Development of dentition &Occlusion

By:
Pratik yadav
MDS 1st yr
Dept of orthodontics
 INTRODUCTION
The development of dentition is an important
part of craniofacial growth as the formation,
eruption, exfoliation and exchange of teeth
take place during this period. This helps in
assimilation of facts, predictions of teeth
eruption , the factors influencing them and
implicate clinically for treatment .
 PRE-NATAL DEVELOPMENTOF
TEETH
The embryonic oral cavity is lined by stratified
squamous epithelium known as the oral ectoderm
Around the 6th week of intra uterine life, the infero-
lateral border of maxillary arch and supero- lateral
border of mandibular arch shows localised proliferation
of oral ectoderm resulting in the formation of a horse-
shoe shaped band of tissue called dental lamina
Dental lamina plays a important role in the
development of dentition
 In certain areas the dental lamina proliferate and
forms knob like structure that grows into underlying
mesenchyma.

Each knob represents a future deciduous tooth and is

called enamel organ

Enamel organ passes through a number of stages

ultimately forming the teeth

Based on shape of the enamel organ develops can be

divided into,

Bud stage
Cap stage
Bell stage
 BUD STAGE
Differentiation of dental lamina leads to formation of round,
ovoid swelling at 10 different points corresponding to future
position of deciduous teeth. These are the primordia of
enamel organ.

Enamel organ consists of peripherally located low columnar

cells and centrally located polygonal cells.

Dental papilla : It is the area of ectomesenchymal

condensation subjacent to enamel organ. Cells of dental
papilla will form tooth pulp & dentine.

Dental sac: It is area of ectomesenchymal condensation

surrounding the tooth bud & dental papilla. Cells of dental
sac will form cementum & periodontal ligament.
Bud
Stage
 CAP STAGE :
Characterized by a shallow invagination of deep surface
of a bud.
Cuboidal cells cover the convexity of the cap
outer enamel epithelium.
Columnar cells cover the concavity of the cap
Inner enamel epithelium.

Stellate Reticulum:
Polygonal cells begin to separate as more
intercellular fluid is produced and forms cellular network
called stellate reticulum.

Enamel Knot:
Cells in center of the enamel organ are densely packed.
This knot projects towards underlying dental papilla .
Vertical extension of enamel knot forms enamel cord.
Both the structures disappear before enamel formation
begins.
 Cap Stage of
Tooth
Development
Dental (enamel) organ

Dental papilla

Dental follicle

Copyright 2007, Thomas G. Hollinger, Gainesville, Fl

 BELL STAGE :

1. The cell of inner enamel epithelium differentiate into tall columnar tissue
called ameloblast

2. A few layers of flat squamous cells are seen between stelate reticulum and
inner enamel epithelim this layer is called stratum intermedium

3. Stellate reticulum expands due to accumulation of intra cellular fluid ,

they r star shaped & as the enamel formation stars it collapse to a narrow
zone thereby reducing the distance between inner & outer enamel
epithelium

4. Before inner enamel epithelium begins to produce enamel, the peripheral

cells of the dental papilla differentiate into odontoblast
 FORMATION OF ROOT

Root start forming after dentin formation has reached

future cementoenamel junction. Both dental organ and
dental papilla play part in formation of root.

Hertwig's epithelial root sheath :

* The outer and inner dental epithelium meets one

another at future cervical area and is called cervical loop.
* This cervical loop forms epithelial sheath of Hertwig,
which moulds the shape of the root and initiates dentin
formation.
 The root sheath consists of only outer and inner dental
epithelium.

The inner layer of cells remains short and do not produce

enamel. These cells induce the differentiation of cell of dental
papilla into Odontoblasts, which lay a layer of dentin. At the same
time the continuity of Hertwig's sheath is destroyed due to
infiltration of connective tissue and the root sheath breaks up into
small strands of epithelium called epithelial rests of Molassez.

While the coronal part of the sheath degenerates, the apical part
continues to grow in length and aid in lengthening of root.
 Occlusion
Term occlusion is derived from the Latin word,
occlusio; defined as the relationship between
all the components of the masticatory system
in normal function, dysfunction and
parafunction.
An ideal occlusion is the perfect interdigitation
of the upper and lower teeth, which is a result
of developmental process consisting of the
three main events, jaw growth, tooth formation
and eruption
 Evolution
To develop a functional occlusion it became
necessary for the teeth and bones to develop
synchronously. Over a period of time there was loss
or fusion of cranial and facial bones, the number of
bones have reduced and the dental formula has also
undergone changes.
Periods of Occlusal Development
Occlusal development can be divided into the following
development periods:

o Neo-natal period.
o Primary dentition period.
o Mixed dentition period.
o Permanent dentition period.
 Neonatal Period
(lasts upto 6 months after birth)
 Gum Pads
Alveolar processes at the time of birth- gum pads.
Pink in colour, firm and are covered by a dense layer of fibrous

periosteum.

