Accidents of dental development.
I- Introduction:
Dental eruption is a physiological phenomenon that allows a tooth to erupt into the oral cavity to a functional position. It involves in particular bone resorption phenomena.
The eruption of permanent teeth is preceded by the resorption of temporary teeth up to the premolars.
Eruption abnormalities occur in both temporary and permanent teeth, although their nature is usually different.
Dental accidents are pathological manifestations of a local, regional or general nature which precede, accompany or follow the eruption of temporary or permanent teeth.
II – Definitions:
- Dentition: or dental evolution is an active biological phenomenon that is part of the general growth of the individual. It is the placement of teeth on the arch. It is a dynamic phenomenon.
- Denture: this is the set of dental organs present on the arch. It is a static phenomenon.
III. Mechanisms of dental eruption
The actual eruption of the tooth generally begins when the first quarter of the root has formed (Van Der Linden, 1983).
This is a complex mechanism, comprising several stages, which has not yet been fully elucidated to date.
This mechanism ensures both:
- the formation of the root and its periodontal environment
- intraosseous displacement of the germ
- the emergence of the crown into the oral cavity
- The path to the occlusal plane.
- Pre-eruptive phase :
It corresponds to the period of pre-eruptive movements within the alveolar bone during the pre-eruptive movements, the bone crypts are transformed and move with the germs. The ceiling of each of them – or wall of the cavity oriented towards the occlusion plane – is pierced by an orifice which corresponds to the entrance of the gubernacular canal.
This bony tunnel connects the crypt to the cortex, and sometimes to the alveolar wall of the deciduous tooth. This is the path that the tooth takes during its eruption.
- Pre-functional eruptive phase
Once the crown forms, the eruption begins.
This movement coincides with the beginning of root formation.
The developing tooth begins to move through the alveolar bone through the polarized phenomenon of bone apposition/resorption.
The mucosa is usually breached when root growth reaches half or two-thirds of the definitive root length.
- Post-eruptive functional phase:
After emerging into the oral cavity, the tooth continues its eruption until it comes into contact with the opposing teeth and gains a functional position.
The eruption will continue throughout life. This is the post-eruptive phase
IV – Temporary dentition:
a/ Chronology of the eruption of temporary teeth:
The eruption of temporary teeth in a healthy infant occurs in groups of teeth per semester:
- Incisors: from the 6th to the 12th month
- 1st Molars: from the 12th to the 18th month
- Canines: from the 18th to the 24th month
- 2nd Molars: from the 24th to the 30th month
* Order of eruption of central and lateral incisors > and < .
- Lower central inc. 🡺Upper central inc. 🡺Upper lateral inc. 🡺Lower lateral inc.
b/ Eruption accidents:
1/ Early eruptions:
Common in the lower incisors
* The following are incriminated: – a hereditary family trait
– infection during pregnancy
– an endocrine factor
* We distinguish:
- vestigial teeth only persisting on the arch for a few days after birth.
2/ Delayed eruptions:
The isolated delay
Isolated delayed eruption is considered to occur in 1 to 2 teeth. Emergence did not occur beyond the age limit for eruption or the age of eruption of its homologous tooth. The majority of delayed eruption has no significant clinical significance, but they
must be evaluated clinically and radiologically. One may find oneself in one of the following situations:
– obstacle on the eruption path: supernumerary tooth or odontoma, closure of the eruption space due to dento-maxillary disharmony or premature loss of the temporary tooth, epulis (benign gingival tumor), etc.;
– resorption disorder due to infection or ankylosis of the overlying temporary tooth;
– dystopic, lacerated or necrotic germ (history of trauma);
– fibrous gum;
– tooth agenesis.
Generalized delay
We speak of generalized eruption delay when all the teeth, or almost all, are delayed. In the majority of cases, the delays
Generalized rashes have no clinical significance, however they should be evaluated.
The factors of chronological variation of the eruption are numerous but poorly understood. There are ethnic, climatic, sexual variations, etc.
Generalized delays can be found in untreated endocrine conditions (hypothyroidism, hypopituitarism, etc.), disorders of phosphocalcic metabolism (rickets,
d’Albright…), drug treatments (anti-cancer chemotherapy, bisphosphonates) or in syndromes (in particular cleidocranial dysostosis in which eruption disorders can reveal the pathology).
