DEVELOPMENT

OF
OCCLUSION

Presented By :
Kanish Aggarwal
PG Student
Department of Orthodontics and
Dentofacial Orthopedics

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 Contents
1. Introduction
2. Development of teeth
3. Mouth of a neonate
4. Primary dentition stage
5. Mixed dentition stage
6. Permanent dentition stage
7. Factors affecting development of occlusion
• Congenital factors
• General factors
• Local factors
8. Conclusion
9. References

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1. Introduction
The word OCCLUSION is made up of two words “Occ” means up and
“Lusion” means closing. Thus the literal meaning of the word “occlusion”
is “closing up”

Edward H. Angle defined occlusion as “ The normal relations of the

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

Glossary Of orthodontic terms defines occlusion as “ The relationship of

the maxillary and mandibular teeth as they are brought into functional
contact.”

Occlusal development begins as early as the development of jaws and the

related oro-facial structures. With the appearance of tooth buds and the
development of teeth, major stages of development of occlusion begins.

2. Development of Teeth

Tooth development can be divided into three overlapping phases

• Initiation: In this stage, the site of future tooth is established. It is

characterized by development of tooth buds. Change in the position of
the teeth (transposition) or any change in the number of the teeth
(oligodontia, supernumery teeth etc.) occurs due to discrepancy at this
stage.
• Morphogenesis: In this stage the shape of the future tooth is
established. Change in the shape of the teeth (peg laterals etc.) occurs
due to discrepancy at this stage
• Histiogenesis: It is the stage of differentiation of cells. In this stage the
cells mature and start laying down the enamel, dentin and pulp.

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The first histological sign of tooth development is the condensation of the
mesenchymal tissue (ectomesenchyme) beneath the dental epithelium of the
primitive oral cavity. These cells are of neural crest origin and have
migrated from the neural tube.
At around 6th week of pre-natal life the oral epithelium thickens and
invaginates into mesenchyme forming a Primary Epithelial Band

Arrow representing Primary Epithelial Band A: Vestibular Lamina

B: Dental Lamina

At around 7th week of prenatal life the Primary epithelial band divides into
two processes:
• Buccally located vestibular lamina: Forms the vestibule of oral
cavity, separating lips and cheek from tooth bearing region. It
proliferates by cell division and then the cell trophy is seen in the
middle region of the vestibular lamina forming the vestibule.
• Lingually situated dental lamina: Forms the tooth and the supporting
structures. The lingual extension of the dental lamina forms
successional lamina, which give rise to the successional teeth and the
posterior growth of the dental lamina gives rise to the permanent
molars.
Dental lamina is active from about 6 weeks in utero and continues beyond
birth to the fourth or fifth year. At this stage the establishment of the site of
future tooth takes place. There are total of 52 dental lamina formed, 20 for
primary dentition and 32 for permanent dentition.

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2.1 Stages of tooth development

Tooth development is divided into 4 stages

• Bud stage
• Cap stage
• Bell stage
• Root formation

2.1.1 Bud stage

This stage is characterized by rounded, localized growth of the epithelial
cells of the dental lamina, which results in the formation of a bud-shaped
enamel organ. It is called enamel organ because it will form the enamel of
the developing tooth.
By 8th week all mandibular and maxillary deciduous tooth buds are present.

2.1.2 Cap stage

This stage is characterized by proliferation of the enamel organ and
appearance of concavity on the deep surface of the bud, which gives it an
appearance of the cap. Mesenchyme also starts to condense around the
enamel organ. Mesenchyme below the concavity of bud forms Dental
Papilla which gives rise to Dentin and pulp
Mesenchyme around the enamel organ form Dental Follicle which forms
cementum, periodontal ligament, and adjacent alveolar bone
Central cells of the enlarging enamel organ start to separate but maintain
contact by desmosomes showing start of formation of stellate reticulum

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The cells of the outer surface of enamel organ form external enamel
epithelium and remain cuboidal, whereas those in the inner surface of
enamel organ forms internal enamel epithelium whose cells become more
columnar from cuboidal in this stage.

2.1.3 Bell stage

In this stage there is enlargement of the overall size of the tooth germ and
deepening of its undersurface. In this stage histo-differentiation of the cells
is seen with enamel organ having following parts
1. Outer enamel epithelium: It is concerned with nutrition and formation of
enamel cuticle, which forms a protective layer around the tooth.
2. Stellate reticulum: Contains GAGs which draw water increasing size of
the tooth germ. Water separates the cells which maintain contact by
desmosomes.
3. Stratum Intermedium: These are spindle shaped cells, which help in
mineralization
4. Inner enamel epithelium: These are columnar cells which after
differentiation transforms into ameloblasts, which lay down the enamel

Late bell stage of tooth development is associated with the formation of the
dental hard tissues, commencing at about the 18th week. Dentine formation
always precedes enamel formation.
The point where inner and outer enamel epithelium meet, forms the
cervical loop

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2.1.4 Root Formation
Cells of the inner and outer enamel epithelium proliferate from the cervical
loop to form a double layer of cells known as Hertwig’s epithelial root
sheath .
This sheath of epithelial cells extends around the dental pulp and
differentiation of odontoblasts at the periphery of the pulp, facing the root
sheath, forms the dentin of the root.

