DEVELOPMEN

T OF
OCCLUSION
CONTENTS
• Introduction
• Development of concept of occlusion
• The mouth of neonate
• The Primary teeth and occlusion
• The mixed Dentition period
• Permanent teeth and occlusion
• Dentitional and occlusal development in Young Adult
• Clinical Implications
• Conclusion
• References
 Introduction
• 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 para-function.”

• An ideal occlusion is the perfect inter-digitation 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
 HISTORY
• In 14 th century B.C Hippocrates noted that deciduous teeth were
formed before birth n described the formation and eruption of
teeth.

• The clear description of teeth and their relation to each other was
given by John Hunter (1771), he says :
“ When the jaws are closed, the cuspidatus of upper jaw falls
between and projects a little over the cuspidatus and bicuspids of
lower jaw.”
 THE DEVELOPMENT OF THE CONCEPTS
OF OCCLUSION

The fictional The

The factual
hypothetical
period, period
period
prior to from1900 to
from1930 to
1900 present
1930.
 FICTIONAL PERIOD

• Pioneers like Fuller, Clark and Imrie talked of

“Antagonism”, “Meeting” or “Gliding” of
teeth.
• The creation of normal standard, a basis on
which to compare departures from normal
was lacking. But this served as a working
hypothesis and subsequently became
established fact after definitive research
 HYPOTHETICAL PERIOD
• Edward H. Angle,
– It was him, who channelised orthodontic thinking
on occlusion and brought the real concept out of
fiction.

– In 1907, Angle summarised his views as ‘occlusion

shall be defied as being the normal relation of the
occlusal inclined planes of the teeth when the jaws
are closed’

– Angle cites the example of a skull of Negro male

from Broomell which he names ‘Old Glory’. In ‘Old
Glory’ all the teeth are present and arranged in a
graceful curve
• Angle furnished his ‘key to occlusion’ and emphasizes
the first permanent molars especially the upper first
permanent molar and considers them to be most
constant in taking normal position.
• From the hypothesis of constancy of first molar and
the ‘line of occlusion’ , Angle developed the concept
that all teeth should be present if normal occlusion is
to be achieved.
 FACTUAL PERIOD
• In 1930 Holly Broadbent and Hans Planer introduced an
accurate technique of cephaolmetry. Investigators were able
to follow longitudinally the orofacial developmental pattern
and the intricacies of tooth formation, eruption and
adjustment.
• Planer laid emphasis on efficiency of masticating mechanism.
He explained physiological rest position and vertical
dimension
• A third element of occlusion, the TMJ has been receiving
more attention. There is an intimate relationship between the
inter-digitation of the teeth, the status of controlling,
musculature and the integrity of the TMJ.
Development of concept of occlusion
Current concept
Occlusal position or tooth contact

Postural resting position

Integrity of stomatognathic system

 Development of concept of occlusion:
Current concept
– Nervous regulation
 Novel sensory apparatus of the teeth – appears with primary
teeth- important for the maturation of the nervous sys and its
interface with the environment

 The development of the muscle matrix and the active growth of

the facial skeleton occurs at a very strategic time for the
maturation of the nervous sys and the development of the oral
motor functions involving the teeth and chewing.

 It is during this time that the jaw positions and posturing of the
mandible in relationship to the teeth takes place
 Definition

• Acc. to Ash and Ramfjord , occlusion may be defined as “the

contact relationship of the teeth in function or para function”.

• Acc. to Angle(early 1900) occlusion is “the normal relation of

the occlusal inclined planes of the teeth when the jaws are
closed .”

• Salzmann & Gregory defined occlusion as:

“The changing interrelationship of the opposing surfaces of the
maxillary & mandibular teeth which occur during movements
of the mandible & terminal full contact of the maxilla &
mandibular arches
 Why study occlusion??

• Occlusion from the time of birth till the adult stage is a

dynamic state.

• A knowledge of growth and development of arches helps to

differentiate abnormal from normal relation of teeth and
helps in diagnosis.

• Helps in treatment planning.

• Helps to undertake preventive or interceptive procedures.

BARNETT’S STAGES OF OCCLUSAL DEVELOPMENT
PERIODS OF TOOTH DEVELOPMENT

Pre-dental Stage
(0-6months)

Deciduous
dentition (6
months-6 years)

Mixed dentition
(6-12 years)

Permanent
dentition
MOUTH OF THE NEONATE
PREDENTATE PERIOD
 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:
Gingival groove-
Separates gum pads from palate.
Dental groove-
Extends from the incisive papilla,
backwards to touch the gingival groove
in the canine region & continues forward
in the molar region.
Transverse grooves-
Depressions between the 10 segments of
the gum pads.
Lateral sulcus-
Transverse groove between the canine &
molar sac region
 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.
 Relation of gum pads
At rest:
• An anterior open bite is present.
• Contact at the molar area only.
• Tongue is interposed between the space.
• Maxillary gum pads is wider than mandibular
& there is total overlapping of maxillary gum
pad. It lies in a class II type relation, where
the upper gum pad is forwardly placed. This is
a transient &self correcting.

• The gum pads grow rapidly during the 1st year

of life & the growth is more in the transverse
direction.
• Length increases, mostly in the posterior
direction.
 Relationship of Gum Pads
• At birth, the alveolar arches are small and
teeth in their crypts are rotated and
imbricated
• In maxillary, the lateral incisor lie lingually to
central incisors and canines may be rotated.

