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Evolution of human dentition Prenatal dental development The predental period The deciduous dentition The mixed dentition The permanent dentition Dental arch development References
There are four stages of tooth evolution: 1.Reptilia stage (Haplodont). This type of dentition is depicted by the simplest form of teeth a single cone. It usually includes many teeth in both jaws. Jaw movements are limited to opening and closing only. No occlusion of teeth is seen in this class. 2.Early mammalian stage (Triconodont). This exhibits three teeth in line in the posterior teeth. Anthropologically, the largest cusp is centered, with a smaller cusp anteriorly and another posteriorly.
3.Triangular stage (Tritubercular stage). The three triconodont lines are changed to three cone-shaped structures, with the teeth more or less by-passing each other when the jaws are opened or closed. 4.Quadritubercular stage. The next stage of development created a projection on the triangular form that finally occluded with the antagonist of the opposing jaw.During this time, as an accommodation to changes in tooth form and anatomy, the articulation of jaws changed accordingly.
Human tooth size has undergone a clear cut reduction during the Upper Paleolithic Age, and the rate of that reduction has accelerated since the end of the last Ice Age. Beginning about 10,000 years ago, the rate of reduction seems to have doubled to about 1% every 1,000 years. Associated with the overall dental reduction is a trend for substantial decrease in sexual dimorphism in tooth size.
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There was shortening of jaws due to decrease in size of olfactory organs, upright body position and wide angle of head to body. Decrease in tooth size occurred, so as to accommodate the teeth into the smaller jaws, with subsequent elimination of some teeth from the dentition. There was progressive shortening and relative widening of the dental arches. The canines reduced in size. The lower premolars became more symmetrical from oval. The first molars became the dominant cheek teeth. The third molars, which were larger than the first molars, were reduced in size and often eliminated.
Pleurodont teeth set inside the jaws. Thecodont teeth inserted inside a bony socket. Diphyodont two sets of teeth.
a.) INITIATION OF ODONTOGENESIS. The first sign of tooth development appears late in the third embryonic week when the epithelial lining of the oral cavity begins to thicken in broad zones. The epithelial thickenings occur on the inferolateral borders of the maxillary and on the superolateral borders of the mandibular arches where the two join to form the lateral borders of the mouth. At 6 weeks, the four maxillary odontogenic zones coalesce to form a continuous dental lamina, and the two mandibular odontogenic zones fuse at the midline. The teeth begin with invagination of the dental lamina into the underlying mesenchyme at specific locations along the free border of each arch.
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Morphologic changes in the dental lamina begin at about 6 weeks in utero and continue beyond birth to the fourth or fifth year. This occurs in three main phases: Initiation of the entire deciduous dentition occurs during the 2nd month in utero. Initiation of the permanent teeth occurs by the growth of the free distal end of the dental lamina into the surrounding connective tissues, giving rise to the successional lamina. The dental lamina elongates distal to the second deciduous molar and gives rise to the permanent molar tooth germs.
b.) BUD STAGE. Soon after dental lamina formation, a vestibular furrow divides the cheeks and lips from the dental arches. Subsequently, the dental lamina shows specific sites of increased mitotic activity which produce knoblike tooth buds corresponding to the ten deciduous teeth in each jaw. The first buds to form are the mandibular anterior teeth, at about the 7th week. By the 8th week, all maxillary and mandibular deciduous tooth buds are present.
c.)CAP STAGE. The growth rate at the periphery of the bud is greater. By the end of the 8th week, there appears a concavity on the deep surface of the bud. The tooth is now in its cap stage. As the epithelium of the cap-shaped organ enlarges and proliferates into the deeper ectomesenchyme, there is increased activity in cells contiguous with the ectodermal tooth bud. At this time, the essential parts of the tooth enamel organ, dental papilla and dental follicle are identifiable. Collectively they are called the tooth
germ.
d.)BELL STAGE.
