c c e s s f u l. D i a g -
m e th o d
T h is
o f c h o ic e w h e r e v e r t h e i m p e d a n c e t o
m u s t b e s u r g ic a lly r e m o v e d , a n d
t h e r e is a
c o i n c i d e n t a l o r t h o d o n t i c p r o b l e m . I t is a ls o i n d i c a t e d
Di Salvo: EVALUATION OF UNERUPTED TEETH ■ 833
w h a te v e r p r e lim in a r y to o th m o v e m e n ts m a y b e n e c e s s a r y . T h e p a t i e n t is t h e n r e f e r r e d t o t h e o r a l s u r g e o n w ho
exposes
th e
c ro w n
o f th e u n e r u p t e d t o o t h
as
w i d e l y as p o s s ib le a n d g a in s a t t a c h m e n t t o i t i n a n y o n e o f a n u m b e r o f w a y s , s u c h as: ■ c ir c u m fe r e n t ia l
lig a tio n
w i t h a s o f t s t a in le s s s t e e l
lig a tu r e p la c e d a p ic a l t o th e h e ig h t o f c r o w n c o n t o u r ; ■ c e m e n ta tio n
o f a p r e fa b r ic a te d
m e ta l c ro w n , o r a
s m a ll m e t a l b a s e , c a r r y in g a n e y e l e t , o r a w i r e l o o p , w ith
z in c o x y p h o s p h a te , b la c k c o p p e r , o r z in c p o ly
a c r y la t e c e m e n t , o r a n e p o x y a d h e s iv e ; ■ c e m e n ta tio n
o f a w ir e o r th r e a d e d p in , c o n ta in in g
a n e y e le t, in t o a h o le d r ille d in to th e c r o w n ; ■ e m b e d d in g o f a w ir e lo o p in t o a n a m a lg a m f illin g p la c e d in t o a p r e p a r e d c a v ity in th e c r o w n ( F ig 7 ). W h a te v e r th e m e th o d o f fix a tio n w ir e
u s e d , a b r a id e d
o r f i n e j e w e l e r ’ s c h a in l e a d i n g f r o m
m ent
on
th e
c ro w n
is
le ft
lo n g
th e a tta c h
enough
to
re a c h
b e y o n d th e le v e l o f t h e s u rfa c e s o f th e n o r m a l a d ja cent
s o ft
t is s u e s .
packed
a ro u n d
r e m a in
fo r
S u r g ic a l g a u z e
th e
exposed
se veral d a y s
to
and
c ro w n m a in ta in
p a s te m a y b e
and
a llo w e d
th e
to
e x p o s u re .
A f t e r i n it i a l h e a lin g , th e o r t h o d o n t is t a p p lie s g e n tle tr a c tio n
fro m
th e
o r th o d o n tic
a p p lia n c e
and
th e
t o o t h is g u i d e d t o i t s p o s i t i o n . 17' 22
S u m m a ry
The F ig 7 ■ V a r io u s m e th o d s o f f i x a t io n to an e r u p te d t o o t h a f t e r s u r g ic a l
e x p o s u re .
Top:
C ir c u m f e r e n tia l
w ir e
lig a tio n .
e v a lu a tio n
d o n tis t
s h o u ld
s u c h te e t h in
o f
u n e ru p te d
ta k e
in to
te e th
by
c o n s id e r a tio n
th e th e
o rth o r o le
of
th e o v e r a ll tr e a tm e n t o f th e m a lo c c lu
(C o u r t e s y , D r . F . R o t h e n b e r g ). C e n te r : C e m e n t a t io n o f w ire
s i o n . W h e r e i n d i c a t e d , s u c h t e e t h m a y b e i n c l u d e d in
lo o p t o lo w e r c a n in e w i t h b la c k c o p p e r c e m e n t. B o t to m : P in
a p la n fo r t o o t h
c e m e n te d in to a h o le d r ille d in to u p p e r l e f t c a n in e . (C o u r te s y , D r . J. B re u e r ).
d e te r m in a tio n v o lv e d a n d th e
o f
re m o v a l. O th e r s itu a tio n s re q u ir e a th e
p o s s ib le
e t io lo g ic
fa c to rs
in
f o r m u la t io n o f a n a p p r o p r ia t e t r e a t
m e n t p la n w h ic h m a y b e n o tr e a tm e n t ; o r t h o d o n t ic w h e n t h e l o n g a x is o f t h e t o o t h d o e s n o t r e a s o n a b l y c o in c id e w i t h th e n o r m a l p a t h o f e r u p t io n , o r w h e n it is l i k e l y t h a t f i n a l t o o t h p o s i t i o n i n g w i l l n e e d o r t h o
tr e a tm e n t
a l o n e ; s u r g ic a l
tre a tm e n t
a lo n e ; o r
com
b in e d o r th o d o n tic - s u r g ic a l m a n a g e m e n t. E x a m p le s o f e a c h h a v e b e e n illu s tr a te d w it h case re c o rd s .
d o n t i c g u i d a n c e , o r i n i n s t a n c e s w h e r e i t is d e s ir a b l e to re d u c e to ta l tr e a tm e n t tim e . A lth o u g h s o m e te e th m ay
be
m ade
to
e ru p t
w ith o u t
th e
a p p lic a t io n
of
o r t h o d o n t i c f o r c e s , t h e r e is l i t t l e d o u b t t h a t t r a c t i o n w ill h a s te n th e p ro c e s s . I n t h i s p r o c e d u r e t h e t r e a t m e n t p l a n is e s t a b l i s h e d in
c o o p e r a t io n w i t h th e o r a l s u r g e o n . T h e c h i e f c o n
s id e r a t io n s a r e th e p r o v is io n f o r s o m e w h a t m o r e th a n a d e q u a t e s p a c e i n t o w h i c h t h e t o o t h is t o b e g u i d e d , and
s u r g ic a l a c c e s s i b i l i t y . T h e o r t h o d o n t i s t p la c e s a
s u it a b le a p p lia n c e , u s u a lly a f i x e d , m u l t i b a n d e d o n e s u c h a s t h e e d g e w is e a r c h m e c h a n i s m , a n d p e r f o r m s
834 ■ JADA, Vol. 82, April 1971
1. N ess, A . R . M o v e m e n t a n d fo rc e s in t o o t h e r u p tio n . In A d v a n c e s in o ra l b io lo g y . S ta p le , P .H ., e d . N e w Y o r k , A c a d e m ic Press, 1 9 6 4 . p 3 3 . 2 . G r ä b e r , T . M . O r t h o d o n tic s , p r in c ip le s a n d p r a c tic e , ed 2 . P h ila d e lp h ia , W .B . S a u n d e rs C o ., 1 9 6 6 . 3 . S ic h e r , H . O ra l a n a to m y , ed 4 . S t L o u is , C . V . M o s b y C o ., 1 9 6 5 . 4 . B e r k o v itz , B .K .B ., a n d T h o m a s , N . R . U n im p e d e d e r u p tio n in th e ro o t-re s e c te d lo w e r in c is o r o f th e r a t w it h a p r e lim in a r y n o te o n r o o t tr a n s e c tio n . A r c h O r o l B io l 1 4 : 7 7 1 J u ly 1 9 6 9 .
