Created by Dr.Venkatesh.

C BDS

Friday, August 05, 2005

An Introduction:
The dentoalveolar changes refer to the changes occuring in the maxilla and
mandible,later followed by the eruption of primary teeth,the shedding of the
primary teeth and the establishment of the normal dental occlusion in the
oral cavity.
The dento-alveolar changes form an important aspect of the
growth and are important for a dentist especialy an orthodontist.For the
proper understanding of the dento-alveolar changes the concept of growth
and development have to be understood. The general concepts of
development of the face, the prenatal formation of the maxilla and mandible
form a basic prerequisite for understanding the dento-alveolar changes.

General concepts of growth and development:

Growth: Growth has been defined by various clinicians from different

aspects .
The entire series of sequential anatomic and physiologic changes taking
place from the beginning of prenatal life to senility.(Meredith)
It is defined as a measurable change in the morphologic
paramteter.(Moss)
Quantitative aspect of biological development per unit
time.(Moyers)
Development: Development is defined as series of unidirectional changes
in a life of an individual from its existence as a single cell to its elaboration
of a multi-functional unit.(Todd)

Differentiation: It is a defined as the change from a generalized size of the

cell or tissue to one which is more specialized.
Concepts of Growth:
Concept of normality:
It states that normal refers to the growth which is usually
expected at that particular age.The concept of normality also changes with
age;the growth which is supposed to be normal for an age might not be

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normal for a different age group.

Scammon's differential growth curve:

Different tissues of the body show growth at different times and
different times.
Lymphoid tissues: Lymphoid tissues grow at a rate of 200% in late
childhood and by 20 years reach their normal size.

Neural tissues: Neural tissues show accelerating proliferating rates till 7-8
years.

General tissues/Visceral tissues: Their growth can be plotted as an 'S'shaped

curve with rapid growth till 2-3 years followed by a lag phase between 3-10
years. From 10 years there is again rapid growth which terminates by 18-20
years

Genital tissues: They show negligible growth until puberty but during 11-15
years they show rapid growth and later growth ceases by 18-20 years.

Cephalo-caudal gradient of growth: The axis of growth shifts from head to

the lower extremities as an child grows into an adult.

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Growth Spurts:
There seems to be periods of sudden acceleration, or rhythmic
increase of growth which is due to the hormonal alteration. The timing of
the growth spurts differ in boys and girls.
Timing of growth spurts:
1) Just before birth
2) One year after birth
3) Mixed dentition growth spurt
Boys: 9-11 years
Girls: 7-9 years

4) Pre-pubertal growth spurt:

Boys: 14-16 yrs
Girls: 11- 13 years
Theories of Craniofacial growth:
Enlows expanding V Principle:
According to Enle many facial bones show a 'V' type
growth pattern. The growth movements and enlargement occur towards the
wide 'V' ends of the bone. This type of growth occurs at the base of the
mandible, ends of long bone, palate, body of mandible

Enlow's Counterpart Principle: According to this principle ,the growth of

the cranial or facial part relates specifically to the structural and geometric
counterparts in the face and the cranium:

Sutural theory:
According to Sicher paired parallel sutures which attach the cranial
base and facial areas of skull push the naso maxillary complex forward.

Cartillaginous theory:
According to James Scott the nasal septal cartillage is fundamental and
intiator of growth for the entire nasomaxillary complex.
Growth in the mandible can also be attributed to the
epiphyseal cartillage which constitutes half of the epiphysis. The elongation

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of mandible which is considered to a modified horse shoe bent diaphysis of

a long bone is due to the growth of the epiphyseal cartillage.

Functional Matrix concept:

According to Melvin Moss the growth of the skeletal structures are always
secondary and compensatory responses to chronologically and
morphologically processes that occur in related non-skeletal tissues, organs
and functioning spaces.
Functional cranial component includes both the skeletal and functional
component which is related in their interaction.

The skeletal unit:

They include the macro and the micro skeletal unit. The mandible(a macro
skeletal unit) may consist of alveolar ,angular, condylar, gonial, mental,
coronoid
And basal microskeletal units.
Maxilla is made up of orbital, pneumatic, palatal and basal
micro skeletal units.

Functional Matrix:
1)Periosteal matrices:These directly act on the related skeletal
units.Alteration in their function may produce a secondary responses by
bone deposition or resorbtion in the skeletal structures.These matrices
include muscles,blood vessels,nerves and glands.

