‫بسم الله الرحمن الرحيم‬

 The slides for this lecture are in the file "chronology of the dentitions" .
This lecture contains the data about the permanent teeth of the Jordanian population
( which is a recent research that has been done by the dr.ashraf and its not in the book ) .
therefore , the doctor ensures us to take the slides of this lecture from the e-learning
because it has these latest modification .

Let's start 
Today we are going to discuss the chronology of eruption and development of teeth .
this is here a plastic model showing some of already erupted teeth , and others that are still
inside the bone , these teeth are waiting their time to erupt . as you know , our teeth do
not erupt all at the same time and there is a sequence for their eruption , and you also
know – from the introduction course – that the first permanent teeth to erupt is the
mandibular and maxillary first molar , notice that these teeth are not successor teeth , so
the first permanent tooth to erupt is a non-successor tooth , followed by the upper
and lower central incisors and then the lateral incisors which erupt at the age of 8 to 9 ,
and after that we have a lack of eruption (‫ )فترة توقف‬which is about one and a half year
until the eruption of the tooth number 4 which erupts nearly at the age of 10 . so mixed
dentition stage ( the stages that marks both dentition together at the same time -
deciduous and permanent) can be further divided into two stages : the early stage and the
late stage.

 The early mixed dentition stage : is the stage where we have the eruption
of the first molars and the incisors .
 Late mixed dentition stage : is the stage of eruption of premolars , and
later on second molars and third molars .
 We will talk about these sub stages in more details later on during this
lecture.

Now , lets answer this question again : why do we have two sets of teeth ? why isn't it only
one dentition ?
- because our jaws grow in size while our teeth don't . once the tooth has formed it has it
doesn't change its size .
So what happens if we have only one set of dentition , the deciduous ? as adults , we are
going to have big jaws and small teeth which won't be very well at fuction , we won't be
able to chew as we do normally , which leads to starving and many health problems , that's
why we need two sets of dentition , one that serves for a limited period of time while we
are growing and other set of dentition that establishes the other sized teeth (5:32).

And we also needs the second dentition to have more teeth not only bigger size ones ,
because our jaws are not only growing in size but also in length , they are anterioposteriorly
elongated so we need teeth to fill the spaces at the back of the mouth which are given for
the molar (non successor )teeth.

Here is a real skull of a dead child at the primary dentition stage , we see that he has the :
central and lateral incisors , canine and first and second deciduous molars in the four
quadrants of his mouth , and after doing dissection of this skull we noticed that he has
teeth that also bigger in size existed in the bone waiting to erupt, note the difference in
size between the permanent and deciduous incisors . this difference will be coped by the
growth of the jaws , if the jaws do not grow they will not be able to contain the bigger
teeth of the second dentition . also notice here that the permanent teeth are not all at the
same stage , for example the central incisors are almost ready to come down but the
canines seems that they need a very long time to come down and this shows that there is
some sequence for these teeth to erupt .
So by looking at the canine we can see that it will be the last to erupt among all the
successor teeth , that's why its very common in dentistry to see people with buccally
erupted canine (which leads them to have an orthodontic issues) , because the canine being
the last one to erupt sometimes it does not find enough space for itself . so buccally
erupted canines indicates that canines are the last to erupt among the
successor permanent teeth .

Now this figure ( dr.ashraf brought this one in a quiz lab last year ) , we see here the
permanent central incisor and the permanent canine and cusps of the first & second
premolars , and here we see the initial cusp formation of the first molar , so all the
permanent teeth here are already established , and this is what happens in teeth
formation , as we will see in histology the first part of the tooth to form is the crown and
after its fully formed , the roots are formed . the crown forms from the top of it , for
example : the first part to form in the incisor is its edge , and for the molar is its cusp .
And the last part to form is the tip of the root . referring to the figure : we can notice the
gradual formation starting from the molars : there are tips of the cusps , some cusp
formation , full cusp formation and then full crown and then we have the root forming until
its complete .

So if we want to see the state of teeth formation for a 3 year old child we will find that the
permanent central incisors ( which are still inside the bone ) , has completed its incisal
edge and the same for the lateral but with smaller part , and only the tip of the canine ,
the tip of the cusp of the first and second premolars , But for the first molar we wil find
that it has completed its crown formation and some part of the root may start to form ,this
means that teeth grow at different levels .
-why the first molar has completed its crown formation at the age of 3 years while all of the
other teeth are still in the early stages ?
- because it will be the first tooth to appear and it needs to have at least its crown already
formed .
Notice that the second molar has only initial calcification of the cusp's tip .
Now , lets come to the sequence of eruption in details :

In a fetus , so called in utero ( inside the uterus ) , at 5 months in utero we see that
some teeth are formed like the incisor edge of the central incisor , and part of the incisor
edge of the lateral incisor , part of the canine and part of the first deciduous molars .
At the age of 7 months in utero , we see that we have the central & lateral incisors , canine
, the first deciduous molar and the second decidouos molar .

