Orthodontics Lecture # 3 Date: 9/10/2012 Done by: Katreen Suleiman

NOTE: Most of the script is similar to the slides, there is some extra info. I tried to write everything but the record wasnt that much clear.

This lecture will be about the development of NORMAL occlusion. ***We will talk about the development of dentition from birth till the eruption of permanent teeth.

1) The development of normal occlusion at birth. 2) The development of deciduous dentition. 3) The development of permanent dentition which starts with the development of the permanent first molar. 4) The characteristics of each stage of the deciduous dentition. 5) The occlusal changes that usually occur in the deciduous and permanent dentitions. 6) The eruption of the first molars followed by the eruption of permanent incisors, premolars and canines.

(1) The development of normal occlusion at birth:

- Usually there are no teeth at birth. Only upper and lower arches with gum pads.

- The upper arch is horseshoe in shape with segmentations, representing the area where the deciduous teeth are going to erupt. In the canine area theres a landmark called Lateral Sulcus. - The lateral sulcus is used to identify the occlusion at birth. - In the normal situation, the lateral sulcus in the upper arch and the lower arch should make a class II relationship.. Which means the upper sulcus is anterior to the lower sulcus. - The lower arch is similar to the upper arch, except its a U-shaped. ***So again: - The occlusion at birth is not clear because there are no teeth, but the upper arch is overlapping the lower arch (maxilla is larger than the mandible). And the lateral sulcus is in class II relationship. - Theres a vertical space between the upper and lower gum pads in an appreciable proportion of cases. Those spaces are going to be occupied by teeth.

(2) The development of deciduous dentition:

Q: Which teeth are the first to erupt in the deciduous dentition? Lower centrals. *** You should know the timing of eruption & calcification of the lower centrals. The doctor said that theres a table in the book about the eruption sequence, please refer to it.

Q: What is the sequence of eruption of deciduous teeth? ABDCE - In the deciduous dentition state, the overbite is usually increased. However, it becomes reduced in the next 3-4 years. - Most of the time theres spacing in the deciduous dentition, especially between incisors. - If you see a child with a crowded dentition, then most probably hes going to have crowding in the permanent dentition. - If theres spacing (6 mm or more), then permanent teeth will not be crowded. Characteristics of anterior teeth 1. Spacing between the anterior teeth. 2. Primate spaces: theres a space distal to the lower primary canine, and mesial to the upper primary canine. 3. Upper incisors are usually upright. 4. Flush terminal or mesial step molar relationship.

*** Now the doctor showed some pictures of models (slides -page 6) and started talking about them, please refer to the slides to see the pictures. The dr. words were: these upper and lower study models represent deciduous dentition state, there is spacing all around, deep bite, primate space distal to lower canines, upper teeth are upright, flush terminal primary molar relationship.

Q: What are the changes in deciduous dentition to prepare for the permanent dentition state? 1) Minimal changes in the dimension of the upper and lower arches. 2) Minimal change in the space condition. 3) Occlusion: forward migration of the lower teeth occupied by the primate space.

*** Remember: the primate space is distal to the canine in the lower arch
and mesial to the canine in the upper arch. Why is it important? To start changing the molar relationship from flush terminal to class I.

(3) The development of permanent dentition:

There are two stages in the eruption of permanent teeth:

Preemergent Eruption Postemergent Eruption

means movment of the tooth erupting inside the bone means once the tooth starts to erupt, it'll continue till it hits the opposing tooth.

(1)

The Preemergent Eruption requires two processes:

a) Bone resorption. b) Tooth movement. The mechanism for the resorption of the bone overlying the tooth and the mechanism of tooth removal are still unknown, some say its the root development, when the root is long, itll pop the crown in an opposite direction, and this is the eruption. Others say that the periodontal ligament starts to contract, but the exact mechanism is still unknown. Some people lack the mechanism of tooth movement, so theyll have a condition called Primary failure of eruption.

 The delayed eruption, or uneruption are seen in some medical syndromes like the cliedocranial dysplasia, which is characterized by the late eruption. Hypothyroidism also causes delayed eruption. (slides-page 11) This is primary failure of eruption, this is in permanent dentition state.. (the record is not clear- min 14:00).

primary failure of eruption - In this case the teeth are erupting within the gingiva, however, they are not fully erupted; they are not contacting each other, and they cannot be moved even with the orthodontic movement, because of the lack of tooth movement mechanism. - It can affect one tooth, it can be unilateral (on one side), bilateral, or all the teeth. Question from a student: What is the treatment for this case? Not an orthodontic treatment for sure, it can be a prosthetic treatment to get crowns or other treatments.

- In this case the root development is completed; this is why the root development as a theory of tooth movement has been rejected. And the exact mechanism of tooth movement is still unknown.

(2)

Postemergent Eruption: a- Postemergent spurt: which is the period when the maximum eruption takes place. b- Juvenile occlusal equilibrium. c- Adult occlusal equilibrium.

a- Postemergent spurt: - Once it starts, the tooth will erupt quickly, until it contacts the opposing tooth. b- Juvenile occlusal equilibrium

- During the adolescent stage, during the growth spurt, the bone will grow, and so the ramus height will increase, taking the lower teeth with it. And because of that, there will be a vertical separation between upper and lower teeth. So the teeth in this stage will continue erupting, until they reach the equilibrium, where no further eruption will take place. c- Adult occlusal equilibrium - In the adult state, if you extract a tooth, the opposing tooth will over-erupt. - So if theres no equilibrium the tooth will continue to grow.

