LECTURE 4-TOOTH DEVELOPMENT, ERUPTION AND OCCLUSION

The development of the teeth begins prior to birth and continues on until about age twenty. In
this lecture we will be discussing the way in which the teeth develop, the way they fit together
and some approaches to the more common orthodontic problems.
4:1 Development and Eruption
The teeth begin their formation deep within the bone and gums in a small sac called a follicle.
The first portion of the tooth to be formed is the occlusal surface. As mentioned before, there are
three major hard tissue components of a tooth and each is formed by a different type of cell.
The enamel is a crystalline like substance and is formed by cells called ameloblasts. Each
crystal is formed nearly perpendicular to the surface of the tooth. The formation of the enamel is
a one time event. Once it is completed for a single tooth enamel will never be formed again for
that particular tooth.
The dentin is formed by cells called odontoblasts. As with the enamel, the formation begins
near the occlusal portion of the tooth and proceeds towards the root ends. When the root is
roughly two thirds formed then the tooth usually erupts through the gums. The process of the
tooth moving up into the mouth is called active eruption. Each tooth proceeds on its own
timetable in this process. It is important to know the average age when teeth erupt because it
allows one to better plan treatment for patients. The following table gives the approximate times
for tooth eruption.
Mandibular
Central-------6 mo
Lateral-------7 mo
Canine-------18 mo
1st molar----14 mo
2nd molar---24 mo

PRIMARY TEETH ERUPTION

Maxillary
Central-------7 mo
Lateral-------8 mo
Canine-------18 mo
1st molar----14 mo
2nd molar---24 mo

Mandibular
Central--------6 yrs
Lateral--------7 yrs
Canine--------10 yrs
1st premolar-10 yrs
2nd premolar-11 yrs
1st molar------6 yrs
2nd molar----12 yrs
3rd molar----20 yrs

PERMANENT TEETH ERUPTION

Maxillary
Central--------7 yrs
Lateral--------8 yrs
Canine---------11 yrs
1st premolar--10 yrs
2nd premolar-11 yrs
1st molar------6 yrs
2nd molar----12 yrs
3rd molar----20 yrs

Considerable variation exists in tooth eruption; however, people tend to vary consistently. For
example a child who is slow to get his first tooth will likely be delayed with all subsequent teeth.

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As a general rule the mandibular teeth come in before the maxillary. For example, the primary
first molars are both listed at 14 months however in reality the mandibular molar will usually
precede the maxillary molar slightly.
After the teeth have completed their growth into the mouth they will continue to grow slowly
through a process called passive eruption. This is seen most prominently following an
extraction. When a tooth no longer has anything to bite against, the tooth and it's supporting
structures, will begin to grow. On a younger person this process occurs fairly rapidly and on
older people it may move so slowly that it may not be detectable. This can lead to restorative
challenges. The time may come when you want to replace a missing tooth with an implant or a
bridge only to discover that the opposing teeth have grown down so much that there is no longer
space for the proposed restoration. In this case you would need to either orthodontically move
the opposing tooth back into its place or maybe cut down and crown the opposing tooth and thus
reduce its height.
4:2 Proximal Contacts
The way that the teeth bite together after they finish eruption into the oral cavity is called
occlusion. In studying occlusion we identify different ways in which the teeth fit together and
group these by type.

The first contacts that a tooth usually establishes are those where it touches teeth on either side.
These are called proximal contacts. When all of the teeth are positioned side by side they form
an arch. The tooth arch, like a stone arch, has each member of the arch depending on the other
members to maintain the shape and integrity of the arch. When a tooth is lost for an extended
period of time the other teeth tend to collapse into the place left by the extracted tooth. The
majority of this movement is towards the midline. This process is therefore called mesial drift.
Sometimes the tooth drifts forward uniformly, especially if the tooth were lost at an early age.
More often the tooth tips forward at an angle to fill the space. This makes for a less than ideal
occlusion.
Where the teeth touch one another on the sides they form small triangular spaces around the
contact point called embrasures. These are formed facial, lingual, incisal/occlusal, and gingival
to the proximal contact. Each of these spaces is named by what it is nearest. The triangular
space nearest the facial surface is called the facial embrasure and so forth.