5 . C a h ill, D .R . E r u p tio n p a t h w a y fo r m a t io n in th e pres e n c e o f e x p e r im e n t a l t o o t h im p a c tio n in p u p p ie s . A n a t R e c 1 6 4 :6 7 M a y 1 9 6 9 . 6 . G o w g ie l, J .M . E r u p tio n o f ir r a d ia tio n -p r o d u c e d r o o t less te e th in m o n k e y s . J D e n t R es 4 0 : 5 3 8 M a y -J u n e 1 9 6 1 . 7 . S te g g e rd a , M . a n d H i ll , T . J . E r u p t io n t im e o f te e th a m o n g W h ite s , N e g ro e s , a n d In d ia n s . A m e r J O r t h o d o n t 2 8 :3 6 1 Jun e 1 9 4 1 . 8 . H u r m e , V . O . R a n g e s o f n o r m a lc y in th e e r u p tio n o f p e r m a n e n t te e t h . J. D e n t C h ild 1 6 : 1 1 , 2 n d q u a r t, 1 9 4 9 . 9 . G u n t e r . J .H . C o n c e r n in g im p a c te d te e t h . A m e r J O rth o d o n t 2 8 :6 4 2 N ov 1 9 4 2 . 1 0 . S a lz m a n n , J .A . O r t h o d o n tic s ; p r in c ip le s a n d p r e v e n tio n . P h ila d e lp h ia , J .B . L ip p e n c o t t C o ., 1 9 5 7 , p 2 9 7 . 1 1 . M a c la u g h lln , J .A .; F o g e ls , H . R . ; a n d S h ie r e , F .R . T h e in flu e n c e o f p r e m a tu r e p r im a r y m o la r e x tr a c t io n o n b i c u s p id e r u p tio n . J D e n t C h ild . 3 4 : 3 9 9 S e p t 1 9 6 7 . 1 2 . H e lm o r e , F .E . S u rg ic a l a id t o e r u p t io n f o r o r t h o d o n t ic tr e a tm e n t . A u s t D e n t J 1 2 : 3 7 2 A u g 1 9 6 7 . 1 3 . M e a d , K . T . , a n d M o n s e n , R .M . S u rg ic a l re p o s itio n in g o f d e v e lo p in g im p a c te d te e t h . J A D A 7 1 : 6 2 1 S e p t 1 9 6 5 . 1 4 . B ie d e r m a n , W . E t io lo g y a n d tr e a t m e n t o f to o th a n k y losis. A m e r J O r t h o d o n t 4 8 : 6 7 0 S e p t 1 9 6 2 . 1 5 . H e r m a n , E . E v a lu a tio n a n d m a n a g e m e n t o f a n k y lo s e d te e t h . N e w Y o r k D e n t J 3 0 : 3 2 7 O c t 1 9 6 4 . 1 6 . G r o n , A . P r e d ic tio n o f t o o t h e m e rg e n c e . J D e n t R es 4 1 : 5 7 3 M a y -J u n e 1 9 6 2 . 1 7 . B u c h a n a n , G . S u rg ic a l in te r v e n tio n as a n a id t o o r t h o d o n tic s . A n n A u s t C o ll D e n t S u r g 1 : 7 0 D e c 1 9 6 7 . 1 8 . L e s lie , H .E . A n e w im p ro v e d m e t h o d o f t r e a tm e n t o f im p a c te d o r u n e r u p t e d te e t h . A m e r J O r t h o d o n t 4 1 : 5 8 3 A u g 1955. 1 9 . J o h n s to n , W .D . T r e a t m e n t o f p a la t a lly im p a c te d ca n in e te e t h . A m e r J O r t h o d o n t 5 6 : 5 8 9 D e c 1 9 6 9 . 2 0 . S m it h , D .C . A n e w d e n ta l c e m e n t. B r i t D e n t J 1 2 5 : 3 8 1 Nov 5, 1968.
2 1 . N e w m a n , G . V . A d h e s io n a n d o r t h o d o n t i c p la s tic a tta c h m e n ts . A m e r J O r t h o d o n t 5 6 : 5 7 3 D e c 1 9 6 9 . 2 2 . W e is s , B .: J a c o b s , B .J .; a n d R a f e l, S .S . A s u rg ic o o r th o d o n t ic a p p ro a c h t o th e tr e a t m e n t o f u n e r u p t e d te e th . A n g le O r t h o d o n t 2 3 : 2 0 1 O c t 1 9 5 3 .
D o c t o r D iS a lv o is p ro fe s s o r o f d e n tis tr y a n d d ir e c to r , d iv is io n o f o r th o d o n tic s , C o lu m b ia U n iv e r s ity S c h o o l o f D e n ta l a n d O ra l S u r g e r y , N e w Y o r k , 1 0 0 3 2 .
Di Salvo: EVALUATION OF UNERUPTED TEETH ■ 835
O rthodontists, in evaluating unerupted teeth, must take into consideration the role o f such teeth in the overall treatm ent o f malocclusions. Such teeth sometimes may be included in a plan fo r too th removal. In certain situations, the possible etiologic factors must be considered, and the treatm ent plan may be either no treatm ent; o rth o d o n tic treatm ent alone; surgical treatm ent alone, or combined orthodontic-surgical management.
An
u n e ru p te d
c o n ta in e d
to o th
w ith in
th e
q u i t e o b v i o u s l y is a n y t o o t h
t is s u e s o f t h e j a w
s u e s o f t h e o r a l c a v i t y . A t s o m e t i m e t h i s is a n o r m a l c o n d it io n
fo r
a ll
t e e t h . H o w e v e r , t h is
p r e s e n ta t io n
w i l l d e a l w i t h th o s e s itu a tio n s in w h ic h th e c o n d it io n p e r s is ts
beyond
th e
tim e
w hen
n o rm a l
e r u p tio n
s h o u l d h a v e o c c u r r e d o n t h e b a s is o f a c c e p t e d c r i t e r i a o f d e n ta l d e v e lo p m e n t. T h e e a s ie r
to
d ea l w ith
e r u p tio n T h e fir s t c o n s id e r a tio n in th e e v a lu a tio n o f u n e r u p t e d
b o n e s , th e
c r o w n o f w h ic h h a s n o t y e t p e n e tr a t e d th e s o ft tis
w e re
i f th e
s u b je c t w o u l d b e m u c h n o rm a l p ro c e s s o f to o th
u n d e rs to o d , b u t
s u c h is n o t y e t t h e
s ta te o f th e a r t . 1
t e e t h b y t h e o r t h o d o n t i s t is t o d e t e r m i n e w h a t r o l e th is c o n d it io n
c a n b e s t p la y in th e o v e r a ll tr e a tm e n t
o f th e m a lo c c lu s io n . S in c e t r e a t m e n t o f t h i s c o n d i t i o n p r e s e n t s c e r t a i n p r o b le m s ,
such
as
th e
p o s s ib ility
o f th e
need
N o rm a l to o th d e ve lo p m e n t
fo r
s u r g ic a l i n t e r v e n t i o n , p r o lo n g a t i o n o f t r e a t m e n t t i m e , u n c e r ta in ty
o f o u t c o m e , a b e r r a tio n s in t o o t h f o r m ,
a n d s o o n , a n a t u r a l i n c l i n a t i o n is t o t r y t o a v o i d t h e is s u e w h e r e v e r e ru p te d to o th w h e re
to o th
t h i s is p o s s ib le b y i n c l u d i n g t h e u n in to
u n it
a p la n c a llin g f o r t o o t h r e m o v a l, r e d u c t io n
is i n d i c a t e d
fo r p ro p e r
t r e a tm e n t o f th e m a lo c c lu s io n .