3/ Dystopian or ectopic dental eruption
Lingual eruption of the incisors
Very common in the mandible, it is often a cause for concern for parents. If the root of the temporary tooth is resorbing or the temporary tooth is mobile, spontaneous progress is favorable. Otherwise and when the child is over 7 years old, extraction of the temporary tooth may be necessary.
necessary.
In all cases, possibly after avulsion of the temporary tooth, the normal positioning of the permanent tooth is spontaneous except when its position is locked by an antagonist tooth. Management is early here to avoid the installation of a malocclusion.
Epstein pearls, Bohn nodules and dental lamina cysts
White epithelial formations, about 1 mm, they are found
on the alveolar mucosa of newborns and can sometimes be confused with natal teeth. The lesions are usually multiple and their size does not change. Spontaneous evolution is towards regression within a few months.
3/ Local accidents
Several theories have been put forward to explain these phenomena:
- Infectious theory: infection or irritation of the pericoronary sac
- Reflex theory: local irritation at the level of the trigeminal nerve would cause remote manifestations by reflex.
- Theory of organic predisposition:
Some subjects are more likely to have accidents than others.
- Other causes: heredity, endocrine diseases, hygiene, maternal diseases, diseases of early childhood could intervene.
a- Gingivo-dental pruritus:
The eruption of temporary teeth is often preceded by hypersalivation and a tendency to put fingers, or an object, in the mouth.
- The infant bites his lips and
- Drooling due to hypersalivation (sialorrhea).
- The gum is inflamed at the site of future eruption
b- Pericoronitis:
It is the inflammation and infection of the pericoronary sac.
- Profuse salivation
- Red, swollen, painful, sometimes purulent gums
- Hyperthermia and Agitation
- Sometimes swelling
c- Stomatitis:
The inflammation can spread to the neighboring mucosa and determine all the aspects of stomatitis
* Aphthoid stomatitis
* Stomatitis of primary herpes infection
d- Follicular cyst
– Usually located at the level of the 2nd temporary molar or on an edentulous gingival ridge.
– It appears as a rounded, bluish, translucent, fluctuating and painless swelling.
– Its content is a stringy, citrine liquid.
– The X-ray shows a radiolucent image around the crown of the tooth.
* treatment: cystotomy (marsupialization). The neighboring germ must be respected.
Eruption cyst and hematoma
A bluish swelling may develop on the gum next to a permanent tooth or more often a temporary tooth, 1 to 2 weeks before its eruption. Secondarily, a hematoma may form, mainly next to the premolar and molar sectors.
Surgical treatment is rarely necessary but may be discussed in the face of dysphagia preventing feeding or progressing to infection.
e – Expulsive folliculitis:
Following an inflammatory phenomenon or a local infection, the dental follicle is eliminated spontaneously.
A fleshy bud then remains which will disappear as well as the local signs.
– Can sometimes be complicated by osteomyelitis
Treatment: Antibiotic therapy + local care.
– Langerhans cell histiocytosis must be ruled out in the presence of any expulsive folliculitis.
4/ Regional accidents:
– erythrosis jugal (tooth burn)
- hypersalivation,
- tearing,
- serous nasal discharge.
5/ General accidents:
- Benign and punctuated by eruptions
We can distinguish:
– thermal disorders: hyperthermia for 48 hours.
– nervous disorders: agitation, insomnia, convulsions
– digestive disorders: vomiting, loss of appetite, diarrhea, slowed growth and height and weight disorders
– respiratory problems: dry or whooping cough accompanying the rash; sometimes bronchitis and bronchoalveolitis.
6/ Retention of temporary teeth:
May affect one or more teeth (especially molars)
Radiologically we can observe:
– rhizal analysis of the retained tooth
– an absence of the corresponding permanent tooth
– a retained tooth stuck between two closely spaced permanent teeth
The evolution is towards spontaneous fall, inclusion, infectious accident.
Maintaining this retained tooth will cause permanent tooth misalignments in the arch.
