Development of dentition & occlusion

Dr. Nabil Al-Zubair

Dental development
Six-week-old embryo

Dental development usually begins in the 5th or 6th week

of prenatal life.
A-mandibular process B-maxillary process C-lateral nasal processes D-medial nasal process E-naso-optic furrows

The embryonic Oral Cavity is lined by Str. squ epithelium known as the Oral Ectoderm

Around the 6th week of intra-uterine life

(1) The

infero-lateral border of the maxillary arch &

(2) The

supero-lateral of the mandibular arch

show Localized proliferation

ORAL ECTODERM Horse-shoe shaped band of tissue

Resulting in the formation

DENTAL LAMINA

(1) The

infero-lateral border of the maxillary arch &

(2) The

supero-lateral of the mandibular

arch

show Localized proliferation ORAL ECTODERM

Resulting in the formation DENTAL LAMINA

Horse-shoe shaped band of tissue

Around the 6th week of intra-uterine life

DENTAL LAMINA: Two meanings

first refers

Thickening in the ectoderm

From this

A secondary dental lamina

Grows down into the mesenchyme

At intervals

Dental Organs (tooth buds) form

Along this deep lamina

DENTAL LAMINA: Two meanings

As the dental organs are established

the original surface lamina reverts to oral lining ectoderm

(differentiating into gingival epithelium)

the secondary lamina starts to disintegrate

leaving

The first dental organ

Successional lamina
for the second tooth bud

DENTAL LAMINA
Plays an important role in the development of the dentition

LAMINA = Sheet

Tongue

Dental lamina Vestibular lamina

Formation of the deciduous tooth

germs occurs on the labial aspect

of the dental lamina (DL).

The free tip of DL proliferates into

the ectomesenchyme as the successional lamina (SL)

providing the anlage for a

permanent tooth. Dental papilla (DP), dental follicle (DF).

All teeth originate from the dental lamina

DECIDUOUS TEETH are formed by DIRECT proliferation of the dental lamina

PERMANENT MOLARS develops as a result of its DISTAL proliferation

Permanent teeth that replace the deciduous teeth form a lingual extension

All teeth originate from

the dental lamina

DENTAL LAMINA will grow back to form germs for 3 permanent molars BONE

DECIDUOUS TEETH
formed by DIRECT proliferation of the dental lamina

10 TOOTH GERM 20 Successional TOOTH GERM on lingual side of 10

PERMANENT MOLARS
develops as a result of its DISTAL proliferation SYMPHYSEAL CARTILAGE

Permanent teeth that replace the deciduous teeth

form a lingual extension

All teeth originate from the dental lamina

DECIDUOUS TEETH are formed by DIRECT proliferation of the dental lamina

PERMANENT MOLARS develops as a result of its DISTAL proliferation

Permanent teeth that replace the deciduous teeth form a lingual extension

Mitotic area

BUD

TOOTH PRIMORDIUM/GERM

The ectoderm in certain areas of the dental lamina proliferates & form knobs-like structures that grow into the underlying mesenchyma

Oral Ectoderm
knobs-like structures

Mesenchyme

Each of this knobs represents a future deciduous tooth & is called ENAMEL ORGAN ENAMEL ORGAN

DENTAL LAMINA

TOOTH GERM

The enamel organ passes through a number of stages ultimately forming the teeth

 Based on the shape of the enamel organ, the development of teeth can be divided into three stages They are the bud, cap & bell stage
BUD CAP

Outer dental epithelium

Stellate reticulum
DENTAL LAMINA

Stratum intermedium

BELL
TOOTH GERM Inner dental epithelium

Stages of Tooth Development

Dental lamina Bud Cap Bell

BUD STAGE
Oral ectoderm
(1) Thickening

in the ectoderm

Next step to the (2) downgrowths of dental lamina

Formation of a BUD from the dental lamina

BUD STAGE

This is the initial stage of tooth formation

where

The enamel organ

resembles

A small bud

Enamel organ

BUD STAGE
Condensation in TWO areas

The surrounding mesenchymal cells

result in

Proliferate

1- Immediately below the enamel organ Dental Papilla

2- Surrounds the tooth bud & the dental papilla Dental Sac

1- Immediately below the enamel organ Dental Papilla

2- Surrounds the tooth bud & the dental papilla Dental Sac

A: ENAMEL ORGAN

The cells of the dental papilla form the DENTIN & PULP

C: DENTAL SAC

while the dental sac forms CEMENTUM &

PERIODONTAL LIGAMENT
B: DENTAL PAPILLA

BUD STAGE
Usually 10 tooth buds are in each dental arch give rise to Future Primary teeth