b irth
s e le c t e d in s t a n c e s
th e
ja w s
o f
th e
hum an
in fa n t n o r m a lly
c o n t a i n a l l 2 0 d e c i d o u s t o o t h c r o w n s i n v a r i o u s s ta g e s of
d e v e lo p m e n t,
as
w e ll
as
th e
buds
o f th e
fir s t
p e r m a n e n t m o la r s . T h e c r o w n s o f th e l a t t e r m a y h a v e begun
to
a lr e a d y
T h i s c a n o f t e n b e d o n e s u c c e s s f u l l y i n in s t a n c e s o f u n e r u p t e d p r e m o la r s , a n d e v e n in
A t
c a lc ify .
fu lly
The
fo rm e d
d e c id o u s and
in c is o r
c a lc if ie d
c ro w n s
and
a re
th e ir
ro o t
g ro w th
and
f o r m a t io n q u ite a d v a n c e d .2 In
th e
n o rm a l
p ro c e s s e s
of
d e v e lo p m e n t, th e
d o e s n o t w o r k v e r y w e ll in o t h e r s itu a tio n s . W h e re n o
fa c e s o f th e a lv e o la r b o n e as r o o t f o r m a t i o n a d v a n c e s . is b e l i e v e d
c ro w n s m o v e
d e n ta l
o f u n e r u p t e d c a n in e s . H o w e v e r , t h i s a p p r o a c h u s u a l l y
to
be
due
to
to w a rd
th e o ra l s u r
p r a c t ic a l m e a n s c a n b e f o u n d t o e lim in a t e th e p r o b
T h is
l e m , o n e p r o c e e d s w i t h a n a n a ly s i s o f t h e s i t u a t i o n .
p r e s s u r e c r e a t e d b y t h e p r o l i f e r a t i o n o f t h e t is s u e s o f
s lig h t in c r e m e n ts o f
JADA, Vol. 82, April 1971 ■ 829
4
*
F ig 1 • F u ll-m o u t h ra d io g ra p h s o f tw o sisters
s h o w in g
g e n e ra liz e d
d e la y e d
e r u p tio n . M o t h e r sta te s b o t h c h ild re n w e r e " la t e te e t h e r s ." O th e rw is e h is to ry is n e g a tiv e . T o p : O n e ag e d 1 4 y e a rs , 1 0 m o n th s . B o t t o m : O th e r ag e d 1 3 y e a rs , 1 m o n t h . N o t e th e p o o r a x ia l in c lin a tio n o f u p p e r c a n in e s in o ld e r sister. These
te e th
a llo w e d
to
w e r e s u rg ic a lly e x p o s e d , e r u p t,
and
f i n a ll y
p o s i
tio n e d o r th o d o n t ic a lly .
th e p u lp
a n d r o o t a g a in s t a n a p i c a l l y s i t u a t e d , r e s is
t a n t b a n d o f tis s u e , th e “ h a m m o c k lig a m e n t .” s h o u ld
One
p o i n t o u t , h o w e v e r , t h a t t h is v ie w h a s b e e n
s e r io u s ly
c h a lle n g e d
s in c e
e x p e r i m e n t a l e v id e n c e i n
ra c e , a n d o t h e r fa c t o r s .7 N e v e rth e le s s , u s e fu l s ta n d a rd s h a v e
been
fo rm u la te d
w ith
re g a rd
to
age a n d
s e q u e n c e o f e r u p t i o n o f th e t e e t h in b o t h d e c id u o u s a n d p e r m a n e n t d e n titio n s .®
W it h d u e a llo w a n c e f o r
a n i m a l s i n d i c a t e s t h a t e r u p t i o n m a y p r o c e e d i n s p it e
n o r m a l in d iv id u a l v a r ia t io n , w h e n
of
to o th
m a d e its a p p e a ra n c e in to th e o r a l c a v ity b y th e tim e
l ig a -
i t s e r u p t i o n is n o r m a l l y e x p e c t e d o n t h e b a s is o f t h e s e
la c k
of
tis s u e s a n d * 3 -6 m e n t.
p r o life r a t io n in
th e
o f a p ic a l b o n e
absence
of
th e
and
ham m ock
s ta n d a rd s , th e
In d u e t im e , th e f o llic le w h ic h c o n ta in s th e t o o t h
c lin ic ia n p r o p e r ly
a to o th
seeks to
has n o t
d e te r m in e
w hy.
c r o w n r e a c h e s a n d p e r f o r a t e s t h e o r a l s u r fa c e o f a lv e
O fte n
th e re
is
c o n s id e r a b le
v a r ia tio n .
In
d e te r
a n d m a k e s it s
m i n i n g w h e t h e r o r n o t a p a r t i c u l a r i n s t a n c e is s i m p l y
a p p e a r a n c e i n t h e o r a l c a v i t y ; i t is t h e n s a id t o h a v e
n o r m a l in d iv id u a l v a r ia tio n o r a b n o r m a l r e ta r d a t io n ,
o la r b o n e
“ e r u p te d .”
and
its o v e r ly in g
m ucosa
T h e p ro c e s s n o r m a lly c o n tin u e s u n t il th e
o n e s h o u l d f i r s t n o t e i f t h e c o n d i t i o n is g e n e r a l i z e d ,
e n t i r e a n a t o m i c c r o w n is e x p o s e d b y a c o m b i n a t i o n
in v o lv in g
o f t o o t h m o v e m e n t t o w a r d th e lin e o f o c c lu s io n , a n d
t e e t h in a p a r tic u la r a re a .
