Journal of Dental Research

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Video Microscope Observations of Human Premolar Eruption

W.R. Proffit, J.R. Prewitt, H.S. Baik and C.F. Lee
J DENT RES 1991 70: 15
DOI: 10.1177/00220345910700010101

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Video Microscope Observations of Human Premolar Eruption
W.R. PROFFIT, J.R. PREWITT, H.S. BAIK1, and C.F. LEE
Department of Orthodontics, School of Dentistry, University of North Carolina, Chapel Hill, North Carolina 27599-7450
It is now possible to observe with an accuracy of 1-2 Arm the
pattern of eruptive movements of a human premolar as it moves
from gingival emergence to the occlusal plane. This was ac-
complished by use of a video microscope to track the position
of an optical ruling on the erupting tooth relative to a reference
ruling mounted on adjacent teeth that were in occlusion. Net
eruptive movements averaging 25-75 pLm occurred from one
day to the next until the tooth was almost in occlusion; then
the eruptive rate slowed. Eruption occurred almost entirely at
night. During the day, there was a marked slowing or cessation
of eruption and often intrusion, which appeared to be related
to masticatory activity.
J Dent Res 70(1):15-18, January, 1991
Introduction.
Because human and similar animal teeth erupt so slowly, it
has been very difficult to measure their movements precisely
enough to evaluate the details of the eruptive process. Eruption
can be divided into six stages-two prior to gingival emer-
gence (follicular growth, intrabony migration) and four after
the tooth emerges into the oral cavity (pre-functional eruptive
spurt, juvenile equilibrium, adolescent acceleration, and adult
equilibrium) (Steedle and Proffit, 1985). Prior to emergence,
the eruptive movements are subject only to the internal envi-
ronment, and it appears from animal experiments that resorp-
tion of the overlying bone is the usual rate-limiting factor (Marks
and Cahill, 1984). After emergence, the tooth erupts at its
maximum rate until it comes into occlusal function, then con-
tinues to erupt in concert with facial growth. The net amount
of eruption would be expected to be determined by the balance
between the force(s) producing eruption and those opposing it
(Proffit, 1989).
Until the last decade, the force of eruption was thought to
be about 5-10 g, based on early work with rodent incisors
(Taylor and Butcher, 1951) and one human patient studied by
Smedley (1975). The straightforward way to determine erup-
tive force is to monitor the position of a tooth and apply known
loads to it until its eruption is just stopped. At that point,
presumably the force opposing eruption just equals the eruption
force. The difficulty comes in measuring precisely enough to
know when eruption has stopped and, secondarily, in quanti-
fying the applied force. Neither the tooth position nor the force
was known with good precision in the older work. Precise
measurements have previously required invasive instrumenta-
tion, and therefore an animal model. In almost all studies, this
has been the rodent incisor, which is both easily accessible
and rapidly erupting. Using this model and modern instrumen-
tation, both Burn-Murdoch and Picton (1981) (with linear dis-
Received for publication May 4, 1990
Accepted for publication August 28, 1990
'Present address: Department of Orthodontics, Yonsei University
College of Dentistry, Seoul, Korea
This work was supported by the Orthodontic Fund, Dental Foun-
dation of North Carolina.
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placement transducers) and our laboratory (Steedle et al., 1983)
(with variable capacitance displacement transducers) have shown
that eruption can be stopped by opposing forces of one gram
or less. If these results can be extrapolated to humans, their
eruption force may also be smaller than previously thought.
The disadvantage of the rodent incisor is that it is rather dis-
similar to slowly erupting teeth-whether the eruption mech-
anism is the same is not known. The ferret canine is a tooth
of limited growth and therefore structurally similar to human
teeth, but erupts rapidly enough to be studied with capacitance
transducers. Moxham and Berkovitz (1983) have reported that
this tooth and the rodent incisor respond similarly to being
loaded, which at least slightly strengthens the case for the
rodent model.