BONE

10 TOOTH GERM
Tooth buds for
Permanent Teeth form b/w the 17th week of fetal life through the age of 5. SYMPHYSEAL CARTILAGE

20 Successional TOOTH GERM on lingual side of 10

DENTAL LAMINA

Tooth Bud
Continue to proliferate

Resulting in

A CAP shaped
Enamel Organ

Continue to proliferate

Tooth Bud

Resulting in

A CAP shaped
Enamel Organ

CAP STAGE
The tooth bud continues to proliferate resulting in a cap shaped Enamel Organ

This is characterized by a shallow invagination on the under surface of the bud

Cap Stage
This stage is also known as

Proliferation
(reproduction or multiplication) in which Cells of the tooth GROW

The tooth bud

Takes a hollowed caplike shape

The outer cells of the cap covering the Convexity are cuboidal & are called the

OUTER ENAMEL EPITHELIUM

The cells lining the Concavity of the cap become tall columnar & are referred to as the INNER ENAMEL EPITHELIUM

The central area of the enamel organ b/w the outer & inner enamel epithelium, acquire more inter-cellular fluid & forms a cellular network called the Stellate reticulum

Cap determines: position, type, & size of tooth

Bell Stage
Due to uneven growth

ENAMEL ORGAN (CAP)

BELL SHAPE

also known as Histodifferentiation

(the acquisition of tissue characteristics by cell groups)

Bell Stage:

DENTAL ORGAN: Cap, becoming Bell stage

The last period of growth is

also known as Histodifferentiation (the acquisition of tissue characteristics by cell

groups) or bell stage.

Bell stage
(5)

Dental papilla
Outer dental epithelium
(3)

Odontoblasts Dentin
DENTAL LAMINA

Stellate reticulum
(2)

Stratum intermedium Stratum intermedium

(1)

TOOTH GERM

Inner dental epithelium

(4)

Ameloblasts

Enamel

Bell stage
Rich in capillary network
(5)

dental papilla

Odontoblasts

Outer dental epithelium

(3) Stellate DENTAL LAMINA

reticulum
(2) Stratum

intermedium

TOOTH GERM
(1) Inner

dental epithelium

Ameloblasts

(4)

Enamel

P. fibres

TOOTH TISSUES: Sources

ENAMEL
DENTAL ORGAN DENTAL LAMINA

MESENCHYME

DENTINE PULP CEMENTUM

DENTAL PAPILLA DENTAL SAC/FOLLICLE

PDL

ALVEOLAR BONE

A BONE

TOOTH TISSUES: Cell Sources

DENTAL LAMINA DENTAL ORGAN DENTAL PAPILLA ENAMEL
Ameloblasts

TOOTH

DENTINE
Odontoblasts

PULP
CT cells

DENTAL SAC/FOLLICLE

CEMENTUM
Cementoblasts

PDL ALVEOLAR BONE

Fibroblasts Osteoblasts & clasts

A BONE

Crest

Root Formation

Root formation
Root development begins:

After the dentine & enamel formation reaches the future cemento-enamel junction

The outer & inner enamel epithelium join & form a sheath that helps in molding the shape of the root

This sheath is called the

HERTWIGS EPITHELIAL ROOT SHEATH

Root Formation

Cervical loop forms the epithelial root sheath (of Hertwig)

Cervical loop Dental papilla

Development of occlusion

Occlusion
Occlusion is the relationship of the mandibular and maxillary teeth when closed or during excursive movements of the mandible; when the teeth of the mandibular arch come into contact with the teeth of

the maxillary arch in any functional

relationship.