m any
t e e t h , o r lo c a liz e d
to
o n e o r a fe w
a n a p ic a l m ig r a t io n o f th e g in g iv a l a t t a c h m e n t t o w a r d th e c e rv ic a l lin e o f th e t o o t h . U p p r o c e s s is c a l l e d fro m
“ a c tiv e ”
e r u p tio n
to to
t h is p o i n t th e
■ G e n e r a liz e d
d is t in g u is h i t
c a te s r e t a r d e d
th e la te r e r u p tio n w h ic h c o n tin u e s th r o u g h o u t
re ta r d a t io n
o f
e r u p t io n :
T h is
in d i
d e n ta l age a n d m a y b e a n o r m a l in d i
v i d u a l v a r i a t i o n , e s p e c i a l l y i f t h e h i s t o r y d is c lo s e s t h a t
l i f e , c o m p e n s a t i n g f o r o c c lu s a l w e a r f r o m a t t r i t i o n i n
th e
fu n c t io n .
u s u a l a g e ( t h a t is , l a t e r t h a n 5 t o 7 m o n t h s o f a g e ) .
p a t ie n t’ s fir s t
to o th
w as
“ c u t”
a t a la te r-th a n -
A l s o t h e r e is s o m e e v id e n c e t h a t l a t e e r u p t i o n m a y b e fa m ilia l ( F ig 1 ). T h u s a f a m ily h is to r y m a y b e h e lp f u l.
V a ria tio n s in e ru p tio n
In
such
i n s t a n c e s , t h e p a t i e n t is s i m p l y k e p t u n d e r
p e r i o d i c o b s e r v a t i o n a n d i n t e r v e n t i o n is n o t i n d i c a t e d as l o n g a s p r o g r e s s is e v i d e n t . S e v e ra l s tu d ie s o f t o o t h e r u p t i o n in d ic a t e t h a t t h e r e m a y b e c o n s id e r a b le v a r ia t io n a c c o r d in g t o a g e , s e x ,
830 ■ JADA, Vol. 82, April 1971
On
t h e o t h e r h a n d , o n e s h o u l d a t le a s t c o n s id e r
th e p o s s ib ility o f m e t a b o lic o r e n d o c r in e d is tu rb a n c e .
A
h i s t o r y s h o u ld b e t a k e n w i t h th is in m in d a n d , i f
i n d i c a t e d , t h is s h o u ld b e f o llo w e d b y a m e d ic a l c o n s u lta tio n .2
T re a tm e n t
w o u ld
th e n
depend
on
th e
m e d ic a l fin d in g s . A n o t h e r p o s s i b i l i t y t o b e c o n s id e r e d is h y p o d o n t i a (p a r t ia l a n o d o n t ia ) in v o lv in g th e s e c o n d a ry te e t h . In th e s e
s itu a tio n s
one
u s u a lly
a tte m p ts
to
r e ta in
as
m a n y a s is p o s s ib le o f t h e d e c id u o u s t e e t h , t h e s u c c e s s o rs o f w h ic h a re a b s e n t. H o w e v e r , th e t r e a t m e n t p la n is i n d i v i d u a l i z e d
a c c o r d in g
to
th e
o v e r a ll o c c lu s io n
a n d th e c o n d it io n o f th e d e c id u o u s t o o t h r o o t s . M o s t c o m m o n ly t h e a b s e n c e in v o lv e s lo w e r s e c o n d p r e m o la r s
w ith
W h e re
u p p e r l a t e r a l in c i s o r s n e x t
o n ly
tre a tm e n t
th e s e
m ay
te e th
be
a re
in
fre q u e n c y .
in v o lv e d ,
o r th o d o n tic
e m p lo y e d , a fte r re m o v a l
d e c i d u o u s t e e t h , t o c lo s e
o f th e
sp a c e s a n d a v o id p r o s th e tic
re p la c e m e n t. F ig 2 ■ T o p : B ila te r a l sp a ce d e f ic ie n c y in lo w e r s e c o n d p r e ■
L o c a liz e d
G u n te r ,9
re ta rd e d
fa ilu r e
o f
A c c o r d in g
e r u p t io n :
e r u p tio n
o c c u rs ,
in
to
d e c re a s in g
o r d e r o f f r e q u e n c y , in m a n d ib u la r t h ir d m o la rs ; m a x illa r y
th ir d
m o la rs ;
m a x illa r y
m o la r areas in a g ir l,
c o n d it io n
is l o c a l i z e d
tr e a te d o r th o d o n tic a lly b y re m o v a l o f f o u r p r e m o la rs .
and
in v o lv e s
o n e o r fe w
U n ila t e r a l fa ilu r e
S a l z m a n n 10 e r u p tio n :
of
e r u p tio n
a ffe c tin g
o f e r u p tio n
o f in d iv id u a l te e t h
in d ic a t e s t h a t lo c a l f a c t o r s a r e m o s t l ik e l y t h e c a u s e .
la te ra l o r u n ila te r a l. fa ilu r e
m o n t h s o ld . B o t to m :
c a n in e s ; m a n d i b u l a r
t e e t h , o n e s h o u l d n o t e w h e t h e r t h e c o n d i t i o n is b i
B ila te r a l
y e a rs , 9
o ld g irl. T h e s e g irls h a d a rc h le n g th d e fic ie n c ie s t h a t w e re
s e c o n d p r e m o la r s ; a n d m a x illa r y s e c o n d p r e m o la r s . I f th e
11
B ila te r a l sp a ce d e f ic ie n c y In u p p e r c a n in e areas in a 1 0 y e a r
a n tim e re s
l is t s
th e
fo llo w in g
causes
■ D is ta n c e o f t o o t h f r o m its p la c e o f e r u p t io n .
p le , b ila te r a l im p a c t io n o f lo w e r s e c o n d p r e m o la r s o r
■ M a lfo r m a tio n o f th e to o th .
upper
■ P re s e n c e o f s u p e rn u m e ra ry te e th .
d e f ic ie n c y e ru p t
m ay
s in c e t h e s e
“ w ith in ”
posed
occur
to
th e
th e
a re
in
u s u a lly
r e s p e c tiv e
m o la rs w h ic h
d is ta l t o
th e
th e re fo r e
o fte n
p e rs o n s w ith
an
a rc h
th e la s t t e e t h to
■ T ra u m a o f to o th g e rm .
d e n ta l a rc h e s , as o p
e ru p t
“ o u ts id e
■ In fe c tio n o f to o th g e rm .
o f ’ or
tr a n s it io n a l d e n titio n . T h e s e te e t h
are
■ D is p la c e m e n t o f t o o t h g e r m o r t o o t h b y a n e o p la s m .