How the balance of forces controls eruption is not under-
stood. In producing orthodontic tooth movement, the duration
of force is more important than its magnitude (Quinn and
Yoshikawa, 1985; Proffit, 1986). This explains why teeth do
not respond to traumatic occlusion by moving to another po-
sition, or why tongue pressure in swallowing or speaking has
little effect on tooth position-the duration is too short, even
though the force or pressure is large enough (Proffit, 1978).
Because of their duration, the light but prolonged pressures
from the lips, cheeks, and tongue at rest do influence dental
arch form and can cause tooth movement.
Eruptive movements are physiologically similar to lateral
or antero-posterior tooth movements in response to soft tissues
or orthodontic force. On the other hand, much of the force
opposing eruption, the part that occurs during chewing, is of
quite short duration. There are no data for the total time of
tooth contacts per day (which would need to include nocturnal
clenching), but long durations are unlikely. Whether this means
that intermittent force plays a larger role in controlling eruptive
movements is unknown.
We have previously used the rabbit incisor model to explore
the effect of intermittent force on eruption (Proffit and Sellers,
1986). These experiments showed that force applied for 50%
of the time (via a cantilever beam transducer) produced effects
very similar to those of full-time force. Eruption stopped or
the tooth intruded, depending on the magnitude of the force.
Force applied 10% of the time had essentially no effect on
eruption, even when it was heavy enough to produce rapid
intrusion if maintained longer; force applied 25% of the time
gave an intermediate effect. The results were very similar to
what would be expected if the periodontal ligament response
to vertical forces were no different from force in other planes
of space, i.e., if force duration were more important than mag-
nitude in determining the response. The limitations of the ro-
dent incisor model, however, make extrapolation directly to
human teeth risky.
The recent development of an optical imaging method to
track the eruptive movements of a human premolar makes it
possible to observe the pattern of eruption in a way that has
not been possible previously. We have used this method to
track eruption of maxillary second premolars during the pre-
functional eruptive spurt, as the tooth moved from initial emer-
gence into the oral cavity toward the occlusal plane. The goals
15
16 PROFFIT et al. J Dent Res January 1991

TABLE anchored to the adjacent first premolar and first molar, and
ERUPTION RATES (pum/day) observed the relative motion of the two rulings with a video
Day Day Day Day microscope.
Subject 1-2 2-3 3-4 4-5 Mean With this magnification, the depth of focus is very small.
Tooth not near occlusion The patient must be held still enough for an image to be ob-
TC 147 17 20 1 46 tained, and the microscope must be oriented precisely. The
EM 145 4 38 23 53 patient-positioning problem was solved by having the patient
BY 132 46 47 74 75 bite into a matrix for the teeth of the other side of the arch
AC 53 15 20 10 25 while pressing his or her head against a headrest. A micro-
MI 66 -4 82 1 36 positioning device was adapted to the video microscope so it
CG 65 36 40 52 48 could be moved small distances while mounted at any angle.
CR 71 17 38 21 37 A videotape was made as the rulings were brought into focus,
AM 81 47 36 44 47
RO 64 119 43 41 67 and the magnification was increased to the maximum (400 x)
ML 47 9 42 3 25 with the video-microscope zoom function.
TC 47 8 55 10 30 Data recordinglanalysis.-The videotape consisted of im-
EM 41 -19 65 9 24 ages that went in and out of focus as the patient moved slightly
Mean 83 26 44 21 44 or the camera vibrated. During a typical session, three minutes
Tooth near occlusion of observation would result in a series of clear images at var-
BN 7 9 11 15 11 ious spots along the tape. For analysis, the tape was played
JO 43 -17 4 26 14 back, and a frame-grabber card in a laboratory computer was
Mean 25 -4 8 21 13 used to transfer a clear image into computer memory. It was
then possible for cursors to be set on the monitor screen, which
were to establish the daily rate of eruption, and to observe the was now perfectly steady because of the single instant in time
pattern of eruptive movements for evidence of a circadian rhythm that had been captured, and measure the distance that the ruling
or for an alteration in eruption related to masticatory activity. attached to the erupting tooth had moved.
