January, 2012

Primary Failure of Eruption (PFE) of Multiple Permanent Teeth: A diagnostic and Rehabilitation challenge


The objective of this article is to help the dentist diagnose a case of primary failure of eruption (PFE)  appropriately and distinguish it from other causes of eruption failure. The literature on the possible etiology of PFE was reviewed and correlated with our patient.  A systematic approach towards the diagnosis and treatment by surgical prosthodontic or orthodontic modalities has been given. This case report presents a rare clinical situation of failure of eruption of multiple permanent teeth in all four quadrants and a methodological approach towards diagnosis along with the treatment plan for rehabilitation.


Tooth eruption, a process involving multiple factors primarily depending on the tooth germ, is defined as the axial or occlusal movement of a tooth from its developmental position in jaw towards its functional position within the occlusal plane1-6. It is a localised event that appears to be regulated by genes expressed in the dental follicle at chronologically critical times. The normal eruptive process involves navigation of the tooth through the bone and oral epithelium in a precise, bilaterally timed sequence that must be co-ordinated with the growth of the jaws in all three planes of space. It is incorrect to think that the erupting tooth forces its way through the overlying tissues. Instead, the controlling factors are resorption of overlying bone, tooth roots and alveolar mucosa. However, significant deviation in the process, as well as timing of eruption are often observed in clinical practice.

Failure of eruption has been divided into three distinctive categories by Sylvia A and Frazier Bowers7 into

1. Primary failure of eruption (PFE).

2. Mechanical failure of eruption (MFE).

3. Indeterminate failure of eruption (IFE).


The diagnostic criteria for these are:

1. PFE:

  • Eruption pathway cleared, no erupting movement along path.
  • Teeth distal to most mesially affected tooth also involved.
  • Any or all posterior quadrants involved.

2. MFE:

  • Radiographic appearance of submergence due to ankylosis.
  • No clear path of eruption.
  • Teeth distal to most mesially affected tooth apparently normal.

3. IFE:

  • Distinction between PFE and MFE not clear.
  • Too young to determine whether teeth distal to most mesially affected tooth are affected or normal.

Primary failure of eruption was described for the first time by Proffit and Vig8 in the year 1981 to describe a condition in which malfunction of the eruption mechanism causes non-ankylosed teeth to fail to erupt. The main identifying characters of this condition are 1) Failure of an affected tooth to move along the eruption path that has been cleared for it. The teeth involved partially erupt and then cease to erupt   becoming  relatively submerged though not ankylosed. 2) Another important feature of this condition is that only posterior teeth are affected resulting in posterior open bite.  All teeth distal to the most mesially affected tooth are also affected. This condition is usually unilateral but can affect all the posterior quadrants. 3) A key characteristic of this condition is an abnormal or complete lack of response to orthodontic force, so that the involved teeth fail to move into proper position.

The etiopathogenesis of various causes of multiple failures of eruption are summarized ( Table 1) by  Sivakumar et al9.

Table 1

Thus, it is apparent that a few patients may present in the dental clinic with multiple unerupted permanent teeth, with no associated symptomatic illness, no underlying endocrine dysfunction and no associated genetic abnormalities. This article deals with a report of one such case.



A 23 year old male reported to the Department of Oral and Maxillofacial surgery, DAV(c) Dental College & Hospital, Yamunanagar, India for consultation regarding his missing posterior teeth. His past medical history was completely unremarklable. He was the product of a normal term delivery and had experienced no serious illness. The family history was equally unremarkable and no other family members had the problem of missing teeth. The results of general physical examination were within normal limits and the haematocrit and WBC counts were also within normal range.   Temporomandibular joints were palpable bilaterally with no crepitus/clicking/grating. Mouth opening was found to be normal i.e approximately 40 mm. Intra orally, the patient showed unerupted 26,27,37,48 and partially erupted 16, 17, 36, 38, 47. No other oral mucosal lesions were seen. (Figures 1-6)

Figure 1: Frontal facial profile: No gross asymmetry observed.

Figure 2: Teeth in occlusion.

Figure 3: Posterior open bite on right side.

Figure 4: Posterior open bite on left side.

Figure 5: Maxillary arch showing partially erupted 16, 17 and unerupted 26, 27.

Figure 6: Mandibular arch showing partially erupted 36,38, 47 and unerupted 37.


Panoramic x-ray revealed unerupted 16, 17, 26, 27,36, 37 and horizontally impacted 38 and 48 teeth. No obvious obliteration of the periodontal space was noticed. Root development of all unerupted teeth was complete. (Figure 7)

Figure 7: Panoramic radiograph showing multiple unerupted maxillary and mandibular teeth.