2)Capsular Matrices:These act indireclty on the skeletal structures and

producitng a secondary response which produces a secondary compensatory
translation in space.

Neurocranial capsule: The neurocranial capsule surrounds and protects the

brain,leptomeninges and the Cerebrospinal fluid.As a child grows the
capsule expands thereby secondarily influencing the growth of its contents.

Orofacial capsule:The expanding of this capsule helps in the growth of the

facial bones.It surround and protects the oro-nasopharyngeal space whose
volume and patency is maintained due to the growth of the facial bones and
orofacial capsule.

Van-Limborgh's theory:

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Van limborgh's theory states that

a) Chondrodranial growth is controlled by intrinsic genetic factors

b) Desmocranial growth is controlled by few intrinsic genetic factors
c) Cartillaginous parts are the growth centers.
d) Sutural growth is controlled by skull cartilages adjacent skull
structures.
e) Periosteal growth depends on adjacent structures
f) Sutural and periosteal growth are additionally governed by local non
genetic environmental factors.

Neurotrophic process in orofacial growth:

Neurotrophism refers to the neural function which is non impulse related

and the harmonious relation which exists between the neurons and the
innervated tissues where the neurons regulate the morphology, growth,
composition and function of the innervated tissues.

a) Neuroepithelial growth: The epithelial growth in the case of orofacial

hypoplasia,taste buds and epithelial malformations are related to the
certain neurotrophic substances whose lack of secretion are nerves
whose lack of innervation in the particular tissues may cause
abnormal or defective growth of those tissues.
b) Neuro muscular trophism:.Embryonic myogenesis is ofcourse
independent of neuromuscular trophism but later after the nerve
innervation is established further myogenesis related to striated
muscles,lower extremity locomotion is related to this innervation.
c) Recent articles state that the Vasoactive intestinal
polypeptide(VIP),calcitonin gene related peptide(CGRP) secreted
from the parasympathetic and sympathetic ends of neurons have an
effect on neurotrophic orofacial growth.

The development of the maxilla and mandible can be divided into three
distinct periods:
1) Prenatal
2) Natal
3) Postnatal

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PRENATAL GROWTH OF MAXILLA AND MANDIBLE:

Prenatal growth can be further divided into:

1) Period of ovum
2) Period of embryo
3) Period of fetus

First evidence of growth of cranial base is seen in the 4th to 8th week of
Intra uterine life. During the period the mesenchymal tissue derived
from the primitive streak, neural crest and occipital sclerotomes
condenses around the brain. The development of the skull and formation
of cartilage of the cranial base is dependent on the presence of other
cranial structures like the brain, cranial nerves and the eyes. The
development of the branchial apparatus develops during this stage. This
apparatus is present on the cephalic portion of the embryo. The five
mesenchymal elevations or processes are first formed after 21-31 days.

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Prenatal embryo of maxilla:

Around the 4th week of intra uterine life, a prominent bulge appears on
the neural aspect of the embryo corresponding to the developing brain.
Below this depression there is a shallow opening stomodaeum which
forms the future mouth. The floor of the stomodaeum (ie:
bucco-pharyngeal membrane) seperates the stomodaeum from the
foregut. Five processes are mainly responsible for the formation of the

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maxilla namely
1) Fronto nasal process
2) 2 Maxillary processes
3) 2 Nasal processes
Nasal processes are formed from the nasal placodes which are the
thickenings of the ectoderm overlying the stomodaeum. As the
maxillary processes undergo growth the frontonasal process
becomes narrow for the two nasal pits to become closer.

Development of the palate:

The palate is formed by contributions of the:
a) Maxillary process
b) Palatal shelves given by the maxillary process
c) Fronto nasal process
The Frontonasal process gives rise to the premaxillary
region while the palatal shelves form the rest of the palate. As the palatal
shelves grow medially, their fusion is prevented by the presence of the
tongue. So they undergo downward growth. During the 7th week of intra
uterine life they change growth from horizontal to vertical position. The
fusion and formation of the palate occurs in the central region of the
secondary palate posterior to the premaxilla. The mesial edges of the
palatal process fuse with the nasal septum forming the nasal cavity.
The ossification of the palate occurs in the 8th week of
intrauterine life.The intramembranous ossification doesn't occur in the
posterior aspect leading to the formation of the soft palate.