At birth , (no teeth appears to us in the mouth But they are inside the bone except in
some rare cases ) , at this stage we have full formation of the crown of the central incisor ,
and 3/4 formation of the lateral incisor , only the cusp of the canine , the cusp of the first
deciduous molar and only the tips of the cusp of the second deciduous molar . notice that
the lower teeth are more advanced than the upper ones , we see that the lower central
incisor has its crown almost fully formed just like the upper one But it also shows part of
the root starts to form , this means that the lower central incisors form before the upper
central incisors ,and the case is the same of the lower lateral incisors , the canine , the
first deciduous molar and second deciduous molar .
So Generally , at birth , mandibular teeth are more advanced in their formation than
maxillary ones .

 Just for your knowledge : Natal teeth appears in about one in every 2,000-3,000 births.
- I saw that it is important to know the difference between these two terms to make it
easier on you understanding the rest of the concepts in this lecture :
Crown  In dentistry, crown refers to the anatomical area of teeth, usually covered
by enamel. The crown is usually visible in the mouth after developing below the gingiva and
then erupting into place…(wikipedia)
Cusp  A cusp is an occlusal or incisal eminence on a tooth…(wikipedia)

At 6 months of age , we will see the first tooth that appears In mouth which is the
mandibular central incisor , followed by the maxillary central incisor and then the
mandibular lateral incisor followed by the maxillary lateral incisor . we will discuss the
sequence shortly inshallah .
and notice here that we have almost full cusp of the upper canine and more than the full
cusp of the lower canine , and we have all the crown formation and part of the root
formation of the mandibular first deciduous molar although th e maxillary first deciduous
molar hasn't yet reached the full crown formation . the second molars are still halfway for
the formation of the crown , and what we need to see here is the initial formation of the
permanent teeth – colored yellow in slides (the ones after the second deciduous molar and
the ones that are above and below the line of the deciduous teeth ) .
the first formation of the permanent teeth is represented by the formation of the cusp's tips
of the permanent first molar , small part of the incisor edge of the mandibular and
maxillary central incisors , a very small part of the lateral incisors .
  When we talk about the teeth eruption at ages of 6 months , 9 months , and
so on , we are not exactly referring to this age , it is the average not definite age ,
that's why we add ( + or – 2 months ) , as we know some children's teeth starts to
erupt teeth before the age of 6 months while others after 6 months of age ( for
example , dr.ashraf's little daughter had her first tooth at the age of 10 months :P
which is still within the normal limits )

At the age of 9 months , the four incisors are erupted , full formation of the crown of
the second deciduous molar and full formation of the first deciduous molar and canine ,
with their roots start to form , we see permanent teeth with advanced formation , the full
cusp of the first permanent molar .

- A student asks about something in the figures, the doctors answers : these are the tips of
the cusps of the second deciduous molar . the doctor says that in the figures of 6 months
and 9 months , these three little pieces in the left belongs all to one tooth , they will fuse
together later on to form the tooth so they are not " three teeth " !

At the age of 1 year , we see that the four incisors with their fully formed crowns and
almost fully formed roots, nearly full crown of first molar , the tip of the canines , part of
the crowns of the permanent incisors .

At the age of 2 years , all the deciduous teeth have all erupted inside the mouth but
not all of them have reached the contact with the opposing teeth , so we see space
between some upper and lower teeth which means that these teeth are still growing toward
each other .
 The contact (occlusion) of all teeth is established at the age of 3 years .

At the age of 3 years , we have the full eruption of the deciduous teeth , and have all
become in contact . the permanent teeth are still in the process of crown formation and we
start to see in this stage the initial cusp formation of the second permanent molar .

 So by this age the child has established the full deciduous dentition , before
that its called the primary dentition stage , and after the age of 3 we call it the
functional primary dentition stage , and " functional " because the child is able now
to use all the teeth in function , like chewing .
At the age of 4 years , we see full crown formation for the permanent first molar and
for the incisors ( while at the 3 the full crown formation was only for the permanent first
molar) , as the permanent teeth erupt they push the bone in their way and resolve it and
they also push the root of the deciduous teeth that they are going to replace , we will start
to see the first parts of the roots of the deciduous teeth resolving because of that .
 So the permanent teeth replace the deciduous teeth by resolving the full
root of the deciduous teeth , which will be eventually without a root and easy to be
replaced .

At the age of 6 years , we start to see a new comer which is the mandibular and
maxillary first permanent molar , which erupt as a non – successor teeth ( without
predecessor ) , we see also big part of the root of the lower central and lateral incisors and
part of the maxillary central and lateral incisors start to resolve which means that these
teeth are going to be lost soon .