One concern with this method is that the measurements are
two-dimensional, while the erupting tooth is moving in three-
Materials and methods. dimensional space. The mobile ruling is mounted approxi-
mately parallel to the long axis of the tooth. On a gross level,
Video imaging system. -An ideal reference for eruption it is known that the erupting tooth moves along its long axis,
studies would be permanent markers within the jaw-a high- in a primarily vertical direction, but off-axis motion as the
resolution analogue of Bjork's metallic implants in the classic tooth erupts is possible. The question would be the magnitude
radiographic studies of dentofacial development (Bjork and of any errors in estimation of movement because of this. Such
Skieller, 1972). Neither radiographs nor implants can now be errors are likely to be small for two reasons:
used in research on normal human subjects, and (in any case) (1) If the erupting tooth did move antero-posteriorly or lat-
that would be feasible only for long-term studies. For medium- erally more than a small distance, this would be observed.
and short-term studies, it is possible to use as the reference Antero-posterior motion would be seen as a tilting of the lines
the teeth adjacent to the one that is erupting, i.e., the motion of the mobile ruling relative to those of the reference ruling.
of the erupting tooth is measured relative to the occlusal plane Only very small changes of this type were observed. Lateral
that it is approaching. The reference teeth are themselves erup- motion would move the mobile ruling away from the reference
ting in concert with vertical facial growth. Even at the height ruling, in which case the limited depth of focus of the imaging
of the adolescent acceleration, however, the maximum rate is system would quickly make it impossible to bring both rulings
approximately 2 mm/year, which can safely be considered neg- into focus simultaneously, or the mobile ruling would move
ligible over minutes, hours, or days. toward the reference ruling. Lateral motion out of focus was
The reference teeth can also be displaced transiently by ap- not observed. The rulings were placed initially so that they
plied forces (Miihlemann, 1967). It has been reported previ- were almost in contact, and there was a salivary fluid film
ously that when a tooth undergoes axial loading, recovery occurs between them. On the laboratory bench, the drag force of one
in two phases. An initial rapid linear phase is followed by a ruling against another with glycerine separating them was found
slower declining phase, requiring a total of 60 to 90 s to return to be so small (<0.001 g/cm2) that it was lost in the noise of
to the pre-loading position (Picton, 1963, 1969). Thus, the the measurement system. This would also be true in the mouth,
reference teeth should be stable in the short term if they had with saliva or water as the fluid. If transverse motion did bring
not been subjected to forces within the last few minutes. the gratings toward each other, the vertical motion would not
During the time between emerging from the gingiva and be distorted by frictional resistance.
coming into contact with its antagonist, a typical premolar (2) If the erupting tooth moved at an angle to the true ver-
erupts 4 mm (relative to the occlusal-plane or to implants in tical, the error would be a cosine function of the deviation
the jaws) over a period of about 14 weeks. The mean eruption from true vertical, i.e., quite small until the angle of deviation
rate, therefore, would be about 40 pum/day, 1.7 pum/h, or 0.03 was large. A 15-degree variation from true vertical (which is
prm/min. The actual rate would be expected to vary around the large enough to be detected rather quickly from direct obser-
mean rate, perhaps by quite a large amount, as the tooth re- vation) would produce only a 3.5% error.
sponded to transient opposing forces (as from food contacts Recently, taking advantage of our initial experience, we re-
during mastication) or was influenced in other ways by un- designed the optical rulings to make the lines narrower (5 tum
known factors. instead of 10) and to provide more orientation markings on the
In order to study human eruption in the medium term (hours, rulings, to make it easier to distinguish locations on the mobile
days), observational accuracy on the order of 2 ,um is required. and reference rulings. An improved frame-grabber was used.