Prenatal development of the mandible:

In the 4th week of intrauterine life after the formation of the two
prominent bulges on the ventral aspect of the embryo the pharyngeal
arches are laid down on the lateral and ventral aspects of the cranialmost
part of the foregut which lies in close approximation with the
stomodaeum. Intially six arches are formed but later the 5th arch
disappear. There is formation of 4 prominent grooves. The first arch is
the mandibular arch.
The mandibular arch forms the lateral wall of
stomodaeum. It gives off a bud on dorsal side which grows as maxillary
process. It grows ventro-medially, cranial to the main part of the arch
which is now termed as mandibular process.

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Meckels cartillage:
It is derived from the first branchial arch around 41st to 45th day of intra
uterine life. It extends from the otic capsule to the midline of symphysis
of the mandibular processes. Major portion of meckels cartillage
disappears forming:
1) Mental ossicles
2) Incus and Malleus
3) Spine of the sphenoid
4) Anterior ligament of the malleus
5) Spheno mandibular ligament

The first structure to develop in the primordium of the jaw is the

mandibular division of the trigeminal nerve. The ossification starts
lateral to the meckels cartillage and its accompanying neurovascular
bundle.Ossification stops at the mandibular lingula where the meckels
cartillage continues into the middle ear and forms the auditory ossicles.

The endochondral bone formation is seen in:

1) The condylar process
2) The coronoid process
3) The mental region

Condylar process: At about the 5th week of intrauterine life, an area of

mesenchymal condensation can be seen above the ventral aspect of the
developing mandible. This develops into a coneshaped cartillage by
about 10th week and starts the ossification by 14th week and later fuses
with the mandibular ramus.

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Coronoid process:
It develops as a secondary accessory process dutin the 10th -14th weeks
of intrauterine life.Its growth is relate to the developing temporalis
muscle.

Mental region:On either sides of symphysis,one or two cartillages

appear and ossify in the 7th month of intrauterine life to form variable
numbers of mental ossicles in the fibrous tissue of symphysis.These
ossicles become incorporated into intramembranous bone when
symphysis ossifies during the first year of postnatal life.

POSTNATAL DEVELOPMENT OF MAXILLA AND

MANDIBLE

The maxilla is attached to the cranial base by means of number of

sutures. The mandible is also attached to the cranial base at the
temporomandibular joint. The growth of the cranial base henceforth
could affect the placement of the maxilla and mandible. The cranial base
grows by:
a) Extensive cortical drift and remodelling
b) Elongation of the synchondoses
c) Sutural growth
Extensive cortical drift refers to the process of dense bone deposition and
old bone resorption which takes place continously leading to the alterations
of positions of the foramina. This is followed by the synchondrosis
elongation. After this process the major sutures of the cranial base

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(ie:sphenofrontal, frontotemporal, sphenoethmoid, frontoethmoid,

frontozygomatic) show bone formation.

POSTNATAL GROWTH OF MAXILLA:

The growth of the naso-maxillary complex is produced by the following
mechanism
a) Displacement
b) Growth at sutures
c) Surface remodelling

a) Displacement: The passive or secondary displacement of the

nasomaxillary complex occurs in a downward and forward direction
as the cranial base grows. In addition to it a primary type of
displacement is also seen in a forward direction. This results in whole
maxilla being carried anteriorly.
b) Sutural growth: The growth of the sutures like frontonasal suture,
fronto maxillary suture,zygomatico-temporal suture,
Zygomatico-maxillary suture, pterygopalatine suture allows the
downward and lateral positioning of the maxilla. As growth of the
surrounding soft tissues occur, the maxilla is carried down and
forward.
c) Surface remodelling: Massive remodelling by bone deposition and
resorption occurs to bring about:
1) Increase in size
2) Change in shape of bone

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The bone deposition occurs along the posterior margin of the maxillary
tuberosity.This causes lengthening of the dental arch and enlargement of the
anterio-posterior dimension of the maxillary body.This helps in
accomodating the erupting molars.As the teeh start erupting deposition
occurs at the alveolar margins.This increases the maxillary height and depth
of the palate.