Treatment :
extraction of the incriminated tooth followed by ODF treatment
* It is mandatory to ensure the existence of the permanent tooth (by X-ray) before extracting the retained analogous temporary tooth.
In case of generalized delay it could be due to a vitamin deficiency, an endocrinopathy or a hereditary disease.
Therapeutic:
1- Local symptomatic treatment in common accidents of temporary tooth eruption based on analgesics (paracetamol), anti-inflammatories (Niflumic acid: nifluril®, ibuprofen).
2- Good hygiene, disinfection, massage and friction using anesthetic balms.
3- Avoid incisions except in cases of pericoronitis
4- Power monitoring
IV/ Permanent dentition
A- Chronology of the eruption of permanent teeth:
After the temporary crown falls out, the crown of the permanent tooth replaces it and migrates axially until it meets its antagonist.
The eruption of permanent teeth is annual: one group of teeth per year.
- 6 years: 1st molar
- 7 years: central incisor
- 8 years: lateral incisor
- 9 years: 1st premolar
- 10 years: canine
- 11 years old: 2nd premolar
- 12 years: 2nd molar
18 – 25 years: 3rd molar (DDS)
B- Accidents of permanent dentition
1/ Early teething:
She is exceptional.
It must be preceded by the loss of temporary teeth.
2/ Delayed teething:
it can be as a result of:
a) local causes:
– Persistence of temporary teeth due to irregular or late rhizalysis
– Closure of diastemas after early extraction of the temporary tooth.
– Radiculo-dental cyst pushing back the germ of the permanent tooth.
– Pericoronal cyst of the permanent tooth.
– Presence of a local tumor hindering the migration of the temporary or permanent tooth (odontoma).
b) general causes:
– Heredity
– Genetic disease: hereditary gingival hypertrophy, cleidocranial dysostosis, picnodysostosis, etc.
– Vitamin deficiency (vit. D)
– Endocrine disorders: hypothyroidism, myxedema, hypopituitarism
- Always look for a local cause first.
- Always request a control X-ray to rule out dental agenesis.
/ Difficult teething:
- These are the complicated eruptions of evolutionary accidents.
- All teeth are affected, but especially the DDS <
- It can occur on teeth in normal or abnormal positions.
- Teething becomes difficult when:
- a) Infectious accidents:
- These accidents mainly affect the DDS < but can affect other teeth:
- a.1) Infectious accidents of the DDS < :
- These infectious accidents are most often related to the disinclusion of the DDS, they generally occur on DDS with closed apices, whose pericoronary sac is in contact with the oral cavity.
a.1.1) Pathogenesis:
These accidents are explained by:
– morphological anomaly of the root, corona, obliquity of the tooth.
– superinfection of physiological pericoronitis of eruption.
- microbial penetration into the pericoronal sac when it opens into the oral cavity.
a.1.2) Symptoms:
Accidents occur between 18 and 25 years of age during the DDS eruption period.
1/ The initial accident: Acute pericoronitis:
It is the infection of the pericoronary sac and the adjoining mucosa.
The diagnosis is based on:
* Pain:
Spontaneous, retromolar, on chewing by bruising of the mucous membrane, on palpation of the mucous hood.
* Dysphagia
* Trismus: more or less severe, tight.
* The clinical examination found:
* a congested, edematous mucosa, marked by the imprint of the opposing tooth.
* a drop of pus on local pressure.
* one or two cusps sometimes surrounded by ulcerated mucosa.
* X-ray: specifies the morphology of the tooth, its relationship with the lower dental nerve, with the neighboring tooth, its inclination, its possible enclavement, the prior existence of a possible marginal cyst.
* The evolution:
– is done either towards temporary remission (medical TTT)
- either towards complicated forms (cellular accidents or general accidents, septicemic).
* Treatment:
extraction in case of repeated accidents, cysts, cavities or misaligned teeth.
2/ Mucosal accidents:
this is unilateral odontiatic stomatitis related to the development of DDS which can be erythematous or ulcerative.
3/Lymph node accidents can be complicated by periadenitis and adenophlegmon.
4/ Cellular accidents: extension of the infection from the pericoronary sac.
5/ Bone accidents: exceptional osteitis.