“ lo c k e d o u t ” b e c a u s e o f in s u f fic ie n t
■ A n k y lo s is o f th e t o o t h w i t h t h e j a w b o n e .
s p a c e in w h ic h t o e r u p t as a re s u lt o f in a d e q u a te b a s a l a rc h le n g th d e v e lo p m e n t ( F ig 2 ) . ( T h e te r m
“ im p a c
d e la y e d
■ E c t o p ic p o s it io n o f th e t o o t h .
m a y b e a n in d ic a t io n o f g r o w th d e f ic ie n c y . F o r e x a m
c a n in e s
of
■
S y s t e m i c d is e a s e s s u c h a s d i e t a r y , m e t a b o l i c a n d
e n d o c r in e d is tu rb a n c e s .
t i o n ” is u s e d t o r e f e r t o s i t u a t i o n s i n w h i c h f a i l u r e o f
T o th e s e m a y b e a d d e d :
e r u p t i o n is a p p a r e n t l y d u e t o a m e c h a n i c a l b l o c k i n g ,
■ O v e r - r e t e n t io n o f d e c id u o u s p r e d e c e s s o r .
such
■ L a c k o f sp a c e fo r th e t o o t h in th e d e n ta l a rc h .
as b y th e p r e s e n c e o f a d ja c e n t te e t h o r o t h e r
s tr u c tu r e in th e p a th o f e r u p t io n .) A n o th e r tio n ”
e x a m p le
is t h e
■ M u c o s a l b a r r ie r d u e t o g in g iv a l fib r o s is .
s o -c a lle d “ e c t o p ic e r u p
A n a ly s is o f a p r o b le m o f la c k o f e r u p t i o n in v o lv e s
o f f i r s t m o l a r s w h e r e e r u p t i o n o f t h i s t o o t h is
e x a m in a t io n o f th e t o o t h w i t h r e s p e c t t o : its p re s e n c e
b lo c k e d b e c a u s e o f a b n o r m a l re s o r p tio n o f th e d is ta l
in
s u rfa c e
n a tu re
o f th e
d is ta l
r o o t o f th e d e c id u o u s s e c o n d
th e j a w ; its p o s it io n
m o la r , le a v in g a n o v e r h a n g in g c r o w n u n d e r w h i c h th e
tio n s
p e rm a n e n t
a lr e a d y lis te d ).
m ay
m o la r b e c o m e s
tr a p p e d . T h is
c o n d it io n
b e a n in d ic a t io n o f in s u f fic ie n t a r c h le n g th to
a c c o m o d a te th e f u ll a d u lt d e n titio n w it h o u t c r o w d
th a t m a y
To
e v a lu a te
it
le m s .
based on
e v a lu a tio n
and
in v o lv e s
u s u a lly
a
c o m p le te
o r th o d o n tic
in c lu d e s r e m o v a l o f t w o
or
be
an
in te r fe r in g
u n e ru p te d
w ith
to o th
its e r u p t io n
an
(a s
in it ia l ju d g
m e n t is r e q u i r e d r e g a r d i n g t h e p r o g n o s i s f o r b r i n g i n g
in g .2 T h e s e s itu a tio n s a re p r im a r ily o r t h o d o n t ic p r o b T re a tm e n t
a n d a t t i t u d e ; t h e s ta g e a n d
o f it s d e v e lo p m e n t ; a n d o b v io u s lo c a l c o n d i
in to
good its
assessed fr o m
f u n c t i o n a l p o s i t i o n . T h i s e v a l u a t i o n is m o r p h o lo g y , p o s it io n , a n d a t t it u d e
as
g o o d r a d i o g r a p h s . T h e f i l m s w i l l a ls o
fo u r p e r m a n e n t te e th in o r d e r to a c c o m m o d a te th e
in d ic a t e w h e t h e r t h e r e a r e a n y o b v io u s f a c t o r s im p e d
d e n t it io n to th e d e f ic ie n t s k e le ta l b as es.
in g e r u p t io n .
Di Salvo: EVALUATION OF UNERUPTED TEETH ■ 831
F ig 4 ■ E r u p tio n o f u p p e r s e c o n d p r e m o la r a f t e r o r th o d o n tic re c re a tio n o f space in a 1 0 y e a r o ld g irl. F ig 3 ■ S p o n ta n e o u s u n a id e d e r u p tio n o f p a r tia lly b lo c k e d o u t u p p e r s e c o n d p r e m o la rs in a g irl b e tw e e n th e ages o f 1 V A (t o p ) a n d
1 2 ( b o t t o m ) . H o w e v e r, lo w e r r ig h t s e c o n d p r e
m o la r , m o r e c o m p le t e ly b lo c k e d , d id n o t e r u p t, a lth o u g h s o m e In c re a s e in sp a ce d id d e v e lo p .
lo s s o f t h e p r o b le m tio n .
d e c id u o u s
The
p ro c e d u re
o r th o d o n tic
C linical m anagem ent
second
m o la r .
H o w e v e r , th e
m a y a r is e i n a l m o s t a n y p a r t o f t h e d e n t i is
to
r e - e s t a b li s h t h e s p a c e b y
m o v e m e n t o f th e a d ja c e n t te e th
w h ic h
h a v e p r e -e m p te d i t , a n d to a llo w th e u n e ru p te d to o th t o m o v e in t o p o s it io n . P e r io d ic r a d io g r a p h s a re ta k e n t o d e te r m in e w h e t h e r e r u p tiv e m o v e m e n ts a re o c c u r
In
th e c lin ic a l m a n a g e m e n t o f u n e r u p t e d t e e t h , f o u r
r in g . I f
th e y
a r e , i t is s i m p l y a m a t t e r o f w a t c h f u l
p o s s ib ilitie s m a y b e c o n s id e r e d : n o t r e a t m e n t ; o r t h o
w a itin g . W h e n e r u p tio n o c c u rs , th e t o o t h m a y o r m a y
d o n t i c t r e a t m e n t a lo n e ; s u r g ic a l t r e a t m e n t a lo n e ; o r
not
c o m b in e d o r th o d o n tic - s u r g ic a l m a n a g e m e n t.
n e e d s o f th e case (F ig 4 ) .
■ N o th e
In
tre a tm e n t:
p o s it io n
g r o w in g
o r a ttitu d e
in d iv id u a ls in
o f th e
to o th
w hom
is s u c h
be
d ir e c te d
o r th o d o n tic a lly
■ S u rg ic a l tre a tm e n t a lo n e :
d e p e n d in g
on
th e
T h is a p p r o a c h le n d s i t
th a t
s e lf b e s t to s itu a tio n s in w h ic h t h e b lo c k t o e r u p tio n
s u r g i c a l a c c e s s is h a z a r d o u s t o t h e s u r r o u n d i n g s t r u c
i n v o l v e s t is s u e w h i c h is e i t h e r e x p e n d a b l e o r i n d i c a t e d
t u r e s , s u c h a s o t h e r t e e t h , s in u s c a v i t i e s , m a j o r b l o o d
fo r
v e s s e ls o r n e r v e s , a n d s o o n , a n d w h e r e
r e t a in e d d e c id u o u s t e e t h , o r p a t h o lo g y in v o lv in g b o n e
t h e r e is n o
re m o v a l
(s u c h
as, s u p e rn u m e ra ry
t e e t h , o v e r ly -
im m e d ia te n e e d to in te rv e n e b e c a u s e o f a p a th o lo g ic
or
c o n d it io n , t r e a t m e n t s h o u ld b e d e f e r r e d a n d th e p a
a t t i t u d e o f t h e t o o t h is f a v o r a b l e f o r e r u p t i o n .