Enlargement of the overall size of the tooth germ and deepening of its undersurface occurs. Epithelial cells next to the papilla develop into an enamel-producing layer of cells, the inner enamel epithelium; epithelial cells along the leading edge of the germ form the outer enamel epithelium, which eventually gives rise to the dental cuticle. The differentiation of dentin producing odontoblasts in the dental papilla is initiated by the neighboring cells of the inner dental epithelium. Neighboring cells of the two epithelia progressively constrict around the dental papilla to leave only a small opening, which will become the apical foramen. At this time, the dentin which forms the tooth root is first laid down. The germ loses its connection with the oral epithelium and the inner dental epithelium begins to fold, making it possible to recognize the crown shape of specific morphologic classes of teeth.
At birth, the gum pads are not sufficiently wide to accommodate the developing incisors, which are crowded and rotated in their crypts. During the first year of life the pads grow rapidly. The growth is most marked in the lateral direction. This increase in width permits the incisors to erupt in good alignment and to be spaced. Also during this period, there is a rapid increase in the labio-lingual dimensions of the gum pads. The length of the gum pads increases more moderately.
The size of the gum pads at birth may be determined by any one of the following factors, according to Leighton : the state of maturity of the infant at birth. the size at birth as expressed by birth weight. the size of the developing primary teeth. genetic factors.
DEVELOPMENT OF THE PRIMARY TEETH 1.Calcification. The sequence of initial calcification of the primary teeth is central incisors (14 weeks), first molars (15 weeks), lateral incisors (16 weeks), canines (17 weeks) and second molars (18 weeks). The crowns of the teeth continue to grow in width until there is coalescence of the calcifying cusps, at which time most of the crown diameter has been determined. The crown morphology, rate and sequence of growth, pattern of calcification and mineral content are under genetic control.
2. Eruption. Eruption of the primary teeth begins in a variable fashion but not until root formation has begun. Occasionally, a natal tooth is present at the time of birth. The natal tooth may be a supernumerary one but usually is a very early erupted normal primary central incisor. For this reason such a tooth should not be extracted casually.
1st Molar 15wk 15wk 6 I.U. I.U. Mo. 2nd Molar 19wk 19wk 11 I.U. I.U. Mo.
16 Mo. 27 Mo.
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In addition to the generalized spacing, localized spacing are often present and are referred to as primate spaces. Such spaces are present in 87% of the maxillary arches between the lateral incisor and canine. In the mandibular arch, their incidence is 78% and they occur between the canines and first molars. The primate spaces are normally present from the time the teeth erupt.
Spacing is normal throughout the anterior part of the primary dentition also. Spaces develop between the deciduous incisors subsequent to their eruption, but become somewhat larger as the child grows and the alveolar processes expand. Failure of incisor spacing to appear before 5 years of age occurs in about 20% of cases and usually indicates crowding in the permanent dentition.
Overbite. Overbite is the vertical overlap between the maxillary and mandibular central incisors. The overbite in the deciduous dentition varies between 10% and 40%. Foster in a study of 100 British children between the ages of 2 and 3 years described the overbite relationship as ideal (19%), reduced (24%), and excessive overbite (20%). The fact that more than 60% of the children in this population have a reduced overbite or an open bite is attributed to the effects of the various oral habits (finger or pacifier sucking) that are common in this age group.
Overjet. Overjet is the horizontal relationship or the distance between the most protruded maxillary central incisor and the opposing mandibular central incisor. The normal range of overjet in the primary dentition varies between 0 and 4 mm. In the same study by Foster, the overjet was ideal in 28% of the cases and excessive in 72% of the cases. Again, this feature was attributed to the effects of the oral habits
Molar relationship. The anteroposterior molar relationship in the primary dentition is described in terms of the terminal planes. The terminal planes are the distal surfaces of the maxillary and mandibular second primary molars. The two terminal planes can be related to each other in one of three ways. In the flush terminal plane relationship, both the maxillary and mandibular planes are at the same level anteroposteriorly. In the mesial step relationship, the maxillary terminal plane is relatively more posterior than the mandibular terminal plane. In the distal step relationship, the maxillary terminal plane is relatively more anterior than the mandibular terminal plane.
In a study of 121 Iowa children 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% Determining the terminal plane relationships in the primary dentition is clinically important because the erupting first permanent molars are guided by the distal surfaces of the second primary molars as they erupt into occlusion. At the late primary dentition stage of development, the maxilla and mandible are housing the greatest number of teeth ever, including 20 erupted primary teeth and at least 28 unerupted but partially forming permanent teeth.