Gum Pads contd
The gum pad soon gets segmented by
a groove called transverse groove, &
each segment is a developing tooth
site.

The pads get divided into labio-

buccal & lingual portion, by a dental

groove.

The groove between the canine and

the 1st molar region is called the lateral
sulcus, useful for judging the inter
arch relationship at a very early stage.
 Gum Pads contd
The upper gum pad is horse shoe
shaped & shows:
o Gingival groove: separates
gum pad from the palate.
o Dental groove: starts at the
incisive papilla, extends
backward to touch the gingival
groove in the canine region &
then moves laterally to end in
the molar region.
o Lateral sulcus.
 Gum Pads contd

The lower gum pad is U

shaped and rectangular,
characterized by:
o Gingival groove: lingual
extension of the gum pads.
o Dental groove.
o Lateral sulcus.
Relationship of Gum Pads
o Anterior open bite is seen at rest with
contact only at the molar region.

o Complete overjet.

oClass II pattern with maxillary gum

pad being more prominent.

oMandible is distal to the maxilla of 2.7

mm- male and 2.5- female. ( Sillman JH
1938)

oThe range of variation of this distal

relationship is from 0 to 7 mm. .
( Sillman JH 1938)
 Relationship of Gum Pads

o Mandibular lateral sulci lies

posterior to maxillary lateral sulci.

o Mandibular functional movements

are mainly vertical, and to a little
extent antero-posterior. Lateral
movements are absent.
Neonatal Jaw Relationship
A precise bite or jaw
relationship is not yet seen.
Therefore, neonatal jaw
relationship cannot be used as
a diagnostic criterion for
reliable prediction of
subsequent occlusion in the
primary dentition.
Status of Dentition at Birth
Precociously Erupted Primary
Teeth

Natal tooth Neonatal teeth

Pre-erupted teeth or Early Infansive teeth are teeth that

erupt during the 2nd or 3rd month.
 Natal/neonatal teeth
Classification
Hebling (1997) classified natal teeth into 4 clinical categories:

1. Shell-shaped crown poorly fixed to the alveolus by gingival

tissue and absence of a root;
2. Solid crown poorly fixed to the alveolus by gingival tissue
and little or no root;
3. Eruption of the incisal margin of the crown through gingival
tissue
4. Edema of gingival tissue with an unerupted but palpable
tooth.
 Gender
Predilection for females
Kates et al (1984) reported a 66% proportion for females
against a 31% proportion for males.

Etiology
It has been related to several factors, such as:-
Superficial position of the germ

Infection or malnutrition

Eruption accelerated by febrile incidents or hormonal

stimulation,
Hereditary transmission of a dominant autosomal gene

hypovitaminosis
 Natal/neonatal teeth
Complications
Interfere with feeding
Risk of aspiration
Traumatic injury to the babys tongue
and/or to the maternal breast
Riga-Fede disease- oral condition
found, rarely in newborns manifests
as an ulceration on the ventral surface
of the tongue or on the inner surface
of the lower lip. Caused by trauma to
the soft tissue from erupted baby Riga-Fede disease
teeth.
 Diagnosis
A radiographic verification of the relationship
between a natal and/or neonatal tooth and
adjacent structures, nearby teeth, and the
presence or absence of a germ in the primary
tooth area would determine whether or not the
tooth belongs to the normal dentition ( Almeida
CM et al 1997)

Most natal and neonatal teeth are primary teeth

of the normal dentition and are not
supernumerary teeth ( Brandt Sk et al 1983)

Correspond to teeth of the normal primary

dentition in 95% of cases, while 5% are
supernumerary (Hawkins C 1932)
 Treatment
If the erupted tooth is diagnosed as a tooth of the normal
dentition -- maintenance of these teeth in the mouth is the first
treatment option, unless this would cause injury to the baby
(Chow MH 1980, Roberts MW 1992)

When well implanted-- these teeth should be left in the arch

and their removal should be indicated only when they interfere
with feeding or when they are highly mobile, with the risk of
aspiration (Toledo AO 1996)

Reasons for removal -- The risk of dislocation and consequent

aspiration, traumatic injury to the babys tongue and/or to the
maternal breast, (Kates GA et al 1984)
 Martins et al (1998) suggested smoothing of the incisal
margin to prevent wounding of the maternal breast during
breast feeding.