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In the anterior the facial embrasures are small and the linguals are quite large. Also the incisal
embrasures are very small and the gingival embrasures are large. As you move towards the
posterior the size and shape of these embrasures become more equal.
4:3 Occlusion and Orthodontics
The second way that teeth contact is with opposing teeth. Normally the upper arch has a slightly
greater width than the lower arch. This means, that in a normal occlusion, the upper teeth fit
slightly outside the lower teeth and overlap them.
On occasion the upper arch is smaller that the lower
arch. This leads to the upper teeth being positioned
inside the lower ones. This condition is referred to
as a crossbite. If the upper arch is only slightly
smaller than normal, the upper teeth will be on the
inside of the lower teeth on one side only. This is
called a unilateral crossbite. If the upper arch is
significantly smaller than it should be, then the
maxillary teeth on both sides will be inside the
lower arch. This would then be called a bilateral
crossbite. You can also have a single tooth positioned on the outside; this is called a
single tooth crossbite
Because the upper anterior teeth are wider than the lower anterior teeth the whole upper
dentition is shifted distal in comparison to the lower dentition. This means that the upper and
lower molars are not going to line up exactly with one another. In a normal occlusion the upper
molar is shifted posterior about 1/2 of a tooth width as it relates to the lower molar. This places
the MB cusp of the upper first molar in the middle of the lower molar or centered on the facial
groove. This type of bite is called a class I bite or class I molar position. If there is a shift
which causes the lower molar to be shifted back farther than normal, in relation to the upper
molar, then the bite is called class II. If the lower molar is shifted more mesially than normal
then the bite is called a class III bite. These are the three bite types which describe the forward
growth of the mandible and maxilla. The prevalence of these three bite types vary among
different races. In the Caucasian population 85% of people have a class I bite, 14% have a class
II bite and less than 1% have a class III bite.

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Class I bites dont usually require

orthodontic movement of the
upper or lower jaw. Class II and
Class III orthodontic cases
require the upper, the lower, or
both jaws to be moved. This can
be done by exerting force in
various ways. These might
include rubber bands, various
pushing appliances like a Herbst
appliance, or through external
forces like headgear. Sometimes
the problem is so severe that surgery is indicated. This can be done by detaching the upper or
lower jaw, moving the jaw to the desired position and then screwing the jaw back together.
In a person with a class I bite the upper front teeth will usually be about 2 mm forward of the
lower anterior teeth. This is called the horizontal overlap. This is usually measured in
millimeters. In a class II bite this distance increases and in a class III bite the measurement may
be a negative number.
Another parameter that we look at is the amount of lower front
teeth that are covered by upper front teeth when the patient is
biting. This is called the vertical overlap. In a normal bite the
upper anterior teeth will cover about 2-3 mm of the lower teeth
(about 30%). In certain people the lower teeth bite much deeper
than normal so that the upper anterior teeth nearly cover the
lower teeth. This is called a deep bite.
In other people the teeth don't overlap at all. There may
even be a gap in the front when the posterior teeth are in
occlusion. This is called an anterior open bite. Anterior
open bites are often caused by thumb sucking or by an
abnormal swallowing pattern. When a person sticks their
tongue out between their front teeth during swallowing it
is called an anterior tongue thrust. Because the teeth
encounter the tongue they will cease to erupt, causing the
open bite.
Another orthodontic problem often encountered is
crowding. This occurs when the total arch length is not
great enough to allow all the teeth to line up side by side.
When this happens the teeth may twist or come in behind
or in front of the others. The most common place to find
crowding is in the lower anterior.

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There are two ways to correct an occlusion that does not have
enough space. The conventional way is to extract several of the
permanent teeth, usually the first premolars, and use the extra
space gained to line up the remaining teeth. Other treatments may
include expanding the arch or pushing all of the teeth toward the
distal to gain the necessary space. Determining which treatment is
best is done case by case.
Treatment, like Invisalign, may be used to resolve slight crowding. When using Invisalign it is
common to polish between the teeth to gain space and allow
the teeth to more easily slide against one another better.
A patient can have more than one orthodontic problem at a
time. For example they might be Class II and crowded. The
most difficult part of an orthodontic case is correctly
diagnosing and treatment planning. The actual execution of
the correction is time consuming but not as difficult.
Whenever a force is exerted on a tooth, that tooth will begin to move through the bone. Bone is
a dynamic, living substance that can be moved and formed. When a pushing force is exerted on
a tooth, bone will begin to be formed on the side of the tooth closest to the force and bone will be
dissolved on the side of the tooth furthest away from the force. This allows the tooth to move
through the bone. Bone formation is carried out by cells called osteoblasts, and bone
degradation is performed by cells called osteoclasts. The periodontal ligament is very important
in this process. It is the stretching and compressing of the periodontal ligament that
communicates forces to the bone. Some times, due to trauma, a tooth will become fused directly
to the bone. The PDL no longer exists. When this happens it is called ankylosis. An ankylosed
tooth cannot be moved orthodontically.

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