Periods of occlusal development

Occlusal development can be divided into

the following developmental periods:

1. Pre dental period

2. The deciduous dentition period 3. The mixed dentition period 4. The permanent dentition period

Pre dental period

This is the period after birth

during which the neonate does not have any teeth

It usually lasts for 6 months after

birth

GUM PADS
The alveolar processes at the time of birth are known as gum pads

The gum pads are:

(1)

pink, firm & covered by a dense layer of fibrous periosteum

(2)

(3)

GUM PADS
They are HORSE-SHOE shaped & develop in two parts:
(1)

the labio-buccal portion & the lingual portion

(2)

The two portions of the gum pads are separated from each other by

a groove called the dental groove

GUM PADS
The gum pads are divided into TEN SEGMENTS by certain grooves called TRANSVERSE GROOVES Each of these segments consist of one developing deciduous tooth sac The gingival groove separates the gum pads from the palate & floor of the mouth

Lateral sulcus

The transverse groove b/w canine & first deciduous molar segment is called the lateral sulcus

Transverse grooves

Lateral sulcus
The lateral sulcus of the mandibular arch is normally more DISTAL to that of the maxillary arch

The upper gum pad is both

(1) wider

as well as
than

(2) longer

the mandibular gum pad

Lateral sulcus

Thus when the upper & lower gum pads are approximated, there is a complete overjet all around

Complete overjet

(1) Contact

occurs b/w the upper &

lower gum pads in the first molar region &

(2) A

space exist b/w them in the

anterior region This infantile open bite is considered normal & it helps in suckling

Open bite

The status of dentition

The neonate is without teeth for about 6 months of life
(1)

At birth:

The gum pads are not sufficiently wide to accommodate the developing incisors which are crowded in their crypts
(2)

During the first year of life:

The gum pads grow rapidly permitting the incisors to erupt in good alignment

The status of dentition

Very rarely teeth are found to have erupted at the birth time
Such teeth that are present at the time of

birth are called NATAL TEETH

Sometimes teeth erupt at an early age Teeth that are erupt during the first month of age are called Neonatal teeth

The natal & neonatal teeth are mostly

(1)

LOCATED in the mandibular incisor

region &
(2)

Show a familial tendency

The deciduous dentition period

Cause
Pre dental period
This is the period after birth during which the (lasts for 6 months after birth) gum pads (divided into TEN SEGMENTS)

Aetiology
(complete overjet)The upper gum pad is both (1) wider as well as
(2) longer

neonate does not have any

teeth

than the mandibular gum

Ant. open bite Contact occurs b/w the upper & lower gum pads in the first molar region

A space exist b/w them in the

anterior region

Deciduous dentition

- Rarely endogenous
tongue thrust

Cause
Deciduous dentition
The eruption begin at about 6 months& completed by 2 - 3 years of age

Aetiology
(lasts from 6 months 1. Spacing usually exists b/w the deciduous teeth after birth to 6 yrs) 2. A normal feature of deciduous sequence of eruption dentition is a Flush Terminal ABDCE Plane
3. A deep bite may occur in the Initial Stages of development

The deciduous dentition period

The initiation of primary tooth buds occurs during the first 6 weeks of intra-uterine life

The primary teeth begin to erupt at the age of about 6 months

The eruption of all primary teeth is completed by 2 - 3 years of age when the second deciduous molars come into occlusion

DECIDUOUS DENTITION
5 months in utero
7 months in utero PRENATAL Birth 6 mos. ( 2 mos.) 9 mos. ( 2 mos.) 1 year ( 3 mos.) 18 months ( 3 mos.) 4 years ( 9 mos.) 3 yrs 2 yrs ( 6 mos.)

( 6 mos.)

5 yrs ( 9 mos.) 6 years ( 9 mos.) EARLY CHILDHOOD (Pre-school age)

INFANCY

Eruption age & sequence of deciduous dentition

The mandibular central incisors are

the first teeth to erupt into the oral

cavity They erupt around 6-7 months of age

The sequence of eruption of the deciduous dentition is:

ABDCE

Central Incisors (6 8 mo) Lateral Incisors (6 10 mo) Canines (16 20 mo)

Usual Order of Appearance:

First Molars (10 15 mo)

Second Molars (2 - 3 years )

Mandibular Teeth Usually Precede Maxillary in order of Appearance

The primary dentition is usually established by 3 years of age on eruption of

the second deciduous molars

B/w 3 6 years of age, the dental arch is relatively stable & very few changes occurs
Central Incisors (6 8 mo) Lateral Incisors (6 10 mo) Canines (16 20 mo)

First Molars (10 15 mo)

Second Molars (2 - 3 years )

