Management of the developing

dentition

Dr:Ahmed .M. Alshaari

Orthodontic resident 1 at UST
 Management of the developing dentition

• Management mean (the dental

practitioners be able to judge when
to intervene in a developing
malocclusion and when to let
nature take its course).
 Normal dental development
Normal means average, rather than ideal.

1-Calcification and eruption times

2-the transition from primary to mixed dentition
3-Development of the dental arches
 Calcification and eruption times
• knowledge of the calcification time is helpful for assessing
dental as opposed to chronological age

• determining whether a developing tooth not present on

radiographic examination can be considered absent

• estimating the timing of any possible causes of localized

hypocalcification or hypoplasia
 the transition from primary to mixed dentition

In primary dentition
• eruption of a baby’s first tooth occurring at 6 months of age.
• it is normal for the mandibular
incisors to erupt at any time in the
first year.
• Eruption of the primary dentition is
usually completed around 3 years
of age.
• Physiologic/developmental spacing in
primary Dentition
• Overbite reduces until the incisors are edge to edge, which can
contribute to marked attrition.
 in mixed dentition phase

• Begin with the eruption of the first permanent molars or the lower
central incisors.

• The lower labial segment teeth erupt before the upper labial
segment teeth and develop lingual to their predecessors

• usually align spontaneously if space becomes available

• The upper permanent incisors also develop lingual to their
predecessors and have greater width than primary one

• Additional space is gained because they

erupt onto a wider arc and are more
proclined than the primary incisors

• If the arch is intrinsically crowded,

the lateral incisors may erupt palatal to
the arch.

• Pressure from the developing lateral incisor often gives rise to

spacing between the central incisors which resolves as the laterals
erupt (ugly duckling stage)
• The upper canines develop palatally, but migrate labially so in normal
development, can be palpated buccally from as young as 8 years of
age

• The combined width of the deciduous canine, first molar, and second
molar is greater than that of their permanent successors

• This difference in widths is called the

leeway space

1–1.5 mm in the maxilla

2–2.5 mm in the mandible
 Development of the dental arches

 Intercanine width

 Arch width

 Arch circumference
Intercanine width
is measured across the cusps of the deciduous/permanent canines

In primary dentition increase of around 1–2 mm.

In the mixed dentition, an increase of about 3 mm.

this growth is largely completed around a developmental stage of 9

years with some minimal increase up to age 13 years.
Arch width
is measured across the arch between the lingual cusps of the second
deciduous molars or second premolars.
an increase of 2–3 mm occurs Between the ages of 3 and 18 years.

Arch circumference
is determined by measuring around the buccal cusps and incisal edges
of the teeth to the distal aspect of the second deciduous molars or
second premolars.

in the mandible, arch circumference decreases by about 4 mm

in the maxilla there is little change with age
 Abnormalities of eruption and exfoliation

Screening
any abnormalities in tooth
development and eruption
requires careful observation
and further investigation
including radiographs for
evidence of any problems.
Natal teeth
• present at birth, or erupts soon after
• Neonatal teeth are teeth that erupt within the first few weeks after
birth.
• commonly arise anteriorly in the
mandible and are typically a lower
primary incisor

• natal teeth can be quite mobile or firm

• If the tooth interferes with breastfeeding or is so mobile that there

is a danger of inhalation, removal is indicated

• If the tooth is symptomless, it can be left in situ.

Eruption cyst
 caused by an accumulation of fluid or blood in the follicular space
overlying the crown of an
erupting tooth .

 They usually rupture

spontaneously, but very
occasionally marsupialization
may be necessary.
Failure of/delayed eruption
 A disruption in the normal sequence of eruption.
 An asymmetry in eruption pattern between contralateral teeth.
 Mixed dentition problems
Premature loss of deciduous teeth
Deciduous incisor: premature loss of a deciduous incisor
has little impact, mainly because they are shed relatively early
in the mixed dentition.

Deciduous canine: unilateral loss of a primary canine in a

crowded mouth will lead to a centreline shift. To avoid this
consideration should be given to balancing with the extraction
of the contralateral tooth.
Deciduous first molar: unilateral loss of this tooth may
result in a centreline shift, particularly in cases of crowding.
balancing extraction can be indicated if the centreline shift
otherwise is not necessary .