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tooth into ten stages: Absence of crypt Presence of crypt Initial calcification One third of crown completed Two thirds of crown completed Crown almost completed
7. One third of root completed 8. Two thirds of root completed 9. Root almost complete, open apex 10. Apical end of root completed
Girls are more advanced in calcification of permanent teeth than are boys at each stage and more so in the later stages.
eruption.
Eruption is the developmental process that moves a tooth from its crypt position through the alveolar process into the oral cavity and to occlusion with its antagonist. Those permanent teeth that follow into a place in the arch once held by a primary tooth are called successional teeth (e.g. incisors, cuspids and bicuspids). Those permanent teeth that erupt posteriorly to the primary teeth are termed
accessional teeth.
During eruption of succedanous teeth, many activities occur simultaneously: the primary tooth resorbs, the root of the permanent tooth lengthens, the alveolar process increases in height, and the permanent tooth moves through the bone. Permanent teeth do not begin eruptive movements until after the crown is completed. They usually emerge when threefourths of their roots are completed. They pass through the crest of the alveolar process at varying stages of root development. It takes from two to five years for the posterior teeth to reach the alveolar crest following completion of their crowns and from 12-20 months to reach occlusion after reaching the alveolar margin. It takes about 2-3 years for the roots to be completed after the tooth has erupted into occlusion.
Developmental processes during eruption of succadaneous teeth. Aelongation of permanent root. B-resorption of primary predecessor. Cmovement of permanent tooth occlusally. D-growth of alveolar process. Einferior border of mandible, which shows much less growth activity than the other four processes.
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1st 20 Premolar Mo. 2nd 27 Premolar Mo. 1st Molar 2nd Molar 3rd Molar 32 Wk I.U. 27 Mo.
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The physiologic principles underlying tooth eruption are the same for both primary and permanent teeth. Pre-emergent Eruption. Eruptive movement of the tooth follicle begins soon after the root begins to form. Two processes are necessary for pre-emergent eruption. First, there must be resorption of the bone and primary roots overlying the crown of the erupting tooth. Second, the eruption mechanism itself must then move the tooth in the direction where the path has been cleared. Failure of tooth eruption due to failure of bone resorption occurs in the case of cleidocranial dysplasia.
The precise mechanism through which eruptive force is generated is still not entirely understood. Various theories have been put forward over the years: Lengthening of the root within its crypt was initially considered to be the mechanism which caused the tooth to erupt. However, eruption of teeth even after removal of their apical area rejected this hypothesis. Localized variations in blood pressure or flow in the vessels surrounding the developing tooth was another theory. Forces derived from contraction of fibroblasts were thought to constitute the eruptive force. Alterations in the extracellular ground substance of the periodontal ligament similar to those that occur in thixotropic gels were thought to be the driving force behind eruption of teeth.
From animal studies, it presently seems clear that the major eruption mechanism is localized within the periodontal ligament. It is theorized that the cross-linking of maturing collagen in the periodontal ligament provides the eruption force. This is supported by the fact that eruptive movements begin when root formation starts and a periodontal ligament begins to develop.
Post-emergent Eruption.
Once a tooth erupts into the mouth, it erupts rapidly until it approaches the occlusal level and is subjected to the forces of mastication. At that point, its eruption slows and then as it reaches the occlusal level of other teeth and is in complete function, eruption all but halts. The stage of relatively rapid eruption from the time a tooth first penetrates the gingiva until it reaches the occlusal level is called the post-emergent spurt, in contrast to the following phase of very slow eruption, termed the juvenile occlusal equilibrium. During the juvenile occlusal equilibrium, teeth that are in function erupt at a rate that is parallel to the rate of vertical growth of the mandibular ramus. As the mandible continues to grow, it moves away from the maxilla, creating a space into which the teeth erupt. Due to this, a pubertal spurt in the eruption of teeth accompanies the pubertal spurt in jaw growth. When the pubertal growth spurt ends, a final phase in tooth eruption called the adult occlusal equilibrium is achieved.
The amount of tooth eruption after the teeth have come into occlusion equals the vertical growth of the ramus. Vertical growth increases the space between the jaws, into which the upper and lower teeth erupt.