• In mandible, both centrals and laterals are

rotated, the centrals mesiolingual, and lateral
distolingual to the line of arch.

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.
• Simpson and Cheung found that only 2% of all neonates have an
anterior open bite gum pad relationship. They also reported that
oral habits had a definite influence on the infantile gum pads,
resulting in significant increase in the incidence of anterior open
bite relationships by age of 4 months
J Can Dent Assoc 1973
 CLEANING OF GUM PADS

Started within the first week of birth.

• The parent can be instructed to:- Lay the baby down with
his/her head in your lap & feet pointing away.
• Take a small gauze ( 2” x2”) between thumb and forefinger
& wipe vigorously over the gum pad .
• Infant tooth brush, Finger coats, Wipes are also used .
• Use adequate pressure just to remove the film that covers
the gum pad.
• Clean at least every day twice after morning & last feed in
the night.
• Duration of cleaning :- 2 to 3 minutes.
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
 Osteoblastic activity inside the germ area related to the
remodeling phenomenon and hypovitaminosis
• Associated syndromes: • Complications:
 Interfere with feeding
 Risk of aspiration
 Hallerman-Streiff  Traumatic injury to the baby’s
tongue and/or to the maternal
 Ellis-Van Creveld breast
 Riga-Fede disease- oral
 Craniofacial dysostosis condition found, rarely in
newborns manifests as an
 Multiple steatocystoma ulceration on the ventral
surface of the tongue or on the
 Congenital pachyonychia inner surface of the lower lip.
Caused by trauma to the soft
 Sotos Syndrome. tissue from erupted baby
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 baby’s 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.
 STATUS OF PREDENTATE PERIOD
• Neonate is without teeth for about 6 months of life.
• At birth gum pads are not sufficiently wide to
accommodate the developing incisors which are
crowded in their crypts.
• During the first year of life the gum pads grow
rapidly permitting the incisor to erupt in good
alignment.
• Very rarely teeth are found to have erupted at the
time of birth or within a month after birth.
 VARIABLES THAT CAN IMPACT ORAL CAVITY AND DEVELOPMENT OF OCCLUSION

• Improper feeding - artificial bottles and nipples.

• Noxious habits - pacifier, excessive infant habits.
• Grossly enlarged tonsils and adenoids.

• High palates and narrow arches

• Ankyloglossia / tongue-tie.

• Facial-skeletal growth abnormalities.

• CNS dysfunction affecting facial muscles.
• Drugs

• Illnesses
 PREDENTATE PERIOD :
SELF CORRECTING ANOMALIES

• Retrognathic mandible
– Differential and forward growth of
mandible

• Anterior open bite

– Eruption of primary incisor

• Infantile swallowing pattern

– Introduction of solid food in diet
 IMPACT OF INFANT HABITS ON OCCLUSION.

EXCESSIVE digit sucking can set up abnormal

forces on the oral cavity and surrounding
structures.

Noxious habits can drive chin back and

contribute to Retruded Class II malocclusion.
Primary Dentition
(From around the 6 month to 6 years)
th

Period
 Studied under

Development of primary Development of primary teeth

teeth occlusion

Calcification Eruption

Terminal Relation of
Type of
Spaces plane anterior
dentition
relations teeth
SEQUENCE OF ERUPTION
ABDCE
 RULE OF “7 + 4”
• A helpful mnemonic to remember the timing of primary
eruption is the 7+4 rule.
• At 7 months of age, children should have their first
teeth;
• At 11 months (4 months later),they should have 4 teeth.
• At 15 months of age (4 months later), they should have
8 teeth;
• At 19 months, they should have 12 teeth;
• At 23 months, they should have 16 teeth;
• And at 27 months, they should have 20 teeth.
 7 months 11 months

15 months 19 months

23 months 27 months
Eruption and occlusion of deciduous
teeth
• Arches increase in size both in length and breadth to allow
teeth to erupt into good alignment and even to be spaced.

• It is usual for the mandibular teeth to erupt before maxillary

teeth, and the Ist tooth to erupt being mandibular Central
Incisor at 6 months of age.

• The morphological character of teeth in the molar region helps to

guide them into correct occlusion.
 DEVELOPMENT OF PRIMARY OCCLUSION

– Neuromuscular consideration – neuromuscular regulation is

important to the development of primary occlusion.

• Sequential inter-dentation begins in the front as the

incisors erupt
• Teeth guided into occlusal position by muscular functional
matrix during very active growth of the facial skeleton.
• Low cusp ht. and ease of wear of occlusal surfaces also
contribute to this adaptability
• Muscle behaviour is adaptive to skeletal morphology
• Acc . to a study by Leighton ,abnormal sucking habits
either largely cause the skeletal differences or contribute to
them.
• When teeth are erupted and muscles are functioning, the arch
formed by the crowns of the teeth is altered by muscular
activities, although the original arch form is probably not
determined by the muscles.

• As the primary teeth are formed the alveolar process develop

vertically and the anterior intermaxillary space is lost in most
children
 Types of primary dentition
Open type:
• Primary teeth with
spaces.
Closed type:
• Primary teeth without
spaces due to larger
teeth of small arch
length.
 PRIMARY DENTAL ARCHES

– Ovoid in shape

– Role of tongue – in early stages of development the tongue plays

an important role in shaping of the dental arches, as the primary
dentition is molded around it.