6/ Remote infection: spread of pericoronary infection by lymphatic or vascular route 🡪 graft at the level of the kidneys (glomerulonephritis); of the heart (bacterial endocarditis); of the eye (uveitis), of the joints…
a.2- Other teeth
- Upper wisdom tooth:
Infectious accidents accompanying the eruption of DDS > associate:
– genial swelling and orbital and sometimes dental pain
– rhinorrhea and sinus signs.
- Canine
These infectious accidents mainly accompany the included canines:
– rhinitis, sinusitis, osteitis
– neuralgia radiating to the sinus and eye
– a neighborhood infection
b) Mechanical accidents:
– Fractures, dento-maxillary disharmonies, articulation disorders with repercussions on the TMJ
c) Nervous and reflex accidents:
- Sensitive: skin hypoesthesia, facial pain, paresthesia, ringing in the ears, etc.
- Synalgia: pain is felt in other mandibular or maxillary teeth.
– Motor: paralysis, facial spasms, trismus
– Sensory: eye or hearing problems.
d) Tumor disorders:
– Pericoronary (follicular) cyst
– Eruptive cyst
4/ Treatment
Treatment depends on the tooth environment as follows:
* The tooth will be saved if:
- The space to accommodate it is sufficient
- There are no obstacles to its development.
- Its position allows it to erupt correctly
* The tooth will be extracted if:
- The X-ray shows that it cannot erupt completely (insufficient space, impacted tooth, cyst, tumor, etc.)
- The tooth is the cause of infectious or mechanical accidents. It is recommended to do this extraction at a distance from the infectious episode (antibiotic therapy).
V – Dental inclusions
A) – Definition:
There is dental inclusion when:
– the tooth does not erupt on the expected date
– the pericoronary sac is not in communication with the oral cavity
– the tooth is located near its usual seat.
Inclusions can affect one tooth or a group of teeth (multiple inclusions)
B) – Differential diagnosis:
- Disimpacted tooth: the pericoronal sac is open in the oral cavity. The apices are closed. The accident occurs after 25 years.
- Retained tooth: there is localized delay in eruption
- Impacted tooth: an obstacle hinders the normal eruption of the tooth.
C) – Frequency:
- The most frequently impacted tooth = DDS inf.
- Then come in descending order: DDS >, canine > , premolars, incisor < , 1st molar < .
D) – Etiopathogenesis:
We are mainly talking about:
– An abnormality of the pericoronary sac
– A coronary or radicular malformation
– An obstacle: cyst, persistence of the temporary tooth
– A tumor
E) – DDS included:
2 cases may arise:
1/ Clinical silence: it is complete, the discovery of the included tooth is fortuitous.
2/Inclusion is revealed on occasion:
a) a systematic examination carried out in the event of swelling or pain
b) a fracture, particularly the mandibular angle.
c) of a complication:
- mechanical (prosthetic fracture, malocclusion, DDM)
- inflammatory (disinclusion, pericoronitis, cellulitis, stomatitis)
- tumor (pericoronary cyst)
- nervous (sensitive, motor, sensory)
F) – Included canine:
The cause of this inclusion is often related to an obstacle, a malformation, a malposition of the germ.
She is suspected of:
- a palatal or vestibular arch.
- an inter-incisal diastema.
- a displacement of the lateral incisor.
It is most often revealed by infectious and/or mechanical accidents
Canine inclusion is confirmed by:
A radiological check (panoramic, occlusal and retroalveolar).
G) – Upper wisdom tooth:
The inclusion of the DDS > is in most cases strictly fibromucosal
H) – Upper central incisor:
Its inclusion is due to trauma to the germ.
Therapeutic attitude:
- Generally, an included, clinically silent tooth does not need to be extracted.
- However, in the context of ODF treatment, or prosthetic restoration, there may be an exception, if not an obligation.
- Extraction is the rule when the tooth becomes symptomatic or when accidents recur.
Conclusion :
Tooth eruption often occurs gradually and without any particular problem. However, it is possible that in some cases, temporary or permanent teeth are accompanied by local, locoregional or general signs that the dental practitioner must master for the most appropriate therapeutic management of the patient.
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