If the treatment option is extraction, certain precautions should

be taken :
Avoiding extraction up to the 10th day of life to prevent
hemorrhage
Assessing the need to administer vitamin K before extraction
(0.5-1.0 mg IM)
Considering the general health condition of the baby
Avoiding unnecessary injury to the gingiva
Being alert to the risk of aspiration during removal.
Primary Dentition
(From around the 6th month to 6 years)

Period
Sequence of Eruption
Chronology of Primary Dentition
Primary First evidence of Crown Eruption Root
(upper) calcification completed (months) completed
(Weeks in utero) (months) (years)
Central 14 (13-16) 11/2 10 11/2

Lateral 16 21/2 11 2
Canine 17 9 19 31/4

1st molar 151/2 6 16 21/2

2nd molar 19 11 29 3

Wheelers
Primary First evidence of Crown Eruption Root
(Lower calcification completed (months) completed
(Weeks in utero) (months) (years)

Central 14 (13-16) 21/2 8(6-10) 11/2

Lateral 16 3 13( 10-16) 11/2

Canine 17 9 20(17-23) 31/4

1st molar 151/2 51/2 16( 14-18) 21/4

2nd molar 18 10 27 3

Wheelers
Status of Dentition
(during primary dentition period)
At around 5 6 Years
There are 48 teeth/parts of teeth present in the jaw. It is at this
time that there are more teeth in the jaws than at any other time.
Features Of Primary
Dentition
Spacing- 2 types of dentition are seen:
A) Spaced dentition - usually seen in the
deciduous dentition to accommodate the
larger permanent teeth in the jaws.

More prominent in the anterior region,

and are called physiological spacing or
developmental spacing.
Absence of spaces in the primary

dentition is an indication that crowding of

teeth may occur when the larger
permanent teeth erupt.
 Features Of Primary
Dentition contd

Most subhuman primates

have it through out life and use
it for interdigitation of the
opposing canines. This space is
used for early mesial shift.

primate spaces, simian spaces or

anthropoid spaces.
 Features Of Primary
Dentition contd
Shallow overjet & overbite. Initially a deep bite may occur due to the fact that
the deciduous incisors are more upright than their successors. The lower incisal
edges often contact the cingulum area of the maxillary incisors. This deep bite
is later reduced by:
oEruption of deciduous molars.
oAttrition of incisors.
oForward movement of the mandible due to growth.
Features Of Primary
Dentition contd

Almost vertical
inclination of anteriors.
Features Of Primary
Dentition contd

Ovoid arch form.

 Molar Relationship
The molar relationship in the primary dentition can be classified
into 3 types:
oStraight/flush terminal plane.
oMesial step.
oDistal step.
Flush Terminal Plane
If the distal surface of
maxillary and mandibular
deciduous second molars are in
the same vertical plane; then it
is called a flush terminal plane

Normal molar relationship in

the primary dentition, because
the mesiodistal width of the
mandibular molar is greater
than the mesiodistal width of
the maxillary molar.
Mesial Step

Distal surface of mandibular

deciduous second molar is
mesial to the distal surface of
maxillary deciduous second
molar.
Distal Step

Distal surface of mandibular

second deciduous molar is
more distal to the distal surface
of the maxillary second
deciduous molar
 Mixed

Dentition
Mixed Dentition Period
(Around 6 years- 12 years)
The mixed dentition period can be divided into three
phases:
o First transitional period.
o Inter-transitional period.
o Second transitional period.
First Transitional Period
Eruption of 1 Permanent Molar
st
The location & relation of the 1st permanent molar depends much
upon the distal surface of the upper & lower 2nd deciduous molar.
Transition to Class I Molar
Relation
The shift in lower molar from a flush
terminal plane to a class I relation can
occur in two ways:
oEarly shift.
oLate shift.
 Early Shift
Early shift occurs during the early mixed dentition period.
Since this occurs early in the mixed dentition, it is called early shift ,

the eruptive force of first permanent molar push the deciduous 1st & 2nd
deciduous molar to close the primate space .
 Late Shift
This occurs in the late mixed
dentition period when the
second deciduous molar
exfoliate the first permanent
molar drift mesialy & use
leeway space and is thus called
late shift.
Leeway Space of Nance
Described by Nance in 1947

Maxilla: 0.9 mm/segment = 1.8 mm.