Deciduous second molar: if a second primary molar is

extracted, the first permanent molar will drift forwards.
balancing or compensating extractions of other sound second
primary molars is not necessary unless they are also of poor
long-term prognosis.
Retained deciduous teeth
• A difference of more than 6 months between the shedding
of contralateral teeth should be regarded with suspicion.
• retained primary teeth
should be extracted if the
permanent successor is
present, particularly if they
are causing deflection of
the permanent tooth.
Infra-occluded (submerged) primary molars

 Infra-occlusion is now the preferred term for describing the

process where a tooth fails to achieve or maintain its occlusal
relationship with adjacent or
opposing teeth .
 When the adjacent permanent
teeth erupt to their normal level,
the ankylosed tooth appears to
be submerged below the level of
occlusion
 this anomaly would appear to occur in around 1–9% of children.
 recent epidemiological studies have suggested a genetic
tendency to this phenomenon and also an association with other
dental anomalies
 Management

 if the permanent successor is missing therefore consideration

should be given to building up the occlusal surface to
maintain occlusal relationships.
 If this is not practicable then extraction may be indicated

extraction of a submerged primary tooth is only necessary under

the following conditions:
• There is a danger of the tooth disappearing below gingival
level
• Root formation of the permanent tooth is nearing completion
(as eruptive force reduces markedly after this event).
Impacted first permanent molars

 occurs in approximately 2–6% of children and is

indicative of crowding.
 most commonly occurs in the upper arch.
 Spontaneous disimpaction may occur, but this is rare
after 8 years of age.
 Management

 Mild cases can sometimes be managed by tightening a brass

separating wire around the contact point between the two
teeth over a period of about 2 months.

 In more severe cases of impaction, an appliance can be used

to distalize the permanent molar and disimpact it.

 extraction of the deciduous tooth may be indicated if it

becomes abscessed or the permanent tooth becomes
carious and restoration is precluded by poor access
Dilaceration

Dilaceration is a distortion or bend in

the root of a tooth. It usually affects
the upper central and/or lateral
incisor.
 Etiology
• Developmental
-usually affects an isolated
central incisor
-occurs more often in
females than males.
-The crown of the affected
tooth is turned upward
and labially --no
disturbance of enamel and
dentine is seen.
• Trauma:
- intrusion of a deciduous incisor
leads to displacement of the
underlying developing
permanent tooth germ.
-the enamel and dentine
forming at the time of the injury
are disturbed, giving rise to
hypoplasia.
-The sexes are equally affected
-more than one tooth may be
involved
 Management

-In sever case the removal of affected tooth is

indicated
-In milder cases, it may be possible to expose the
crown surgically and apply traction to align the
tooth,
Supernumerary teeth
-occurs in the permanent dentition in approximately 2% of the
population
-the primary dentition in less than 1%,
-a supernumerary in the deciduous
dentition is often followed by a
supernumerary in the permanent
dentition
-The etiology is not completely understood, but
appears to have a genetic component.

-It occurs more commonly in males than females.

-Supernumerary teeth are also commonly found in

patient with a cleft of the alveolus.

Supernumerary teeth can be described according to

their morphology or position in the arch.
Morphology
1-Supplemental: this type resembles a tooth and occurs at the
end of a tooth series, for example, an additional lateral incisor,
second premolar, or fourth molar.
2-Conical: or peg-shaped
supernumerary most often
occurs between the upper
central incisors .
It is said to be more commonly
associated with displacement
of the adjacent teeth, but can
also cause failure of eruption or not affect the other teeth.
3-Tuberculate: this type is described as being barrel shaped,
but usually any supernumerary which does not fall into the
conical or supplemental categories is included.

4-Odontome: this variant is rare.

Both compound
(a conglomeration of small
tooth-like structures) and
complex (an amorphous mass of
enamel and dentine) forms
have been described.
Position
• when they develop between the central incisors they are
often described as a mesiodens.
• A supernumerary tooth
distal to the arch is called
a distomolar,
• adjacent to the molars is
known as a paramolar.
• Eighty per cent of
supernumeraries occur in the anterior maxilla.
Effects of supernumerary teeth and their
management
1-Failure of eruption
Management by removal of supernumerary
teeth ,sometimes followed by orthodontic treatment
2-Displacement
Management by removal of supernumerary
teeth ,usually followed by orthodontic treatment
3-Crowding
Management by removing the most poorly formed or
more displaced tooth
4-No effect
it can be left in situ under radiographic observation.
 Habits
The effect of a habit will depend upon the
frequency and intensity of indulgence.
First permanent molars of poor long-term
prognosis

• First permanent molars are rarely the first tooth of

choice for extraction as their position within the arch
means that little space is provided anteriorly for relief of
crowding or correction of the incisor relationship unless
appliances are used.
• Removal of maxillary first molars often compromises
anchorage in the upper arch, and a good spontaneous
result in the lower arch following extraction of the first
molars is rare
If a two-surface restoration is present or required in the first
permanent molar of a child, the prognosis for that tooth and the
remaining first molars should be considered as the planned
extraction of first permanent molars of poor quality may be
preferable to their enforced extraction later on.
Factors to consider when assessing first
permanent molars of poor long-term prognosis

• Check for the presence of all permanent teeth. If any are absent,
extraction of the first permanent molar in that quadrant should be
avoided.

