Essentials of

Oral Biology

Oral Anatomy, Histology, Physiology and

Embryology

Second Edition
 Essentials of
Oral Biology

Oral Anatomy, Histology, Physiology and

Embryology

Second Edition

Maji Jose MDS, PhD

Professor and Head
Department of Oral Pathology
Yenepoya Dental College and
Hospital
Yenepoya University
Deralakatte, Mangalore 575018
Karnataka, India
Email: majiajoyin@yahoo.co.in
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 Foreword

O ral biology, which includes oral anatomy, histology, physiology and

embryology is one of the most important and useful subjects among the
various basic science subjects, in the dental curriculum. Understanding
of this subject widens the mental comprehension and strengthens the basic
concepts of different dental science specialties. A thorough knowledge of this
subject is sure to mould a dental student into an effective and efficient
clinician.
I am happy that Dr Maji Jose is bringing out a textbook Essentials of
Oral Biology (Oral Anatomy, Histology, Physiology and Embryology)
for students pursuing dentistry. Visualizing the integrated perspective of the
subject, she has been successful in gathering together the diverse elements of
oral biological sciences, which in the past had been scattered throughout
many textbooks. I am sure that this book will be useful for dental students to
improve their knowledge in oral biological sciences as well as to help them to
confidently face the exam.
I hope that this work will receive the deserved attention and
encouragement from both dental students and teachers.
I wish the author and this book all success.

BH Sripathi Rao MDS

Principal
Yenepoya Dental College and Hospital
Former Executive Committee Member;
Dental Council of India
 Contributors

▪ Dr Heera R
Professor, Department of Oral Pathology
Government Dental College
Thiruvananthapuram

▪ Dr Girish KL
Professor, Department of Oral Pathology
Sri Mookambika Institute of Dental Sciences
Kulasekaram, Kanyakumari
Tamil Nadu

▪ Dr Rajeesh Mohammed PK
Professor, Department of Oral Pathology
KMCT Dental College
Mukkam, Kozhikode
Kerala

▪ Dr Usha Balan
Assistant Professor
College of Dentistry
King Khalid University
Abah, KSA

▪ Dr Ajeesha Feroz
Department of Oral Pathology
Mahe Institute of Dental Sciences
Mahe, UT of Puducherry
 Preface to Second Edition

T he textbook Essentials of Oral Biology presents all subsections of Oral

Biology in single book, described in five sections: Oral Embryology,
Oral Histology, Oral and Dental Anatomy, Oral Physiology and Allied
Topics. This text provides a comprehensive coverage of all the topics
included in the curriculum specified by Dental Council of India and various
Indian universities. Different topics are dealt in detail in 50 chapters with
flowcharts, tables and color diagrams to make learning more simple and
pleasant. This book also includes an additional section on expected questions
from each chapter, commonly asked in examinations of various Indian
universities, to assist the students in examination preparations.
This book has been designed in a way to keep the characteristics of a
standard textbook for undergraduate students. The topics are explained in
simple and lucid language. Concepts are presented in a simple and clear
manner to help an undergraduate student develop a comprehensive
knowledge in this basic science subject which makes a sound base for
learning pathologic basis of diseases.
I am gratified that original edition has received a good response. A positive
feedback on the first edition of the book and various encouraging comments
received from students and teachers, who have used the book, has encouraged
me to come out with second edition. The second edition is a revised and
updated version with flowcharts, more tables and color diagrams to further
ease the learning process. A discussion on clinical considerations is added to
each chapter in order to guide the students to clinical application of oral
biology. While preparing the second edition, I have followed the original
policy “simple presentation and lucid language” which enables a self-study.
I offer this book to the dental students, hoping that this will ensure an
enjoyable and rewarding study of oral biology.
Maji Jose
 Acknowledgements

I thank God Almighty for all the blessings He has showered on me in this
venture. The preparation of this textbook was possible only with the help
and cooperation of a number of people.
I would like to express my gratitude to Dr Sripathi Rao, Principal,
Yenepoya Dental College, for his kind words of encouragement and moral
support, received at every stage of the preparation of this book. I also thank
him for writing the Foreword to the book.
I would like to express my heartfelt thanks to Dr Heera R, faculty of Oral
Pathology, Government Dental College, Thiruvananthapuram, my teacher
and friend, for giving me all guidance, moral support, and for sharing her
knowledge at different stages of my work, and also for contribution in the
book.
I gratefully acknowledge the constant support of Dr Rajeesh Mohammed
PK, Dr Girish KL, Dr Usha Balan and Dr Ajeesha Firoz who have also
contributed chapters to this book. I am indebted to Head of the Department
and all my colleagues of Department of Oral Pathology, Yenepoya Dental
College, Mangalore, especially Dr Joshy, Dr Meera and Dr Haziel Diana
Jenifer, for their constructive suggestions and timely support.
The talented staff of CBS Publishers & Distributors deserve praise for their
role in shaping this book.
I owe a great deal of regard and gratitude to my parents, teachers and
beloved students who have played a major role in making me what I am
today. I thank my husband Mr Ajoy S. Joseph, and my children, Joe and Jiya,
who stood by me at all the stages and exhibited patience and affection which
enabled me to carry on with the work smoothly.
We would like to thank Mr S.K. Jain (CMD), Mr. Varun Jain (Director),
Mr. YN Arjuna (Senior Vice President – Publishing and Editorial), and Mr.
Ashish Dixit (Business Head – Digital Publishing, Marketing & Sales) and
his team at CBS Publishers & Distributors Pvt. Ltd. for their skill,
enthusiasm, support, patience and excellent professional approach in
producing and publishing this eBook.
Finally, I thank each and everyone whose contribution, direct or indirect,
has made the preparation of this book a pleasant task.

Maji Jose
 Syllabus

Oral Biology course includes instructions in the subject of Dental

Morphology, Oral Embryology, Oral Histology and Oral Physiology.

I. TOOTH MORPHOLOGY

1. Introduction to tooth morphology: Human dentition, types of

teeth, function, Palmer’s and binomial notation systems, tooth
surfaces, their junctions—line angles and point angles, definition of
terms used in dental morphology, geometric concepts in tooth
morphology, contact areas and embrasures—clinical significance.
2. Morphology of permanent teeth: Description of individual teeth,
including a note on their chronology of development, differences
between similar class of teeth and identification of individual teeth.
3. Morphology of deciduous teeth: Generalized differences between
deciduous and permanent teeth. Description of individual deciduous
teeth, including their chronology of development.
4. Occlusion

II. ORAL EMBRYOLOGY

1. Brief review of development of face, jaws, lip, palate, and

tongue, with applied aspects.
2. Development of teeth: Detailed study of different stages of
development of crown, root and supporting tissues of tooth and
detailed study of formation of calcified tissues. Applied aspects of
 disorders in development of teeth.
3. Eruption of deciduous and permanent teeth: Mechanisms in tooth
eruption, different theories and histology of eruption, formation of
dentogingival junction, role of gubernacular cord in eruption of
permanent teeth.
4. Shedding of teeth: Mechanisms of shedding of deciduous teeth.
Complications of shedding.

III. ORAL HISTOLOGY

1. Detailed microscopic study of enamel, dentin, cementum and

pulp tissue: Age changes.
2. Detailed microscopic study of periodontal ligament and alveolar
bone: Age changes, histological changes in periodontal ligament.
3. Detailed microscopic study of oral mucosa: Variation in structure
in relation to functional requirements, mechanisms of keratinization
clinical parts of gingiva, dentogingival and mucocutaneous junctions
and lingual papillae and age changes.
4. Salivary glands: Detailed microscopic study of acini and ductal
system.
5. TM joint: Review of basic anatomical aspects and microscopic
study.
6. Maxillary sinus: Microscopic study, functions and clinical
relevance of maxillary sinus in dental practice.
7. Processing of hard and soft tissues for microscopic study:
Ground sections, decalcified sections and routine staining
procedures.

IV. ORAL PHYSIOLOGY

1. Saliva: Composition of saliva—formation of saliva and mechanisms

of secretion, functions of saliva.
2. Mastication: Masticatory force, need for mastication, peculiarities
 of masticatory muscles, masticatory cycle, masticatory reflexes and
neural control of mastication.
3. Deglutition: Review of the steps in deglutition, swallowing in
infants, neural control of deglutition.
4. Calcium and phosphorus metabolism: Source, requirements,
absorption, distribution, functions and excretion, clinical
considerations.
5. Theories of mineralization: Definition, mechanisms, theories of
mineralization.
6. Physiology of taste: Innervation of taste buds and taste pathway,
physiologic basis of taste sensation, age changes.
7. Physiology of speech
 About the Book
Essentials of
Oral Biology
Oral Anatomy, Histology, Physiology and
Embroyology

is the completely rewritten, thoroughly revised, fairly enlarged and

prudently updated edition of the popular book. All topics of oral biology
are described in five sections: • Oral Embryology, • Oral Histology, • Oral
and Dental Anatomy, • Oral Physiology and • Allied Topics.
This text provides a comprehensive coverage of all the topics included
in the curriculum specified by Dental Council of India and various Indian
universities.
Various topics covered in 50 different chapters, revised and updated
with flowcharts, tables and colour diagrams to make learning more simple
and pleasant. A discussion on clinical considerations is added to guide the
students to clinical application of oral biology. An additional section on
expected questions of each chapter, commonly asked in examinations of
various Indian universities, will assist the students on examination
preparations.
This book is based on more than two decades of experience of the author
as a teacher and examiner of oral biology. This edition maintains the
hallmark of the earlier edition: Lucid language and simple presentation.
 About the Author

Maji Jose MDS, PhD is currently Professor and Head,

Department of Oral Pathology, Yenepoya Dental College and
Hospital, Yenepoya University, Deralakatte, Mangalore,
Karnataka. She has more than two decades of experience in
teaching oral biology and oral pathology to undergraduate and
postgraduate students in various distinguished dental colleges such as
Manipal College of Dental Sciences, KVG Dental College, Sullia, and
Yenepoya Dental College. She has been examiner for both undergraduate
and postgraduate students at various universities.
Dr Jose, well acknowledged as a teacher, examiner and researcher,
obtained PhD in 2013 from Yenepoya University and has to her credit over
50 scientific publications in Indian and international journals of repute. Her
other textbook Manual of Oral Histology and Oral Pathology (CBS) is
well accepted and widely used by dental students and teachers of many
Indian and foreign universities.
 Contents

Foreword by BH Sripathi Rao

Contributors
Preface to Second Edition
About The Book
About The Author

Section 1: Oral Embryology

1. General Embryology
2. Development of Orofacial Structures

Section 2: Oral Histology

3. Development of Tooth
4. Enamel and Amelogenesis
5. Dentin and Dentinogenesis
6. Pulp
7. Cementum and Cementogenesis
8. Periodontal Ligament
9. Alveolar Bone
10. Oral Mucosa
11. Salivary Glands
12. Temporomandibular Joint
13. Maxillary Sinus

Section 3: Oral and Dental Anatomy

14. Introduction to Dental Anatomy
15. Deciduous Maxillary Anterior Teeth
16. Deciduous Mandibular Anterior Teeth
17. Deciduous Maxillary Molars
18. Deciduous Mandibular Molars
19. Comparison between Deciduous and Permanent Dentition
20. Permanent Maxillary Central Incisors
21. Permanent Maxillary Lateral Incisors
22. Permanent Mandibular Central Incisors
23. Permanent Mandibular Lateral Incisors
24. Permanent Maxillary Canines
25. Permanent Mandibular Canines
26. Permanent Maxillary First Premolars
27. Permanent Maxillary Second Premolars
28. Permanent Mandibular First Premolars
29. Permanent Mandibular Second Premolars
30. Permanent Maxillary First Molars
31. Permanent Maxillary Second Molars
32. Permanent Maxillary Third Molars
33. Permanent Mandibular First Molars
34. Permanent Mandibular Second Molars
35. Permanent Mandibular Third Molars
36. Occlusion

Section 4: Oral Physiology

37. Eruption
38. Shedding
39. Saliva
40. Physiology of Taste and Speech
41. Mastication
42. Deglutition
43. Calcium Phosphorus Metabolism
44. Mineralization
45. Hormonal Influence on Orofacial Structures
46. Age Changes of Oral Tissues

Section 5: Allied Topics

47. Tissue Processing
48. Microscope
49. Muscles of Orofacial Region
50. Vascular and Nerve Supply of Orofacial Region
Appendix
Section 1

Oral Embryology

1. General Embryology
2. Development of Orofacial Structures
 1
General Embryology

Formation of blastocyst
Germ layers
Neural crest cells
Pharyngeal arches and pouches

E mbryology is the study of growth and differentiation which an organism

undergo during its development from a single fertilized cell to a complex
independent living being.
Every animal starts life in the form of a simple cell, i.e. the fertilized egg or
zygote. Zygote is formed by two cells, namely the germ cells of parents.
Fertilization occurs when male and female gamates (spermatozoon and
ovum) unite to form zygote.
The intrauterine life of human beings can be devided into embryonic
period which lasts for 8 weeks after fertilization which will be followed by
fetal period which continues throughout pregnancy that ends in birth
approximately after 280 days.
After fertilization, rapid proliferation of cells takes place leading to
formation of a cell mass called morula. This morula is a “golf ball” like a
little mass of cells and consists of a group of centrally placed cells termed as
inner cell mass, surrounded by a peripheral layer of cells (Fig. 1.1). Once
morula enters into the uterine cavity by 7 to 8 days, it turns into a fluid filled
structure due to seepage of fluid, which separates the inner cell mass from
peripheral layer of cells. The resultant structure is called blastocyst (Fig. 1.2).
This blastocyst is lined by a layer of cells called trophoblasts. The
trophoblasts are derived from the outer layer of morula, which later gives rise
to placenta and is also involved in implantation of the embryo. Within the
blastocyst, the inner cell mass can be seen attached to one side of the inner
aspect. This inner cell mass or embryoblasts forms the embryonic stem cells
that gives rise to embryo.

Fig. 1.1: Morula

Fig. 1.2: Blastocyst

At this stage, the blastocyst has two different types of cells. The inner cell
mass that occupies the center portion and an outer layer that surrounds this
cell mass. As the blastocyst develops further, some cells of the inner cell
mass differentiate into flattened cells and line the free surface while the other
cells change into columnar cells. The flattened cells constitute the endoderm
while the columnar cells forms the ectoderm. Thus, by 8th day of gestation
the embryo appears like a ‘bilaminar circular disc’.
As the development proceeds, in a localized area close to the future
cephalic end of the disc, flattened cells of endoderm changes into columnar
cells. This circular area where the changes takes place is called ‘prochordal
plate’. The region where the prochordal plate is formed is the head end and
opposing end is tail end of the embryo. Prochordal plate provides the disc an
antero-posterior axis and a bilateral symmetry.
After the formation of the prochordal plate, the cells of ectoderm
proliferate near the tail end, forming another structure called the primitive
streak. These proliferating cells initially form a thickening and later spread
sideways between ectoderm and endoderm forming a third layer called
mesoderm. This mesodermal layer spreads and separates the ectoderm and
endoderm throughout the disc except for the circular region of prochordal
plate. So by the 16th day, the embryonic disc has three layers: Ectoderm,
endoderm and mesoderm. These three primary germ layers give rise to
different tissues and organs of our body.

Germ Layer Derivatives

Structures of Ectodermal Origin are
Cutaneous structures
• Skin and its appendages
• Oral mucous membrane
• Enamel of teeth
Neural system-central and peripheral nerve systems

Structures of Mesodermal Origin are

Cardiovascular system—heart and blood vessels
Locomotor system—bones and muscles
Connective tissue
Components of teeth other than enamel

Structures of Endodermal Origin are

Lining epithelium of respiratory tract
Lining epithelium of alimentary tract
Secretory cells of liver and pancreas
As the development progresses, the circular disc shaped embryo becomes
elongated and pear shaped. The region of prochordal plate where ectoderm
and endoderm remain in contact forms the ‘buccopharyngeal membrane’.
The cranial end of the primitive streak thickens to form primitive node.
The cells proliferate from primitive node and extend between the ectoderm
and endoderm, along the central axis up till the prochordal plate. This forms
notochordal process or head process. Ectoderm over the notochord
differentiates to form neural plate which develops an invagination and forms
the neural tube. This neural tube extends from primitive node to prochordal
plate. The cranial part of neural tube forms the brain and caudal part forms
the spinal cord.
The enlarging embryonic disc develops folds at its head end (cranial fold),
tail end (caudal fold) and laterally, making the embryo entirely covered by
ectoderm.

Neural Crest Cells

Neural crest cells are a group of pleuripotent cells that develop from
ectoderm along the lateral margins of neural plate. These cells migrate
extensively in the developing embryo between ectoderm and endoderm and
intra-mesodermally and differentiate into different types of cells that forms
various tissues of the body.
The neural crest cells move around the sides of the developing head
beneath the surface of ectoderm as sheets of cells. They migrate and form the
entire connective tissue of upper facial region; while in the lower facial
region they migrate into already existing mesenchyme. Therefore the
connective tissue beneath the developing ectoderm in this region is called
ectomesenchyme.

Derivatives of the branchial arches, pharyngeal pouches and cranial

somites
The Structures that Develop from the Neural Crest Cells
In the head and neck region neural crest cells differentiate to form most of the
connective tissue components including bone, cartilage, dermis and tissues
that form tooth except enamel and also contributes to formation of muscles
and arteries of this region.
Neural crest cells migrate to the trunk region giving rise to neural, endocrine
and pigment producing cells. In the trunk sensory ganglions, Schwann cells
and neurons are also derived from neural crest cells.
Neural crest cells have a significant role in craniofacial development and
formation of teeth. A developmental disorder called Treacher Collin
syndrome which manifest with various craniofacial developmental defects is
caused due to defective migration of neural crest cells. Defective migration of
neural crest cells can also cause defective dentition.

Branchial Arches and Pouches

The developing oral cavity, stomatodeum is situated between the developing
brain and pericardium. In the early stages, neck is not present. Later, series of
mesodermal thickenings develop in the wall of the cranial part of foregut
resulting in the formation of neck between stomodeum and pericardium.
These cylindrical thickenings are called branchial arches or pharyngeal
arches (Fig. 1.3).
Pharyngeal arches are six in number and extend from lateral wall of
pharynx, towards the medial direction, to approach its counterpart extending
from other side. The inner aspect of each arch is covered by endoderm and
outer aspect by ectoderm. The central core is made up of mesenchyme, which
is surrounded by ectomesenchyme, which is of neural crest origin. The
endoderm extends outwards between the branchial arches in the form of
pouches called pharyngeal pouches. The pharyngeal pouches meet the
ectodermal clefts which are formed by invagination of ectoderm lining the
outer surface of the pharyngeal arches.
 Fig. 1.3: Pharyngeal arches and pouches
The mesoderm of each arch gives rise to a skeletal element (which can be
either a cartilage or bone), muscle and an arterial arch. Each pharyngeal arch
has a nerve which supplies the structures that develop from that arch.
There are six pharyngeal arches. 1st arch is named as mandibular arch,
which plays a very important role in craniofacial development.
2nd arch is hyoid arch and the 5th arch disappears soon after formation.
The remaining 3, 4, 6 arches do not have specific names.
 2
Development of Orofacial
Structures

Formation of orofacial structure

O rofacial structures develop primarily from first, second and third

branchial arches by fusion of various processes.

Formation of Face
Brain and pericardium forms two prominent bulgings on the ventral aspect of
the embryo after the head fold is formed. These two prominences are
separated by a central depression called stomatodeum which is the
developing oral cavity and is formed by an invagination of ectoderm on the
ventral surface of future head of the embryo. In the deepest part of the
stomatodeum, the lining ectoderm is in contact with endoderm of the foregut.
This combined ectoderm and endoderm constitute the buccopharyrngeal
membrane which separates the developing oral cavity from foregut. The
mesoderm of the forebrain proliferates and forms a bulge that overlaps the
upper part of stomatodeum. This downward bulge is called frontonasal
process. Face develops from the frontonasal process and the 1st pharyngeal
(mandibular) arch of each side.
The ectoderm lining the frontal process forms thickenings on both infero-
lateral borders. These are called nasal or olfactory placodes. These nasal
placodes invaginate to form nasal pit. This nasal pit is surrounded by a
horseshoe shaped ridge which is formed by rapid proliferation of underlying
mesoderm. The medial edge of this ridge is called medial nasal process and
lateral edge is called lateral nasal process and the depressed area between the
two medial nasal processes is called frontonasal process.
 At the same time the mandibular arches that form the lateral wall of
stomatodeum gives off a bud-like projection called maxillary process (on
either side). The remaining part of the mandibular arch forms the mandibular
process.
The face is derived from the five prominences that surround the
stomatodeum. These prominences are frontonasal process, pair of maxillary
processes and a pair of mandibular processes (Fig. 2.1).

Lower Lip
Lower lip develops from the mandibular processes which grow medially
towards each other and fuses at midline. This forms the lower margin of
stomatodeum. As the development continues an ectodermal proliferation
occurs which extends into the ectomesenchyme. The structure developed is
called vestibular lamina and it gives rise to a V-shaped sulcus that separates
the lip from the tooth bearing area.
 Fig. 2.1: Development of face

Upper Lip
Mandibular arch on either side gives rise to process called maxillary
processes. These processes grow forward and medially towards one another
above the stomatodeum. As they do so, these processes first fuse with lateral
nasal process and later with medial nasal process. The frontonasal process
grows downwards at a faster rate and reaches the same level that of maxillary
process. The inferolateral part of the frontonasal process is now called as
globular process. As the maxillary process grows, the frontonasal process
becomes narrower and the external nares formed by the fusion of medial and
lateral processes come closer. Both maxillary processes form the major part
of lip except for philtrum region. In this region mesoderm is derived from
frontonasal process. The ectoderm of the maxillary process overgrows this
mesoderm to meet that of the opposite side. The upper lip is separated from
the developing jaw in the same manner as that of lower lip.

Cheek
After formation of upper and lower lip the lateral margins of maxillary and
mandibular processes fuses with each other to form cheek.

FORMATION OF PALATE

During the medial growth of maxillary processes, they not only form the
upper lip but also extend backward on either side of stomatodeum. From this
backward extension of maxillary process, two plates like shelves grow
medially. These are called palatal processes (Fig. 2.2). Meanwhile the
primary palate is formed from the frontonasal process. Initially these three
structures are widely separated because of the vertical orientation of palatal
processes (lateral shelves) on either side of the tongue. During 8th week of
intrauterine development after the descent of tongue, the palatine shelves
alter their position from vertical to horizontal direction as a preparation to
their fusion. Two palatal shelves, which grows medially towards each other
and fuse in the midline and with the posterior margin of the primary palate to
form a flat and unarched roof of the mouth, separating nasal cavity from oral
cavity. Palatal shelves also fuse with nasal septum to separate two nasal
cavities. The fusing palatal shelves overlap the primary anterior palate and
the junction of union of these three palatal components is marked by incisive
papilla overlying the incisive canal.

Fig. 2.2: Development of palate

Ossification of palate starts at the 8th week of intrauterine life by
intramembranous ossification of mesoderm. The hard palate grows in length,
breadth and height and changes into an arch shaped roof for the mouth. The
apposition growth of the alveolar process also contributes to deepening as
well as widening of the vault of palate.
Ossification does not occur in the most posterior part of the palate giving
rise to the region of soft palate. Myogenic mesenchyme from the 1st, 2nd and
4th arches migrate to this region giving rise to musculature of soft palate.

Development of Tongue
The tongue develops in the ventral wall of the primitive oropharynx from the
inner lining of 1st, 2nd, 3rd and 4th pharyngeal arches (Fig. 2.3). The mucous
membrane lining the oropharynx rises into the developing oral cavity as
swellings as a result of invasion by muscle tissue from occipital somites.

Fig. 2.3: Development of tongue

During 4th week of intrauterine life, from the internal aspect of both
mandibular arches (1st branchial) mesenchymal thickenings develop which
are called lateral lingual swellings. Between and behind these lateral
swellings a median swelling named tuberculum impar appears. Immediately
behind tuberculum impar the epithelium proliferates to form a down growth
from which the thyroid develops. This structure is called thyroid diverticulum
or thyroglossal duct. The region where the thyroglossal duct originates is
marked by a depression called foramen caecum.

Lateral Lingual Swellings

Anterior 2/3rds of the tongue is formed from the mandibular arch by the
fusion of two lateral lingual swellings and tuberculum impar. As the lingual
swellings grow and fuse with each other, they over grow the tuberculum
impar and therefore the ectodermal lining of entire anterior 2/3rds is derived
from these two swellings and is of ectodermal origin. After these structures
fuses the epithelium at the periphery proliferates into the mesenchyme to
form a horseshoe shaped lamina all around. The central cells of this lamina
degenerate to form linguo-gingival groove which separate the body of the
tongue from floor of the mouth except for the region of frenum of tongue.
The posterior 1/3rd of the tongue develops from another swelling known as
hypobranchial eminence. This hypobranchial eminence is derived from 2nd,
3rd and 4th arches. The epithelial lining of posterior 1/3rd is endodermal in
origin. As the development progresses the mesoderm of the 3rd branchial
arch overgrow the mesoderm of 2nd arch and joins with mesoderm of 1st
arch. The second arch mesoderm remains buried below the surface (Fig. 2.3).
A V-shaped ‘sulcus terminalis’ demarcate the anterior 2/3rds and posterior
1/3rd of tongue. The posterior most part of the tongue is derived from the 4th
arch.
The epithelium of the tongue is derived partly from both ectoderm and
endoderm and is single layered initially which later turns to stratified
squamous epithelium. Circumvallate papillae develop by 2nd to 5th months
of intrauterine life. Fungiform papillae develop at an earlier stage by 11th
week of intrauterine life while filiform papillae develop later and
development is completed only postnatally. The taste buds develop by the
inductive interaction between epithelial cells and invading gustatory nerve
cells from chorda tympani, glossopharyngeal and vagus nerves. The mucosa
lining the posterior part of the tongue becomes pitted by deep crypts that
develop into lingual tonsil.
The muscles of the tongue have a dual origin. The intrinsic muscles
probably arise in situ in the pharyngeal arch mesenchyme while the extrinsic
muscles arise in the occipital somite region opposite to origin of hypoglossal
nerve. The muscle mass migrates forward beneath the mucosal layers of the
tongue which also carries the hypoglossal nerve.
In the initial stages of development, tongue enlarges rapidly and occupies
the whole of stomatodeum. Later as the stomatodeum increases in size the
tongue descends down allowing the palatal shelves to become horizontal. The
entire tongue is in the mouth at birth and by the 4th year posterior 1/3rd
descends down to pharynx. The size of the tongue doubles in length, width
and thickness after birth, reaching its maximal size by 8 years.

DEVELOPMENT OF MANDIBLE

Mandible develops from the mandibular process of first branchial arch. The
cartilage and the bone of the mandibular skeleton are formed from neural
crest cells. 1st branchial arch has its cartilage namely Meckel’s cartilage;
which is a solid rod of hyaline cartilage surrounded by fibrocellular tissue.
Meckel’s cartilage attains its full length after six weeks of intrauterine life
and extends from midline to the developing ear region. Meckel’s cartilage of
each arch shows an upward curve at the ventral end and is separated at the
midline by mesenchyme. A great portion of Meckel’s cartilage disappears
without contributing to formation of mandible. A small part of the ventral end
(near mental foramen) forms the accessory endochondral ossicles that are
incorporated in the mandible. The part of the cartilage extending from the
mental foramen to the lingula is not incorporated into ossification of
mandible. A part of Meckel’s cartilage transforms into sphenomandibular and
malleolar ligament. The dorsal end of Meckel’s cartilage ossifies to form
incus and malleus, two of the auditory ossicles.
The mandibular branch of trigeminal nerve is found in close association
with Meckel’s cartilage. This nerve divides into two branches: Lingual nerve
and inferior alveolar nerve. The lingual nerve travels along the medial aspect
of the cartilage and inferior alveolar nerve along the lateral aspect. More
anteriorly the inferior alveolar nerve again divide giving rise to mental and
incisive branches.
First sign of mandibular development is seen as a condensation of
ectomesenchyme in the fibrocellular tissue in the region of division of
inferior alveolar nerve to mental and incisive branches. An osteogenic
membrane is formed from this condensed ectomesenchyme that is located
lateral to cartilage where the ossification of the mandible begins. A single
ossification center for each half of the mandible arises in the 6th week of
intrauterine life. The ossification spreads from this primary center below and
around the inferior alveolar nerve and incisive branch and upwards to form
outer and inner plates with a trough between them for the nerve. The spread
of intramembranous ossification ventrally and dorsally forms the body and
ramus of mandible. As the ossification proceeds, the trough is converted into
a canal containing the nerves. As a result of formation of buccal and lingual
bony plates above the level of roof of alveolar canal the developing teeth are
found in a bony troughs which is subsequently partitioned by transverse bony
septae to form individual bony crypts. Ossification stops dorsally near the
point of division of mandibular nerve.
The ramus of the mandible develops by the spread of ossification
posteriorly into the mesenchyme turning away from Meckel’s cartilage.
Between 10th and 14th week of intrauterine life, secondary cartilage
develops, which are not related to Meckel’s cartilage which include the
condylar cartilage, the coronoid and symphyseal secondary cartilage. The
condylar cartilage gives rise to condyle and secondary cartilage of coronoid
process form part of coronoid and the secondary cartilage in mental region
form variable number of mental ossicles that are incorporated into the bone in
symphysis region. The two halves of mandible are united at midline only by
4th-12th month postnatally. The mass of cartilage is converted into bone by
endochondral ossification. A thin layer of cartilage persists in the condylar
head till the 2nd decade of life which helps in development of mandible while
the cartilage component of coronoid disappear before birth.

Alveolar Bone
By 2nd month of intrauterine life when the mandible and maxilla is being
formed the ossification extend to form a trough-like structure; to protect the
developing tooth buds. As the bone formation continues, the part of trough
occupying the tooth buds are separated from the nerve by a horizontal plate
of bone. Bony septa develop in the trough separating each tooth germ. As the
growth continues part of the alveolar bone gets incorporated into the basal
bone, adding to its height and thickness. The development of the alveolus
depends on the teeth. Alveolar process fails to develop when teeth are absent
and undergoes resorption when teeth are lost.

Maxilla
Maxilla develops from the mesenchyme of maxillary process of the 1st
branchial arch. A primary intramembranous ossification center appears for
each maxilla in the 7th week at the termination of infraorbital nerve just
above the dental lamina of developing canine. From this center, the
ossification proceeds in all directions to form different processes of maxilla.
Ossification also spreads posteriorly to the palate, forming hard palate. A
medial alveolar plate develop from the junction of body of maxilla and
palatal process which together with the lateral alveolar plate forms a trough
around the developing tooth. By the formation of bony septa these troughs
are converted into separate bony crypts occupying the developing tooth
germs.

Temporomandibular Joint
The temporomandibular joint develops from temporal and condylar blastema;
which are widely separated initially. Temporal blastema develops from the
otic capsule, a component of basicranium that forms the petrous part of the
temporal bone. The condylar blastema arises from the secondary condylar
cartilage of the mandible. Initially the temporal articular fossa is convex
which later turns to concave shape. Temporal and condylar blastema are
widely separated by mesenchyme which gradually become closer by the
growth of condyle. By 10th week of intrauterine life two clefts develop in the
interposed fibrovascular connective tissue resulting in formation of two
distinct joint cavities. The remaining strip of connective tissue becomes
articular disc. Condensation of mesenchyme around the developing joint
forms the analage of joint capsule, progressively isolating the joint with its
synovial membrane from surrounding connective tissue. Immediately after
birth, the temporomandibular joint is a lax structure with the mandibular
fossa and articular eminence forming the flat surfaces. The joint attains the
adult form by the 12th year of life.

Maxillary Sinus/Paranasal Sinuses

Paranasal sinuses include maxillary, sphenoid, frontal and ethmoid, which
begin their development as outpouching of mucous membrane of the middle
and superior nasal meatus and sphenoethmoidal recess at mound 4th month
of intrauterine life. Expansion of paranasal sinus occurs in two stages.
Primary pneumatization causes expansion of the sinus to the cartilage wall
and root of nasal fossa by growth of mucous membrane sac into maxillary,
sphenoid, frontal and ethmoid bone.
Secondary pneumatization causes enlargement of the sinus into the bone,
always retaining the communication with nasal fossa through ostea.
 At the time of birth maxillary sinus is the only paranasal sinus which is
large enough to be evident radiographically. Other sinuses are rudimentary at
the time of birth. Development of all paranasal sinuses continues in postnatal
life.

Salivary Glands
The development of salivary gland begins with proliferation of epithelium to
form a bud under the influence of underlying ectomesenchyme. The epithelial
bud undergoes further proliferation and turns into a solid chord of cells.
Multiplication of cells at the end of these chord leads to formation of bulbs,
which undergo extensive branching to form numerous bulbs. As the
development progresses canalization of the chords occurs forming a central
tube or duct. The terminal secretary acini and intercalated ducts differentiate
from the terminal ends of the branches. The connective tissue below the
epithelial chord differentiates into a capsule which surrounds the entire
glandular structure.
Parotid buds are the first to appear at 6th week of intrauterine life on the
inner cheek, near the angle of the mouth and then grow back towards the ear.
As the maxillary and mandibular processes fuse the opening of the duct is
pushed backwards.
The submandibular gland bud appears later by 6th to 8th weeks of
intrauterine life on either side of the midline in the linguo-gingival groove of
the floor of the mouth at the site of future papillae.
Sublingual gland arises in the 8th week just lateral to the submandibular
gland bud. Minor salivary glands also develop nearly at the same time.
Section 2

Oral Histology

3. Development of Tooth
4. Enamel and Amelogenesis
5. Dentin and Dentinogenesis
6. Pulp
7. Cementum
8. Periodontal Ligament
9. Alveolar Bone
10. Oral Mucosa
11. Salivary Glands
12. Temporomandibular Joint
13. Maxillary Sinus
 3
Development of Tooth

Introduction
Dental lamina
Stages in development of tooth
– Physiological stages
– Morphological stages
Root formation
Clinical considerations

D evelopment of tooth is a complex process initiated, mediated and

controlled by the interaction between ectoderm and supporting
ectomesenchyme. The epithelium lining the developing oral cavity, i.e.
stomodeum/stomatodeum, is derived from ectoderm of first branchial arch
and is composed of stratified squamous epithelium and the supporting
connective tissue is ectomesenchymal in nature which are derived from
neural crest cells.
Tooth development begins at 3rd week of intrauterine life after the
developing oral cavity establishes a communication with developing pharynx.
Rupture of buccopharyngeal membrane, i.e. a membrane formed by
juxtaposition of stomodeal ectoderm with the foregut endoderm without
supporting mesoderm, results in this communication. First sign of the tooth
development is proliferation of oral ectodermal cells to form an epithelial
thickening called primary epithelial band, that projects into the underlying
ectomesenchyme along the future tooth bearing regions of each jaw (Fig.
3.1a). Primary epithelial band forms partly because of proliferation of
epithelial cells and partly due to change in orientation of mitotic spindles of
dividing epithelial cells from parallel to a perpendicular direction. This
primary epithelial band is formed by the 6th week of intrauterine life.
The primary epithelial band continue the proliferative activity and by 7th
week, two subdivisions arise: One buccal and one lingual. The lingual
extension is dental lamina and facial or buccal extension which develop a
little later from the primary epithelial band is called vestibular lamina (Fig.
3.1b). The vestibular lamina proliferates further and form a wedge shaped
structure, the central cells of which enlarge and further undergo degeneration
forming a ‘V’ shaped cleft or vestibule. This vestibule separates the lips and
cheeks from the tooth bearing area. This vestibular lamina is also called lip
furrow band. The lingual extension, the dental lamina contributes to
formation of teeth (Fig. 3.1c).

DENTAL LAMINA

Dental lamina is the lingual subdivision that forms from the primary
epithelial band and is intimately concerned with tooth formation. The dental
lamina proliferates into the underlying ectomesenchyme and forms a U-
shaped band along the future dental arches in each jaw (Fig. 3.2). This
structure that forms in the 7th teeth (Fig. 3.1c) Localized/differential week of
intrauterine life, acts as the primor-proliferative activity at 10 specific regions
of dium for the enamel organ of the deciduous dental lamina of upper and
lower dental arches, between 6th and 8th weeks of intrauterine life, results in
formation of round or ovoid structures that protrude into the
ectomesenchyme. These dental placodes form along the dental lamina further
develop into tooth buds that gives rise to enamel organ of 10 deciduous teeth
in each arch. Later in prenatal life, permanent successors develop from the
lingual extensions that proliferate from the developing deciduous tooth
germs. These lingual extensions are called successional lamina. Successional
lamina of central incisor develops at 5th month in utero and second premolar
at 10th month of age. The permanent molars develop from the distal/posterior
extension of dental lamina, referred to as accessional lamina or parent
dental lamina or lamina of permanent molars. Permanent first molar buds
develop at 4th month of intrauterine life and second molar at 1st year and
third molar at 4th or 5th year of life.
 Fig. 3.1a: Formation of primary epithelial band

Fig. 3.1b: Vestibular lamina and dental lamina

Fig. 3.1c: Formation of tooth bud from dental lamina and vestibule from vestibular
lamina
 Fig. 3.2: U-shaped dental lamina
The activity of dental lamina starts at the midline of each arch and
progresses posteriorly. As the tooth development proceeds through various
stages, the dental lamina related to those particular tooth breaks up by
mesenchymal invasion and eventually degenerates, while it is still active in
the region of posterior teeth. Average period of activity of dental lamina is 5
years. A few remnant cells may persist even after the degeneration of dental
lamina. These remnants may be seen in connective tissue of gingiva or in the
jaw bones and are named as cell rests of Serres. These cell rests may
proliferate under certain conditions giving rise to odontogenic cysts or
tumors.

STAGES OF DEVELOPMENT OF TOOTH

Proliferation at 10 specific locations of dental lamina in each arch gives rise

to 10 knob like small swellings that project into the ectomesenchyme, each
refers to as a bud. These buds along with underlying ectomesenchyme form
the tooth germ of 10 different deciduous teeth in each dental arch.
 The tooth germ is an aggregate of different types of cells, derived from the
ectoderm of the first branchial arch and the ectomesenchyme containing the
neural crest cells. This tooth germ is the primordia for developing tooth and
eventually contribute to formation of different tissues of a tooth. These cells
of tooth germ are organized into three distinct parts, i.e. the enamel organ, the
dental papilla and the dental sac or follicle. Thus, the components of tooth
germ are:
Enamel organ: This develops from the dental lamina and hence is
ectodermal in origin and is primarily involved in formation of enamel.
Dental papilla: This component is ectomesenchymal in origin and gives rise
to dentin and pulp.
Dental follicle or sac: This is also an ectomesenchymal component and is
responsible for formation of cementum, periodontal ligament and part of the
alveolar socket.
As the tooth development proceeds, various changes are observed in
different components of the tooth germ. The enamel organ enlarges and
changes its shape to determine the shape of the tooth to be developed. Based
on the shape of the enamel organ, the developmental stages of tooth can be
divided into various morphological stages, namely bud stage, cap stage and
bell stage. As the tooth development proceeds through various morphological
stages, many physiological changes also take place in different components
of tooth germ which are named as physiological processes.

Morphological Stages
Bud stage
Cap stage
• Early cap stage
• Late cap stage
Bell stage
• Early bell stage
• Advanced bell stage

Physiological Phases
Initiation
Proliferation
Morphodifferentiation
Histodifferentiation
Apposition

PHYSIOLOGICAL PHASES AND ITS

IMPORTANCE

As the morphological changes progress in different components of tooth

germ, physiological process goes on simultaneously to ensure formation of a
normal tooth of appropriate size, shape and structure. Different physiological
changes occur concurrently in each morphological stage and this overlaps
makes a direct correlation of both these stages difficult. The physiological
process happen in a tooth germ can be considered under the following
subheadings:
Initiation: The evidence of tooth formation is observed as early as the 6th
week of intrauterine life with formation of dental lamina. At ten specific
regions of this dental lamina, bud-like structures develop, which forms the
primordium of ten deciduous teeth in each arch. Similarly, permanent teeth
also develop from lingual and distal extensions of the dental lamina. The
process of initiation is the result of epithelial mesenchymal interaction and
this decides the commencement of tooth formation. It decides the number of
teeth to be formed and their location in the dental arch.
 Any disturbance in initiation can lead to disturbance in number of teeth.
Congenital absence of teeth is due to lack of initiation which can be single or
multiple. Similarly, development of extra tooth, i.e. supernumerary tooth will
be formed due to continued budding off from the dental lamina.
Proliferation: The process of proliferation of cells begins at bud stage and
continues through bell stage. This process helps to provide adequate cells for
the further development of tooth germs and also contribute to the
determination of shape of crown.
 As with defect in initiation, a defect in proliferation in early stages of tooth
formation results in failure of tooth germ to develop further and leads to
formation of less number of teeth than normal. Lack of proliferation in later
stages may lead to formation of a tooth which is defective in size and shape.
Excessive proliferation of cells may lead large and defective teeth and
continued inherent proliferative potential of epithelial rests, may lead to
formation of odontogenic cysts and tumors.
Morphodifferentiation: It is the physiological process that ensure the normal
shape and size of the developing tooth. This process begins in cap stage and
becomes maximum at early bell stage. The process of morphodifferentiation,
as it proceed through different stages, make sure that the tooth germ is
changed from an undifferentiated stage (bud stage) to more differentiated bell
stage. Enamel organ develops an invagination in the deeper part in cap stage
which further deepens in bell stage. The shape of the tooth crown is defined
and established in early bell stage when the formative cells, i.e. ameloblasts
derived from inner enamel epithelium and odontoblasts derived from dental
papilla are arranged to outline the future dentino-enamel junction designated
by basement membrane. At this stage the basement membrane separating the
inner enamel epithelium/ameloblasts from dental papilla/odontoblasts is
called ‘membrana preformativa’ and is considered as the blue print for crown
formation as this indicate the form and size of the tooth to be formed.
 The process of morphodifferentiation continues in advanced bell stage
during root formation, when the Hertwig’s epithelial root sheath determines
the shape, size and number of roots of forming tooth.
 Disturbance in morphodifferentiation lead to abnormal form and size of
teeth. Examples are peg-shaped laterals, microdontia, macrodontia, etc.
Histodifferentiation: It is the physiologic process by which the cells undergo
morphologic and functional changes to perform their function. This stage is
the forerunner of appositional activity and the differentiated cells loose the
capacity to proliferate. Histodifferentiation begins in the cap stage and is
maximum in bell stage. During this stage, the inner enamel epithelial cells
differentiate into ameloblasts, the enamel forming cells and dental papilla
cells into odontoblasts, the dentin forming cells. Interaction between inner
enamel epithelium and dental papilla is essential for proper
histodifferentiation.
 Amelogenesis imperfecta, characterized by defective enamel formation is
caused by defective histodifferentiation of ameloblasts. Vitamin A deficiency
can also affect differentiation of ameloblasts leading to defective enamel and
dentin formation. Similarly, defective histodifferentiation of odontoblasts
results in a condition called dentinogenesis imperfecta.
Apposition: The process of rhythmic deposition of dental hard tissue is called
apposition. Once the dentino-enamel junction is established, the formative
cells start successive deposition of organic matrix which gets mineralized to
form dental hard tissues.
 Any systemic or local factors that affect the activity of ameloblasts can
cause arrest or interruption of matrix deposition or mineralization, leading to
a condition called enamel hypoplasia. Since the ameloblasts are highly
sensitive cells, enamel hypoplasia is a common condition while hypoplasia of
dentin occurs only in case of severe systemic disturbance.

MORPHOLOGICAL STAGES OF TOOTH

DEVELOPMENT

Bud Stage (Fig. 3.3)

The primordia for teeth are seen as structures budding off from the basal
layer of the oral ectoderm, lining the dental lamina. These buds form the
enamel organ of tooth germs. In this stage, the enamel organ is round or
ovoid resembling a bud and hence this stage is referred to as bud stage. The
enamel organ is separated from the surrounding connective tissue by a
distinct basement membrane. At this stage, two types of cells are seen
histologically. The cells lining the periphery of the bud are cuboidal and the
central cells are polyhedral. The cuboidal cells are continuous with the basal
layer of oral epithelium.

Fig. 3.3: Bud stage of tooth development

The ectomesenchymal cells adjacent to enamel organ undergoes
proliferation and condensation forming dental papilla which gives rise to
dentin and pulp. The peripheral portion of the condensed ectomesenchymal
cells encloses the dental papilla and enamel organ and is called dental sac or
dental follicle, which later contributes to formation of cementum, periodontal
ligament and part of alveolar socket. During this stage the dental papilla and
dental sac cannot be differentiated as distinct parts.
The cells of the enamel organ in this stage are in the physiologic phase of
proliferation.

Cap Stage (Fig. 3.4)

The cells of the enamel organ proliferate further resulting in increased size of
enamel organ. Since the growth is unequal, the tooth bud does not expand
uniformly and it gradually evolves into a cap shaped structure. This results
from an invagination that develops at its deeper part. The convex surface of
the cap faces the oral cavity. At this stage the tooth germ appears like a cap of
enamel organ sitting on a ball of dental papilla, both enclosed in a sac of
dental follicle. The physiological changes that can be appreciated are
proliferation, histodifferentiation and morphodifferentiation.
Cap stage of the tooth development is arbitrarily divided into early and late
stages solely based on phase of development of stellate reticulum, i.e. the
central cells of enamel organ are polyhedral in early stage and form a
network of stellate shaped cells in later stage.

Histology of Cap Stage

Enamel organ: In this stage the cells of the cap shaped enamel organ exhibits
distinct arrangement and shows three different types of cells.
Inner enamel/dental epithelium: The cells lining the invaginated portion of
enamel organ changes into low columnar cells and are named as inner
enamel/inner dental epithelium. This layer is separated from dental papilla by
a distinct basement membrane. The cells are attached to each other and to the
cells adjacent layers by desmosomal junctions and to the basement membrane
by hemidesmosomes.

Fig. 3.4: Cap stage of tooth development

Outer enamel/dental epithelium: The cells lining the convex portion of the
cap remain cuboidal and are named as outer enamel/outer dental epithelium.
This layer is separated from dental follicle by a distinct basement membrane.
The cells of this layer are also attached to each other by desmosomal
junctions and to the basement membrane by hemidesmosomes.
Stellate reticulum: The central cells are polyhedral in early cap stage and later
turn into star-shaped cells called stellate reticulum.

Stellate Reticulum
Stellate reticulum is layers of star-shaped cells present at the center of enamel
organ of cap and bell stage of tooth development. In cap stage, the central
cells proliferate and increase number. When this happens, the central cells
move away from its source of nutrition. So, these cells start secreting
glycosaminoglycans into the intercellular spaces. Since glycosaminoglycans
are hydrophilic, water is attracted to the intercellular spaces, leading to
widening of the intercellular compartment. Hence, the cells are forced apart
while retaining their intercellular junctions which results in the change of
polyhedral cells into starshaped cells. This gives the appearance of a network
of star-shaped cells at the center portion of the enamel organ referred to as
stellate reticulum. Stellate reticulum is also called enamel pulp. This stellate
reticulum cells undergo degeneration and collapses during bell stage.

Functions of Stellate Reticulum

Mechanical protection: The stellate reticulum with its rich content of water
and glycosaminoglycans, act as a shock absorber and protect the ameloblast
layer (inner enamel epithelium) from any type of mechanical insult.
Nutrition: Because of high glycosaminoglycans, this layer may act as a
source of nutrition to the neighboring cells, especially at the time when there
is a change in source of nutrition of ameloblasts.

Transitory Structures of Enamel Organ

The enamel organ shows the presence of some transitory or temporary
structures during the cap stage which may disappear in bell stage. These
structures may or may not be present and may not have any specific role in
tooth development. These structures are:
Enamel knot: It is a transitory cluster of non-dividing ectodermal cells,
present as knob-like projection at the deepest part of invagination of enamel
organ which partly project into the dental papilla. The primary enamel knot
forms in both incisors and molar tooth germs at the cap stage of tooth
development. Secondary and tertiary enamel knots only develop in molar
tooth germs and are seen at the sites of future cusp tips from the early bell
stage of tooth development. Enamel knot cells do not show cell division and
after their transient organizing role is complete, they undergo apoptosis at the
end of the bell stage.
 The enamel knots are thought to have significant role in tooth development
and morphogenesis. Cells of enamel knot express several signaling
molecules, together with mesenchymal signals, play important roles in
regulating the patterning of the cusps and hence the shape of the tooth crown.
Enamel cord: This structure is seen as a condensation of ectodermal cells in a
linear pattern extending from enamel knot to the outer enamel epithelium.
The attachment of the enamel cord to outer enamel epithelium is close to the
attachment of dental lamina to enamel organ. This is composed of cells with
elongated nuclei and can be easily differentiated. This enamel cord may also
be playing role in determination of crown pattern.
Enamel septum: Sometimes the enamel cord becomes thick in a bucco-
lingual direction forming a septum partly dividing the enamel organ which is
called enamel septum.
The above three structures are formed due to the rapid proliferation of the
enamel organ cells and these structures act as reservoirs of extra cells, later
contributing them to the growing enamel organ. The enamel knot and cord
may also be playing a role in determination of crown pattern.
A small invagination is seen in the area where the enamel cord joins the
outer enamel epithelium and is named as enamel navel.
Enamel niche: In histological sections of cap stage and early bell stage of
tooth development, another apparent structure is seen called as ‘Enamel
niche’. Niche by definition is a defect in an otherwise even surface. The
dental lamina is a sheet of cells with irregular depressions into which the
surrounding ectomesenchyme is packed in. So when the sections of
developing teeth are prepared in a single plane, it appear as the enamel organ
is attached to the oral epithelium by two dental laminae; one buccal and one
lingual separated by area filled with mesenchymal tissue and is referred to as
enamel niche.