POSTNATAL GROWTH OF MANDIBLE:

The bone which undergoes the largest amount of growth post natally is the
mandible. The development of the mandible takes place at the

1) Ramus:
The movement of the ramus is in posterior direction or resorption
occurs in the anterior region and deposition on the posterior
region.The increase in size of ramus serves the following
functions:
a) To accommodate the increasing size of masticatory muscles
inserted into it
b) To accommodate the enlarged breadth of the pharyngeal space.
c) To facilitate the length of the mandibular body which in turn
accomodates the erupting molars.
2) Body of the mandible:
The posterior growth of the ramus helps in lengthening of the body of the
mandible creating space for the accomodating the erupting molars.

3) Lingual tuberosity:
The deposition of bone occurs in the medial surface of the lingual
tuberosity and resorption occurs in the lingual fossa which in turn attenuates
the prominence of the lingual tuberosity.

1) Alveolar process:
The alveolar process develops in response to the
presence of tooth buds.As the teeth erupt,the alveolar process develops and
increases in height by bone deposition at the margins.The alveolar bone
adds to the height and thickness of body of the mandible and is particularly
manifested as a ledge extending lingual to the ramus to accommodate the
3rd molars.In case of absence of teeth,the alveolar bome fails to develop and

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it resorbs in the event of tooth extraction.

5) The chin:
The growth of the chin is influences by sexual and genetic characters
males having more prominent chin than the females.

1) Condyle:
The growth of the condyle is by bone deposition.This bone
deposition follows secondary to the growth of the soft tissues.
2) Coronoid process:
The growth of coronoid process follows the enlarging 'v' principle
a) V shaped growth pattern of the mandible and maxilla.

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b) Bone deposition in the ramus.

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DENTOALVEOLAR CHANGES DURING INFANCY:

Even before the emergence of the tooth the jaw has a

primordial appearance. The regions round the tooth form the gum pads
from which later the deciduous teeth erupt.

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At birth there is no dental occlusion but only the occlusion of the gum pads
at the maxillary and mandibular posterior region.
The below image illustrates the occlusion or the
alignment of the maxillary and mandibular gum pads.

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The development of the primary teeth would be dealt here.The development

of the crown of the tooth is an important factor.The development of the
crown occurs after the stages of the tooth ends.The completion of the crown
is followed by the root development.The hertwigs epithelial root sheath
which is formed after the continuation of growth of inner and outer enamel
epithelium at the root region is responsible for the size and shape of the
rooth and the eruption of the tooth.
Eruption can be categorized as:
1) Pre-eruptive phase
2) Eruptive phase(Prefunctional)
3) Eruptive phase (functional)

1) The pre-eruptive phase is that period during which the tooth root begins
its formation and begins to move towards the surface of the oral cavity.
2) The pre-functional phase refers to the eruption of the tooth following
the completion of the root formation followed by the tooth emergence.
3) The functional phase refers to the stage where the tooth erupts in the oral
cavity and meets its antagonist.

Various processes help in eruption of a tooth:

1) Root formation
2) Proliferation of the hertwigs epithelial root sheath
3) Proliferation of the connective tissue of the dental papilla
4) Simultaneous growth of the jaw
5) Pressures from the muscular action.
6) Appostion and resorption of bone

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At the 6th week of the intrauterine life the inferio-lateral border of the
maxillary arch and the superio-lateral border of the maxillary arch show
localized proliferation of the oral ectoderm resulting in the formation of the
horse shoe shaped band of tissue called dental lamina. The permanent
molars develop as a result of its distal proliferation while the permanent
teeth that replace deciduous teeth develop from the lingual extension of the
dental lamina.
The ectoderm in certain areas of dental lamina proliferates and
forms knot like structure that grow into the underlying mesenchyme. Each
of these knots represent a future deciduous tooth and is called enamel organ.

The enamel organ passes through three stages:

a) Bud stage
b) Cap stage
c) Bell stage

Developing dental lamina and tooth buds

a) Bud stage:

b) Cap Stage:

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c) Bell Stage:

PRIMARY DENTITION TO AGE THREE:

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The primary teeth begin to form at 7 weeks in-utero and the

enamel of all the primary teeth is usually completed by first year
of age. All of the primary teeth generally would have erupted by
24 to 36 months of age. The histologic analysis shows that the
calcification occurs in 24 units in maxilla and mandible.20 are
deciduous and 4 permanent.
The first tooth to erupt in the oral cavity is the
mandibular primary incisor. The tooth usually erupts in a
vertically upright position. As other primary teeth erupt, they may
be spaced apart from each other particularly in the incisor area.
Primate spaces are frequently recognized which are spaces
between the mandibular primary cuspid and the first molar and
between the lateral incisor and primary cuspid.