During adult life, teeth continue to erupt at an extremely slow rate. If its antagonist is lost at any age, a tooth can again erupt more rapidly, a condition called supraeruption.
Ectopic eruption of maxillary first molars is associated with (1) large primary and permanent teeth, (2) a diminished maxillary length, (3) posterior positioning of the maxilla and (4) an atypical angle of eruption of the first molar. The treatment for this problem is best begun early in dental development in order to utilize the natural forces of eruption. Surgical uncovering and repositioning are required before orthodontic treatment. Impacted teeth are ones that cannot erupt because of impingement. Third molars and maxillary cuspids are most commonly impacted. Transposition is a very rare form of ectopy, which involves exchanged positions between cuspids and first premolars or cuspids and lateral incisors.
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drifting tendency.
Once the oral cavity has been entered, the tooth can be moved by the lip, cheek and tongue muscles, or by extraneous objects brought into the mouth(e.g. thumb, fingers, pencils). In the occlusal stage of eruption, the muscles of mastication exert an influence through the interdigitation of cusps. The upward forces of eruption and alveolar growth are countered by the opposition of the apically directed force of occlusion. The periodontal ligament disseminates the forces of chewing to the alveolar bone. The axial inclination of the permanent teeth is such that some of the forces of chewing produce a mesial resultant through the contact points of the teeth, the anterior component of force. This is countered by the approximal contacts of the teeth and by the musculature of the lips and cheeks.
When the central incisors erupt, they use up almost the entire space available in the primary dentition. With the eruption of the lateral incisors, the space situation in both arches becomes tight. The maxillary arch usually has just enough space to accommodate the permanent lateral incisors when they erupt. However, in the mandibular arch, when the lateral incisors erupt, there is an average deficit of 1.6mm space to align the four permanent incisors. This difference between the amount of space needed for the incisors and the amount available for them is called the incisor liability. Due to this, a child goes through a transitory stage of mandibular incisor crowding at age 8 to 9. Continued development of the arches improves the spacing situation, and by the time the canines erupt, space is once again adequate.
The extra space to overcome the incisor liability and to accommodate the incisors comes from three sources: 1. A slight increase in the inter-canine width of the dental arch. As growth continues, the teeth erupt upward and slightly outward. This increase is only about 2mm. but it contributes to the resolution of early incisor crowding. More width is gained in the maxillary arch than in the mandible, and more is gained by boys than by girls. 2. Labial positioning of the permanent incisors relative to the primary incisors. This contributes 1 to 2mm. of additional space in the arch, and thus helps resolve crowding. 3. Repositioning of the canines in the mandibular arch. As the permanent incisors erupt, the canine teeth widen out slightly, and also move slightly back into the primate spaces. These changes occur without significant skeletal growth in the anterior part of the jaws.
In a study by Turkkahraman & Sayin (Angle Orthod., 2004) , it was determined that patients with crowding had smaller lower incisor to NB angles, maxillary skeletal length, mandibular skeletal length and mandibular dental measurements. They also had greater interincisal angles, overjet, overbite and Wits appraisal measurements and FMIA. Thus the study concluded that crowding of mandibular incisors is not only a tooth size- arch length discrepancy. Dentofacial characteristics also contribute to this malalignment.
Another study by Sayin & Turkkahraman (Angle Orthod.. 2000) showed that crowded dentitions had significantly smaller mandibular deciduous intercanine width, mandibular deciduous inter-molar width, mandibular permanent inter-molar width and mandibular inter-alveolar width. The space available for the mandibular permanent incisors was also less in crowded dentitions, as was the total arch length. However, the total width of the four permanent incisors did not vary greatly between crowded and non-crowded dentitions.
At the time the primary second molars are lost, both the maxillary and mandibular molars tend to shift mesially into the leeway space, but the mandibular molar normally moves mesially more than the maxillary molar. This differential movement contributes to the normal transition from a flush terminal plane relationship in the mixed dentition to a Class I relationship in the permanent dentition. Also, differential growth of the mandible more than the maxilla carries the lower molar more mesial than the upper molar and helps to establish a Class I relationship in the permanent dentition.