Dental Papilla
The dental papilla cells undergo further proliferation and condensation during
cap stage. As the enamel organ invaginates, the dental papilla becomes partly
enclosed in the invaginated portion. Dental papilla also shows active
proliferation of blood vessels. At this stage of tooth development, dental
papilla is the main source of nutrition to the inner enamel epithelium.

Dental Follicle
The marginal condensation of the ectomesenchymal cells enclosing the dental
papilla and enamel organ becomes more conspicuous at this stage. This layer
becomes denser and fibrous, forming a well-formed structure that encloses
the enamel organ and dental papilla. This layer gives rise to cementum,
periodontal ligament and a part of alveolar socket.

BELL STAGE

Early Bell Stage (Fig. 3.5)

Different components of the tooth germ undergo further changes, which
include proliferation, histodifferentiation and morphodifferentiation so that it
enters the bell stage. During this stage the enamel organ enlarges and the
invagination deepens further to resemble a bell. Various synthetic cells
undergo differentiation in bell stage. The shape of the tooth to be formed is
also determined during this stage. Therefore histodifferentiation and
morphodifferentiation occurs in a rapid manner in bell stage.
Dental lamina which was providing an attachment of enamel organ to the
oral ectoderm undergoes degeneration and the enamel organ looses its
connection to oral ectoderm.

Histology of Early Bell Stage

Enamel organ: Enamel organ shows four distinct groups of cells during early
bell stage.
Inner enamel epithelium: The inner enamel epithelial cells undergo
histodifferentiation to form ameloblasts; the cells that synthesize enamel.
These cells are separated from dental papilla by a distinct basement
membrane, which is called membrana preformativa, which is considered as
the blue print of crown. Differentiated inner enamel epithelial cells are
columnar in shape with a length of 40 microns and width of 4 to 5 microns.
As preparation to amelogenesis, these cells develop rich cytoplasmic
organelles required for protein synthesis. The nucleus is situated at the center
of the cell. Shortly before the beginning of amelogenesis the nucleus of these
cells shifts to the proximal end (away from base), allowing the synthetic
organelles to move to the secretory end of the cell, i.e. basal region. This
phenomenon is called reversal of polarity. As the tooth germ enters into
advanced bell stage, these inner enamel epithelial cells become fully
functional ameloblasts and later changes its shape and structure according to
the function it performs. Once the enamel formation is completed it becomes
a part of reduced enamel epithelium.
Stratum intermedium: During bell stage a new layer composed of 2-3 layers
of squamous cells appear in the enamel organ, immediately above the inner
enamel epithelium. These cells are attached to each other and to adjacent
layers by desmosomes and are rich in synthetic organelles and high alkaline
phosphatase content. Therefore these cells are thought to be supporting the
ameloblasts in formation of enamel and both these cell layers are considered
as single functional unit contributing to enamel formation. Furthermore, the
absence of this layer in Hertwig’s epithelial root sheath that helps in
formation of root; also support their possible role in enamel formation. The
inability of the inner enamel epithelial cells of Hertwig’s epithelial root
sheath to perform a secretory function is probably due to the absence of
stratum intermedium in Hertwig’s epithelial root sheath. Enamel knot is
thought to be contributing cells for formation of this layer.
 Fig. 3.5: Early bell stage of tooth development
Stellate reticulum: During early bell stage this layer is well recognizable as a
network of star shaped cells with long processes anastomosing with those of
adjacent cells. The cells contain nucleus and other cytoplasmic organelles and
they are tightly attached to adjacent cells by desmosomes. Alkaline
phosphatase content is also present in these cells.
 As the tooth development progresses the stellate reticulum collapses and
reduce the distance between inner enamel epithelial cells and nutrient
capillaries located in dental follicle adjacent to outer enamel epithelium. This
is of importance as the source of nutritional supply changes after the
initiation of apposition. Later stellate reticulum completely collapses and
becomes a part of reduced enamel epithelium.
Outer enamel epithelium: The cuboidal cells forming the outer enamel
epithelium changes to flattened cells. In the early bell stage this layer forms a
regular smooth convex outer boundary of enamel organ. Before the enamel
formation starts, as stellate reticulum collapses, the outer enamel epithelium
becomes irregular and folded, allowing the capillaries in dental follicles to
become more closer to ameloblasts to ensure adequate nutritional supply.
Adjacent cells are attached to each other by desmosomes and are separated
from dental follicle by a distinct basement membrane.
Cervical loop or zone of reflection: In the cervical part of enamel organ, the
outer enamel epithelium loops inwards and joins the inner enamel epithelium
to form cervical loop. The cervical loop has only two layers; stellate
reticulum and stratum intermedium are absent between these layers of outer
and inner enamel epithelium. In advanced bell stage, after enamel formation
is complete, cervical loop proliferates giving rise to Hertwig’s epithelial root
sheath that helps in formation of root.
Dental lamina that attaches the enamel organ to the oral ectoderm starts to
degenerate in early bell stage. The remnants of this dental lamina may persist,
which are called ‘cell rests of Serres’. From the bell stage onwards the
enamel organ is not connected to oral ectoderm.
Successional lamina During early bell stage, before dental lamina begin to
degenerate, a lingual extension of dental lamina develop by proliferation of
cells in the region closer to attachment of dental lamina to the enamel organ.

Table 3.1: Layers of enamel organ in different morphologicai stages

Bud stage
Peripheral cuboidal cells
Central polyhedral cells
Cap stage
Inner enamel epithelium
Stellate reticulum
Outer enamel epithelium
Bell stage
Inner enamel epithelium
Stratum intermedium
Stellate reticulum
Outer enamel epithelium

This structure is called successional lamina and these forms the primordia
of permanent successors which go through various morphological stages and
physiological processes as the primary tooth bud, to give rise to permanent
successors.
Dental papilla In bell stage, the dental papilla becomes completely enclosed
in the invagination of enamel organ. The ectomesenchymal cells are closely
packed and interspersed with fine collagen fibers and capillaries. Dental
papilla is separated from enamel organ by basement membrane and the
basement membrane at this stage is referred to as membrana preformativa,
the blue print of crown.
During bell stage, the inner enamel epithelial cells exert an organizing
influence on the dental papilla cells adjacent to them so that a peripheral layer
of cells undergo histodifferentiation into odontoblasts, the synthetic cells of
dentin. Initially the peripheral cells arrange themselves to a distinct layer.
Later they change their shape to cuboidal and then become columnar. As a
preparation to dentin deposition, these cells develop rich cytoplasmic
synthetic organelles and nucleus shifts away from the secretory end of cells.
The remaining portion of dental papilla becomes the pulp of the formed
tooth.

Dental Sac/Follicle
The dental follicle becomes more distinct at this stage of tooth development;
with more dense fibrous component. Three distinct layers, i.e. the inner
vascular fibrocellular condensation of two to four cell layer thick, middle
loose connective tissue and outer vascular mesenchymal layer can be
appreciated in the dental follicle. The dental follicle gives rise to three
important entities: Cementoblasts forming the cementum of a tooth;
fibroblasts of developing periodontal ligament which connect teeth to the
alveolar bone and osteoblasts forming the alveolar socket.

Advanced Bell Stage (Fig. 3.6)

Once the apposition process begins, the tooth germ enters into advanced bell
stage. Dentin is the first hard tissue formed in a tooth and enamel formation
can be initiated only after a layer of dentin is deposited. During this stage,
histological evidence of enamel and dentin formation can be appreciated. As
the hard tissue formation continues the outer enamel epithelium becomes
more irregular and stellate reticulum collapses further. Dentin deposition by
differentiated odontoblasts begins at dentino-enamel junction in the region of
cusp tip, progresses inwards/pulpally and cervically. The differentiated
ameloblasts deposit enamel over dentin which starts at the incisal edge or
cusp tip at dentino-enamel junction and progresses outward and cervically.
Once the enamel and dentin formation reaches the cervical region of tooth,
root formation begins by formation of Hertwig’s epithelial root sheath from
the cervical loop of enamel organ.

Fig. 3.6: Advanced bell stage of tooth development

Once the formation of enamel is completed the columnar ameloblasts
shorten to cuboidal and along with other collapsed layers of enamel organs
form a 2-3 layered stratified epithelium which is termed as reduced enamel
epithelium (REE). This reduced enamel epithelium covers the newly formed
enamel and protects it till the tooth erupts into oral cavity and also play an
important role in establishing the dento-gingival junction.

ROOT FORMATION

Root formation (Fig. 3.7) begins in advanced bell stage after the enamel and
dentin formation reaches the cervical region at future cemento-enamel
junction. At this stage, the enamel organ at the cervical loop proliferates
giving rise to a structure called Hertwig’s epithelial root sheath (HERS).
This Hertwig’s epithelial root sheath determines the number, size and shape
of the root. As it is developing from a bilayered cervical loop, the Hertwig’s
epithelial root sheath has only two layers; inner layer of columnar cells
derived from inner enamel epithelium and outer layer of cuboidal cells
derived from outer enamel epithelium. The Hertwig’s epithelial root sheath is
supported by a basement membrane which separates this structure from the
dental papilla present at inner aspect and dental follicle present at the outer
aspect. As it proliferates, Hertwig’s epithelial root sheath bends to attain a
horizontal position to form a structure termed epithelial diaphragm. This
structure extends between dental papilla and dental sac separating both,
except for a small portion at the center. This part is the future apical foramen.
Once the epithelial diaphragm is formed, further proliferation of HERS
occurs at the proximal end adjacent to the cervical part of the tooth. This
proliferation results in the downward shift of epithelial diaphragm which
maintains the same horizontal plane. As the HERS proliferates, the cells of
dental papilla also proliferate to fill the gap created by the apical shift of
epithelial diaphragm. Meanwhile, the inner enamel epithelial cells lining the
inner aspect of HERS exert an organizing influence on adjacent dental papilla
cells to differentiate into odontoblasts. These odontoblasts begin to secrete
dentin and once a layer of radicular dentin is formed, in that region HERS
loose continuity due to invasion by proliferating dental follicle cells. At this
stage HERS appears as network of cells which eventually undergoes
degeneration to leave only few remnants. Degeneration of HERS allows the
dental follicle cells to come in contact with newly formed dentin. These
dental follicle cells that come in contact with newly formed dentin
differentiate into cementoblasts and begin to deposit cementum on the outer
surface of dentin. Radicular dentin formation continues apically and inward
while cementum formation continues apically and outward till the entire
length of the root is formed. As the cementum formation proceeds the
collagen fibers of the dental follicle get inserted into the cementum which
becomes a part of periodontal ligament. Formation of HERS and deposition
of dentin and cementum are step-by-step processes. So the entire length of
HERS cannot be appreciated in a histological section of root formation. Once
the desired length of root is formed, the lengthening of HERS stops. After
this, the inner cells of epithelial diaphragm causes differentiation of
odontoblasts adjacent to them. These odontoblasts deposit dentin along the
inner aspect of epithelial diaphragm narrowing the opening of the apical
foramen.

Fig. 3.7: Root formation

Fig. 3.8: Multiple root formation
 (Note the tongue-like extentions growing towards each other and fusing to divide the
single root into 2 or 3 roots)
The Hertwig’s epithelial root sheath do not undergo complete
degeneration, instead remnants may persist, which move away from the root
surface and remain in the periodontal ligament and are called cell rests of
Malassez. These cell rests may proliferate under certain conditions and can
give rise to pathologies like odontogenic cysts or tumors.
The roots of multirooted teeth develop in a manner similar to that of
single-rooted tooth till the furcation area. To form multiple roots, tongue-like
projections develop from the inner aspect of epithelial diaphragm, due to
differential growth, which grow towards each other and then fuse. This
results in division of single opening into two or three. The number and type
of root formed depends on the number and position of the tongue-like
projections.
Thus, the HERS helps to determine the number, size and shape of the root
and help in differentiation of odontoblast that deposit radicular dentin.
All three components of the tooth germ function together, to give rise to
various tissue component of teeth. Enamel organ, the only ectodermal
component of tooth germ perform many functions other than giving rise to
enamel.

Functions of Enamel Organ

Enamel organ determine the morphological form or the shape and size of the
crown
Inner enamel epithelial cells differentiate to form ameloblasts that deposit
enamel
Inner enamel epithelial cells helps in odontoblast differentiation
Cervical loop of enamel organ proliferates to give rise to Hertwig’s epithelial
root sheath; the structure that determines the size, shape, type and number of
roots.
Once the formative function is completed enamel organ assumes a protective
function by forming a reduced enamel epithelial layer around the newly
formed enamel.
Reduced enamel epithelium which is developed from enamel organ,
elaborates enzymes that have a role in eruption of tooth.
Reduced enamel epithelium helps in establishing a dento-gingival junction.

Clinical Considerations
The development of tooth is a complex process controlled by various
factors. Therefore this process may be disturbed by defect in genetic
control, nutritional or hormonal imbalances, infections or disturbances in
local environment where the tooth development occurs, resulting in
various anomalies. Developmental anomalies of teeth may be grouped into
those affecting number, size, shape, structure, location, etc.
1. Supernumerary teeth or hyperdontia refers to a condition where
extra teeth than normal are present in dental arch. This may develop
from an additional initiation of dental lamina near the permanent tooth
bud or by splitting of the permanent tooth bud itself. The most common
supernumerary tooth is ‘mesiodens’ occur as an extra small conical
tooth located between the two maxillary central incisors. Other
supernumerary teeth include: Distomolar situated distal to the third
molar and paramolars located either buccal or palatal to the molars.
Multiple supernumerary teeth are present in disease conditions such as
‘Gardner’s syndrome’ and ‘cleidocranial dysplasia’.
2. Anodontia or hypodontia refers to absence of all teeth, i.e. total
anodontia or some teeth, i.e. partial anodontia. True anodontia is
congenital absence of teeth which occur due to lack of initiation. The
absence of third molars is very common, followed by the second
premolar and lateral incisor. Anodontia or hypodontia is usually a
feature of a condition termed as hereditary ectodermal dysplasia.
3. Microdontia is a condition wherein the teeth are smaller and
Macrodontia is larger teeth than normal. Pituitary dwarfism causes
generalized microdontia and pituitary gigantism causes generalized
macrodontia. Peg shaped lateral incisor is the most common single
tooth that appear as microdont. The term Rhizomicry is used when the
roots are smaller than normal and Rhizomegaly refers to abnormally
larger roots. Tooth may have extra root or cusps than normally
expected referred to as supernumerary cusps or roots.
4. Disturbances affecting the shape of the teeth: Talon cusp is an
anomalous cusp-like structure projecting from the lingual aspect, in the
region of cingulum of maxillary and mandibular incisors and
Taurodontism characterized by rectangular shaped tooth resembling
that of a Bull’s tooth. Gemination is a condition that occur when a
single tooth germ divide, by an invagination resulting in incomplete
formation of two teeth. If complete division occurs giving rise to two
smaller teeth, identical in appearance, it is referred to as twinning.
Similarly, two normally separated tooth germs may fuse (join) together
to form a single large tooth. When fusion of two teeth occurs by the
deposition of cementum, it is called concrescence. Dens evaginatus is
a developmental anomaly characterized by the presence of a globule of
enamel or an extra cusp on the occlusal aspect between the buccal and
lingual cusps of premolars. Dens invaginatus (dens in dente) is a
developmental anomaly affecting the shape of the tooth which occur
due to invagination of enamel organ into the dental papilla during
odontogenesis giving rise to a tooth within a tooth appearance. Trauma
to a developing tooth germ may cause a bend or curve in the crown or
root and is referred to as dilaceration. Congenital syphilis is a bacterial
infection that may result in gross anomalies of incisors and first molars
and collectively these defects are called Hutchinson’s teeth. Central
incisors may assume a screwdriver shape and molars, a characteristic
mulberry-like appearance.
5. Amelogenesis imperfecta, dentinogenesis imperfecta, dentin
dysplasia and regional odontodysplasia are a few of the
developmental structural defects. Various environmental factors such
as fluorosis, nutritional deficiencies, infections, etc. may also disturb
odontogenesis.
6. During root formation, some of the remnants of Hertwig’s epithelial
root sheath remain attached to the root surface and may attain a
capacity to form enamel and deposit a globule enamel on surface of
root near cemento-enamel junction or close to furcation area, referred
to as enamel pearl. Similarly, degeneration of Hertwig’s epithelial root
sheath before radicular dentin formation may result in accessory root
canals.
 4
Enamel and Amelogenesis

Introduction
Physical properties and chemical composition
Amelogenesis
Structure of enamel
Clinical considerations

E namel is the hardest calcified tissue of the body covering the anatomic
crown of tooth. Enamel is a unique calcified tissue which is different
from other calcified tissues of the body.

Characteristic Features of Enamel

Ameloblasts, the enamel forming cells are ectodermal in origin
Enamel formation occurs only for a limited period of time till the desired
thickness is formed
In an erupted tooth enamel is not lined by formative cells
Enamel does not have the capacity to repair or regenerate
Enamel is a nonliving tissue not containing cells or cellular components
Enamel is avascular and insensitive
Organic matrix of enamel is unique composed of enamel protein and is non-
collagenous.

Physical Properties
Color: Ranges from grayish white to yellowish white. Yellowish white color
is appreciated where enamel is thin as it is translucent and allows the yellow
color of dentin visible through it. Translucency of enamel is related to the
high mineral content and homogeneity of enamel.
Hardness: Enamel is the hardest biologic tissue of human body and the
hardness is compared to mild steel. Hardness of enamel is 343 KHN (Knoop
Hardness Number). The high mineral content and complex crystalline
arrangement makes it very hard, suitable to resist heavy masticatory stress.
Hardness varies in different parts of same tooth with maximum at the cusp tip
and incisal edge and less in the cervical region. Similarly, surface enamel is
more harder than in deeper portion.
Brittleness: Enamel is highly brittle and tend to fracture because of less
tensile strength. Therefore resilient dentin support is very essential for the
integrity of enamel. Loss of dentin due to caries or improper cavity cutting
leads to fracture of unsupported enamel.
Thickness: Enamel thickness vary considerably over different parts of crown.
Maximum thickness (2.5 mm) is observed at the cusp tip or incisal edge and
thinnest at cervix where it ends at a feather edge. As a functional adaptation,
thickness of enamel is reported to be more in lingual aspect of maxillary
molars and buccal aspect of maxillary teeth, in relation to functional cusps.
Permeability: Enamel is semi-permeable and allows the passage of certain
molecules. Distribution of pores between and around the enamel rods is
responsible for this property of enamel. These pores permit entry of some
bacteria and bacterial products, may result in caries initiation.
Density: Enamel density varies in different parts. Density decreases from
surface to dentino-enamel junction and from incisal to cervical region.
Refractive index: Enamel is birefringent and its refractive index is 1.62.
Solubility: Enamel is soluble in acids. Solubility depends on the presence of
certain ions like fluoride. Surface enamel is less soluble.
Specific gravity: Specific gravity of enamel is 2.8.

Chemical Composition
Enamel is a highly mineralized tissue with 96% of inorganic components, in
the form of hydroxyapatite crystals; 4% of organic components, forming a
lace-like network between the crystals; and water, filling the pores between
crystals and at rod boundaries.

Inorganic Components
Calcium and phosphate in the form of hydroxyapatite crystals.
Traces of strontium, magnesium, lead and fluoride.

Organic Components
Amelogenin (90%)
Non-amelogenins (10%)
Tyrosine rich amelogenin polypeptide (TRAP) and non-amelogenin
proteins make up the major organic components.

AMELOGENESIS

Amelogenesis is the process of formation of enamel. The cells responsible for

amelogenesis are ameloblasts, which are derived from inner enamel
epithelium of enamel organ, an ectodermal component.
Ameloblasts during their life time undergo morphological and
physiological changes that are directly related to their function. These
changes can be described as life cycle of ameloblasts (Fig. 4.1).
According to the functions performed, the life cycle of ameloblasts can be
divided into:
Pre-secretory stage
• Morphogenic stage
• Organizing/differentiating stage
Secretory stage
• Formative stage
Post-secretory stages
• Maturative stage
 • Protective stage
• Desmolytic stage

Morphogenic Stage
The function of ameloblasts during this stage is determination of shape of the
tooth. The inner enamel epithelium interacts with underlying connective
tissue and through differential growth helps to establish the dentino-enamel
junction and thereby determine the shape of the tooth to be formed.
The ameloblasts at this stage are low columnar in shape with centrally
placed nucleus. Cytoplasmic organelles are not abundant, the centrioles and
Golgi complex are located at the apical part of cytoplasm and mitochondria is
evenly distributed throughout the cytoplasm.

Organizing Stage or Differentiation Stage

During this stage, the inner enamel epithelial cells undergo differentiation to
ameloblasts as a prerequisite for enamel formation. This stage is also named
as organizing stage because during this stage, the ameloblasts exert
organizing influence on dental papilla cells which are adjacent to them and
help in their differentiation to odontoblasts.
 Fig. 4.1: Life cycle of ameloblast
In the differentiation stage, the ameloblasts increase in length to attain a
length of 40 microns and also develop abundant cytoplasmic organelles
necessary for protein synthesis. As the cells elongate, the nucleus shifts to the
apical or proximal end of cell. The centrioles and Golgi apparatus also move
from apical cytoplasm to basal or distal part of the cell and mitochondria
becomes concentrated at the proximal end. This change in position of nucleus
and the other organelles is called reversal of polarity. This is a preparation to
secretion because the organelles are moved to the secretory end of the cell
which is at the basal region. The cells also develop intercellular junctions at
the proximal and distal ends which are termed as proximal and distal terminal
bars.
During the terminal phase of organizing stage the dentin formation begins
and the basal lamina supporting the ameloblast layer disintegrates.
Deposition of dentin is an important event in life cycle of ameloblasts
because the ameloblasts can attain the secretory function only after a layer of
dentin is deposited. The interdependence between ameloblasts and
odontoblasts is referred to as reciprocal induction. Ameloblasts also derive
alternate source of nutritional supply from dental sac because the dentin
deposited blocks the nutritional supply from the dental papilla.

Formative or Secretory Stage

In this stage, ameloblasts perform the function of secretion of enamel matrix
and partial mineralization. The ameloblasts which are fully differentiated
starts secretory function only after a layer of dentin is deposited. The
secretory ameloblasts are structurally suited for synthesis and secretion of
enamel proteins. The cells have many mitochondria, well developed Golgi
complex and extensive cisterns of rough endoplasmic reticulum. Cytoplasm
also shows many secretory granules, vacuoles, free ribosome, various types
of vesicles, microtubules, etc. Microtubules are involved in the movement of
secretory granules to the basal plasma membrane.

During this stage, ameloblasts synthesize enamel protein.

Steps involved are
Messenger RNA carries the message from nucleus to cytoplasm
↓
Ribosomes translate the message
↓
Protein is synthesized in rough endoplasmic reticulum
↓
Protein undergoes post-translation modification in Golgi complex
↓
Packing of protein into secretory granules

The basal portion of cytoplasm of ameloblasts contains numerous secretory

granules packed with enamel proteins. The secretory granules move towards
the basal plasma membrane, fuse with it and release the matrix protein into
the extracellular space against the newly formed dentin by a process called
exocytosis.
Secretory ameloblasts have several junctional specializations at basal and
lateral cell surfaces. At the proximal and distal end of cell body the adjacent
cells are attached to each other by junctional complexes. These intercellular
junctions help to maintain organization of ameloblast layer and also to
control the metabolite diffusion along extracellular spaces. The proximal
intercellular junctions are relatively leaky while distal ones act as a
permeability barrier to macromolecules such as enamel proteins and calcium.
Therefore calcium is prevented from reaching the matrix through
extracellular space.
In the initial stage of secretory phase the ameloblasts have a flat basal
region. After a little thickness of enamel matrix is deposited, ameloblasts
develop a conical process at the base, which is called Tomes’ process.
Tomes’ process is partially separated from cell body by an incomplete septa
formed by the microfilaments and tonofilaments extending from the distal
terminal bars. Cytoplasm of cell body is in continuation with that of Tomes’
process. The cytoplasm of Tomes’ process does not contain any organelles
other than secretory granules, microtubules, microfilament and a few
mitochondria. After the Tomes’ process is formed, the secretion of enamel
takes place from two different sites and is responsible for the rod structure of
enamel. Tomes’ process is lost before the last phase of secretory stage, before
the surface layer of enamel is deposited.

Maturative Stage
During this stage, ameloblasts helps in the mineralization and maturation of
enamel.
Ameloblasts enter into the maturative phase only after the desired
thickness of enamel matrix is laid down. In this stage, ameloblasts have to
introduce the inorganic material necessary for maturation and also reabsorb
proteins and water to provide space for the minerals. Ameloblasts performing
these dual functions shows morphological alterations. Ameloblasts are ruffle
ended when they are performing the function of introducing inorganic
components and smooth ended when they are reabsorbing proteins and water.
The series of repetitive morphological changes that occur in ameloblasts of
maturative stage, from ruffled ended to smooth ended is referred to as
ameloblast modulation. During this process, tight junctions and deep
membrane infoldings periodically appear (ruffle-ended), then disappear for
short intervals (smooth-ended), from the apical ends of the cells.
Ameloblasts in maturative phase shows slight reduction in height, decrease
in volume and organelle content. Excess synthetic organelles are removed
and the remaining organelles are shifted to the distal end of the cells. The
basal plasma membrane of the ruffle-ended ameloblasts shows a brush border
with many foldings, while that of the smooth ended ameloblasts is smooth.
The cytoplasm of ameloblasts also has vacuoles which contain material
resembling enamel matrix indicating the absorptive function of these cells.

Protective Stage
In this stage, ameloblasts along with other layers of enamel organ has to
perform a protective function. After the enamel formation is completed the
basal plasma membrane of ameloblasts looses the brush border and become
smooth. They secrete protein similar to basal lamina onto the surface of
newly formed enamel. Ameloblasts develop hemidesmosomal attachments to
these basal lamina structure which help in holding these firmly to the tooth
surface. After this, the columnar ameloblasts shorten to cuboidal and along
with other collapsed layers of enamel organs form a 2–3 layered stratified
epithelium which is termed as reduced enamel epithelium (REE). This
reduced enamel epithelium covers the newly formed enamel and protects it,
till the tooth erupts into oral cavity. This also has an important role in
establishing the dentogingival junction.
If not protected, enamel may be resorbed or cementum deposition may
occur on enamel surface.

Desmolytic Stage
In this stage the REE secretes collagenase enzyme which destroy the
connective tissue between oral mucosa and erupting tooth. This facilitates the
eruption process. During this stage the reduced enamel epithelium
proliferates and fuses with the oral epithelium to form a solid plug of
epithelial cells. The central cells of this degenerate to form a canal through
which the tooth erupts.
Amelogenesis, the process of formation of enamel involves two steps:
Matrix deposition and mineralization.

Enamel Matrix Deposition

The secretory ameloblasts which are structurally suited for synthesis and
secretion of enamel proteins, start secretory function after a layer of dentin is
deposited. The secretory granules packed with enamel proteins fuses with the
basal plasma membrane and release the matrix protein against the newly
formed dentin by a process called exocytosis. Enamel formation begins in the
cusp tips and incisal edges, from which it progresses outward and cervically.
As the matrix deposition progresses the ameloblasts move outward, away
from the matrix.
In early stages of amelogenesis the enamel matrix consists of 20–30% of
protein and the proportion of this protein gradually decreases during the
process of mineralization. Ameloblast synthesize and secrete the enamel
matrix which is composed of enamel proteins such as amelogenin and non-
amelogenin (5 to 20%). The non-amelogenin proteins include enamelin,
tuftelin, ameloblastin (amelin or sheathlin), enzymes like proteinases, etc.
Amelogenin is characterized by the presence of large amount of proline. The
enamelin contains less amount proline than amelogenin, but greater quantities
of glycine. Amelogenins are located in the intercrystalline spaces and are
postulated to be involved in control of crystal growth. Enamelins are closely
attached to the crystals surface and form an envelope around individual
crystals and have been hypothesized to have role in nucleation of enamel
crystals and crystal growth. Thus, the enamel proteins are participating in
enamel mineralization either by promoting nucleation or by regulating crystal
growth.
In addition to these proteins, enamel matrix also contains sulfated
glycoconjugates. Enamel proteinases present in the matrix help to cause
degradation of Amelogenins to facilitate its reabsorption during maturation.
Enamel matrix is devoid of both collagen and keratin.
In the initial stage of secretory phase the ameloblasts have a flat basal
region. After a little thickness of enamel matrix is deposited ameloblasts
develop a conical process at the base which is called Tomes’ process. In
secretory ameloblasts, after formation of Tomes’s process, a dual area of
secretion becomes operational. The Tomes’s process contains many secretory
granules, microtubules, microfilaments, a few mitochondria, etc. Once the
Tomes’ process is formed it extends behind the distal junctional complex and
is the only cellular site to interact with the growing enamel surface; matrix
deposition and mineral transport takes place only through this.
Enamel secretion takes place through two sites in Tomes’ process: One is
inter-rod growth region formed by the proximal end of Tomes’ process of
contiguous co-operative ameloblasts. This site is located adjacent to the distal
terminal bar all around the cell and these results in accumulation of enamel
matrix between adjacent Tomes’ process to produce inter-rod enamel. Other
site is rod growth region located at distal portion of Tomes’ process of each
individual ameloblast and this is associated with formation of enamel rod. At
the border between the rod and inter-rod enamel a sheath-like zone (prism
sheath) with slightly more concentrated organic matrix persists and it
demarcates the rod and inter-rod region. Thus, Tomes’s process is
responsible for the rod structure of enamel (Fig. 4.2). Deposition from the
proximal end precedes the deposition from distal surface. Therefore the rod
enamel is deposited into a pit created by the adjacent inter-rod enamel.

Mineralization of Enamel Matrix

Mineralization takes place in two steps: Immediate partial mineralization and
maturation.
Mineralization of enamel occurs extracellularly by the deposition of
minerals in the secreted protein matrix. During enamel formation secretory
ameloblasts are directly involved in both the production of enamel matrix and
its mineralization. Calcium required for mineralization reaches through the
circulation to tissue fluid. The calcium from tissue fluid is actively
transported into the cell where it gets attached to the calcium binding
proteins. The complex of calcium and calcium binding proteins move
towards the distal cytoplasm, where it is released and then the free calcium
ions are extruded to the enamel matrix by Ca-ATPase in the plasma
membrane of Tomes’ process.
 Fig. 4.2: Amelogenesis (deposition from site 1 forms enamel rod and from site 2 forms
inter-rod enamel. Note the difference in crystal orientation)
Mineral deposition in enamel matrix occurs in four phases. Primary
mineralization corresponds to immediate partial mineralization which
accounts for 30% of mineral deposition. The secondary stage starts at the
surface and proceeds toward dentino-enamel junction. In tertiary stage,
mineral rebounds from inner layer of enamel outward. The fourth stage is
responsible for further deposition of minerals in the surface enamel which
makes it hypermineralized than the rest of enamel.
Immediate partial mineralization: The enamel matrix undergoes immediate
partial mineralization, immediately after it is laid down. During this
immediate partial mineralization 25 to 30% of total mineral content is
deposited in the matrix. Mineralization of enamel begins at dentino-enamel
junction where the tuftelin, ameloblastin and/or enamelin proteins are
deposited on the layer of dentin. The initial enamel crystallites form a needle
or a ribbon of minerals generally oriented perpendicular to dentino-enamel
junction. Whether the initial enamel crystals are formed de novo or originate
from the dentin minerals remain controversial. After nucleation, the
ameloblasts deposit matrix rich in amelogenin. The initial enamel crystallites
elongate to produce enamel ribbons and the process continues till the entire
thickness of secreted enamel matrix.
Maturation: Maturation is characterized by gradual completion of
mineralization. During maturation, a massive re-absorption of matrix protein
and water takes place by ameloblasts, concomitant with the rapid growth of
crystallites which grow in width and thickness to make large mineral crystals
that characterizes the mature enamel. Initially the amelogenin proteins are
absorbed onto the specific crystal faces, thus controlling their growth. The
amelogenin proteins are removed from the mineralizing front by proteolytic
cleavage mediated by proteinase enzymes and is reabsorbed by endocytic
action of ameloblasts to bring about crystal growth.
In tertiary stage of mineralization, the maturation process starts at dentino
enamel junction and progresses to the surface, similarly it proceeds from cusp
or incisal tip to the cervical region.

STRUCTURE OF ENAMEL

Enamel is composed of millions of enamel rods and varying amounts of

inter-rod enamel between them.

Methods used to Study Structure of Enamel

To study the structure of enamel, a ground section should be prepared. Unlike
other hard tissues, decalcified sections cannot be used to study enamel as
major portion of enamel would be lost during decalcification because of its
high mineral content. Enamel can be studied using a light microscope or by a
polarized microscope. Electron microscope may be used to study the ultra
structure.
Light microscopic examination of ground section of enamel shows
enamel rods, various structural lines, hypocalcified structures (enamel
lamellae, tufts and spindles), dentinoenamel junction, etc.

1. Enamel Rods
Enamel rods are the fundamental structural unit of enamel; each rod is
extending from its site of origin at the dentino-enamel junction (DEJ) to the
outer surface of enamel. The enamel rods are separated by varying amounts
of inter-rod materials. The number of enamel rods varies in different teeth.
The rods are roughly cylindrical in the longitudinal section (Fig. 4.3) with an
average diameter of around 3 to 4 microns near dentino-enamel junction,
which increases gradually to the surface at a ratio of 1:2, to cover the larger
surface area of outer surface compared to DEJ.
In transverse section, the enamel rods have a keyhole shape (Fig. 4.4) with
a head formed by the rod and a tail formed by inter-rod enamel immediately
cervical to it. The rounded heads are commonly directed towards the incisal
or occlusal aspect while the tails are directed towards the cervical region of
the teeth. In enamel, the enamel rods and inter-rod enamel are arranged in
such a way that the heads abuts against the tail of adjacent rods. The width of
body of the enamel rod is approximately 5 microns in head region and 1
micron in tail, and the total length (head + tail) is approximately 9 microns.

Fig. 4.3: Longitudinal section of enamel rod with cylindrical appearance

Fig. 4.4: Keyhole shape of enamel rod in cross section

Although the predominant pattern in transverse section of enamel is
keyhole pattern, in some parts it may appear round, oval, hexagonal or even
as series of arcades resembling fish scales. (Previously enamel rods were also
referred to as enamel prisms.)

Sub-microscopic/Electron Microscopic
Structure/Ultrastructure of Enamel Rods
Enamel rods and inter-rod enamel are composed of millions of tightly packed
hydroxyapatite crystals. Apatite crystals are flattened hexagonal structures
with length ranging from 600 to 1000 Å, width of 400 Å and thickness of 250
Å. These crystals are 30 times larger than that of dentin. The direction of the
crystals is different in rods and inter-rod substance.
In the rods the apatite crystals are arranged parallel to the long axis of the
rod, especially close to the center. But as it goes to periphery the crystals
show lateral flaring (Fig. 4.5).
In the cervical 1/3rd portion of the rod, the lateral flaring goes to the extent
that the crystals become confluent with that of the inter-rod enamel located
immediately cervical to it. Thus, making the boundary between indistinct,
and inter-rod enamel appear like a tail attached to rod. In the remaining
2/3rds portion of the rod, there is marked difference in crystal orientation
between rod and adjacent inter-rod region. The inter crystalline space created
by this abrupt change in direction of apatite crystals gets filled with organic
components. The thin structure formed by the accumulation of organic
material delineating the coronal 2/3rds boundary of enamel rod is called rod
sheath. Thus, enamel rods with distinct rod sheath covering coronal 2/3rds
portion and confluent inter-rod at cervical 1/3rd portion, present keyhole
pattern in the cross section.

Fig. 4.5: Enamel rod with crystals parallel to long axis of rods and inter-rod substance
with different crystal arrangement
In the innermost portion of enamel, close to the DEJ (5 microns thickness),
enamel does not have rod structure. Similarly, in the outermost 30 microns
thick enamel, the rod structure is absent or irregular. In these regions, the
crystals are arranged uniformly with their long axis perpendicular to the
surface. This is due to the absence of Tomes’ process during the formation of
innermost and outermost enamel.

Direction of Enamel Rod

The direction of movement of secretory ameloblasts dictates the orientation
of enamel rod in mature enamel. Enamel rods are set in rows arranged
circumferentially around the long axis of the tooth. The enamel rods (Figs
4.6a and b) are horizontally arranged at the midportion of the tooth. From
midportion as it goes to occlusal aspect, rods are obliquely arranged with
inclination towards the occlusal surface and becomes vertical at the cusp tips
and incisal edges. Enamel rods follow an oblique direction along the cusp
slopes and appear to be converging in the pit and fissure region.
From the midportion as it goes cervically, enamel rods again follows an
oblique course but deviates cervically. This feature is specific for permanent
teeth. In deciduous teeth the enamel rods at the cervical region shows
horizontal arrangements or slopes occlusally (Fig. 4.7).
The angle between the DEJ and the enamel rod is about 70° and increases
to about 90° cervically, sometimes exceeding 90° in cervical region.
In general, enamel rods follow a wavy or tortuous course as it travels from
the dentinoenamel junction to the outer surface of the enamel. Therefore the
actual length of the enamel rod is more than the thickness of the enamel.
Enamel rods bend up and down in a vertical direction and right and left in a
horizontal direction. A variation in course may be noted, between adjacent
zones of rods (a zone consisting of 10–13 rods). In addition, the enamel rods
of adjacent rods may intertwine with each other in the inner 2/3rds of enamel
thickness. Any tendency of enamel rod to cleave is reduced by the wavy
pattern and nonparallelism of adjacent rows.
 Figs 4.6a and b: Direction of enamel rods in permanent teeth

Fig. 4.7: Direction of enamel rods in deciduous teeth in cervical region

2. Structural Lines
Cross striations: In longitudinal ground sections, the enamel rods appear to
be divided into uniform segments which are separated by fine dark lines.
These periodic lines are called cross striations. Cross striations are arranged
perpendicular to the enamel rods, at a regular distance of 4 μm giving them a
striated appearance. Thus, each segment is of 4 microns length, representing
the daily deposition of enamel.
 Cross striations are better appreciated, in less calcified enamel or after
application of mild acids. There are various views about this cross striations.
It reflects the daily rhythmic deposition of enamel; or created due to relation
between enamel rods and inter-rod substance; or particular orientation of
crystals within the rod. Scanning electron microscopy has revealed periodic
constrictions along the length of a rod which is responsible for cross striation.
Another view regarding these striations is these could be representing an area
of higher organic content and less inorganic content,
Incremental lines of Retzius or striae of Retzius: These are the incremental
growth lines in enamel representing the rhythmic deposition of enamel. In
longitudinal sections of enamel, striae of Retzius (Fig. 4.8) appear as series of
brownish dark lines which extend from the DEJ to the outer enamel surface.
These lines run obliquely across the enamel rods and show an occlusal
deviation as they travel to the surface. Striae of Retzius appear as concentric
circles in transverse sections of enamel, comparable to growth rings of a tree.
Each striae is separated by varying distance ranging from 20–40 microns
separating weekly increments of enamel deposition and appears to be the
result of cyclic disturbance in the rod formation occurring at every 7 to 8
days. The striae are closer and numerous in the cervical region.

Fig. 4.8: Incremental lines of Retzius

 Incremental lines of Retizus are seen encircling the dentin in the incisal or
cuspal region while at the cervical region, these striae extend to the surface
creating wave like grooves on the enamel surface which are called
perikymata or imbrication lines of Pickerill.
 Microradiographic studies have shown change in inorganic components in
the region of striae of Retzius, and therefore, are considered as a
hypomineralized structure of enamel. These lines become more prominent in
case of disturbance in enamel deposition. Shift in rod direction is also been
reported to be associated with these structures.
Neonatal line (Fig. 4.9): In the deciduous teeth and permanent first molars,
enamel is deposited partly before birth and partly after birth. The incremental
line separating the enamel deposited before birth (prenatal enamel) and
enamel deposited after birth (postnatal enamel) becomes accentuated because
of disturbance in formation that has occurred at the time of birth due to the
abrupt change in environment. This accentuated incremental line is called
neonatal line. The prenatal enamel is more homogeneous than the postnatal
enamel, probably due to more constant surroundings and good nutritional
supply. This variation in nature of pre- and postnatal enamel also may
contribute to making neonatal line prominent.

3. Gnarled enamel
This is the term used to describe an optical appearance that is seen in the
longitudinal section of the enamel at the incisal or cuspal regions. Enamel
rods follow a wavy, tortuous course (Fig. 4.10) as it travels from the
dentinoenamel junction to the outer surface. Enamel rods undulate back and
forth in a vertical direction and right and left in a horizontal direction. In
addition, the enamel rods of adjacent region may intertwine with each other
in the inner 2/3rds of enamel. This irregular twisting and intertwining is more
prominent and complex at the incisal or cuspal regions, creating this optical
appearance. The irregular twisting and intertwining may be associated with
increased strength of enamel enabling it to withstand the strong masticatory
forces.
 Fig. 4.9: Neonatal line in enamel

Fig. 4.10: Gnarled enamel

4. Hunter-Schreger Bands
This term is used to describe alternate dark and light bands found to be
extending from DEJ towards the enamel surface. These lines are curved with
the convexities facing the cervical region. Hunter-Schreger bands (Fig. 4.11)
are considered as optical phenomenon and are observed when longitudinal
section of enamel is examined under reflected light or polarized light.

Fig. 4.11: Hunter-Schreger bands

This optical effect is created due to variation in course of adjacent groups
of enamel rods and each band consists of 10–13 enamel rods. Because of this
when a section is taken some rods are cut longitudinally while some
transversely. When light passes through enamel those rods which are parallel
to light reflect light away from microscope and appear dark (diazones) and
the rods which are less parallel to light reflect, light through the microscope
and appear bright (parazones). Since the enamel rods are nearly parallel in the
outer 1/3rd of enamel, Hunter-Schreger bands do not extend to the surface
rather will be restricted to the inner 2/3rds. The position of Hunter-Schreger
bands can be reversed by altering the direction of light.
It is thought that the relatively complicated rod arrangement observed in
the region of Hunter-Schreger bands serve to reduce the propagation of
fracture.

5. Amelo-dentinal Junction or Dentino-enamel Junction

(DEJ)
The junction between the dentin and enamel is called dentino-enamel
junction (Fig. 4.12). The union of dentin with enamel is intimate without any
dividing plane between the two. The matrix of enamel intermeshes into the
surface of dentin. In microscopic sections of tooth, due to change in
orientation and difference in size of crystals, the DEJ appears distinct.
The dentino-enamel junction is scalloped with convexity facing the dentin.
The dome shaped elevations on the dentinal surface of enamel fits into
depressions on the surface of dentin. The scalloped pattern is occasionally
indistinct or even absent and is best appreciated in regions where the stresses
on tooth structure are the greatest. This scalloped junction increases the
surface area of contact between enamel and dentin and therefore strengthens
the adhesion and union between them. The scalloped dentino-enamel junction
also serves to reduce the chance of development of cracks along the junction,
because of the numerous changes in direction of DEJ.

Fig. 4.12: Dentino-enamel junction

6. Enamel Spindles
These are the spindle shaped structures, extending from the DEJ into the
enamel to a distance 10 microns. These structures are the odontoblastic
processes that are entrapped in enamel matrix. This occurs because some of
the odontoblastic processes penetrate between ameloblast cells before enamel
formation and subsequently get entrapped in the enamel matrix.
In longitudinal sections of teeth, the enamel spindles (Fig. 4.13) are seen as
dark spindle shaped structures, because the organic matrix is lost while
sectioning and is replaced by air. They are found mainly in the incisal or
cuspal region. Enamel spindles are arranged perpendicular to the dentinal
surface and may not follow the direction of enamel rods.
The enamel spindles are responsible for increased sensitivity at DEJ. These
structures are found more in incisal or cuspal region and thought to be
improving the attachment between enamel and dentin.

7. Enamel Tufts
Developmental faulting occurs in enamel prior to full maturation, probably to
release the built in strain resulting from an internal swelling pressure created
by ongoing crystal growth. Enamel tufts develop where enamel matrix
proteins migrate to fill in the faulting voids, which therefore contain reduced
minerals and enhanced organic matrix concentration. Early faulting leads to
formation of enamel tufts while late faulting produces enamel lamellae.
Enamel tufts are hypocalcified structures extending from the DEJ to the
enamel, to a distance of about 1/5th or 1/3rd of enamel thickness. These
structures are better appreciated in transverse sections of enamel. In ground
sections they appear as tuft of grass, therefore the name enamel tuft is given.
Enamel tufts (Fig. 4.14) are ribbon shaped structures with free ends
undulating to the sides. In a thick ground section, these structures originating
at different planes and curving in different directions are projected to one
plane giving the appearance of tuft of grass. Enamel tufts are seen in the
region where the prism sheath is prominent and these structures contain more
of organic contents which is similar to enamelin.

8. Enamel Lamellae
These are hypocalcified structures that extend from the enamel surface
towards the dentin to varying distance (Fig. 4.14). These structures can be
well identified as leaf like structures in transverse sections of enamel and are
seen more in the cervical half of the tooth than coronal half.
 Fig. 4.13: Enamel spindles
The enamel lamellae can be grouped based on time of development into
pre-eruptive or post-eruptive lamellae. Pre-eruptive lamellae are formed due
to stress or tension that is created during formation of enamel. When enamel
rod crosses regions of stress or tension, a small segment of the rod in that
region may remain hypocalcified or uncalcified depending on the degree of
stress. The regions remaining uncalcified manifest as a crack like defect in
formed enamel and get filled with surrounding cells.
The post-eruptive lamellae are formed due to physical or thermal insult to
which the tooth is exposed to. This leads to formation of crack like defect in
formed enamel and gets filled by organic material from saliva.
Based on the nature or content present in the defect, enamel lamellae can
be categorized into three types. They are type A, B and C.
Type A: These are composed of hypocalcified enamel rods and are restricted
to enamel.
Type B: These are crack-like defects formed due to early developmental
faulting caused by the internal swelling pressure that occur due to ongoing
crystal growth. Since these defects are formed before the eruption of tooth
they get filled with cells from surroundings. The cells in the deeper portion
degenerate, while superficial cells form cornfield cuticle or cementum like
material (depending on of the cells entering; either from enamel organ or
connective tissue), which is found in these defects. Type B lamellae may
cross DEJ and reach dentin.
Type C: These are also crack-like defects formed due to late developmental
faulting or due to various physical or thermal insult. In contrast to type B, in
this type the crack-like defects are filled with organic materials probably
derived from saliva. Type C lamellae also may reach dentin.
Enamel lamellae may be mistaken for cracks formed while making ground
sections. To differentiate both, decalcification of the ground section can be
done. The structure that remains after decalcification can be considered as
true enamel lamella.

Fig. 4.14: Enamel tufts and lamellae

Enamel lamellae are considered to be weak points in enamel which may
allow the penetration of microorganism and therefore a point of dental caries
initiation.

9. Surface Structures of Enamel

Surface enamel: Physical characteristics and chemical composition of
surface enamel is slightly different from rest of enamel. Around 30 microns
thickness of enamel found on the surface is called structureless enamel or
aprismatic enamel because it is devoid of rod structure, instead apatite
crystals are arranged parallel to each other and perpendicular to the surface.
This occurs because ameloblasts loses the Tomes’ process, which is
responsible for rod structure, before the deposition of surface layer of enamel.
This structureless enamel is found in all deciduous teeth and most of
permanent teeth and is most commonly seen in cervical region. (A layer of
structureless enamel is also seen near DEJ.)
 The surface enamel is highly mineralized, harder and less soluble than the
rest of enamel. Fluoride content of this enamel is more. This layer is of a
great clinical importance because it resists the initiation and spread of caries.
Perikymata: The surface of enamel, especially those not exposed to abrasive
forces appear corrugated with alternating horizontal ridges and troughs.
These troughs that form wave-like transverse grooves in the cervical region
of the surface of enamel are called perikymata or imbrication lines of
Pickerill (Fig. 4.15). These structures are parallel to the cemento-enamel
junction and to each other. Perikymata are the external manifestation of striae
of Retzius; therefore considered as the external manifestation of internal
layering. Perikymata is prominent in the cervical region because the striae of
Retzius in this region are incomplete and extend to the enamel surface.
Around thirty perikymata per mm is seen in the cervical region, while only
ten perikymata per mm is seen in other parts of teeth.