The treatment plan called for application of orthodontic force on the partially erupted 36 by orthodontic extrusion forces generated by extrusion cantilever appliance. The appliance was applied for a time period of 4 months and no movement was noticed, thus confirming the diagnosis of PFE. In order to prevent the intrusion of adjacent teeth, all teeth in the mandibular arch were consolidated to serve as a unit to dissipate the reactionary intrusion forces. (Figure 8)

The planned rehabilitation of the patient is removal of both impacted mandibular molars 38 and 48 which has already been done. The second step is to provide onlay crowns on 16, 17 and uprighting of 47 which would bring these teeth into occlusion on the right side. For the left side removal of 26, 27 and 36, 37 followed by bone grafting and prosthetic rehabilitation with the help of implants has been planned.


Figure 8: Extrusion cantilever appliance applied on 36 to facilitate its eruption.




Disorders of tooth eruption can be difficult to diagnose, given the lack of knowledge about the eruptive process. The diagnosis is based on clinical and radiographic characteristics and sometimes on the response to treatment. In the diagnosis of eruption failures, the first step is to rule out any local, systemic, and endocrine factors. Finally, the main differential diagnosis is mechanical obstruction (ankylosis) vs failure of the eruption mechanism. Distinguishing between the two is the key to determining the prognosis for the affected teeth. Unfortunately, MFE and PFE can have similar presentations in the early stages. If so, a definitive diagnosis cannot be made without sufficient longitudinal data and therapeutic diagnosis. However, diagnosis of PFE demands a logistic and systematic approach. The following flow chart 9 (Table 2) provides a direction for methodological pathway to reach upto the ultimate diagnosis of this idiopathic rare entity.

Table 2


Our patient was growing at a normal rate, was within normal limits with respect to facial and skeletal growth, and was of normal intelligence. Through careful clinical and radiological examination any local and systemic causes for obstruction in eruption pathway were ruled out. There was no family history of the disorder, and once again a defect in eruption of the primary dentition has not been reported in this syndrome. Some other syndromes enlisted in table were also ruled out on the basis of lack association with any clinical or radiographic symptoms. No abnormalities in thyroid function were noted and serum calcium, phosphorus, and alkaline phosphatase levels were within the normal range. On the basis of absence of any systemic and local findings diagnosis of PFE was figured out.

PFE appears to be a condition that predominantly affects the posterior dentition, the eruption failure can be preceded by a period of normal eruption, but any attempt to extrude an affected tooth orthodontically is likely to result in ankylosis8, 10, 11, 12

(Proffit and Vig, 1981). Although these teeth might have a slight response to orthodontic forces, the response is abnormal and the teeth invariably become ankylosed before reaching occlusion. In our case we tried to facilitate the eruption of 36 through orthodontic extrusion forces generated by an extrusion cantilever. But no movement of the tooth was observed over a period of four months. Moreover, some case studies demonstrate that not only do affected teeth fail to respond to treatment, but also adjacent normal teeth are adversely affected by intrusion to the level of the affected teeth13,14. In order to prevent the intrusion of adjacent teeth, all teeth from 36 to 46 in the mandibular arch were consolidated to serve as a unit to dissipate the reactionary intrusion forces.


The treatment modalities of PFE are complicated not only because diagnosis of this condition depends mainly on exclusion, where all possible causative factors are to be considered and eliminated. Active orthodontic force will most likely result in localized ankylosis and failure to extrude an affected tooth into occlusion, a finding that is essentially diagnostic8 (Proffit and Vig, 1981). Moreover, after obtaining the diagnosis, treatment options are challenging and limited. Patients and orthodontists have to satisfy themselves with premolar occlusion or try for more invasive techniques, which may not succeed. In very mild cases, teeth can be restored with onlays and crowns15 and further definitive restorations can be planned once vertical growth is completed. For moderately severe cases, extraction of teeth with placement of implants might be an option, but bone grafts before implants are likely to be required. Cases where multiple teeth are involved are more difficult to manage; the only available method of bringing them into occlusion is a segmental osteotomy (Proffit and Vig8, 1981; Piattelli and Eleuterio16, 1991). In severe cases, as in this case, a significant deficit in alveolar bone height precludes subapical osteotomy.  However, careful planning in these cases is essential to ensure that no damage is caused to adjacent teeth. While surgical repositioning may not move teeth into an entirely acceptable position, it will certainly aid prosthetic management.