Permanent dentition till the age of 3 years:

The first permanent molar is the first tooth to show germ

formation at age 3 ½ to 4 months in utero. It is followed by the
central and the lateral incisors which demonstrate formation at 5 to
5 ½ months in utero. The first and the second bicuspids and the
second and third molars demonstrate the germ formation after
birth. The hard tissue formation doesn't occur at birth except for
permanent molars.
At the age of 3, most of the teeth undergo hard
tissue formation.

THE PRIMARY DENTITION YEARS:

Craniofacial changes:
The growth of the head and the face continues during this period
from 3 to 6 years. But there is increased growth of the face
compared to cranium. The face becomes larger, wider, longer and
more detailed. The soft tissue prominence of the nose and to some
extent the mandible continue to increase consistently with some
reduction in facial convexity. Vertically there is lowering of the
palatal vault with sutural growth and apposition on the oral side of
the palate and resorption on the nasal side. The growth of the
mandible is such that it stays parallel to the original plane. This

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occurs due to the reason that condylar growth exceeds the vertical
maxillary growth, which prevents opening of the mandibular plane
angle. Transverse maxillary growth is largely a result of
midpalatal sutural changes whereas the growth of the body and the
angle of mandible are result of apposition and resorption.
Posterior maxillary and mandibular growth
helps to accommodate the emerging permanent first molars.
Consistent with eruption of primary teeth, often the magnitude of
vertical change is appreciated. The permanent anteriors will also
occupy more anterior and protrusive position in the face.

Dental changes:

This is relatively a stable period clinically for the primary

dentition before its eruption was completed by 24 to 36 months
and before root formation and completed by 3 years. This is the
significant period of time for the development of clinical crown of
the permanent dentition and their subsequent eruption. There will
be some root resorption during this period.
The occurrence of the primate spaces in
deciduous dentition is a significant aspect as this would allow for
the eruption of the permanent successors which have wider
mesio-distal diameter.

THE TRANSITIONAL YEARS:

Mixed dentition refers to the stage where both the permanent and

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the primary teeth are present in the mouth.There are three stages in
mixed dentition.

STAGE: INTRA ARCH GROWTH AND DEVELOPMENT

The early phase of stage 1 is the period when four permanent

molars erupt distal to the second primary molars and eight
permanent incisors erupt after the primary incisors are shed. These
events occur in a variable sequence from 5 to 8 years of age. Most
children experience these events around 6- 8 years. The
permanent first molars erupt end to end as Angle Class 1.
Dental development is a function of tooth formation
and not chronologic age or skeletal development. Teeth usually
erupt with the root ½ or ¾ formed .If ¾ of the root is formed, the
tooth is not erupted and methods to assist tooth eruption are
indicated. Permanent incisors that erupt before the loss of the
primary successor may be deflected lingually. In the case of
maxillary incisor it may result in lingual crossbite.
When the permanent crown is visible in the mouth
its corresponding primary predecessor should be exfoliated.
Contralateral teeth that erupt within 6 months of each other is
considered normal. But if one central incisor has erupted and the
other incisor has not even erupted after 6 months; an obstacle has
to be suspected. The problem can be trauma, midline
supernumerary teeth, or early loss of permanent teeth leading to
the formation of dense avascular gingival tissue.
Crowding is generally common when the
maxillary dental arch is narrow. The crowding is usually
manifested as lingual blockade or rotation of lateral incisors. It
may also result in lateral incisors more labially placed and central
incisor more lingually placed leading to Class 2 division 2
malocclusion.
The 'UGLY DUCKLING STAGE” refers to the stage
where the maxillary lateral incisor has strong distal crown
inclination.

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In the lower arch erupting permanent lateral incisors

often manifest crowding. The lower arch is contained by the upper
arch and therefore, when crowding is a characteristic of an arch, it
is more manifested in the lower arch where crowding is severe,
insufficient arch may lead to the permanent lateral incisor causing
resorption of both the primary lateral and primary cuspid roots.
The permanent lateral incisors will then erupt crowded but leave
only the first and second primary molars to hold space for the
cuspids and bicuspids. This happens much more frequently in the
mandible than in the maxilla.