Fig. 4.15: Incremental lines of enamel and perikymata

Enamel rod-ends: On the surface of enamel, enamel rods may show concave
depressions of varying depth. The depth of concavity is more in rod ends of
incisal and occlusal edges and less in the cervical region.
Enamel lamellae and cracks: Since the enamel lamellae and cracks are
structures extending from surface of enamel towards DEJ, they can be
observed as surface structures, when present.
Pits and fissures: Pits and fissures are the developmental defects found in
the enamel surface associated with developmental grooves, which can act as a
site for initiation of caries.
Afibrillar cementum: Afibrillar cementum is seen on the surface of enamel
in the cervical region of tooth in the region of overlap type of cemento-
enamel junction and also in other enamel surfaces due to premature loss of
reduced enamel epithelium.
Organic structures on the surface of enamel
Enamel cuticle: Enamel cuticle is the delicate covering of organic material
found on the surface of newly erupted teeth. This delicate covering is also
called Nasmyth’s membrane. This enamel cuticle is structurally similar to
basal lamina and is secreted by the ameloblasts on the surface of newly
formed enamel which helps in attachment of the reduced enamel epithelium
to the enamel. The enamel cuticle is lost shortly after eruption of tooth.
Pellicle: Pellicle is a layer of organic materials found covering the enamel of
erupted tooth which is derived from saliva. Salivary proteins are deposited on
tooth surface within hours after mechanical cleansing. Micro-organisms from
the oral cavity colonize onto the pellicle and convert it into bacterial plaque
within one or two days.
(Age changes, refer page 320–321)

Clinical Considerations
Enamel hypoplasia: Ameloblasts are very sensitive type of cells and
therefore the function may be affected by a number of environmental as
well as hereditary conditions resulting in defective enamel formation,
which is collectively referred to as enamel hypoplasia.
a. Amelogenesis imperfecta is a hereditary type of enamel hypoplasia
which may be, 1. Hypoplastic type caused due to defective matrix
 deposition resulting in teeth with thin layer of normal enamel, 2.
Hypocalcification type with defective calcification resulting in soft
enamel that can be scrapped with blunt instrument or 3.
Hypomaturation type with defective maturation resulting in enamel
that can be scrapped with sharp instrument.
b. Environmental enamel hypoplasia: A number of environmental
conditions including nutritional deficiency, infections, endocrine
disturbances, birth injury, etc. may cause defective enamel formation.
Turner’s hypoplasia is one of the most common forms of enamel
hypoplasia occurs in permanent successor tooth due to trauma or
infection to deciduous predecessor tooth. In patients affected by
congenital syphilis, enamel deposition may be defective resulting in
characteristic Mulberry molar Ingestion of excess amounts of fluoride
can result in enamel defect known as dental fluorosis/mottled enamel.
c. Direction of enamel rods must be kept in mind during cavity
preparation for restoration, to ensure that unsupported enamel is not
left behind. Enamel rods which are not supported by dentin may break
and leads to failure of restoration. For example, as the enamel rods at
cervical part of permanent teeth are inclined cervically, a bevel has to
be prepared at gingival seat to remove unsupported enamel.
d. Enamel lamellae can act as pathway for entry of caries causing bacteria
and act as a point of caries initiation.
 5
Dentin and Dentinogenesis

Introduction
Physical properties and chemical composition
Dentinogenesis
Microscopic structure of dentin
Age changes in dentin
Dentin sensitivity
Clinical considerations

D entin is a mineralized connective tissue component of the tooth that

makes up the bulk of the tooth and is located between pulp and external
surface tissues. Dentin is covered by enamel in the crown region and by
cementum in root region. Physically and chemically, dentin resembles bone;
but unlike bone, dentin is avascular and do not contain entrapped cells.
Dentin together with pulp is considered as a functional complex and denoted
as dentin-pulp complex. Dentin is different from enamel in various aspects
(Table 5.1).

Physical Properties of Dentin

Color: It is yellowish and this impart color to the tooth because it is visible
through translucent enamel. Color of dentin darkens as age advances.
Thickness: Usually ranges from 3 to 10 mm. Dentin thickness vary in
different teeth and in different aspects of the same tooth; reported to be
thicker on buccal aspect than lingual.
Hardness: Dentin is much softer than enamel and the hardness is only 68
KHN compared to 343 KHN of enamel. Therefore dentin wears off much
faster than enamel. Dentin hardness varies in different parts, with more hard
at the central portion than pulpal and peripheral regions. Dentin is harder than
cementum and bone.
Elasticity: Dentin has a high degree of elasticity which makes it flexible. The
modulus of elasticity is approximately 1.79 × 106 lb/in. The peripheral layer
of dentin which is more resilient, has significant functional importance
because it allows dissipation of stress/forces and thus dentin function as
shock absorber for the overlying brittle enamel. This explains why the
enamel unsupported by dentin fracture when exposed to masticatory stress.
Density: The average density of dentin is approximately 2.1 gm/ml.
Radio density: Dentin is more radiolucent than enamel due to less mineral
content.
Permeability: Because of dentinal tubules, dentin is highly permeable and
permeability depends on patency of the tubules. In conditions when the
tubules are blocked, permeability decreases considerably.

Chemical Composition of Dentin

Dentin consists of 65% inorganic components, 20% organic components,
15% water.

Dentin and Dentinogenesis

Table 5.1: Comparison between enamel and dentin
Enamel Dentin
Ectodermal in origin, formed by Ectomesenchymal in origin, formed
ameloblasts derived from enamel by odontoblasts derived from dental
organ papilla

Formation is limited to a limited Formation of dentin is a lifelong

period process

High mineral content: 96% Mineral content is less: 65%

 Hydroxyapatite crystals are larger Apatite crystals are smaller

Organic content is unique with Collagen is the main organic content

enamel proteins: Collagen is
absent

Non living tissue; do not contain Living tissue; contain cytoplasmic

cells or cellular components extensions of odontoblasts

Do not respond to stimuli, do not Respond to stimuli, and have capacity

have capacity to repair or to repair and regenerate
regenerate

Found only in coronal region Found in both crown and root

Inorganic components are mainly calcium and phosphate in the form of

hydroxyapatite crystals. Small amounts of carbonate, sulfate, calcium
hydroxide and trace elements such as copper, fluoride, iron, zinc, etc. are also
present.
Apatite crystals are described as calcium deficient carbonate apatite of
which crystal size is smaller than that of enamel and larger than that of bone
and cementum. Crystals are plate shaped having length of 200–1000 Å and
width of about 30 Å.
Good to Know
In the early stages of odontogenesis, the dental papilla cells will be actively
dividing. During the last mitosis, the daughter cells located near or in
contact with the basement membrane become pre-secretory odontoblasts.
Initially these cells are roughly parallel to the basement membrane, but
after a short period, they align with long axis, right angles to the basement
membrane, as a palisade-like structure. The cells located beneath, form the
subodontoblast/Hoehl’s layer which constitute a reservoir for the renewal
of odontoblasts.
When odontoblasts are differentiated, they undergo polarization with
migration of nucleus to basal region and Golgi apparatus from the basal
part to a supranuclear area. Cells also develop cytoskeletal proteins, and
junctional distal complex comprising desmosome-like junctions, gap-
 junctions and in some species, tight junctions. These junctional complexes
constitute a permeability membrane, and intercellular diffusions are
restricted to molecules with small molecular weight. Fenestrated capillaries
infiltrate the odontoblast layer which permits the precursors of intracellular
and extracellular matrix molecules to cross the space between endothelial
cells and the basement membrane.
The terminal polarization leads to the partition between cell body
containing rich synthetic organelles such as rough endoplasmic reticulum,
Golgi apparatus, immature and mature secretory vesicles, lysosomes, and a
long process protruding in the pre-dentin and adhering to the dentinal walls
of the tubules.
The role of odontoblasts in dentinogenesis is crucial. It is observed that
the secretion occurs through two sites, i.e. the proximal pre-dentin or at the
distal pre-dentin—inner dentin edge. The former site releases collagen
fibrils and their associated proteoglycans in pre-dentin, while the latter
discharges non-collagenous phosphorylated proteins and mineral
associated proteoglycans that are secreted at the mineralization front. Some
matrix components migrate directly from the serum to the dentin
compartment. They follow mainly an intercellular pathway, albumin and
phospholipids being implicated in the transport of minerals. [Goldberg M,
Kulkarni AB, Young M, Boskey A. Dentin: Structure, Composition and
Mineralization: The role of dentin ECM in dentin formation and
mineralization. Front Biosci, 2011; 3: 711–735].

90% of organic components of dentin comprises collagen fibers; majority

being type I, with trace amounts of type III and V. The dentin matrix also
contains proteins and proteoglycans referred to as non-collagenous proteins.
Major non-collagenous proteins are phosphophorin, dentin matrix protein-I
and dentin sialoproteins and dentin glycoproteins. In addition, osteonectin,
osteopondin, bone morphogenic proteins and growth factors like
transforming growth factors, fibroblast growth factors and insulin-like growth
factors are also present. These non-collagenous proteins participate in
initiation of dentin mineralization and control the growth of apatite crystals.

DENTINOGENESIS
The process of formation of dentin is called dentinogenesis. The cells that
form dentin are odontoblasts, which are derived from dental papilla, which in
turn, is an ectomesenchymal component of tooth germ.
In the early bell stage the cells of dental papilla adjacent to inner enamel
epithelium align to form a distinct layer. Initially these cells become cuboidal
and later turn to columnar cells utilizing the acellular space between inner
enamel epithelium and dental papilla. These cells develop rich cytoplasmic
organelles for protein synthesis and the nucleus shift from the center to the
basal region. These cells form odontoblast layer that deposit dentin later. The
differentiation of odontoblasts occurs under the organizing influence of inner
enamel epithelium.

Formation of dentin involves two steps

Deposition of matrix which includes collagen and ground substance

Mineralization

Matrix Deposition
Mantle dentin: During the initial stage of dentin deposition, odontoblasts are
not grown to its full size and have space in between, containing ground
substance of dental papilla (Fig. 5.1a). To this pre-existing ground substance
of dental papilla, odontoblasts deposit collagen which together form the
organic matrix of the first formed dentin. The first formed dentin is referred
to as mantle dentin. The collagen fibers deposited are large diameter (0.1–0.2
pm), discrete and arranged perpendicular to the basement membrane. After
the deposition of collagen odontoblasts leave out many matrix vesicles which
help in initiation of mineralization. As the deposition of dentin matrix
proceeds the odontoblasts move inwards pulpally, leaving behind its
cytoplasmic process, referred to as Tomes’ fibers. These cytoplasmic
extensions can be seen in mineralized dentin as odontoblast processes in
dentinal tubules.
Good to Know
The term ‘Von Korff fibers’ is used to describe silver-staining ‘fiber
bundles’, presumed to be collagenous, seen with the light microscope,
which seem to arise from the sub-odontoblast zone of the dental papilla,
pass between the odontoblasts, and fan out to form the fibrous matrix of
the first formed, or mantle dentin, von Korff inl905 demonstrated these
argyrophilic fibers and therefore the term Von Korff fibers’. These fibers
were considered to be aligned parallel to the dentinal tubules in mantle
dentin, whereas in the collagen fibers of circumpulpal dentin lie at right
angles to the tubules.
Later, Ten Cate et al. (1970) concluded that von Korff fiber is an artefact
of light microscopy, created by the deposition of silver in the extracellular
compartment. The reducing sugars in an extensive extracellular
compartment between widely separated pre-odontoblasts, take up the silver
stain, giving a false appearance of black argyrophilic fibers. On this basis,
with continued hypertrophy of the odontoblasts, and the exclusion ofthis
extracellular compartment, the well-recognized reduction in the number of
the so-called von Korff fibers during circumpulpal dentinogenesis was
justifiable. From his research findings, he concluded that classical
collagenous von Korff fibers do not exist and are artefacts. However,
mantle dentin has large diameter collagen fibrils, lying parallel to the
dentinal tubules. Whether it is worth retaining the term von Korff fibers for
these large diameter fibers in dentin is a matter of discussion, as recent
evidence suggests that all dentinal collagen is the product of odontoblastic
activity.
(Ten Cate AR. A fine structural study of coronal and root dentinogenesis in
the mouse: observations on the so-called Von Korff fibers’ and their
contribution to mantle dentin. J. Anat. 1978; 125(1): 183–97)
 Fig. 5.1a: Mantle dentin formation
(Note: The large diameter collagen, perpendicular to dentino-enamel junction)
Circumpulpal dentin: After deposition of mantle dentin the odontoblasts
enlarge and get fully differentiated, obliterating the space between them. This
makes it essential for the odontoblasts to secrete both collagen and ground
substance to form organic matrix (Fig. 5.1b). These collagen fibers deposited
are small diameter (50–200 nm), arranged in closely packed bundles which
are parallel to the basement membrane. Odontoblasts do not release matrix
vesicles rather secrete further components such as lipids, phosphoproteins,
etc. to the matrix which may have role in mineralization. The dentin
formation proceeds in the same manner throughout life of the tooth. The rate
of dentin formation is around 4 microns/day till the crown completion which
slows down to 1 micron/day till crown completion. Afterwards it becomes a
slow process which continues throughout life.
 Fig. 5.1b: Formation of circumpulpal dentin
(Note: The difference in the type and arrangement of collagen in mantle dentin and
circumpulpal dentin)

Mineralization
For proper mineralization of dentin, three components are necessary, namely
(i) collagen which forms a scaffold, (ii) non-collagenous proteins that bind to
the collagen template and function as a mineral nucleator, and (iii) crystalline
calcium phosphate deposited in an ordered manner. Non-collagenous dentin
matrix proteins 1 and 2 and dentin sialoprotein are important during
mineralized tissue formation. These highly phosphorylated dentin
phosphoproteins (phosphophoryn) are capable of inducing the formation of
hydroxyapatite and can also inhibit mineral growth and regulate crystal size.
Different patterns of mineralization observed in dentin are linear pattern,
globular pattern, and a combination of the two. Linear calcification
primarily found in the mantle dentin, where the deposition of crystals occurs
along an uninterrupted front. Globular, or calcospheric calcification refers to
the deposition of crystals in several areas of the matrix at same time. Crystal
growth takes place in the form of globular or calcopheric mass. These
globular mass enlarges by addition of more crystals and eventually fuses
together to form a homogenous mineralized dentin; failure of which leads to
formation of interglobular dentin. This type of mineralization is seen
principally in the circumpulpal dentin formed just below mantle dentin. The
size of globular mass depends on rate of deposition. As the rate of dentin
formation decreases the size of globules progressively reduces so that
mineralizing front gets a linear pattern giving a relatively smooth surface.
Thus, in the rest of the circumpulpal dentin, a combined pattern of
calcification occurs with a globular phase alternating with a linear phase.

TYPES OF DENTIN

Based on time of formation

Primary dentin
• Mantle dentin
• Circumpulpal dentin
Secondary dentin
Based on stimulus that evokes dentin formation
Physiological dentin: Primary and secondary dentin
Response dentin/tertiary dentin
• Reactive dentin
• Reparative dentin
 • Sclerotic dentin
Based on the relation to dentinal tubules
Peritubular/intratubular dentin
Intertubular dentin
Other types
Pre-dentin
Interglobular dentin
Osteodentin

Primary Dentin
The physiological dentin that is formed till the root formation is completed is
referred to as primary dentin. This primary dentin forms the major part of
dentin, both in crown and root. Primary dentin consists of two different types.
Mantle dentin: This is the portion of primary dentin found at the outermost
portions adjacent to dentino-enamel junction and dentino-cemental junction.
This is the first formed dentin and is roughly of 20 microns thickness. This
layer extends from DEJ up to the zone of interglobular dentin. This layer is
different from rest of primary dentin in that, it contains collagen fibers which
are of large diameter, loosely packed and arranged perpendicular to dentino-
enamel junction. The large diameter collagen bundles observed in early
mantle dentin formation, which are extending from the region between
odontoblasts and fanning out to end near the basal region of ameloblasts is
referred to as von Korff’s fibers. The ground substance is derived from dental
papilla which lacks phosphophoryn. The mantle dentin has high organic
component and is slightly less mineralized than rest of dentin (around 4%).
Mantle dentin is better formed with fewer defects.
Circumpulpal dentin: Circumpulpal dentin forms the remaining part of
primary dentin which makes up the bulk of dentin. Circumpulpal dentin is
composed of organic matrix and closely packed, smaller (50–200 nm)
diameter collagen fibers which are arranged parallel to dentino-enamel
junction. The ground substance is also secreted by odontoblasts which
contain phosphophoryn. Circumpulpal dentin is 4% more mineralized than
mantle dentin and may show mineralization defects referred to as
interglobular dentin. Circumpulpal dentin also include the physiological
secondary dentin.

Secondary Dentin
Although at a slower rate, dentin deposition continues throughout the life of
the tooth. The physiological dentin that is formed after root completion as a
part of continuous, lifelong deposition of dentin is referred to as secondary
dentin. This designation is specifically used for part of physiological dentin
that is formed after root formation and is located internally to primary dentin
in crown and root. Although the number of tubules is lesser than in primary
dentin, secondary dentin has regular tubular structure; therefore the term
regular secondary dentin is also used to designate this type of dentin. The
continuous formation of secondary dentin reduces the size of the pulp
chamber gradually. The rate of deposition of secondary dentin is more at the
roof and floor of the pulp chamber causing reduction in the size of the pulp
chamber and decrease in height of pulp horn.

Tertiary Dentin
This is also referred to as irregular secondary dentin, reactive or reparative
dentin which is formed in response to stimuli such as attrition, abrasion,
erosion, cavity preparation, etc. Tertiary dentin in contrast to physiological
secondary dentin is deposited on the pulpal surface of dentin only in the
affected area.

STRUCTURE OF DENTIN

Dentin is a mesenchyme derived mineralized tissue composed of numerous

dentinal tubules surrounded by highly mineralized peritubular dentin,
embedded within a relatively less mineralized collagen matrix called
intertubular dentin.
The microscopic structure of dentin can be studied using ground sections
or decalcified sections. The structures that can he appreciated in dentin on
microscopic examination are dentinal tubules, peritubular and intertubular
dentin, interglobular dentin, Tomes’ granular layer, structural lines and
other age and functional changes. Along with these, the dentino-enamel and
dentino-cemental junctions also can be appreciated.

1. Dentinal Tubules
Dentinal tubules are basic structural and functional units of dentin. It is
tubular or canallike branched structures extending from pulpal end to the
dentino-enamel/dentino-cemental junction. Dentin is composed of numerous
dentinal tubules housing protoplasmic processes of odontoblasts.

Characteristics of Dentinal Tubules (Fig. 5.2)

Dentinal tubules do not follow a straight course but has a curved morphology.
In longitudinal sections dentinal tubules have a shallow S-shaped curvature
(Fig. 5.3). The S shape of tubule is described as primary curvature of dentinal
tubules. The first convexity of this primary curvature from the pulpal side is
in an apical direction and the second convexity towards the crown. The
curved path is more clearly evident in coronal and cervical region of the
teeth. In radicular dentin the curvature is less distinct and may be even
absent.
When observed under higher magnification dentinal tubules also show
minute undulations or a wavy course all along its length. These are referred
to as secondary curvatures which may be the result of spiral course taken by
odontoblasts as it move pulpally during dentin formation.
Dentinal tubules show a ‘Y’ shaped terminal branching near the dentino-
enamel junction The branches fork off at an angle of 45°. Extensive terminal
branching and looping of dentinal tubules are seen in root dentin.
Dentinal tubules show lateral branches along its course at a distance of 1–2
microns and are referred to as canaliculi or microtubules. The lateral branches
are of 1 micron diameter and are somewhat perpendicular to the main tubule.
These branches may contain odontoblast process and they may communicate
with those of adjacent ones or blindly end in the intertubular dentin.
 Fig. 5.2: Characteristics of dentinal tubule
Dentinal tubules have a tapered morphology or inverted cone shape with the
smallest diameter at dentino-enamel junction and larger diameter on the
pulpal end near the cell body of odontoblasts. The dentinal tubules converge
at a ratio of 5:1 with an average diameter at pulpal end is 3–4 microns and 1
micron at dentinoenamel junction.
The density of dentinal tubules is more at the pulpal end than near dentino-
enamel junction with more number of tubules per unit area at the pulpal end
compared to periphery. The ratio of tubules of peripheral dentin to the pulpal
region may vary from 1 : 2 to 1 : 5. The tubule population is approximately
15,000/mm2 near the dentino-enamel junction which increases towards the
pulp up to 30,000 to 75,000/mm2. The number of tubules in radicular dentin
is lesser than of coronal dentin.
In a transverse section dentinal tubules are seen as circular space surrounded
by a hypermineralized zone of peritubular dentin. The inner aspect of the
tubule is lined by an organic layer of extracellular in nature, with high content
of glycosaminoglycan, which is referred to as lamina limitans.
Dentinal tubules contain odontoblast process, nonmyelinated nerve fibers,
and dental lymph (tissue fluid in the periodontoblast space). The dental
lymph is hypotonic with relatively low Na+ and high K+ and contains a few
collagen fibers, apatite crystals, plasma proteins, etc.
Fluid filled dentinal tubules are important in hydraulically transferring and
relieving stresses imparted to dentin through the supporting structures of the
periodontium and enamel. This may explain why endodontically treated teeth
are more brittle than vital teeth.

Odontoblast Processes
In vital teeth, the odontoblasts are arranged as a continuous layer along the
periphery of pulp adjacent to pulpal surface of dentin. Each cell has a
protoplasmic process that extends for varying distance into the dentinal
tubule. These extensions are referred to as odontoblast processes and are the
major content of dentinal tubules. These processes are of 3–4 microns in
diameter at pulpal end and taper to 1 μ near the periphery. Each process has
many fine branches along its entire length and lie in the corresponding lateral
branches of the tubules.
 Fig. 5.3: S-shaped dentinal tubules
The odontoblasts processes contain a fine network of microfilaments (5–
7.5 μm) and microtubules (20 μm) running longitudinally. Cytoplasmic
organelles such as ribosomes, endoplasmic reticulum, mitochondria, ly
sosomes and micro vesicles are also seen in odontoblast processes especially
in the portion closer to cell body. Presence of vesicles indicates a secretory
function of odontoblast processes and is responsible for formation of
peritubular dentin.
The question of the length of the process remains unanswered. Formerly, it
was assumed that the processes reach the dentinoenamel junctions. It is,
however, possible that the processes withdraw, but some nonfunctional
remnants of the process may remain, adhering to the tubule wall.
The distance to which the odontoblast processes extend into dentin is
subjected to much research. Recent electron microscopic studies have
confirmed their presence up to the outer surface of dentin till the
dentinoenamel junction. But they do not follow a regular pattern. In certain
region of the tooth these processes may extend beyond the dentinoenamel
junction and remain in calcified enamel and are referred to as enamel
spindles.

2. Peritubular or Intratubular Dentin

Peritubular dentin is a zone of hypermineralized dentin which surrounds the
dentinal tubule (Fig. 5.4). This is also referred to as intratubular dentin
(dentin inside the tubule) because it is formed by the deposition along the
inner aspect of dentinal tubules.
Peritubular dentin is deposited by the odontoblast process and is 40% more
mineralized and also harder than the rest of dentin. Microradiographs show
the peritubular dentin to be more radiopaque than intertubular dentin
indicating a higher mineral content. The peritubular dentin is more
homogeneously mineralized with smaller tightly packed appetite crystals and
organic components. Albumin, glycoprotein, choline-rich phospholipids
contribute to the formation of a highly mineralized dense ring reinforcing the
tubule, where there is a little or no collagen.

Fig. 5.4: Cross-section of dentinal tubules with peritubular and intertubular dentin
The width of peritubular dentin is highest near dentino-enamel junction
(0.75 μm) and progressively decreases in a pulpward direction (0.4 μm). In
pre-dentin the zone of peritubular dentin is absent. Because it is
hypermineralized, in ground sections of teeth, the zone of peritubular dentin
appear lighter when compared to somewhat darker intertubular dentin and is
seen as a clear transparent ring around each tubule lumen. In decalcified
section peritubular dentin is lost and is represented by a space because of
which the dentinal tubules appear larger.

3. Intertubular Dentin
The major bulk of dentin present between the dentinal tubules, i.e. between
the zones of peritubular dentin is called intertubular dentin (Table 5.2). This
dentin is less mineralized than peritubular dentin. The thickness of
intertubular dentin is highest in the region of dentino-enamel junction where
the dentinal tubules are widely separated.
 Intertubular dentin is formed by cell body of odontoblasts and is composed
of organic components and apatite crystals, and is arranged in bundles almost
perpendicular to the dentin tubules and the apatite crystals are deposited
along the fibers with long axis of crystals parallel to the long axis of fibers.
Although highly mineralized, intertubular dentin is retained after
decalcification.

Table 5.2: Differences between infra- and intertubular dentin

Peri-/Intratubular dentin
Restricted to around/within the lumen Makes up the major bulk of
of the tubules which makes up only
about 10–20% of total dentin bulk
Deposition occur through odontoblast
process
Contains a little or no collagen
Extracellular matrix consists of
noncollagenous proteins and some
plasma proteins
High mineral content, therefore more
radiopaque and harder
Apatite crystals are smaller closely
packed, isodiametric structures about
25 nm in diameter.
They form a ring around the lumen of
the tubules
Peritubular dentin is lost after
decalcification due to high mineral
content
Mineralization process does not
involve transformation of pre-dentin
Intertubular dentin
dentin, located between the
dentinal tubules
Deposition occur through cell
body
Collagen forms the major organic
component (90%)
Mineral content is slightly lesser
than peritubular dentin, therefore
radiodensity and hardness is
lesser
Plate-like crystallites, 2–5 nm in
thickness and 60 nm in length
located either at the surface the
collagen fibrils, parallel with the
collagen fibril axis; or randomly
fill interfibrillar spaces
Demineralization of intertubular
dentin reveals a dense network of
collagen fibrils, coated by
noncollagenous proteins
glycosaminoglycans
The formation of intertubular
dentin involves, the immature
 into dentin, rather mineralization of pre-dentin layer formation by a
amorphous matrix secreted by the layer of odontoblasts, followed
odontoblast processes or taking origin by mineralization
from the serum (dentinal lymph)

4. Interglobular Dentin
The mineralization of dentin begin as calcospheric or globular masses. These
globular masses enlarge by peripheral addition of new crystallites and
eventually fuses together to form a homogeneous calcified mass, i.e. the
mineralized dentin. Sometimes, few of the globular masses remain discrete
and fail to fuse with each other retaining areas of uncalcified or hypocalcified
dentin matrix between them. The term interglobular dentin is used to describe
these uncalcified or hypocalcified zone that exists in mineralized dentin
matrix. Generally the interglobular dentin has a star shape or they have the
curved outlines of globular masses (Fig. 5.5a).
This type of mineralization defects are seen in the coronal circumpulpal
dentin immediately beneath the mantle dentin and this follows an incremental
pattern. It is not unusual for the interglobular dentin to extend to radicular
dentin, to some extent especially in the cervical portion. In the region of
interglobular dentin, the dentinal tubules traverse uninterruptedly (Fig. 5.5b)
indicating that this is purely a mineralization defect and not a defect in matrix
deposition. The dentinal tubules passing this zone do not show peritubular
dentin covering that portion of its course.
While preparing the sections, the organic matrix in the interglobular dentin
is lost and these areas get filled with air. Therefore in ground sections, the
interglobular dentin appear dark under transmitted light and bright under
reflected light.
 Fig. 5.5a: Interglobular dentin

Fig. 5.5b: Interglobular dentin

(Note: The dentinal tubule and absence of peritubular dentin)

5. Granular Dentin or Tomes’ Granular Layer

In longitudinal ground sections of tooth a peripheral layer of radicular dentin
adjacent to cementum appears granular. This layer is termed as Tomes’
granular layer (Fig. 5.6). This layer increases in thickness from
dentinoenamel junction towards the apex. The exact nature of this layer is not
known. Previously it was thought that this layer is composed of many minute
interglobular dentin caused by some interference with mineralization in this
area. But electron microscopic examination failed to reveal any organic
content in this area. A more recent view is that these granules represent true
spaces created by extensive looping and coalescing terminal portions of
dentinal tubules, possibly resulting from turning of odontoblasts on
themselves during early dentin formation. While sectioning these dentinal
tubules are exposed and get filled with air and therefore appear as small dark
spaces giving a granular appearance. Under transmitted light Tomes’ granular
layer appear dark and under reflected light bright.

Fig. 5.6: Tonnes’ granular layer

6. Structural Lines
Incremental lines: Dentin formation is a rhythmic process with alternating
periods of activity and rest. This cyclic process is registered as incremental
lines which are perpendicular to the dentinal tubules. These incremental lines
in dentin are called imbrication lines/incremental lines of von Ebner. The
dentin matrix is deposited in daily increments of approximately 4
microns/day. The incremental lines correspond to the rest period and separate
each increment of dentin that is formed. Since the rate of deposition vary in
different teeth and in different regions of the same tooth, the distance
between the incremental lines also vary. These lines are closer in the
radicular region than coronal region.
 During dentinogenesis, the matrix that is deposited for four or more days
enter into calcifying period at the same time. The incremental lines separating
these adjacent bands of matrix calcifying at different times are more
prominent and are termed as contour lines of Owen (Fig. 5.7). These contour
lines of Owen are hypomineralized areas and some people believe that these
are incremental lines that are accentuated due to disturbance in
mineralization.
Neonatal line: In all deciduous teeth and in permanent first molars, part of
dentin is formed before and part is formed after birth. The prenatal and
postnatal dentin is separated by a distinct incremental line called neonatal
line. This is formed due to disturbance in mineralization as a result of change
in environment at the time of birth.

Fig. 5.7: Incremental lines of dentin

Good to Know
The exact nature of Tomes’ granular layer is not known. Previously it
was considered as hypomineralized area of radicular dentin, composed of
many minute interglobular dentin. Later these granules were thought to
represent true spaces created by extensive looping and coalescing terminal
portions of dentinal tubules at cemento-dentinal junction. A recent study
by Kagayama et al., using confocal microscopy, demonstrated fluorescent
fibers running parallel to the surface of dentin in the longitudinal sections
in the granules of Tomes’ layer. From these results the researchers
concluded that Tomes’ granular layer may be the collagen fiber bundles
that remained uncalcified or hypocalcified within the radicular dentin.
[Kagayama M, Sasano Y, Tsuchiya M, Watanabe M, Mizoguchi I,
Kamakura S, Motegi K. Confocal microscopy of Tomes’ granular layer in
dog premolar teeth. Anat Embryol (Berl) 2000 Feb; 201(2):131–7.]
7. Pre-dentin
The pulpal surface of dentin is lined by a layer of non-mineralized dentin
matrix. This layer is comparable to osteoid of bone and is termed as pre-
dentin. The pre-dentin layer varies in thickness between 2 and 6 microns or
even up to 20 microns depending on odontoblastic activity; thick during
active dentinogenesis and decreases with age. This is the mineralizing front
of dentin and is always present throughout the life of a vital tooth. This layer
always exists because the mineralization process lags behind matrix
deposition.
This unmineralized pre-dentin layer acts as a protective layer separating
odontoblasts from mineralized dentin. Presence of this layer also has a
functional significance because it covers the mineralized dentin and protects
it from being resorbed.
In a decalcified section, predentin layer appears pale in color, compared to
dark pink colored mineralized dentin.

8. Dentino-enamel Junction
The junction between the dentin and enamel is called dentino-enamel
junction (see Fig. 4.12). The union of dentin with enamel is intimate without
any dividing plane between the two. The matrix of enamel intermeshes into
the surface of dentin. In microscopic section of tooth, due to change in
orientation and difference in size of crystals the DEJ appear distinct.
The dentino-enamel junction is scalloped with convexity facing the dentin.
The domeshaped elevations on the dentinal surface of enamel fits into
depressions on the surface of dentin. The scalloped pattern is occasionally
indistinct or even absent and is best appreciated in regions where the stresses
on tooth structure are the greatest. This scalloped junction increases the
surface area of contact between enamel and dentin and therefore strengthens
the adhesion and union between them. The scalloped dentino-enamel junction
also serves to reduce the chance of development of cracks along the junction,
because of the numerous changes in direction of DEJ.

9. Cemento-dentinal Junction
This is the junction between dentin and cementum and is relatively straight,
in contrast to scalloped DEJ. The cemento-dentinal junction may be scalloped
in deciduous teeth. The junction between dentin and cementum is not very
distinct in acellular cementum while is somewhat distinct in cellular
cementum.
In decalcified sections, cemento-dentinal junction can be identified easily
because cementum stains more intensely than dentin. Collagen fibers of
dentin are dispersed randomly, whereas those of cementum are more orderly
arranged and aggregated into discrete bundles. At the cemento-dentinal
junction, the fibers of dentin and cementum are found to be intertwining.
Sometimes dentin and cementum are separated by a layer of 10 microns
thickness and is termed as Hyaline layer of Hopewell Smith.

AGE AND FUNCTIONAL CHANGES OF DENTIN

Vitality of dentin: Dentin is considered as a vital tissue because of the

odontoblast processes in the tubules and it can respond to any stimulus. As
age advances, the ability of dentin to respond to stimuli decreases.
Secondary dentin formation: The secondary dentin resembles primary
dentin in structure but contains less tubules. Primary dentin and secondary
dentin are usually separated by a prominent contour line which is formed due
to a bend that develop as a result of sudden curve in the direction of dentinal
tubules. This accentuated curve is due to the gradual space restriction of
odontoblasts, located at the periphery of a withdrawing pulp.
Dead tracts: When the teeth are subjected to traumatic insult sufficient to
injure or destroy the odontoblast process, death of odontoblasts occur. In the
affected areas dentinal tubules become empty due to loss of odontoblast
processes. These emptied dentinal tubules are referred to as dead tracts (Fig.
5.8). These empty tubules get filled with air and in a ground section appear
dark under transmitted light and white under reflected light. The dead tracts
have an inverted cone shape with apex facing the pulpal surface; this is due to
progressive crowding of dentinal tubules from periphery towards the pulp.
 Fig. 5.8: Dead tracts
 Dentin in the region of dead tract is less sensitive than those with tubules
containing odontoblasts processes. The affected dentinal tubules are sealed
off from the pulpal end by deposition of tertiary dentin. Dead tracts are also
isolated from surrounding normal dentin by a layer of sclerotic dentin.
 Occasionally dead tracts are also seen in teeth without obvious attrition or
other damage. In such situations these changes are mainly observed in cusp
tips and incisal edges. This could be due to death and degeneration of
odontoblasts due to overcrowding in these regions and this is regarded as a
pure age change rather than functional change.
Reparative or reactionary dentin: The pulp dentin complex represents a
unique organ capable of responding in a variety of ways to environmental
stimuli. Extensive tooth wear as in case of attrition, abrasion, erosion, dental
caries, cavity cutting procedures, etc. can result in substantial tissue injury. In
such cases, the odontoblasts may either survive the injury and go on
participating in the tissue response, or if the injury is sufficiently severe it
may die. In the second case the progenitor cells of pulp give rise to new
odontoblasts that participate in reparative response.
 The term reparative dentin is used to describe the tertiary dentin secreted
by new generation of odontoblasts developed from progenitor cells in the
subodontoblast/Hoehl’s layer, in response to appropriate stimulus, after the
death of original odontoblasts responsible for primary and secondary dentin
formation. The tertiary dentin formed by surviving odontoblasts in response
to an appropriate stimulus is called reactionary dentin. Thus, the reparative
and reactionary dentin are subdivisions of tertiary dentin.
 Formation of reactionary or reparative dentin is a rapid process and
therefore shows variation in structures. The dentin formed may show the
same regular tubular structure as primary dentin or may have irregular and
fewer tubules or even atubular (without tubules). The irregular nature of
tubules is the reason for the name irregular secondary dentin. Since the
formation is at a rapid rate, incorporation of cells in the tertiary dentin matrix
is not uncommon, leading to formation of osteodentin. The term osteodentin
is used because entrapped cells gives a structural similarity to bone.
 Formation of this tertiary dentin is a protective mechanism because it seals
off the injury and prevents the stimulus reaching the pulp. A line of
demarcation is seen between physiological dentin and tertiary dentin. The
dentinal tubules of both are not continuous. The atubular tertiary dentin
blocks the irritant stimulus from reaching the pulp.
Sclerotic dentin: Continuous deposition of intratubular dentin as a result of
aging or in response to tooth wear or slowly progressing dental caries, results
in progressive reduction in the lumen of dentinal tubules and if continues
obliterates the tubules. This dentin with obliterated tubules is called sclerotic
dentin.
 As a protective change in the existing dentinal tubules, dentinal sclerosis is
observed in the crown region of the tooth. The stimuli may induce an active
response on the part of odontoblast process resulting in deposition of organic
matrix followed by mineralization. The apatite crystals are deposited
gradually reducing the diameter of lumen of dentinal tubules eventually
causing obliteration. The dentin deposited is structurally similar to peritubular
dentin. The sclerotic dentin is formed at the expense of odontoblastic process
which is either retracted or shortened by the loss of its distal extremity.
 When this dentin deposition obliterates many tubules in adjacent areas, the
dentin assumes a glassy or transparent or translucent appearance. This occurs
because the refractive index of this dentin becomes uniform and therefore this
sclerotic dentin is also referred to as transparent or translucent dentin. In
ground sections, the sclerotic dentin appears translucent or light under
transmitted light and dark under reflected light.
 Sclerosis is a protective mechanism because dentinal tubules are blocked
and this reduces the permeability of dentin. This blocks any irritant stimulus
reaching the pulp and therefore may help to prolong the vitality.
 Sclerotic dentin as an age change is mainly observed in the apical third of
the root which makes the root apex appear transparent and this increases with
age.

SENSORY MECHANISMS OF DENTIN AND

DENTIN SENSITIVITY

Dentin is sensitive throughout its thickness. It is also been observed that

dentin close to DEJ is more sensitive than dentin at slightly deeper layer and
the pain perception then increased as the dental pulp is approached.
Different types of stimuli including heat, cold, mechanical, drying, and
solutions of high osmotic pressure, etc. produce pain sensation. There is no
evidence that any of these stimuli produce any sensation other than pain. The
above stimuli except for thermal stimulus must be applied to an exposed
dentin surface to produce pain and they are most effective when the ends of
dentinal tubules are patent.
Despite the lack of vital cellular elements in the outer ends of dentinal
tubules this area of dentin is highly sensitive. This has raised many questions.
Where are the receptors that respond to pain producing stimuli? And how
these receptors are stimulated?
The mechanism by which the sensitivity is perceived is not clearly
understood. Three possibilities have been widely investigated and
accordingly three theories of dentin sensitivity have been evolved.
Direct nerve stimulation: According to this theory the nerves present in the
dentinal tubule are responsible for dentin sensitivity. Although there is clear
evidence that some nerve fibers enter into dentinal tubules, the nerve fibers
are observed in only few dentinal tubules, and they travel to a short distance
into dentin (50 μ distance from pulpal surface). Therefore this theory is
insufficient to explain certain facts
• Extreme sensitivity which is not in proportion to the nerve supply.
• Marked sensitivity in the peripheral dentin
• Sensitivity in newly erupted teeth because the intratubular nerves are
established only often some time after eruption.
• Application of local anesthetics or protein precipitants such as silver
nitrate does not eliminate sensitivity indicating that nerves are not
directly involved in sensitivity.
Transduction theory: This theory suggests that odontoblasts themselves can
act as a receptor cell that can be stimulated by various stimuli and can
transmit the impulse through the pulpal nerves which are functionally
connected to them.
 The receptor function is suggested because of the origin of odontoblasts
from neural crest cells, and therefore would be retaining some properties of
nerve cells. Studies have shown that the odontoblast processes extend into
dentinal tubules and have gap junctions between odontoblasts and pulpal
nerves suggesting the possibility of nerve like function of these cells. But
experimental studies have shown that the membrane potential of odontoblasts
and their processes was too low to permit conduction of nerve impulses. Also
topical anesthetics and protein precipitants do not abolish the sensitivity
which is against this theory.
Hydrodynamic theory: According to this theory the receptors in the nerves
distributed in the peripheral portion of pulp react to local changes brought
about by mechanical factors such as fluid movement, in dentin.
 It is understood that the dentinal tubules contain the tissue fluid: Dental
lymph which is in continuation with extracellular compartment of pulp.
Dentinal tubules are channels which can act as a capillary tube. When dentin
is exposed the dentinal fluid is lost from the exposed surface. This results in
rapid movement of fluid due to capillary action. Since this fluid in the tubules
is in continuation with extracellular fluid of pulp, the fluid movement in
dentinal tubules disturbs the peripheral pulpal environment by disturbing the
hydrostatic pressure equilibrium in the peripheral extracellular compartment
of pulp. The pressure changes in this area stimulate the nerve endings in the
vicinity of odontoblasts and initiate pain impulse.
 This theory is able to explain the extreme sensitivity of peripheral dentin
near dentino-enamel junction. Near DEJ the dentinal tubules branch
extensively and any irritation of this area may result in sudden displacement
of a large volume of intratubular fluid. This also explains why application of
local anesthetic does not reduce sensitivity and the sensitivity on application
of hypertonic solutions.
(Age changes, refer page 321–322)

Clinical Considerations
Developmental defects: Mutations of genes (DSPP and DMP-1) involved
in dentin formation lead to different forms of developmental disturbances,
namely dentinogenesis imperfecta or dentin dysplasia. Similarly
environmental conditions affecting mineralization such as calcium
deficiency or vitamin D deficiency also cause defective dentin formation.
Dentin sensitivity: Normally dentin is protected from external
environment by enamel in crown and cementum in root. When the dentin
is exposed, patients experiences severe sensitivity, due to patent dentinal
tubules. Exposed dentin becomes less permeable with time. Partial tubule
occlusion occur due to the growth of intratubular crystals from salivary or
dentinal fluid mineral, adsorption of plasma proteins to the inner surfaces
of dentinal tubules, or formation of a smear layer on the exposed dentin
surface. If the patients continue to have sensitive dentin therapeutic
intervention is needed, i.e. use dentin desensitizing agents.
Smear layer: Whenever dentin is cut using hand or rotary instruments, the
mineralized tissue is shattered to produce considerable quantities of debris,
comprising of very small particles of mineralized collagen matrix, and is
spread over the surface to form what is called the smear layer. This layer
extend a few micrometers into the dentinal tubules and may also contain
bacteria and their by-products. This layer may partly block the tubules and
help to reduce sensitivity. However, it need to be removed before placing
restorations.
Protection from injuries: The odontoblast processes in the dentinal
tubules and pulpal tissue has to be protected from chemical, thermal or
galvanic injury. Chemicals from the restorative materials can seep through
patent tubules in to pulp. To prevent these injuries insulating bases need to
be placed under deep restorations.
 6
Pulp
Dr Rajeesh Mohammed PK and Dr Girish KL

Introduction
Morphological characteristics of pulp
Zones of pulp
Structure of pulp
Functions of pulp
Age changes
Clinical considerations

P ulp is an ectomesenchymal connective tissue that supports the dentin. It

occupies the pulp cavity in the central part of the teeth. Because it is the
central or innermost tissue of the tooth, it is sometimes called
endodontium. It is surrounded by dentin on all sides except at the apical
foramen and accessory pulp canal openings, where it is in communication
with periodontal soft tissue. Even though the composition and structure of the
dental pulp and dentin are quite different, they are closely related
embryologically and functionally and are usually considered together as a
functional complex, termed the dentin-pulp complex.

DEVELOPMENT

Pulp is derived from dental papilla, an ectomesenchymal component of tooth

germ. During bell stage of tooth development, highly cellular dental papilla
becomes well organized and well vascularized. Under the organizing
influence of inner enamel epithelium the peripheral cells surrounding the
dental papilla differentiate into odontoblasts which forms dentin. Once dentin
formation starts, the dental papilla is designated as dental pulp organ. As the
dentin formation proceeds the dental papilla becomes enclosed in the central
space within the tooth and remain as pulp tissue. The pulp is considered as
mature dental papilla and the term pulp is used after dentin forms around it.

Morphological Characteristics of Pulp

It is a soft connective tissue which occupies center cavity of each tooth. Each
person normally has 52 pulp organs (20 primary + 32 secondary). The shape,
size and volume of the pulp organ vary in different teeth. The total volume of
all permanent teeth pulp organs is 0.38 cc. The mean volume of a single adult
pulp is 0.02 cc. Molar pulps are 3 to 4 times larger than incisor pulps.
The portion of the tooth that houses the pulp is divided into pulp chamber
and root canal. The pulp chamber is the area located in the crown of the
tooth and the root canal is seen in the root portion.
The portion of pulp that occupies the pulp chamber is called coronal pulp
and the portion that occupies the root canal is called the radicular pulp. The
pulp communicates with the peri-radicular tissue through the apical foramen
and the accessory canals or lateral canals. The apical foramen is the opening
from the pulp at the apex of the tooth. Accessory canals or lateral canals are
extra canals located on the lateral portions of the root.

Coronal Pulp
Coronal pulp is located centrally in the crown of the teeth (Fig. 6.1). In young
teeth, the shape of the pulp chamber resembles outer surface of dentin. The
coronal pulp has pulp horns (cornua), which are protrusions that extend into
the cusps of the tooth. The number of pulp horns in most cases equals the
number of cusps. The pulp horns can be inadvertently exposed during cavity
preparation and is more common in case of deciduous dentition. The coronal
pulp has six surfaces, namely the occlusal, mesial, distal, buccal, lingual and
the floor.
At the cervical region, the pulp organ constricts and at this zone coronal
pulp joins the radicular pulp. The pulp chamber is large at the time of
eruption, but decreases in size with advancing age due to continuous
deposition of secondary dentin.
Radicular Pulp
Radicular pulp (Fig. 6.1) extends from the cervical region of crown to the
root apex. Depending on the tooth, they vary in size, shape and number. It
may be seen as a single extension of the coronal pulp in case of anterior tooth
which single root and as multiple extensions in case of multi-rooted teeth. It
may be straight or curved depending on the shape of the root canal. The
radicular pulp is continuous with periapical tissues through apical foramen or
accessory foramen. The radicular pulp is initially tubular in shape, which
later becomes narrower as it goes to apical region. The radicular pulp is
continuous with periapical tissues through apical foramen.

Apical Foramen
Apical foramen (Fig. 6.1) is the opening seen at the root apex, through which
the radicular pulp communicates with the peri-radicular area. It is through
this opening, that the blood vessels and nerves enter the tooth. They vary in
location, size, shape and number. The average size is 0.4 mm in maxillary
tooth and 0.3 mm in mandibular tooth. The apical foramen is wide in young
tooth and becomes narrower with age. The location and shape undergoes
changes as a result of functional influences on the teeth. In case of mesial
migration of tooth, the apex tilts to the opposite direction leading to
relocation of the foramen. Occasionally the opening is found on lateral side
of the root apex. Sometimes there may be two or more foramen, separated by
dentin and cementum or cementum only.

Accessory Canals or Lateral Canals

Accessory canals or lateral canals (Fig. 6.1) are extra canals that are present
in the root dentin. They may be seen anywhere along the length of root, but
are more numerous in the apical third of the root. They are formed as a result
of premature loss of root sheath or when a developing root encounters blood
vessel and the developing tooth root winds around the blood vessel, which
later forms the extra canal. Accessory canals may be seen in furcation area
due to lack of complete fusion of tongue like extensions of epithelial
diaphragm that helps in division of roots. They result in communications
between the radicular pulp and periodontal tissue which can lead to pulpo-
periodontal lesions and failure of conventional root canal treatment (RCT).
 Fig. 6.1: Morphological characteristics of pulp

HISTOLOGICAL STRUCTURE OF DENTAL

PULP

The structure of pulp can be studied by microscopic examination of

decalcified sections of tooth. Histologically four distinct zones can be
distinguished which include odontoblastic zone, cell free zone, cell rich zone
and pulp core (Fig. 6.2).