MOLAR RELATION IN PERMANENT DENTITION. The occlusal relationships in the mixed dentitions determine the molar relation in the permanent dentition. The transition in molar relation from the mixed dentition to the early permanent dentition is usually accompanied by a one-half cusp (3 to 4mm.) relative forward movement of the lower molar, accomplished by a combination of differential growth and tooth movement
A childs distal step relation may change to an end-to-end relationship in the permanent dentition, but it is not likely to change all the way to a Class I relation. It is also possible that the pattern of growth may not lead to greater prominence of the mandible, in which case the molar relation in the permanent dentition will remain a full cusp Class II. Similarly, a flush terminal plane relation in the mixed dentition can change to a Class I relation in the permanent dentition or can remain end-to-end if the growth pattern is not favorable. A mesial step relation in the primary molars may produce a Class I permanent molar relation at an early age. It can proceed to a half-cusp Class III during the molar transition and progress further to a full Class III relationship with continued mandibular growth.
Arch Curvatures: the anteroposterior curvature in the mandibular arch is called the curve of Spee. The corresponding curve in the maxillary arch is called the compensating curve. The buccolingual curvature from one side to the other is called the Monson curve or Wilson curve. Overbite and overjet: the overbite often ranges between 10 % and 50%, and the overjet ranges between 1 mm and 3 mm. Posterior relationships: the maxillary and mandibular molars are in Class I occlusion( i.e. the mesiobuccal cusp of the maxillary first molar is in the buccal groove of the mandibular first molar). In addition the whole posterior segment needs to be well interdigitated.
LATE CHANGES IN THE PERMANENT DENTITION STAGE After the eruption of the permanent teeth, the dentition is relatively stable when compared with the cascade of changes observed in the mixed dentition stage. Changes considered to be of clinical importance are : In both males and females the lips become more retruded relative to the nose and chin between 25 and 45 years of age. The implication is that orthodontic treatment at earlier ages should not result in an overly straight soft tissue profile and overly retrusive lips because the expected changes in the relative positions of the nose, lips and chin may exaggerate these characteristics. In both males and females, interincisor and intercanine arch widths decreased. Also, total arch lengths decreased and , as a result, anterior crowding increased.
b.) Distally directed forces which may cause retroclination of the lower incisors, with reduction in arch length and consequent crowding. These forces may be due to incisor uprighting, growth patterns, skeletal structure or soft tissue maturation.
c.) Occlusal factors which may produce a different pattern of masticatory forces or an occlusion with premature contacts. Such occlusal changes may be due to tooth loss, restorations, development of parafunctional habits or orthodontic treatment.
d.) Direction of eruption mesially inclined molars and distally inclined incisors that continue to erupt in the same direction would result in reduction in arch depth and increased crowding.
e.) Tooth morphology well aligned lower incisors are smaller mesiodistally and larger labiolingually.
f.) Degenerative tissue changes gingival recession and bone loss are likely causes of late crowding. g.) Orthodontic treatment teeth that have been moved orthodontically have a tendency to return to their original (crowded) positions.
Both overbite and overjet decrease throughout the second decade of life, due to relatively greater forward growth of the mandible. Third molar development: third molars show more variability in calcification and eruption than do any other teeth. Impaction of third molars is a frequent and serious problem in modern man. Mandibular third molar impactions, which are usually more serious, are seen more often with skeletal Class II particularly when the body of the mandible is short and acutely angled. By the end of the second decade most persons display idiopathic resorption of one or more teeth. Nearly 90% of all teeth show some evidence of resorption by the time a person is 19 years of age.
DENTAL AGE
On the basis of dentition, 3 related estimates of dental age can be made: 1. From the number and type of teeth visible in the oral cavity. 2. Based on the schedule of calcification of permanent mandibular first molar. However, this is a limited estimate. 3. Based on schedule of calcification of the dentition as a whole. Dental age is highly correlated with body height and chronologic age.
The usual arch dimensions measured are: (1) widths at the canines, primary molars (premolars), and first permanent molars; (2) length (or depth) and; (3) circumference.