DECIDUOUS DENTITION

1. Spacing usually exists b/w

the deciduous teeth

2. A normal feature of deciduous dentition is a Flush Terminal Plane

3. A deep bite may occur in the Initial Stages of development

Spacing in deciduous dentition

Spacing usually exists b/w the

deciduous teeth

These spaces are called

Physiological spaces or Developmental spaces

Spacing in deciduous dentition

The presence of spaces in the PRIMARY DENTITION is important for the normal development of the
PERMANENT DENTITION Spacing

Spacing in deciduous dentition

No Spacing

Absence of spaces in the primary dentition is an

indication that crowding of

teeth may occur when the LARGER permanent teeth erupt

Flush terminal plane

The mesio distal relation b/w the DISTAL SURFACE of the lower & upper Second Deciduous Molars is called the terminal plane

A normal feature of deciduous dentition is a Flush Terminal Plane

where the distal surfaces of the upper

& lower second deciduous molars are in the same vertical plane

Deep bite

A deep bite may occur in the Initial Stages of development

The deep bite is accentuated by the fact that the deciduous

incisors are more upright than

their successors

The lower incisal edges often

contact the cingulum area of the maxillary incisors

Deep bite

This deep bite is later Reduced

due to the following factors: a. Eruption of deciduous molars b. Attrition of incisors c. Forward movement of the mandible due to growth

The mixed dentition period

A panoramic x-ray of a 7 year-old child. One can notice the complex mix of the permanent and the primary teeth at this stage.

The mixed dentition period

The mixed dentition period begins at approximately 6 years of age with the eruption of the first permanent molars

During the mixed dentition period, the deciduous teeth along with some permanent

teeth are present in the oral

cavity

The mixed dentition period

The mixed dentition period can be classified into three phases:

1. First transitional period 2. Inter-transitional period 3. Second transitional period

First transitional period

The first transitional period is characterized by : (1) the emergence of the first permanent molars & (2) the exchange of the deciduous incisors with the permanent incisors

Emergence of the first permanent molars:

The mandibular first molar is the first permanent tooth to erupt at around 6 years of age

Emergence of the first permanent molars:

The (1) location & (2) relationship of the first permanent molars depends much
upon the DISTAL SURFACE relationship b/w the lower & upper second deciduous molars

Emergence of the first permanent molars:

The first permanent molars are Guided into the dental arch by distal surface
of the second deciduous molars The mesio-distal relation b/w the Distal Surfaces of the upper & lower second deciduous molars can be of three types

THE THREE TYPES OF TERMINAL PLANES

FLUSH PLANE TYPE

MESIAL STEP TYPE

DISTAL STEP TYPE

A. Flush terminal plane:

The distal surface of the upper & lower second deciduous molars are in VERTICAL PLANE

This is a normal feature of the deciduous dentition

Thus the erupting first

permanent molars may also be in a flush or end on Class I molar relationship

This type of relationship is called flush or vertical terminal plane

Flush

Class I molar
For such transition

the lower molar has to move forward by about 3 5 mm relative to the upper molar

Flush

Class I molar
This occurs by of the physiological spaces & leeway
(1) utilization

space in the lower arch &

(2) by

differential forward growth of the mandible

Flush

The shift in lower molar can occur in two ways

Class I relation

They are designated as the

Early shift

Late shift

Shift: Refers to mandibular permanent molar moving mesially

Early shift:
Occurs during the early mixed
dentition period

Primate space

The ERUPTIVE FORCE of the first permanent molar is sufficient to push the deciduous first & second molars forward in the arch to close the PRIMATE SPACE

Since this occur early in the mixed dentition period it is called early shift

Many children lack the primate space lack the primate

space & thus

Late shift

the erupting permanent molars

unable to move forward to

establish Class I relationship

In this cases, when the deciduous second molar exfoliate the permanent first molars

DRIFT MESIALLY
utilizing the leeway space

Leeway space

This occurs in the late mixed dentition period & is thus called late shift

Late Mesial Shift (cont.)

FTP

Molar moves into this space...

Class I

Late Mesial Shift (cont.)