At the age of 7 years , the opposing two permanent first molar become in contact ,
the first successor tooth erupt at this age which is the mandibular central incisor followed
by the maxillary central incisor , the mandibular lateral incisor and the maxillary lateral
incisor respectively .

At the age of 10 years , we have all the permanent incisors and first molars erupted
and already in contact (occlusion) , we see some lost deciduous teeth , replaced by the
erupted permanent teeth .

- Here are some important notes :

 The lost of deciduous teeth starts usually at the age of 7 .
 The deciduous (primary)dentition stage : from 6 months with the eruption
of the first deciduous until all the teeth become in contact (at the age of 3 ) to
 start a stage called the functional deciduous/primary dentition because all teeth
are in contact and ready to function .
 The mixed (transitional) dentition stage starts with the eruption of the first
permanent molar at the age of 6 . in this stage , we have both deciduous and
permanent teeth at the same time . and its divided into two sub stages : early ,
late.
 The early mixed dentition stage is marked by the eruption of the incisors
and first molars .
 The late mixed dentition stage starts with the eruption of the first
premolar (maxillary and mandibular), so it marks the eruption of premolars in
particular .
 At the age of 12 years , we don't have any deciduous teeth , so it is the end
of the mixed dentition stage. however , it's not considered as the full permanent
dentition stage , because second molars are not yet in contact and third molars are
still in the stage of crown formation , so it's not the "functional" permanent
dentition stage , which is established when the second molars come in
contact (occlusion), and not of the third molars because as you know some
teeth may not have third molars at all (unerupted )and sometimes they have
impacted third molars that do not appear in mouth.

 And to summarize the different stages of dentition :

-the first stage is called the edentulous stage , edentulous means no teeth , it starts at
birth and ends at the age of 6 months .
-after that from 6 months to 2 and a half – 3 years , it is called the deciduous or primary
dentition stage , during this stage we have eruption of deciduous teeth .
-at the age of 3 years the deciduous teeth are already in contact and the child will use all
of his deciduous teeth in function that's why it's called the functional deciduous dentition
stage ( 3 – 6 years ) until the eruption of the first permanent molar .
-after that we call it the mixed dentition stage . the early mixed dentition stage starts with
the eruption of incisors and first permanent molars and later on the late mixed dentition
stage with the eruption of the premolars , at age of 12 all the deciduous teeth will be lost
and replaced by the permanent successor teeth (called the permanent dentition stage ) but
we only call it functional permanent dentition stage with the eruption of the second molar
nearly at the age of 13 .

let's discuss the order of eruption in both inter-arch and intra-arch :

* in intra-arch we discuss the order of eruption in the upper and lower teeth at the same
time :
 (this figure does not represent a palmar notation … slide 15)
 This is the sequence of eruption , the numbers indicates the order , and in
the permanent sequence of eruption the doctor presents the Jordanian sequence of
eruption for the first time , previously he used to present the data related to the
western populations .

So in the permanent sequence of eruption (slide 15) number 1 indicates the first teeth that
come at the same time in both arches which are mandibular first permanent molar , the
maxillary first permanent molar and the lower central incisor ( they may not come at the
same time in the public individual , we are talking about the average of eruption) . number
2 is the maxillary central incisor , 3 is the mandibular lateral incisor , 4 is the maxillary
lateral incisor , 5 are the maxillary and mandibular first premolar and the mandibular
canine , 6 are the maxillary and mandibular second premolar and the maxillary canine , 7 is
the mandibular second permanent molar , 8 is the maxillary second permanent molar , 9 is
the maxillary and mandibular third molars . the sequence of eruption here is for the left
side but we can apply it for the right side as well .

For the deciduous teeth (slide 15), the data is for the western population, the sequence of
eruption is : 1 is for the mandibular central incisor , 2 is for the maxillary central incisor , 3
is for both maxillary & mandibular lateral incisor , 4 is for both both maxillary & mandibular
first deciduous molar , 5 is for both maxillary & mandibular canine , 6 is for both maxillary
& mandibular second deciduous molar.

* in intra-arch we discuss the sequence of eruption within the arch itself , not across
arches: (slide 16)
For permanent teeth (Jordanian population) the sequence is :
maxillary  first permanent molar , central , lateral , first premolar , and together the
canine and the second premolar , second permanent molar .
mandibular  together the central and the first permanent molar at the same time , lateral
,canine together with the first premolar , second premolar , second permanent molar .

For the deciduous teeth ( western population ) the sequence is :

Maxillary  central , lateral , first deciduous molar, canine , second deciduous molar and
the same for the mandibular .