– But its role diminishes with age with age, the establishment of
occlusal reflexes, and the more mature activities of lips after the
eruption of the incisors and the cessation of nursing.

– Generalised interdental spacing decreses with age

– There is no pattern of spacing common to all primary dentition.

– The anterior part of the dental arches increases slightly from birth
to 12 months and changes very little thereafter

– Maxilla increases more than the mandible

 ARCH DIMENSIONS
o Zigmondy 1890
o Frank & Baume- changes that take place in arch by
loss of primary teeth and development of occlusion

 Arch Size
 Arch Length
 Arch Circumference
 Arch Width
• Arch width
– No substantial increase
– Increase to accommodate permanent
molars

• Arch height
– Increase in height of alveolar bone

• Arch length and circumference

- Small amt. of decrease

Mesial migration of 2nd primary molar

during eruption

Proximal caries
 IN MAXILLA

• Increased intercanine width by 6 mm between 3-13 yrs

• Increased Intermolar width of 2 mm between 3-5 yr

• Palatal vault increases from birth to about 12 months and

remains relatively constant throughout the first 2 yrs
 IN MANDIBLE

• Increased intercanine width by 3.7

mm between 3-13 yrs

• Increased Intermolar width of 1.5 mm

between 3-5 yr

– Loss of arch length in mixed and

permanent dentition

• Up righting of incisors, loss of leeway

space
 CONTACTS IN DECIDUOUS DENTITION

• Factors influencing the development of

contact relations
1. Position of the tooth germ
2. Presence of permanent teeth
3. Development of the condyles
4. Cuspal inclines
5. Neuromuscular influences
 Hellman (1921-33) has described 4 diff kinds of occlusion contacts
as follows :
 Surface contact
 Cusp point contact with fossa, groove or division between
them.
 Ridge contact with embrasure.
 Ridge contact with grooves.
OCCLUSAL RELATION(baume’classification
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

• It is a 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.
2. MESIAL STEP
– Distal surface of lower more mesial to upper
– Mesial step terminal plane most commonly occur due to
early forward growth of mandible
– Favourable – permanent incisors erupt with less overbite
and the first molars erupt at ones into a firm neutrocclusion
– 19.1%
3. DISTAL STEP
– Distal surface of lower more distal to upper
– Sucking habits – greater anteroposterior growth of the
mandible causes natural occlusal interferences usually in the
cuspid region.
– Prognostically unfavourable – class II molar relationship

– 4.8%
 Deciduous dentition: Development of
occlusion
• Acc. to a study by Bishara et al , the distribution of
terminal plane relationships was found to be:
• Distal step - 10%
• Flush terminal plane - 29%
• Mesial step of 1-0 mm -42%
• Mesial step > 1-0 mm -19%

Samir E Bishara – ‘Changes in molar relation between deciduous and

permanent dentition –a longitudinal study. Am J Orthod 1988;93:19-28 44
 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:
o Eruption of deciduous molars.
o Attrition of incisors.
o Forward movement of the mandible due to growth

(The average overjet in primary dentition is 1-2 mm.)

INTERINCISAL ANGULATIONS
– 150º in primary
– 123º in permanent

• Dental arch circumference wider

 CANINE RELATIONSHIP

• Relationship of maxillary & mandibular deciduous canines is

one of the most stable in primary dentition

• Classified as:
• CLASS I
• CLASS II
 CHARACTERISTICS OF
PRIMARY DENTITION
• Spaced anteriors
• Shallow overbite and overjet
• Straight terminal plane
• Class I molar and Canine Relationship
• Vertical inclination of anterior teeth
• Ovoid arch form
SPACING
– According to Baume
• Closed dentition
• Spaced dentition
– Localized –Primate spaces (anthropoid/
simion spaces)
– Generalized- Physiologic Pressure from the
tongue (Barber)

– Total space-
• Maxi-0 to 8mm
• Mandible-0 to 7mm
Prevalence of Spaced and Closed Dentition and its Relation
to Malocclusion in Primary and Permanent Dentition
Suma Vinay, Vinayk Keshav, and Shreya Sankalecha

study was conducted to find the relationship of spacing and closed

dentition with malocclusion in primary and permanent dentition in children
during their deciduous dentition period.
 Sample size: A total number of thousand schoolchildren below 6 years of
age were taken for the study to find out the relationship of spacing and
closed dentition with malocclusion in primary dentition.
Out of thousand children, 51.9% of them were male and 48.1% of them
were female children
• Eighty-one percent of children had spaced dentition and 19% of children
had closed dentition respectively. .
• Closed dentition is seen more in female children than males depicting
that the frequency of developing malocclusion in permanent dentition
was more in females than in males.
• Leighton's hypothesis suggests that there should be 6 mm or
more space between the mandibular teeth in order for there
to be no chance of developing incisor crowding in the
permanent dentition
• Dong-Hyuk Im et al showed that in both sexes spacing in the
primary dentition was more frequent in the maxilla than in
the mandible
• Alexander and Prabu reported that 75% of south Indians had
both physiologic and primate spaces in both arches.1 Absence
of primate or secondary spaces in the primary dentition is
expression of disproportion between jaw/tooth sizes.
Development of primary occlusion