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3. Mouth of a Neonate
It is the pre dental period i.e. the period after birth during which the neonate
doesn't have any teeth. It usually lasts for 6 months after birth. Gum pads
form the main feature of this period.

3.1 Gum pads

These are alveolar processes at the time of birth. These are pink in color,
firm and are covered by a dense layer of fibrous periosteum. These are
horse shoe shaped in Maxilla and U-shaped in mandible
Gum pads develop in two parts
1. Labio-buccal portion (differentiates first)
2. Lingual portion (differentiates later)

• These two portions are separated from each other by Dental Groove.
• Both the gum pads are divided into ten segments by Transverse grooves.
Each of the segment contains a developing tooth bud and the gum pads
are separated from palate and floor of mouth by Gingival Groove
• Transverse groove between developing canine and first deciduous molar
is known as Lateral Sulcus. It is useful in assessing the interarch
relationship at a very early stage.

3.1.1 Maxillary Gum Pad

Features of maxillary gum pad are:
§ Horse shoe shaped
§ The dental groove passes from the incisive papilla, runs laterally
joins with the gingival groove at the lateral sulcus area from there it
runs distally and buccally to the first molar crypt.
§ Gingival groove demarcates the palate from gum pads.

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3.1.2 Mandibular Gum Pad
Features of mandibular gum pad are:
§ U- Shaped
§ Anteriorly gum pad is everted.
§ Transverse grooves are less defined when compared to maxillary gum
pad.

According to Leighton the size of the gum pads at birth can be determined
by:
• State of maturity of the infant at birth
• Size at birth as expressed by birth weight
• Size of the developing primary teeth
• Genetic factors.

At birth gum pads are not sufficiently wide. The incisors are crowded in
their crypts. During first year of life they grow rapidly in lateral direction to
permit incisors to erupt in good alignment

3.2 Relationship between Gum Pads

Maxillary gum pad is longer and wider than the mandibular gum pad, which
leads to overjet all around when gum pads are approximated. When
approximated contact occurs only around first molar region
The lower lateral sulcus is distal to upper lateral sulcus and space exists in
anterior region which helps in suckling

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Sillman JH (Am. J. Orthod. 24: 409-424, 1938) reported that
§ Mandibular lateral sulcus is distal to the maxillary lateral sulcus by an
average of 2.7 mm in males and 2.5 in females
§ The range of variation of this distal relationship is from 0 to 7 mm.
§ There is a limited antero-posterior movement of the mandible but no
lateral movement.
§ When the jaws are at rest, the gum pads do not meet.

Clinch classified the relationship of the gum pad in 3 categories:

• The mandibular arch positioned slightly lingual to the maxillary arch
in both the incisor and the molar region (70%);
• The mandibular arch positioned slightly lingual and distal to the
maxillary arch in the molar region, but definitely distal in the incisor
region (27%);
• The mandibular arch positioned definitely distal in both the molar and
the incisor regions (3%).

Leighton reported that there is so much of variability in the relationship of

upper and lower gum pads that they cannot be used for predicting future
occlusion in the primary dentition

3.3 Precociously Erupted Teeth

Sometimes teeth are present in the oral cavity at the time of birth or erupt
much before their eruption time; these are called Precociously Erupted
Teeth. These can be of 3 types
• Natal (present at birth)
• Neonatal (erupted during the first month)
• Pre-erupted (erupted during the 2nd or 3rd months)

Most commonly these are mandibular incisors, which frequently display

enamel hypoplasia. Familial tendencies are commonly seen in such cases
These teeth leads to various complications like interference with the
feeding, risk of aspiration or traumatic injury to the tongue and/or to the
maternal breast
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4. Primary Dentition Stage
Primary dentition period starts at the age of 6 months with the eruption of
mandibular central incisors and continues up to the age of around 6 years
with the eruption of mandibular 1st molar. During this period there is
increased anterior repositioning of the mandible as compared to maxilla

Primary dentition acts as a base on which the foundation of permanent

dentition is laid. The development of occlusion in primary dentition can
serve as a guide to know about developing malocclusion in permanent
dentition. Primary second molars have a major role to play in development
of occlusion as they guide the permanent molars into the oral cavity and
affect the molar relationship in permanent dentition

4.1 Chronology

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4.2 Features Of Primary Dentition

4.2.1. Spacing in Deciduous Dentition

Baume (1950) classified the primary dentition into 2 categories based on
spacing
• Type I / Open/ Spaced dentition
• Type II / Closed/ Non-spaced dentition

Delabarre first described spacing in the deciduous teeth in the year 1819. It
was called as physiological spaces by Korkhans & Newmann and
developmental spacing by Graber
According to Bishara et al, generalized spacing in both the arches is as
follows :
• Maxillary = 0 – 10 mm (avg 5 mm)
• Mandible = 0 – 6mm (avg 3mm)

Primate Spaces
Primate spaces are naturally occurring spaces in the primary dentition,
existing distal to the primary mandibular canine and mesial to the primary
maxillary canine

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These spaces were named as Simian Gap by Baume in 1950, Primate
Spacing by Bokya in 1968 and Anthropoid Spacing by Foster and Hamilton
in 1969.