Mandible: 1.7 mm/segment = 3.4mm.
Secondary spacing

Term was coined by Baume

Observed in closed primary dentition

Secondary spacing can also occur

during the eruption of permanent
central incisors
Distal Step
When the deciduous second
molars are in a distal step, the
permanent first molar will
erupt into a class II relation.
This molar configuration is not
self correcting and will cause a
class II malocclusion despite
Leeway space and differential
growth.
Mesial Step

Primary second molars in

mesial step relationship lead to
a class I molar relation in
mixed dentition. This may
remain or progress to a half or
full cusp class III with
continued mandibular growth.
 Exchange of Incisors
During the first transitional period the deciduous incisors are
During thebyfirst
replaced thetransitional period theThe
permanent incisors. deciduous
mandibular incisors are
central
replaced
incisors are by the permanent
usually the first toincisors. Thepermanent
erupt. The mandibular centralare
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incisors are usually
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thanfirst
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erupt. Theteeth
permanent incisors
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This
considerably
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difference of
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the
accomodationfor of the
this,incisors
is calledand the amount
Incisal of space available
liability.
for this,isisroughly
The incisal liability called Incisal liability.
about 7.6 mm in the maxillary
The arch
incisal liability
& about is roughly
6 mm about 7.6 mm
in the mandibular archin (Wayne).
the maxillary
arch & about 6 mm in the mandibular arch (Wayne).
Transition of Incisors
The incisal liability is over come by the
following factors:
Interdental physiological spacing in the primary incisor region.
(4 mm in maxillary arch & 3 mm in mandibular arch)
Transition of Incisors contd
Increase in inter-canine arch width:
Significant amount of growth occurs with the eruption of
incisors and canines.
Transition of Incisors contd
Increase in anterior length of the dental arches:
Permanent incisors erupt labial to the primary incisors to obtain
an added space of around 2-3 mm.
Transition of Incisors contd
Change in inclination of
permanent incisors:
Primary teeth are upright but
permanent teeth incline to the
labial surface, thus decreasing
the inter-incisal angle from
about 151 degrees in the
deciduous dentition to 124
degrees in the permanent
dentition. This increases the
arch parameter.
Inter-Transitional Period

This is a stable phase where little changes take

place in the dentition. The teeth present are the
permanent incisors and first molar along with
the deciduous canines and molars. This phase
prepares for the second transitional phase.
Some of the features of this stage are:
o Any asymmetry in emergence and corresponding
differences in height levels or crown lengths between
the right and left side teeth are made up.
Inter-Transitional Period contd
Root formation of emerged
incisors, and molars
continues, along with
concomitant increase in
alveolar process height.
Inter-Transitional Period contd

Resorption of roots of
deciduous canines and
molars.
Second Transitional Period
The second transitional period is characterized
by the replacement of the deciduous molars
and canines by the premolars and permanent
canines respectively.
At around 10 years of age the deciduous
canines shed, but just before the shedding
there is a transient or self correcting
malocclusion seen in the maxillary incisor
region between the age of 8 9 years.
 Ugly Duckling Stage
(Broadbents phenomenon)

Around the age of 8 - 9 years, a

midline diastema is commonly
seen in the upper arch, which
is usually misinterpreted by the
parents as a malocclusion.
Its typical features are:
oFlaring of the lateral incisors.
oMaxillary midline diastema.
Ugly Duckling Stage contd

Crowns of canines on young

jaws impinge on developing
lateral incisor roots, thus
driving the roots medially and
causing the crowns to flare
laterally.
Ugly Duckling Stage contd
The roots of the central incisors are also forced
together, thus causing a maxillary midline diastema.
Ugly Duckling Stage contd
With the eruption of the
canines, the impingement from
the roots shift incisally thus
driving the incisor crowns
medially, resulting in closure
of the diastema as well as the
correction of the flared lateral
incisors.
Ugly Duckling Stage contd
Hence this unaesthetic metamorphosis, eventually leads to an
aesthetic result.
Self correcting anomalies
Sequence of Eruption
The canines in the upper arch erupt only after the premolars
have replaced the deciduous molars, whereas the canine erupt
before the premolars in the lower arch.
Second Transitional Period contd
Favorable occlusion in this
area is largely dependent on:
o Favorable eruption sequence.
o Satisfactory tooth size to available
space ratio.
o Attainment of normal molar
relation with minimum diminution of
space available for the bicuspids.
Second Transitional Period contd
Eruption of permanent second molars
Before emergence- second molars, oriented in a mesial &
lingual direction