B. Mesial step terminal plane

In this type of relationship the Distal Surface of the lower

second deciduous molar is more

Mesial than that of the upper

Thus the permanent molars erupt directly into Angles Class I occlusion

B. Mesial step terminal plane

This type of mesial step terminal plane most commonly occurs due

to
EARLY FORWARD GROWTH OF THE MANDIBLE

If the differential growth of the

mandible in a forward direction persist, it can lead to an Angles Class III molar relation

If the forward mandibular growth is minimal, it can establish a Class I molar relationship

B. Mesial step terminal plane

This type of mesial step terminal plane most commonly occurs due

to
EARLY FORWARD GROWTH OF THE MANDIBLE

If the differential growth of the

mandible in a forward direction persist, it can lead to an Angles Class III molar relation

C. Distal step terminal plane

This is characterized by the Distal

Surface of the lower second

deciduous molar being more DISTAL to that of the upper

Thus the erupting permanent molars maybe in Angles Class II

occlusion

C. Distal step terminal plane

This is characterized by the Distal

Surface of the lower second

deciduous molar being more DISTAL to that of the upper

Thus the erupting permanent molars maybe in Angles Class II

occlusion

Primary

Permanent

Distal Step

Class II

Flush Terminal Plane

End-End

Mesial Step

Class I

Minimal Growth Differential Forward Growth of Mandible Shift of Teeth

Class III

First transitional period

The first transitional period is characterized by : (1) the emergence of the first permanent molars & (2) the exchange of the deciduous incisors with the permanent incisors

The exchange of incisors:

During the first transitional period:

The deciduous incisors are replaced by the permanent incisors The mandibular central incisors are usually the first to erupt The permanent incisors are considerably larger than the deciduous teeth they replace

The exchange of incisors:

This difference b/w the amount of
space needed for the accommodation of the incisors & amount of space available for this is called INCISAL LIABILITY

7 mm in the maxillary arch

5 mm in the mandibular arch

Overcoming Incisal Liability

The incisal liability is overcome by the following factors:

A. Utilization of interdental
spaces seen in primary dentition B. Increase in the inter canine width C. Change in incisor inclination

Overcoming Incisal Liability

A. Utilization of interdental spaces seen in primary dentition:

The physiologic or the

developmental spaces that exists in the primary dentition are utilized to partly account for the incisal liability

Overcoming Incisal Liability

A. Utilization of interdental spaces seen in primary dentition: The Permanent Incisors are much more
easily accommodated in normal alignment in cases exhibiting

Adequate Inter-dental Spaces than in an arch that has No space

Primary dentition, baby teeth, with normal spaces between the teeth

Overcoming Incisal Liability B. Increase in the inter canine width:

WIDTH GROWTH creates more room for the permanent incisors
(1) Mandibular intercanine growth

occurs mostly during permanent

incisor eruption
(2) Maxillary intercanine growth

occurs during incisor eruption, and continues

Overcoming Incisal Liability

C. Change in incisor inclination:

One of the differences b/w deciduous & permanent incisors is

their inclination

The primary incisors are

more upright
than the permanent incisors

Overcoming Incisal Liability C. Change in incisor inclination:s

Since the Permanent Incisors erupt more labially inclined they tend to increase

the Dental Arch Perimeter

This is another factor that

helps in accommodating the larger Permanent Incisors

The mixed dentition period

The mixed dentition period can be classified into three phases:

1. First transitional period 2. Inter-transitional period 3. Second transitional period

Inter transitional period

In this period the maxillary & mandibular arches consist of Sets

of deciduous & permanent teeth

6edc21 6edc21

12cde6 12cde6

B/w the permanent incisors & the first permanent molars are the deciduous molars & canines

This phase during the mixed dentition

period is relatively stable & no

change occurs

The mixed dentition period

The mixed dentition period can be classified into three phases:

1. First transitional period 2. Inter-transitional period 3. Second transitional period

Cause
The mixed dentition period
deciduous teeth along with
some permanent

Aetiology
The first transitional period is characterized by : (1) the emergence of the first permanent molars Flush transition to Class I molar (2) the exchange of the deciduous incisors with the permanent incisors INCISAL LIABILITY Inter transitional period

The eruption begin

approximately at 6 years of age with the eruption of the first permanent molars

teeth are present in the oral cavity Classified into

three phases: ( First , Relatively stable & no change occurs

Inter-transitional , Second) transitional period

The second transitional period Replacement of the deciduous molars & canines by the premolars & permanent cuspids respectively