Primate spaces are significant factors in development of occlusion as:

• Spaced primary arches generally produce more favorable alignment of
the permanent successors
• The presence of primate space helps in development of proper molar
occlusion by means of an early shift of mandibular molars (primary)
into this primate space on eruption.

In some individuals the spaces might be absent in the primary dentition. It

may be due to narrow dental arches or wider teeth. It usually indicates
crowding in permanent dentition but it’s not always the case in every
individual with non – spaced dentition. There may be growth of jaw at later
stages aligning the permanent successors by creating space for them

According to Leighton crowding can be predicted on the basis of space

present in primary dentition as follows

• Crowding in primary teeth 10 in 10 dev. Crowding

• No spaces 7 in 10 dev. Crowding
• Spaces below 3 mm 5 in 10 dev. Crowding
• 3 to 6 mm of spaces 2 in 10 dev. Crowding
• Over 6 mm of spaces No crowding

4.2.2. Deep Bite

Deep bite is generally seen in the initial stages of primary dentition, as the
deciduous incisors are more upright. The incisal edges of the mandibular
incisors often contact the cingulum area of the upper incisors.
Deep bite later reduced due to
1. Eruption of deciduous molars leading to opening of the bite in the
anterior region
2. Attrition of incisors, which reduce the overbite in the incisors.

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4.2.3 Occlusal relationship in Primary dentition
The relationship between the maxillary and mandibular primary 2nd molar is
the key to determine molar relation in primary dentition. The terminal
planes are the distal surfaces of the maxillary and mandibular second
primary molars. Essentially the two terminal planes can be related to each
other in one of three ways

1. Flush terminal plane

When primary posterior teeth occlude, mandibular cusp articulates just
ahead of its corresponding maxillary cusp. The mesiolingual cusp of the
maxillary molars occludes in the central fossae of the mandibular molars.
The mandibular second primary molar usually is wider mesiodistally than
the maxillary, giving rise, typically, to a flush terminal plane. In the flush
terminal plane relationship, both the maxillary and mandibular planes are at
the same level anteroposteriorly

2. Mesial Step
In this type of relationship the distal surface of the lower 2nd molar is more
mesial than that of upper. It most commonly occurs due to early forward
growth of the mandible

3. Distal Step
It is characterized by distal surface of lower 2nd deciduous more being more
distal to the upper This relationship favors development of Class II molar
relation
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In a study on 121 Iowa children by Bishara et al at age 5 years, the
distribution of the terminal plane relationships of the primary second molars
were found to be as follows:
§ Distal step : 10%
§ Flush terminal plane : 29%
§ Mesial step of 1.0 mm : 42%
§ Mesial step >1.0 mm : 19%

5. Mixed Dentition Period

During this period both primary and permanent teeth are present together in
the mouth. The permanent teeth erupting in place of deciduous teeth are
called successional teeth while those erupting posterior to deciduous teeth
are called accessional teeth

Mixed dentition period begins at around 6 years of age with the eruption of
Mandibular 1st molar

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Permanent tooth crown pierce the alveolar crest when approximately 2/3rd
of root development is complete and the teeth emerge in the oral cavity
when around 3/4th of root development is complete. Development of the
root completes around 2-3 years after eruption
The mixed dentition period can be divided into three phases:
o First transitional period.
o Inter-transitional period.
o Second transitional period.

5.1 First Transitional Period

First transitional period is characterized by emergence of first permanent
molars and exchange of deciduous incisors with permanent incisors

5.1.1 Emergence of 1st Permanent Molar

Mandibular 1st permanent molar is the first permanent tooth to erupt at
around 6 year of age. The location & relation of the 1st permanent molar
depends upon the distal surface of the upper & lower 2nd deciduous molar as
they are guided into the dental arch by distal surface of 2nd deciduous
molars
When the terminal plane relationship in the primary dentition stage is flush,
the permanent molars erupt in a "cusp-to-cusp" or "end-to-end" first
permanent molar relationship. For transition of end to end relation to Class I
relation the lower molar has to move forward by about 3-5mm relative to
the upper molar. This occurs in 2 ways
§ Early shift.
§ Late shift

Early shift
Early shift occurs during the early mixed dentition period. The eruptive
forces of the 1st permanent molar push deciduous 1st and 2nd molar forward
in the arch, which leads to closure of the primate space    

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5.1.2 Exchange of Incisors
During the first transitional period the permanent incisors replace the
deciduous incisors. Mandibular central incisors are usually the first to erupt.
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 them,
is called ‘Incisal liability’. Warren Mayne coined the term Incisor liability
in 1969

The incisal liability is roughly about

§ 7.6 mm in the maxillary arch
§ 6 mm in the mandibular arch

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The incisal liability is over come by the following factors:
• Interdental physiological spacing
In the primary incisor region its is around 4 mm in maxilla and 3 mm
in mandible. These spaces are utilized to align the larger successors.