1. Odontoblastic Zone
This zone is found at the periphery of the pulp and consists of the cell bodies
of odontoblasts which lie in a continuous row near the dentinal end of the
pulp. Many nerve fibers enter this zone and terminate between the
odontoblasts. The odontoblastic layer and the subodontoblastic nerve network
combine to form a sensory complex (peripheral sensory unit) that completely
envelop or encapsulate the central pulp core.
 Fig. 6.2: Histological zones of pulp

2. Cell Free Zone

Beneath the odontoblastic zone a layer of approximately 40 microns width is
seen which is relatively devoid of cells. This layer is called zone of Weil or
subodontoblastic layer. The cell free zone is more prominent in the coronal
pulp. The major components of this zone are ground substance with reticular
fibers and it appears to be relatively free of cells. The cell free zone
diminishes in size or temporarily disappears when the dentin formation
occurs at a rapid rate. This zone contains network of nerve fibers that have
lost their myelin sheath and are known as subodontoblastic plexus or plexus
of Rashkow. These terminal, naked, free fibers are dendrites of sensory
nerves and are specific receptors of pain.

3. Cell Rich Zone

Cell rich zone is situated just below the cell free zone. It is a narrow zone
with increased density of cells and rich capillary network. Although the cell
rich zone is present both in coronal and radicular pulp, it is more prominent
in coronal pulp. It consists of fibroblasts, undifferentiated mesenchymal cells,
macrophages, immunocompetent cells and young collagen fibers. It serves as
a reservoir for replacing the destroyed odontoblasts.

4. Pulp Core or Pulp Proper

The connective tissue located in the center of the coronal and radicular pulp
is referred to as pulp core. It is a core of loose connective tissue with
abundant cellular elements which also contains the larger nerves and blood
vessels that branch out towards the peripheral pulp area. In young pulp, the
core contains more cells while in older pulp, it contains more of fibrous
components.

STRUCTURAL COMPONENTS OF DENTAL

PULP

Dental pulp is a delicate connective tissue and is composed of cells, collagen

fibers and other connective tissue structures distributed in abundant
gelatinous ground substance.

Cells in the dental pulp include

Odontoblasts
Fibroblasts
Undifferentiated mesenchymal cells
Immunocompetent cells
Extracellular components
Fibers: Collagen
Intercellular ground substance

Connective tissue structures

Blood vessels
Lymphatic channels
Nerve fibers

CELLS IN THE PULP

Odontoblasts
Odontoblasts are dentin forming cells which are of ectomesenchymal origin
and are the most distinctive and the second most prominent cells in the pulp.
They have a constant location adjacent to the dentin, with their cell bodies in
the pulp and the cell processes in the dentinal tubules, i.e. the odontoblastic
zone of the pulp. The number of odontoblasts equals the number of dentinal
tubules and the average number is about 59,000–76,000 per square millimeter
in coronal dentin. They are numerous and larger in the coronal pulp than the
radicular pulp. Morphologic variations of odontoblasts range from the tall
columnar cells in the crown of the tooth to a low columnar type in the middle
of the root and are flattened near the apex of the tooth.

Structure
Odontoblasts have a cell body residing in pulp and cytoplasmic process
extending to the dentinal tubules. The cells are approximately 5–7 μm in
diameter and 25–40 μm in length. The odontoblastic cells lie very close to
each other and are connected to adjacent cells by junctional complexes. The
shape of the cell may be influenced by the degree of activity. More active
cells are taller and contain rich synthetic organelles in cytoplasm such as
rough endoplasmic reticulum, Golgi apparatus, mitochondria, vesicles,
granules, etc. The apical part of the cytoplasm, that is near the pulpal—pre-
dentin junction is devoid of cytoplasmic organelles. The cell body contains
an oval nucleus situated at the pulpal end. The cytoplasmic processes begin at
the apical end of the cell just above the apical junctional complex, where the
cell gradually begins to narrow (3–4 μ) as it enters the pre-dentin. The
odontoblastic process is devoid of major cell organelles but microtubules,
filaments and vesicles are present in abundance.
The size, shape and structure of odontoblasts in the pulp are variable
according to the functional activity of the cells. Accordingly, odontoblasts in
three different stages can be identified in pulp which includes synthetic or
active odontoblasts, intermediate or transitional odontoblasts and resting or
aged odontoblasts.

Synthetic or Active Odontoblasts

The synthetic odontoblasts can be distinguished under light microscope and
appears elongated and having a basal nucleus with a basophilic cytoplasm.
These cells have abundant synthetic cellular organelles required for synthesis
and secretion of dentin matrix. Numerous secretory granules are found near
the secreting end.

Intermediate or Transitional Odontoblasts

The intermediate odontoblasts show all features of synthetic cells, but the
organellae are less in number and less prominent. The nucleus shows
condensation of chromatin with the organelles distributed around the nucleus.
Secretory granules are less in number. The difference between the synthetic
and transitional odontoblasts can be appreciated only under electron
microscope.

Resting or Aged Odontoblasts

The resting odontoblasts are stubby cells and can be appreciated under light
microscope. These cells have a little cytoplasm with a dark, close faced
nucleus. They have less of cellular organelles at pulpal end. Vacuoles and
secretory granules are scarce or absent.

Fibroblasts
Fibroblasts are the most numerous cell types in the pulp, especially abundant
in the coronal pulp. The shape of fibroblasts vary from fusiform with long
slender protoplasmic processes to stellate (star shaped) with shorter numerous
branches. The fibroblasts are numerous in young teeth and decreases with
age. They help in synthesis, maintenance and degradation of pulp matrix.

Undifferentiated Mesenchymal Cells

Represent the pool of reserve cells from which the connective tissue cells of
the pulp are derived. They are found along the pulp vessels in the cell rich
zone and are scattered throughout the central pulp. They appear larger than
fibroblasts and are polyhedral in shape with peripheral processes and a large
oval nucleus. They are totipotent cells and can give rise to odontoblasts,
fibroblasts, etc. They are more in young pulp and decreases with age, which
reduces the regenerative potential of the pulp.

Immunocompetent Cells
The immune-competent cells are predominated by macrophages, dendritic
cells and lymphocytes. Apart from these, mast cells, plasma cells,
neutrophils, lymphocytes, monocytes, etc. are also seen.

Macrophages
Macrophages are distributed in the central part of pulp. They are large oval or
spindle shaped irregular cells with a clear cytoplasm containing
mitochondria, rough endoplasmic reticulum and free ribosomes and have a
small round dark staining nucleus. They function as scavenger cells, helping
in elimination of dead cells.

Dendritic Cells
Dendritic cells are antigen expressing or antigen presenting cells and are
found in and around the odontoblast layer with dendritic processes extending
between the odontoblasts. They have a close relationship to vascular and
neural elements. They are non phagocytic cells and participate in
immunosurviellance of pulp by capturing and presenting the foreign antigen
to T cells. The number of dendritic cells increases in carious teeth.

Lymphocytes and Eosinophils

They are found extravascularly in normal pulp, which increase noticeably in
number during inflammation.

EXTRACELLULAR COMPONENTS

Fibers
Fibers present in the pulp are predominantly collagen type I and III in the
ratio of 55:45. The collagen fibers are distributed throughout the pulp and
forms a delicate network. Collagen fibers in pulp, exhibit typical cross
striations at 64 nm. In young pulp the fibrils are of smaller diameter ranging
from 10 to 12 nm and in older pulp the fibrils aggregate into fibers of greater
dimension. The number of collagen fibers increases with age. They may
appear scattered throughout the pulp or may appear in bundles; and
accordingly termed diffuse or bundle collagen. In addition to collagen, the
pulp also contains a few reticulin fibers and elastic fibers.

Ground Substance
The ground substance is particularly abundant in young pulp and is composed
of acid mucopolysaccharides and protein polysaccharide complex
(glycosaminoglycans and proteoglycans). Ground substance provides a
medium for distribution of cells and extracellular fibers and gives support to
cells of the pulp. It serves as a means of transport of nutrients from the
vessels to cells, as well as for transport of catabolites from cells to blood
vessels. The amount of ground substance decreases with age.

CONNECTIVE TISSUE STRUCTURES

Blood Vessels
The pulp organ is well vascularized and is supplied by superior and inferior
alveolar arteries. The blood vessels enter and exit the dental pulp through
apical and accessory foramina. The arterioles entering the apical foramen
follow a straight course up to the coronal pulp. In the coronal pulp the vessels
undergo extensive branching and some travel to the periphery of the pulp to
form a subodontoblastic capillary network (Fig. 6.2). During dentinogenesis
some of the capillaries even loop around the odontoblasts. The arterioles in
the pulp vary in diameter; greatest of 50 to 100 microns to 10 to 15 microns
for terminal arterioles. The arterioles divide to give rise to meta-arterioles,
precapillaries and capillaries. Capillaries of pulp vary in diameter from 7 to
10 microns and shows pores or fenestrations to facilitate exchange of
materials between vessels and its environment. Veins draining the pulp
follow the same course as the arterioles. Arteriovenous anastomoses is also
seen in coronal pulp.

Lymphatic Channels
The lymph vessels that drain the pulp are thin walled having an irregular
lumen composed of endothelial cells surrounded by an incomplete layer of
smooth muscle cells. The anterior teeth drains into the submental lymph
nodes and the posterior teeth drains into the submandibular and the deep
cervical lymph nodes.

Nerves
Nerve supply to pulp is abundant. Nerve bundles enter pulp through apical
foramen. Pulp receives sensory supply from trigeminal nerve and superior
cervical ganglion. The nerves in the pulp are non-myelinated—A δ and A β
fibers which transmits sharp pain or nonmyelinated or “c” fibers which
transmits dull pain. The non-myelinated fibers are sympathetic and are
mainly controlling the luminal diameter of the vessels. The myelinated fibers
entering the foramen follow a course similar to the arterioles. In the coronal
pulp they undergo extensive branching and advance towards the cell rich
zone, again branch and form a network of nerves in the cell free zone below
the odontoblastic zone. This network of nerves are known as plexus of
Raschkow (Fig. 6.2).

FUNCTIONS OF DENTAL PULP

Dental pulp performs various functions such as nutritive, sensory, formative,

defensive and protective functions.
1. Nutritive
The blood vascular system of dental pulp nourishes and maintains the vitality
of dentin by providing oxygen and nutrients to the odontoblasts and their
processes, as well as providing a continuing source of dentinal fluid.

2. Sensory
The pulp has both myelinated and non-myelinated nerve fibers. Sensory
nerve fibers present in the pulp respond to stimuli such as changes in
temperature, pressure, vibration and chemical agents that affect the dentin
and pulp.

3. Inductive
The dental papilla, the primordium of dental pulp performs an important
function in determining the crown pattern and differentiation of ameloblasts
through its inductive influence.

4. Formative
The pulp performs the formative function because of the presence of
odontoblasts which are the formative cells of dentin. These cells are involved
in the support, maintenance and continued formation of dentin.

5. Defensive and Protective

The pulp responds to irritation and protects itself and the vitality of the tooth
by producing reparative dentin or inducing dentinal sclerosis which can block
the dentinal tubules and prevent the irritating stimulus reaching the pulp.
Pulp being a highly vascularized connective tissue may initiate an
inflammatory reaction in response to an irritating stimulus. Various immune
cells such as macrophages, lymphocytes, plasma cells, neutrophils, etc. are
involved which aid in the process of repair of pulp.

AGE OR REGRESSIVE CHANGES IN PULP

1. Size
With age there is progressive reduction in pulp size due to continuous
secondary dentin deposition. As a result the pulp horns become less
prominent or even obliterated.

2. Cellular and Fibrous Components

In aging pulp the fibrous component becomes more prominent. The number
of collagen fibers increases with age and in older pulp the fibrils aggregate
into fibers of a great dimension. They may be more diffuse and randomly
arranged in coronal pulp but are in bundled form in radicular pulp.
In older teeth, more fibrous appearance of the pulp may be apparent,
possibly due to reduction in size of pulp reducing the space available for their
distribution.
The number of cells in the pulp including fibroblasts and odontoblasts
decreases with age. The cells also show a decrease in the amount of
cytoplasm and cytoplasmic synthetic organelles.

3. Changes in Blood Supply and Innervations

Loss and degeneration of myelinated and unmyelinated axons occur which
can be correlated with an age related reduction in sensitivity. As this
progresses, the number of nerves gets greatly diminished. There is a decrease
in the blood supply as the apical foramen is almost obliterated by secondary
dentin and cementum which initiates most of the other changes in the pulp.
Blood vessels may also show fibrosis or calcification of vessel walls or
atherosclerotic changes, from the age of 40 years.

4. Reduction in Sensitivity and Healing Potential

As age advances the sensitivity and healing or reparative capacity of pulp
decreases. Decreased sensitivity can be directly related to nerve degeneration.
Overall reduction in vascular supply and cellular component could be
responsible for decreased reparative capacity of pulp.

5. Pulpal Calcifications
Calcification may occur in pulp tissue as a result of aging or external stimuli.
These may be nodular, calcified masses referred to as pulp stones or diffuse
calcifications.
 Pulp stones or denticles are nodular calcified masses present in coronal or
radicular pulp. They are seen in functional as well as embedded or unerupted
teeth. Incidence increases with age: 66% between the age group of 10–30
years, 80% between 30 and 50 years and 90% above 50 years.
Various other etiological factors such as infection, trauma due to operative
procedures, vascular injury resulting in thrombosis and systemic diseases
(atherosclerosis) also have been considered (Flowchart 6.1).

Pulp stones are classified based on its relation to adjacent

dentin into three sroups (Flowchart 6.2)
Free pulp stones are those calcified structures lying free in the pulp without
being attached to the dentin.
Attached pulp stones: Those which are attached to the dentin.
Embedded pulp stones: When pulp stone is completely surrounded by dentin
it is called embedded pulp stone. They are believed to be formed as free pulp
stones which later becomes attached or embedded due to progressive dentin
formation.
Flowchart 6.1: Pathogenesis of pulp calcifications

Flowchart 6.2: Types of pulp calcifications

Depending on structure pulp stones can be grouped into
True denticles: True denticles are localized masses of calcified tissue having
tubular structure containing odontoblast processes and thereby resembling
dentin and hence called as true denticles. They are very small and are seen
only rarely. The true denticles are thought to be formed due to entrapped
remnants of root sheath in pulp. These cells may induce the differentiation of
odontoblasts which form calcified structures; resembling dentin.
False denticles: False denticles are localized masses of calcified tissue
having a laminated structure made of concentric layers of calcium deposited
around a central nidus, which could be dead cells. They do not have a tubular
structure or structural resemblance to dentin. They are larger than the true
denticles and may fill the entire pulp chamber.

Diffuse Calcification
Diffuse calcification is composed of small calcified particles with a few
larger masses. The calcified structures are arranged as linear strands parallel
to the long axis of pulp. They are found to be closely associated with blood
vessels with an orientation parallel to the vessels and nerves. It is usually
seen only in radicular pulp.

Clinical Significance
Affected tooth is vital, and usually symptomatic but sometimes manifest mild
neurologic pain. Pulpal calcifications may cause difficulty in extripating the
pulp during RCT.

Clinical Considerations
• In young teeth pulp chambers are large with high pulp horns. Therefore
care should be taken while cavity preparation to avoid inadvertent
pulpal exposure.
• Presence of multiple accessory canals in some teeth may cause failure
of endodontic treatment. Similarly, presence of pulp stones also may
cause difficulty in endodontic treatment.
• Pulpal tissue is highly sensitive to various types of trauma which may
be thermal, chemical or mechanical. Mechanical or thermal trauma
during cavity preparation prior to restoration of teeth may permanently
damage the pulp. Similarly, chemicals leached out from restorative
materials or heat transmitted due to inadequate thermal insulation while
restoring the tooth also may have adverse effect on pulp. Therefore
precautions need to be taken while cavity preparation and restoration.
Permanent damage to the pulp causes death of pulp and therefore loss
of vitality of the tooth.
• Vital teeth respond to thermal and electric stimuli and vitality testing is
a basic procedure carried out in dental clinic to diagnose pulpal
diseases. Routinely used pulp testing strategies may involve sensitivity
tests such as thermal or electric pulp testing, which assess whether
there is response to a stimulus.
• Pulp is connective tissue and any type of insult resulting from dental
caries or trauma can cause the inflammation as in case of any other
tissues of the body. Inflammation of dental pulp is called pulpitis.
Pulpitis may be reversible or irreversible. Irreversible pulpitis results in
permanent damage to the pulp and if not treated, progresses further to
infection of periapical tissue. Chronic mild infection of pulp may
induce a proliferative reaction of pulp which is referred to as pulp
polyp. A pulp polyp will present as a pink globular soft tissue mass
filling a large carious cavity. Once the pulpal tissue is involved in
disease process, the tooth needs root canal treatment.
• As pulpal tissue is located in a closed chamber, surrounded by rigid
dentin, pressure built up in pulp due to inflammation result in intense
pain.
• Dental pulp stem cells found within the cell rich zone of dental pulp
has gained significant importance as a potential resource of stem cells
which may be used for regeneration and repair of a multitude of
diseased and injured organs and tissues. These cells exhibit
multipotency due to their embryonic origin, from neural crests. These
mesenchymal stem cells are capable of extensive proliferation and
differentiation, which makes them important. Because of their ability to
produce and secrete neurotrophic factors, these cells may also be
beneficial for the treatment of neurodegenerative diseases and the
repair of motoneurons following the injury.
 7
Cementum and
Cementogenesis

Introduction
Physical properties and chemical composition
Cementogenesis
Types of cementum
Structure
Functions
Clinical considerations

C ementum is a calcified connective tissue that forms the outer covering of

the anatomic root of the tooth. Cementum is also considered as a part of
periodontium, the attachment apparatus of the tooth, because it provides
a medium for insertion of periodontal ligament fibers. The name cementum is
derived from the word ‘caementum’ which means quarried stone or chips of
stone. It is a specialized connective tissue that shares some physical, chemical
and structural properties of bone. Unlike bone, cementum is avascular,
insensitive, do not undergo remodeling under normal circumstances and is
more resistant to resorption.

Physical Characteristics of Cementum

Color: Cementum is yellowish in color which is lesser than that of dentin.
Cementum do not have a shining surface, therefore it can be easily
differentiated from enamel which is white and shiny.
Hardness: Cementum is softest of all the dental hard tissue components.
Permeability: Cementum is permeable for certain substances and is more
permeable than enamel. Cellular cementum is more permeable than acellular
cementum due to high organic component. With age the permeability
decreases.
Resistance to resorption: Cementum is resistant to resorption when
compared to bone and could be related to the avascular nature of cementum.
This property is utilized in orthodontic movement of teeth.
Thickness: Cementum thickness varies in different part of root. Thinnest at
cervical region, with a thickness of 50 μ, gradually increases to 200 μ at the
apical region.
Insensitive: Cementum is insensitive to pain due to lack of nerve innervation.
When root scaling is necessary, patient do not experience pain. However,
when the thin cementum layer that seal dentinal tubules are lost sensitivity is
experienced.

Composition of Cementum
Cementum is composed of 45–55% inorganic components and 50–55%
organic material and water.
Inorganic components are mainly calcium and phosphate in the form of
hydroxyapatite crystals which are of the same size as that of bone. In
addition, cementum also contains some trace elements such as copper, iron,
magnesium, potassium, silica, sodium, zinc and fluoride. Cementum has
highest fluoride content of all mineralized structures of the body.
Organic components include collagenous and non-collagenous matrix.
Collagenous matrix primarily comprises type I collagen fibers (90%) and
some type III fibers in extrinsic fibers.
Collagen fibers of cementum are intrinsic and extrinsic fibers based on
their origin (source). Intrinsic fibers are secreted by cementoblasts, the
synthetic cells of cementum while extrinsic fibers are from outside the
cementum, i.e. from periodontal ligament (Sharpey’s fibers) which get
inserted to the cementum. Intrinsic fibers are smaller, of 1–2 μ diameter and
are arranged parallel to the root surface. Extrinsic fibers are of 5–7 μ
diameter, arranges perpendicular to the root surface.
Noncollagenous matix of cementum contains various proteins, of which
major ones are bone sialoprotein and osteopontin, generally accumulate in
cement lines and in the spaces among the mineralized collagen fibrils. In
addition, cementum derived attachment protein, osteocalcin, osteonectin,
tenascin, fibronectin, alkaline phosphatase, proteoglycans such as chondroitin
sulfate, heparin sulfate, hyaluronate as well as several growth factors have
been identified in cementum.
The noncollagenous matrix has a significant role in initiation and
regulation of mineralization process. The amount of non-collagenous
proteins, depends on cementum types and with speed of formation of the
tissue and packing density of collagen fibrils.

Cementogenesis
Cementogenesis is the formation of cementum and is a rhythmic process.
Cells responsible are cementoblasts that are derived from dental follicle of
the tooth germ.
The formation of cementum can be subdivided into a pre-functional and
functional developmental stage. Pre-functional stage refers to formation of
main cementum varieties that occur during root development. On the other
hand, the functional development of cementum commences when the tooth is
about to reach the occlusal level and continues throughout life. Biological
responsiveness of cementum, i.e. adaptive and reparative functions of
cementum is possible because of functional development, which in turn,
influences the alterations in the distribution and appearance of the cementum
varieties on the root surface with time.

Steps Involved in Cementum Formation

The process of cementogenesis involves two stages; matrix deposition and
mineralization.

Matrix deposition
After the deposition of radicular dentin, Hertwig’s epithelial root sheath
degenerates and loses continuity, exposing the newly formed dentin. This
allows the cells from the inner part of dental follicle to come in contact with
newly formed dentin. These infiltrating dental follicle cells differentiate into
cementoblasts under the inductive influence of dentin or Hertwig’s epithelial
root sheath. These cells develop rich cytoplasmic synthetic organelles and
increased hydrolytic and oxidative enzymes. They deposit cementum matrix
(cementoid) which include both collagen fibers and ground substance.
Cementoblasts deposit collagen onto the dentin matrix which is in the
process of mineralization, permitting intermingling of fibers of these two
tissues at the future dentino-cemental junction. Noncollagenous matrix
proteins are deposited into the spaces between the fibers.
Once the inner part of the cementum is formed, the periodontal ligament
that get inserted into cementum matrix forms the collagen matrix and further,
cementocytes deposit only noncollagenous matrix proteins.

Mineralization
Mineralization of cementum begins after some amount of organic matrix has
been laid down, by deposition of hydroxyapatite crystals in the form of plates
and spicules. Noncollagenous matrix proteins play a significant role in
mineralization. A calcium binding amino acid, known as Gla protein and
osteocalcin and osteonectin act as nucleating substances to initiate
mineralization, bone sialoprotein promote mineralization and osteopondin
regulate crystal growth.
Possible role of cementoblasts released matrix vesicles, in mineralization
of the initial cementum has been suggested by Yamamoto et al. Based on
experimental findings these researchers suggest that during the initial
cementogenesis, cementoblasts release matrix vesicles which result in
formation of calciferous spherules, that trigger the mineralization. After
insertion of principal fibers, mineralization advances along collagen fibrils
without matrix vesicles (Yamamoto et al. Mineralization process during
acellular cementogenesis in rat molars: A histochemical and
immunohistochemical study using fresh-frozen sections. Histochem Cell Biol
2007 Mar; 127(3):303–11).
Cementoblasts that form cementum recedes outward as the formation
proceeds. So the outer surface of cementum will always have cementoblasts
lining the periphery. Since the mineralization process lags behind matrix
formation, a layer of cementoid is seen lining the mineralized cementum at
the inner aspect of cementoblast layer. The cemetoid layer is less distinct or
even absent in relation to acellular cementum. Sometimes a few
cementoblasts get entrapped in cementum matrix which remains in
mineralized cementum in spaces called lacunae. This happens when the rate
of formation of cementum is faster and the formed cementum is referred to as
cellular cementum. As the cementogenesis proceeds fibers from developing
periodontal ligament get inserted into cementum and the portion of principal
fibers embedded in cementum is called Sharpey’s fibers.

Classification of Cementum
Depending on time of formation
• Primary cementum
• Secondary cementum
Based on presence or absence of cells
• Acellular cementum
• Cellular cementum
Good to Know
Origin of cementoblasts
It was generally accepted that cementoblasts originate by differentiation of
the mesenchymal cells of the dental follicle. Recently, a different
hypothesis for the origin of cementoblasts has been proposed, i.e. epithelial
- mesenchymal transformation of Hertwig’s epithelial root sheath cells
result in formation of cementoblasts.
Accordingly, two types of cementoblasts have been identified 1. Cells
derived from Hertwig’s epithelial root sheath that are involved in
formation of acellular cementum; 2. Cells derived from dental follicle, that
form cellular cementum. These cells were reported to be different in
receptors expressed on cell surface as well as in their reaction to signaling
molecules, e.g. receptor for PTH is expressed by cementoblasts derived
from dental follicle, while those derived from Hertwig’s epithelial root
sheath do not express. The former cells express extracellular protein
osteopondin and osteocalcin, thus phenotypically similar to osteoblasts
while latter express only osteopondin and partial osteoblastic phenotype.
However, investigations carried out by Yamamoto et al., suggested that
there is no intermediate phenotype transforming epithelial to mesenchymal
cells, and that epithelial sheath cells do not generate mineralized tissue.
They concluded that the epithelial-mesenchymal transformation does not
occur in Hertwig’s epithelial root sheath in acellular or cellular
 cementogenesis and that the dental follicle is the origin of cementoblasts,
as has been proposed in the original hypothesis. (Yamamoto T, Takahashi
S. Hertwig’s epithelial root sheath cells do not transform into
cementoblasts in rat molar cementogenesis. Ann Anat 2009 Dec;191(6):
547–55.) (Yamamoto T, Yamamoto T, Yamada T, et. al. Hertwig’s
epithelial root sheath cell behavior during initial acellular cementogenesis
in rat molars. Histochem Cell Biol 2014 Nov;142(5): 489–96.)

Based on presence or absence of fibers

• Fibrillar cementum
• Afibrillar cementum
Based on type of fibers
• Intrinsic fiber cementum
• Extrinsic fiber cementum
• Mixed fiber cementum
Accordingly cementum can be of different types
Primary acellular intrinsic fiber cementum
Primary acellular extrinsic fiber cementum
Secondary cellular intrinsic fiber cementum
Secondary cellular mixed fiber cementum
Acellular afibrillar cementum
Intermediate cementum
Mixed stratified cementum

STRUCTURE OF CEMENTUM

Primary Acellular Cementum

This is the first formed cementum covering the cervical 2/3rds of the root.
The rate of deposition of primary cementum is slow during its formation,
which allows sufficient time for the cementoblasts to move away. As a result
of this, cells are not entrapped in the matrix and therefore primary cementum
is always acellular. Cementoid layer covering this cementum is indistinct.
Cementum is thinnest at cervical region with thickness of 50 pm which
gradually increases towards the root apex.
In a ground section acellular cementum (Fig. 7.1) appears as a structureless
layer without any entrapped cells. Incremental lines, indicating periodic
rhythmic deposition of cementum, are seen as dark lines which are parallel to
the root surface and are relatively closer to each other because of slow
deposition. These lines are called incremental lines of Salter that can also be
seen in decalcified sections as basophilic lines. Sharpey’s fibers (part of
principal fibers of periodontal ligament inserted to cementum) may be seen as
fine striations perpendicular to the root surface. Although the Sharpey’s
fibers are more in number in acellular cementum than in cellular cementum,
they are less distinct as they are fully mineralized.

Fig. 7.1: Acellular cementum

Good to Know
The cellular cementum, generally consists of more of intrinsic fibers
exhibiting alternate intensely and weakly stained lamellae (each about 2.5
microns thick). It has been suggested that this pattern results from periodic
changes of arrangement of the intrinsic fibers. According to Yamamoto et
al., the alternate lamellar pattern conforms to the twisted plywood model,
 in which collagen fibrils rotate regularly in the same direction to form two
alternating types of lamellae; one type consists of transversely and almost
transversely cut fibrils and the other consists of longitudinally and almost
longitudinally cut fibrils. The development of the intrinsic fiber
arrangement may be controlled by cementoblasts; the cementoblasts move
finger-like processes synchronously and periodically to create alternate
changes in the intrinsic fiber arrangement, and this dynamic sequence
results in the alternate lamellar pattern. (Yamamoto et al., histological
review of the human cellular cementum with special reference to an
alternating lamellar pattern. Odontology 2010 Jul; 98(2): 102–9.)

Innermost portion of cementum of 15–20 microns adjacent to dentin has

only collagen fibers deposited by the cementoblasts. So this portion is called
primary acellular, intrinsic fibrillar cementum. The remaining part of
cementum is formed after the establishment of periodontal ligament and in
this portion the extrinsic fibers make up the bulk of collagen. Therefore this
part of cementum is called primary acellular extrinsic fiber cementum.

Secondary Cellular Cementum

Secondary cellular cementum is seen at the apical 1/3rd of root and the
thickness gradually increases as it approaches the apex of the root. The rate of
deposition is faster leading to entrapment of cementoblasts in the matrix and
they remain as resting cementocytes in the mineralized cementum. This
cementum is thicker up to 150–200 microns.
Cementocytes (Fig. 7.2) are the entrapped cells found in cellular
cementum and are located in lacunae (Fig. 7.3). They are spider shaped with
an ovoid cell body of 8 to 15 microns diameter and up to 30 processes or
canaliculi projecting from the cell body. These canaliculi branch and
anastomose with those of adjacent cells. Most of these processes are directed
towards the periodontal ligament from where the cells derive nutrition, while
some are directed inwards and laterally. The cytoplasm of these cells contains
only a few organelles and the cells in deeper portions; more than a distance of
60 microns from the source of nutrition shows degenerative changes. In
ground sections, the cementocytes are lost and lacunae appear as dark spaces.
In decalcified sections, cementocytes are clearly visible.
 Fig. 7.2: Cementocytes (Note the direction of cell processes).

Fig. 7.3: Cellular cementum

Cellular cementum also shows incremental lines of Salter which are
parallel to root surface and slightly far apart because of increased thickness of
each increment resulting from faster deposition. Sharpey’s fibers are seen as
striations at an angle to the root surface. The actual number of Sharpey’s
fibers is lesser than that of acellular cementum, but they are more distinct as
the fibers are not fully mineralized. They have a mineralized periphery and an
unmineralized core. So in ground sections the organic component at the
unmineralized core is lost and appears dark, making it more distinct. Cellular
cementum always has a peripheral layer of cementoid lined by cementoblasts.
In decalcified sections, cementoblasts are found lining the surface of
cementum, interposed between bundles of periodontal ligament fibers and are
separated from mineralized cementum by a layer of cementoid. The
cementoid or precementum layer provide a compatible environment for the
cementoblasts and serve a protective function preventing odnotoclastic
resorption. Cementoblasts maybe either active (formative) or inactive
(resting). Active cementoblasts are round or ovoid plumb cells with slightly
basophilic cytoplasm and open faced nucleus, while the resting cells have
closed faced nucleus and a little eosinophilic cytoplasm. Because of the
cementoblasts lining the surface, cementum formation can continued
throughout life.
Similar to acellular cementum, the portion of cellular cementum that is
formed before the establishment of periodontal ligament, has mainly intrinsic
fibers and therefore called secondary cellular intrinsic fiber cementum. The
portion formed after the establishment of periodontal ligament has both
extrinsic and intrinsic fibers, therefore called secondary cellular mixed fiber
cementum.

Acellular Afibrillar Cementum

This is the type of cementum found at the overlapping type of cemento-
enamel junction. Acellular afibrillar cementum do not contain any entrapped
cells. Although this cementum is referred to as afibrillar cementum, it
contains fibrillar component in the matrix. But the fibrillar component does
not bear characteristic collagen periodicity. Gradually the thickness of
afibrillar cementum increases by deposition of fibrillar cementum due to
contact with the connective tissue. The afibrillar cementum is also called
coronal cementum because it may be seen on the occlusal fissures and other
sites where the break in the reduced enamel epithelium has occurred.

Intermediate Cementum
The term intermediate cementum is used to describe a type of secondary
cementum found near root tip region of molars and premolars, which shows
some entrapped cellular debris derived from Hertwig’s epithelial root sheath
or odontoblasts layer. This type of cementum is not generally observed in
deciduous teeth and anterior teeth.
Mixed Stratified Cementum
Generally the acellular cementum is distributed in cervical 2/3rds and cellular
cementum at apical third. At times in the apical region or in furcation areas of
multi-rooted teeth, these two types of cementum show an alternate layered
arrangement where the cellular cementum is covered by a layer of acellular
cementum to which in turn, may be added another layer of cellular
cementum. This type of layered arrangement of cementum is referred to as
mixed stratified cementum. This may represent cementum deposited at
different rates in response to adaptive needs.

Differences between acellular and cellular cementum

Acellular cementum Cellular cementum
Primary cementum Secondary cementum
Thickness is less Thickness is more
Rate of deposition is Faster rate of deposition
slower
No entrapped cells seen Entrapped cells (cementocytes) are seen
Incremental lines of Salter Incremental lines are slightly far apart
are closer
Located at cervical 2/3rds Located at apical 1/3rds
Contain more extrinsic Contain more intrinsic fibers
fibers
Sharpey’s fibers are less Sharpey’s fibers are more prominent because
prominent and they are they are not fully mineralized and have
fully mineralized central unmineralized core
The junction between Cemento-dentinal junction is more distinct
dentin and cementum is
less distinct
Cementoid layer is thin Definite thicker layer of cementoid seen
and not distinct
Function is mainly Function is mainly adaptation
attachment

Cemento-enamel Junction
This is the junction between cementum and enamel at the cervical region of
tooth (Figs 7.4 and 7.5). The relationship between cementum and enamel at
cervical part of the tooth can be of three types (Fig. 7.4). More than one
relationship may occur at different sites around the neck of a given tooth.
Sharp junction or Butt joint or end-to-end approximating CEJ, where enamel
and cementum meet at a sharp line. This type is reported in around 30%
teeth.
Overlap junction: In this type cementum overlaps the cervical region of
enamel. This occurs due to degeneration of cervical region of reduced enamel
epithelium allowing the dental follicle cells to come in contact with newly
formed enamel. The follicle cells differentiate into cementoblasts and deposit
cementum. This type of junction is seen in 60% of teeth. The type of
cementum that is overlapping enamel is acellular, afibrillar type without any
entrapped cells but containing fibrillar component that does not bear
characteristic collagen periodicity.

Fig. 7.4: Types of cemento-enamel junctions

Gap junction: In this type, there is no actual junction between enamel and
cementum. Instead, a cervical region of root devoid of cementum is seen.
This occurs due to delayed degeneration of Hertwig’s epithelial root sheath
preventing the contact between dental follicle cells and newly formed dentin
which causes lack of differentiation of cementoblasts. In that region a gap
between enamel and cementum is seen due to lack of deposition of
cementum. This type of junction is seen in 15% teeth. Normally the
cementoenamel junction is covered by gingiva. Gingival recession causes
exposure of cementoenamel junction leading to sensitivity due to exposed
dentin in gap type junction.
Good to Know
Another pattern of CEJ has been reported in about 1.6% of teeth, where the
enamel overlap cementum at cervical region of tooth. (Arambawatta, et al.
J Oral Sci 2009 Dec; 51(4):623–7.) The existence of this pattern is
controversial as cementum formation is initiated only after completion of
enamel formation. Some researchers consider it as an optical illusion,
while rare micro-regions of enamel over cementum has been demonstrated
by some researchers through scanning electron microscopic (SEM)
analysis.

Fig. 7.5: Cemento-enamel junction

Cemento-dentinal Junction
This is the junction between dentin and cementum and is relatively straight in
contrast to scalloped DEJ. The cemento-dentinal junction may be scalloped in
deciduous teeth. The junction between dentin and cementum is not very
distinct in acellular cementum while is somewhat distinct in cellular
cementum.
In decalcified sections cemento-dentinal junction can be identified easily
because cementum stains more intensely than dentin. Collagen fibers of
dentin are dispersed randomly whereas those of cementum are more orderly
arranged and aggregated into discrete bundles. At the cemento-dentinal
junction the fibers of dentin and cementum are found to be intertwining,
which is more pronounced in cellular cementum. This intertwining fibers
along with proteoglycans present between, contribute to attachment between
cementum and dentin. It was thought that dentin and cementum are separated
by 10 microns thickness layer termed as hyaline layer of Hopewell Smith.

FUNCTIONS OF CEMENTUM

Attachment: Cementum is one of the components of periodontium which is

the attachment apparatus of tooth. The periodontal ligament fibers are
inserted into cementum therefore providing attachment of the tooth to
alveolar bone. Acellular cementum is primarily involved in attachment.
(Cellular cementum is at times absent in some teeth particularly in anterior
teeth indicating that it is not essential for attachment.) Continuous deposition
of cementum provides the new layers to keep the attachment apparatus intact.
Functional adaptation: Due to masticatory force there is continuous wearing
away of occlusal or incisal part of teeth causing decrease in length. This
decrease in length is compensated by cellular cementum deposition in the
apical region of tooth. Thus apical cementogenesis helps to maintain occlusal
functional relationship of teeth.
Repair: Any damage caused to the root is repaired by continuous deposition
of cementum. In case of rapid repair, cellular cementum with small apatite
crystals are deposited while in case of slow repair, acellular cementum is
deposited.
Cementum protects the dentin by forming a continuous layer covering it and
thus preventing possibility of the direct exposure of dentin to oral
environment, in case of gingival recession and root exposure. Exposure of
dentinal tubules causes sensitivity.
Cementogenesis assist in maintenance of width of periodontal ligament.
Probably helping in the eruption procedure by deposition in apical region.
(Age changes, refer page 322)

Clinical Considerations
▪ Hypercementosis is the deposition of excessive amount of secondary
cementum on the root surface. This may involve single tooth or
multiple teeth. Excessive cementum deposition may be only at the apex
or nearly over the entire root area. Hypercementosis may or may not be
increasing the functional efficiency. If hypercementosis is associated
with improved functional quality, it is called cementum hypertrophy
and if it is not related to function as in a nonfunctional tooth, it is called
cementum hyperplasia. Hypercementosis can occur due to local factors
such as abnormal occlusal trauma, chronic periapical inflammation or
unopposed teeth. As a functional adaptation to compensate for the
occlusal wear there can be excessive cementum deposition in some
teeth. Generalized hypercementosis involving multiple teeth is a
finding in Paget’s disease of bone. Teeth affected do not show any
clinical symptoms. Radiographs reveal thickening of root with a round
apex. Hypercementosis may cause problems while extracting, therefore
care should be taken.
▪ Avascular nature of cementum makes it more resistant to resorption
than bone and this nature permits the orthodontic tooth movement
without causing damage to tooth. However, excessive orthodontic
force may result in resorption of cementum.
▪ Cementum resorption or even fracture can occur due to trauma or
excessive forces, but the damage usually is repaired by formation of
new cementum, either acellular or cellular cementum.
▪ Gingival recession or periodontal surgery leads to exposure of cervical
cementum may result in sensitivity particularly in case of gap type of
CEJ.
▪ Absence of cementum or defective cementum formation and therefore
premature loss of deciduous teeth has been reported in conditions like
hypophosphatemia. Congenital absence of cellular cementum in the
deciduous and permanent dentition has been reported in cleidocranial
dysplasia, an autosomal dominant disorder, in which this is related to
 the failure in the eruption.
▪ Continuous rhythmic deposition of cementum throughout life is used
for age estimation in forensic odontology.
▪ Cemetum, once exposed to oral environment undergo various changes:
Due to incorporation of minerals from oral environment or adsorption
of microbial toxins from oral microflora, etc.
 8
Periodontal Ligament
Dr Rajeesh Mohammed PK and Dr Girish KL

Introduction
Components of periodontium
Structure of periodontal ligament
– Cellular components
– Extracellular component
Functions of periodontal ligament
Clinical considerations

T he tissues which invest and support the tooth in its natural and functional
state are collectively called periodontium. These tissues form the
attachment apparatus of the tooth. The periodontium is comprised of two
mineralized tissues and two fibrous tissues. The alveolar bone and the
cementum form the mineralized components and the periodontal ligament
and the lamina propria of gingiva which contains the gingival group of fibers
forms the fibrous component of the periodontium.

Components of Periodontium
Two mineralized tissues
– Alveolar bone
– Cementum
Two fibrous tissues
– Periodontal ligament
 – Lamina propria of gingiva

PERIODONTAL LIGAMENT

It is a soft fibrous connective tissue that is noticeably cellular and vascular,

which surrounds the tooth root and anchors it to the bony socket. The
periodontal ligament is interposed between the roots of teeth and the inner
wall of the alveolar socket, the periodontal space. It is neither a true ligament
nor a membrane. The periodontal ligament is continuous with the gingival
connective tissue above the alveolar crest. It communicates with the dental
pulp at the apical foramen and with bone marrow of the alveolar process
through vascular channels. The infection from these tissues, i.e. gingiva and
pulp, can involve the ligament if left untreated.
Various synonyms are used in the literature to describe periodontal
ligament such as desmodont, gomphosis (fibrous joint), pericementum, dental
periosteum, alveolar ligament, periodontal membrane, etc.

Shape
Periodontal ligament resembles the “Hour glass” in shape as it is narrowest in
the middle third of the root and widens both apically and near the alveolar
crest.

Width
The width of periodontal ligament is variable, the average width ranging from
0.15 to 0.38 mm. The width of periodontal ligament decreases with age,
which can be partly attributed to the reduced functional load.

Development
The periodontal ligament develops from the dental follicle, an
ectomesenchymal component of tooth germ. As the root formation
progresses, the dental follicle cells differentiate into cementoblasts to
produces cementum, osteoblasts to produces bone and fibroblasts to produce
the fibers and ground substance of periodontal ligament. As the root
formation proceeds the fibers get embedded in the forming cementum and
alveolar bone.
 In the initial stages of formation of periodontal ligament, the ligament
space consists of unorganized short connective tissue fiber bundles which
extend from the cementum and the alveolar bone. As the tooth erupts the
fibers orient themselves in various characteristic planes.

Microscopic Structure of Periodontal Ligament

The periodontal ligament is comprised of cellular components and
extracellular substances. Various connective tissue structures such as
neurovascular elements are also found to be distributed in the periodontal
ligament.
The cellular components of the periodontal ligament include synthetic cells
and resorptive cells of various structural components of periodontium. A
synchronized functioning of these cellular components helps to maintain the
integrity of the attachment apparatus of tooth. In addition, progenitor cells,
epithelial cell rests of Malassez and other defense cells are also present.
Cells of periodontal ligament
Synthetic cells
• Osteoblasts
• Cementoblasts
• Fibroblasts
Resorptive cells
• Osteoclasts
• Cementoclasts
• Fibroblasts
Progenitor cells
Epithelial cell rests of Malassez
Defense cells
• Mast cells
• Macrophages, etc.

Osteoblasts
Osteoblasts are the bone forming cells derived from the multipotent
mesenchymal cells. They cover the periodontal surface of alveolar bone and
constitute a modified endosteum. The osteoblasts help in the formation of
organic matrix of bone (osteoid) and in the mineralization of the matrix.
Osteoblasts lining the periodontal surface of the alveolar bone may be either
resting or active. Active osteoblasts are plump with abundant synthetic
organelles while resting cells are flattened (for details refer page 95).

Cementoblasts
Cementoblasts are the cementum forming cells which are derived from the
undifferentiated ectomesenchymal cells of the dental follicle and they
resemble osteoblasts and are most often in resting stage. These cells are
distributed along the periodontal surface of cementum. The cementoblasts
help in the formation of cementum which has a functional importance in
maintaining the width of periodontal ligament (for details refer page 79).

Fibroblasts
Fibroblasts are the most numerous and functionally important connective
tissue cells in periodontal ligament. They may be plump, spindle-shaped or
fusiform and are oriented parallel to the collagen fibers. They are large cells
with extensive cytoplasm containing abundant cellular organelles associated
with protein synthesis and secretion such as rough endoplasmic reticulum,
Golgi complex, mitochondria, etc. Unlike other cells, the fibroblasts perform
the dual function of synthesis as well as degradation of collagen fibers,
thereby helping to maintain the turnover of collagen and homeostasis of
periodontal ligament. Fibroblasts produces collagen and ground substance
required for periodontal ligament. They participate in collagen degradation by
secreting collagenase enzyme and by phagocytosing and degrading the
collagen molecules. The fibroblasts in the ligament exist as different
subpopulation, although they look alike at both light and electron
microscopic levels. Fibroblasts in the periodontal ligament are also referred
to as myofibroblasts because of the presence of contractile elements such as
actin and myosin in their cytoplasm, to provide contractile force required for
tooth movement.

Osteoclasts
Osteoclasts are multinucleated giant cells, approximately 20–100 microns in
diameter (refer Figs 9.4a and b). These cells are found in Howship’s lacunae
and have a brush or ruffled border towards the surface to be resorbed. The
osteoclasts help in the resorption of bone (for details refer page 96–97).

Cementoclasts
Cementoclasts resemble osteoclasts structurally and functionally and helps in
the resorption of cementum and other dental hard tissues (for details refer
page 289–290).

Progenitor Cells
Progenitor cells are undifferentiated mesenchymal cells which have the
capacity to undergo mitotic division. Pleuripotent undifferentiated
mesenchymal cells are present in the periodontal ligament which can give
rise to various synthetic cells. They have a perivascular location and are
usually found in a quiescent state having a small close-faced nucleus and a
little cytoplasm. These cells can enter the cell cycle when triggered by stimuli
and undergoes cell division, giving rise two daughter cells, one of which
differentiates into the synthetic cell type while the other remains in the
progenitor compartment.

Epithelial Cell Rests of Malassez

Epithelial cell rests of Malassez are the remnants of Hertwig’s epithelial root
sheath (HERS) (Fig. 8.1). They are found in the periodontal ligament close to
the cementum. These cell rests persists as network, strands, islands or tubule-
like structures near or parallel to the root surface and are most numerous in
the apical and cervical areas. These epithelial cells exhibits tonofilaments and
are attached to one another by desmosomes. Cell shape varies from squamoid
to cuboidal with round or ovoid hyperchromatic nucleus. These cells are
surrounded by a periodic acid-Schiff (PAS) positive, argyrophilic, fibrillar
material, from which they are separated by a basal lamina. These cell rests
decreases with age by degenerating and disappearing or by undergoing
calcification to form cementicles. The physiologic role of the epithelial cell
rests of Malassez is unknown. They can undergo rapid proliferation when
stimulated and give rise to certain pathologic conditions like cysts or tumors.
 Fig. 8.1: Epithelial cell rest of Malassez

Mast Cells (Labrocyte, Mastocyte)

Mast cells are defense cells found in periodontal ligament and are round or
ovoid in shape with a small, pale and a centrally placed nucleus. The
cytoplasm of these cells contains numerous metachromatic granules. The
granules possess histamine, heparin, serotonin and other inflammatory
mediators. The granules stain with metachromatic dyes like azure A and
toluidine blue.

Macrophages
Macrophages are the scavenger cells with a round or ovoid shape with a
horseshoe or kidney shaped nucleus. The cytoplasm contains numerous
lysosomes. These cells are derived from blood monocytes are usually located
near the blood vessels.
The extracellular components of periodontal ligament
Fibers
– Collagen (type I, III and XII)
– Oxytalan
– Eluanin
Ground substances
– Glycosaminoglycans
– Glycoproteins
Structures present in the connective tissue
– Blood vessels
– Lymphatics
– Nerves
– Cementicles
– —

Fibers of the Periodontal Ligament

More than 90% of connective tissue fibers of periodontal ligament are mainly
collagen. In addition, oxytalan and eluanin fibers are also seen.

Collagen Fibers
Collagen is a high molecular weight protein to which small numbers of
sugars are attached. Collagen fibrils have a transverse striation with a
characteristic periodicity of 64 nm. Collagen is secreted mainly by
fibroblasts, and are secreted as tropocollagen which aggregates into
microfibrils which are arranged to form fibrils. These fibrils are packed to
form fibers and the fibers are then packed to form bundles. Periodontal
ligament has predominantly collagen type I, III and XII.
The collagen fibers in the periodontal ligament are found to be gathered
into bundles and organized as functional groups having clear orientation
relative to the periodontal space. These fiber groups are termed as principal
fibers and are assisted in function by a second group of fibers called
accessory fibers.

The Principal Fibers of Periodontal Ligament

There are five different principal fiber groups (Fig. 8.2) of which four groups
are distinguished in all teeth and include alveolar crest group, horizontal
group, oblique group and apical group. In addition, a fifth group of fibers
called as inter-radicular fibers are seen in multirooted teeth.
1. Alveolar Crest Group
The alveolar crest group of fibers radiates obliquely from the crest of alveolar
bone to the cervical part of cementum just beneath the junctional epithelium.
Function: Alveolar crest fibers help to secure the tooth in the socket and
prevents extrusion of tooth. They also resist lateral tooth movements.