t i e n t k e p t u n d e r p e r io d ic r a d io g r a p h ic e x a m in a t io n .
s o ft
t is s u e s ) a n d
T h e p ro c e d u re
a g a in , w h e r e
th e
p o s itio n
and
is t o r e m o v e t h e i m p e d i m e n t , a n d
O f t e n th e p o s it io n s o f th e s e te e t h w i l l c h a n g e , m a k in g
t o a s s is t e r u p t i o n b y e x p o s i n g t h e c r o w n a s m u c h a s is
th e
m o r e fa v o r a b le . A ls o
p o s s ib le . I d e a l l y
in
th a t
c e r v ix , o r a t le a s t b e l o w t h e h e ig h t o f c r o w n c o n t o u r ,
s e e m e d h o p e le s s ly s it u a t e d , o r b lo c k e d o u t b e c a u s e o f
so t h a t a p la s t ic o r m e t a l c r o w n f o r m m a y b e c e m e n t
p r o g n o s is f o r in t e r v e n t i o n
in s ta n c e s
have
been
re p o rte d
w h ic h
te e th
th e
bone
is r e m o v e d t o
th e to o t h
s p a c e lo s s h a v e e v e n t u a l l y e r u p t e d u n a i d e d i n t o g o o d
e d a n d th e t o o t h a llo w e d to e r u p t o n its o w n (F ig 5 ) .
p o s it io n . S o m e h o w
The
c re a te d as th e
th e sp a ce w a s s p o n ta n e o u s ly re
b l o c k e d - o u t t o o t h e r u p t e d . 11
U n fo r
p r im a r y
c o n s id e r a tio n
h e re
is t o
p re v e n t co m
p le t e c lo s u r e o f th e s u r g ic a l w o u n d , w i t h e p i t h e l ia liz a -
t u n a t e l y t h is h a p p y r e s u lt c a n n o t b e e x p e c t e d w i t h
tio n
a n y re a s o n a b le d e g re e o f fr e q u e n c y ( F ig 3 ) .
w o u l d r e c r e a t e t h e b a r r i e r t o e r u p t i o n . O n e s t u d y 12 of
■ O r th o d o n tic
tre a tm e n t
a lo n e :
T h is m e t h o d
m ay
and
over
a lo n e
subsequent
200
w ith
re fo r m a tio n
cases in d ic a te s
p a c k in g
th a t
o f
bone,
w h ic h
s u r g ic a l e x p o s u r e
w a s a lm o s t a lw a y s f o llo w e d b y
b e u s e d w h e r e l a c k o f e r u p t i o n is d u e t o s p a c e d e f i
t o o t h e r u p t i o n . W h e r e a n o v e r l y i n g o b s t r u c t i o n is t o
c i e n c y t h a t is n o t r e l a t e d t o b a s a l a r c h s iz e d e f i c i e n c y ,
b e r e m o v e d , b u t t h e t o o t h b u d is t o o d e e p , o r i n a c
a n d w h e r e t h e p o s it io n a n d a t t it u d e o f th e u n e r u p t e d
c e s s ib le w i t h o u t d a m a g in g s u r r o u n d i n g s t r u c t u r e s , t h e
to o th
bone
is f a v o r a b l e .
T y p ic a l in s ta n c e s
in v o lv e
lo w e r
s e c o n d p r e m o la r s w h ic h b e c o m e b lo c k e d o u t b e c a u s e o f fo rw a rd
d r ift
o f th e fir s t m o la r a f te r p r e m a tu r e
832 ■ JADA, Vol. 82, April 1971
in
th e
e r u p tio n
p a th
s h o u ld b e c h a n n e le d to
f a c ilita te e r u p tio n . A n o t h e r p r o c e d u r e t h a t h a s b e e n d e s c r i b e d is s u r -
F i g 6 « T o p : B ila te r a l h o r iz o n t a lly d e v e lo p in g lo w e r s e co n d p re m o la rs . C e n te r : D e c id u o u s s e c o n d m o la rs w e r e re m o v e d a n d th e s e c o n d p r e m o la r b u d s s u rg ic a lly re p o s itio n e d . B o t t o m : T e e t h e r u p te d in to p o s itio n b u t r o o t a p e x e s d id n o t d e v e lo p n o r m a lly . (C o u rte s y , D r . A . S m i t h ) . F ig 5 ■ T o p , C e n t e r : F a ilu r e o f e r u p tio n o f u p p e r rig h t c e n tr a l in c is o r, a s s o c ia te d w it h p re s e n c e o f s u p e rn u m e ra rie s , in a 1 0 y e a r o ld b o y w h o h a d c le id o c r a n ia l d ys o sto sis. P a t ie n t h ad
n o s is m a y s o m e t i m e s b e m a d e r a d i o g r a p h i c a l l y i f t h e
m a n y o t h e r e x t r a te e t h . B o t t o m : E r u p tio n o f th e to o t h 6
la m in a
w e e k s a f t e r re m o v a l o f th e a s s o c ia te d s u p e rn u m e ra r y to o th ,
t i n u o u s o r n o t e v i d e n t . H o w e v e r , i t is u s u a l l y a f t e r a ll
e x p o s u re o f th e c r o w n , a n d c e m e n ta tio n o f a c e llu lo id c r o w n
a t te m p t s to e n c o u ra g e e r u p tio n p r o v e fr u itle s s th a t a
fo r m .
d u ra
d e f in it e
g ic a l r e p o s i t i o n i n g . 13
T h is h a s b e e n u s e d w h e r e th e
t o o t h b u d is e i t h e r o u t o f i t s n o r m a l e r u p t i v e p o s i t i o n o r in a b n o r m a l in c lin a t io n
s u c h as i n a n i n v e r t e d o r
h o r iz o n ta l a t t it u d e . H e r e th e ra te d fr o m e d tim e
b u d is p h y s i c a l l y s e p a
its b o n y c r y p t , r e lo c a t e d , a n d th e n a llo w
t o d e v e l o p a n d e r u p t . T h e p r o c e d u r e is n o t
or
d i a g n o s is
p e r io d o n ta l
of
m e m b ra n e
a n k y lo s is
is
is
d is c o n
m ade. T he
o n ly
t r e a t m e n t t h e n is r e m o v a l . 1 4 ’ 15 In
a ll
of
th e
f o r e g o in g
m e th o d s ,
r e lia n c e
is o n
n a t u r a l e r u p t i v e f o r c e s . I t is i m p o r t a n t , t h e r e f o r e , t o r e a liz e t h a t th e s e m e t h o d s s u c c e e d b e s t w h e n a p p lie d w ith in
tw o
to
th re e y e a rs o f th e n o r m a lly e x p e c te d
t i m e o f e r u p t i o n , a n d t h a t e r u p t i o n is m o r e l i k e l y t o
w i d e l y p r a c t i c e d b e c a u s e i t is p o t e n t i a l l y d a m a g i n g t o
occur
th e d e v e lo p m e n ta l p ro c e s s o f th e t o o t h ( F ig 6 ) .