• Increase in intercanine width

In a study conducted by Barrow et al (The Angle Orthodontist 22, no.
1 (1952): 41-46.) following findings were reported:
o There was a little change in the intercanine width from 3-5 years
of age
o Intercanine width increases rapidly from 5 to 9 years of age with
an average of 4mm increase in maxilla and 3 mm increase in
mandible
o There was a decreases in intercanine width ranging from 0.5 -1.4
mm after the age of 14 years

According to Morrees and Chadha there is a continuous increase in

intercanine width till around 9 years of age

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 • Incisor Labiality
Labial movement of permanent incisors relative to primary incisors
(labiality) that, helps to compensate for incisor liability is called
incisor labiality. According to Mayne the permanent incisors erupt
labial to primary incisors by 2.2mm in maxilla and by 1.3mm in
mandible. Permanent incisors erupt more labially inclined and tend to
increase the arch perimeter

5.1.3 UGLY DUCKLING STAGE

At around 9 to 10 year of age a common physiologic malocclusion is seen
which is characterized by increase in midline diastema and lateral incisor
flaring. It is caused due to the pressure of erupting permanent canine
crowns on the roots of lateral incisors causing them to flare. It’s a self-
correcting condition

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5.2 Inter- Transitional Stage
After first permanent molars and incisors establish occlusion, an interim
period of 1-2 years is seen before the second transitional phase starts. This
phase is a relatively stable phase with a very few changes

5.3 Second Transitional Period

Second transitional period involves the replacement of primary molars and
canines by permanent premolars and canines

5.3.1 Leeway Space of Nance

It was described by Nance in 1947. The sum of the mesiodistal width of the
primary canine and the primary first and second molars is larger than the
sum of their succedaneous teeth, namely, the permanent canine and first and
second premolars. This difference is called the leeway space and is present
in both the maxillary and mandibular arches

E Space
The difference between the mesiodistal widths of the primary second molar
and the second premolar is called E space. It is of importance as most of the
leeway space is contributed by E space

Tooth Mesiodistal width Mesiodistal width

of crown at cervix
Max Primary 2nd molar 8.2 6.4

Max Perm 2nd premolar 7 5

Mand primary 2nd molar 9.9 7.2

Mand perm 2nd premolar 7 5

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The leeway space is larger in the mandibular arch than in the maxillary arch
• Maxillary arch : 1.8mm (0.9mm on each side)
• Mandibular arch : 3.4 mm (1.7mm on each side)

According To William R. Profitt, Leeway space in both the arches is:

• Maxilla : 1.5 mm
• Mandibular : 2.5 mm
•
According to Lo and Moyers (Am J Orthod. 1953;39:460.)
• 2.6 mm (1.3 mm on each side) in the maxilla
• 6.2 mm (3.1 mm on each side) in the mandible.

5.3.2 Late mesial shift

This occurs in the late mixed dentition period mostly in individuals with
lack of primate spaces. In this the deciduous 2nd molars exfoliate and the
permanent 1st molar drifts mesially utilizing leeway space

Bishara et all evaluated the changes in the molar relationship from the
primary dentition stage to the permanent dentition stage on 121 Iowa
subjects (242 sides) followed for an average period of 8 years between 5
and 13 years of age and found that :
• Of the cases with a flush terminal plane relationship in the primary
dentition stage, 56% developed into a Class I molar relationship and
44% developed into a Class II molar relationship in the permanent
dentition stage.

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 • The cases with a 1-mm mesial step, 76% became Class I molar
relationships, 23% became Class 11 molar relationships, and 1%
became Class III molar relationships.
• In cases with a mesial step of 2 mm or more in the primary dentition
stage, 68% became Class I molar relationships, 13% became Class 11
molar relationships, and 19% became Class III molar relationships

6. Permanent Dentition Stage

The permanent dentition stage of dental development starts after the
shedding of the last primary tooth and the eruption of all the permanent
teeth excluding third molars

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6.1 Chronology

Characteristics of the "normal” occlusion in the permanent dentition stage

include the following:
§ Overlap: In a normally occluding dentition, the maxillary teeth are
labial/buccal to the mandibular teeth.
§ Angulations: In the primary dentition stage the teeth are, in general,
vertically positioned in the alveolar bone. On the other hand, in the
permanent dentition stage the teeth have buccolingual and mesiodistal
angulations.
§ Arch curvatures: The anteroposterior curvature is called the curve of
Spee. The buccolingual curvature from the one side to the other is
called the Monson curve or the Wilson curve.