Fig. 8.2: Principal fibers of periodontal ligament

2. Horizontal Group
These are found immediately apical to the alveolar crest group. The
horizontal group of fibers, as the name indicate are oriented horizontally from
the cementum to the alveolar bone, almost at right angles to the long axis of
the tooth. They constitute only a minor group and are restricted to the coronal
third of periodontal ligament space.
Function: The horizontal fibers help to resist tooth displacement against
lateral pressure.
3. Oblique Group
The oblique group is the major groups of fibers in periodontal ligament and
have an oblique orientation within the periodontal space. They extend from
the cementum to the alveolar bone with the insertion into the cementum in an
apical position when compared to the insertion into the alveolar bone.
Function: Since oblique fibers are the major group of fibers, they have a
significant role in holding the tooth in its socket. The oblique orientation
serves to resist apically directed masticatory forces.
4. Apical Group
These fiber bundles radiate from apical region of root to the surrounding
alveolar bone (base of the alveolar socket). These fibers are absent in teeth
with incompletely formed roots.
Function: Apical group of fibers function to resist forces of luxation and
may prevent tooth tipping. These fibers may also have a role in protecting the
vasculature and nerve fibers in the apical region.
5. Inter-radicular Group
The inter-radicular group of fibers are seen only in multi-rooted teeth. The
fibers fan out from the crest of inter-radicular septum and get inserted into the
cementum in furcation areas of a multi-rooted tooth.
Function: They may be help in resisting tooth tipping, torquing and luxation.
The principal fibers run a wavy course from the cementum to the bone in
various planes. These fibers straighten out under load, thereby helping in
force transmission. The unique molecular configuration of collagen imparts
flexibility and strength to the tissues. The periodontal ligament fibers are
capable of functional adaptation, depending on the requirement. These fibers
are attached to cementum on one side and alveolar bone on the other side.
The portion of the principal fibers that is embedded into either cementum or
bone is called Sharpey’s fibers. These fibers occasionally pass through the
bone of the alveolar process to continue as principal fibers of an adjacent
periodontal ligament and are referred to as transalveolar fibers. Sharpey’s
fibers are associated with high levels of noncollagenous proteins (osteopontin
and bone sialoprotein) mainly found in bone and cementum.
Between and among the dense bundles of principal fibers, areas of loose
connective tissue are found and are referred to as interstitial tissues. These
regions contain blood vessels, and nerves and are responsible for providing
nutrients to the periodontal ligament and cells of the cementum.
Accessory Fibers of Periodontal Ligament
This group includes gingival fibers and transseptal fibers.
Gingival fibers (Fig. 8.3) are group of fibers which vary in size and
orientation and are found in the connective tissue of gingiva underlying the
crevicular and junctional epithelium. These fibers are also called gingival
ligament and play a very important role in maintaining the integrity of
supporting apparatus of the tooth.

The gingival group of fibers include

Dento-gingival fibers: These fibers extend from the cervical portion of the
cementum to the lamina propria of gingiva.
Dento-periosteal fibers: These fibers extend from the cervical part of
cementum to the periosteum of the alveolar crest and the vestibular and oral
surface of the alveolar bone.

Fig. 8.3: Gingival group of fibers

Alveolo-gingival fibers: These fibers extend from the crest of the alveolar
bone to the lamina propria of gingiva.
Circular fibers: These fibers are arranged in the gingival connective tissue,
encircling the neck of the tooth like a collar. These fibers are also known as
the marginal ligament and they play an important role in maintaining a tightly
fitting gingival collar.
Trans-septal fibers: Trans-septal fibers which are also called interdental
ligament are also found in gingival connective tissue as accessory fibers
extending interproximally between two adjacent teeth. These fibers extend
from cementum of one tooth to cementum of adjacent tooth over the
interdental bony alveolar crest.
Indifferent fiber plexus: Indifferent fiber plexus are formed by small
collagen fibers that are seen in association with the larger principal collagen
fibers and runs in all directions to form a fiber plexus.
Intermediate plexus: Light microscopic examination of longitudinal section
of periodontal ligament gives an appearance, as though fibers arising from
cementum and alveolar bone are joined in mid-region of the periodontal
space giving rise to a zone of distinct appearance. This is called intermediate
plexus. It was believed that intermediate plexus provide a site where rapid
remodeling of fibers occur, allowing adjustments in periodontal ligament to
accommodate small tooth movement. After electron microscopic,
radioautographic studies and surgical experiments, intermediate plexus is
considered as an artifact arising out of the plane of sectioning.
Oxytalan and eluanin fibers: Oxytalan and Eluanin fibers are immature
elastic fibers found in the periodontal ligament. They run in an axial
direction, one end being embedded in cementum or alveolar bone and the
other end in the wall of a blood vessel. These fibers are numerous and dense
in the cervical region.
These fibers supports the blood vessels of the periodontal ligament and
regulates the blood flow.
Ground substance: The space between cells, fibers, blood vessel and nerves
in periodontal ligament space is occupied by ground substance. The principal
ground substance has been estimated to be water (70%). The ground
substance is composed of two components; glycosaminoglycans such as
hyaluronic acid and proteoglycans, and glycoproteins such as fibronectin and
laminin. Ground substance acts as a gel-like base in which cells and fibers are
arranged in an organized pattern.
Cementicles: Cementicles are small foci of calcified tissue which lie free in
the periodontal ligament. They represent areas of dystrophic calcification.
They are commonly seen in older individuals. The size varies from 0.2 to 0.3
mm in diameter and are too small to be seen in radiographs. Cementicles
does not have any clinical significance. They may be lying free in periodontal
ligament, attached to cementum or embedded in cementum.
Cementicles may be formed by calcification of degenerated epithelial cell
rests, Sharpey’s fibers or thrombosed blood vessels. Spicules of alveolar bone
or cementum traumatically displaced also may remain in periodontal
ligament as calcified mass.

FUNCTIONS OF PERIODONTAL LIGAMENT

The functions of periodontal ligament can be broadly categorized into:

Supportive or physical
Sensory
Nutritive
Homeostatic/formative/developmental

a. Supportive Function
The periodontal ligament fibers provide attachment of the tooth to the bone.
It helps to transmit masticatory forces to the bone and acts as a shock
absorber against external forces. By providing cushioning effect, the
periodontal ligament protects the vessels and nerves from mechanical injury.
The periodontal ligament also helps to maintain the proper relationship
between gingiva and the tooth.
Tooth support and shock absorption is explained on the basis of three
theories.
Tensional theory: Attributes the major role for the principal fibers of the
periodontal ligament in supporting the tooth and transmitting forces to the
bone.
Viscoelastic system theory: According to this theory displacement of tooth
is largely controlled by fluid movements while fibers have only secondary
role.
Thixotropic theory: Periodontal ligament has rheologic behavior of a
thixotropic gel.

b. Sensory Function
The periodontal ligament through its nerve supply provides efficient
proprioceptive mechanism. This mechanism is so effective that, it is possible
to sense even a grain of sand that is caught between the teeth.

c. Nutritive Function
The periodontal ligament transmits blood vessels which provide anabolites
and remove catabolites from the cells of ligament, cementum, and alveolar
bone. This is of particular importance in case of cementum, as it is avascular
and has to depend entirely on the periodontal ligament for nutrition.

d. Homeostatic Function
Periodontal ligament has synthetic cells and resorptive cells of various
structural components of periodontal ligament. These cells synthesis and
resorb the connective tissue components of periodontal ligament cementum
and alveolar bone. Therefore they help in remodeling of these components
which is very essential for maintaining functional integrity of periodontium.
The activity of these cells are well controlled and balanced, therefore
various components of periodontium are able to maintain their integrity and
relationship to each other. Any disturbance in homeostatic function may
disturb the functional efficiency of attachment apparatus of teeth.
(Age changes, refer page 323)

Clinical Considerations
▪ Periodontal ligament thickness varies in different teeth, is thicker in
functioning teeth than in non-functioning teeth. Abnormal occlusal
forces can damage the periodontal ligament resulting in stretching of
periodontal ligament and expressed as widening of periodontal
ligament space. Abnormal thickening of periodontal ligament,
expressed in a radiograph as uniform widening of periodontal ligament
involving many teeth is a characteristic finding in a disease called
scleroderma.
▪ Ankylosis is a condition in which the tooth roots become fused directly
to the alveolar bone proper and poses difficulty in extraction. Trauma
that damages the periodontal ligament may result in ankylosis.
▪ Tooth which is accidentally knocked out (avulsion) can be reimplanted
only if the periodontal ligament cells are viable.
▪ Untreated gingival inflammation (gingivitis) may progress to involve
the supporting structures. This condition is termed as periodontitis,
which leads to destruction of periodontal ligament and supporting
alveolar bone and mobility of teeth, eventually premature loss of tooth.
▪ Resorption (on the pressure side) and formation (on tension side) of
both bone and PDL forms the basis for orthodontic tooth movement.
 9
Alveolar Bone
Dr Heera R

Introduction
Structure of alveolar bone
Development
Chemical composition
Bone histology
Bone remodeling
Clinical considerations

T he alveolar process is that part of the jaw bones in which teeth are found.
It can also be defined as the part of maxilla or mandible that forms and
supports the socket of the teeth in which the teeth are anchored.
Alveolar bone is seen as an extension from the body of maxilla and mandible
without any distinct boundary between them. But an arbitrary boundary can
be drawn at the level of root apices of the teeth which separates the alveolar
process and the basal bone. Like bones in other sites, alveolar bone function
as a mineralized supporting tissue, giving attachment to muscles, providing
frame work for bone marrow and acting as a reservoir of ions, especially
calcium. Alveolar bone is dependent on the presence of teeth for its
development and maintenance.

STRUCTURE

The maxillary alveolar process extends interiorly and mandibular alveolar

process superiorly from their respective jaw bones. They support the teeth
within the bony sockets. The alveolar process is composed of two parallel
plates of cortical bone, the buccal and lingual or palatal alveolar plates,
between which lie the sockets of teeth. The individual sockets are separated
from the adjacent ones by plates of bone called interdental septa and the
sockets of multi-rooted teeth are separated by inter-radicular septa. The
floor of the socket is termed as fundus and its rim, the alveolar crest. The
form and depth of each socket depends upon the form and length of the root
and the functional demands placed upon the teeth.
As an adaptation to its function, the alveolar bone (process) can be divided
into two parts, alveolar bone proper and supporting alveolar bone.
The parts of the alveolar bone include (Figs 9.1a and b)
Alveolar bone proper
Supporting alveolar bone
• Buccal and lingual cortical plates
• Central spongy bone

Alveolar Bone Proper

Alveolar bone proper is a layer of compact bone lining the tooth socket and it
varies in thickness from 0.1 to 0.5 mm. It has been given various names.
 Fig. 9.1a: Parts of alveolar bone—proximal view
It is referred to as cribriform plate due to the sieve like appearance
produced by numerous vascular canals (Volkmann’s canals). These
foraminae transmits the vessels from the alveolar bone into the periodontal
ligament.
Alveolar bone proper is composed of two parts; bundle bone (the portion
adjacent to the periodontal ligament) and lamellated bone. Bundle bone is
called so, because numerous bundles of Sharpey’s fibers from the periodontal
ligament are inserted and cemented into it. The bundle bone contains only
fewer number of intrinsic collagen fibers in the matrix which are arranged at
right angles to Sharpey’s fibers. The decreased fibril density is associated by
increase in ground substance. This increase of cementing substance with high
amount of minerals is responsible for its dense opaque appearance in the
radiographs. The lamellated portion of the alveolar bone proper shows
lamellae which are arranged parallel to the root surface with few Haversian
system.
Based on radiographic appearance, alveolar bone proper is referred to as
lamina dura because of increased radiopacity which makes it appear as a
radio-dense layer. Lamina dura, appears as a continuous radiopaque lining of
the socket and usually is continuous with buccal and lingual cortical bone at
the alveolar crest.

Fig. 9.1b: Alveolar bone from occlusal view

In histological sections, the layer of cribriform plate appears to stain more
intensely. The bundle bone is the most important part of the alveolar process
in terms of tooth support and is considered to be a very important structure in
the radiographic interpretation of periodontal and periapical pathologies.

Supporting Alveolar Bone

Supporting alveolar bone consists of two parts:
Cortical plates, which is made up of compact bone and forms an outer
(buccal) and inner (lingual) plates of alveolar process.
Spongy (trabecular) bone, which fills the area between the cortical plates and
the alveolar bone proper.
The cortical plate consists of surface layers of lamellar bone supported by
compact Haversian system. The outer surfaces of these cortical plates are
covered by periosteum and different types of lamellae such as
circumferential, concentric and interstitial lamellae are seen. The cortical
plates are continuous with the compact bones of the maxilla and mandibular
body. The cortical plate and the alveolar bone proper meet at the alveolar
crest which is located usually 1.5 to 2 mm below the level of cemento-enamel
junction of the tooth. The cortical plates are generally thinner in the maxilla
than in mandible. The thickness of the cortical plate of mandible tends to
increase from anterior to posterior region with the greatest thickness in the
molar region. Generally the lingual cortical plates of both the arches are
found to be thicker than the buccal cortical plate. The outer cortical plate
shows numerous small openings (Volkmann’s canal) through which vessels
and nerves enter the bone. Mandibular alveolar bone has fewer but larger
Volkmann’s canals.
Spongy bone is the cancellous bone, occupying the space between cortical
plates and cribriform plates of the alveolar process. It is composed of
irregular interlacing bony trabeculae, each consisting of one or more lamellae
with osteocytes enclosed in lacunae. The inter trabecular spaces are generally
filled with yellow marrow rich in adipose cells or sometimes red or
hemopoietic marrow.
Based on the radiographic appearance, the spongiosa is classified into two
main types: type I and type II. In type I the interdental and interradicular
trabeculae are regular and horizontal in a step ladder type arrangement. This
architecture is most often seen in the mandible where trajectorial pattern of
spongy bone is seen. Type II shows irregularly arranged, numerous delicate
interdental and inter radicular trabeculae. This arrangement is more common
in maxilla and lacks a distinct trajectory pattern.
In general the amount of spongiosa is less in mandible than maxilla and the
distribution vary depending on the inclination of roots. In the anterior region
of both jaws, the supporting bone is usually very thin with less or no spongy
bone in between; hence the cortical plate may be fused with the alveolar bone
proper in this region.
The shape of the crest of the alveolar septa in radiographs depends on the
position of adjacent teeth. The interdental and interradicular septa contain
perforating canals of Zuckerkandl and Hirschfeld which house the
interdental and interradicular arteries, veins, lymph vessels and nerves.

DEVELOPMENT

Alveolar bone is formed during fetal growth by intramembraneous

ossification. As the developing tooth germs reach the bell stage, developing
bone becomes closely related to the tooth germ to form the alveolus. The size
of the alveolus is dependent upon the size of the growing tooth germ.
Resorption occurs on the inner wall of the alveolus and deposition occurs on
the outer wall. The developing teeth therefore come to lie in a trough of bone.
Later, the teeth become separated from each other by development of
interdental septa. With the onset of root formation interradicular bone
develops in multirooted teeth. Much later the primitive mandibular canal is
separated from the dental crypts by a horizontal plate of bone.

CHEMICAL COMPOSITION OF BONE

Bone is a mineralized connective tissue composed of:

By weight
60% inorganic material
25% organic material
15% water
By volume
36% inorganic material
36% organic material
28% water
Inorganic component is carbonated, hydroxyapatite in the form of small
plates, most of which lodged in the holes and pores of collagen fibrils.
Organic matrix of bone is about 90% collagen. Most of the collagen is
secreted by osteoblasts and are considered as intrinsic collagen. However,
collagen fibers in Sharpey’s fibers are extrinsic collagen formed by
fibroblasts. Most dominant collagen in bone is type I collagen, but small
amounts of type III and type V collagen are also found.
Noncollagenous proteins: 10% of organic content of bone matrix is
constituted by a heterogenous group of noncollagenous protein and about 200
of this type of proteins have been identified. Most of these are endogenous,
produced by bone cells. Bone also contains exogenous proteins which
circulate in the blood and become locked up in the bone matrix themselves.
Some of the noncollagenous proteins are proteoglycans, which may regulate
the collagen fibril diameters and may play a role in mineralization and
glycoproteins like osteocalcin, osteonectin, osteopontin, bones sialoprotein,
thrombopondin and fibronectin. Osteonectin with its ability to bind calcium
may have role in mineralization. Osteopontin, ostonectin and fibronectin help
in attachment of cells to the bone matrix. Osteocalcin is a calcium binding
protein synthesized only by osteoblasts and odontoblasts.

BONE HISTOLOGY

All bones have a dense outer sheet of compact bone and a central medullary
cavity. The medullary cavity is filled with red or yellow bone marrow. The
marrow is interrupted by a network of bony trabeculae and is known as
trabecular, cancellous or spongy bone.
In adult bone, histologically, both the compact and the trabecular bone
consists of lamellae. Three types of lamellae have been recognized:
circumferential, concentric and interstitial lamellae (Fig. 9.2).
Circumferential lamellae form the outer perimeter of the bone. The bulk of
compact bone is made up of concentric lamellae. The interstitial lamellae fill
the space between adjacent concentric lamellae. The interstitial lamellae are
considered as the fragments of previous concentric lamellae as a result of
remodeling and they contain old remnants of circumferential lamellae as well
as osteonal remnants.

Fig. 9.2: Longitudinal section of bone

The concentric lamellae (Fig. 9.3) are arranged around a central vascular
canal, the Haversian canal. The Haversian canal contains capillaries and is
lined by a single layer of bone cells. The Haversian canal together with the
concentric lamellae is known as osteon or Haversian system which is the
basic structural and functional unit of bone. There may be 9–20 concentric
lamellae with in each Haversian system. The collagen fibers with in each
lamellae spiral along the length of the lamellae but have different orientation
to those in adjacent lamellae. The change in orientation can be demonstrated
by viewing the bone in polarized light. The longitudinally running Haversian
canals are connected by horizontal interconnecting canals known as
Volkmann’s canal which also contain blood vessels.
 In spongy bone the lamellae are apposed to each other to form trabeculae.
The trabeculae are about 50 microns thick and aligned along the lines of
stress to withstand the force applied to the bone. The trabeculae usually do
not have Haversian canal and they get their nutrients from the marrow spaces.
In young bone the marrow is red and hematopoietic and contains stem cells
of both mesenchymal type and blood cell lineage. In old bone, the marrow is
yellow due to accumulation of fat cells and hence lose hematopoietic
potential.

Fig. 9.3: Portion of osteon with concentric lamellae and osteocytes

Surrounding the outer aspect of every compact bone is the periosteum
which contains two layers, an outer fibrous layer of dense irregular
connective tissue and inner cellular layer of bone cells and their precursors.
The periosteum has rich blood supply. The inner surface of compact bone and
cancellous bone are covered by cellular endosteum. The periosteal surface is
more active in bone formation than the endosteal surface.

Cells of Bone
Different cell types are responsible for formation, resorption and maintenance
of bone. Two cell lineages are present in bone:
Osteogenic cells derived from mesenchymal (or ectomesenchymal) stem
cells, including osteoprogenitors, preosteoblasts, osteoblasts and osteocytes
which form and maintain the bone.
Osteoclasts, which resorb bone are derived from monocytes and
macrophages and form part of hematopoietic system.

Osteoblasts
Osteoblasts are mononucleated cells of mesenchymal origin and seen as a
layer of cuboidal cells on the surface of bone where bone formation is taking
place. The cells are polarized with a prominent, round nucleus located at the
basal end. The active osteoblasts exhibit basophilic cytoplasm due to the
presence of large amount of RNA content. The cytoplasm contains rich
synthetic organelles such as, rough endoplasmic reticulum, numerous
mitochondria, Golgi complexes and vesicles, etc. The cells contact one
another by means of adherence and gap junction. These cells exhibit high
levels of alkaline phosphatase on the outer surface of their plasma membrane.
Osteoblasts are the synthetic cells of the bone which are involved in
secretion of the organic matrix of bone, i.e. osteoid and also help in
mineralization of uncalcified matrix.
In addition the osteoblasts have a controlling influence in activating
osteoclasts. They contain receptors for parathyroid hormone and regulate
osteoclastic response to this hormone. They also participate in matrix
degradation though the production of hydrolytic enzyme and interleukin-6.
When the bone surfaces are neither in the formative nor resorptive phase,
the layer of osteoblasts lining the bone surface flatten and these cells are
called bone lining cells. These cells cover most surfaces in the adult skeleton
and contain only few cell organelles with little sign of synthetic activity.
They retain their gap junctions with the osteocytes. They are regarded as post
proliferative osteoblasts and protect the bone from resorptive activity of
osteoclasts. They can be reactivated to form osteoblasts.

Osteocytes
During bone formation, some osteoblasts become entrapped with in the
matrix of the bone; these entrapped cells are called osteocytes (Fig. 9.4a).
The number of osteoblasts, that become osteocytes depend, on the rate of
bone formation. The more rapid the formation the more osteocytes are
present per unit volume. So the embryonic (woven) bone and repair bone
have more osteocytes than does lamellar bone. Usually about 15% of
osteoblasts become embedded in the organic matrix as osteocytes.
Approximately 25,000 osteocytes can be seen per cubic mm of bone. The
space in the matrix, occupied by an osteocyte is called the lacuna. Many fine
canals called canaliculae radiate from the lacunae in all directions which
contain cell processes of the osteocytes (Fig. 9.3). Through this canaliculae,
osteocytes maintain contact with adjacent osteocytes, osteoblasts and lining
cells. As a result of this inter connections the osteocytes are regarded as the
main mechanoreceptors of bone. Osteocytes are thought to be capable of
taking part in bone resorption which is referred to as osteocytic osteolysis.
At the ultra structural level, the appearance of osteocytes vary according to
its position in relation to the surface layer. Osteocytes which are newly
incorporated into the bone matrix contain larger amount of organelle like
osteoblasts. With continued bone formation, the osteocytes become more
deeply situated and the number of organelles shows reduction, reflecting
decreased cellular activity.

Osteoclasts
Osteoclasts are multinucleated giant cells responsible for bone resorption;
they are derived from hematopoietic cells of monocyte or macrophage
lineage by fusion of mononuclear precursors. They can be easily
differentiated under light microscope because of their large size and multiple
nuclei. The cells show considerable variation in size and shape. The cell body
is irregularly oval and may show many branching processes. Usually
osteoclasts contain 10–20 nuclei and the size is about 100 microns in
diameter (Fig. 9.4a).
Tissue culture studies indicate that osteoclasts are highly motile and is
evident from the ‘snail tracks’ on the bone surface. The osteoclasts are
recruited only when required since there is no significant reservoir of inactive
osteoclasts. The life span of osteoclasts is thought to be about 10–14 days.
Osteoclasts are characterized cytochemically by possessing tartrate resistant
acid phosphatase within its cytoplasmic vesicles and vacuoles which,
distinguishes it from other multinucleated giant cells.
Typically osteoclasts are found occupying hollowed out depressions on the
resorbing surface known as Howship’s lacunae that they have created.
Scanning electron microscopy shows that the Howship’s lacunae are shallow
troughs with irregular shape which reflect activity and mobility of osteoclasts
during active resorption.
Under electron microscopy, osteoclasts exhibit the following morphologic
characteristics (Fig. 9.4b). The cell membrane of the osteoclast that lies
adjacent to resorbing bone surface is thrown into a number of deep folds that
form the ruffled border. It is composed of many tightly packed microvilli.
This ruffled border provides a large surface area for the resorptive process.
The cytoplasm adjacent to the ruffled border is devoid of cell organelle but
contains numerous contractile actin microfilaments and this zone is referred
to as clear zone. At the periphery of the ruffled border, the plasma membrane
is apposed closely to the bone surface. This sealing zone serve to attach the
cell very closely to the surface of bone and create a microenvironment in
which resorption can take place without diffusion of the hydrolytic enzymes
produced by the cell into adjacent tissue.

Fig. 9.4a: Cells of bone

 Fig. 9.4b: Osteoclast in Howship’s lacunae
There are several mechanisms by which the osteoclasts bind to bone
surface. One of the mechanism is concentration of osteopontin on bone
surface which may facilitate osteoclasts adhesion at the sealing zone due to
the presence of cell membrane protein known as integrins (especially a2 b3
integrin).
In addition to multiple nuclei osteoclast also contain various cytoplasmic
organelles such as endoplasmic reticulum, Golgi complexes, many
mitochondria, numerous vesicles of different sizes and types, some
containing lysosomal enzymes, etc. distributed through out the cytoplasm
except near the ruffled border.

Bone Resorption
Once the osteoclast has been activated against the bone surface, bone
resorption occurs in two stages. Initially, the mineral phase is removed and
later the organic matrix. A sealed acidic microenvironment is created in the
resorption lacunae which dissolves the mineral crystals in bone and exposes
the organic matrix. To provide the low pH, the osteoclast secretes protons
across the ruffled border by means of ATP dependent protein pump that
pumps H+ ions to sealed compartment. The H+ ions are generated by the
action of enzyme carbonic anhydrase II on the carbon dioxide and water to
form carbonic acid. The organic matrix is then degraded by the action of
enzymes like collagenase, lysosomal acid proteases (cathepsin B1). The
inorganic and organic bone degradation products are taken inside the
osteoclasts by endocytosis at the ruffled border. These endocytosed products
are translocated in transport vesicles and released extracellularly along the
membrane opposite the ruffled border.

REMODELING OF BONE

The process by which the over all size and shape of bone is established is
referred to as bone remodeling and extends from embryonic bone
development to the preadult period of human growth. During this phase bone
is formed on the periosteal surface. Bone is laid down rhythmically; there are
periods of active deposition and quiescence which result in formation of
regular parallel incremental lines, called resting lines. The resting lines are
formed in periods of relative quiescence (rest period). Simultaneous with
bone deposition bone is resorbed along the endosteal surface at focal points.
During the growing phase of a child, the amount of bone deposition
exceeds that of resorption resulting in increase in bone mass. During adult
phase, the amount of bone deposition is equivalent to that of bone resorption
and bone mass is more or less constant. In old age and in diseases like
osteoporosis bone deposition is generally less when compared to resorption.
Therefore there is an overall decrease in bone mass. The replacement of old
bone, by new bone is called remodeling or bone turn over. In rapidly growing
children bone turn over is about 30–100%. The rate of remodeling decreases
in adults. This bone turn over occurs in discrete focal areas involving groups
of cells called bone remodeling units. The rate of cortical bone turn over is
approximately 5% per year, where as trabecular bone and endosteal surface
of cortical bone is 15% per year.
As the bone deposition continue at the periphery by deposition of
circumferential lamellae, the internal reconstruction of Haversian system take
place to meet the functional and nutritional demands. During this process,
osteoclasts differentiate in the peripheral Haversian canals to cause resorption
of concentric lamellae. The leading edge of resorption is always towards the
periphery and is called cutting cone or resorption tunnel. Initially, the
resorbed area gets filled with loose connective tissue followed by migration
of mononucleated cells onto the area. As these cells differentiate into
osteoblasts, they produce a coating, a thin layer of glycoprotein (mainly bone
sialoprotein and osteopontin) that, acts as a cohesive, mineralized layer
between the old bone and the new bone to be secreted. On top of this
osteoblasts begin to lay down new bone matrix mineralizing it from outside
in. The area of active formation is termed as the filling cone. As bone
formation proceeds some osteoblasts become osteocytes. The old and new
bones are separated by a distinct curved hematoxiphilic line with its
convexity facing the old bone. These lines are called reversal lines and are
indicators of continuous remodeling of bone.
A considerable amount of internal remodeling occurs within the bone by
means of resorption and deposition. The repeated deposition and removal of
bone tissue accommodates the growth of a bone without losing function or its
relationship to neighboring structures during remodeling phase. The
remodeling is enabled by the coordinated action of osteoclasts and
osteoblasts. Bone metabolism is directly under the control of various
hormones (for details refer Chapter 43).
(Age changes, refer Chapter 46)

Clinical Considerations
• Alveolar bone being part of jaw bone bearing teeth, existence of
alveolar bone is significantly dependent on teeth. Alveolar bone may
not be well developed in disease conditions where there is complete or
partial absence of teeth. Similarly alveolar bone undergo resorption
once the teeth are lost.
• Alveolar bone undergoes continuous remodeling to maintain functional
integrity. The response of alveolar bone to applied force and
remodeling capacity forms the basis of orthodontic tooth movement
• Alveolar bone undergoes destruction or resorption in cases of local
conditions such as periodontitis or due to pressure from cysts or
tumours. Alveolar bone loss may eventually results in mobility of
teeth.
• Alveolar bone or the basal bone can be common site of involvement of
various bone disorders such as fibrous dysplasia, Paget’s disease, etc.
• Radiographic examination of status of lamina dura and periapical bone
tissue is a routine procedure carried out in the diagnosis of periapical
diseases.
 10
Oral Mucosa

Introduction
Functions of oral mucosa
Classification of oral mucosa
Structure of oral mucosa
Structural variations
Clinical considerations

O ral mucosa is the moist lining of the oral cavity. The mucous lining of
oral cavity shares some features with skin as well as the mucosa lining
the gastrointestinal tract.

Functions of Oral Mucosa

Protection: Protection of underlying structures against mechanical trauma
that may result from heavy masticatory stress or from hard food.
Defense: Intact mucosa acts as a protective barrier against invasion of
microorganisms and various bacterial products and toxins. Any breach in the
epithelium permits the entry of microorganism in to the mucosal tissue and
may initiate related disease process. Furthermore oral mucosa contributes to
defense function due to the presence of Langerhans cells and lymphocytes,
which are part of defense system of the body. These cells identify any foreign
material entering the mucosa and present to the immune system and ensure
the removal of the same.
Sensory: Oral mucosa has a special sensory function, i.e. taste perception due
to the presence of taste buds. Oral mucosa also has receptors that respond to
pain, temperature and touch.
Secretory function: The presence of minor salivary glands within the mucosa
aids in secretory function.
Thermal regulation: Heat regulation of the body is one of the functions of
oral mucosa which is mainly seen in animals especially dogs.

Classification of Oral Mucosa

Based on function
• Lining/reflecting mucosa: Lines the inner aspect of lips and cheeks,
soft palate, floor of mouth, ventral aspect of tongue, alveolar
mucosa, vestibule, faucial pillars, etc.
• Masticatory mucosa: Lines the hard palate and gingiva. This
mucosa is subjected to considerable friction during mastication.
• Specialized mucosa: Lines dorsal aspect of tongue and this mucosa
shares the characteristics of both masticatory mucosa and gustatory
mucosa because of presence of papillae and taste buds.
Based on type of epithelium covering the mucosa
• Keratinized mucosa: It is found in the region of hard palate, gingiva,
vermilion border of lip and some papillae of tongue.
• Nonkeratinized mucosa: It is found in the region of lining mucosa
and certain areas lining the dorsal aspect of tongue and parts of
gingiva.

STRUCTURE OF ORAL MUCOSA

Oral mucosa resembles skin in its structure and is composed of two

components: epithelium and connective tissue (Fig. 10.1). The interface
between epithelium and connective tissue is not flat, rather is irregular.
Epithelium has many irregular projections that interdigitate with similar
projections from connective tissue. The epithelial projections are called rete
ridges, rete pegs or epithelial ridges and connective tissue projections are
called connective tissue papillae. The epithelium and the connective tissue
are separated by a basement membrane of 1–2 microns thickness. The
irregular epithelial-connective tissue junction increases the surface area of
contact between these two components which helps in better adhesion, and
transport of nutrients and other materials between the two. This also helps to
disperse the forces applied on epithelium, over a great area of connective
tissue. The number and configuration of rete ridges vary in different regions
of oral mucosa. Masticatory mucosa has relatively long rete ridges compared
to lining mucosa. In addition, more number of rete ridges in masticatory
mucosa ensures stronger adhesion between epithelium and connective tissue.
 Fig. 10.1: The structure of oral mucosa

CONNECTIVE TISSUE COMPONENT OF ORAL

MUCOSA

Connective tissue of oral mucosa is called as lamina propria. The loose

connective tissue below the lamina propria is continuous with it and is called
submucosa.
Lamina propria, seen subjacent to the epithelium is arbitrarily divided into
papillary portion occupying the region of papillae and reticular portion
found beneath the papillary portion. Papillary portion contains loose
connective tissue with many capillary loops and nerves. A few nerve fibers
from here also enter into the epithelium and remain as free nerve endings,
perceiving sensations such as cold, heat, touch, pain and taste. In reticular
region connective tissue is less cellular and denser with fibers having more
parallel arrangement to the epithelial surface. Lamina propria shows all the
normal connective tissue components which include cells such as fibroblasts
and defense cells, extracellular components including collagen fibers, elastic
fibers, oxytalan fibers and ground substance. Reticular portion is always
present, but papillary portion can vary depending on the presence and
absence of rete ridges.
Submucosa is the deeper connective tissue seen beneath the mucosa. The
submucosa comprises of loose connective tissue and the texture and density
of this determines the stretchability of the mucosa. In addition to the normal
connective tissue components submucosa contains large blood vessels and
nerves, minor salivary glands, fat cells, etc. Submucosa is divided into
compartments by bundles of vertically arranged collagen fibers extending
from the lamina propria to fascia of the muscle or periosteum. These bands of
collagen along with elastic fibers attach the mucosa to the underlying
structures and therefore prevent the folding of mucosa which might otherwise
become entrapped between the teeth.
Submucosa is absent in gingiva and some regions of hard palate. In these
regions lamina propria is directly bound to periosteum of underlying bone.
This type of attachment is called mucoperiosteal attachment and this makes
mucosa tough, immovable and tightly bound to the bone.
 ORAL EPITHELIUM

The covering epithelium of the oral mucous membrane is stratified squamous

variety. The cells are tightly bound to each other and arranged to form
different layers or strata. The integrity of oral epithelium is maintained by a
system of continuous renewal mechanism. Old cells are continuously lost
from the surface by a process termed as desquamation and are replaced by
new cells formed by the process of mitotic division.
Stem cell population in the basal cell compartment of the epithelium
undergo mitotic division giving rise to two daughter cells. One of the
daughter cell remains in the progenitor compartment while the other cell
enters in to the maturing compartment. The cells entering into the maturing
compartment undergo further differentiation. As cells leave the basal layer
and enter into differentiation, they become larger and begin to flatten and
accumulate cytoplasmic protein filaments, representing the cytokeratins.
Keratins represent 30 different proteins of differing molecular weights. All
stratified oral epithelia possess keratins 5 and 14 in the basal cells, but
changes as the cells undergo further differentiation. Orthokeratinized oral
epithelium, such as the palate, contains keratins 1 and 10, whereas gingiva
and parakeratinized palatal epithelium contains keratins 1 and 10 or keratins
4 and 13. Nonkeratinized epithelium, contains keratins 4 and 13. These cells
passes through different layers till it reaches the surface layer from where
these are desquamated. The maturation of oral epithelium follows two
patterns, keratinization or nonkeratinization. Different types of maturation
pattern are observed in different regions of oral mucosa.
The cells in the progenitor compartment undergo mitotic division to
maintain the structural integrity. The rate of cell proliferation vary in different
types of epitheliam, but, in general, the rate is highest for cells in the thin
nonkeratinized regions, such as floor of mouth and underside of tongue, than
for the thicker keratinized regions, such as palate and gingiva. The mitotic
index also correlated significantly with epithelial thickness, with the thicker
regions showing a higher rate of proliferation. The lowest value is noted in
skin.
The time it takes for a cell to divide and pass through the entire epithelium
till it desquamates is termed as turnover time of the epithelium and varies in
different epithelia.Turnover times range from a median value of 34 days for
epidermis to 4 days for the small intestine with the values for oral and
esophageal epithelium falling between. Nonkeratinized buccal epithelium
turns over faster than keratinized gingival epithelium. Regional differences in
the turn over time is reported as follows: Floor of mouth 20 days, buccal and
labial mucosa 14 days, gingiva 40 days, attached gingiva 10 days, junctional
epithelium 4 to 6 days, and hard palate 24 days.

HISTOLOGICAL STRUCTURE OF ORAL

EPITHELIUM

Microscopically oral epithelium shows different layers which vary in

keratinized and nonkeratinized epithelium. Majority of cells of both
keratinized and nonkeratinized epithelium have the capacity to produce
keratin and therefore called as keratinocytes. These cells show some common
features unique to epithelial cells which include presence of keratin
tonofilaments as a component of cytoskeleton and intercellular attachment in
the form of desmosomes.

Keratinized Epithelium
Light microscopic structure: Four different layers are seen in keratinized
oral epithelium (Figs 10.2a and b).
Stratum basale/basal cell layer: This layer is composed of single layer of
cuboidal or columnar cells that rest on the basement membrane. Basal and
parabasal cells have the capacity to undergo mitotic division. So these cell
layers are also called as proliferative or germinative layer (stratum
germinativum). Basal cells have basophilic cytoplasm and centrally placed
nucleus which is hyper chromatic and relatively larger, occupying 1/3rd of
cytoplasm. The nucleus is arranged perpendicular to basement membrane.
Stratum spinosum/prickle cell layer: It is seen above basal layer and
composed of several rows of polyhedral cells. As the cells pass from basal
layer to prickle cell layer, there is considerable decrease in basophilia,
making the boundary between these layers distinct. Cells are larger than basal
cells and have centrally placed round or ovoid nucleus. The nuclear
cytoplasmic ratio of spinous cells is 1:6. This layer is also called prickle cell
layer because in histological sections, cells have a spiny or prickly
appearance. While tissue processing, cells shrink away from each other
remaining in contact only in the areas of intercellular attachment, resulting in
a prickly appearance. In stratum spinosum as the cell mature and move
superficially they increase in size and become more flattened with flattened
nucleus in a plane parallel to the surface.
Stratum granulosum/granular cell layer: This layer is composed of few
layers of flattened cells seen immediately above stratum spinosum. The
cytoplasm of the cells in this layer is filled with basophilic granules called
keratohyaline granules and hence the name stratum granulosum. The
nucleus of these cells are flattened with long axis parallel to the outer surface
of epithelium.
 Figs 10.2a and b: Keratinized mucosa
Stratum corneum/cornified layer: This is the most superficial layer found in
keratinized epithelium and is composed of keratin squames which are larger
and flatter than the cells of stratum granulosum. This layer appears as
eosinophilic amorphous layer in histologic sections. As the cells reach the
cornified layer nucleus undergoes degeneration. If the nucleus is completely
absent in surface layer, the pattern of maturation is called as
orthokeratinization. If pyknotic nucleus is retained in all or some squames it
is called as parakeratinization. Parakeratinized epithelium is mainly seen in
gingiva. In parakeratinized epithelium the keratohyaline granules in stratum
granulosum is less prominent.

Ultrastructure or Electron Microscopic Structure

Basal cells
Basal cells are the least differentiated cells of the epithelium. These cells
contain nucleus occupying 1/3rd of the cells with evenly distributed
chromatin and 2–3 nucleoli. Basal cells are involved in protein synthesis and
therefore cytoplasm has rich cellular organelles like rough endoplasmic
reticulum, mitochondria, Golgi complex, few lysosomes, etc. These cells
synthesize the proteins of basement membrane and also proteins which form
intermediate filaments of basal cells.
Basal cell layer has two populations of cells. One group of cells is serrated
with protoplasmic processes at basal region and is heavily packed with
tonofilaments. These cells are adapted for attachment. Second population of
cells are the stem cells which undergo division and provide cells for maturing
compartment. The basal cells are attached to each other by desmosomes and
to the basement membrane by hemidesmosomes. These cells also contain
tonofilaments like any other epithelial cell but are few in number.

Prickle cells
Overall size of the cell and nucleus increases as it passes to spinous cell layer
(Fig. 10.3). Nucleus has evenly distributed chromatin with 2–3 nucleoli.
Cytoplasm is rich in organelles for protein synthesis. The proteins
synthesized by these cells are primarily the fibrilar proteins, known as
cytokeratin and this indicate these cells are in the process of differentiation.
The concentration of the tonofilaments increases and gets arranged to form
bundles. The cells are attached to each other by desmosomes. The number of
desmosomes and width of intercellular space is more in keratinized
epithelium. The size of desmosome is wider in prickle cell layer than basal
cell layer. As the cell passes to upper prickle layers the desmosomes become
smaller.
 Fig. 10.3: Ultrastructure of cells of keratinized epithelium
Cells in the upper part of prickle cell layer show new cytoplasmic
organelles called Odland bodies. These are also known as membrane coating
granules, cytoplasmic lamellated body, keratinosomes, microgranules or
cementosomes. (Odland bodies are also present in nonkeratinized epithelium
but are structurally different.)
In keratinized epithelium Odland bodies appear as ovoid membrane bound
organelles of 0.25 microns length, containing a series of parallel internal
lamellae consisting of alternate electron lucent and electron dense bands.
These organelles may be derived from Golgi bodies. The size of the Odland
bodies do not increase but the density increases as the cell passes to more
superficial layer and also these structures move closer of superficial cell
membrane.
Granular layer cells: In this layer the size of the cells still increases. The
cells are flatter with long axis parallel to the epithelial surface. Nucleus is
also flattened and shows pyknotic changes. The cells still retain the capacity
for protein synthesis, only to a lesser extent. This is indicated by decrease in
number of cytoplasmic organelles. Although the cells show a decrease in
cytoplasmic components, the amount of tonofilaments is found to be more.
The cell surfaces become more regular and closely approximated with each
other. Odland bodies are also present in these cells where they fuse with the
superficial cell membrane and discharge the contents into the intercellular
spaces. This discharged material provide lipid rich permeability barrier, at the
junction of stratum granulosum and stratum corneum, that limits the
movements of substances through intercellular spaces.
Desmosomes maintain their structure in this layer while the intercellular
contact layer of desmosomes becomes more condensed. Cytoplasm of
stratum granulosum cells also shows keratohyaline granules. In keratinized
epithelium these are variable in size ranging from 0.1–1.5 microns. Their size
and number increases as the cell moves through the granular layer.
Keratohyaline granules are usually angular or irregular and they are usually
associated with ribosomes suggesting they are synthesized by ribosomes.
Keratohyaline granules contain sulphur rich proteins fillagrin and loricrin
which provide an embedding matrix for the tonofilaments and therefore help
in aggregating the tonofilaments. They also contain a protein involucrin
which provide constituents for the cell membrane thickening and makes it
resistant to chemical solvents.
Stratum corneum: Ultrastructurally stratum corneum is composed of cells
resembling hexagonal discs called squames (Fig. 10.3). Large amount of
bundles of keratin tonofilaments are found to be embedded in a matrix that is
contained in a thick envelope. Keratin is a tough insoluble protein which
more or less completely fills the interior of shrunken cells. Cellular organelles
are almost completely lost and these cells do not produce protein. The
nucleus may be completely lost in case of orthokeratinization or remain
pyknotic in parakeratinization. The cell membrane is thickened. Desmosomes
can be still recognized but they become less distinct. As the cell passes to the
superficial layer, desmosomes tend to degenerate resulting in desquamation
of cells.

Desquamation
The physiological process of shedding off of the superficial cells of
epithelium is called as desquamation. Mechanism of desquamation is not
fully understood. The possible mechanisms include:
Release of hydrolytic enzymes from membrane coating granules causing
destruction of desmosomes which leads to desquamation.
Intercellular junctions have a physiological life span after which there will be
rapid breakdown, leading to desquamation.

Nonkeratinized Epithelium
Light microscopically three different layers are seen in nonkeratinized
oral epithelium (Fig. 10.4)
Stratum basale/basal cell layer: This layer is similar to that of basal layer of
keratinized epithelium and is composed of single layer of cuboidal or
columnar cells immediately adjacent to basement membrane. Basal cells have
centrally placed nucleus which is hyper chromatic and relatively larger and
occupies 1/3rd of cytoplasm. The cytoplasm of these cells shows significant
basophilia due to high RNA content.
Stratum intermedium: This layer is composed of several rows of polyhedral
cells located above basal layer. The cytoplasm of these cells takes up
eosinophilic stain and therefore this layer can be easily differentiated from
basal cells exhibiting basophilic cytoplasm. Cells are larger than basal cells
and have centrally placed round nucleus. The nuclear cytoplasmic ratio of
spinous cells is 1:6. In contrast to stratum spinosum of keratinized
epithelium, the cells of this layer are closely apposed to each other and
prickly appearance is not distinct. As in stratum spinosum, these cells
increase in size when they mature and move superficially and also become
more flattened with flattened nucleus in a plane parallel to the outer surface.
Stratum superficiale: This is the most superficial layer found in
nonkeratinized epithelium and is composed of few layers of flattened cells.
The nucleus of these cells are flattened with long axis parallel to the outer
surface of epithelium. These cells ultimately undergo desquamation.

Ultrastructure or Electron Microscopic Structure

Basal cells: Ultrastructurally basal cells of nonkeratinized epithelium
resemble the basal cells of keratinized epithelium in all respects (Fig. 10.5).
These are the least differentiated cells of the epithelium. These cells contain
nucleus occupying 1/3rd of the cells with evenly distributed chromatin and 2–
3 nucleoli. These cells are involved in protein synthesis and therefore
cytoplasm has rich cellular organelles like rough endoplasmic reticulum,
mitochondria, Golgi complex, few lysosomes, etc.

Fig. 10.4: Nonkeratinized mucosa

Fig. 10.5: Ultrastructure of cells of nonkeratinized epithelium

As in keratinized epithelium, basal cell layer has two populations of cells,
serrated cells with protoplasmic processes at basal region and cytoplasm
heavily packed with tonofilaments, which are adapted for attachment. Second
population of cells are the stem cells which undergo division and provide
cells for maturing compartment. The basal cells are attached to each other by
desmosomes and to the basement membrane by hemidesmosomes. These
cells also contain tonofilaments like any other epithelial cell but are few in
number.

Stratum Intermedium
Overall size of the cell and nucleus increases as it passes to stratum
intermedium (Fig. 10.5). Relative increase in size of the cell and nucleus is
more in nonkeratinized epithelium than in keratinized epithelium. Nucleus
has evenly distributed chromatin with 2–3 nucleoli. Cytoplasm is rich in
organelles for protein synthesis. The concentration of tonofilaments is more
than that in basal cells but in contrast to the cells of stratum spinosum,
tonofilaments are found in unbundled form. The cells are attached to each
other by desmosomes. The number of desmosomes and width of intercellular
space is less in nonkeratinized epithelium. The size of desmosome is wider in
stratum intermedium than basal cell layer but as the cells move more
superficially the number of desmosomes becomes lesser.
Superficial cells of stratum intermedium show cytoplasmic organelles
called Odland bodies which are structurally different from that of the
keratinized epithelium.
In nonkeratinized epithelium Odland bodies appear as spherical membrane
bound organelles of 0.2 microns diameter. These structures have an electron
dense core from which delicate radiating strands are observed. The size of the
Odland bodies do not increase but their density increases as the cell passes to
more superficial layers and also these structures move closer to superficial
cell membrane.

Stratum Superficiale
In this layer, there is further increase in the size of the cells. The cells are
flatter with long axis parallel to the epithelial surface (Fig. 10.5). Nucleus is
also flattened and shows pyknotic changes. The cytoplasmic organelles
decrease in number indicating a lesser capacity to produce protein. Although
the cells show a decrease in cytoplasmic components, the amount of
tonofilaments is found to be more but in unbundled form. The cell surfaces
become more regular and closely approximated with each other.
Desmosomes decrease in size and number and intercellular space becomes
wider and irregular and maintain their structure in this layer while the
intercellular contact layer of desmosomes become more condensed.

Fig. 10.6: Junctions of epithelium

In contrast to superficial layer of keratinized epithelium, the superficial
cells of nonkeratinized epithelium show nucleus and various cytoplasmic
organelles. These cells undergo desquamation.

Intercellular Junctions
Intercellular junctions are cell junctions that bind the cells to one another and
allow intercellular communication. Three different types of junctions may be
seen between the epithelial cells, which include desmosomes, tight junctions
and gap junctions (Fig. 10.6).

Desmosomes
Desmosomes are the most characteristic and most numerous type of
intercellular junctions seen in epithelial cells. Ultrastructurally desmosomes
(Fig. 10.7) are present as a circular or ovoid area of 0.2–0.5 microns in which
plasma membranes of adjacent cells remain in juxtaposition to each other
with a distance of 25–30 nm. This space between the plasma membrane
contains an electron dense lamina called intercellular contact layer. This layer
is composed of protein particles of 5 nm diameter which are arranged in a
row.
On the cytoplasmic side, plasma membrane of each of the adjoining cells
show a thickening called attachment plaque and this structure contain the
proteins desmoplakin, plakoglobin and plakophilin. The tonofilaments
present in cytoplasm of each cell run into attachment plaque and loop out
again. The tonofilaments are not attached to the plasma membrane. This
arrangement of tonofilaments helps to dissipate physical forces from
attachment site throughout the cell. There are a separate group of smaller
filaments containing protein cadherins (desmogleins and desmocollin)
attaches the tonofilaments to plasma membrane, penetrate the cell membrane.
These filaments are called as traversing filaments and they traverse the
intercellular region to extend into the intercellular contact layer. The
traversing filaments from both cells come and attach to the intercellular
contact layer retaining the attachment between the cells.