• Physiologic spacing:
– This is present due to antero-posterior growth of jaws.
– In maxilla it is 4 mm & in mandible it is 3mm.
– It is preferable since the chances of crowding in the
succedenous dentition is minimal.
• Primate space:
– Aka Simian/Anthropoid space (also seen in monkeys).
– Present between:
• Lateral incisor & canine in the maxilla
• Canine & first molar in the mandible
 B

C
 SECONDARY SPACES
• Usually occurs in primary
arches that have no
primary spacing.
• When the md permanent
lateral incisors erupt, the
primary md canines are
moved laterally, thus
creating space for the
maxillary permanent
lateral incisors.
NON-SPACED DENTITION:-
1. No spaces between the primary teeth
 Narrowness of the dental arches/
teeth are wide
 Indicates crowding in developing
permanent dentition
 Also depends on individual’s growth of
the jaws
 TEETHING

• Signs and symptoms

a) Vomiting
b) Fever
c) Diarrhea
d) 60% of infants exhibit disturbances such as
rhinorrhea, irritability and diarrhea which occur for
a short time before tooth eruption and resolves
after tooth emergence
e) More serious symptoms – upper respiratory
infection, febrile convulsions, wheezing,
bronchitis, infantile eczema
 DECIDUOUS DENTITION:
ANOMALIES OF PRIMARY TEETH
ANKYLOSIS
– Molars
• Mand: Max -2:1
• Seen mostly during the late primary
dentition and early mixed
dentition period
• PDL resorption
– Osseous bridging and fusion
between bone and dentin
• Submerged tooth
– Failure of vertical development
– Posterior open bite
– Often bilateral
 DISORDERS OF THE DECIDUOUS DENTITION
• Prevalence
– Crossbite, Cl-II molar relationship, Excessive overjet,
Openbite

Bruxism in primary dentition is a special problem –

functional malocclusion. 10% prevalence
• Almost always unconscious being manifested by
occasional or habitual grinding or clenching of the teeth
• Not necessarily pathogenic
• Etiology :- 1. Genetic factor
• 2. Psychosomatic symptoms
• 3. Allergy
 SELF CORRECTING ANOMALIES OF DECIDUOUS
DENTITION
Anterior deep bite
– Cause- Incisors more upright
– Correction

• Attrition of incisal edges

• Eruption of deciduous molars

• Forward and downward growth of mandible

Overjet:
– initially it is more in primary dentition. By movement of
whole arch, the overjet decreases gradually. Generally it
is 1-2 mm for primary dentition.
 PHYSIOLOGIC SPACES
– Permanent incisor accommodation

• Maxilla-7mm

• Mandible-5mm

Significance of spacing
Spacing in the primary dentition is
essential to the normal eruption &
alignment of the larger permanent
successors.

Failure of incisor spacing to appear

before 5years of age usually indicates
crowding in the permanent dentition.
MIXED
DENTITION
 INTRODUCTION
• That period during which both
primary and permanent teeth are in
the mouth together is know as Mixed
Dentition Period.

• Those permanent teeth that follow

into a place in the arch ones held by
the primary tooth are called as
Successional Teeth.

• Those permanent teeth that erupt

posteriorly to the primary tooth are
called as Accessional Teeth
 VARIOUS THEORIES ON ARCH PERIMETER

1. Suggested theory – eruption of the 1st permanent

molar causes an “early mesial shift” which closes the
primate space and other interdental spaces from the
rear.

2. Alternative theory – primary spaces are closed by the

eruption of the incisors without the loss of arch
perimeter.
PHASES OF MIXED DENTITION CAN
BE DIVIDED INTO 3 PERIODS
 FIRST TRANSITIONAL PERIOD
– Emergence of first permanent molars.

– Exchange of deciduous incisors with permanent incisors.

– Establishment of occlusion
 The concept of bite opener
• According to Schwarz; there are 3 periods of
physiologic raising of the bite, with the
eruption of:
– 1st permanent molar @ 6 years
– 2nd permanent molars @ 12 years
– 3rd permanent molar @18.
 6-7 years
Eruption of first permanent molars:
• The 1st molars erupt, the pad of tissue overlying
them creates a premature contact.
• Propioceptive responses conditions the child
against biting on the natural “bite opener”, &
thus the deciduous teeth anterior to the 1st
permanent molar erupt, reducing the overbite.
• The upper and the lower molars show different
paths of eruption.
– Maxillary: buccal and distal
– Mandibular: lingual and mesial.
 FIRST TRANSITIONAL PERIOD
1st molar eruption

Guidance by distal surface of 2nd primary molar

The occlusal relationship – terminal relationship of the sec
primary molar
Mesial and lingual path of eruption
• By the time the 1st perm molar erupts any initial spaces between
the deciduous molars and canine will generally diminish or
disappear

• In both the jaws the 1st perm molars erupt more or less in a
perpendicular orientation to the occlusal plane.

• They originate one above the other in the ramus and come
downward with the maxillary permanent molars being
accommodated by additions at the tuberosity.
Molar adjustment
1. Closure of primate space – decreases arch length
• Early mesial shift

2. Late mesial shift-

no space exist
• Mesial migration of first permanent molar after loss of second
deciduous molar using Leeway space.