e d . 1 2 ’ 16 H o w e v e r , i t is d o u b t f u l i f e r u p t i v e f o r c e s a r e
A
v a r ia tio n
o f
th e
re p o s itio n in g
te c h n iq u e
has
ever
b e fo re
th e
c o m p le te ly
ro o t
lo s t
apex
is
s in c e t h e r e
c o m p le te ly
a re
fo rm
n u m e ro u s
in
b e e n u s e d w h e r e la c k o f e r u p t io n w a s b e lie v e d d u e to
s ta n c e s r e c o r d e d o f e r u p t io n o c c u r r in g w e ll in t o la te r
a n k y lo s is . T h is m e t h o d in v o lv e s l u x a t io n o f th e t o o t h
a d u lt lif e .
to fr e e it f r o m
th e b o n e a n d th e n a llo w in g tim e f o r
e r u p t i o n . I t s h o u ld b e m e n t io n e d h e r e t h a t a n k y lo s is
■ C o m b in e d o r th o d o n t ic -s u r g ic a l m a n a g e m e n t:
p r e s e n t s o n e o f t h e m o r e d i f f i c u l t p r o b l e m s t o r e s o lv e
is t h e
s a tis fa c t o r ily .
e r u p tio n
s c u re , a n d
its
The
e t io lo g y
o f th e
c o n d it io n
is o b
t r e a t m e n t u s u a l l y u n s u c c e s s f u l. D i a g -
m e th o d
T h is
o f c h o ic e w h e r e v e r t h e i m p e d a n c e t o
m u s t b e s u r g ic a lly r e m o v e d , a n d
t h e r e is a
c o i n c i d e n t a l o r t h o d o n t i c p r o b l e m . I t is a ls o i n d i c a t e d
Di Salvo: EVALUATION OF UNERUPTED TEETH ■ 833
w h a te v e r p r e lim in a r y to o th m o v e m e n ts m a y b e n e c e s s a r y . T h e p a t i e n t is t h e n r e f e r r e d t o t h e o r a l s u r g e o n w ho
exposes
th e
c ro w n
o f th e u n e r u p t e d t o o t h
as
w i d e l y as p o s s ib le a n d g a in s a t t a c h m e n t t o i t i n a n y o n e o f a n u m b e r o f w a y s , s u c h as: ■ c ir c u m fe r e n t ia l
lig a tio n
w i t h a s o f t s t a in le s s s t e e l
lig a tu r e p la c e d a p ic a l t o th e h e ig h t o f c r o w n c o n t o u r ; ■ c e m e n ta tio n
o f a p r e fa b r ic a te d
m e ta l c ro w n , o r a
s m a ll m e t a l b a s e , c a r r y in g a n e y e l e t , o r a w i r e l o o p , w ith
z in c o x y p h o s p h a te , b la c k c o p p e r , o r z in c p o ly
a c r y la t e c e m e n t , o r a n e p o x y a d h e s iv e ; ■ c e m e n ta tio n
o f a w ir e o r th r e a d e d p in , c o n ta in in g
a n e y e le t, in t o a h o le d r ille d in to th e c r o w n ; ■ e m b e d d in g o f a w ir e lo o p in t o a n a m a lg a m f illin g p la c e d in t o a p r e p a r e d c a v ity in th e c r o w n ( F ig 7 ). W h a te v e r th e m e th o d o f fix a tio n w ir e
u s e d , a b r a id e d
o r f i n e j e w e l e r ’ s c h a in l e a d i n g f r o m
m ent
on
th e
c ro w n
is
le ft
lo n g
th e a tta c h
enough
to
re a c h
b e y o n d th e le v e l o f t h e s u rfa c e s o f th e n o r m a l a d ja cent
s o ft
t is s u e s .
packed
a ro u n d
r e m a in
fo r
S u r g ic a l g a u z e
th e
exposed
se veral d a y s
to
and
c ro w n m a in ta in
p a s te m a y b e
and
a llo w e d
th e
to
e x p o s u re .
A f t e r i n it i a l h e a lin g , th e o r t h o d o n t is t a p p lie s g e n tle tr a c tio n
fro m
th e
o r th o d o n tic
a p p lia n c e
and
th e
t o o t h is g u i d e d t o i t s p o s i t i o n . 17' 22
S u m m a ry
The F ig 7 ■ V a r io u s m e th o d s o f f i x a t io n to an e r u p te d t o o t h a f t e r s u r g ic a l
e x p o s u re .
Top:
C ir c u m f e r e n tia l
w ir e
lig a tio n .
e v a lu a tio n
d o n tis t
s h o u ld
s u c h te e t h in
o f
u n e ru p te d
ta k e
in to
te e th
by
c o n s id e r a tio n
th e th e
o rth o r o le
of
th e o v e r a ll tr e a tm e n t o f th e m a lo c c lu
(C o u r t e s y , D r . F . R o t h e n b e r g ). C e n te r : C e m e n t a t io n o f w ire
s i o n . W h e r e i n d i c a t e d , s u c h t e e t h m a y b e i n c l u d e d in
lo o p t o lo w e r c a n in e w i t h b la c k c o p p e r c e m e n t. B o t to m : P in
a p la n fo r t o o t h
c e m e n te d in to a h o le d r ille d in to u p p e r l e f t c a n in e . (C o u r te s y , D r . J. B re u e r ).
d e te r m in a tio n v o lv e d a n d th e
o f
re m o v a l. O th e r s itu a tio n s re q u ir e a th e
p o s s ib le
e t io lo g ic
fa c to rs
in
f o r m u la t io n o f a n a p p r o p r ia t e t r e a t
m e n t p la n w h ic h m a y b e n o tr e a tm e n t ; o r t h o d o n t ic w h e n t h e l o n g a x is o f t h e t o o t h d o e s n o t r e a s o n a b l y c o in c id e w i t h th e n o r m a l p a t h o f e r u p t io n , o r w h e n it is l i k e l y t h a t f i n a l t o o t h p o s i t i o n i n g w i l l n e e d o r t h o
tr e a tm e n t
a l o n e ; s u r g ic a l
tre a tm e n t
a lo n e ; o r
com
b in e d o r th o d o n tic - s u r g ic a l m a n a g e m e n t. E x a m p le s o f e a c h h a v e b e e n illu s tr a te d w it h case re c o rd s .
