DEVELOPMENT OF DENTITION FROM

6-12 YEARS
(MIXED DENTITION STAGE)

Presented By Guided By
Dr. Santosh Chavan Dr. (Mrs.) W.A. Bhad
P.G. Student Assoc. Prof. & Head

Department of Orthodontics & Dentofacial Orthopedics

Government Dental College & Hospital, Nagpur
 Introduction

 Dental arch dimensions

 Utilization of arch – perimeter

 Adaptive occlusal changes in transitional dentition

 Dental age 6

 Dental age 7

 Dental age 8

 Dental age 9-10

 Dental age 11

 Dental age 12

 Clinical considerations

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INTRODUCTION
The period during which both primary and permanent teeth are in
the mouth together is known as mixed dentition period.
This period is from age 6 years to 12 years or onset of puberty.
From a clinical point of view, there are two very important aspects of
mixed dentition stage.
 The utilization of arch perimeter, and
 The adaptive change in occlusion that occurs during the
transition from one dentition to another.

DENTAL ARCH DIMENSIONS

The usual arch dimensions measured:
Width
Length
Circumference

Arch width
Width dimensional increase involves alveolar process growth
almost totally since there is little skeletal width increase at this time.
Maxillary alveolar processes diverge while the mandibular alveolar
processes are more parallel. So maxillary arch width increases are much
greater and can be easily altered in treatment.
The intercanine diameter increases only slightly in mandible due to
distal tipping of the primary cuspids into the primate spaces. Since the
mandibular incisors are not normally moved labially through time.
Maxillary first premolar width increases significantly more than
does in mandibular.

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Arch length
Dental arch length is measured at the midline from a point midway
between centre incisor to a tangent touching the distal surfaces of second
primary molars or second premolars.
There is scientific evidence to indicate that the posterior teeth
move forward throughout life. This would reduce arch length. Moorees
has established that arch length decreases 2 to 3mm between 10  12
years of age, when the primary molars are being replaced by permanent
molars.

Arch circumference or perimeter

It is measured from the distal surface of the second primary molar
or mesial surface of first permanent molar around the arch over the
contact points and incisal edges in a smoothed curve to the distal surface
of the second primary molar of the opposite side.
Moorees has demonstrated that the arch circumference is reduced
approximately 3.5 mm in the mandible of boys and 4.5mm in girls during
the mixed dentition stage.
The reduction in mandibular arch perimeter during the transitional
and early adolescent dentition is the result of:
o The late mesial shift of the first permanent molar as the ‘leeway
space’ is preempted.
o The mesial drifting tendency of the posterior teeth throughout
all of life.
o Slight amounts of interproximal wear of teeth.
o Lingual positioning of the incisors as a result of differentiated
maxillo-mandibular growth.

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Utilization of arch - perimeter
The arch perimeter is used in 3 ways:
o Alignment of permanent incisors
o Space for cuspids and premolars
o Adjustment of the molar occlusion.

Alignment of the permanent incisors

The permanent incisor teeth are considerably larger than the
primary incisors that they replace. The difference between the amount of
space available for them is termed as ‘incisor liability’ by Warren
Mayne. The amount of space available is the size of primary incisors plus
the spaces between them.
A normal child will go through a transitory stage of mandibular
incisor crowding at age 8 to 9 years. The extra space to align these mildly
crowded incisors comes from 3 sources.
1. A slight increase in width of the dental arch across the canines.
This increase is about 2mm.
2. Labial positioning of the permanent incisors relative to the
primary incisors. It gives 1 to 2mm of additional space in the
average child.
3. Repositioning of the canines in the mandibular arch
Secondary spacing in closed primary dentition the permanent
mandibular lateral incisors emerge and primary mandibular canines
moved laterally.

Space for cuspid and premolars

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 In contrast to the anteriors, the premolars are smaller than their
predecessor. The difference between the combined width of premolars
and permanent cuspid and combined width of their predecessor is called
as “leeway space” by Nance.
According to Nance this difference is 3.4mm in mandibular arch
and 1.8 mm in maxillary arch.
The normal leeway according to Moyers is 2.6 mm in maxilla and
6.2 mm in mandible.
However, this leeway space varies considerably and should be
measured on each patient.

Adaptive occlusal changes in transitional dentition

The transition from the primary to the permanent dentition begins
at about age six with the eruption of first permanent molars followed by
permanent incisors permanent teeth erupt in groups and may be divided
in different eruption stages.
The stages are used in the calculation of dental ages, which is
determined from three characteristics.
First is which teeth have erupted.
Second and third which are closely related, are the amount of
development of permanent teeth.