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6.2 Nolla’s Stages of Tooth Development
In 1960, Nolla divided the eruption of tooth into 11 stages, which are
labeled as 0-10 or A to K. These stages were used to study the dental age of
 
an individual. In this study by C.M. Nolla serial radiographs at different
ages were studied. Nolla studied serial oral radiographs of 25 boys and 25
girls. Each set of radiograph consisted of
§ Extra-oral right and left lateral jaw views
§ Intra-oral maxillary and mandibular occlusals,
§ Intra-oral right and left maxillary periapicals of posterior teeth.

Nolla gave a developmental table, which is a set of drawings illustrating the

ten stages of development of the teeth as observed radiographically.

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In order to obtain an appraisal of the development of a particular tooth, the
lateral jaw radiograph was matched as closely as possible with the
comparative figure and the value was given accordingly.
• When the radiographic reading lay between two grades this appraisal
was indicated as the value of 0.5. For example, if the reading of the
radiograph was between one-third and two-thirds of the root
completed it was given the value of 7.5.
• When the radiograph showed a reading that was slightly greater than
the illustrated grade, but not as much as half way between that stage
and the next, the value 0.2 was added. For example, if slightly more
than two-thirds of the crown were completed if would become 4.2
• If the development were slightly less than the grade indicated the
value 0.7 was added. For example, if two-thirds of the crown were
approximately completed the grade would become 3.7

He plotted the developmental stages on graph with the chronological age

and gave the comparative tables

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Calcification of teeth in this way can be used as a criterion of dental age and
of the physiologic age of a patient. It provides an index of physiologic
maturity of the permanent dentition. The limitation of the radiographic
study is that the, developmental changes which occur prior to calcification
are not observed radiographically. On the other hand, a study of serial
radiographs of the same individual provides, a good method for the
longitudinal study of growth

6.3 Demirjian’s Stages of Dental Development

In this method dental maturity is estimated using radiographic appearance

of the tooth. There are 8 stages for the development of the teeth, from A to
H, and 0 is given for non-appearance. A score is given to each tooth
depending upon the stage. The scores of all teeth are then added to give a
maturity score. This maturity score can be used to predict the age using
conversion tables
Panoramic radiographs were used in this method as they are easier to make
than the intraoral radiographs in young and nervous children. They also
give less radiation exposure than the full mouth radiographs. The drawback
is, there is a distortion of around 3-10 % but as the scoring system is based
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on relative criteria rather than absolute values, hence this drawback was
negligible

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6.4 DEVELOPMENTAL STAGES OF THIRD MOLARS
(MODIFIED DEMIRJIAN`S CLASSIFICATION SYSTEM)

This system also included 3rd molars, which were excluded in the original
Demirjian’s Stages of Dental Development. 8 stages of 3rd molar
development were described.
• Stage A: Cusp tips are mineralised but have not coalesced
• Stage B: Mineralized cusps are united so the matured coronal
morphology is well defined
• Stage C: The crown is about half formed and the pulp chamber is
evident and dentinal deposition is occuring
• Stage D: Crown formation is complete to the dentinoenamel junction.
The crown is about half formed and the pulp chamber is trapezoidal
form
• Stage E: Formation of the inter-radicular bifurcation has begun. Root
length is less than the crown length
• Stage F: Root length is atleast as great as crown length. Roots have
funnel-shaped endings
• Stage G: Root walls are parallel, but apices remain open
• Stage H: Apical ends of the roots are completely closed, and the
periodontal membrane has a uniform width around the root

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6.5 Helicoidal Plane Of Occlusion
The helicoidal plane of dental occlusion is a composite feature which
involves the axial inclination of teeth and effects of dental attrition.
Increasing axial inclination of molars from first to third, is primarily
responsible for the helicoidal plane and attrition acts to increase its
expression. In the mandible, worn first molar surfaces slope downward to
the buccal, whereas third molar surfaces slope to the lingual. Maxilla and
mandible show complementary curves

Helicoidal plane of dental occlusion is explained on the basis of 2 concepts

1. Arcadal Hypothesis : According to this theory
• Maxilla is wider than mandible due to which there is maxillary molar
overjet
• Mandibular buccal and maxillary lingual cusps being the functional
cups receive the most wear
• This relationship reverses in 3rd molar region. In 3rd molar region the
mandible becomes wider than the maxilla leading to “reversed
occlusion” and the mandibular lingual cusps and maxillary buccal
cusp receive the most of the wear

2. Axial Tilt : According to this concept

• Each molar in mandibular arch has certain lingual axial tilt
• A study by Dempster et al. (1963) found that molars have an axial tilt
that increased from first to third molars
• This produces an increasing tilt of the occlusal surfaces of unworn
molars, providing a morphological basis for the helicoidal plane

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7. Factors affecting Development of Occlusion