5 Yr

7 Yr
 Early mesial shift
• In children with open primary dentition, the mandibular 1st molars
close the primate space distal to canine.
• Thereby, the flush terminal plain gets converted into a mesial step.
• This allows the permanent maxillary first molars to erupt into class
1 molar relationship.
• This is called “early mesial shift”.
Late mesial shift
Leeway Space Of Nance

• The combined mesio-distal width of the

permanent canine and premolars is
usually less than that of the deciduous
canine and molars
• The surplus space is called Leeway
Space Of Nance
• Mandibular > maxilla

• Mandible- Per quadrant 1.7mm

totally 3.4mm
• Maxilla- 0.9mm
totally 1.8mm
• Although the deciduous posterior segment of teeth is larger
than the permanent segment, converse is true of the anterior
segments

• Nance did not consider large difference in mesiodistal size

between the deciduous incisor teeth & their permanent
successors– arch needs to be looked in its totality

• Maxillary incisors, as a group in one quadrant– 3.2to 3.5 mm

larger

• Mandibular incisors, as a group in one quadrant – 2.4 to 2.5 mm

larger

• The latter figures balance out or cancel the 1.7 mm of so called

leeway space
Influence of terminal plane on the position of 1st
permanent molar
 INCISOR ERUPTION
• The permanent mandibular incisors develop lingually to the
resorbing roots of the primary incisors, forcing the latter labially to
be exfoliated.

• Lingual eruptive- no alarm if primary incisors are resorbing normally

• As soon as the primary central incisors have been exfoliated, further

eruption and lingual activity moves the permanent incisors labially
to their normal balanced position between the tongue and lips and
facial musculature.
 Lateral incisors
– Experience more difficulty in assuming their normal positions
• Developing crowns of cuspids lie labially and distally to its
roots
– Eruption more labially than centrals

Secondary spacing
It is observed in closed primary dentition. When the permanent
mandibular laterals emerge, they push the primary canine laterally
creating a space. This was termed as secondary spacing by Baume.

Secondary spacing can also occur during the eruption of

permanent central incisors.
• B)THE EXCHANGE OF INCISORS
• During the first transitional period the deciduous
incisors are replaced by the permanent incisors.
• The permanent incisors are considerably larger
than the deciduous teeth they replace.
• This difference between the amount of space
needed for the accommodation of the incisors and
the amount of space available for this, is called
‘Incisal liability’.
• 7.6 mm in the maxillary arch.
• 6 mm in the mandibular arch. (Wayne).
 Incisal liability is overcome by:
Interdental physiological spacing in the primary incisor
region. (4 mm in maxillary arch & 3 mm in mandibular
arch)
 Increase in inter-canine arch width:
Significant amount of growth occurs with the eruption of
incisors and canines.

Sex Dental Arch Width Increase Between 2-18yrrs

Males Maxilla 6mm
Mandible 4mm
Females Maxilla 4.5mm
Mandible 4mm
 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.
• 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
151degrees to 124 degrees in permanent
dentition.
• This increases the arch perimeter.
 Safety Valve Mechanism
 Mandibular intercanine width - complete by 9-
10 years of age in both boys and girls.

 Maxillary intercanine width - complete by 12

years of age in girls but continues to grow until
18 years of age in boys.

 The final horizontal growth increments in the

mandible causes a forward movement of the
mandibular base with its teeth. This basal
change eliminates any flush terminal plane
tendencies that have persisted beyond the
mixed dentition.. 
• But , the bodily mandibular thrust forward is
unmatched by comparable maxillary
horizontal growth changes. Hence, the
maxillary intercanine "dimension serves as a
"safety valve " for pubertal growth spurts
 INTERTRANSITIONAL PERIOD

– Both sets of dentition

• Permanent incisors, 1st molars
• Deciduous canines, 1st ,2nd molars
 FEATURES
• Lasts about 1.5yrs.

• Asymmetry in emergence and associated differences in height

levels and lengths of clinical crowns of the left and right teeth are
made up.

• Corrections of small rotations – pressure exerted by the tongue

and lips

• Wearing of deciduous teeth with attrition of cusp tips.

• Antero-posterior relationship of the jaws not fixed. No

interferences from occlusal contacts are present, so the
mandibular teeth attain slightly more mesial position.

• Under the influence of the tongue, mandibular lateral incisors

attain the proper sites within the dental arch and their initial
lingual location is eliminated
 Second Transitional Period.
• The second transitional period is
characterized by the
replacement of the deciduous
molars and canines by the
premolars and permanent
canines and second permanent
molars respectively.

• The features of second

transitional period are:
Leeway Space of Nance.
Ugly Duckling Stage.
 Ugly Duckling Stage
(Broadbent’s phenomenon,1937)
• It is a transient or self
correcting malocclusion seen
in the maxillary incisor
region.

• Seen in children between 8 –

9 years of age, during
eruption of permanent
canines.

• Its typical features are:

o Flaring of the lateral incisors.
o Maxillary midline diastema
 How it develops?
• Crowns of canines in
young jaws impinge on
developing lateral
incisor roots, thus
driving the roots
medially and causing
the crowns to flare
laterally.
• The roots of the central
incisors are also forced
together, thus causing a
maxillary midline
diastema
• 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.
• Hence this unaesthetic
metamorphosis,
eventually leads to an
aesthetic result.
 FEATURES OF SECOND TRANSITIONAL PERIOD

• At around 9-10 yrs with shedding of posterior teeth.