Fig. 10.7: Desmosomes

Differences between lining and masticatory mucosa

Masticatory mucosa/keratinizcd mucosa
Tough and tightly bound to underlying•
structures
Lining
mucosa/nonkeratinized
mucosa
Loosely attached to the
underlying structures

Non stretchable • Stretchable to adapt to the

contraction and relaxation
of underlying muscles.
Relatively low rate of mitotic cell division • Relatively higher rate of
mitotic cell division

Turnover rate is slow • Turnover rate is relatively

faster

Lamina propria is dense • Lamina propria is less

dense

Submucosa may or may not be present.• Distinct submucosa is

Some regions show mucoperiosteal present which vary in
attachment. thickness

Epithelium connective tissue interface is• Rete ridges are short and
very irregular with long and narrow rete irregular
ridges, interdigitating with connective tissue
papillae.

Covering epithelium is keratinized stratified• Covering epithelium is

squamous epithelium nonkeratinized stratified
squamous epithelium

Epithelial thickness is less • Epithelium is thicker

Four distinct layers are seen in epithelium:• Only three layers are seen:
stratum basale, stratum spinosum, stratum Stratum basale, stratum
granulosum, stratum corneum intermedium, stratum
superficiale

Differences in various layers of epithelium

Stratum basale
Hemidesmosomes anchoring it to the• Hemi desmosomes are fewer and
basal lamina is more in number and smaller
larger
Stratum spinosum
 Cells are polygonal with prickly•
appearance
Number of desmosomes are more • Number of desmosomes is lesser
Percentage of cell membrane•
occupied by desmosomes is more
Intercellular space are more•
prominent
Cytokeratin present are 1, 6, 10, 16 •
Relative size of the cells in this layer•
is less
Adjacent cell surfaces are less•
closely applied
Tonofilaments are in bundles and•
more organized
Odland bodies are ovoid with•
alternating electron dense and lucent
areas
Stratum granulosum with distinct
keratohyaline granules are seen
Superficial layer is composed of
keratin flakes Superficial cells do not
have nucleus or cytoplasmic
organelles
Tight Junctions
Tight junctions are characterized by fusion between adjacent plasma
Cells are roughly rounded and
prickly appearance is not distinct
than that of masticatory mucosa
Percentage of cell membrane
occupied by desmosomes is less
Intercellular space are less
prominent
Cytokeratin present are 3, 14, 19
Cells are larger
Adjacent cell surfaces are more
closely applied
Tonofilaments are in unbundled
form and less organized
Odland bodies are round in shape
with central electron dense core
and radiating lines
No layer called stratum
granulosum is found, no
keratohyaline granules.
Superficial layer is composed of
flattened cells Surface cells
contain nucleus and cytoplasmic
organelles
membranes without any intervening space and act as diffusion barriers.

Gap Junctions
The junctions that allow cytoplasmic compartments of adjacent cells to
communicate are special adaptation of mucous membrane channels and are
called gap junctions.
In gap junctions, adjacent cell membranes run parallel to each other with a
gap of 2–5 microns. In these areas some channels are present that allow
communication between the cells.

Hemidesmosomes
These are specific type of attachments seen between basal cells and basement
membrane. These attachments are called as hemidesmosomes because the
structure is equivalent to half ot a desmosome. The hemidesmosomes have
one attachment plaque in the basal plasma membrane of basal cells. The
traversing filaments extending from this attachment plaque enter into the
basal lamina to provide attachment between epithelium and connective tissue
(Fig. 10.8).
 Fig. 10.8: Ultrastructure of basal lamina

Basement Membrane and Basal Lamina Complex

The epithelium-connective tissue interface is irregular and the epithelium is
separated from connective tissue by a distinct homogeneous structureless
layer of 1–2 microns thickness called basement membrane. The basement
membrane acts as a barrier which controls the movement of various materials
from epithelium to connective tissue and vice versa. The term basement
membrane is given based on light microscopic structure and it does not
appear distinct in hematoxylin and eosin stained sections. Special stains like
periodic acid-Schiff stain (PAS) or silver stains can be used to demonstrate it.
Electron microscopically, the basement membrane is composed of two
distinct layers: lamina lucida and lamina densa (Fig. 10.8). Therefore based
on electron microscopic structure the term basal lamina is used to denote this
structure.
 The layer of basal lamina adjacent to the basal cell is around 45 nm thick
and appears electron lucent. This layer is called as lamina lucida. Lamina
lucida contain laminin and bullous pemphigoid antigen. Beneath the lamina
lucida an electron dense layer of 55 nm thickness is seen which is termed as
lamina densa. Type IV collagen fibers are found in lamina densa which show
a chicken-wire pattern. This layer also contains proteoglycans such as
heparan sulfate and chondroitin sulfate. The proteoglycans control the
passage of ions across basement membrane. Smaller diameter collagen fibers
(type VII) are found, beneath lamina densa, forming loops with both ends
attached to the lamina densa. These fibers are called anchoring fibrils.
Collagen fibers from connective tissue pass through these and loop around to
form a strong attachment between epithelium and connective tissue. Both
layers of basal lamina and the anchoring fibrils are together called as basal
lamina complex. The basal lamina is of epithelial origin while the anchoring
fibrils are of connective tissue origin.

Functions of Basement Membrane

Structural attachment, i.e. providing attachment between epithelium and
connective tissue.
Compartmentalization: Basement membrane isolates the epithelium from
connective tissue.
Filtration: Transport of materials to and from the connective tissue is
regulated by basement membrane.
Tissue scaffolding: Basement membrane act as a scaffold during regeneration
of epithelium.
Polarity induction: Epithelial cells gets organized into normal layered
arrangement only if they are supported by a basement membrane.

Nonkeratinocytes
In the oral epithelium, both keratinized and nonkeratinized, 90% of the cells
are keratinocytes which have the capability of producing keratin. Another
10% of the cells belong to a group called nonkeratinocytes. They are
melanocytes, Langerhans’ cells, Merkel cells and inflammatory cells. These
cells do not produce keratin and except for Merkel cells do not possess
desmosomal junctions or tonofilaments.
Melanocytes: Melanocytes are dendritic cells scattered among the basal cells
of epithelium and these are the melanin producing cells. The origin of these
cells is from neural crest cells which migrate to ectoderm by 8–11 weeks of
intrauterine life and have the capacity to replicate throughout postnatal life,
though at a much slower rate than keratinocytes. These cells have a cell body
containing the nucleus located at basal region and multiple long processes
extending between the keratinocytes of stratum spinosum. The melanocytes
neither contain tonofilaments nor possess desmosomal attachment. Because
of absence of desmosomal attachment, the cell tend to shrink against the
nucleus during tissue processing creating a clear halo around. Hence, these
cells appear as clear cells in between the basal cells. Since they are located in
basal layer as clear cells, melanocytes are called low level clear cells. The
melanocytes contain characteristic electron dense cytoplasmic organelles
called melano-somes that contain melanin pigments. Production of melanin
depends on melanocyte stimulating hormone. The variation in pigmentation
seen in different individuals depends on the activity of melanocytes and not
on number of melanocytes.
 The melanocytes help to impart color to skin and mucosa and also protect
against u-v light.
 Melanocytes can be demonstrated using special stains like silver stain and
also by DOPA reaction.
Langerhans’ cells: Langerhans’ cells are dendritic cells present in the
epithelium of skin and mucosa. These cells have a cell body harboring the
nucleus and long processes extending between the prickle cell layers.
Langerhans’ cells do not have desmosomal attachment and tonofilaments.
These cells also appear as clear cells in histological section because of
shrinkage of cells. Because of their location in upper layer of epithelium
compared to melanocytes, Langerhans’ cells are called high level clear cells.
These cells cannot be differentiated by routine H and E stain. They can be
demonstrated by histochemical, immuno-fluorescent or
immunohistochemical techniques which reveal the cell surface antigen or
ATPase reaction.
 Election microscopically, Langerhans’ cells show a characteristic racquet
or flask or rod shaped cytoplasmic organelle called Birbeck granules or
Langerhans’ granules.
 The origin of Langerhans’ cells is from bone marrow and they are
immuno-competent cells. They trap the antigens entering the mucosa, process
it and present it to the immune system. They are referred to as antigen
presenting cells.
Merkel cells: These are modified keratinocytes located in the basal layer of
oral epithelium. In contrast to other nonkeratinocytes these Merkel cells are
nondendritic cells which form occasional desmosomal attachment with
neighbouring epithelial cells and contain some tonofilaments. Because of
few desmosomal attachments these cells do not appear as clear cells in
histological sections. Electron microscopically these cells show cytoplasmic
granules with dense core resembling neurosecretory granules. Presence of
these granules and the close association of these cells with nerve endings
suggest the possible role of sensory function of Merkel cells. The Merkel
cells are considered as pressure sensitive cells responding to touch and may
be demonstrated using PAS stain.
 There is a controversy regarding the origin of Merkel cells. One opinion is
that these cells could be of neural crest origin, while few others consider that
they are formed by the division of keratinocyte like cells.
Inflammatory cells: Inflammatory cells like lymphocytes are also present in
the epithelium. These cells are of bone marrow origin. Since these cells move
from connective tissue to epithelium and also back, they can be seen at
different levels of epithelium. Lymphocytes appear as round cells with
nucleus occupying the major part of the cell with little cytoplasm. They can
also be demonstrated by immuno histochemical techniques that demonstrate
the surface markers (OKT-3) of these cells. Lymphocytes perform defense
function.

STRUCTURAL VARIATIONS OF ORAL MUCOSA

Oral mucosa is composed of epithelium (either keratinized or nonkeratinized)

and connective tissue. Yet, as an adaptation to the function to be performed,
different parts of oral mucosa show some structural variations.
Lining Mucosa
Lining mucosa includes mucosa lining the cheeks, lips, alveolar mucosa,
vestibule, floor of the mouth, ventral aspect of tongue, soft palate, etc. The
lining mucosa is nonkeratinized mucosa.

Characteristic Features of Lip and Cheek Mucosa

Lip and cheek are lined by nonkeratinized mucosa. Epithelial ridges seen at
the interface between the epithelium and connective tissue are small and
irregular and interdigitate with few, short irregular connective tissue papillae.
Lamina propria is thick and has less dense collagen fibers. Lip and cheek
mucosa has a distinct submucosa that contains mixed salivary glands, fat
cells, etc. Mucosa is stretchable and is well adapted to contraction and
relaxation of underlying musculature.
Vertical band of collagen fibers with elastic fibers are found extending
from lamina propria to fascia covering the underlying muscle which provides
attachment between the mucosa and muscle. Thus the folding of mucosa is
prevented while muscle relaxation and avoids mucosa being caught between
the teeth.

Vestibular Mucosa and Alveolar Mucosa

Vestibular mucosa lines the vestibule; a V-shaped sulcus separating the
alveolar mucosa from cheek and lip. Vestibular mucosa is in continuation
with alveolar mucosa which lines the alveolar bone. Alveolar mucosa appears
reddish and extends up to mucogingival junction which separates it from
gingival mucosa. In contrast to cheek and lip mucosa which is tightly bound
to the underlying muscle, this alveolar and vestibular mucosa is loosely
attached to the underlying structures. This permits the easy movement of lip
and cheek. Median and lateral labial frena are seen as folds of mucous
membrane containing loose connective tissue.
Alveolar mucosa is thin with a thin nonkeratinized epithelium lining it.
The epithelial connective tissue junction is relatively flat with small rete
ridges and connective tissue papillae which may even be absent at times.
Alveolar mucosa is loosely attached to underlying bone by a loose connective
tissue that also contains minor salivary gland.
Ventral Surface of Tongue and Floor of the Mouth
Floor of the mouth is a small horseshoe shaped region beneath the movable
part of the tongue. Mucosa lining the floor of the mouth and ventral surface
of the tongue share many common features. Mucosa is thin with a
nonkeratinized epithelium. The epithelial rete ridges and connective tissue
papillae are short. Connective tissue shows rich blood supply which is
particularly prominent in floor of the mouth. Submucosa of floor of the
mouth contains adipose tissue and minor salivary glands. In the ventral aspect
of tongue, submucosa may be very thin or even absent where the mucosa will
be tightly bound to the underlying musculature. The thin epithelial lining and
rich blood supply permit the rapid absorption of medicines administered
sublingually.

Soft Palate
Soft palate is lined by nonkeratinized stratified squamous epithelium.
Epithelium may show presence of few taste buds. Lamina propria is highly
vascular because of which soft palate appears reddish clinically. The
epithelium connective tissue interface is irregular with thick and short rete
ridges and connective tissue papillae. A distinct layer of elastic fibers are
found forming a lamina between lamina propria and submucosa. The
submucosa is composed of diffuse loose connective tissue containing
numerous minor salivary glands.

Vermilion Border of Lip (Transitional Zone)

This zone is the transitional zone between the skin covering the external
surface of the lip and the labial mucosa lining the inner aspect (Fig. 10.9).
The skin is composed of keratinized stratified squamous epithelium with all
appendages like hair follicles, sweat glands and sebaceous glands. The labial
mucosa is lined by nonkeratinized stratified squamous epithelium. The
connective tissue beneath the labial mucosa shows minor salivary glands. The
central most region of lip shows orbicularis oris muscle. The transitional zone
has a thin lining epithelium with mild keratinization on the surface. There are
many long connective tissue papillae reaching high into epithelium, carrying
many capillary loops. This makes it more reddish compared to labial mucosa.
Underlying connective tissue is characteristically devoid of glands which
causes the mucosa to dry up.

Fig. 10.9: Vermilion border of lip

Gingiva
Gingiva is the part of the oral mucosa that covers the alveolar process and
surrounds the neck of the tooth. The gingiva is relatively tightly bound to the
buccal and lingual plates of alveolar process and extends from the dento-
gingival junction to the alveolar mucosa.

Macroscopic Structure of Gingiva

Gingiva is pink in colour with some degree of melanin pigmentation.
Anatomically gingiva can be divided into three parts; marginal gingiva,
interdental papilla and attached gingiva (Fig. 10.10).
Marginal gingiva: It is the unattached portion of gingiva that forms the
border which surrounds the teeth in a collar like fashion. Marginal gingiva
follows a scalloped line on the facial and lingual surface of the teeth. The
contour depends on shape and alignment of teeth. Marginal gingiva forms the
soft tissue wall of the gingival sulcus and is separated from attached gingiva
by a free gingival groove which runs parallel to the terminal edge of the
gingiva at a distance of 0.5–1.5 mm almost at the level of bottom of gingival
sulcus.
Gingival sulcus: It is a shallow crevice or V-shaped space present around the
tooth bounded by tooth surface on one side and marginal gingiva on other
side. The depth of this sulcus varies from 0.5 to 3 mm with an average of 1.8
mm. More than 3 mm is considered as pathological and is called as gingival
or periodontal pocket.
Interdental papilla: The part of the gingiva that fills the interdental space
between two adjacent teeth is called interdental papilla. Interdental papilla
appears pyramidal or triangular from the facial and lingual aspect with its
lateral borders and tip formed by a continuation of marginal gingiva of
adjacent teeth. Three dimensionally the anterior interdental gingiva is
described to have a pyramidal shape with facial and lingual gingiva tapering
towards the interdental area. In the posterior region interdental gingiva has a
‘tent’ shape. This shape is formed because the interdental papillae present on
lingual and buccal sides of each interproximal space are connected by a
depressed central area. The facial and lingual portions of papillae forms the
high points and a concave or valley like area fits below the contact area. This
valley like area is called ‘col’ which is lined by nonkeratinized epithelium.
This col is considered as a weak point in gingiva and is more prone to
periodontal diseases. When the adjacent teeth are not in contact, the
interdental gingiva appears smooth with round surface, firmly adherent to
interdental bone.
 Fig. 10.10: Parts of gingiva
Attached gingiva: The firm, resilient immobile portion of the gingiva which
is tightly bound to the alveolar bone is called attached gingiva. This extends
from free gingival groove to mucogingival junction by which it is separated
from alveolar mucosa. On the palatal aspect attached gingiva blends with
palatal mucosa. The width of attached gingiva varies in different regions. In
maxilla, it ranges from 3.5–4.5 mm, while in mandible it is 3.3–3.9 mm. The
surface of the attached gingiva is irregular with elevations and depression.
The orange peel appearance created by these elevations and depression is
described as stippling. These are considered as functional adaptations to
mechanical stress and may be caused by traction on mucosa by underlying
fibrous attachment to the bone. Loss of stippling is one of the initial signs of
gingival inflammation. The pattern and extent of stippling varies in different
regions of the mouth; being less prominent on lingual than on facial surface.
Males tend to have more stippling than females. Gingiva may show slight
vertical depression between the alveolar bone eminences of adjacent teeth.
These are called interdental grooves.

Microscopic Structure of Gingiva

Structurally gingiva is composed of stratified squamous epithelium and
connective tissue.
Covering epithelium shows structural variations in different regions.
Accordingly it can be categorized as epithelium covering oral region of
gingiva (outer portion), sulcular epithelium and junctional epithelium (Fig.
10.11).
Oral region: Epithelium lining the oral region of gingiva is keratinized or
parakeratinized stratified squamous epithelium which has four distinct layers,
i.e. stratum basale, stratum spinosum, stratum granulosum and stratum
corneum. Microscopically a shallow ‘V’ shaped notch on the surface
corresponding to a heavy epithelial ridge which represent the free gingival
groove. In the region of attached gingiva stippling is reflected by alternate
rounded protuberances and depressions on the surface. The depressions
correspond to the center of heavy epithelial ridges.
The epithelium connective tissue interface is irregular with numerous long
narrow rete ridges interdigitating with long connective tissue papillae.
This extensive interdigitation increases the strength to withstand the
masticatory stresses. This long branching rete ridges help in microscopic
identification of gingiva from other parts of oral mucosa. Gingival epithelium
is parakeratinized in 75% of population.
Sulcular epithelium: Sulcular epithelium lines the gingival sulcus and it
extends from the coronal limit of junctional epithelium to the crest of gingival
margin. Sulcular epithelium is composed of thin layer of nonkeratinized
epithelium. The junction between epithelium and connective tissue is flat
without rete ridge formation. Lack of keratinization is thought to be due to
inflammation of connective tissue.

Fig. 10.11: Structural variation of gingival epithelium

Junctional epithelium: The part of the gingival epithelium that is attached to
the cervical part of the tooth and therefore forming a junction between the
tooth and gingiva is called junctional epithelium.
Junctional epithelium is stratified squamous epithelium which appears as a
triangular strip with 15–30 cell layer thickness at the cervical portion (floor of
sulcus) and 3–4 cell layer thickness at the apical margin. Junctional
epithelium is composed of flattened cells which are arranged parallel to the
tooth surface. The cells have lesser number of desmosomal junctions and
more intercellular spaces helping in migration of polymorpho nuclear
leucocytes (PMNLs) into the epithelium and to the sulcus. The epithelium-
connective tissue interface is flat. One of the most important feature which
makes it differ from other epithelium is the presence of basal lamina on both
sides, i.e. at the junction of epithelium and connective tissue and also on
the surface adjacent to the tooth. This basal lamina on the surface is attached
to the tooth by hemidesmosomes. The junctional epithelium also shows high
turnover rate. The cells from the basal layer migrate to within 2–3 layers of
junctional epithelium and join a migratory root in a coronal direction and
finally exfoliate at the gingival sulcus.

Gingival Connective Tissue

The connective tissue beneath the gingival epithelium is lamina proprina with
papillary and reticular layer. The connective tissue of gingiva consists of
dense collagenous tissue arranged in bundles of fibers which play a very
important role in maintaining the integrity of the supporting apparatus of the
tooth. These fiber groups are referred to as the secondary fibers of
periodontal ligament or gingival ligament or gingival fibers of periodontal
ligament (Refer Fig. 8.3). In addition to collagen fibers, oxytalan fibers and
elastic fibers are also present in gingival connective tissue.

The Gingival Fibers Include

Dento-gingival fibers: These fibers extend from the cervical portion of the
cementum to the lamina propria of gingiva.
Dento-periosteal fibers extending from cervical part of cementum to the
periosteum of the alveolar crest and the vestibular and oral surface of the
alveolar bone.
Alveologingival fibers extend from the crest of the alveolar bone to the
lamina propria of gingiva.
Circular fibers: These fibers are arranged in the gingival connective tissue,
encircling the neck of tooth like a collar. These fibers are also known as the
marginal ligament and they play an important role in maintaining a tightly
fitting gingival collar.
Trans-septal fibers which are also called interdental ligament is also found
in gingival connective tissue as accessory fibers extending inter proximally
between adjacent teeth, from cementum of one tooth to cementum of adjacent
tooth over the interdental bony alveolar crest.
Lamina propria of oral gingival epithelium is firmly attached to periosteum
of the alveolar bone by course collagen bundles. This type of attachment is
called mucoperiosteum. Subucosa is absent in gingiva therefore no large
blood vessels or minor salivary glands are observed in gingiva. The lamina
propria of sulcular and junctional epithelium is different from that of oral
gingival epithelium. Connective tissue in this region is delicate with presence
of inflammatory cells.

Palate
The palate forms the roof of the oral cavity and is divided into immovable
hard palate anteriorly and the movable soft palate posteriorly. The hard palate
has a hard bony support while soft palate has only fibrous tissue.
The mucosa covering the hard palate differs in microscopic and
macroscopic structure in different regions.

Macroscopic Structure of Hard Palate

Palate can be divided into different zones (Fig. 10.12).
Gingival zone: It consists of peripheral portion of hard palate found adjacent
to teeth.
Midpalatine raphae: A narrow zone in the midline of hard palate extending
from incisive papilla posteriorly. This zone appears depressed compared to
adjacent areas.
Incisive papilla: Incisive papilla is an oval prominence seen at the extreme
anterior region of palate immediately behind the maxillary central incisors
covering the oral opening of incisive canal.
Anterolateral region between raphae and gingiva containing much of fat
tissue in submucosa. The fatty zone meets the glandular zone as an arc, the
lateral arm of which generally terminate in the region of first molar.
Posterolateral region between raphae and gingiva containing mainly minor
salivary glands in sub mucosa.
Palatine rugae: Radiating outwards from the palatine raphae in the anterior
region of hard palate are irregular transverse palatine ridges referred to as
palatine rugae. These ridges may have a role in suckling in infants and also
may be helping in backward movement of food during mastication.
Fovia palatina: It is an elongated depression of few millimeters depth in post
part of palate on either side of midline.

Fig. 10.12: Palate

Microscopic Structure of Hard Palate

The hard palate is covered by keratinized mucosa. The keratinized stratified
squamous epithelium lining the mucosa has four different layers, stratum
basale, stratum spinosum, stratum granulosum and stratum corneum. As a
functional adaptation, to bear with masticatory stress, the cells show more
dense tonofilaments, increased number and length of desmosomes, etc. The
epithelium connective tissue interface is irregular with many long regular
epithelial ridges interdigitating with connective tissue papillae.
The lamina propria is dense throughout the hard palate and is thicker in
anterior region than in posterior region. In the region of rugae the connective
tissue core is dense with interwoven collagen fibers. Incisive or palatine
papilla is also composed of dense connective tissue. This contains the
remnants of nasopalatine duct which is lined by pseudostratified squamous
epithelium. Small islands of hyaline cartilage may be seen around the duct
opening.
 Structure of submucosa varies in different regions of palate. Submucosa is
absent in the peripheral zone of palate adjacent to the teeth, i.e. the gingival
zone and in the mid palatine raphae. In these regions, the lamina propria is
tightly bound to the periosteum of bone which is referred to as
mucoperiosteal attachment.
In between the gingival zone and mid palatine raphae, the palate has
distinct submucosa. The submucosa is thicker in the posterior region than
anterior region. The submucosa in the anterior part of the hard palate is filled
with adipose tissue and in posterior region with mucous glands. Therefore
anterolateral part of hard palate is referred to as fatty zone and posterolateral
part the glandular zone.
In spite of thick submucosa in certain regions, the mucosa of the hard
palate is tightly fixed to the underlying bone and is immobile. This is
achieved by dense vertical band of connective tissue which attaches mucosa
firmly to the periosteum of palatal bone. These dense bands of connective
tissue are at right angle to surface and divide the submucosa into
compartments.
The wedge-shaped area where the alveolar process joins to the horizontal
plate of hard palate contains loose connective tissue which carry large vessels
and nerves. The thickness of this loose connective tissue gradually increases
from anterior region of palate to posterior region (structure of soft palate—
refer page 114).

Tongue
Tongue is a muscular organ situated in the floor of the mouth which play
important role in speech, mastication, deglutition, taste sensation, etc.

Macroscopic Features
Dorsum of the tongue is convex in all directions (Fig. 10.13). A V-shaped
sulcus divides the dorsal aspect of the tongue into anterior 2/3rd, body or oral
part and posterior 1/3rd, base or pharyngeal part. A small pit is seen where
the two arms of ‘V’ meet. It is called foramen caecum representing the
opening of thyroglossal duct. Anterior 2/3rds of the tongue is also called
papillary part because the mucosa has numerous papillae which give it a
velvety appearance. The most numerous papillae are fine pointed, cone-
shaped filiform papillae that are widely distributed on the dorsal surface.
These papillae make the surface of the tongue rough and help in crushing the
food particles while pressing against hard palate. Numerous fungiform
papillae are also seen distributed between the filiform papillae on the dorsal
aspect mainly on the tip and lateral margins. Fungiform papillae are seen as
red round, projections. Anterior to sulcus terminalis, 8–12 large papillae
called circumvallate papillae are seen. Circumvallate papillae are partly
submerged and do not project above the surface of tongue and are surrounded
by a V-shaped sulcus. Margins of the papillae may project above the surface.
In the posterior region of anterior 2/3rds of tongue, on the lateral margin
foliate papillae are seen which consists of series of folds forming clefts.
These foliate papillae are rudimentary in humans.

Fig. 10.13: Macroscopic structure of tongue

Posterior 1/3rd of the tongue has an irregular surface with round
projection, the lingual follicles containing lymphoid component. Therefore
posterior 1/3rd of the tongue is also called lymphoid region. The mucous
membrane lining the posterior 1/3rd does not show papillae and is relatively
smoother.
Inferior surface or ventral aspect of the tongue is covered with smooth
mucous membrane. Papillae are not seen on this aspect of tongue. The
inferior surface is attached to the floor of the mouth by a loose lingual
frenum. On either side of lingual frenum, prominent lingual veins are seen.
Lateral part of inferior surface shows the presence of two folds called plica
fimbriata which runs forward and medially to the tip of the tongue.
Microscopic Structure of Tongue
The tongue is lined by stratified squamous epithelium which varies in
structure and thickness in different regions. The mucosa lining the ventral
aspect is nonkeratinized and is tightly bound to the underlying musculature.
The epithelium is thin with many but short rete ridges. Lamina propria is
relatively thin and loosely arranged.
The mucosa lining the dorsal aspect of tongue is referred to as specialized
mucosa because of the presence of special sense organs, i.e. taste buds. The
epithelium lining is mostly keratinized. Thickness of epithelium varies with
respect to papillae. Lamina propria is compact and tightly attached to the
underlying muscle. Minor salivary glands are seen in the anteroventral and
posterior regions. On the dorsal surface the mucosa evaginates to form
papillae.

Papillae of the Tongue

Filiform papillae
Filiform (hair-like) papillae are seen as hair like or thread like projections on
the dorsal aspect of the tongue. Filiform papilla in a histological section is
seen as cone-shaped structure (Fig. 10.14a) lined by stratified squamous
epithelium with thick keratin on the surface. Central core of connective tissue
supports the blood vessels. Taste buds are not seen in these papillae. The
mucosa between the filiform paillae is nonkeratinized and stretchable
permitting the mucosa to adapt to the changes in shape of tongue.
Fungiform papillae
Fungiform (fungus like) papillae are mushroomshaped structure (Fig. 10.14b)
projecting above the surface of the tongue and located between the filiform
papillae. The epithelium covering the fungiform papillae is thin
nonkeratinized stratified squamous epithelium. The superficial surface of the
papillae contains few taste buds. The supporting connective tissue shows
collagen fibers, fibroblasts and rich capillary network. Fungiform papillae
appear reddish in color because of the capillary network visible through
relatively thin nonkeratinized epithelium.
 Fig. 10.14a: Filiform papillae

Fig. 10.14b: Fungiform papillae

Circumvallate papillae
The circumvallate (walled) papillae are seen in the anterior two-thirds of
tongue just anterior to sulcus terminals. These are 10–12 in number. The
superficial surface of these papillae is at the level of surface of tongue and a
V-shaped sulcus is present all around the papillae separating them from the
adjacent portion of tongue (Fig. 10.14c). The lining epithelium is keratinized
stratified squamous epithelium at the superficial surface and nonkeratinized
on the lateral surface of circumvallate papillae. Taste buds are seen only on
the lateral surface. Central portion is occupied by the connective tissue. The
characteristic feature of this papilla is presence of serous minor salivary
glands (von Ebner’s gland) in the connective tissue beneath it. These glands
secrete watery saliva into the V-shaped trough around the papillae to flush
out the food debris.

Taste Buds
Taste buds are specialized sense organs that can perceive the taste sensation.
They are mainly located in papillae of tongue, i.e. superficial surface of
fungiform papillae, lateral walls of circumvallate papillae and in the cleft
walls of foliate papillae. In addition, taste buds are also seen in posterior part
of palate, uvula, epiglottis, pharyngeal region, etc.
Taste buds (Figs 10.15a and b) are barrelshaped structures composed of
30–50 spindle-shaped, modified epithelial cells that extend from basement
membrane to epithelial surface. The taste buds measure around 50–80
microns in height and 30–50 microns in diameter. At the epithelial surface
the tapered end of all cells end in a small opening of 2–5 microns called taste
pore through with the cells communicate to exterior.
Based on the morphological features 4 different types of cells can be seen
in taste buds.
Type I cells (dark cells): They are long narrow cells which make up the
major population (60%) of cells. The base of the cells rests on basement
membrane and apex end as a long finger like microvilli in the taste pore.
These cells have dark nucleus, rich cytoplasmic organelles and large dense
cored vesicles in apical cytoplasm.
 Fig. 10.14c: Circumvallate papilla

Figs 10.15a and b: Taste buds

Type II cells (light cells): They are more or less regularly oval shaped cells
with electron-lucent cytoplasm having few organelles and large round or oval
light stained nuclei. Around 30–40% of the cells of taste bud belong to this
group. These cells also extend from basement membrane to taste pore where
they end in short microvilli.
Type III cells (intermediate cells): These cells are some what similar to type
II cells in morphology. They make up only 5–15% of cells. These cells end in
a narrow club-shaped projection in the taste pore. In contrast to the type II
cells, type III cells have numerous dense covered vesicles concentrated in the
basal region.
Type IV cells (basal cells): These cells rest on basement membrane, but do
not extend to the taste pore. These cells have been considered as
undifferentiated precursor cells which can give rise to all three different types
of cells.
Difference in opinion exists about taste receptor cells. Some authors
consider the type III cells are taste receptors cells because of the electron
dense vesicles at the basal region and their close proximity to the nerve
endings. They consider other cells as supporting cells.
But others are of the opinion that the types I, II and III cells are transitional
form of a single cell and all the types could act as chemoreceptor transduction
cells because synapses have been observed on all three cells.
The nerve fibers enter the taste buds by penetrating the basal lamina,
within the taste bud they undergo extensive branching and contact with the
taste receptor cells.
Taste buds of fungiform papillae of tip of tongue have receptors for sweet,
and that of lateral borders of tongue have receptors for salty taste. Bitter taste
is perceived by taste receptors of circumvallate papillae and the sour taste by
foliate papillae (physiology of taste, refer page 297–298).

Dentogingival Junction
The junction between the tooth and gingiva called dentogingival junction.
The junctional epithelium has an important role in this. The epithelium, i.e.
the junctional epithelium that is attached to the tooth to form a dentogingival
junction is called attachment epithelium and the mode by which this
epithelium is attached to the tooth is called epithelial attachment (for details
refer page 117).
Formation of dentogingival junction: Once the enamel formation is
completed the ameloblasts secrete proteinaceous material on to the surface of
newly formed enamel which is structurally similar to basal lamina. This
structure is called primary enamel cuticle. Once the enamel organ transforms
into reduced enamel epithelium (REE) it gets attached to the surface of
enamel with the help of this basal lamina through hemidesmosomes.
During the process of eruption, the connective tissue between the REE and
oral epithelium degenerate, followed by proliferation of oral epithelium and
REE. These layers ultimately fuse together to form a solid plug of epithelium
(Fig. 10.16). The central cells of this plug degenerate forming a canal through
which the tooth emerges into the oral cavity. As the tooth move to the
occlusal plane, the epithelium covering the enamel surface shortens. Even
after the tooth reaches the occlusal plane 1/3rd of the tooth is still covered by
epithelium. Once the tip of the cusp emerges into the oral cavity the part of
reduced enamel epithelium attached to the tooth is called primary attachment
epithelium and is in continuation with oral epithelium. The reduced enamel
epithelium gradually shortens to expose the crown of the tooth completely
and is slowly replaced by the oral epithelium. The attachment epithelium
derived from oral epithelium is referred to as secondary attachment
epithelium. The actual movement of the tooth to occlusal plane is called
active eruption and the exposure of the crown by the apical migration of the
covering epithelium without actual movement of the tooth is called passive
eruption.

Shift of Dentogingival Junction

Once the dentogingival junction is established, the attachment epithelium
shows a gradual migration an apical direction, exposing more tooth surface
into the oral cavity. This shift can be discussed under four stages (Fig. 10.17).
 Fig. 10.16: Passive eruption and formation of dento-gingival junction
First Stage: During this stage, the attachment epithelium is completely
attached to enamel with its apical end at the cemento-enamel junction. The
bottom of gingival sulcus is located on enamel surface. This level of
attachment is seen between 20 and 30 years. In this stage, the clinical crown
of the tooth is shorter than anatomic crown.
Second Stage: In this stage, the attachment epithelium migrates apically and
is attached partly onto enamel and partly onto cemental surface and apical
end is on cementum. The bottom of gingival sulcus is on enamel itself. This
stage is seen at 40 years. Even in this stage, the clinical crown of the tooth is
shorter than anatomic crown.
Third Stage: As the apical migration of attachment epithelium progresses
gradually, in 3rd stage it becomes completely attached on to the cementum
surface with bottom of gingival sulcus at cemento-enamel junction. At this
stage the complete anatomic crown is exposed to oral cavity.
Fourth Stage: In this stage, the attachment epithelium still migrates apically
on the surface of cementum and the bottom of gingival sulcus is located on
the cemental surface exposing even a part of root. At this stage clinical crown
is longer than anatomic crown.
First two stages are physiological while the 3rd, 4th may be physiological
or pathological.
(Age changes—refer page 324)

Fig. 10.17: Shift of dento-gingival junction

Clinical Considerations
1. Clinical conditions resulting in alteration in structure of oral mucosa
– Oral cavity is the mirror of general health of a person. Various
local and systemic disease conditions such as nutritional
deficiency, metabolic disturbances, anemia, endocrine
disturbances, present with oral mucosal changes.
– Pale pink colour of oral mucosa may be altered in different
clinical conditions. Mucosa may appear reddish in case of
inflammatory conditions, pale in anemias and oral submucous
fibrosis. Patchy areas of brownish pigmentations may be noted in
conditions involving melanocytes.
– Mucosa which is soft in texture and stretchable normally becomes
stiff and non-stretchable in oral submucous fibrosis and
 scleroderma due to excessive fibrosis of connective tissue.
– A number of dermatological disorders manifest oral mucosal
lesions such as fluid filled vesicles, ulcers, erosions, red patches,
etc. Examples are: Oral lichen planus, pemphigus, pemphigoid,
etc.
– Loss of papillae of tongue resulting in bald appearance is a
characteristic feature in anemias.
– Use of tobacco may cause oral mucosal cancer or potentially
malignant disorders, which may present as white patches or
plaques, ulcers, ulceroproliferative growth, involving various parts
of oral mucosa.
– Histological alterations noted in different layers of epithelium in
various disease conditions. Identification of these features helps in
diagnosing the lesions accurately and providing appropriate
treatment. Following are some of the important changes:
1. Hyperkeratosis—increase in thickness of keratin layer
2. Acanthosis and atrophy—acanthosis refers to abnormal
thickening of spinous cell layer while atrophy is thinning of
epithelium.
3. Acantholysis—destruction of desmosomal junctions resulting
in loss of intercellular adhesion and is a characteristic feature
in blistering diseases such as Pemphigus and viral infections.
4. Basillar hyperplasia—increased cell proliferation in the basal
cell layer resulting in multiple layers of basal cells
5. Basal cell degeneration-destruction of basal cells and is a
characteristic feature in lichen planus
6. Loss of stratification—refers to loss of arrangement of
epithelial cells in different layers with progressive level of
differentiation and this can be a feature of epithelial dysplasia
7. Potentially malignant disorders and oral mucosal cancer
present with a number of cellular and architectural changes in
epithelium which is collectively referred to as features of
epithelial dysplasia.
2. Clinical considerations related to structural variations
The volume and texture of submucosa in different part of the mucosa
has particular clinical significance. In masticatory mucosa, where there
is no or little submucosa, the mucosa is not stretchable and is firmly
attached to the underlying bone. Therefore injections in these regions
will be painful as the solution cannot be dispersed easily. Any wound
in these region do not gape open. Wounds in these region do not
require suturing and the wound healing in these regions is by secondary
intention. In contrast injections in lining mucosa is less painful.
Wounds in the lining mucosa gape open, requires suturing and wound
healing is by primary intention.
 11
Salivary Glands

Introduction
Classification of salivary glands
Gross morphology
Microscopic structure
Clinical considerations

S alivary glands are exocrine glands that synthesize and secrete saliva that
reaches the oral cavity through a ductal system.

Classification of Salivary Glands

Based on size
• Major: Parotid, submandibular and sublingual glands
• Minor: Group of small glands located in the oral mucosa.
Based on location
• Extraoral: Three pairs of major glands located outside the oral
cavity
• Intraoral: Groups of minor glands widely distributed in the oral
mucosa.
Based on nature of secretion
• Serous glands: Parotid and von Ebner’s glands
• Mucous: Sublingual gland and all minor salivary glands except von
Ebner’s gland
 • Mixed: Submandibular glands.

Salivary Glands Gross Morphology

There are three pairs of major salivary glands which produce around 95% of
total salivary volume and numerous minor salivary glands producing
relatively less amount of saliva.
Major salivary glands include parotid glands, submandibular glands and
sublingual glands
Parotid glands: (Par-otid = near to the ear). These are the largest of all
salivary glands. These are a pair of pyramidal-shaped gland, located on either
side of the face, enclosed by a dense fibrous capsule. The parotid gland is
located subcutaneously, below and in front of the ear in the space between
the ramus of the mandible and the styloid process of the temporal bone. It
secretes approximately 25–30% of total output of saliva.
The main parotid duct (Stensen’s duct) leaves the mesial angle of gland to
traverse over the masseter muscle and turn to enter the buccinator muscle to
open into the vestibule opposite to maxillary second molar.
Submandibular glands: These are another pair of major mixed salivary
glands which are irregular and has a shape comparable to walnut. These
glands are located in the anterior part of digastric triangle (submandibular
region). Wharton’s duct, the major duct of submandibular gland, starts from
the anterior end of the gland, follows a tortuous course and opens in the oral
cavity at the sublingual papilla situated at the side ot lingual fossa. 60% of
total saliva is secreted by these glands.
Sublingual glands: These are the smallest of all major salivary glands. These
glands lie immediately below the oral mucosal lining of floor of the mouth.
These glands releases the secretion through a major duct called Bartholin’s
duct or often through a series of smaller ducts called duct of Rivinus. The
Bartholin’s duct opens to oral cavity along with submandibular duct. Ducts of
Rivinus open directly to the floor of the mouth along the submandibular
folds. These glands secrete mucous saliva which makes up 5% of total saliva.

Minor Salivary Glands

Minor salivary glands are small groups of salivary secretory units, distributed
almost throughout the oral mucosa except anterior part of the hard palate,
gingiva and anterior 2/3rd of dorsal aspect of tongue. Around 600–1000
collections of minor salivary glands are named according to the location and
together contribute around 5% of total saliva secreted. They release the
secretions into the oral cavity through small ducts.
Labial glands: These are minor salivary glands present in the labial mucosa.
Although they are described as mixed, ultrastructurally only mucous cells are
seen.
Buccal glands: These are present in buccal mucosa which are purely serous
or mixed.
Palatal/palatine glands: Minor salivary glands scattered in the posterior
region of hard palate and soft palate are called palatal glands. They produce
mucous secretions.
Glossopalatine glands: These are pure mucous glands localized to the region
of isthmus in the glossopalatine/tonsillar fold.
Lingual Glands: Mainly three categories of lingual minor salivary gland are
seen.
van Ebner’s glands: These are the minor salivary glands which are
physiologically most important. They are the only serous minor salivary
glands and are located below the sulcus of the circumvallate and foliate
papillae of the tongue. These are purely serous in nature and their ducts open
into the trough surrounding the circumvallate papillae and to the grooves
between foliate papillae. The secretions of these glands wash out the trough
of the papillae and ready the taste receptors for new stimulus. These glands
also produce several protective and digestive enzymes such as
lactoperoxidase, lysozyme, amylase and lipase, etc.
Glands of Blandin-Nuhn: These are mucous/mixed glands located on ventral
aspect of tongue anteriorly near the tip of the tongue.
Weber glands: These are pure mucous glands located posteriorly on either
side of tongue.

Development of Salivary Glands

The development of salivary glands begins early in intrauterine life; Parotid
gland at 4–6 weeks, submandibular gland at 6 weeks and sublingual and
minor salivary glands at 8–12 weeks. Although the parenchymal components
attain maturity by 2nd month of gestation, up to two years of life the
development continues with further increase in secretory units.
As in case of tooth, salivary gland development begins with proliferation
of oral ectoderm in to underlying ectomesenchyme. This epithelial
proliferation, which is a result of epithelial mesenchymal interaction, initially
form an epithelial thickening. This on further proliferation form a cord of
epithelial cells with a bud at the free end, surrounded by condensed
ectomesenchyme. The proliferation eventually creates, highly branched
epithelial cords with bulbous ends. Degeneration or apoptotic death of central
cells of the branching cords results in formation of lumen. The inner cells of
the terminal bud like structure differentiate into secretory cells, i.e. serous, or
mucous depending on the gland and peripheral cells give rise to
myoepithelial cells. Thus the cords become ducts, and the bulbous ends
become secretory acini. The condensed ectomesenchyme in due course, form
connective tissue component of the gland, i.e. capsule enclosing and septa
extending between the glandular tissue.
The epithelial buds of parotid glands are located on the inner part of the
cheek, near the labial commissures of the primitive mouth. These buds grow
posteriorly toward the otic placodes of the ears, near the developing facial
nerve, where further development continues. Submandibular glands develop
bilaterally from epithelial buds in the sulcus surrounding the sublingual folds
on the floor of the primitive mouth. Solid cords branch from the buds and
grow posteriorly, lateral to the developing tongue. Epithelial buds of
sublingual gland develop in the sulcus surrounding the sublingual folds on
the floor of the mouth, lateral to the developing submandibular gland.
Similarly minor salivary glands also develop as buddings from oral ectoderm
of corresponding region.

STRUCTURE OF SALIVARY GLAND

Irrespective of the size and location, all the salivary glands are composed of
parenchymal components which includes the secretory units and the ductal
systems.
All the major glands also show a second structural component, i.e.
connective tissue that forms a capsule around the salivary gland, which also
extend between parenchymal components, dividing the gland into lobes and
lobules. In contrast, minor salivary glands do not have a distinct connective
tissue component.

Parenchymal Components of Salivary Gland

Parenchymal components of the salivary gland include acini (secretory unit)
and the ductal system. These components are compared to a ‘bunch of
grapes’ with acini representing the fruits and ductal system representing
stalks (Fig. 11.1).
Secretory units of salivary glands are composed of serous and/or mucous
secretory cells arranged to form round or tubular configuration around a
central lumen, which is termed as an acinus (acinus—singular and acini—
plural). In addition to secretory cells, these acini also have myoepithelial cells
which cradle each acinus.

Fig. 11.1: Parenchymal components of salivary glands

Acinus (acinus is a Latin word for berry or grape): Acinus is the basic
functional unit of salivary gland. It comprises round or tubular collection of
secretory cells which synthesizes and secretes saliva and therefore called the
terminal secretory unit of a salivary gland. Serous salivary glands are
predominantly composed of numerous serous acini and mucous gland has
mostly mucous acini. A mixed salivary gland is composed of varying
proportions of both serous and mucous acini along with few mixed acini.

Serous Secretory Cell and Acinus

Serous secretory cells are specialized cells which synthesize, store and
secrete the serous saliva which is thin and watery, rich in both nonenzymatic
and enzymatic proteins and containing small amount of carbohydrates. These
serous cells are the main secretory cell type in parotid and submandibular
gland and some are also present in mixed acini of sublingual gland. Among
minor salivary glands, serous cells are found only in von Ebner’s gland.

Light Microscopic Structure

A serous cell, under the light microscope appears as a pyramidal cell with a
broad base resting on a basement membrane and a narrow apex bordering the
lumen. Nucleus of these cells is round and placed at the basal one-third of the
cells. In H and E sections, apical part of the cytoplasm appears granular and
stain distinctly eosinophilic because of the secretory granules while the
cytoplasm in the basal portion stains with hematoxylin because of the
abundant rough endoplasmic reticulum and the free ribosomes.
8–12 serous cells are arranged around a small lumen to form a serous
acinus which is roughly round in shape (Fig. 11.2a). The central lumen
extends between the secretory cells as intercellular canaliculi. The serous
acinus is smaller in size than a mucous acinus with less number of cells and
has relatively smaller lumen.
Electron microscopic structure of serous cells
Electron microscope can reveal all the details of cytoplasmic components of
the cells and specialization of plasma membrane (Fig. 11.2b).
Electron microscopic picture of the serous cells show all the organelles
required for the synthesis and therefore indicate that these cells are
specialized and active in protein synthesis.
Shape of the Cell and Specialization of Plasma
Membrane
The plasma membrane bounding the cells shows various structural
specializations. Basal plasma membrane is irregular with multiple foldings.
Some of these foldings extend laterally beyond the boundary of the cell and
inter digitate with those of the adjacent cells. This specialization increases
surface area of the cell by 60 times for diffusion of water and minerals
required for the saliva from tissue fluid. The basal plasma membrane is
supported by a basement membrane.
Plasma membrane at the lateral region and apical portion of the cell also
shows foldings called microvilli which increase the surface area of secretion.
The cells on the lateral region have complex interrelationship with adjacent
cells. Near the apical portion, adjacent cells are connected by intercellular
junctions like tight junctions, intermediate junctions and desmosomal
junctions. These junctions help to hold the cells together and prevent leakage
of material from the lumen. Between the adjacent cells there is well defined
intercellular space or canaliculus that extends from the lumen which is sealed
off by intercellular junctions.

Cytoplasmic Components
Cytoplasm of a secretory cell shows abundant cytoplasmic organelles
required for synthesis and storage of proteinaceous materials. Large number
of rough endoplasmic reticulum (RER) arranged parallelly is found in the
cytoplasm basal and lateral to the nucleus. A prominent Golgi apparatus
consisting of several stacks are seen lateral and apical to the nucleus. The
Golgi apparatus are functionally connected to RER through a series of
budding vesicles at the end of RER. Mitochondria, the energy source of
various synthetic and transportation activities, are also abundant and are
dispersed in the basal and lateral region.