Congenital
Factors Skeletal  factors

Factors  
General   Muscle  factors
affecting  
development   Factors
of  occlusion
Dental  factors

Local  Factors

7.1 Congenital Factors

Congenital factors are the factors, which are seen at the time of birth. There
may be presence of congenital defects, which are caused by genetic,
radiological, chemical, endocrine etc. factors

CLEFT LIP AND PALATE

• Clefts of lip and palate are congenital defects which are caused due to
the non-fusion of embryonic processes.
• They commonly lead to missing teeth, rotations, cross bite etc
•

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CONGENITAL SYPHILLIS:
• Abnormally shaped teeth (Mulberry molars, Hutchinson's Incisors)
• Malposed teeth
• Deficiency of maxilla
• Anterior cross bite

BIRTH INJURY TO TMJ: Ankylosis affects mandible growth.

CEREBRAL PALSY: Paralysis or lack of muscular co-ordination affects
mastication, deglutition, respiration, and speech and upsets muscle balance,
which is necessary for establishment and maintenance of normal occlusion.

7.2 Skeletal Factors

The teeth are supported by the alveolar bone, which in turn is based on the
basal bone of the jaw. The relationship of the jaws to each other and to the
cranial base has a large influence on the relationship of the dental arches.
Thus in turn affects the development of occlusion

7.2.1 Jaws in relation to each other

The antero-posterior relationship of the basal parts of the upper and lower
jaws to each other, with the teeth in occlusion, is known as the skeletal
relationship. On the basis of skeletal relation, jaws are classified as:
1. Skeletal Class I—in which the jaws are in their ideal antero-posterior
relationship in occlusion. Maxilla being in front by 2-3 mm
2. Skeletal Class II—in which the lower jaw in occlusion is positioned
further back in relation to the upper jaw than in skeletal Class I.

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3. Skeletal Class III—in which the lower jaw in occlusion is positioned
further forward than in skeletal Class I

Variation in the skeletal relationship can be brought about by:.

1. Variation in size of the jaws.
2. Variation in position of the jaws in relation to the cranial base

If one jaw is excessively small or large in relation to the other in antero-

posterior dimension the development of skeletal Class II or Class III
relationship is seen. If one jaw is set further back or further forward than the
other in relation to the cranial base skeletal Class II or Class III relationship
may result.

Skeletal Class II relation places maxilla in front of mandible, which leads to

§ Increase in the overjet
§ Proclination or retroclination of upper anteriors in association with
other factors like muscular forces
§ There might be proclination of the lower anterior teeth to compensate
for the increased overjet
§ Change in molar relationship
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Skeletal Class III relation places mandible in front of maxilla which lead to:
§ Edge to edge relationship of incisors or lower incisors being is front of
upper incisors leading to reverse overjet
§ Change of molar relationship

Sizes of the jaws in lateral dimension also has an effect on the development
of occlusion. If one jaw is wider than the other
§ Buccal crossbite if the lower jaw is wider
§ Lingual occlusion of the lower teeth if the upper jaw is wider

The vertical relationship of the upper and lower jaws also affects the
occlusion. The effect is most clearly seen with variation in the shape of the
lower jaw at the gonial angle
§ The mandible with a high gonial angle tends to produce a longer
vertical dimension of the face which can lead to an anterior open bite.
§ Mandible with a low gonial angle tends to produce a shorter vertical
dimension of the face

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7.3 Muscle Factors
Muscles of the tongue, lips and cheeks are important in guiding the teeth
into their final position, and variation in muscle form and function can
affect the position and occlusion of the teeth. Perioral muscles and tongue
exert force on the teeth. These forces should be in equilibrium to each other
so as to dentition to develop in normal occlusion. Lack of equilibrium will
lead to excessive forces changing the position of the tooth

7.3.1 Lips

1. Vertical form of the lips

• In the ideal lip form, the vertical dimension is such that, with the lip
muscles in their position of resting posture, the lips meet together
• There is minimal muscle contraction to maintain the position of the
lips. This position of lips in electromyography is called 'electrical
silence’ as the muscle show minimum tonic contraction
• If the lips at rest are apart, then muscular contraction will be required
to bring them together during swallowing and speech, and such
contraction will impose extra forces on the erupting teeth.
• When lips do not meet at rest, the person may maintain a conscious lip
closure for much of the time imposing excessive muscular forces on
the teeth. This disturbs the equilibrium, excessive forces by the lips
may lead to retroclination of the teeth disturbing the occlusion

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In a study conducted by Joshi et al (2015) in 150 randomly selected
Northeastern Chinese subjects between the age of 18 -25 years it was found
that
• Skeletal class II group have the most protrusive UL and retrusive LL
in comparison to skeletal class I and class III
• Skeletal class III group has the most protrusive LL in comparison to
skeletal class II and class I
• Thus skeletal relationship plays a major role in lip position which may
disturb the equilibrium of forces, affecting the occlusion