Dental age 6
It is characterized by eruption of first permanent molars and
mandibular central incisor usually the mandibular molar precede the
maxillary molar.
With the eruption of first permanent molars excessive overbite
present in deciduous dentition get corrected.

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 So they are called as natural bite opener. After this the deciduous
central incisors are lost and permanent successors start their eruptive
path.
Mandibular central incisor erupt lingually to the deciduous counter
part and move forward under influence of tongue pressure as they erupt.
The occlusal relationship that the mandibular first permanent molar
initially obtaining with its antagonist is determined by the terminal plane
relationship of the primary molars.
Flush terminal – End on relation of permanent molar and later on
by late mesial shift and mandibular growth – Angle’s Class I molar
relation.
Mesial step – Class III relation
Distal step – Class II relation
During formation the crowns of maxillary molars face distally
rather than occlusally. As the maxilla moves forward, space is created
posteriorly, permitting oppositional enlargement of maxillary tuberosity.
During this rapid tuberosity growth, the first permanent molar rotates, and
by the time the crown pierces the gingival, it is facing more occlusally.

Dental age 7
At dental age 7 maxillary central incisors and mandibular lateral
incisors erupt. Root formation of maxillary lateral incisor is well
advanced. While canines and premolars are still in the stage of crown
completion or just at the beginning of root formation.
Dental age 8
Dental age 8 is characterized by eruption of maxillary lateral
incisors.

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 The maxillary permanent incisors erupt with a more labial
inclination than their predecessors, in accordance with their greater labio-
lingual thickness and wider diameter.
The maxillary central incisors erupt with a slight distal inclination
and some midline space between them.
The erupting lateral incisors are placed distal to the roots of central
incisor and this causes the distal tipping of central – incisors.
The developing cuspid crown lies just labially and distally to the
roots of lateral incisors. The cuspid in this position can cause the crown
of lateral incisor to erupt move labially than the central incisor and are
flared. There is a formation of midline diastema. This stage in mixed
dentition is called as ‘Ugly duckling stage’ by Broadbent.
This is a temporary stage and will correct by itself with the
eruption of cuspid. The cuspids which are erupting facing mesially and
labially closes the spaces between the incisors.

Dental age 9 and 10

Since no teeth are erupting at that time, dental ages 9 and 10 must
be distinguished by the extent of resorption of the primary canines and
molars and the extent of root development of their permanent successors.

Dental age 11
Dental age 11 is characterized by the eruption of another group of
teeth the mandibular canine, mandibular 1st premolar and maxillary first
premolar, with all erupt more or less simultaneously.
At dental age 11, the only remaining primary teeth are the
maxillary canine and second molar, and mandibular second molar.

Dental age 12

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 At dental age 12, the remaining succedaneous permanent teeth
erupt. In addition at age 12 the second permanent molar in both arches are
nearing eruption. The succedaneous teeth complete their eruption before
emergence of second molar in most cases.
The most favorable eruption sequence in the mandible is cuspid,
first bicuspid, second bicuspid and second molar. It is useful cuspid
erupts first, since it tends to maintain arch perimeter and lingual tipping
of incisors.
The sequence of eruption is different in maxilla, being first
bicuspid, second bicuspid and cuspid or first bicuspid, cuspid and second
bicuspid.
Eruption of second molar usually occurs shortly after the
appearance of second premolars. Both upper and lower second molars
erupt at about the same time.
Second permanent molar also raise the bite.

The eruption sequence of permanent dentition is as follows:

Maxillary arch
6 – 1 – 2 – 4 – 3 – 5 – 7 or
6–1–2–4–5–3–7
Mandibular arch
6 – 1 – 2 – 3 – 4 – 5 – 7 or
6–1–2–4–3–5–7

Eruption timing of permanent dentition

Maxillary
Central incisor – 7-8 years
Lateral incisor – 8-9 years
Cuspid – 11-13 years

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 First bicuspid – 11-12 years
Second bicuspid – 10-12 years
First molar – 6-7 years
Second molar – 12-13 years

Mandibular
Central incisor – 6-7 years
Lateral incisor – 7-8 years
Cuspid – 9-10 years
First bicuspid – 10-12 years
Second bicuspid – 11-12 years
First molar – 6-7 years
Second molar – 11-13 years

CLINICAL CONSIDERATION IN MIXED DENTITION

Unless there is a specific indication for diastema closure in the
early mixed dentition stage, it should be left untreated to avoid impacting
the permanent maxillary canines. This is because at the early stages of
dental development the cusp tips of erupting canines are too close to the
apices of lateral incisors.
Indication for the early treatment of large diastema includes the
presence of supernumerary tooth between the central incisors or the
presence of abnormally large diastema of 4mm or more. In these cases
the diverging crown of the central incisors will be encroaching on the
space needed for eruption of lateral incisors.
The observations of changes in molar relationship are of
importance to clinicians involved in the management and treatment of
young patients, in the primary and mixed dentition stages.