Stage 2: Intra arch growth and development:

The transition from mid-arch dentition to permanent dentition

occurs from ages 9 to 13 years. The primary cuspid,the first and
the second molars are replaced by the permanent cuspid, the first
molar and the second molar. Even the permanent second molar
erupts during the second time. The primary cuspid is narrower
than its permanent sucessor, the permanent first molars are slightly
larger or equal in size to permanent first bicuspids and the second
primary molar, especially in the mandible are significantly larger

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than the secondary bicuspids. The sum of the widths of the

primary cuspuds and molars mesiodistally averages in each of
quadrant about 1-3mm greater in maxilla and 3.1 mm greater in
mandible than the sum of permanent cuspids and bicuspids. The
difference in arch length available by exchange of the primary and
permanent dentition is the leeway space.

The leeway space is used either anteriorly to

permit improvement in crowded incisors,or posteriorly to allow
the lower permanent first molars to migrate more mesially.When
end to end molar relations exist in the mixed dentition, migration
is necessary to achieve a class 1 permanent molar relation. The
status of eruption of permanent molar is an important factor. The
second permanent molar exerts a mesial force as it erupts and if by
that time second bicuspid has not reached the plane of occlusion,
considerable mesial migration of the first permanent molar can
occur in a relatively short period of time. Therefore in order to
prevent the mesial movement of the permanent first molar, either
the second permanent molar must be completely erupted or it must
start to erupt until the second primary molar is lost and the second
bicuspid has reached the plane of occlusion. A tooth usually

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requires six months or more from the time it is first visible in the
mouth until it reaches the plane of occlusion.
The Late shift of the permanent molars is
influenced by the leeway space at the age of 13-14 years.

INTRA ARCH GROWTH AND DEVELOPMENT:

The relationship between the maxillary and mandibular teeth can

vary in three planes of space.Changes in relationship however can
occur by changes at one or more of four specific sites of change.

a) Maxillary teeth can move with cellular changes in periodontal

tissues.

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b) The maxilla can grow at its sutural articulations causing the

maxillary teeth with it.
c) Mandibular teeth can move with cellular changes.
d) The mandible can grow at its articulations,carrying the
mandibular teeth with it.
Before it was thought that growth of jaws
was very much similar or equal. A vector is created between two points and
changes between the record is termed as variation. Nowadays the concept of
dissimilar growth had been recognized.
Variation occuring in dental occlusion due to growth are:
1) Anterio-posterior variation
2) Vertical variation

Vertical variation:

The Angles system of anterior posterior growth had been demonstrated

to have flaws.It is apparent to know that the face grows in a straight
like.It has been said that each bones joined together undergo dissimilar
amounts of growth and the bone turns in relation to other adjacent
structures. The dissimilar growth could result in forward or backward
rotation.

INCISOR DIASTEMA:

Midline diastema are common at the time of eruption of maxillary

central incisor.The other causes of incisor diastema are congenital
microdontia, missing laterals,peg shaped laterals, supernumerary teeth,
pathologies or habits. The maxillary labial frenum is frequently
responsible.The frenum normally appears lower with growth patterns
demonstrating less vertical dento-alveolar growth.

Significant dimensional changes occur at an age of

6-7 years ie: during the eruption of permanent first molars. Prior to their
eruption ,the posterior interdental spaces start to close slightly,decreasing
total arch length.When the mandibular first molar erupt,the posterior
interdental spaces start to close,slightly decreasing the arch length.When
the mandibular first molar erupts the posterior interdental
spaces,possibly under the influence of the erupting first molars close
fully as the posterior teeth move mesially. This shortens the posterior

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archlength slightly.However the total arch length does not change during
this period because the larger permanent incisor teeth erupt labial to their
primary predecessors,the arch length would probably increase. Yet the
arch length to the same extent that the more labial placement of the
incisors increases the length. In contrast the length of the maxillary arch
increases indicating that the increase in arch length that occurs during the
incisor interchange more than compensated for the arch length decrease
due to the closure of the posterior interdental spaces.
During the same period, the intercanine width in the
maxillary arch increases by approximately 3mm as the incisors erupt.
This movement occurs because of the need of space as the large
maxillary incisors erupt and push the canines distally and labially. In the
mandibular arch,the intercanine width increases by 2-3mm.The
intercanine perimeter which is more significant than the intercanine
width also increases during the eruption of the permanent canines
indicating that they tend to erupt labial to the primary teeth.