2. Sagittal relationship of the lips

• The lower lip tends to be further back than the upper lip in a skeletal
Class II relationship, and further forward in a skeletal Class III
relationship
• With a skeletal Class II relationship the lower lip may function behind
the upper incisors. The lip may procline the upper incisors so that the
occlusal relationship is more severely Class II than the skeletal
relationship

7.3.2 Effect of Tongue

Tongue size, position and function have important contribution in the
development of occlusions. A large tongue is usually responsible for wide
dental arches and Buccal or labial inclination of teeth with spacing. If the
tongue is too small the dental arches are narrow and can lead to crowding
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According to Robert Swinehart
• Normal arch form requires sufficient dimension to accommodate the
teeth.
• The most important natural forces, which can increase mandibular
arch dimension, are those of the tongue.
• The normal expansive forces of the tongue are exerted to their
maximum only when it can be accommodated with in the mandibular
arch.
• Certain mandibular arches are too narrow to accommodate the tongue
between the buccal teeth during deglutition. Following sufficient
orthodontic expansion of the posterior portion of the arch, the tongue
assumes its normal position and can exert its normal expansive forces.
• If resumption of normal tongue action occurs early in the formation of
the permanent dentiton, it results in marked growth in the mandibular
arch.
• Arch dimension gained through the influences of normal tongue
function tends to remain stable. The coordinating forces of the tongue,
lips, and cheeks, when allowed to develop a proper equilibrium during
the early stages of facial growth, usually maintain their balance.
• The highly abnormal form and the diminutive size of the mandibular
arch found associated with congenital aglossia provide proof of the
vital importance of normal tongue form and function to normal
occlusion.

7.3.3 Oral Habits

1. Thumb and Finger sucking

It is the placement of thumb or one or more fingers upto varying depths in
the mouth. It is common in young children but when prolonged into later
childhood it can lead to malocclusion
Larsson (1988) studied a group of Swedish children, found that 50% of
those who had a thumb of finger sucking activity in infancy retained the
habit to at least 7 years of age.

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 Thumb and finger sucking leads to
• Labial tipping of maxillary anterior teeth
• Lingual tipping of mandibular anterior teeth
• Anterior open bite, which can be asymmetrical, being more
pronounced on the side on which the thumb is sucked
• Crossbite is brought about by the slight narrowing of the upper dental
arch resulting from the reduced intra oral air pressure combined with
the activity of the buccal musculature

2. Tongue Thrusting
Tongue thrust is placement of tongue tip forward between the incisors
during swallowing

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 • It usually affects the developing teeth to the extent of preventing the
full vertical development of the anterior dento-alveolar segments, so
that an incomplete overbite or, more usually, an anterior open bite,
develops.
• The upper and lower incisors may be proclined by the action of the
tongue

7.4 Dental Factors

7.4.1 The size of the dentition in relation to jaw size

Excessive tooth size in relation to jaw size leads to crowding while smaller
tooth size will lead to spacings. In the primary dentition, actual overlapping
of the teeth is unusual, and a disproportion between jaw size and tooth size
is usually manifested as a lack of spacing rather than as actual crowding. In
the permanent dentition, however, crowding of the teeth is much more
common
Excessive tooth size can lead to
[Link] and displacement of teeth.
2. Impaction of teeth.

7.4.2. Early loss of primary teeth

Early loss of primary teeth before the eruption of successor teeth can have
major impact on development of occlusion as it can lead to
• Over-eruption of opposing teeth
• Due to mesial drift of the teeth, they space tends to close

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 • Mesial drift of the permanent first molar after a primary second molar
is lost prematurely can significantly contribute to the development of
crowding in the posterior part of the dental arch

7.5 Localized Factors

7.5.1 Aberrant developmental position of individual teeth

The developmental position of any tooth, before it erupts into the mouth,
may be such that it cannot erupt into its correct position in the dental arch.
The teeth most commonly seen to be developing in an aberrant position are
the upper canines, the lower third molars and upper central incisors

7.5.2 Trauma affecting developmental position

The teeth most commonly seen to be developing incorrectly due to trauma
are the upper central incisors. Trauma to the deciduous teeth may cause the
permanent tooth to be displaced. If the permanent developing tooth is
shifted horizontally dilaceration is also seen as the root continues to develop
vertically

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7.5.3 Supernumerary teeth
Supernumerary teeth in the permanent dentition are of three main types.
• Supplemental teeth—extra teeth of normal form
• Conical teeth—teeth with coniform crowns.
• Tuberculate teeth—teeth with tuberculate or invaginated crowns.

The main effect of supplemental teeth on the occlusion is that they increase
the crowding potential

Typical conical supernumery teeth affecting occlusion is mesiodens. The

occlusal problems caused by conical supernumerary teeth are usually
confined to localized malalignment of the upper incisors. In particular, the
central incisors may be rotated, or there may be a wide upper median
diastema
The main effect of the tuberculate supernumerary tooth on occlusal
development is that it delays the eruption of the permanent upper central
incisor

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7.5.4 Developmental hypodontia
Hypodontia is the developmental absence of one or more teeth from the
dentition. Hypodontia can modify the occlusion and position of the teeth by
virtue of its effects on:
1. The form of the teeth.
2. The position of the teeth.
3. The growth of the jaws.