Synthesis of Saliva
The organic component of the saliva is synthe-sized by the secretory cells
utilizing the substrate provided by the nutrients that reach the cell. Water and
electrolytes required for the saliva reaches the cell from circulation and from
tissue fluid.
Fig. 11.2a: Light microscopic structure of serous acinus

Fig. 11.2b: Electron microscopic structure of serous cell

 Protein synthesis begins when the messenger RNA carries the message
from the nucleus to the cytoplasm. The ribosomes translate the message and
initiates protein synthesis by adding amino acids in required sequence. Thus
forms a pre-protein with a signal sequence—an extension of 16–30 amino
acids—attached to it. With the help of this signal sequence, protein
synthesized, enters the RER. In the RER, the signal sequence is removed by
proteolytic enzymes, and the protein assumes a helical structure. After
structural modification, protein is transferred to Golgi complex through a
series of budding vesicles which attach to cis or convex face of Golgi bodies.
Glycosylation began in the RER continues in Golgi complex. Carbohydrates
added to amino acids (like asparagine, serine, and threonine) are galactose,
mannose, fructose, glucosamine, galactosamine and sialic acid.
Then the secretory products are packed into secretory granules which bud
off from the trans or concave face of Golgi complex. These secretory
granules are termed as pre secretory granules or condensing vacuoles or
immature granules. The limiting membranes of these granules are irregular
indicating further addition of molecules. The secretory granules are then
stored in the apical cytoplasm till the secretory unit is stimulated and the
stored products are expelled out.
Secretion of saliva
The secretion of the stored protein is by a process called exocytosis. When
the cell receives appropriate stimuli the secretory granules move towards the
apical and lateral plasma membrane with the help of microfilaments and
fuses to the plasma membrane. After fusion the plasma membrane of the
joined region opens up releasing the content in to the lumen without
disruption of plasma membrane continuity. This process is repeated till all the
granules are emptied. The added fraction of membrane is retrieved by
formation of endocytic vesicles, which may be destroyed by lysozymes or
may be utilized for packing of secretory materials. The salivary glands are
categorized as merocrine glands because of this mode of secretion.

Decision for protein synthesis is taken in the nucleus

↓
Messenger RNA in ribosomes carry the message to the cytoplasm through
ribosomes
↓
 Ribosomes translate the message and initiate protein synthesis by adding
amino acids in required sequence. Thus forms a pre-protein with a signal
sequence attached to it
↓
With the help of signal sequence (an extension of 16–30 amino acids),
protein synthesized enters the RER where the signal sequence is removed
by proteolytic cleavage and protein assumes a helical structure
↓
Protein synthesized is transferred to Golgi complex, through cis or convex
face
↓
Structural modification in the Golgi complex by addition of carbohydrates
↓
Packing of secretory product into secretory granules which are released
through trans face of Golgi complex. These secretory granules are called
pre-secretory granules, immature granules or condensing vacuoles
↓
Further addition of molecules resulting in maturation of secretory granules
↓
Storage of secretory granules in the apical cytoplasm
↓
Secretion of material by a process of exocytosis

Mucous Secretory Cells and Mucous Acinus

Mucous cells are the specialized cells that synthesize, store and secrete
mucinous secretion which is ropey and thick, rich in carbohydrates and
containing small amount of non-enzymatic proteins. Since the major part of
the secretion is glycoproteins, the secretion from these cells mainly helps in
lubrication. The mucous cells are the predominant secretory cells in the
sublingual glands and majority of minor salivary glands. Submandibular
glands also have some mucous secretory cells.

Light Microscopic Structure of Mucous Cells

Mucous cells are also pyramidal in shape similar to serous cells but are larger
and have a relatively broader luminal surface. The broad base of the cell,
rests on a basement membrane and apex borders the lumen. Nucleus of these
cells is flattened and placed at the basal part of the cells, pressed against the
base, along with thin rim of cytoplasm. Apical part of the cytoplasm is filled
with secretory granules which is rich in carbohydrates. In a hematoxylin and
eosin stained section apical portion of mucous secretory cell appears empty,
except for fine strands of cytoplasm, because the secretory droplets contain
heavily glycosylated proteins (mucins) that do not take up the stain. Special
stains such as mucicarmine or periodic acid Schiff stain or Alcian blue reveal
the secretory products. The cytoplasm in the basal portion may show a
basophilic staining due to abundant rough endoplasmic reticulum.
These mucous cells are arranged around a relatively larger lumen to form a
mucous acinus which is tubular in shape (Fig. 11.3a). The mucous acinus is
larger in size than a serous acinus with more number of cells.

Electron Microscopic Structure of Mucous Cells

Electron microscopic examination reveals various cytoplasmic components
of the cells and specialization of plasma membrane (Fig. 11.3b). The mucous
cells show all the synthetic organelles and therefore indicate that these cells
are specialized and active in protein and carbohydrate synthesis.

Specialization of Plasma Membrane

The plasma membrane surrounding the cells shows various structural
specializations similar to that of serous cells. Basal plasma membrane is
irregular with multiple foldings which may extend laterally even beyond the
boundary of the cell to interdigitate with those of the adjacent cells. But the
basal plasma membrane extensions are much less extensive than serous cell.
This specialization increases surface area of the cell for diffusion of water
and minerals required for the saliva from tissue fluid. The basal plasma
membrane is supported by a basement membrane.
Plasma membrane at the lateral region and apical portion of the cell also
shows foldings called microvilli which increase the surface area of secretion.
The cells on the lateral region have complex interrelationship with adjacent
cells. The mucous cells posses apical junctional complex similar to the serous
cells. Near the apical portion, adjacent cells are connected by intercellular
junctions like tight junctions, intermediate junctions and desmosomal
junctions. These junctions help to hold the cells together and prevent leakage
of material from the lumen. Between the adjacent cells there are intercellular
spaces or canaliculi that extends from the lumen, which is sealed off by
intercellular junctions. The intercellular canaliculi are relatively less distinct
in mucous acini. If serous demilunes are present in relation to a mucous acini,
the intercellular canaliculi extends from the lumen, between the cells to the
serous cells and serve as a delivery route for serous secretion.

Cytoplasmic Components
Cytoplasm of a secretory cell shows cytoplasmic organelles required for
synthesis and storage of proteinaceous materials. Organelles are not so
abundant as in serous cells. All the synthetic cytoplasmic organelles are
mainly located in the peri-nuclear area and are relatively less in number and
are chiefly restricted to the basal region of cells. Rough endoplasmic
reticulum and mitochondria are dispersed in the basal and lateral region of
nucleus. But mitochondria are few in number and rough endoplasmic
reticulum is less extensive. A prominent Golgi apparatus consisting of several
stacks (10–12 sacules) are seen lateral and apical to the nucleus, compressed
between RER and secretory droplets. One of the major differences observed
from that of serous cell is, considerably greater Golgi apparatus which
indicates a greater carbohydrate metabolism. In the Golgi complex
carbohydrate component is added to protein to synthesize glycoprotein of
mucin. Golgi complex is also involved in proteolytic processing steps and
trimming of oligosaccharides. The diluted protein received from rough
endoplasmic reticulum is concentrated in the Golgi complex, which is a
required step for efficient intracellular storage.
 Fig. 11.3a: Light microscopic structure of mucous acinus

Fig. 11.3b: Electron microscope structure of mucous cell

The mechanism of release of stored secretory products in the apical
cytoplasm may be variable. The droplet may fuse with the plasma membrane
and release the content in the same way as that of exocytosis in serous acini.
Alternatively the mucin droplet may be discharged with the limiting
membrane intact. This is achieved by the fragmentation of plasma membrane
which occur after the fusion of secretory droplet. During rapid discharge the
entire mucin along with some cytoplasmic components are spilled through
this break into the lumen.

Mixed Acinus
In mixed salivary glands both serous and mucous acini are seen, which vary
in proportion based on the type of gland, i.e. predominantly serous or
predominantly mucous. Along with these, there are few mixed acini (Fig.
11.4). The basic secretory unit of a mixed acinus is a tubular mucous acinus.
At the blind end this acinus serous cells are arranged to form a crescent
shaped structure called demilune of Gianuzzi (demilune-half moon). The
secretions of the serous cells reaches the lumen through the intercellular
canaliculi present between the mucous cells.

Myoepithelial Cells
Myoepithelial cells are contractile cells found to be embracing/enveloping the
secretory end piece and the first portion of the ductal system, the intercalated
ducts. These cells are epithelial in origin, but exhibit contractile function like
muscles, hence the name myoepithelial cells. The myoepithelial cells are
ectodermal in origin. But it is not clear whether it is from intercalated duct
reserve cells or from neural crest cells.
Myoepithelial cells are situated between the basal plasma membrane of
parenchymal cells and basement membrane supporting the secretory unit or
duct. Shape varies depending on location. Cells associated with acini are
dentritic cells with a cell body containing the nucleus and 4–8 cytoplasmic
processes extending from the cell body, each with two or more secondary
branches. Therefore these cells are compared to an ‘Octopus sitting on a
rock’. The cell body is located in a region where basal region of 2–3
secretory cells come together. The cells processes run parallel to the long axis
of acinus and cradle it like a basket. Therefore, these cells were called as
‘basket cells’.
 Fig. 11.4: Light microscopic structure of mixed acinus

Good to Know
Demilunes in mixed ocini-Fixation Artifacts?
Yamashina et al published a scientific article “The serous demilune of rat
sublingual gland is an artificial structure produced by conventional
fixation” (HistolCytol 62: 347–354) claiming that demilunes are ‘created’
due to fixation artefacts. These researchers proposed this concept based on
their findings in a study conducted using rapid freezing of the salivary
gland tissue in liquid nitrogen, followed by rapid freeze substitution with
osmium tetroxide in cold acetone. They demonstrated that both mucous
and serous cells, aligned in the same row to surround the lumen of the
secretory acinus. Sections from the same specimen fixed using
conventional methods showed swollen mucous cells with enlarged
secretory granules and typical serous demilunes at the periphery with
slender cytoplasmic processes interposed between the mucous cells. The
process of demilune formation was explained, to be caused by expansion
of mucinogen of secretory granules, during routine fixation. This
expansion increases the volume of the mucous cells and displaces the
serous cells from their original position, thus creating the ‘demilune
effect’. However Tandler raised many queries about this concept and
 claimed that demilunes are real, basic units of salivary gland structure
[Tandler B (2014) Are Demilunes in Mixed Salivary Glands Real or
Fixation Artifacts? A Critique. J CytolHistol 5: 218.]

The myoepithelial cells are attached to parenchymal cells by desmosomal

junctions. The cell body contains the nucleus and few cytoplasmic organelles
such as rough endoplasmic reticulum, mitochondria Golgi complex, etc.
which are restricted to the perinuclear cytoplasm. The processes are filled
with fine microfilaments (actin and myosin) and some dense bodies therefore
resemble the smooth muscles. In addition cytoplasm of these cells also
exhibit cytokeratin intermediate filaments, confirming epithelial origin.
Myoepithelial cells are not readily identifiable in routine hematoxylin and
eosin stained sections. However, to detect these cells histochemical tests that
can demonstrate ATPase reaction or electron microscopic examination can be
used. Demonstration of the cytoplasmic filaments by histochemical or
immunofluorescent technique can also be used in identification of
myoepithelial cells.
Myoepithelial cells associated with intercalated ducts are spindle shaped
with few processes, running parallel to the ducts which seldom divide.
Functions of Myoepithelial Cells
Since the myoepithelial cells have a contractile property, they help to squeeze
and expel the secretory material from lumen to the ducts.
They also prevent the back flow of saliva from the duct back to the lumen.
Myoepithelial cells support the acinus by bracing it like basket. Thus, prevent
over distention and subsequent disruption by accumulation of secretory
product.
Contraction of myoepithelial cells facilitates rapid expulsion of secretory
material in mucous cells by causing rupture of plasma membrane.
Contraction of myoepithelial cells surrounding the intercalated ducts shorten
and widen the duct and thereby reduces peripheral resistance and helps to
maintain patency. Extension of the processes of these cells on to proximal
surface of associated secretory acini may serve to align the lumen of acini
and duct during contraction, which facilitate flow of saliva.
Myoepithelial cells may have a role in maintaining cell polarity and structural
organization of secretory end piece.
The proteinase inhibitors and antiangiogenesis factor secreted by
myoepithelial cells have tumour suppressor property and protect the
glandular tissue from invasive epithelial neoplasms.
Myoepithelial cells may have a possible role in modifying the concentration
of saliva by decreasing the surface area of secretory apparatus exposed to
interstitial tissue.

Ductal System
The ductal system of salivary gland is composed of network of ducts where
the smaller ducts join to form larger caliber ducts. The intralobular ducts, i.e.
the intercalated and striated ducts join together to form interlobular ducts.
The interlobular ducts join together to form a lobar duct which drain a lobe of
the gland. The lobar ducts join to form interlobar duct which runs in the
connective tissue between the lobes and is continued as terminal excretory
duct. In the ductal system, microscopically three structurally different
sequential segments can be identified: Intercalated duct and striated duct
which are intralobular and excretory duct which is interlobular and inter lobar
in location (Fig. 11.5).
Intercalated ducts: These are the smallest diameter duct at the first portion
of ductal system which is seen as a continuation of lumen of secretory acini.
The intercalated ducts carry the saliva from the lumen to the striated duct.
These ducts are inconspicuous and vary in length in different glands: Being
least prominent in mucus-secreting salivary glands (sublingual glands) and
particularly long and prominent in serous glands (parotid gland).
 The intercalated ducts are intralobular ducts found among the secretory
acini. Light microscopically these ducts are seen as small diameter structures
lined by a single layer of cuboidal cells with faintly eosinophilic cytoplasm
and centrally located nucleus. Ultrastructurally the lining cells of the
intercalated duct show some resemblance to secretory cells. The cytoplasm
contains basally located rough endoplasmic reticulum, mitochondria, Golgi
complex, few secretory granules, etc. The intercalated ducts are supported by
basement membrane and adjacent cells are attached to each other by
intercellular junctions. Myoepithelial cells are found between basal plasma
membrane of lining cells and supporting basement membrane. A few
undifferentiated mesenchymal cells are also present.
 The intercalated ducts not only act as a conduit for saliva, but also
contribute some materials to it.
Striated duct: The intercalated ducts are continuous with the striated ducts
which carry the saliva to the excretory duct. They have a comparatively
larger lumen lined by a single layer of columnar cells, well supported by
connective tissue. These cells have a centrally placed round nucleus and
abundant eosinophilic cytoplasm. The basal portion of the cells present a
striated appearance, thereby the name striated duct. Electron microscopically
the lining cells of striated ducts show some similarity to cells involved in
water electrolyte balance (Fig. 11.6). These cells show numerous infoldings
at the basal part of plasma membrane which helps to increase the surface area
of basal plasma membrane. Many large mitochondria are seen in the
cytoplasm which are arranged within these infolding with long axis parallel
to the infoldings and to each other. These basal infoldings along with
mitochondria is responsible for the striated appearance under light
microscope.

Fig. 11.5: Ductal system of salivary glands

 Fig. 11.6: Striated duct lining cell
Excretory duct: The striated ducts are followed by larger excretory duct
which constitute the principal ducts of each of the major glands. The main or
terminal excretory duct which drains the saliva to the oral cavity is formed by
the continued confluence of interlobular excretory duct.
 Excretory ducts are the largest ducts of the salivary gland, the structure of
which vary in different portions. In the initial part, near the striated duct, the
excretory duct is lined by tall columnar cells with occasional basal cells. As
the duct becomes larger the lining gradually becomes pseudostratified with
more basal cells and few goblet cells. The ductal portion near its opening to
the oral cavity is lined by stratified squamous epithelium which merges with
the oral mucosal lining. Oncocytes may be present among the lining cells of
the excretory duct.

Functions of Ductal System

Ductal system acts as a passage through which the saliva secreted by acini
reaches the oral cavity. The saliva that is secreted by acini is called primary
saliva. This primary saliva undergoes modifications as it passes through
various ducts and the secretion that comes out of the excretory duct is called
secondary saliva.
Intercalated ducts contribute some secretory materials to saliva. They also
release lysozymes and lactoferrin, two important antimicrobial components to
saliva.
Intercalated duct and striated duct reabsorbs some amounts of proteins.
Striated ducts secretes some glycoproteins such as and kallikrein and
epidermal growth factors to saliva.
An important function of striated duct is to modify the electrolyte
concentration of the saliva. Saliva that enters the striated duct is hypertonic or
isotonic with more concentration of Na+, Cl– ions and less concentration of
K+ and HCO3–. The structure of striated duct is such that it has Na+ pumping
ability. The striated duct lining cells actively reabsorb the Na+ ions from the
lumen and secrete K+ actively in exchange of Na+. The Na+ ions reaching the
cell is pumped out to the tissue fluid, creating a concentration gradient which
leads to further Na+ reabsorption from the lumen. Therefore the Na+
concentration of saliva becomes greatly reduced, whereas K+ concentration
becomes increased making the saliva hypotonic. Along with Na+, Cl– are also
reabsorbed passively as it follows the same chemical gradient. As an
exchange for Cl–, HCO3– ions are secreted into saliva. Therefore the saliva
coming out of striated duct has less of Na+ and Ch concentration and more of
K+ and bicarbonate ions. Since the ducts cannot alter the water level,
alteration in ions make the saliva hypotonic. However, when secretion is very
rapid, the saliva remain isotonic to hypertonic, because the process of
reabsorption and secondary secretion systems cannot keep up with the rate of
primary secretion.
Excretory duct releases mucin into the saliva because of the goblet cells in
the lining epithelium.
Excretory ducts also assist the striated duct in changing the tonicity of saliva.

Connective Tissue Components

The connective tissue component of salivary gland forms a well formed
capsule surrounding the glandular structure. The capsule is more distinct and
extensive in parotid. Connective tissue septa extends from the capsule in
between the parenchymal components and divide the gland into larger
compartments called lobes and smaller compartments called lobules. The
connective tissue supports the ducts and carries blood vessels, lymphatics and
nerves that supply the gland. The thickness of connective tissue is higher in
relation to excretory duct.
The connective tissue is composed of parallely arranged collagen fibers,
with fibroblasts, fat cells, defense cells like macrophages, mast cells and
plasma cells and few lymphocytes, etc. The ground substance of connective
tissue is composed of proteoglycans and glycoproteins.
Extensive capillary network is observed in the connective tissue which
ensure adequate supply of water and electrolytes for saliva. Vascular
channels that enter the duct along the excretory duct, follow the branching
ducts to reach the lobes and lobules.

Nerve Supply
Salivary secretion is mediated by innervating nerves. The salivary glands are
supplied by parasympathetic and sympathetic arms of the autonomic nervous
system, which travel to the glands by separate routes. Parasympathetic
innervation to the salivary glands is carried via cranial nerves; parotid gland
from the glossopharyngeal nerve (CNIX) via the otic ganglion from which
the auriculotemporal nerve carries parasympathetic fibres; the submandibular
and sublingual glands from the facial nerve (CN VII) via the submandibular
ganglion. Direct sympathetic innervation of the salivary glands takes place
via preganglionic nerves in the thoracic segments T1–T3 which synapse in
the superior cervical ganglion. Fibres from this ganglion travel along the
external carotid artery to reach the glands.
Once in the glands, the nerves follow the course of blood vessels and
undergo extensive branching reach up to the adjacent region of acini. The
axons from each type of nerve intermingle and travel together in association
with Schwann cells, forming Schwann-axon bundles. The nerve endings,
maintain two types of neuro-effector relationships with salivary parenchymal
and myoepithelial cells:
Hypolemmal or intraepithelial type (within the parenchymal basement
membrane): In this type myelinated axons that split off from the nerve bundle
penetrate the basement membrane of the acinus to reach very close to
secretory cells. The distance between the secretory cell and nerve ending is
only 10–20 nm. The axons show varicosities which are considered as
neuroeffector site. These varicosities contain chemical neurotransmitters such
as nor epinephrine and acetyl choline stored in small vesicles. Afferent nerves
are found to form a hypolemmal association with the epithelial cells of main
salivary ducts.
Epilemmal or subepithelial or interstitial type (outside the parenchymal
basement membrane): In this, the axons remain in the connective tissue and
do not penetrate the basal lamina. Here the distance between the secretory
cell and axon is more and is around 100–200 nm. The neuro-transmitters
from the varicosities of nerve axons have to diffuses through the basal lamina
to reach the secretory cells. Salivary blood vessels receive epilemmal
innervations by both sympathetic and parasympathetic axons.
The relative frequencies of either type of nerve differ greatly between
glands and species. The classical transmitters for parasympathetic axons is
acetylcholine and substance P while in sympathetic axon is noradrenaline. At
least four types of influence can be exerted on salivary parenchymal cells by
the nerves: hydrokinetic (water mobilizing), proteokinetic (protein secreting),
synthetic (inducing synthesis), and trophic (maintaining normal functional
size and state).
Both parasympathetic and sympathetic stimuli result in an increase in
salivary gland secretions. However, increased activity of the sympathetic
nervous system can also inhibits saliva secretion, via vasoconstriction,
thereby decreasing the volume of fluid in salivary secretions, producing an
enzyme rich mucous saliva. To sum up, parasympathetic stimulation results
in secretion of large amount of watery saliva with low organic components
while sympathetic stimulation produces relatively less quantity of thick,
enzyme rich saliva. (Age changes—refer page 324, functions of saliva—
refer page 292)

Difference between serous and mucous acini

Serous acini Mucous acini
Circular or round in shape Ovoid or tubular in shape

Smaller in size Larger

Composed of less number of cells More number of cells

Has small lumen Wider lumen

Cells are pyramidal in shape Cells are pyramidal/columnar in

shape

Nucleus is round and placed at Nucleus is flattened and pressed

basal 1/3rd of the cell against basal plasma membrane of the
cell

Apical cytoplasm appears Apical cytoplasm appears empty in H

eosinophilic because of zymogen and E sections because of mucin
granules

Clinical Considerations
A number of disease conditions can involve salivary glands which include
a. Developmental defects like aplasia (lack of development) hypoplasia
(under development)
b. Infections that may be caused by virus or bacteria referred to as
sialadenitis; causing pain and swelling of salivary gland. Mumps is a
common viral sialadenitis primarily affecting parotid gland.
c. Sialolithiasis is a condition characterized by intermittent swelling and
pain particularly while eating, caused by blocking of salivary flow by
sialolith (stone in the salivary duct).
d. Sjogren’s syndrome is an autoimmune disorder affecting the salivary
gland resulting in marked reduction in salivary secretion resulting in
xerostomia or dry mouth.
e. Cysts of salivary gland—mucocele is an example for cysts involving
saliary gland, frequently, the minor salivary glands of the lower lip.
f. Benign or malignant tumors—a number of benign and malignant
tumors develop in the salivary gland tissue with abnormal proliferation
of ductal, acinar or myoepithelial cells, each one causing swelling and
other manifestations, e.g. of benign tumours are pleomorphic adenoma
and monomorphic adenoma. Malignant tumours are adenoid cystic
carcinoma, muco-epidermoid carcinoma, acinic cell carcinoma, etc.
 12
Temporomandibular Joint

Introduction
Anatomy and histology of TMJ
Ligaments of TMJ
Movements of TMJ
Clinical considerations

T emporomandibular joint (TMJ) is the joint or articulation between the

movable mandible and fixed temporal bone of the cranium. It is a
ginglimo diarthrodial synovial joint. The joint is capable of a
combination of sliding and a hinge movement or rotation and both right and
left joints move together. Articulation is achieved by two joints between the
condyles of mandible and glenoid fossa.

ANATOMY AND HISTOLOGY OF TMJ

TMJ comprises of two bony structures and interposed fibrous disc, enclosed
in a fibrous capsule (Fig. 12.1).

1. Bones Forming Articulation or Articulating Surfaces

Bony element of the joint is made up of the condyle below and articular
surface of glenoid fossa above.

Condyle
Condyle is a large solid oblong structure which is wider medio-laterally (20
mm) than anteroposteriorly (10 mm). It is noticeably convex capsule when
viewed from the side, but only slightly convex when viewed from the front.
The long axis of each condyle inclines slightly backward and medially.
Articulating surface is convex and is located on the superior and anterior
surface of the head of the condyle. The anterior border of the articulating
surface is distinctly marked. A triangular depression beneath this border
marks the insertion of the lower fibers of lateral pterygoid muscle. The
medial and lateral poles of the condyle are also distinct.

Fig. 12.1: Temporomandibular joint

The Articular Surface of Temporal Bone

The articular surface of temporal bone consists of concave posterior part
called articular fossa and a convex anterior part called articular tubercle or
eminence.
Articular fossa (glenoid fossa or mandibular fossa) is an ovoid depression
in the temporal bone just anterior to auditory canal. The boundaries of the
fossa can be readily determined. The boundaries are, anteriorly articular
eminence, medially the spine of sphenoid, laterally root of zygomatic
process, posteriorly the tympanic plates of petrous portion of temporal bone.
Articular eminence is the bony prominence located immediately anterior to
the articular fossa.

Histology of Articulating Surfaces

The bony surface of the head of the condyle is made up of a dense compact
bone with cancellous bone in the center. The cancellous bone contains red
cellular marrow which may be replaced by fatty marrow in older individuals.
As age advances, the trabeculae of cancellous bone increases in thickness,
thereby reducing the marrow spaces. The trabeculae are found to be radiating
from the neck of the condyle and end at the cortex at right angle.
The articular fossa is lined by a thin layer of compact bone. The articular
eminence has a core of cancellous bone covered by a layer of compact bone.
Articular fibrous covering: The articular surface of the condyle and the
articular fossa are composed of four distinct layers. The most superficial zone
is called articular zone and is composed of fibrous tissue in contrast to the
hyaline cartilage covering of articular surfaces of other synovial joints. This
fibrous layer consists of few fibroblasts scattered in a dense largely avascular
layer of type I collagen fibers which are arranged in bundles oriented nearly
parallel to the articular surface. These connective tissue may contain few
cartilage cells which increase with age.
The second zone is proliferative zone which is highly cellular and
composed of undifferentiated mesenchymal tissue. This layer is responsible
for proliferation of articular capsule in response to functional demand. The
proliferative zone also plays an important role in remodeling and repair of
articular surfaces.
Third zone is fibrocartilagenous zone made up of bundles of collagen
fibers arranged in a crossing pattern and some in radiating pattern. This layer
provides resistance against compressive or lateral forces.
The fourth zone is calcified zone made up of chondrocytes and
chondroblasts distributed throughout the articular cartilage. This zone
provides an active site for remodeling activity as endosteal bone growth
proceeds.
Articular fibrous covering layer is fairly of even thickness and may be
particularly thick on the articular surfaces which oppose one another, i.e. in
the anterosuperior surface of condyle and on inferoposterior surface of
articular eminence of temporal bone.

2. Articular Capsule
Articular capsule is a dense collagenous sheet of tissue or a sac that encloses
the joint space. The articular capsule is circumferentially attached to the rim
of glenoid fossa and articular eminence above and to the neck of the condyle
below. The anterior portion of the capsule is attached above to the ascending
slope of the articular eminence and below to the anterior margin of condyle.
The posterior portion is attached above to the squamotympanic fissure and
below to the posterior margin of ramus of mandible, adjacent to neck of
mandible. Anterolateral aspect of the capsule may be thickened to form
temporomandibular ligament. Posterior fibers of the capsule blend with
articular disc as they traverse from temporal bone to mandible.

Histology of Articular Capsule

Fibrous capsule is composed of two layers; Outer fibrous layer of dense
connective tissue and an inner layer termed as synovial membrane.
Synovial membrane lines the inner aspect of fibrous capsule and therefore
forms the lining of joint cavity. The inner surface of the synovial membrane
is thrown into folds giving rise to villi like processes projecting into the joint
cavity. Histology of the synovial membrane varies in different regions. The
synovial membrane consists of two layers: inner cellular intimal layer
resting on a highly vascular subintimal layer (Fig. 12.2).
The subintimal layer is composed of loose connective tissue containing
blood vessels, scattered fibroblasts, macrophages, mast cells etc. Some elastic
fibers are also present along with collagen fibers which prevent the folding of
membrane which might otherwise become entrapped in between articular
surfaces.
Intimal layer consists of few layers (1–4) of synovial cells, distributed in an
amorphous intercellular matrix. These cells are not attached to each other and
do not form a continuous layer. Three types of cells are mainly observed in
the intimal layer. They are:
Type A cells (macrophage like cells): These cells have irregular outline with
plasma membrane invaginations. Cytoplasm is rich in mitochondria, Golgi
apparatus and lysosomes while rough endoplasmic reticulum (RER) is less
distinct. Type A cells have phagocytic properties.
Type B cells (fibroblast like cells or secretory—S cells): These cells are rich
in RER and involved in synthesis of hyaluronic acid which is found in
synovial fluid.
Third type of cells have cellular morphology between the other two types.
Joint cavity contains approximately 1 ml of synovial fluid which is formed by
diffusion of plasma from the rich capillaries of subintimal layer, to which
proteins and hyaluronic acid secreted by fibroblast like cells are added.
Synovial fluid also contains few synovial cells and defense cells.

Fig. 12.2: Synovial membrane

Functions of Synovial Membrane

Lubrication: Helps in lubrication of the joint by providing a fluid
environment for the joint.
Nutritive: Provides nutrition to the avascular fibrous tissue of joint, i.e.
articular fibrous covering and the center part of the articular disc.
Regulatory: Controls the movement of nutrients, electrolytes and other
materials to the synovial fluid
Secretory: The intimal cells secrete proteins and hyaluronic acid to the
synovial fluid.
Phagocytic: Type B cells are phagocytic and therefore help in debriding.

3. Articular Disc
Articular disc or the meniscus is a tough biconcave pad of dense fibrous
connective tissue, located between the condyle and articular surface of
temporal bone, i.e. the glenoid fossa and articular eminence. The disc is
thinnest at the center (about 1 mm) and thicker towards the periphery (2–3
mm). Varying thickness of the disc has lead to the description of four distinct
regions namely anterior band, intermediate zone, posterior band and
bilaminar region.
The shape confirms to the articular surfaces to which it is opposed. The
upper contour of the disc is concave in the anterior region to fit under
articular eminence and convex posteriorly and loosely rest against articular
fossa. The lower surface of the disc is concave in both directions thus
adapting to the upper surface of mandibular condyle.
The medial and lateral margins of the disc blend with the capsule. In the
anterior region disc is divided into two lamellae, the upper one running
forward to fuse with capsule and periosteum in the anterior slope of articular
eminence while the lower one runs down to attach to the front of neck of the
condyle. The region of disc between upper and lower lamellae merges with
the capsule or with lateral pterygoid muscle.
Posteriorly also the disc is divided into two lamellae, upper lamellae
consisting of fibrous and elastic tissue fusing with capsule and inserting into
the squamotympanic fissure. The lower lamella is nonelastic as it is
composed of only collagen and turns down to blend with periosteum of neck
of condyle. Between the lamellae, loose highly vascular connective tissue is
found which is called bilaminar zone.
The articular disc divides the joint space into upper compartment called
temporo-discal which is between disc and temporal fossa and a lower
compartment called condylo-discal situated between disc and condyle. Lower
joint allows the rotational movement of head of the condyle which is also
called hinge movement. Upper joint space allows a translatory movement
anteriorly along the slopes of the articular eminence to produce an anterior
and inferior movement of the jaw.
Histolosy of Articular Disc
Articular disc is composed of dense fibrous tissue with tightly packed
interlacing collagen fibers. The fibroblasts are elongated with long processes.
A few elastic fibers may be present. As an age change, in older persons
articular disc may show cartilage cells. These cartilage cells may be
increasing the resilience and resistance of fibrous tissue. The center portion of
the disc is devoid of blood vessels and nerves while periphery is highly
vascular.
Periphery of articular disc is attached to the fibrous capsule. Anterior part
of the disc fuses with the capsule while posteriorly it is loosely attached.
Being loosely attached posteriorly the disc moves with head of the condyle
but only about half as far.

Functions of Articular Disc

Divide the joint cavity into two compartments, therefore allowing different
types of the mandibular movements. Upper joint cavity mediates a translatory
or gliding movement while the lower joint cavity allows rotation.
Since it is a soft tissue component between two hard tissue components of the
joint, it prevents rubbing or friction between these components, therefore
reducing physical wear.
Articular disc acts as a cushion against heavy load and therefore helps in
shock absorption
Stabilizes the condyle by filling up the space between the articulating
surfaces.
The proprioceptive nerve fibers present in the anterior and posterior portion
of disc help to regulate movements of condyle.
Assists in lubricating mechanism (synovial fluid)
Articular disc being loosely attached posteriorly, the disc moves with head of
the condyle but only about half as far and prevents, undue forward movement
of condyle.
Helps in distribution of weight across the joint by increasing the area of
contact which may thus prevent wear.
 LIGAMENTS OF TMJ

1. Capsular Ligament
Capsular ligament or articular capsule is a fibrous sac that encloses the joint
cavity. It is attached to the articular margins of the temporal bone superiorly
and to the neck of condyle inferiorly. An articular disc intervenes between the
two articular surfaces and is attached peripherally to the inner surface of the
capsule. The capsule is thin and loose between the temporal bone and
articular disc, but between the disc and mandible it is thicker and stronger. It
is lined by synovial membrane. Anteriorly the tendon of lateral pterygoid
muscle is inserted into it.

2. Temporomandibular Ligament
Temporomandibular ligament or lateral ligament is a strong fan-shaped
ligament functioning to reinforce the lateral wall of the articular capsule and
thus act to limit the lateral and posterior movements of the joint. It is attached
superiorly to the articular tubercle and a segment of the zygomatic process
and runs posteroinferiorly to attach to the condyle and posterolateral aspect of
the neck of mandible.

3. Accessory Ligaments
There are two accessory ligaments which do not contribute to support of the
temporomandibular joint, but facilitate and limit the movements. Accessory
ligaments include:
Sphenomandibular ligament extends from the spine of the sphenoid to the
lingula and lower margin of the mandibular foramen. It represents the
unossified intermediate part of the sheath of the Meckel’s cartilage of the first
pharyngeal arch. Over movement of the mandible is limited by this ligament.
Stylomandibular ligament extends from the lateral border of the styloid
process to the posterior border of the ramus of the mandible above its angle.
It is the thickened part of the investing layer of the deep fascia of the neck. It
separates the parotid gland from the submandibular salivary gland. This
ligament participates in limiting the protrusive movement.
These ligaments are thought to play a significant role during protrusion and
depression of the jaw.

MOVEMENTS OF TMJ

Temporomandibular joint exhibits two types of movements; namely rotation

(hinge movement) and translation (gliding movement). The upper
compartment of the joint shows anteroposterior gliding movement during
which condyle and articular disc move as a single unit against the glenoid
fossa. The lower compartment shows a hinge movement during which
condyle moves against the articular disc and glenoid fossa which together act
as a single unit.
The mandibular movements are determined by:
Condylar guidance, which is the mandibular guidance generated by condyle
and articular disc traversing the contour of glenoid fossa. The glenoid fossa
along with articular eminence forms an S-shaped path along which the
condyle moves. This shape of the glenoid fossa, which determines the path of
movement of condyle, is called condylar guidance.
Incisal guidance: It is defined as the influence of the, contacting surfaces of
the mandibular and maxillary anterior teeth during mandibular movements.
When the mandible is moved forward, the incisal edge of lower anterior teeth
slide along the lingual surface of maxillary anterior teeth. Therefore the
lingual surface of the maxillary anterior teeth guides the mandible during
protrusive movement and is called incisal guidance.
Neuromuscular factors: The movement of the jaw is determined to a greater
extend by the muscles of mastication which coordinate together to move the
mandible in a symmetric manner.

Types of Mandibular Movements

1. Rotation
Mandible can rotate in three directions around three axis.
Rotation around transverse or hinge axis: In this case, mandible rotates
around a horizontal axis extending from right side to left side condyle. This
type of movement is seen during protrusive movement.
Rotation around sagittal axis: This type of movement is seen in association
with lateral movement. Here the mandible rotates around an imaginary axis
running along the mid sagittal plane. During this movement, condyle on the
working side (the side to which mandible is moved) moves laterally and
upward while condyle of balancing or nonworking side moves medially and
downward along the medial slope of glenoid fossa.
Rotation around vertical axis: Mandible rotates around a vertical axis that
runs through the condyle and posterior border of ramus of mandible. This
type of movement occurs when the jaw is moved to the side (lateral
movement). When a person opens the mouth to about 20–25 mm, the
mandible moves around the horizontal axis. This kind of movements are
observed while crushing the food or taking the food.
After a certain degree of mouth opening, i.e. beyond 13° rotation of
condyle in TMJ, the condyle begins to glide forward and downward along the
anterior slope of glenoid fossa. This type of movement occurs while incising
or grasping food.

2. Lateral Jaw Movements

Lateral jaw movements can be of two types, i.e. lateral rotation and Bennett
movement.
Lateral rotation occurs when the mandible move away from mid sagittal
plane.
This can occur on right or left side and take place while chewing the food.
During this lateral rotation condyles on either side do not share the common
path of movement.
The condyle on working side (the side to which the mandible moves) move
laterally and upward, downward, forward, backward or outward. While the
condyle on balancing or non-working side move forward downward and
medially.
Bennett movement: It is defined as the bodily lateral movement or lateral
shift of mandible resulting in movements of the condyles along the lateral
inclines along the mandibular fossae in lateral jaw movements.
During this, lateral translation of the condyle occurs and the mandible shift
by 1-A mm towards the working side. This movement of mandible is called
Bennett movement and is recorded in the region of translating condyle of the
nonworking side. This lateral shift of condyle occurs along with or before
lateral rotation.
Bennett movement can be classified based on the time of shift in relation to
the forward movement of non-working condyle.
Immediate shift: This movement of mandible occurs before the forward
movement of non-working condyle. Average movement is 0.75 mm.
Precurrent side shift: This occurs during the first 2–3 mm of forward
movement of non working condyle. During this mandible shift rapidly in
initial stage (2–3 mm lateral shift) followed by less rapid shift.
Progressive side shift or Bennett side shift movement. This lateral shift is
gradual and occurs often 2–3 mm of forward movement of nonworking
condyle.

Clinical Considerations
1. TMJ ankylosis: It is the stiffening (immobility) or fixation (fusion) of
the joint which leads to chronic, painless limitation of the movements
of the joint. This can be a true bony fusion or due to enlargement of the
coronoid process, depressed fracture of the zygomatic arch, scarring
from surgery, irradiation, infection, etc. Ankylosis of TMJ may result
in restricted jaw movements, inadequate masticatory (chewing)
function, restricted mouth opening, inhibited facial and physical
growth, impaired speech, etc.
2. Luxation and subluxation: Luxation refers to complete dislocation of
TMJ with head of the condyle moves anteriorly over the articular
eminence into such a position that it cannot be returned voluntarily to
its normal position. Luxation can be caused due to traumatic injury or
is a result of yawning or opening mouth too wide for dental procedures,
etc. Subluxation refers to partial or incomplete dislocation of TMJ,
where the condyle may lie well anterior to the articular eminence. Such
anterior positioning is normal for many people
3. TMJ pain dysfunction syndrome/Myofacial pain dysfunction syndrome:
It is a psycho-physiologic disorder that involves the masticatory
muscles and is characterized by dull, aching and radiating pain that is
 exacerbated by mandibular function, tenderness on muscle palpation
and limited movement of joint. This condition may be caused due to
bilateral loss of posterior teeth, excessive alveolar bone resorption in
patients with complete dentures, malocclusion, improperly occluding
restorations, stress, etc. Patients may experience pain, muscle
tenderness, limitation of mouth opening, clicking or popping sound
while opening the mouth.
4. Degenerative disease: As other joints of the body, TMJ is prone to
degenerative joint disease (arthritis and arthrosis). Arthritis is
characterized by inflammation while arthrosis, by the presence of low
and no inflammation. Osteoarthritis of TMJ results from wear and
degeneration caused by normal use or parafunctional use of the joint.
Rheumatoid arthritis, an autoimmune joint disease, can also affect the
TMJs. Degenerative joint diseases may lead to defects in the shape of
the tissues of the joint, limitation of jaw movements, and joint pain.
 13
Maxillary Sinus
Dr Usha Balan

Introduction
Anatomy and maxillary sinus
Microscopic features of maxillary sinus
Clinical considerations

P aranasal sinuses are air filled spaces or pneumatic spaces situated as

bilateral pairs in the frontobasal region of skull communicating with the
nasal cavity. Various paranasal sinuses are maxillary, frontal, sphenoid
and ethmoidal sinuses (Fig. 13.1).
Maxillary sinus is a paranasal air sinus located in the body of the maxilla
which communicates with the middle meatus of the nose. It is the largest of
all the sinuses and also called Antrum of Highmore or Maxillary antrum.
Development—Refer page 14, embyology.

Anatomy
Maxillary sinus is the largest of the paranasal sinuses and is pyramidal in
shape. It has a volume of approximately 15 ml (34 × 33 × 23 mm).
Maxillary sinus has four sides and a base. The base faces medially towards
the nasal wall and apex points laterally towards the body of the zygomatic
bone. Anterior side is towards the facial surface of the body of maxilla, while
the posterior side is towards the infratemporal surface of maxilla. Inferior
side is bordered by the alveolar and zygomatic processes of maxilla and the
superior side is bordered by orbital surface of maxilla. The base of the sinus
is thinnest of all the walls. The floor may extend between the roots of
maxillary teeth.

Fig. 13.1: Paranasal sinuses

The maxillary sinus communicates with the nasal cavity through the
ostium, which is located at the level of middle nasal meatus in the lower part
of the hiatus semilunaris. A second opening is often present at the posterior
end of the hiatus in middle meatus. Both the openings are above the level of
the floor of sinus.

Microscopic Features
Maxillary sinus is lined by respiratory epithelium composed of
pseudostratified ciliated columnar epithelium (Fig. 13.2). Epithelial lining is
made up of columnar cells of varying sizes arranged in a single layer on a
basement membiane. The nuclei of the cells are placed at different levels
giving the erroneous appearance of stratification. The cells on the superficial
aspect have got cilia which help in the movement of the mucous secretions.
Along with these ciliated columnar cells, nonciliated columnar cells, basal
cells and goblet cells are also present. Goblet cells (Fig. 13.3) are unicellular
secretory organs which are goblet shaped with a basally placed nucleus and
apical cytoplasm filled with secretory products. Various cellular organelles
like smooth and rough endoplasmic reticulum, and Golgi bodies are also
located in the basal region. The secretions are rich in mucopolysaccharides
and are finally secreted by exocytosis on the surface of epithelium. Since the
secretory material is mucopolysaccharides, in a hematoxylin and eosin
stained section, the goblet cells appear empty.
The epithelium is separated from subepithelial connective tissue by a basal
lamina. Subepithelial connective tissue layer has collagen fibers and
fibroblasts, protective cells such as lymphocytes, plasma cells and
eosinophils. Minor salivary glands including both serous and mucous glands
are distributed in the connective tissue. This layer is attached to the
periosteum lining the bony wall of the maxillary sinus.

Functions of the Maxillary Sinus

Conditioning of inspired air
a. Warming up of the inspired air is possible, because of the rich
arterial supply and it helps to maintain an even and tolerable
temperature.
b. Humidification of the inspired air is achieved and the possibility of
irritation to the respiratory mucosa by dry air is prevented.

Fig. 13.2: Histology of maxillary sinus lining

 Fig. 13.3: Pseudostratified ciliated epithelium with goblet cells
Reduction of weight of facial skeleton:
Maxillary sinus lightens the weight of skull as it is filled with air.
Increases the craniofacial resistance to trauma.
Phonetic resonance and auditory feed back: The maxillary sinus may act
as a resonating box for the voice. Sinuses also affect the conductance of voice
to ones own ear.
Increases the area for olfaction
Production of lysozymes which has bactericidal property.
Filtration: Because of the presence of mucous blanket and cilia, the
maxillary sinus mechanically trap the micro-organisms and dust particles
present in inspired air and helps in filtration of inspired air.
Insulation: The temperature of inspired air can vary. The maxillary sinus
may insulate the orbit from intranasal temperature variations.
Growth and development of facial skeleton: Expansion of sinuses
particularly maxillary sinus helps in rapid growth of facial skeleton.

Clinical Considerations
1. Oro-antrai communication/fistula is the connection that is established
between oral cavity and maxillary sinus. This condition commonly
arises as a result of complication of extraction of maxillary first and
second molar especially when the bony wall separating sinus from root
is very thin. Palatal root of maxillary first molar is found in very close
 proximity to sinus and therefore any surgical manipulation or chronic
periapical inflammation related to this tooth can erode the bone,
establishing a communication between oral cavity and maxillary sinus.
The communication might get epithelialized and establishes permanent
connection between maxillary sinus and the oral cavity.
2. Developmental defects: such as agenesis (absence), hypoplasia (small
sinus), supernumerary (extra) sinus may involve maxillary sinus.
3. Infection/Inflammation: Maxillary sinus is prone to infection and
inflammation due to various causes and this condition is referred to as
maxillary sinusitis.
4. Sinusitis and toothache: Infection from maxillary teeth may spread to
the sinus and may be one of the possi ble cause for sinusitis. Likewise
sinusitis may lead to toothache. Swelling and the concentration of
mucus fluids resulting from sinusitis can build-up of pressure inside the
sinus cavity and over the upper jaw bones. The nerves innervating the
roots of the maxillary molar teeth which are in close proximity to the
sinus may be affected by this pressure and the patient experiences a
pain much similar to toothache. This is called a sinus toothache. The
intensity of pain depends on the extend of sinus infection and swelling
along with the proximity of the root endings to the infected sinus.
Section 3

Oral and Dental Anatomy

14. Introduction to Dental Anatomy

15. Deciduous Maxillary Anterior Teeth
16. Deciduous Mandibular Anterior Teeth
17. Deciduous Maxillary Molars
18. Deciduous Mandibular Molars
19. Comparison between Deciduous and Permanent Dentition
20. Permanent Maxillary Central Incisors
21. Permanent Maxillary Lateral Incisors
22. Permanent Mandibular Central Incisors
23. Permanent Mandibular Lateral Incisors
24. Permanent Maxillary Canines
25. Permanent Mandibular Canines
26. Permanent Maxillary First Premolars
27. Permanent Maxillary Second Premolars
28. Permanent Mandibular First Premolars
29. Permanent Mandibular Second Premolars
30. Permanent Maxillary First Molars
31. Permanent Maxillary Second Molars
32. Permanent Maxillary Third Molars
33. Permanent Mandibular First Molars
34. Permanent Mandibular Second Molars
35. Permanent Mandibular Third Molars
36. Occlusion
 14
Introduction to Dental
Anatomy
Dr Rajeesh Mohammed PK and Dr Girish KL

Human dentition
Tooth and supporting structures
Types of dentition and teeth
Chronology and sequence of eruption
Tooth numbering systems
Terminologies used in dental morphology

H uman face which plays a major role in visual recognition of an

individual is constituted by many a feature. Of these, the teeth along
with a pleasing smile always leave a striking impression. The feature of
each tooth is of utmost importance for a dental student. This section aims in
describing all the features that are required to enable the student in easier
identification of normal features of the tooth.
Dental anatomy/morphology is the field of anatomy dedicated to the study
of the anatomical and morphological characteristics of the teeth. Dental
morphology can be considered to be a subdivision of oral anatomy, which
deals with the study of all the structures in and around the oral cavity. It is
important to study dental morphology as it forms the background knowledge
of all the subjects associated with dentistry. A thorough knowledge of dental
morphology is therefore of a great importance and can be considered to be
the first step in becoming a successful dentist.
Objectives of Dental Anatomy
To describe the detailed morphology of individual tooth so that the normal
features can be differentiated from abnormal.
To use of appropriate dental terminology so as to communicate with other
people in the dental field.
To describe the detailed morphology of individual tooth.
To describe the eruption sequence of the primary and permanent teeth. This
knowledge helps in determining if a child has missing or impacted teeth, or
some abnormality in growth and development.
To describe the intra-arch and inter-arch relationship of the teeth and their
effect on the health of the supporting structures.
To impart proper restorative and esthetic treatment.
As the process of evolution continued, the human beings have become
specialized to enable them to cope up with the changing situations and
different lifestyles. Those features which were of use were retained or
modified and those which were not required were discarded. Same is the case
with human dentition also, which have become modified to enable us to make
the most out of our resources, that is, to chew food more efficiently and to
extract nutrients more quickly and thoroughly. The dentition of the present
day human being, when compared to the prehistoric man has undergone a lot
of changes. These changes can be attributed to the change in lifestyle which
includes use of cooked and refined food substances. The shape of an animal’s
teeth is related to its diet. In carnivorous animals the teeth are more pointed
and sharp, while in herbivorous animals the teeth have a broad occlusal
surface. The dentitions of human beings are a combination of teeth that are
seen in case of carnivorous and herbivorous animals.
The size, shape, number, construction, location and lifespan of teeth reflect
their function and their evolution history. We retain many of the early
patterns from the ancient past. The order of eruption, the interdigitation of the
teeth, the regional specializations of teeth into classes, and the replacement of
deciduous teeth with permanent successors are among a few of those
patterns.
In humans two sets of teeth are present: primary and permanent teeth
(called diphyodont), composed of different kinds of teeth (called heterodont),
inserted into sockets and connected to the bone by a suspensory ligament
(called thecodont), teeth are arranged in opposing arches: maxillary (or upper
teeth) and mandibular (or lower teeth) and can be divided along the mid
sagittal plane, into left and right halves.
Teeth fossilize more consistently than any other part of a mammal, and
indeed many species of extinct mammals are known only from their teeth.
Teeth are unique in their own way; they show features which may be similar
or dissimilar to teeth in a person’s oral cavity, and also show characteristic
features when compared to another individuals teeth. These features along
with their positioning in the jaws makes teeth as a source of identification of
victims in case of disasters, by the forensic odontologists.