The below image shows the occurrence of typical midline diastema in an

18 year old male patient. This midline spacing can be corrected by using
fixed orthodontic treatment using reciprocal elastics.

CLINICAL SIGNIFICANCE OF PRIMARY DENTITION

YEARS:
The primary dentition years ie: dento-alveolar changes from 6 to
12 years help the pedodontist in estimating treatment, occlusion,
the relation of the inter-canine width and the dimensional change
occurring in the eruption of tooth structure also play a major role
deciding the mode of treatment the child could be given.
The shedding of the deciduous second molar generally
occurs at 11-12 years and if at that particular age such a tooth is
infected it is indicated for extraction rather than conservation.

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THE ADOLESCENT YEARS:

The important changes taking place in dentition happens to be

eruption of the second and third molars. The craniofacial changes
occuring in the face leads to the slow increase in height of the face
leading to prognathism. The mandible exhibits greater prognathic
changes than the maxilla. The circumpubertal growth spurt is
generally recognized to take place between the age of 10 and 12
years(males) and 12 to 14 years(females).
The maxillary sinuses which have since birth
expanded laterally and vertically occupy the space left by the
permanent teeth where they erupt and the sinuses grow downward.
By puberty the sinuses become fully developed and continue to
enlarge. There is average increase in the palatal vault of
approximately 10mm from birth to adolescence but
simultaneously the palate moves downward as a result of
appositional growth. The growth of the jaws continue during this
period. The growth would be sufficient to develop room for the
third molars. In many cases, the growth becomes adequate and
third molars become permanent teeth diminishes as mandible
completes the growth under the maxilla and lower incisors
become more upright resulting in crowding. The most marked
change in the adolescent alveolar bone is the increased protrusive
ness and prominence of this bone. Till adolescence, the maxilla
grows faster than the mandible,an in adolescence the mandibular
growth catches up with that of maxilla.
By the completion of adolescence all the 27 bones of
the skull are closely adopted and skull can be considered as a
single bone. But growth is considered as a lifelong process and
subtle changes keep on occurring.

DENTAL CHANGES DURING ADOLESCENT YEARS:

All the permanent teeth generally would have erupted by the age
of 12 years excepting the second molars. The presence of any
unerupted tooth except the third molars must indeed be an
anomaly.
The roots of all the teeth would have completely formed

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by the age of 16 years except for those of third molars which are
completed at an age of 25 years.

Additional images which may assist in understanding this topic

Tooth eruption through the ages

The first two images show the dentition during the primary
dentition years. The third image illustrates the transitional years.
The fourth and fifth illustrate the adolescent years and the last one
the fully mature adult with the eruption of the third molars.

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Created by Dr.Venkatesh.C BDS

The above images show the tooth eruption charts of the

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Created by Dr.Venkatesh.C BDS

a) The deciduous teeth

b) The permanent teeth

CONCLUSION:

The dento-alveolar changes which have been dealt with in the

preceding pages illustrate the biological processes operating and
how there is this sort of harmonious synchronization of the oral
processes with that of the craniofacial development. The more
Indepth the topic is discussed the more it is understood that its
rather juvenile to use the term the dental or oral cavity and better
refer it as a oro-facial complex or oro-cranio-facial growth. The
portending realities which would come into this evergreen topic in
the future, hope so would improve this topic in a further better
way.

ACKNOWLEDGEMENTS:

This project had taken me many sleepless nights and almost 3-4
months. I had liberally borrowed from lots of sources and the web
had been extremely useful for me.

1) Textbook of Orthodontics by S.M Bhalajee

The scanned images are irretrievable property of this author.

Copyright reserved.

2) Orthodontics Current principles and Techniques by Thomas

Grabber

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Created by Dr.Venkatesh.C BDS

3) Contemporary Orthodontics by William.R.Profit

4) Neurotrophic factors referred from Neurotrophic journal

http://www.neuro.wustl.edu/neuromuscular/lab/trophic.htm

5) Dental development images from University of Texas Cell

biology program.

6) Midline diastema image from pediatriconcall.com

7) Pub med National library of medicine

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi

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Created by Dr.Venkatesh.C BDS

©venkidrc
Created by Dr.Venkatesh.C BDS

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