Distraction osteogenesis has been reported to correct an extreme posterior open bite thereby it can be considered as an alternative treatment modality17.



Idiopathic multiple failure of eruption of teeth is a very rare anomaly and can be regarded as an eruption defect, manifesting as a complete failure of eruption or cessation of initial eruption with no obvious local or systemic aetiology. Therefore, it is imperative for clinicians to follow a methodical approach towards the diagnosis and rehabilitation of the patient through surgical, orthodontic or by prosthodontic measures.


1.      Massler M, Schour I. Studies in tooth development: theories of eruption. American Journal of Orthodontics and Oral Surgery 1941;27:52-76.
2.      Berkovitz BKB. The effects of root transaction and partial root resection on the unimpeded eruption rate of the rat incisor. Archives of Oral Biology 1971;16:1033-43.
3.      Moxham BJ, Berkowitz BKB. The effects root transaction on the unimpeded eruption rate of the rabbit mandibular incisor. Archives of Oral Biology 1974;19:903-9.
4.      Cahill DR, Marks SC. Tooth eruption: evidence for the central role of the dental follicle. Journal of Oral Pathology 1980;9:189-200.
5.      Marks SC Jr, Cahill DR. Experimental Study in the dog of the nonactive role of the tooth in the eruptive process. Archives of Oral Biology 1984;29:311-22.
6.      Wise GE, Marks SCJr, Cahill DR. Ultrastructural features of the dental follicle associated with formation of tooth eruption pathway in the dog. Journal of Oral Pathology 1985;14:15-26.
7.      Sylvia A. Frazier-Bowers, Karen E. Koehler, James L. Ackerman,  William R. Proffit Primary failure of eruption: Further characterization of a rare eruption disorder. American Journal of Orthodontics and Dentofacial Orthopedics 2007; 131:578.e1-578.e11.
8.      Proffit WR, Vig KW. Primary failure of eruption: a possible cause of posterior open-bite. American Journal of  Orthodontics 1981;80:173-90.
9.      Sivakumar A, Valiathan, Gandhi S, Mohandas A. Idiopathic failure of eruption of multiple permanent teeth: Report of 2 adults with a highlight on molecular biology. American Journal of Orthodontics and Dentofacial Orthopedics 2007; 132:687-92.

10. Biederman W. Etiology and treatment of tooth ankylosis. American Journal of Orthodontics 1962;48:670-84.

11. Mancini G, Francini E, Vichi M, Tollaro I, Romagnoli P. Primary tooth ankylosis: report of case with histological analysis. Asdc Journal of Dentistry For Children 1995;62:215-9.

12. Mitchell DL, West JD. Attempted orthodontic movement in the presence of suspected ankylosis. American Journal of Orthodontics 1975;68:404-11.

13. Raghoebar GM, Boering G, Jansen HW, Vissink A. Secondary retention of permanent molars: a histologic study. Journal of Oral Pathology and Medicine 1989;18:427-31.

14. Winter GB, Gelbier MJ, Goodman JR. Severe infra-occlusion and failed eruption of deciduous molars associated with eruptive and developmental disturbances in the permanent dentition: a report of 28 selected cases. British Journal of Orthodontics 1997; 24:149-57.

15. Yatani H, Watanabe EK, Kaneshima T, Yamashita A, Suzuki K. Etched-porcelain resin-bonded onlay technique for posterior teeth. Journal of Esthetic Dentistry 1998; 10:325-32.

16. Piattelli A, Eleuterio A 1991 Primary failure of eruption. Acta Stomatologica Belgica; 88 : 127 – 130

17. Kater WM, Kawa D, Schafer D, Toll D. Treatment of posterior open bite   using distraction osteogenesis. Journal of Clinical Orthodontics 2004;38:501-4.






Reader, Dept. of OMFS,

D.A.V Dental College and M.M General Hospital, Yamunanagar – 135001,


Contact No. 09813147040

Email- naveenprisha@yahoo.co.in




Professor, Dept. of OMFS,

DAV Dental College and MM General hospital,

Yamunanagar –135001, India.

Contact No: 09813013083

Email- naveenprisha@gmail.com




MDS 3RD year resident, Dept of OMFS

DAV Dental College & MM General hospital,

Yamunanagar– 135001, India.

Contact No: +919466437123

Email –sharmadr.rahul@yahoo.com



MDS 2nd year resident, Dept of OMFS

DAV Dental College & MM General hospital,

Yamunanagar– 135001, India.

Contact No:+919896503262

Email- saurabh_nagrath@yahoo.co.in




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