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 The findings imply that cases with distal steps in the primary
dentition stage should be observed on a regular basis and treatment
started as soon as the clinician and patient are ready to initiate it because
the condition will not self-correct with time.
Patients with a flush terminal plane relationship present a more
challenging diagnostic question. This is because the findings suggest that
slightly more than half of cases progress to normal Class I molar
relationship, where as 44% of the cases progress to a Class II, or end to
end occlusion. These findings imply that what is considered normal
occlusion in the primary or mixed dentition stage does not necessarily
lead to a normal occlusion in permanent dentition stage. Therefore it is
important for a clinician to closely observe these cases and when needed,
initiate orthodontic treatment at the appropriate time.
The findings also indicate that the presence of favorable difference
in the leeway spaces between the maxillary and mandibular arches is not
a good predictor of where a Class I molar relationship will be established
in the permanent dentition stage. In addition then final molar occlusion is
dependant on a number of dental and skeletal facial changes. An
unfavorable sequence can produce crowding. For instance, if the second
molars erupt relatively early, they may affects the canines in the maxilla
and II premolars in the mandible. Maxillary second molars erupt ahead of
mandibular molars in 89.11 of Class II patients, where as in only 56.5%
do maxillary first molars erupt ahead of their mandibular counterparts.
Therefore second molars are more important than first molars in the
development of a Class II relationship.
In the maxilla approximately 90% of the time first premolar
emerges ahead of the canines. This is favorable for serial extraction.
Approximately 10% of the time the sequence is unfavorable.

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 In the mandibular approx 80% of the time the canine emerges
ahead of first premolar. It is not favorable for serial extraction.
Approximately 20% of time sequence is favorable for serial extraction.
Before the primary molar lost, a mixed dentition analysis must be
done to determine weather mesial movement of first permanent molar
need to be controlled. When leeway space is insufficient, the I molar must
not be allowed to move mesially until the second bicuspid has a chance at
its proper position in arch both genetic and environmental, that interact to
achieve or not achieve a normal occlusion.
These findings indicate that the change in molar relationship might
be more complex than was previously assumed and is associated with
changes in a number of variables in both of dental arches and the rest of
dentofacial structures. The complexity may explain why non of the cases
with distal step and mandibular of the cases with flush terminal plane or a
mesial step in the primary dentition stage did not change to a Class I
permanent molar relationship. Maintaining the Class II occlusion
occurred in spite of the fact that these cases also exhibited positive
leeway spaces and significant mandibular growth.
Research conducted by Moorees and Chadha has revealed 2mm
of crowding in incisor segment in the mandible of boys will recover to no
crowding by 8 years on the average. Girls recover to approximately 1mm
of crowding. This is significant finding because it tells the clinician not to
be alarmed with a slight amount of crowding in the early stages of
emergence of permanent incisors.
An impossible situation exists with a true hereditary tooth size/jaw
– size discrepancy and an incisor liability that cannot be compensated by
interdental spacing, an increase in intercanine width or labial positioning
of permanent incisors. Serial extraction can be beneficial for the
individuals.

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Serial extraction in Class I treatment
Anterior discrepancy: crowding
Extraction of primary canines  primary first molar  extraction
of I premolar
Anterior discrepancy: dentoalveolar protrusion
Primary I molar  primary canines and first premolars
Middle discrepancy: impacted canines
Primary I molar  I premolar

Space maintenance during transition of the dentition

TPA
Lingual arch
Orthopedic expansion

Correction of sagittal malocclusion in mixed dentition.

Patient with Class II tendency
Extraoral traction
Functional jaw orthopedic appliance
Twin block appliance
FR-2 appliance of Frankel
Herbst appliance

Patient with Class III malocclusion

Orthopedic face mask
FR-3 appliance of Frankel
Orthopedic chin cup.

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