• It takes about 1½ to complete the exchange of all the lateral teeth

• Transition from ugly duckling to a mature stage of dentition – pre-

pubertal period – correlative with the maturation of the child.

• Child loses his roundness of her body and advances towards

adolescence

• The most common sequence of eruption of permanent canine

teeth in max is 4-3-5 & in mandible 3-4-5. if the seq of eruption is
changed to 4-3-5/ 4-5-3, the Leeway space will not be utilized as
efficiently & dentition will become crowded without Leeway
space helping to improve.
• The arch circumference becomes shortened than that of the
primary dental arch by the utilization of leeway space with the
exchange of the sec primary molar to the sec premolar.

• It is quite possible that eruption of sec premolar may accentuate

the crowding if it was already present.

• Proximal caries or early extraction of sec primary molars – early

loss of space.

• In some cases the perm molars erupt prior to II premolars. If the

space is not maintained following extraction there will be rapid
loss of space.
 • Favorable occlusion in this period 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.
o Favorable bucco- lingual relationship of alveolar process
 IDEAL DENTAL ARCH PATTERN IN MIXED DENTITION

• Class I molar & canine relation.

• Positive Leeway space.
• Minor/ no tooth rotations/ incisor crowding.
• Normal buccolingual axial inclination.
• Normal m-d axial inclination.
• Tight proximal contacts.
• Even marginal ridges vertically.
• Flat occlusal plane/ no Curve of Spee.
 CLINICAL CONSIDERATIONS

• Observe the change in molar relationship.

• Distal step in primary dentition – treatment should be initiated as

early as possible, as the condition will not self correct with time.

• Flush terminal presents more challenging diagnostic condition.

• What is considered normal in primary/ mixed dentition does not

necessarily lead to normal occlusion in permanent dentition.

• The final molar relation is dependent on number of dental and

skeletal facial changes, both genetic and environmental, that
interact to achieve or not to achieve normal occlusion.
SELF CORRECTING ANOMALIES IN MIXED DENTITION

1. Anterior deep bite

• Proprio-ceptive condition response of patient with slight

supra-eruption of permanent molars and premature contact
of pads of tissue
2) Mandibular anterior crowding

• Increased intercanine width

• Tongue pressure
– Labial movement and inclination of incisors
3) Ugly Duckling Midline diastema

– Eruption of canine

7 Year

8 Year 11 Year
4),End on molar relation
– Late mesial shift
• Leeway space
 Permanent Dentition Period
(This period is marked by the eruption of the four
permanent second molars)
 By Lunt & Law

Chronology Of Eruption.
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

• Eruption of 2nd molar teeth occurs shortly after the
appearance of the 2nd bicuspid.

• The gingival pads overlying the 2nd molar contact

prematurely again, blocking open the bite anteriorly,
allowing the eruption of teeth anterior to the 2nd
molars. (This is the 2nd bite opener as stated by
Schwarz).

• The reduction in the overbite is minimal and variable.

 ERUPTION

Sequence of eruption :-
– Maxillary-
• 6-1-2-4-3-5-7 or 6-1-2-4-5-3-7
– Mandibular-
• 6-1-2-4-3-5-7 or 6-1-2-3-4-5-7
Features of Permanent Dentition

Coinciding midline. Class I molar relationship.

• At approximately 13 years of age all
permanent teeth except third molars are fully
erupted.
 Changes in Permanent Occlusion

• Arch dimensional Changes:

• Arch length decreases to a surprising amount
during the late adolescent period.
• Fish found that Mandibular arch perimeter
decreases by 5.0mm between 9-16 years whereas
maxillary arch perimeter decreased by about half
the amount as it was in the mandibular arch.
Occlusal changes:

• Both overjet and overbite decreases throughout the

second decade of life.
• It is due to greater forward growth of the mandible
and the eruption of permanent molars.
• Overbite decreases up to the age of 18 years by 0.5mm
• Overjet decreases by 0.7mm between 12 and 20 years
of age.
• The alveolar process may grow in height beyond 16
years of age.
 Factors determining the tooth’s position
– Anterior component of force
• Muscular forces (lip, cheek, tongue)
– Habits

– Rate of resorption of primary teeth

– Localized pathosis
“First molars, the key to normal occlusion”, Angle’s argumentation
“ All teeth are essential, yet in function and influence, some are
of greater importance than others, the most important of all being
the first permanent molars, especially the upper first molars,
which we call the keys to occlusion.” Angle E.H.

“The most important teeth are the first permanent molars”.

Angle´s argumentation for his postulation:

1. They are the biggest teeth and their anchorage is strongest.

2. Their local position in the occlusal arch supports the main

masticatory duty and operation .
3. They influence the vertical distance of upper and lower jaws, the
occlusal height and aesthetic proportions.

4. As the permanent molars are the first erupting teeth of permanent

dentition, they have “mighty” control on the teeth erupting later
behind and in front of them, as they are forced to position to the
already erupted and in occlusion functioning 1st molars.

