DEPT.

OF ORTHODONTICS
AND
DENTOFACIAL ORTHOPAEDICS
SRI AUROBINDO COLLEGE OF DENTISTRY
AND P.G. INSTITUTE
JOURNALCLUB-3
Primary Eruption Failure : a possible cause of posterior
open bite
(W.R.Proffit, K.Vig, AJODO August 1981, Vol 80, pg173-190)

BY : CHAITREE DE
P.G. 1ST YEAR
 POSTERIOR OPEN BITE

• Partial or complete failure of posterior teeth to erupt

and come into occlusion produces a lateral (posterior)
open-bite.

• occurrence of this problem is too infrequent.

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 ETIOLOGY

(1) Mechanical interference with eruption, either before

or after the tooth emerges from the alveolar bone.
Caused by:
• Ankylosis of tooth (spontaneously / trauma)
• Non- resorbing bone or deciduous tooth root.
• Supernumerary teeth
• Soft tissues (tongue, cheek, lips)

(2) Primary failure of eruption.

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 Eruption failure due to
mechanical obstruction

Primary eruption failure

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 INFLUENCES ON TOOTH ERUPTION

1. Gubernacular cord
• Seen in succedaneous teeth as part of dental lamina.

• Determines the path of eruption and actively pulls

the enamel organ.

Gubernacular cord

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2. Resorption of overlying bone and/or tooth
• Biochemical and cellular changes in dental follicle
produce signals to bring about resorption .

• Mechanical pressure from erupting teeth.

• Resorption of bone acts as rate limiting factor for

eruption of tooth.

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3. Opposing tooth
• Once the erupting tooth comes into occlusion the
process of eruption slows down.

• Continuous eruption of all teeth accompanies

growth of alveolus, maxilla, mandible and face.

• Renewed eruption seen in case the antagonist teeth

is removed.

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4. Eruptive forces
• Hydrostatic forces in PDL (periodontal ligament)
derived from vascular system of pulp.

• Traction through PDL due cross linking and

maturation of collagen fibers.

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5. Developmental syndromes
• The unerupted teeth in cleidocranial dysplasia are not
ankylosed.

• The eruption failure is due to mechanical obstruction

from abnormal resorption of overlying bone.

• Other syndromes are: osteoporosis, GAPO syndrome

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 PRIMARY ERUPTION FAILURE
Primary failure of eruption (PFE) is a rare condition
characterized by non-syndromic eruption failure of
permanent teeth in the absence of mechanical obstruction.

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CHARACTERISTICS of PFE
1. Posterior teeth are involved more than anterior teeth.
• Most affected is 1st permanent molar and least are
incisors.

• Varying degrees of abnormality seem present distal

to the first involved.

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2. Affected teeth may erupt all the way into occlusion
and then cease to erupt, even though they are not
ankylosed , or they may never erupt.
• If they erupt initially, affected teeth appears
submerged.

• A tooth which never erupted appears to be at the

bottom of a large vertical bony defect.

• In some cases, enlarged follicle around the unerupted

crown can be seen.

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2. Deciduous as well as permanent molars can be
affected.

3. Involvement maybe unilateral or bilateral (*

unilateral variety is more common) and non
symmetric.

4. Involved permanent teeth do tend to become

ankylosed, but failure of eruption is apparent before
definite ankylosis occurs.

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6. Application of orthodontic force leads to ankylosis
rather than normal tooth movement.

7. No hereditary or syndromic association seen.

8. The age of onset is not clear.

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 TREATMENT for
FAILURE OF
ERUPTION

TOOTH DID TOOTH ERUPTS

NOT ERUPT BUT NOT IN
OCCLUSION

FAILURE OF
MECHANICAL
OBSTRUCTION
BONE PFE MECHANICAL
RESORPTION OBSTRUCTION PFE

EXTRACTION OSTEOTOMY LIP

OSTEOTOMY, /CHEEK
AND AND
PROSTHESIS SHIELD
ORTHODONTICS ORTHODONTICS
OSTEOTOMY
AND BONE
GRAFTING
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 PFE CASE I
• 13 year old girl with multiple unerupted posterior
teeth in all 4 quadrants.

• Treatment plan- surgical exposure and manipulation

of the affected teeth to bring them into occlusion.

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• Maxillary left posterior teeth on surgical exposure
could be easily displaced.

• Maxillary right canine and premolars were

repositioned.

• Mandibular right 1st molar was extracted.

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• Since unerupted teeth were not ankylosed,
orthodontic treatment was attempted.

• 6 months later no change was observed.

• All teeth except the upper and lower incisors

appeared to be ankylosed.

• After 16 months of treatment, situation remained

same except closure of anterior spaces.

• Ultimately, maxillary and mandibular onlay dentures

were constructed.
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 PFE CASE II

• A 13-year-old girl was referred for surgical correction

of mandibular prognathism at a later date.

• She had been under treatment for the previous 12

months, with a full edgewise appliance.

• After 12 months of treatment, the maxillary right 1st

molar remained some 6 mm out of occlusion, and a
lateral open-bite extended posteriorly on the right side
from the lateral incisor.

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Lateral
open bite

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• In response to the orthodontic force, the first molar
had ankylosed and had provided the anchorage
necessary for intrusion of the premolars and canine

• Extraction of the maxillary right first molar was

advised and was carried out.

• A light round arch wire placed back through the

maxillary second premolar, to bring canine and
premolar back in occlusion.

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• The unerupted maxillary 2nd molar was surgically
exposed. A band was placed on it and an arch wire
was extended including the tooth to bring it in
occlusion.

• Vertical elastics were placed between the upper and

lower second molars.

• When the patient was seen for another surgical

consultation, the second molar had not moved
appreciably.

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• The canines and premolars on the maxillary right side
were intruding and a lateral open-bite extended
posteriorly from the lateral incisor.

• The othodontist was advised to disconnect the second

molar and the open-bite improved forward from the
molar.

• At this stage, a bilateral ramus osteotomy was used to

set the mandible back 7 mm.

• At the same time an alveolar osteotomy was done to

bring the maxillary right 2nd molar into occlusion.
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• A graft of freeze-dried cadaver bone was placed
above the alveolar segment.

• Following surgery, light elastics on round arch wires

settled the teeth into occlusion.

• The maxillary right 2nd molar remained about 2 mm

out of occlusion, thus a restoration was done to bring
it into function.

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BEFORE AFTER

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 DISCUSSION
• Once the teeth are in occlusion they are subjected to
equal and opposing forces in all directions , this
equilibrium brings about the stable position of the
teeth in its socket.

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• Mechanical obstructions and detrimental habits like
tongue thrust may not always be the cause of open
bite .

• Thus a failure of the eruption mechanism should be

considered for a realistic and fair diagnosis of
posterior/ lateral open bite.

• Distinguishing between the two causative

phenomenon is important clinically because this
determines the prognosis for conventional
orthodontic treatment.

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 TAKE HOME MESSAGE

Since hyper- or hypoeruption of teeth in addition to jaw

positioning is involved in all types of malocclusion
involving the vertical dimension, a more complete
understanding of the eruption mechanism and why it
sometimes fails should facilitate treatment for many
orthodontic patients.

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 REFERENCES

• Profitt
• Kelly, J. E., and Harvey, C. R.: An assessment of the
occlusion of the teeth of youths age 12-17 years,
• Cahill, D. R.: Eruption pathway formation in the
presence of experimental tooth impaction in puppies
• Primary failure of eruption: Clinical and genetic
findings in the mixed dentition-Angle Orthodontist,
Vol 88, No 3, 2018

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