Arch dimensions. A, arch length. B1, bicanine diameter. B2,bimolar diameter. C-C, arch perimeter/circumference
I. Width.
Dental arch width increases correlate highly with vertical alveolar process growth, whose direction is different in the two arches. Maxillary alveolar processes diverge, due to vertical growth of the alveolar processes (which also coincides with eruption of teeth), while the mandibular processes are more parallel. As a result maxillary width increases are much greater and can be more easily altered in treatment.
The crowns of the first molars erupt tipped somewhat lingually and do not upright fully until the time of the eruption of the second molars. As the first molars upright, they cause an increase in the bimolar width. Furthermore, both first molars move forward at the time of the late mesial shift to use up any remaining leeway space and thus assume a narrower diameter along the convergent dental arch.
The only postnatal mechanism for widening the basal bony width of the mandible is deposition on the lateral borders of the corpus mandibularis. Such deposition occurs only in small amounts. The maxilla, in contrast, widens with vertical growth because the alveolar processes diverge; therefore, more width increase is seen and more can be procured during treatment. Furthermore, the midpalatal suture can be reopened with rapid palatal expansion to acquire large amounts of actual widening of the maxilla.
A study by Marshall,
Northway in 1977 reported that moderate caries, severe caries, and early loss of primary molars caused dramatic increases in the amount of perimeter loss. Hunter and Smith in 1972 noted that children with crowded arches in the early mixed dentition showed less arch perimeter loss by the time of the completed permanent dentition and more continued crowding.
A study by Slaj et. al (Angle Orthod., 2003) suggests that dental arch dimensions are more defined by tooth eruption and less so by the growth of the supporting bone during the mixed dentition. In the early mixed dentition, intercanine relations are primarily defined by the early onset of mandibular growth. However, the skeletal growth of the maxillofacial complex in the late mixed dentition is not always predictable. The period between the early and late mixed dentition is suitable for environmental factors to disrupt the pattern of ideal symmetrical development of ideal arch form. Since a number of orthodontic treatments may be planned or applied in the period of early or late mixed dentition, this factor should be kept in mind for deciding upon and administering the appropriate orthodontic therapy.
REFERENCES
1. Gardiner J.H., Leighton B.C., Luffingham J.K, Valiathan, A.: Orthodontics for Dental Students. Oxford University Press, 1998; 4th Edition. 2. Moyers Robert E.: Hand book of Orthodontics. Year book Medical publishers, Inc, 1988; 4th Edition. 3. Bishara Samir E.: Text book of Orthodontics. Saunders 2003. 4. Nanda Surender K.: The developmental basis of occlusion and malocclusion. Quintessence Publishing Co. Inc. 1983.
5. Proffit W.R.: Contemporary Orthodontics. Mosby 2000. 3rd Edition. 6. Salzmann J.A.: Practice of Orthodontics Vol. 1. J.B. Lippincott Co. 1966. 7. Orbans Oral Histology and Embryology. Harcourt Asia Pvt. Ltd. 11th Edition. 8. Tencate R.: Oral histology development, structure and function. Mosby 2001. 5th Edition.
9. Tibana H.W., Palagi L.M., Miguel J.A.M.: Changes in dental arch measurements of young adults with normal occlusion-a longitudinal study. Angle Orthod. 2004;74:618-623. 10. Sayin, Turkkahraman: Factors contributing to mandibular anterior crowding in the early mixed dentition. Angle Orthod. 2004; 74:754-758. 11. Turkkahraman, Sayin: Relationship between mandibular anterior crowding and lateral dentofacial morphology in the early mixed dentition. Angle Orthod. 2004; 74:759-764. 12. Slaj M., Jezina M.A., Lauc R., Rajic-Mestrovic S., Miksic M.: Longitudnal dental arch changes in the mixed dentition. Angle Orthod. 2003;73:509-514
13. Marshall S., Dawson D., Southard K.A., Lee A.N., Casko J.S., Southard T.E.: Transverse molar movements during growth. Am J Orthod Dentofacial Orthop 2003; 124:615-24. 14. Richardson M.E.: Late lower arch crowding: the aetiology reviewed. Dent Update 2002; 29: 234238. 15. Moorrees C.F.A.: Growth studies of the dentition-a review. Am J Orthod Dentofacial Orthop 1969 55:600-616.