5. As the permanent teeth of the lower jaw are erupting prior to the
upper it is to resume, that the lower jaw is the form that defines
and creates the form of the upper jaw.
6. The anomalies in dental positioning are mostly due to a more
prominent dislocated position of the crowns of upper permanent
molars to normal, less and minor due to a dislocation of their
apex.

7. These findings lead Angle to postulate, “that the first upper

permanent molar, more than any other tooth or anatomical point
gives a precise scientific basis for defining occlusal disharmony
and occlusal anomalies.“
 DENTITIONAL AND OCCLUSAL CHANGES IN
YOUNG ADULTS
• Dimensional changes
– Decreased arch perimeter

• Occlusal changes
– Decreased overjet and overbite in 2nd decade
• Forward growth of mandible

– Changes in Sagittal relationship

• Mesial drifting tendency
• Interproximal wear
• Continuing growth of mandible
• 3rd molar eruption
 DENTITIONAL AND OCCLUSAL CHANGES IN
YOUNG ADULTS
• 3rd molar development
– Most variable in
calcification and eruption
– Role of 3rd molar in
crowding
– Simultaneous events
• Arch perimeter
shortening
• Increased incisor
crowding
• More Forward
Mandibular growth than
maxilla
 DENTITIONAL AND OCCLUSAL CHANGES IN
YOUNG ADULTS
Inter arch tooth alignment:-

• Mandibular arch length and

width is slightly less than
maxillary arch.

• Occlusal contacts occur mainly

through two types
– Cusp to fosse relationship
– Cusp to embrasure
relationship
 AJO 1972;62:296-309

These are a set of six characteristics that were consistently present in

collection of 120 casts of naturally optimal occlusion, identified by Dr.
Lawrence F Andrews.

Andrew’s six keys of occlusion

Dr. Larry Andrew Dr. Edward Angle

 ANDREW’S SIX KEYS OF OCCLUSION

1. Molar inter-arch relationship

2. Mesio-distal crown angulation
3. Labiolingual crown inclination
4. Absence of rotation
5. Tight contact
6. Curve of spee
 Andrews 6 Keys to Normal Occlusion
• Key I – Molar relationship
MB cusp of the max 1st
molar falls into the
mesiobuccal groove of the
mandibular 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.
• Key II: Mesial- Distal Crown
Angulation
• The gingival portion of the
long axis of all the crowns
must be distal than the incisal
portion.

• The angulation of the facial

axis of every clinical crown
should be positive.
• Key III : Labio-Lingual Crown
inclination .
• Cervical area of crown is
lingually placed then it is
called as positive crown
inclination and if it is more
buccally then it is called as
negative crown inclination.
• Maxillary incisors: Positive.
• Mandibular incisors and
maxillary and mandibular
posteriors : Negative
• Key IV – Rotations

• The fourth key to

normal occlusion is that
the teeth should be free
of undesirable
rotations.
• 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.
• Key VI – Curve of Spee

• The curve of Spee should have no

more than a slight arch.(Not
exceeding 1.5mm)

• Inter-cuspation 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.
• Key VII – Correct tooth size or the bolton’s ratio

• Bennett and Mc Laughlin in 1993 gave seventh key

to normal occlusion. i.e. the upper and lower tooth
size should be correct.
 Roth (1981) added some functional keys to the previous six
keys to normal occlusion by Andrew:

a) Centric relationship and centric occlusion should be

coincident.

b) In protrusion, the incisors should dis-occlude the posterior

teeth, with the guidance provided by the lower incisal edges
passing along the palatal contour of the upper incisors.

c) In lateral excursions of the mandible, the canine should guide

the working side whilst all other teeth on that and the other
side are dis-occluded.

d) When the teeth are in centric occlusion, there should be even

bilateral contacts in the buccal segments.
 FACTORS AFFECTING OCCLUSAL
DEVELOPMENT
1)GENERAL FACTORS:
• Skeletal factors: The position, size and relation of
bone in which the tooth develops.
• Muscle factors: The form and function of the muscle
which surround the teeth.
• Dental Factors: The size of the dentition in relation to
the size of the jaws.
• The position and relationship of the teeth within the
bone.
 SKELETAL FACTORS
• Conditions that affect jaw growth are;
• 1)Any pathological condition
• 2)Inherited and acquired congenital
malformation
• 3)Trauma or infection during the growing
years
 Jaw relationship can be considered as