The second transitional period

The second transitional period is characterized by

The surplus is called leeway space of Nance

the replacement of the deciduous molars & canines by the premolars & permanent cuspids

respectively

The combined mesio-distal width of the permanent canines & premolars is usually less than that of the deciduous canines & molars

The leeway spaces

Maxillary arch

1.8mm (0.9 mm on each side of the arch)

The amount of leeway space is greater in the mandibular arch than in the maxillary arch

Mandibular arch
3.4mm (1.7 mm on each side of the arch)

The leeway spaces

Maxillary c-d-e minus 3-4-5 is 0.9 mm per side Mandibular c-d-e minus 3-4-5 is 1.7 mm per side

The ugly duckling stage:

Sometimes a Transient or Self Correcting malocclusion is seen

in

the MAXILLARY INCISOR REGION b/w 8

9 years of age

This is a particular situation seen during the Eruption of the permanent canines

The ugly duckling stage:

7 years old
9 years old

14 years old

As the developing permanent canines erupt, they displace the roots

of the lateral incisors mesially This result in transmitting of the force on to the roots of the central

incisors which also get displaced mesially

The ugly duckling stage:

7 years old
9 years old

14 years old

A resultant distal divergence of the crowns of the two central incisors

causes a midline spacing

This situation has been described by Broadbent as the ugly duckling stage

as children tend to look ugly during this phase of development

The ugly duckling stage:

7 years old

9 years old

14 years old

Parents are often apprehensive during this stage & consult the dentist

This condition usually corrects by itself when the canines erupt & the pressure is transferred from the roots to the coronal area of the incisors

The permanent dentition period

The permanent dentition period

The permanent dentition forms within the jaws soon after birth, except the cusps of the first permanent molars which form before birth

The permanent incisors develop lingual or palatal to

the deciduous incisors & move

labially as they erupt

The permanent dentition period

The premolars develop below the diverging roots of the deciduous molars
The eruption sequence of the permanent dentition may exhibit variation

The permanent dentition period

The frequently seen
sequences in the maxillary arch are: 6 1 2 4 3 5 7 or 6123457 In case of the mandibular arch the sequence is 6 1 2 3 4 5 7 or 6124357

Time of Eruption (Years)

Tooth 1 2 3 4 5 6 7 8 Maxilla 7-8 8-9 11-12 10-11 10-12 6-7 12-13 17-21 Mandible 6-7 7-8 9-10 10-12 11-12 6-7 11-13 17-21

Chronology of Tooth Development Permanent Dentition

Calcification begins
Tooth
Central Lateral

Crown completed
Max.
4 yr. 5 yr.

Eruption
Max.
7 yr. 8 yr.

Root completed
Max.
10 yr. 11 yr.

Max.
3 mo. 11 mo.

Mand.
3 mo. 3 mo.

Mand.
3 yr. 4 yr.

Mand.
6 yr. 7 yr.

Mand.
9 yr. 10 yr.

Canine 1st Pre Molar 2nd Pre Molar 1st Molar 2nd Molar 3rd Molar

4 mo. 20 mo. 27 mo. 32 wk. in utero 27 mo. 8 yr.

4 mo. 22 mo. 28 mo. 32 wk. in utero 27 mo. 9 yr.

6 yr. 7 yr. 7 yr. 4 yr. 7 yr. 14 yr.

5 yr. 6 yr. 7 yr. 3 yr. 7 yr. 14 yr.

11 yr. 10 yr. 11 yr. 6 yr. 12 yr. 20 yr.

10 yr. 10 yr. 11 yr. 6 yr. 12 yr. 20 yr.

13 yr. 13 yr. 14 yr. 10 yr. 15 yr. 22 yr.

12 yr. 13 yr. 15 yr. 10 yr. 16 yr. 22 yr.

SEQUENCES of DENTAL ERUPTION

Favorable sequence

Unfavorable sequence

SEQUENCES of DENTAL ERUPTION

Favorable sequence

-345
-435 - (3 4) 5 - 3 (4 5)

SEQUENCES of DENTAL ERUPTION

Unfavorable sequence

- 543
-534 - 5 (3 4) -453

SEQUENCES of DENTAL ERUPTION

Unfavorable sequence SECOND MOLARS

erupting before

Second premolars and/or CANINES

4. Favorable sequences of eruption. 5. Tooth size and jaw in harmony.

Thank you for listening!

Dr. Nabil Al-Zubair