-(slide 17) this is the timing of emergence of the permanent teeth in the Jordanian
population , we have the maxillary teeth and the mandibular teeth , each numbered from 1
to 7 , in the firs column we consider the median age (‫ )الوسط الحسابي للعمر‬for each of
these teeth . for example : the median age of eruption for the maxillary central incisor is
7.18 . and in the second column we have the percentile ,5th percentile means that 5% of
population have the eruption of the (for example) maxillary central incisor lower than 5.8 ,
and 95th percentile means that 95% of population have the eruption of the same tooth lower
than 8.56 and only 5% have the eruption of it higher than 8.56 .
From the upper level to the lower level is the normal range , so when we say the median
age is 7.18 this means that anyone with eruption between 5.8 to 8.56 is considered normal ,
a person who has eruption outside this limit for the maxillary central incisor tooth is
considered abnormal . this table has 3 parts one for combined gender and one for each
gender male and female .
**Notice that females always have eruption before males , for example : the median age of
the female for the eruption of tooth number 1 ( central incisor ) is 7.1 while in males it is
7.25 , and the difference between the two genders is always small in the stage of early
mixed dentition , for example : in females the median age for tooth number 2 is 8.07 and in
males it is 8.45 . however , in the stage of late mixed dentition the difference is always
large for example : for the tooth number 7 in males the median age is 12.6 , in females it is
12.3 .

• The doctor announces that this table is for memorization ! . we don't have
to memorize the percentile , only the median age ( of the combined , males ,
females ) . we are allowed to round it first and the memorize it (‫قربوا لقرب منزلة‬
‫ )عشرية‬so 7.18 becomes 7.2 … the doctor says that in practical exams he brings the
table for us but in the theoretical exams he does not .

-(slide 18 ) it repeats the sequence of eruption , divided into ranks , it has the sequence for
inter-arch , and intra-arch maxillary and mandibular .

-(slide 19) Times of development stage: so far , we talked about the eruption or emergence
of teeth through the gum, but we also have different stages of development. The formation
of the tooth is continuous but during the formation of that tooth we can identify four
different stages of that formation , we call them the critical stages . the first one is the
first evidence of calcification , that's when we see the tip or the cusp is calcified , then
when the crown is completed , then when the tooth establishes contact with the opposing
tooth , then when the root is complete .
*When the teeth erupt and come in contact with the opposing ones that does not mean
necessarily that the root is fully formed . permanent teeth need 2 to 3 years after occlusal
contact for root formation , and 1 to 1 and a half years for the deciduous teeth .

• For table in slide 21 , is also for memorization , BUT do not memorize the
eruption of permanent teeth from this table , memorize it from the one in slide 17.

-(slide 22) is a diagram shows presentation for the different stages , the doctor will explain
this diagram to us and how to use it in the next lab inshAllah .

-(Slide 23) when we tell the age of the child from his teeth , we estimate it not calculate it
(‫ )نحن نقدر عمر الطفل من أسنانه و ل نحسبه حسابا دقيقا‬, so we are not expecting to tell the
date of birth of that child from his teeth but at least we need to know that the child is for
example 7 to 8 years , so it is estimation not determination .
The methods we use to estimate the age of the child are : clinical examination for the
teeth that are already in the mouth , models , x-rays and we will be using x-rays inshAllah
next week for age estimation .
The significance of age estimation in dentistry are : for forensic investigation like in
police science sometimes it is important to tell the age of the child , in disasters like in an
earthquake where there are many dead people we need to know these children so we first
need to know if they are a male or a female and then the age of that child , also if we need
to confirm abnormality like if we want to decide if the child has problems in eruption we
need to know the normal timing of eruption , for example : if I know that the range for
eruption of a specific tooth is from 5.3 to 9 and I see that the child has an eruption of it
earlier than the range then this is abnormal , so sometimes we can tell the abnormality
when I know the normality .

-(slide 24) tips of estimation we will take in the lab inshAllah.

-(slide 25) this is an x-ray for a child in the mixed dentition stage , the mandibular first
molar has already erupted and it erupts at the age of 6 so this child is above the age of 6 ,
the root of this tooth is already completed and I know that this root completes at the age of
9 so this child is above 9 , tooth number 7 ( the second molar ) is in the stage of crown
completion , and the crown completion of this teeth is around the age of 8 . So this child is
from 8 to 9 years old .

-(slide 27) how old is this child ?

Is it a child's ? no this is for a person who lost all of his teeth ! :D

That's all !
‫ الحمدلله الذي هدانا لهذا و ما كنا لنهتدي لول أن هدانا الله‬.

"‫)علي بن أبي طالب‬."‫ والدب خير ميراث‬،‫ والعقل خير صاحب‬،‫ وحسن الخلق خير قرين‬،‫) التوفيق خير قائد‬

 ‫ دمتم سالمين‬
Done by : Aya Qassem Alali .