Developmental hypodontia not only reduces the total number of teeth, but
also may modify the shape of the teeth which are present.
Foster and Van Roey (1970) have described the characteristic malformation
of teeth which can occur in this condition.
• Incisors or canines may be coniform, cusp deficiencies may be seen
on premolars and molars and various other malformations of teeth
may occur

7.5.5 The labial frenum

The labial frenum occasionally causes localized modification to the position
of the teeth. Lower attachment of the labial frenum can lead to midline
diastema

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In a thick and fleshy labial frenum, the fibro-elastic band crosses the
alveolus and inserts into the incisive papilli, preventing the approximation
of the maxillary central incisors.

7.5.6 Prolonged retention of deciduous teeth

Deciduous teeth, which fail to undergo exfoliation, prevent the normal
eruption of its permanent successors. Prolonged retention of deciduous teeth
results in lingual or palatal eruption of the permanent successors. Prolonged
retention of posterior teeth lead to buccal or lingual deviation or impaction
of the teeth

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8. Conclusion
• The positions of the teeth within the jaws and the occlusion are
determined by various developmental processes that influence the
teeth and their associated structures during the periods of formation,
growth and modification throughout the life
• There are large number of factors which are responsible for
development of occlusion. When these factors are in harmony, a
functionally and esthetically stable occlusion is seen

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9. References

1. Books
• Handbook Of Orthodontics, Robert E. Moyers
• Textbook of Orthodontics, Samir E. Bishara
• Orthodontics : Current Principles and Techniques
• Orthodontics Diagnosis and Management of Malocclusion and
Dentofacial Deformities, O.P. Kharbanda
• Oral Anatomy, Histology and Embryology, Berkovitz
• Oral Development and Histology, James Avery
• Ten Cate’s Oral Histology- Development, Structure, and Function
• Wheeler’s Dental Anatomy, Physiology and Occlusion
• Dentistry for the Child and Adolescent
• A textbook of Orthodontics, T.D. Foster

2. Articles
• Botero P1, Appraisal of the difference between the mesiodistal diameters
of deciduous incisors and molars and permanent teeth. Eur J Paediatr
Dent. 2015 Mar;16(1):39-44.
• Simpson WJ, Cheung DK: Gum pad relationships of infants at birth. J
Can Dent Assoc 1973; 39:182-188.
• Moorrees, C.F.A., Chadha, J.M. Available space for the incisors during
dental development—A growth studybased on physiologic age. Angle
Orthodontist. 1965;35:12–22.
• SILLMAN, J.H.: Relationship of maxillary andmandibular gum pads in
the newborn infant. Am. J. Orthod. 24: 409-424, 1938
• West CM: The development of the gums and their relationship to the
deciduous teeth in the human fetus. Contrib Embryol 1925; 16:25.
• Baume LJ. Physiologic tooth migration and its significance for the
development of occlusion. J Dent Res. 1950;29:123–32.
• Lo RT, Moyers RE. Studies on the etiology and prevention of
malocclusion. I. The sequence of eruption of the permanent dentition.
Am J Orthod. 1953;39:460

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• Clinch L: Variations in the degree of overbite between birth and three
years. Dent Rec (London) 1938;58:585–597.
• Barrow et al, Developmental changes in maxillary and mandibular dental
arch, The Angle Orthodontist22,no. 1(1952):41-46
• Holly Smith, B. ".Development and evolution of the helicoidal plane of
dental occlusion.". American Journal of Physical Anthropology,
1986,69(1):21-35.
• PROFFIT, WILLIAM R.". Equilibrium theory revisited: factors
influencing position of the teeth. The Angle orthodontist 48,no.
3(1978):175-186.
• Swinehart, D. Robert. ".The importance of the tongue in the development
of normal occlusion.". American journal of orthodontics 36,no.
11(1950):813-830.
• Larsson, E. (1988)Treatment of children with a prolonged dummy or
finger- sucking [Link], 10,244-248.
• Foster, T. D. & Van Roey, O. (1970)The form of the dentition in partial
anodontia. Dent Practit, 20,163-...169
• Joshi , Merina, Li Peng Wu, Surendra Maharjan, and Mukunda Raj
Regmi. "Sagittal lip positions in different skeletal malocclusions: a
cephalometric analysis." Progress in orthodontics 16, no. 1 (2015): 1-8.
• Nolla, C.M. (1960) The development of permanent teeth. Journal of
Dentistry for Children, 27, 254-266.
• Demirjian, A., A NEW SYSTEM OF DENTAL AGE ASSESSMENT ,
Human Biology, 45:2 (1973:May) p.211

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