1 ,Jaws in relation to cranial base

2, Jaws in relation to each other
-Skeletal Cl.1,2,3
-Buccal crossbite or lingual occlusion
-High gonial angle-Increased VD
-Low gonial angle-Decreased VD
3, Alveolar bone in relation to basalbone
 MUSCLE FACTORS
• Lip form
• Lip activity
• Tongue size resting position and function
• Adaptive resting posture or adaptive
swallowing
• Endogenous tongue thrust
• Thumb and finger sucking
• Neutral zone
 DENTAL FACTORS
• The third major factor affecting occlusal development
is the relationship between the size of the
dentition.But it is more realistic to consider dentition
size in relation to the dental arch size,than to jaw
size
• -EFFECT OF EXCESSIVE DENTITION SIZE
• -Overlapping and displacement of teeth
• -Impaction of teeth
• -Space closure after extractions
• Effect of early loss of primary
teeth
• -Function and oral health
• -Over eruption of opposing teeth
• -Psychological effects on child and parent
• -Position of permnent teeth
• Effects of asymmetric loss of primary
teeth
• -Midline shift—important to maintain space
 2)LOCAL FACTORS
Aberrant developmental position of
individual teeth
-Trauma
-Malposed crown
-Dilacerated root
-Unknown etiology(per max canines)
Presence of supernumerary teeth
-Supplemental(teeth of normal form)
-Conical(the mesiodens)
-Tuberculate(usually palatal to the upper
centrals,delaying their eruption)
Developmental Hypodontia
Hypodontia can modify the occlusion and
position of the teeth by virtue of its effects
on:
-The form of teeth
-The position of teeth
-The growth of the jaw
The upper labial frenum
This may cause midline diastema .Other
possible causes are:
-Hypodontia
-Supernumerary tooth
-Generalized spacing
-Proclination of upper incisors
 3)Heredity
- Heredity has for long been
attributed as one of the causes are influenced by the genes
of malocclusion.
- Another reason attributed for
genetically determined
malocclusion is the racial,
ethical & regional inter-
mixture.
- Number of human traits that
include (according to
Lundstrom):
i. Tooth size
ii. Arch dimension
iii. crowding/spacing
iv. Abnormalities of tooth
shape
v. Abnormalities of tooth
number
vi. Overjet
vii. Inter-arch variations
viii. Frenum
 Clinical Significance:
• No longer can a dentist look at a child’s mouth, observe a
space deficiency and then attribute it to the premature loss
of teeth or prolonged retention of teeth. In the past, local
“causes” were stressed but today we know the importance
of general factors in etiology of malocclusion along with the
local causes.

• Knowledge of the contribution of genetic and

environmental causes of malocclusion obligates clinicians to
differentiate between patients whose malocclusions are
primarily of genetic origin from patients whose
malocclusions are primarily of environmental origin.
• Abnormal morphologic structures in the face and
dentition that have a high degree of heritability
require different treatment approaches from those
structures that are influenced primarily by
environmental factors.

• For most patients the differentiation between

genetic and local environmental factors is of great
importance when choosing the appropriate
treatment and retention plans.
 TRANSIENT MALOCCLUSIONS
• They are self correcting
malocclusions encountered during
the development of dental occlusions
which are normal to the age
TRANSIENT MALOCCLUSION
IN
PREDENTATE PERIOD
RETROGNATHIC MANDIBLE
• The retrognathia is for the most part corrected
by the increased pace of forward growth of
the mandible as compared to that of the
maxilla seen in most people
• Although the mandibular deficit (ANB)may
approach 14 degree at birth,by adulthood it is
reduced to only 2 degree
INFANTILE SWALLOWING
• The milk is directed continuously into the
pharynx by an automatic peristalic movement
of the tongue and myloid muscle.During the
process ,regular breathing continues.The milk
passes betweefaucialpillar and the lateral
channel of the pharynx.
• The infantile swallowing pattern changes to the
mature or adult type during the first year of life
with the introduction of solid foods in the diet
ANTERIOR OPEN BITE
TRANSIENT MALOCCLUSIONS
IN
PRIMARY DENTITION PERIOD
SPACING
– According to Baume
• Closed dentition
• Spaced dentition
– Localized –Primate spaces (anthropoid/
simion spaces)
– Generalized- Physiologic Pressure from the
tongue (Barber)

– Total space-
• Maxi-0 to 8mm
• Mandible-0 to 7mm
OCCLUSAL RELATION(baume’classification
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

• It is a 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.
ANTERIOR DEEP BITE

• Primary teeth are upright ie.they have an

almost vertical inclination with an interincisal
angle of about 150 degree between the
maxillary and mandibular primary central
incisors.The primary incisors generally erupt
into a rather deep overbite.
• This deepbite is reduced by the eruption of the
primary molars and attrition of the incisal edge
of the primry anterior teeth
TRANSIENT MALOCCLUSIONS
IN
MIXED DENTITION PERIOD
SELF CORRECTING ANOMALIES IN MIXED DENTITION

1. Anterior deep bite

• Proprio-ceptive condition response of patient with slight

supra-eruption of permanent molars and premature contact
of pads of tissue
2) Mandibular anterior crowding

• Increased intercanine width

• Tongue pressure
– Labial movement and inclination of incisors
3) Ugly Duckling Midline diastema

– Eruption of canine

7 Year

8 Year 11 Year
4),End on molar relation
– Late mesial shift
• Leeway space
 Conclusion
 Occlusion constantly changes with development, maturity, and
aging.

 Development of dentition in human is complex and depends on

many variables.

 Development of dentition deviates markedly from that of other

parts and structures of the body.

 To determine an abnormal course of development, it is the

responsibility of an pedodontist to have adequate knowledge on
the subject to differentiate abnormal from normal before
initiating therapy.
 References
Text Books
• Handbook of orthodontics – Robert Moyers.
• Wheelers dental anatomy
• Shobha Tandon
• Graber
• Profit
• Bhalaji
• Text book of orthodontics – Nakata
• Stewart

Journals
• Andrews six keys to normal occlusion – AJO 1972;62:296-309
• Ped.Dent:2001:118-122
• Relationship of gumpads AJO1938
• Development of ideal occlusion AJO1954
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