To accomplish this in a non-invasive way, we attached an Recent data for within-day eruptive movements were obtained
optical ruling ((larmann Rulings, Manchester, NH) to the when these improvements were used.
erupting second premolar tooth and a reference ruling to a bar Subjects. -Subjects for these studies were recruited from
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 cl)
Vol. 70 No. 1 MEASUREMENT OF HUMAN PREMOLAR ERUPTION 17

the population of children who attend the School of Dentistry
for their regular dental care. The selection criteria were that
the subject should be a normal and cooperative child with a
maxillary second premolar erupting toward the occlusal plane,
but not yet in occlusion, and that the first molar and first
premolar in the same quadrant should be in normal occlusal
function (i.e., children with severe malocclusion were ex-
cluded). The children were paid $75 or $100 for their coop-
eration over the period of observation.
The apparatus was fitted on dental casts in the laboratory,
with the mobile ruling attached to the buccal surface of the
erupting second premolar and the reference ruling attached to
a bar spanning between the first molar and first premolar. The
apparatus was then bonded to the teeth and maintained for
periods of observation up to five days. At each recording ses-
sion, the rulings were washed gently to remove plaque build-
ups and then dried with an air syringe. The subject was placed
in the head positioner, and a video recording was made as
described above; the subject was then re-positioned for a rep-
licate recording. The repeated measurements within each re-
cording session demonstrated excellent reproducibility: When
the patient was re-positioned, the data points were consistently
within 1-2 pm.
The system was used to observe eruption in 18 subjects-
in each case, a 12-13-year-old with an erupting maxillary sec-
ond premolar. The clarity of the images improved noticeably
with experience and with the introduction of the second-gen-
eration rulings.
Results.
Possible methodological errors.-When physiological re-
cordings are made, there is always the possibility that the pres-
ence of the recording instruments will affect the process that
is being observed. There are at least two ways in which the
imaging apparatus could influence the observed eruption: (1)
The weight of the apparatus could affect the position of the
erupting tooth or the reference teeth, elongating them more
than would have occurred otherwise. If the reference teeth
were elongated, the apparent movement of the erupting tooth
would be less than it really was; if the erupting tooth were
pulled down further by the apparatus, the apparent rate of
eruption would increase. The total assembly for the reference
teeth (support bar, bonding pads, ruling) weighed 0.92 g, which
seems unlikely to be enough to displace two multi-rooted teeth.
The ruling for the erupting tooth weighed only 0.03 g, and the
bonding material to hold it in position added only another small
fraction of a gram. When a load of any magnitude is applied,
teeth are displaced rather quickly within the periodontal liga-
ment space, then stabilize in their new position. There was no
evidence of a short-term effect that could be attributed to dis-
placement by the apparatus, and a significant error from this
source seems unlikely.
(2) Altered occlusal function over a period of time could
affect the stability of the reference teeth. In these experiments,
300
Subj 1 JS
250 .
C
._2
m 200
Subj 2 DB
---OF---

Daily eruption rate. -The initial studies were of 14 children 0 Subj 3 HB

who were observed at 24-hour intervals for four consecutive CL 150
No 6
days, to obtain data for the amount of daily eruption of teeth. u, Subj 4 TB
0 --.-
The imaging apparatus was placed during the late afternoon, o 100
and the child was observed at the same time on the next four 0.
Night:
afternoons. In 12 children with a premolar that was well out 50
of occlusion, mean daily eruption over a four-day period varied 0
from 25 to 75 ALm (Table). In two children with a tooth that 0 12 24 36 48 60 72
had erupted almost into occlusion, mean daily eruption aver- Hours
aged 11 and 14 jum.
The amount of eruption from one day to the next varied for Fig. 1-Plots of daily eruptive movements for four children who had
all subjects, and negative eruption over a one-day period was overnight observations and repeated observations during a day in the lab-
observed twice in the 14 subjects. The amount of eruption oratory. For all four patients, the laboratory day was Saturday. For three,
the optical device was bonded on Friday afternoon and the initial obser-
during the first 24 h of observation was usually greater than vation was made then; for the other subject, the device was placed on
that observed thereafter. Analysis of variance confirmed that Wednesday.
the difference was statistically significant (p<0.001).