d o n t i c g u i d a n c e , o r i n i n s t a n c e s w h e r e i t is d e s ir a b l e to re d u c e to ta l tr e a tm e n t tim e . A lth o u g h s o m e te e th m ay
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o r t h o d o n t i c f o r c e s , t h e r e is l i t t l e d o u b t t h a t t r a c t i o n w ill h a s te n th e p ro c e s s . I n t h i s p r o c e d u r e t h e t r e a t m e n t p l a n is e s t a b l i s h e d in
c o o p e r a t io n w i t h th e o r a l s u r g e o n . T h e c h i e f c o n
s id e r a t io n s a r e th e p r o v is io n f o r s o m e w h a t m o r e th a n a d e q u a t e s p a c e i n t o w h i c h t h e t o o t h is t o b e g u i d e d , and
s u r g ic a l a c c e s s i b i l i t y . T h e o r t h o d o n t i s t p la c e s a
s u it a b le a p p lia n c e , u s u a lly a f i x e d , m u l t i b a n d e d o n e s u c h a s t h e e d g e w is e a r c h m e c h a n i s m , a n d p e r f o r m s
834 ■ JADA, Vol. 82, April 1971
1. N ess, A . R . M o v e m e n t a n d fo rc e s in t o o t h e r u p tio n . In A d v a n c e s in o ra l b io lo g y . S ta p le , P .H ., e d . N e w Y o r k , A c a d e m ic Press, 1 9 6 4 . p 3 3 . 2 . G r ä b e r , T . M . O r t h o d o n tic s , p r in c ip le s a n d p r a c tic e , ed 2 . P h ila d e lp h ia , W .B . S a u n d e rs C o ., 1 9 6 6 . 3 . S ic h e r , H . O ra l a n a to m y , ed 4 . S t L o u is , C . V . M o s b y C o ., 1 9 6 5 . 4 . B e r k o v itz , B .K .B ., a n d T h o m a s , N . R . U n im p e d e d e r u p tio n in th e ro o t-re s e c te d lo w e r in c is o r o f th e r a t w it h a p r e lim in a r y n o te o n r o o t tr a n s e c tio n . A r c h O r o l B io l 1 4 : 7 7 1 J u ly 1 9 6 9 .
5 . C a h ill, D .R . E r u p tio n p a t h w a y fo r m a t io n in th e pres e n c e o f e x p e r im e n t a l t o o t h im p a c tio n in p u p p ie s . A n a t R e c 1 6 4 :6 7 M a y 1 9 6 9 . 6 . G o w g ie l, J .M . E r u p tio n o f ir r a d ia tio n -p r o d u c e d r o o t less te e th in m o n k e y s . J D e n t R es 4 0 : 5 3 8 M a y -J u n e 1 9 6 1 . 7 . S te g g e rd a , M . a n d H i ll , T . J . E r u p t io n t im e o f te e th a m o n g W h ite s , N e g ro e s , a n d In d ia n s . A m e r J O r t h o d o n t 2 8 :3 6 1 Jun e 1 9 4 1 . 8 . H u r m e , V . O . R a n g e s o f n o r m a lc y in th e e r u p tio n o f p e r m a n e n t te e t h . J. D e n t C h ild 1 6 : 1 1 , 2 n d q u a r t, 1 9 4 9 . 9 . G u n t e r . J .H . C o n c e r n in g im p a c te d te e t h . A m e r J O rth o d o n t 2 8 :6 4 2 N ov 1 9 4 2 . 1 0 . S a lz m a n n , J .A . O r t h o d o n tic s ; p r in c ip le s a n d p r e v e n tio n . P h ila d e lp h ia , J .B . L ip p e n c o t t C o ., 1 9 5 7 , p 2 9 7 . 1 1 . M a c la u g h lln , J .A .; F o g e ls , H . R . ; a n d S h ie r e , F .R . T h e in flu e n c e o f p r e m a tu r e p r im a r y m o la r e x tr a c t io n o n b i c u s p id e r u p tio n . J D e n t C h ild . 3 4 : 3 9 9 S e p t 1 9 6 7 . 1 2 . H e lm o r e , F .E . S u rg ic a l a id t o e r u p t io n f o r o r t h o d o n t ic tr e a tm e n t . A u s t D e n t J 1 2 : 3 7 2 A u g 1 9 6 7 . 1 3 . M e a d , K . T . , a n d M o n s e n , R .M . S u rg ic a l re p o s itio n in g o f d e v e lo p in g im p a c te d te e t h . J A D A 7 1 : 6 2 1 S e p t 1 9 6 5 . 1 4 . B ie d e r m a n , W . E t io lo g y a n d tr e a t m e n t o f to o th a n k y losis. A m e r J O r t h o d o n t 4 8 : 6 7 0 S e p t 1 9 6 2 . 1 5 . H e r m a n , E . E v a lu a tio n a n d m a n a g e m e n t o f a n k y lo s e d te e t h . N e w Y o r k D e n t J 3 0 : 3 2 7 O c t 1 9 6 4 . 1 6 . G r o n , A . P r e d ic tio n o f t o o t h e m e rg e n c e . J D e n t R es 4 1 : 5 7 3 M a y -J u n e 1 9 6 2 . 1 7 . B u c h a n a n , G . S u rg ic a l in te r v e n tio n as a n a id t o o r t h o d o n tic s . A n n A u s t C o ll D e n t S u r g 1 : 7 0 D e c 1 9 6 7 . 1 8 . L e s lie , H .E . A n e w im p ro v e d m e t h o d o f t r e a tm e n t o f im p a c te d o r u n e r u p t e d te e t h . A m e r J O r t h o d o n t 4 1 : 5 8 3 A u g 1955. 1 9 . J o h n s to n , W .D . T r e a t m e n t o f p a la t a lly im p a c te d ca n in e te e t h . A m e r J O r t h o d o n t 5 6 : 5 8 9 D e c 1 9 6 9 . 2 0 . S m it h , D .C . A n e w d e n ta l c e m e n t. B r i t D e n t J 1 2 5 : 3 8 1 Nov 5, 1968.
2 1 . N e w m a n , G . V . A d h e s io n a n d o r t h o d o n t i c p la s tic a tta c h m e n ts . A m e r J O r t h o d o n t 5 6 : 5 7 3 D e c 1 9 6 9 . 2 2 . W e is s , B .: J a c o b s , B .J .; a n d R a f e l, S .S . A s u rg ic o o r th o d o n t ic a p p ro a c h t o th e tr e a t m e n t o f u n e r u p t e d te e th . A n g le O r t h o d o n t 2 3 : 2 0 1 O c t 1 9 5 3 .
D o c t o r D iS a lv o is p ro fe s s o r o f d e n tis tr y a n d d ir e c to r , d iv is io n o f o r th o d o n tic s , C o lu m b ia U n iv e r s ity S c h o o l o f D e n ta l a n d O ra l S u r g e r y , N e w Y o r k , 1 0 0 3 2 .
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