Eruption of first molar

- The first molar is the first permanent tooth to erupt. Usually at the age of 6 years. - At first, the 1st premolar erupts into cusp to cusp relationship. Why? Because the primary molar relationship is flush terminal.

***** The 1st molar erupts into cusp to cusp relationship if the second deciduous molar is in flush terminal relationship. ***** But if the E (second primary molar) has a mesial step relationship, the permanent 1 st molar will have class I.

***If the 1st molar erupted cusp to cusp or class II relationship, what are the changes that will convert this relationship into normal ( class I)? 1. The initial growth of the mandible is faster than the maxilla (I am not sure of this info, the record wasnt clear), so Itll carry the lower molar with it anteriorly more than the lower molar. 2. Primate space, its distal to lower canines and mesial to upper canines, so the posterior teeth will not move forward. 3. Leeway space: its the difference in the mes iodistal width between the primary and permanent premolars and canines. Leeway space in the lower arch is larger than Leeway space in the upper arch. Which means that the lower molar will move anteriorly more than the upper arch. ** All these factors will convert the relationship into class I. The 1st permanent molar may gain the normal occlusion post eruption as a result of (the doctor just read the slides): 1. Early mesial drift of the lower deciduous molars, to the anthropoid space. 2. Late utilization of the leeway space. 3. Differential forward mandibular growth. - Leeway space: when the lower 3 is prematurely lost, lower molar will start to drift mesially.

Eruption of permanent incisors

- Incisors will erupt after the permanent 1 st molars. - Permanent incisors lay lingual to the deciduous ones throughout their development. - They start to resorp the deciduous teeth roots then normal shedding then eruption of the permanents.

Q: In this stage, is there going to be crowding, absence of crowding or spacing? => Usually crowding occurs, mild crowding. Why? - Because of the larger mesiodistal width of permanent incisors compared to deciduous ones. Also they are lingual (have less space).

So usually theres mild crowding, and this is called Incisor liability. This crowding is considered as normal.

The permanent incisors are larger than the deciduous ones. The extra space required for their alignment comes from: (the doctor read the slide- page 16) 1. Already existing spaces. 2. Arch width increase 3. Labial eruption path of the permanent incisors. 4. Repositioning the lower permanent canines in the mandibular arch. (they will erupt distally and buccally). distal: which means more space in the mesial area. buccally: they will erupt more labially 5. And the incisors will start to procline, and this will give space.

In the maxillary arch, the central incisors erupt with a space (diastema) , and this is considered a normal development. This space will be closed by laterals and later by canines. So every space creation will be in steps, first theres a space between the central incisors ( diastema), then its closed or decreased by laterals incisors, and then it should be eliminated after the eruption of permanent canines. This stage is called ugly duckling stage. And its considered a normal development stage.

Eruption of permanent premolars and canines

The overall size of the deciduous molar and canine is greater than that of the premolars and permanent canines. This space is known as Leeway space. In the upper arch this space is around 1.6 mm per quadrant, while in the lower its 3.4 mm. (the numbers are not exact, but the main idea is that the leeway space is larger in the mandible). Unless utilized, this space is used for the adjustment of the molar relationship flush terminal to class I. However, if the primary molars (D/E) have been lost prematurely, there will be space loss, and the 6 will move forward, even more than the limit required to change the molar relationship from cusp to cusp to class I. and in this case we will end up with crowding. And there wont be enough space for other permanent teeth. Usually NO orthodontic treatment required until the permanent canines erupt. (slide-page 20) this is the ugly duckling stage, theres diastema, and theres space between centrals and laterals, and the primary canines are still there. (Slide-page 21) theres no space between centrals and laterals, and no diastema, because the permanent canines are erupted. Summary: We talked about the eruption of deciduous teeth, permanent fist molar, permenet incisors, permanent canines and premolars. Also we talked about the changing in molar dentition from cusp to cusp to class I, which is the normal situation. Also the eruption and alignment of incisors and spacing, midline diastema, ugly duckling stage, and the closure of this spacing by the eruption of permanent canines. This is what normally happens, if anything abnormal occurs, well end up with malocclusion.

Changes in Arch dimension

Q: do teeth move after eruption? Even if theres no space? Yes they do, under the effect of growth and occlusal forces. Occlusal forces have two components: - downward - Forward From 6 weeks to 2 years both arches increase by 14-16 mm with greater increase in the upper arch and in males. Maxillary arch continue to increase till the age of 13 years by 2.4 mm in females and 4 mm in males. Mandibular arch continue to increase till the age of 8 years by 2mm. this means that after 13 years in the upper, and 8 years in the lower, teeth will start moving forward to reduce the arch length ( not the bone, but the distance between the last molar and incisors) so movement of the teeth forward may end up with something called late lower incisor crowding. Some people may notice crowding in the anterior teeth after a certain age ( 12-13 years) or adolescence.. and this is the late lower incisor crowding. After that both arch lengths decrease by 4.6-5.7 mm in the upper arch and 7.4-8.3 mm in the lower arch with more reduction in females. which means there is more crowding in females.

Thank you Done by: Katreen Suleiman