Pattern of eruption within a day.-Eruption often occurred co
much more quickly than the 1-2 jxm/h expected from the mean 150 -
rate over several weeks, and therefore, observations could be
made at much shorter intervals. By use of the second-gener- 0 ~~~~~~
ation rulings, four children were observed repeatedly during a 1 0S
it00
0:: tig;Subj
0t; 0g ;, ,
day, with overnight observations before and after. As the plots 0.
show (Figs. 1 and 2), significant amounts of eruption occurred Subj 2DB
overnight, but eruption was stopped by eating, and the tooth Subj 3 HB
often intruded somewhat (even though the tooth that was being Subj 4 TB
observed was not in occlusion). Eruption resumed some time
after the subjects stopped eating, but there was rarely net erup-
tion during the day. :;X ES. tA3 A. .,
8AM Noon 4PM
Discussion.
The variations in the daily rate of eruption, and particularly Fig. 2-Details of the laboratory day for the same four patients (time
scale expanded). Note that the pattern of eruption was similar in each
the greater eruption at night than during the day, have not been patient: significant net eruption overnight; intrusive movements during and
demonstrated previously in humans. Important points for dis- after breakfast, with a tendency to resume eruption later in the morning;
cussion are the possibility of methodological errors and the lesser intrusion with lunch, and again a tendency to resume eruption later
implications of the variations in eruption rates. in the afternoon; and further net eruption over the next night.
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18 PROFFIT et a.
children tolerated the presence of the apparatus over as much
as four nights, but were instructed not to chew on the side
with the apparatus. It is possible that if the reference teeth did
not experience normal masticatory function, they could begin
to erupt, which would make it appear that the eruptive rate of
the premolar not yet in occlusion had slowed. The data showed
that the 24-hour eruption rate was less for the second and later
days than for the first day, and a change in the position of the
reference teeth could be the explanation. This point requires
further experimentation, however.
Variations in eruption rate: occlusal force or circadian
rhythm?-The existing animal data clearly show a relationship
between the rate of eruption and occlusal function-taking a
rodent incisor out of occlusion significantly accelerates its
eruption rate. There is also clear evidence of a similar rela-
tionship in humans-when its antagonist is extracted, a human
tooth will begin to erupt again, even many years after eruption
had stopped. The data for day-to-day eruption of human pre-
molars indicate that the rate of eruption slows as a premolar
comes close to the occlusal plane and to its antagonist. An
erupting tooth would not be affected by contact with its antag-
onist until it reached the occlusal plane, but a force opposing
eruption would be generated by contacts with food or soft
tissues during mastication as the erupting tooth was increas-
ingly exposed to the oral environment. This is one logical
explanation for the slowing of eruption and the transient intru-
sion that was observed during the day. The apparent associa-
tion of intrusion with meals and the resumption of eruption
sometime later are what would be expected if this explanation
were correct.
It is also possible that a biological rhythm exists in eruption,
reflecting an underlying circadian rhythm of cellular activity.
Although this has not been documented previously, some an-
imal data suggest that tooth eruption occurs more rapidly dur-
ing quiet periods than during active wakefulness and that it
occurs more at one time of day than another. For instance, in
the rodent incisor model, a reduction in blood pressure in-
creased the rate of eruption, while increased blood pressure
reduced it (Thomas, 1965). In both the rodent incisor (Ber-
kovitz, 1983) and the ferret canine (Moxham and Berkovitz,
1983), the rate of eruption is faster at some times of day than
others. The nocturnal ferret has its maximum eruption rate
during the day, when it would normally be sleeping.
High-precision optical observations of erupting human teeth
have the potential to establish the pattern of eruption and its
relationship to masticatory or other activity vs. an innate daily
rhythm. They will also make it possible to use human teeth in
experiments to determine the relationship between eruptive ac-
tivity and force applications to the erupting tooth. This should
clarify the role of occlusal forces in controlling eruption, and
whether and how the equilibrium of forces that ultimately de-
termines tooth position differs according to the plane of space
in which force is applied.
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J Dent Res January 1991
Acknowledgment.
We thank Robert Paterson, IBM Research Laboratories,
Lexington, Kentucky, for invaluable technical support.
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