• If the dentition is uncrowded, extraction of first permanent molars

should be avoided as space closure will be difficult.

• in the maxilla there is a greater tendency for mesial drift and so the
timing of the extraction of upper first permanent molars is less
critical if aiming for space closure
• In the lower arch, a good spontaneous result is more likely if:

(a) the lower second permanent molar has developed as far as its
bifurcation

(b) the angle between the long axis of the crypt of the lower second
permanent molar and the first permanent molar is between 15° and
30°

(c) the crypt of the second molar overlaps the root of the first molar
(a space between the two reduces the likelihood of good space
closure).
• Extraction of the first molars alone will relieve buccal segment
crowding, but will have little effect on a crowded labial segment.

• If space is needed anteriorly for the relief of labial segment

crowding or for retraction of incisors (i.e. the upper arch in Class II
cases or the lower arch in Class III cases), then it may be prudent to
delay extraction of the first molar, if possible, until the second
permanent molar has erupted in that arch. The space can then be
utilized, in conjunction with appliance therapy, for correction of the
labial segment.
• Serious consideration should be given to extracting the opposing
upper first permanent molar, should extraction of a lower molar be
necessary. If the upper molar is not extracted, it will over-erupt and
prevent forward drift of the lower second molar.

• A compensating extraction in the

lower arch (when extraction of
an upper first permanent molar is
necessary) should be avoided
where possible as a good
spontaneous result in the
mandibular arch is less likely.

• Impaction of the third permanent molars is less likely, but not

impossible, following extraction of the first molar.
Median diastema
• A median diastema is normally present between
the maxillary permanent central incisors when
they first erupt.
• diastema is a normal feature of the developing
dentition (ugly duckling stage ).
Prevalence
Median diastema occurs in around 98% of 6-year-
olds, 49% of 11-year-olds, and 7% of 12–18-year-
olds.
Etiology
Factors which have been considered to lead to a median diastema
include the following:
• Physiological (normal dental development)
• Familial or racial trait
• Small teeth in large jaws (a spaced dentition)
• Missing teeth
• Midline supernumerary tooth/teeth
• Proclination of the upper labial segment
• Prominent fraenum.
Diagnosis

• When the fraenum is placed under tension there is blanching of

the incisive papilla.

• Radiographically, a notch can be seen

at the crest of the interdental bone
between the upper central incisor.

• The anterior teeth may be crowded.

 Management

• periapical radiograph to exclude the presence of a midline

supernumerary tooth .
• In the developing dentition, a diastema of less than 3 mm rarely
warrants intervention.
• extraction of the deciduous canines should be avoided as this will
tend to make the diastema worse
• if the diastema is greater than 3 mm and the lateral incisors are
present, it may be necessary to consider appliance treatment.
• Closure of a diastema has a notable tendency to relapse,
therefore long-term retention is required.
 Planned extraction of deciduous teeth

Serial extraction
• a historic approach involving a planned sequence of
extractions (initially the deciduous canines, then the
deciduous first molars) designed to allow crowded incisor
segments to align spontaneously during the mixed dentition
by shifting labial segment crowding to the buccal segments
where it could be dealt with by first premolar extractions.

• The disadvantages to this approach are that it involves putting

the child through several sequences of extractions
Indications for the extraction of deciduous canines
• In a crowded upper arch, the erupting lateral incisors may be forced
palatally. In a Class I malocclusion, this will result in a crossbite and in
addition the apex of the affected lateral incisor will be palatally
positioned.
• In a crowded lower labial segment, one incisor may be pushed
through the labial plate of bone, resulting in a compromised labial
periodontal attachment.
• Extraction of the lower deciduous canines in a Class III
malocclusion can be advantageous

• To provide space for appliance therapy in the upper arch, for

example, correction of an instanding lateral incisor, or to facilitate
eruption of an incisor prevented from erupting by a supernumerary
tooth.

• To improve the position of a displaced permanent canine .

 What to refer and when
Deciduous dentition

• Cleft lip and/or palate (if patient not under the

care of a cleft team).
• Other craniofacial anomalies (if patient not
under the care of a multidisciplinary team).
 Mixed dentition

• Severe Class III skeletal problems which would benefit from

orthopaedic treatment.
• Delayed eruption of the permanent incisors.
• Presence of a supplemental incisor and the decision as to which
to extract is not clear-cut.
• Impaction or failure of eruption of the first permanent molars.
• First permanent molars of poor long-term prognosis where forced
extraction is being considered.
• Ectopic maxillary canines.
• Hypodontia.
• Marked mandibular displacement on closure and/or anterior
crossbites which compromise periodontal support.
• Patients with medical problems where monitoring of the occlusion
would be beneficial.
• Pathology (e.g. cysts).