Teeth- formed palatally, guided into occlusion by Cone

Funnel mechanism , upper palatal cusps (cone) slides into the
lower occlusal fossa (funnel)

Arch length is reduced by mesial eruptive forces

Thereby, crowding if present is accentuated

The Permanent
Dentition Period
The Permanent Dentition

This period is marked by the

eruption of the four permanent
second molars.
The Permanent Dentition contd

Calcification begins at birth

with the calcification of the
cusps of the first permanent
molar and extends as late as
the 25th year of life. Complete
calcification of incisor crowns
take place by 4 5 years and
of the other permanent teeth by
6 8 years except for third
molars.
 Chronology of Permanent Dentition
Permanent First evidence Crown Eruption Root
(Upper) of calcification completed ( months) completed
( weeks in (months) (years)
utero)

Central 3-4 mo 4-5 yr 7-8 yr 10

Lateral 10-12 mo 4-5 yr 8-9 yr 11
Canine 4-5 mo 6-7 yr 11-12 yr 13-15
1st premolar 11/2-13/4 yr 5-6 yr 10-11 yr 12-13

2nd premolar 2-21/4 yr 6-7 yr 10-12 yr 12-14

1st molar At birth 21/3-3 yr 6-7 yr 9-10

2nd molar 21/3-3 yr 7-8 yr 12-13 yr 14-16

3rd molar 7-9 yr 12-16 yr 17-21 yr 18-25

Wheelers
Permanent First evidence of Crown Eruption Root completed
(Lower) calcification completed ( months) ( years)
( weeks in utero) (months)

Central 3-4 mo 4-5 yr 6-7 yr 9

Lateral 3-4 mo 4-5 yr 7-8 yr 10
Canine 4- 5 mo 6-7 yr 9-10 yr 12-14
1st premolar 13/4-2yr 5-6 yr 10-12 yr 12-13

2nd premolar 21/4-21/2 yr 6-7 yr 11-12 yr 13-14

1st molar At birth 21/2-3yr 6-7 yr 9-10

2nd molar 21/2-3yr 7-8 yr 11-13 yr 14-15

3rd molar 8-10 yr 12-16 yr 17-21 yr 18-25

Wheelers
The Permanent Dentition contd

The permanent incisors

develop lingual to the
deciduous incisors and move
labially as they erupt.
The Permanent Dentition contd

The premolars develop below

the diverging roots of the
deciduous molars.
The Permanent Dentition contd

At approximately 13
years of age all
permanent teeth
except third molars
are fully erupted.
Features of Permanent
Dentition
Coinciding midline. Class I molar relationship.
 Features of Permanent
Dentition contd
Vertical overbite of about
one third the clinical
crown height of the
mandibular central
incisors. Overjet and over
bite decreases throughout
the second decade of life
due to greater forward
growth of the mandible.
 Andrews keys to normal
occlusion
Key I Molar relationship
MB cusp of the max 1st molar falls
into the mesiobuccal groove of the
mand 1st molar and that the distal
surface of the DB cusp of the upper
first permanent molar should make
contact and occlude with mesial
surface of the MB cusp of the lower
second molar.
 Andrews keys to normal
occlusion
Key II Crown angulation (Tip)

The angulation of the facial axis of

every clinical crown should be
positive

The gingival portion of the long axis

of the all crowns must be distal than
the incisal portion.
 Andrews keys to normal
occlusion
Key III Crown inclination

In upper incisors, the gingival

portion of the crowns labial surface
is lingual to the incisal portion.
 Andrews keys to normal
occlusion
Key IV Rotations

The fourth key to normal

occlusion is that the teeth should
be free of undesirable rotations.
 Andrews keys to normal
occlusion
Key V Tight contacts

contact points should be tight

(no spaces).

In absence of abnormalities
such as genuine tooth size
discrepancies, contact point
should be tight.
 Andrews keys to normal
occlusion
Key VI Occlusal plane or curve
of spee
The curve of Spee should have no

more than a slight arch.

Intercuspation of teeth is best

when the plane of occlusion is
relatively flat.

A deep curve of spee results in a

more contained area for the upper
teeth, making normal occlusion
impossible.
 Andrews keys to normal
occlusion
Key VII Correct tooth size or the boltons ratio

Bennett and McLaughlin in 1993 gave seventh key

to normal occlusion. i.e. the upper and lower tooth
size should be correct.
 Th
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