Tooth (Latin: Dentes)

The hardest calcified tissue present in the human body, which is normally
present in the oral cavity, helping in mastication (chewing), phonation
(speech), esthetics (appearance), self protection and attack (mainly in
animals). Teeth are among the most distinctive features of mammal species.
Teeth are very important part of the human body. Besides being an
important member of the digestive system, the dentition also has a vital role
to play in the facial appearance of the person. Teeth are often the focus of
attention in a human face and therefore their health and appearance is of
utmost importance for the psychological well being.

FUNCTIONS OF TEETH

Mastication
• Teeth helps to tear, grind, and chew food in the first step of
digestion, enabling salivary enzymes in the mouth to further break
down food.
Appearance
• Teeth plays an important role in a person’s appearance. They support
the tissues around the mouth and provide an appealing look to the
face.
Speech
 • Teeth along with the lips and tongue, plays an important role in
forming a clear and understandable speech. The role of teeth is of
paramount importance, as speech plays a huge part in development
of one’s personality and social acceptance.
Growth of jaws
• Teeth play a role in the growth of the jaws in some periods of life.
Self protection and attack
• Primarily in animals.

PARTS OF A TOOTH

The tooth can be divided into (Fig. 14.1):

Crown
Root
Cervix/neck

Fig. 14.1: Parts of a tooth

Crown
Portion of the tooth that is covered by enamel is called crown.
Clinical crown This term is used to describe the portion of the tooth that is
visible in the oral cavity.
Anatomic crown The entire portion of the crown that is covered by enamel is
called anatomic crown.
In case of an erupting tooth the clinical crown is shorter than anatomic
crown, as the full anatomic crown is not yet exposed to the oral cavity. In
contrast, in a tooth with gingival recession and root exposure, the clinical
crown is longer than anatomic crown, because this include full anatomic
crown and part of the root that is exposed to oral cavity.

Root
The portion of the tooth which is covered by cementum is called root and is
embedded within the alveolar bone; may be single or multiple (double or
tripleroots).

Single-rooted Permanent Teeth

All the anterior teeth
Mandibular premolars
Maxillary second premolar

Multi-rooted Permanent Teeth

Two-rooted teeth
Maxillary first premolars (one buccal and one lingual).
Mandibular molars (one mesial and one distal).

Three-rooted teeth
Maxillary molars (two buccal [1 mesiobuccal, 1 disto-buccal], and one
palatal).
Single-rooted Deciduous Teeth
All the anterior teeth

Multi-rooted Deciduous Teeth

Two-rooted teeth
Mandibular molars (one mesial and one distal)

Three-rooted teeth
Maxillary molars (two buccal [1 mesiobuccal, 1 disto-buccal], and one
palatal).
Variations frequently occur. In single-rooted teeth, roots generally present a
conical shape, narrow down towards the tip. The tip of the root is referred to
as root apex. In multi-rooted teeth the root begins at the cervix as undivided
portion and then divides at various levels.
Clinical root is the portion of the root that is embedded in the jaw bone and
covered by the gingival (gum) tissue and not exposed to the oral cavity.
Anatomical root is the entire portion of the root covered by cementum.

Cervix or Neck
The constricted portion of the tooth, where the anatomic crown and the root
meets, i.e. junction between the enamel and cementum is referred to as cervix
of the tooth.

STRUCTURE OF THE TOOTH AND

SUPPORTING STRUCTURES

The tooth is made up of three hard tissue components and one soft tissue
component (Fig. 14.2).
Hard tissue components are enamel, dentin and cementum.
Soft tissue component is pulp.
Enamel
The enamel is the outermost layer and covers the anatomic crown. It is the
hardest and most highly mineralized tissue of the body. Enamel is translucent
in nature and the color varies from light yellow to grayish white. Enamel is a
nonliving tissue and is incapable of remodeling and repair. Specialized cells
called ameloblasts forms enamel and the process of enamel formation is
called amelogenesis.

Dentin
Dentin is a hard, connective tissue which makes up the bulk of the tooth. It is
covered by enamel on the crown portion and cementum on the root portion. It
is located between enamel or cementum and the pulp chamber. Dentin is
yellowish in color. Unlike enamel, dentin is a living tissue and responds to
stimulus and the exposed dentin is often sensitive to cold, hot, air and touch.
The hardness of dentin is lesser than enamel. The process of dentin formation
is called dentinogenesis and odontoblasts are the specialized cells that form
dentin.

Cementum
The cementum covers the root portion of the tooth. It overlies the radicular
dentin and joins the enamel at the cemento-enamel junction (CEJ).
Cementum is yellowish in color and is softer in consistency than enamel.
Formation of cementum takes place by the specialized cells called
cementoblasts. Primary function of cementum is to anchor the tooth to the
bony socket by providing a media for attachment of the periodontal ligament
fibers.

Pulp
Pulp is the only soft tissue component of tooth and occupies the central
portion of the tooth. Pulp is a mesenchymal connective tissue that supports
the dentin and is surrounded by dentin on all sides except at the apical
foramen and accessory pulp canal openings, where it is in communication
with periodontal soft tissue. The pulp consists of connective tissue, nerves
and blood vessels, which enter the pulp through a small opening at the apex
called apical foramen. It consists of cells (odontoblast, fibroblast,
undifferentiated mesenchymal cells, macrophages, immunocompetent cells),
fibers and intercellular substance.

Fig. 14.2: Section of a tooth with supporting structures

Supporting Structures of Teeth

Teeth are suspended in alveolar sockets of maxilla and mandible with the
help of periodontal ligament. Periodontal ligament comprises connective
tissue with bundles of collagen fibers attached on one side to cementum of
tooth and other side to alveolar bone.

JUNCTIONS BETWEEN HARD TISSUES OF THE

TOOTH

Cemento-enamel Junction (CEJ)

The cemento-enamel junction can be described as the junction between the
enamel covering the crown and the cementum covering the root. This
junction is located at the cervix of the tooth.

Dentino-enamel Junction (DEJ)

The junction between coronal dentin and the enamel of the tooth is referred to
as dentinoenamel junction and is scalloped in nature. If this junction is weak,
the enamel is separated from the dentin easily and the enamel is chipped off
or lost.

Cemento-dentinal Junction (CDJ)

Cemento-dentinal junction is the junction between radicular dentin and the
cementum covering the root.

ARRANGEMENT OF TEETH (THE JAWS OR

ARCHES AND QUADRANTS)

The teeth are arranged in the jaw bones which follow a U-shaped arch form.
The upper jaw is the maxilla and lower jaw is mandible. Therefore, the teeth
in the maxillary arch are referred to as maxillary or upper teeth, while those
in the mandibular arch are referred to as mandibular or lower teeth.
The maxillary and mandibular arches can be divided along the mid sagittal
plane into right and left halves. Accordingly, in humans, teeth are arranged in
four quadrants, namely right maxillary, left maxillary, right mandibular, and
left mandibular.

TYPES OF DENTITION AND TEETH

In humans, varieties of teeth can be observed which can be grouped into

different classes, based on form and function. In each class there will be one
or more types of teeth exhibiting specific morphological characteristics.
Classes of teeth in permanent dentition are: Incisors, canines, premolars
and molars. In deciduous dentition incisors, canines and molars are present.
Premolars are absent in deciduous dentition.
The types of teeth in each class of deciduous and permanent dentition is as
follows:
Permanent Deciduous
Incisors a. Incisors
 • Central incisor • Central incisor
• Lateral incisor • Lateral incisor

Canine b. Canine

c. Premolars Premolars absent

• First premolar
• Second premolar

Molars c. Molars

• First molar • First molar

• Second molar • Second molar
• Third molar

DENTITION

The term dentition is used to collectively consider upper and lower teeth. In
human dentition two sets of teeth can be identified: Deciduous or primary
dentition and permanent dentition.

Deciduous Dentition
It is also known as the primary, baby, milk or lacteal dentition. There are 20
deciduous teeth in total of which 10 are present in the upper and 10 in the
lower jaw. The deciduous dentition consists of 2 incisors, 1 canine (0
premolar) and 2 molars in one quadrant, i.e. 5 in one quadrant, 10 on one side
and 20 in total (Fig. 14.3). There are no premolars in deciduous dentition.
The first deciduous tooth erupts into oral cavity by the age of six months and
the last one by two and a half to three years. The child has only deciduous
teeth till the age of six years until the first permanent tooth erupts.
Dental formula of a human deciduous dentition on left/right side
Permanent Dentition
Permanent teeth are the second set of teeth formed in humans that replace the
deciduous teeth in normal conditions. They are also called secondary
dentition. There are 32 permanent teeth in total, 16 on either arch and 8 in
each quadrant. The deciduous anteriors are replaced by the corresponding
permanent anterior tooth and the deciduous molars are replaced by the
premolars. The permanent teeth that replace the deciduous predecessors are
called as successor or succedaneous teeth. The permanent molars erupt
distal to the space occupied by the deciduous dentition. The permanent
molars are called non-successor teeth ornon-succedaneous teeth as they do
not have deciduous predecessors. The first permanent tooth usually erupts in
the mouth at around six years of age and the last one usually erupts at around
18 years of age, but this can vary greatly between individuals.
The permanent dentition consists of 2 incisors, 1 canine, 2 premolars and 3
molars in one quadrant, i.e. 8 in one quadrant, 16 on one arch and 32 in total
(Fig. 14.4).
Fig. 14.3: Deciduous dentition
 Fig. 14.4: Permanent dentition
Dental formula of a human permanent dentition on left/right side

The dentition will be in a transition period with both deciduous teeth and
permanent teeth from the age of 6 years to 12 years, until the last deciduous
tooth is exfoliated and replaced by permanent tooth. The period where there
is presence of both deciduous and permanent dentition is called mixed
dentition period and does not constitute a third stage of dentition.

Chronology of Human Dentition and Sequence of

Eruption
The word chronology means a record of events in the order of their
occurrence. Chronology of dentition denotes the time at which various events
related to milestones of tooth development such as initiation, first evidence of
calcification, crown completion, eruption and root completion occur (Table
14.1). Both deciduous and permanent teeth develop in the jaw bones and
make their appearance in the oral cavity at different times. Root formation is
completed only approximately two years after the tooth erupts into oral
cavity. The order in which teeth appear in the oral cavity is described as
sequence of eruption. The knowledge of chronology and sequence of eruption
help a clinician to assess the dental age and detect the defect in
developmental process.

Table 14.1: Chronology of the human dentition

Sequence of Eruption of Deciduous Teeth
First deciduous tooth that appear in oral cavity is central incisor followed by
laterals, first molars, canines and then the second molars. Mandibular teeth
erupt slightly earlier than maxillary teeth. Both right and left teeth erupt
nearly at the same time.

Sequence of Eruption of Permanent Teeth

First permanent tooth that erupt into the oral cavity is first molars at the age
of 6 years followed by mandibular central and lateral incisors, maxillary
central incisors, maxillary lateral incisors, mandibular canine, maxillary and
mandibular first premolars, maxillary and mandibular second premolars,
maxillary canine, maxillary and mandibular second molars and maxillary and
mandibular third molars. Third molars erupt only by 17 to 21 years.

POSITION OF TEETH WITH RESPECT TO THE

MIDLINE

Anterior Teeth
The term anterior teeth is used to describe those teeth which are closer to the
midline; consists of 12 teeth in the front, facing the lips, 6 in each arch and
includes 4 incisors and 2 canines (Figs 14.3 and 14.4).

Posterior Teeth
These are teeth, which are further away from the midline. In permanent
dentition, the posterior teeth consist of 10 teeth behind the anterior teeth,
facing the cheek, which includes 2 premolars and 3 molars in one quadrant;
10 teeth on one side and 20 posterior teeth in total. In deciduous dentition, the
posterior teeth consist of 8 teeth behind the anterior teeth, facing the cheek
and include 2 molars in one quadrant; 4 teeth in one side and 8 in total (Figs
14.3 and 14.4).

SURFACES OF TEETH (Fig. 14.5)

Facial Surface
This term is used to describe the surface of a tooth that “faced” toward the
lips or cheeks. When there is a requirement to be more specific, terms like
labial and buccal are used.

Labial Surface
The surface of the tooth that is facing the lip. This term is used while
describing anterior teeth.

Buccal Surface
The surface of the tooth that is facing the inner cheek. This term is used while
describing posterior teeth.

Lingual and Palatal Surfaces

Linsual Surface
The surface of the tooth that is closest to the tongue.

Palatal Surface
The surface of the tooth that is closest to the palate.
Although the term lingual is used generally to describe the inner surface of
both maxillary and mandibular teeth facing the oral cavity proper, the term
palatal is more appropriate in case of maxillary teeth because it is closer to
the palate. The use of the term lingual may be restricted to the mandibular
teeth.

Proximal Surface
This term is used to describe sides of the tooth or the surfaces that lie next to
an adjacent tooth. All teeth have two proximal surfaces, the mesial and the
distal.

Mesial Surface
Mesial surface is the surface of the tooth that is oriented toward or closer to
the midline of the dental arch.

Distal Surface
Distal surface is the surface of the tooth that is oriented away from the
midline of the dental arch.

Fig. 14.5: Surfaces of teeth

Except for the maxillary and mandibular central incisors, the mesial
surface of the tooth contacts the distal surface of the adjacent tooth. The
mesial surface of central incisor contacts the mesial surface of the adjacent
central incisor. The distal surface of third molars does not contact any other
tooth.

Occlusal and Incisal Surfaces

This term is used to refer to the cutting or chewing surface of the tooth.

Occlusal Surface
Occlusal surface is the broad chewing surface of posterior teeth.

Incisal Surface
Incisal surface is the narrow cutting surface of anterior teeth. Since the incisal
or cutting surface of a newly erupted anterior tooth is narrow and resemble a
ridge the term incisal ridge is preferred. As the teeth undergo physiological
wearing, the ridge becomes flat and form a sharp angle with the labial surface
and is then referred to as incisal edge.

TOOTH NUMBERING SYSTEMS

Dental notations are the name given for the systems that are used to identify a
tooth in relation to one another, to the midline and to the arches and helps in
the documentation of these data. Tooth numbering provides the dentists with
an essential shortcut in clinical record-keeping. Different dental notation
systems are used by dentists worldwide for associating information to a
specific tooth. Since tooth numbering systems are used like shortcuts, they
are easier and save time. It allows everyone in the oral health team to
efficiently share information amongst them and further provides those outside
the team with clear and precise information about their work. The three most
common systems are the FDI World Dental Federation notation, Universal
numbering system, and Zsigmondy Palmer notation. Each of these systems
has their own merits and demerits and no single system is superior to the
other. Orientation of the chart in all the systems is traditionally “patient’s
view”, i.e. patient’s right corresponds to notation-chart right. The
designations “left” and “right” on the chart correspond to the patient’s left
and right, respectively.
Requirements of ideal tooth numbering system
Simple to understand and teach
Easy to pronounce in conversation and dictation
Readily communicable in print
Easy to translate into computer input
Easily adaptable to standard charts used in general practice

Zsigmondy Palmer Notation/Grid System

The Palmer notation is the commonly used system by dentists to associate
information to a specific tooth. It was originally termed as “Zsigmondy
system” after the Austrian dentist Adolf Zsigmondy who developed the idea,
using a Zsigmondy cross to record quadrants of tooth positions. This was
modified later by Palmer and the system came to be known as Zsigmondy
Palmer notation. In this system, the dentition is divided into quadrants and
symbols (brackets) are used to designate, in which quadrant the tooth is
found. The symbol ″⌋″ represents upper right quadrant, the symbol ″⌊″
represents upper left quadrant, the symbol ″⌈″ represents lower left quadrant
and the symbol ″⌉″ represents lower right quadrant. A number is placed
within these brackets, which denotes the position of the tooth from the
midline. Permanent teeth are numbered 1 to 8, with the lowest digit assigned
to the teeth closer to the midline (1 is permanent central incisor and 8 is third
molar). The deciduous teeth are indicated by a letter A to E, with the starting
letter ′A′ assigned to the teeth closer to the midline (′A′ is deciduous central
incisor and ′E′ is deciduous second molar). Hence, the left and right maxillary
central incisor would have the same number, ′1′, but the right one would have
the symbol, ″⌋″, along with it, while the left one would have, ″⌊″. Even
though the Palmer notation is used commonly, it has the drawback of not
being able to record them using the conventional keyboard input and word
processing software.
Palmer notation is simple, easy to use and most often used by clinicians.
Since the quadrant symbols are same for deciduous and permanent dentition,
it becomes easy for use with basic understanding about different quadrants.
However, the major drawback of this system is inability to record them using
the conventional keyboard input and word processing software. Furthermore,
using this system in verbal communication is not possible.
Deciduous dentition—Palmer system

Permanent dentition—Palmer system

Universal Numbering System
The universal numbering was first suggested by Parreidt in 1882 and uses
numbers 1–32 for permanent teeth and uppercase letters A through T for
primary teeth. The numbering starts from the upper right third molar and ends
with the lower right third molar in a clockwise direction. Tooth number 1 is
the patient’s upper right third molar and the numbering continues toward the
front and across to the third molar tooth back on the upper left side (number
16). The tooth numbering continues by descending to the lower left third
molar (number 17) and the numbering continues toward the front and across
to the right third molar tooth (number 32). All teeth should be numbered,
including those teeth that have been removed for any reason or have not
erupted yet (e.g. wisdom teeth).
In this system each tooth is assigned a unique number or alphabet,
allowing easier use on keyboards and word processing software. Use of this
system in verbal communication is possible. Nevertheless, memorizing the
assigned number becomes difficult without adequate practise.
Deciduous dentition—universal system

Permanent dentition—universal system

FDI World Dental Federation Notation
The FDI (Federation Dentaire Internationale) World Dental Federation
developed in 1971, a system to identify teeth with a number. This system is
called the FDI Two-Digit Notation, also known as the ISO-3950 notation.
Each tooth, deciduous or permanent is given a two digit number. The first
digit indicates dentition, arch and quadrant. In permanent, the dentition is
divided into quadrants which are numbered from 1 to 4, in a clockwise
direction, starting from the upper right quadrant. The digit 1 is upper right
quadrant, 2 is upper left, 3 is lower left and 4 is lower right quadrant.
Similarly, the deciduous dentition is also divided into quadrants which are
numbered from 5 to 8, in a clockwise direction, starting from the upper right
quadrant. The digit 5 is upper right quadrant, 6 is upper left, 7 is lower left
and 8 is lower right quadrant.
The second digit indicates the position of the tooth relative to the midline
(similar to Palmer notation). For permanent dentition, a number is assigned to
a tooth from 1 to 8, starting from the central incisor (number 1) and moving
backwards up to the third molar (number 8) in each quadrant. For deciduous
dentition, a number is assigned to a tooth from 1 to 5, starting from the
central incisor (number 1) and moving backwards up to the second molar
(number 5) in each quadrant. The combination of these two numbers
(quadrant code number and tooth code number which are pronounced
separately) is the Two-Digit World Dental Federation Notation.
Deciduous dentition—FDI system
 Permanent dentition—FDI system

FDI system is internationally accepted and followed in many countries,

ideal system for verbal communication and visual sense. Furthermore
suitable for computer processing.

TRAIT CATEGORIES

The human dentition is peculiar in that, it shows features which are similar or
dissimilar to the adjacent and opposing tooth. Features that help to
differentiate the dentition and teeth into different groups are called trait
categories, which include:

Set Trait
Teeth in primary and permanent dentition show some common characteristics
so that they can be categorized as deciduous or permanent teeth. These
features which help in differentiating permanent teeth from deciduous teeth
are referred to as set trait.
Example: Deciduous teeth are much smaller compared to permanent
teeth(with few exceptions).

Arch Trait
Common features observed in teeth of maxillary or mandibular arch that help
in differentiating the maxillary (upper) teeth from the mandibular (lower)
teeth are referred to as arch trait.
Example: From the proximal aspect, crowns of all mandibular teeth show a
lingual inclination.
Class Trait
Features which help to categorize the teeth, depending on the prominent
features into various classes like incisors, canines, premolars and molars.
Example: Incisors have crowns compressed labiolingually for efficient
cutting; canines have single pointed cusps for piercing food; premolars have
two or three cusps for shearing and grinding; molars have 3–5 somewhat
flattened cusps for grinding.

Type Trait
Features that helps in differentiating different teeth within one class (incisors,
canines, premolars and molars) into central and lateral incisors, first and
second premolar, first, second and third molars.
Example: Maxillary central incisor has a straight incisal edge while lateral
incisor has a curved incisal edge.
The term permanent maxillary central incisor denotes all the four trait
categories, i.e. Permanent: Set trait Maxillary: Arch trait Incisor: Class trait
Central: Type trait

DESCRIPTIVE DIVISION OF THE TOOTH

1. Division of Crown into Thirds

The facial or lingual surface of the crown portion of the tooth can be divided
into three portions in cervico-incisal/cervico-occlusal direction, by arbitrary
horizontal lines into (Fig. 14.6a):
Cervical third
Middle third
Incisal/occlusal third
The facial or lingual surface of the crown portion of the tooth can also be
divided into three portions in a mesio-distal direction by arbitrary vertical
lines into (Fig. 14.6b):
Mesial third
Middle third
Distal third
The mesial or distal surface of the crown portion of the tooth can also be
divided in a cervico-occlusal/incisal direction into three parts by arbitrary
horizontal lines into (Fig. 14.6c):
Cervical third
Middle third
Incisal/occlusal third
The mesial or distal surface of the crown portion of the tooth can also be
divided in facio-lingual direction into three parts by arbitrary vertical lines
into (Fig. 14.6d):
Facial/labial third
Middle third
Lingual third

2. Division of Root into Thirds

The root can be divided from the facial or lingual surface and the mesial or
distal surface in a cervico-apical direction into three parts by arbitrary
horizontal lines into (Figs 14.6a and c):
Cervical third
Middle third
Apical third
The root portion from the facial or lingual surface can be divided in a
mesiodistal direction into three parts by arbitrary vertical lines into (Fig.
14.7b):
Mesial third
Middle third
Distal third
The mesial or distal surface of the root portion can be divided in facio-lingual
direction into three parts by arbitrary vertical lines into (Fig. 14.6d):
Facial third
Middle third
Lingual third

Figs 14.6a to d: Division of teeth in thirds

 Fig. 14.7: Division of the crown cervico-occlusally and root cervico-apically

LINE ANGLES AND POINT ANGLES

Line angle is the junction between two surfaces that meet each other. The
name of the line angle is based on the two surfaces which meet to form that
line angle. Accordingly, posterior teeth have eight line angles, namely mesio-
buccal, disto-buccal, mesio-lingual, disto-lingual, mesio-occlusal, disto-
occlusal, bucco-occlusal and linguo-occlusal. Mesioincisal and distoincisal
line angles are not considered in anterior teeth and therefore anterior teeth
have only six line angles; namely mesio-labial, disto-labial, mesio-lingual,
disto-lingual, labio-incisal and linguo-incisal.
Point angles are the point where three surfaces meet and are named by
joining the name of those three surfaces which meet. Both anterior and
posterior teeth have four point angles each. The point angles of anterior teeth
are mesio-labio-incisal, mesio-linguo-incisal, disto-labio-incisal and disto-
linguo-incisal. The point angles of posterior teeth are mesio-bucco-occlusal,
mesio-linguo-occlusal, disto-bucco-occlusal and disto-linguo-occlusal.

DESCRIPTIVE TERMS USED IN TOOTH

MORPHOLOGY

Teeth may show various anatomic landmarks in the form of elevations or

depressions. These elevations and depressions help the tooth to interdigitate
with the opposing tooth and helps them in efficient functioning in mastication
and also to withstand both the functional and parafunctional occlusal loads
without damage. While explaining the morphology of teeth, different
terminologies are used to describe these landmarks, the knowledge of which
is very essential for understanding the subject.

Terminologies used While Describing the Crown

A cusp is a point, peak, rounded elevation or mound on the crown portion of
a tooth making up a divisional part of the occlusal surface. Each cusp has two
inclines or slopes; the mesial cusp slope and the distal cusp slope which meet
at different angles. All the cusps have a basic shape of gothic pyramid,
having four ridges. The ridges that is associated with a cusp are: Mesial cusp
ridge, distal cusp ridge, buccal cusp ridge and triangular ridge (in canines
lingual ridge is seen instead of triangular ridge). They are seen on the
occlusal surface of a cuspid, bicuspid, or molar tooth. Each cusp is
representative of a center of calcification (a lobe) in the developing tooth.
The number of cusps varies from each class and type of tooth.
One cusp (cuspid)
– Deciduous and permanent canines
Two cusps (bicuspid)
– Maxillary 1st and 2nd premolars
– Mandibular 1st premolars
Three cusps
– Mandibular 2nd premolars (may be even 2 cusps)
Four cusps
– Permanent maxillary 2nd molars
– Permanent mandibular 2nd molars
– Deciduous maxillary 1st molar
– Deciduous mandibular 1st molar
Five cusps
– Permanent maxillary 1st molars (if cusp of Carabelli present)
 – Permanent mandibular 1st molars
– Deciduous maxillary 2nd molar (if cusp of Carabelli present)
– Deciduous mandibular 2nd molar
The cusps can be a functional cusp or nonfunctional cusp; in maxillary arch,
the palatal cusp is the functional cusp and in mandibular arch, the buccal cusp
is the functional cusp.
A tubercle is a smaller elevation on some portion of the crown produced by
an extra formation of enamel. They are variable in size and shape, but usually
smaller than cusps and are considered to be deviations from the typical form.
These occur on the marginal ridges of posterior teeth or on the cingulum of
anterior teeth, e.g. cusp/tubercle of Carabelli.
A cingulum is a bulge or elevation on the lingual surface of incisors or
canines. It is the lingual lobe of an anterior tooth and makes up the bulk of
the cervical third of the lingual surface. The term is derived from the Latin
word for girdle because its convexity mesio-distally resembles a girdle
encircling the lingual surface at the cervical third. The cingulum forms the
upper border or boundary of the lingual fossa of the incisors.
A ridge is any linear elevation present on the surface of the tooth and is
usually named according to its location (e.g. buccal ridge, incisal ridge,
marginal ridge).
1. Marginal ridges are those rounded borders of the enamel that form
the mesial and distal margins of the occlusal surfaces of premolars
and molars and the mesial and distal margins of the lingual surfaces
of the incisors and canines. The marginal ridges of anterior teeth run
vertically in a cervico-incisal direction and the marginal ridges of
posterior teeth run horizontally in a bucco-lingual direction. In
anterior teeth the marginal ridges on either side form the boundary of
the lingual surface and in posterior teeth they form the boundary of
the occlusal surface.
2. Triangular ridges are the ridges that run from the tips of the cusps
of premolars and molars toward the center of the occlusal surfaces.
They are so named because the slopes of each side of the ridge are
inclined to resemble two sides of a triangle. They are named after the
cusps, to which they belong, e.g. the triangular ridge of the buccal
 cusp of the maxillary first premolar.
3. Transverse ridges are formed by two triangular ridges (buccal and
lingual triangular ridge) that join transversely across the occlusal
surface of the posterior teeth.
4. The oblique ridge is a ridge that runs obliquely on the occlusal
surfaces of maxillary molars. It is formed by the union of the
triangular ridge of the disto-buccal cusp and the distal ridge of the
mesio-palatal cusp.
5. Labial ridge is a ridge that runs vertically in a cervico-incisal
direction on the labial surface of canines. It starts from the cusp tip
and extends to the cervical region of the tooth. Labial ridge is more
prominent in maxillary canine than mandibular canine.
6. Lingual ridge is a ridge that runs vertically in a cervico-incisal
direction on the lingual surface of canines. It starts from the cusp tip
and extends to the cingulum dividing the lingual fossa into two.
Lingual ridge is more prominent in maxillary canine than
mandibular canine.
7. Linguo-incisal ridge is a ridge that runs horizontally in a mesio-
distal direction on the incisal one-third of the lingual surface of the
crown of the upper incisors. It forms the lower border of the lingual
fossa on the incisors.
8. Buccal ridge is a ridge that runs vertically in a cervico-occlusal
direction on the buccal surface of premolars. It starts from the cusp
tip and extends to the cervical area of the tooth. It is more prominent
on the first premolars than the second premolars.
9. Cervical ridge is a ridge that runs horizontally in a mesio-distal
direction on the cervical one-third of the buccal surface of the
crown. Cervical ridge is prominent in all deciduous teeth and on the
permanent molars.
10. Cusp ridges are the mesial and distal slopes or inclined surfaces of
the cusps which meet at different angles to form cusps of varying
sharpness.

Fossa
Fossa is an irregular depression or concavity found on the lingual surface of
anterior teeth or occlusal surface of posterior tooth.
Fossae can be lingual fossa, central fossa, distal fossa and triangular
fossa.
A lingual fossa is found on the lingual surface of anterior teeth, bounded by
marginal ridges, cingulum and linguoincisal ridge. The lingual fossa in
canines are divided into two by lingual ridge.
A central fossa is a major fossa found on the occlusal surface of molars
which are formed by the converging ridges, terminating at a central point in
the bottom of a depression, where there is a junction of grooves.
Distal fossa is another major fossa seen on the occlusal aspect of maxillary
molars which is located distal to the oblique ridge
Triangular fossae are found in molars and premolars on the occlusal surfaces
just inside the marginal ridges. There are two triangular fossae including
mesial triangular fossa which is seen adjacent to mesial marginal ridge and
distal triangular fossa which is seen adjacent to distal marginal ridge.
A sulcus is a broad linear depression or valley on the surface of a posterior
teeth. Sulcus is the area between ridges and cusps, the inclines of which meet
at an angle to form a groove called developmental groove.
A groove is a linear depression or a line present at the deepest part of the
sulcus. The grooves can be developmental grooves or supplemental grooves.
Developmental grooves are sharply defined, narrow and linear depression
seen, separating the major portions of a tooth developing from different
lobes. All posterior teeth have a distinct central developmental groove which
divides the occlusal aspect into two parts. Additional developmental grooves
are found extending in buccal or lingual direction separating the cusps from
adjacent ones which may extend onto the buccal and lingual surfaces as
buccal and lingual grooves.
A supplemental groove is a small irregularly placed shallow groove which is
less distinct than the developmental groove. Supplemental grooves are
supplemental to a developmental groove and are not found between
developmental portions of a tooth.
Pits are small pinpoint depressions located at the junction of developmental
grooves or at terminals of the grooves. Pits are usually found at the deepest
part of fossae, and depending on the location they are named as central pit,
mesial or distal pit, lingual or palatal pit and buccal pit. Pits can be a site for
initiation of caries.
Fissure is a cleft or ditch formed at the bottom of a developmental groove.
This also can be a site for initiation of caries.
A lobe is one of the primary sections of formation in the development of the
crown. Cusps and mamelons are representative of lobes.
All the deciduous incisors develop from one lobe while the second
deciduous molars develop from five lobes.
All the permanent anterior teeth develop from four lobes: Three labially
(mesial, labial and distal lobes) and one lingually (lingual lobe). The lingual
lobe is represented by cingulum. Mamelons are the three rounded
protuberances found on the incisal ridges of newly erupted incisor teeth (Fig.
14.8) representing the three lobes from which the labial portion of the tooth
develop.
Premolars also develop from four lobes, namely mesial, buccal, distal and
lingual lobe. Mandibular second premolar which is three cusp type develop
from five lobes: Three for buccal portion and two for lingual portion. In this
tooth, the lobes are named as mesial, buccal, distal, mesio-lingual and disto-
lingual lobes.

Fig. 14.8: Mamelons

The number of lobes from which molar develop vary depending on the
number of cusps and are named same as the cusps. Maxillary molars develop
from two buccal and two lingual lobes while the mandibular first molar
develops from three buccal lobes and two lingual lobes. The ‘cusp of
Carabelli’, an accessory cusp on the maxillary first molar, when present may
be a part of the large mesio-palatal lobe or may form from a fifth lobe.
Terminologies used While Describing the Root (Fig.
14.9)
Root trunk: This term is used to describe the undivided cervical portion of
the root of multirooted teeth.
Furcation is the division of the root of the multirooted teeth. When the root
is dividing into two, it is referred to as bifurcation and when three,
trifurcation.
Apical and accessory foramen are small openings found at the apical region
of root through which the connective tissue of pulp communicate with
surrounding periodontal soft tissue.

FUNCTIONAL OR FUNDAMENTAL
CURVATURES OF TEETH

All the teeth show a form that is directly related to the function it has to
perform. The fundamental curvatures of teeth are proximal contours creating
contact points and interproximal spaces, facial and lingual contours and
curvature of cervical line.

Fig. 14.9: Parts of the root

Contact Point or Contact Areas

Contact areas are the places on the proximal surfaces of tooth crowns where a
tooth touches the adjacent tooth in the same arch, when the teeth are in proper
alignment. The proximal contact areas are located on the mesial and distal
surface of each tooth at the widest portion and at the greatest curvature. The
distal contact area of one tooth touches the mesial contact area of the tooth
posterior to it, with the exception of central incisors, where the mesial contact
area of one central touches the mesial contact area of the other, and in third
molars distal surface do not contact with any tooth, as the third molars on
both the arches does not have tooth distal to it. Even though there are 32
teeth, there are only 60 contacting proximal surfaces. The contact area may
be lacking or modified in some instances like in diastema, poor dental
position, drifting of teeth, etc.
While describing proximal contact, two terms can be used; contact point
and contact area. In newly erupted teeth, the contact is limited in size and is
circular or slightly oval in form and is called contact point. The teeth wear by
rubbing against one another as they move slightly in their sockets during
mastication and the contact point becomes more extensive and is denoted as
the contact area.

Location of the Contact Areas

Contact Areas from Facial View
Anterior teeth (Fig. 14.10a)
– Contact areas are closer to the incisal third of the teeth
– Except distal surface of canine—in middle third
Posterior teeth (Fig. 14.10b)
Contact areas are located nearer to the middle third of the teeth. The more
posterior the tooth, the more cervical is the location of its contact area.

Contact Areas from Occlusal or Incisal View

Anterior teeth
Contact areas are located approximately in the center of proximal surface in a
facio-lingual direction.
Posterior teeth (Fig. 14.10c)
Contact areas are located more facially to the center of proximal surface in a
facio-lingual direction.

Importance of Proper Interproximal Contact

Proper contact area helps to prevent food wedging during mastication and
allows transmission of the masticatory forces in a sagittal plane. It also helps
to stabilize the dental arch and to maintain the arch length. The shape of the
interdental gingival contour is determined by interproximal contact area.
Open contacts can lead to food impaction, followed by gingival
inflammation, periodontal complication, etc.

Facial and Lingual Contours

Contours are curvatures that are seen on the cervical or middle third on the
facial or lingual aspect of all the teeth in dental arch. The facial and lingual
surface posses some degree of convexity that help in protection and
stimulation of the supporting tissues during mastication. Normal tooth
contours deflect food away so that the passing food only stimulates (by gentle
massage) rather than irritates the investing tissues. Convexities are generally
located at the cervical third of the crown on the facial surface of all teeth and
the lingual surface of the incisors and canines. On lingual surface of posterior
teeth, the height of contour is located in the middle third of the crown. In
young children, most curvatures, buccal and lingual curvatures lie beneath
the gingiva and as the teeth erupt, the curvature becomes more apparent
clinically. In normal adults whose tooth eruption has been completed, the
gingival crest is cervical to the facial and lingual contours of all teeth.

Fig. 14.10a: Contact area of anterior teeth

Fig. 14.10b: Contact area of posterior teeth—facial view

 Fig. 14.10c: Contact area of posterior teeth—occlusal view

Functions
Buccal and lingual contours can deflect the food material away from gingival
margin during mastication and therefore helps in maintenance of health of
periodontal tissues. Cervical contours also serve to decrease the tooth bulk
from its gingival third to incisal third.
Height of contour or crest of curvature is the greatest bulge of the curved
outlines of a tooth (Fig. 14.11). As a general rule, height of contour of facial
and lingual surfaces of both anterior and posterior teeth are in the cervical
third, except lingual crest of curvature of posterior teeth which is near the
middle third. The crest of curvature of proximal surfaces represent the contact
areas.

Interproximal Spaces
Triangular or V-shaped spaces seen between adjacent teeth, cervical to their
contact is called interproximal spaces. The sides of the triangle are formed by
the proximal surfaces of adjacent teeth, the base is formed by the alveolar
bone and the contact area of the two teeth forms the apex of the triangle.
These spaces are normally filled with gingival tissues called papillary gingiva
or interdental papilla. When gingival recession occurs between the teeth, the
interdental papilla and bone no longer fill the entire interproximal space, and
creates a void which exists cervical to the contact and is called a cervical
embrasure or gingival embrasure.

Embrasures
Embrasures (spillways) are triangular or V-shaped spaces seen on facial,
lingual or occlusal to the contact areas (Figs 14.10b and c). They allow the
passage of food around the teeth, so that food is not forced into the contact
area between the teeth. These embrasures or spillways are named for their
locations in relation to the contact area and are facial (buccal or labial),
lingual, incisal or occlusal. The gingival or cervical embrasure is generally
termed as interproximal space. The term gingival embrasure is used if the
interdental gingiva is not filling the space as in case of gingival recession.

Fig. 14.11: Crest of contour

Facial embrasures are spaces that widen out facially from the area of
contact. Lingual embrasures are spaces that widen out lingually from the area
of contact. Incisal or occlusal embrasures are spaces that widen out above the
contact areas in an incisal or occlusal direction and are bounded by the
marginal ridges. The facial, lingual and incisal or occlusal embrasures are
continuous with each other.

Functions of Embrasures
Makes a spillway and allow food to be forced away from contact areas and
thus prevent food from being packed between them.
Embrasures help to dissipate and reduce occlusal forces.
They permit a slight amount of stimulation to the gingiva by fractional
massage of food while at the same time protecting the gingiva from undue
trauma.

Curvature of Cervical Line

The cervical line of a tooth represents the cemento-enamel junction. When
the teeth are in its normal alignment, the epithelial attachment, i.e. the
attachment between the teeth and gingiva follows the same contour as that of
cervical line. Since the height of gingival tissue of interproximal region
directly depends on epithelial attachment, the curvature of cervical line has a
functional significance.
As a rule, the cervical line on the labial and lingual aspect of a tooth curve
towards the root and on mesial and distal aspect towards the crown.
Generally cervical line on the mesial aspect shows more curvature than the
distal aspect. The degree of curvature of cervical line depends on location of
contact area and bucco-lingual or labio-lingual diameter of the crown.
Anterior teeth exhibit greater curvature compared to posterior teeth. Highest
curvature of cervical line is observed on the mesial aspect of maxillary and
mandibular central incisors (about 3.5 mm). In posterior teeth the extent of
curvature is only 1 mm or less on mesial aspect and very less or no curvature
on distal aspect.
 15
Deciduous Maxillary Anterior
Teeth

Introduction
Importance of deciduous teeth
Description of morphology of maxillary central incisor, lateral incisor and
canine

P rimary dentition is seen in children up to the age of six years. The first
primary tooth appears in the oral cavity at the age of six months and the
dentition is completed by two and a half years. These teeth are called
deciduous teeth because they fall off to give space for permanent successors.
The term deciduous is derived from a Latin word which means ‘falls off’.
Other names used to describe these teeth are ‘milk teeth’, ‘temporary teeth’
or ‘baby teeth’.
The deciduous teeth are twenty in number which include two incisors, one
canine and two molars in each quadrant. There are no premolars in primary
dentition. The primary molars are replaced by premolars of permanent
dentition.

Importance of Primary Teeth

Primary teeth are important for the physical and psychological development
of a child. They are necessary for efficient mastication of food, development
of normal speech, esthetics, etc.
Badly decayed or missing anterior teeth can cause psychological trauma to
the child. Primary teeth are also essential to maintain space and arch
continuity for the eruption of permanent teeth. Premature loss of these teeth
may lead to malocclusion in permanent dentition. Since the periapical
infection of primary teeth can cause developmental defects like enamel
hypoplasia of permanent successors, avoidance of infection is also important.

PRIMARY MAXILLARY CENTRAL INCISOR

The deciduous maxillary central incisors are two in number, one on each side
of the midline.

Crown
Crown is mesio-distally wider than cervico-incisally, i.e. width of crown is
more than the length. The opposite holds true for the corresponding
permanent tooth. Mesial outline is relatively straight while distal outline is
convex. Incisal edge is straight with sharp mesio-incisal angle and rounded
disto-incisal angle. Cervical line is curved towards the root. Labial surface is
slightly convex and smooth without any developemental grooves. Cervical
third of labial surface shows a prominent cervical ridge running in a mesio-
distal direction.
From the lingual aspect, a significant lingual convergence of the crown can
be appreciated. Cingulum and marginal ridges are well developed, making
lingual fossa more distinct. Cingulum may extend beyond the cervical one-
third towards the incisal region resulting in partial division of lingual fossa.
Mesial and distal aspects of deciduous maxillary central incisors show
marked convexity. Cervical one-third of crown is wider bucco-lingually
because of well developed cingulum and a prominent cervical ridge on buccal
aspect. Curvature of cervical line is greater on the mesial aspect than distal.
A wider mesio-distal dimension of crown than bucco-lingual can be well
appreciated from incisal aspect. Incisal edge is straight and is centered over
the bulk of crown.

Root
Root is cone shaped with evenly tapered sides till the blunt apex. Root is
longer in proportion to the crown length. Because of lingual tapering, in
cross-section root is triangular in shape with base at the labial aspect and tip
at the lingual aspect. A prominent developmental groove may be present on
the mesial surface of root.

PRIMARY MAXILLARY LATERAL INCISOR

Maxillary lateral incisor is located distal to the central incisor, one on each
side of the maxillary arch.
Morphology of maxillary lateral incisor is similar to that of central incisor.
The differences are:
Crown is wider cervico-incisally than mesio-distally, i.e. crown length is
more than its width.
Crown is smaller in all dimensions and less symmetrical.
Disto-incisal angle is more rounded
Root is much longer in proportion to the crown length.

PRIMARY MAXILLARY CANINE

It is the third tooth from the midline in the maxillary arch. It is located distal
to the lateral incisor on either side. It is also called cuspid.

Crown
Primary maxillary canine is larger than central and lateral incisors. Crown
length is almost equal to the width and is constricted at the cervix. Mesial and
distal outlines are convex with both mesial and distal contact areas located
nearly at the same level, i.e. at middle of middle one-third. Primary maxillary
canine has a well developed sharp cusp. The mesial cusp slope is longer
than the distal cusp slope. Labial surface shows a labial ridge extending
vertically from the cervical region to the cusp tip.
Lingual aspect of this tooth shows a bulky cingulum and prominent
marginal ridges and lingual fossa. A distinct lingual ridge is also present
which divides lingual fossa into mesio-lingual and disto-lingual fossae.
From the proximal aspect a greater labio-lingual measurement especially at
cervical one-third can be appreciated which is due to prominent labial
cervical ridge.
Cervical line curves incisally to a greater degree on mesial aspect than on
the distal.
When observed from incisal aspect, crown is wider mesio-distally than
labio-lingually. Cingulum is centered over the crown.

Root
Root is long, slender and tapering. Length of root is twice as that of crown.

Measurement table of deciduous maxillary central incisor

Measurement table of deciduous maxillary lateral incisor

Measurement table of deciduous maxillary canine

Deciduous maxillary central incisor

Deciduous maxillary lateral incisor
Deciduous maxillary canine
 16
Deciduous Mandibular
Anterior Teeth

Description of morphology of mandibular central incisor, lateral incisor and

canine.

DECIDUOUS MANDIBULAR CENTRAL

INCISORS

The deciduous mandibular central incisors are two in number, one on each
side of the midline of mandible.

Crown
Deciduous mandibular central incisors have considerable morphological
resemblance to permanent counterparts but are significantly smaller in size.
These teeth are the smallest incisors in the mouth.
From labial aspect this tooth is smooth and relatively flat except for the
cervical 1/3rd. The mesial and distal surfaces tapers evenly to a narrow cervix
and contact areas mesially and distally are located at incisal 1/3rd. The incisal
edge is straight and is at right angles to the long axis of tooth. Both mesio-
incisal and disto-incisal angles are sharp.
Crown is narrower lingually and cingulum, marginal ridges and lingual
fossae are less prominent. When a deciduous mandibular central incisor is
examined from proximal aspect, cervical convexity of labial and lingual
outlines appears to be prominent. Incisal edge is centered over the crown,
from the proximal aspect. Distally the curvature of cervical line is lesser
when compared to mesial side.

Root
Root is twice as long as crown and it tapers to a sharp tip. There may be
developmental depression on the distal aspect of root.

DECIDUOUS MANDIBULAR LATERAL

INCISORS

Mandibular lateral incisors are two in number and are located distal to the
central incisors, one on each side of the mandibular arch. In general this tooth
resembles a deciduous mandibular central incisor. Differences are:
Larger than centrals in all dimensions except labio-lingual dimension which
is same in central and lateral incisors.
Incisal edge is slopping distally with distal contact area located at a lower
level.
Mesio-incisal angle is sharp while disto-incisal angle is rounded.
Cingulum, marginal ridges and lingual fossa are more prominent.

DECIDUOUS MANDIBULAR CANINE

It is the third tooth from the midline in the mandibular arch. It is located
distal to the lateral incisor on either side. It is also called cuspid. The
mandibular primary canine has the same general form as the maxillary
canine. Differences observed are:
Crown is longer and narrower mesio-distally but thicker labio-lingually, but
to a lesser extent when compared to maxillary canine.
Cusp tip is pointed with a longer distal cusp slope than mesial slope.
Labial ridge is less prominent.
Labio-lingual measurement is not as great as maxillary canine because of less
prominent cervical ridge and cingulum.
On lingual aspect the cingulum, marginal ridges, lingual ridge and lingual
fossae are less prominent.

Root
Root is shorter and tapers to a pointed tip.

Measurement table of deciduous mandibular central incisor

Measurement table of deciduous mandibular lateral incisor

Measurement table of deciduous mandibular canine

Deciduous mandibular central incisor

Deciduous mandibular lateral incisor
Deciduous mandibular canine
 17
Deciduous Maxillary Molars

Description of morphology of deciduous maxillary first molar and

deciduous maxillary second molar.

DECIDUOUS MAXILLARY MOLARS

The deciduous maxillary molars are four in number, two on either side of the
arch, which includes the first and second molars.

DECIDUOUS MAXILLARY FIRST MOLAR

Deciduous maxillary first molar is quite different from permanent maxillary

first molars. This tooth more closely resembles the maxillary first premolar,
which is its succedaneous tooth.

BUCCAL ASPECT

Crown
Shape of Buccal Aspect
Crown appears wider mesio-distally than cervico-incisally, i.e. width of
crown is more than the length. Mesial half of the tooth is longer than distal
half.
The crown tapers considerably towards the cervix with the cervical
measurement 2 mm less than that at contact area. This gives a narrower
appearance to the cervical portion of crown and root.

Outlines of Buccal Aspect

Mesial outline is nearly straight with contact area in the occlusal 1/3rd.
The distal outline is more convex and distal contact area is located at the
middle 1/3rd.
Occlusal outline is represented by cusps and cusp slopes and is scalloped
without definite cusp form. The scalloped outline divides the large mesio-
buccal cusp from indistinct disto-buccal cusp.
Cervical outline is slightly convex towards the root.

Buccal Surface
Buccal surface is smooth with a little evidence of developmental grooves. A
poorly developed buccal developmental groove extending onto buccal
surface is located distal to the center, separating the larger mesio-buccal cusp
from disto-buccal cusp. A prominent buccal ridge is present, running from
the tip of mesio-buccal cusp to a cervical direction. The cervical ridge is
distinct on the buccal surface running in a mesio-distal direction and is
significantly prominent on the mesial half.

Root
Deciduous maxillary first molar has three roots: Two buccal and one palatal,
namely mesio-buccal, disto-buccal and palatal. All three roots can be seen
from this aspect and are long, slender and widely separated. The furcation is
close to the cervical line. So the root trunk is very small.

PALATAL ASPECT

The form of the palatal aspect is similar to that of buccal aspect. Features
observed are:
Crown is narrower palatally
Palatal surface is slightly convex cervico-occlusally and markedly convex
mesio-distally
Mesio-palatal cusp is the most prominent cusp of this tooth and is largest and
sharpest.
Disto-palatal cusp may or may not be present. If present is small, rounded
and poorly defined. The disto-palatal cusp is separated from mesio-palatal
cusp by a less defined palatal groove. When disto-palatal cusp is absent it is
called three cusp type and in such types die palatal cusp occupies the entire
palatal portion of occlusal aspect.
Because of the small disto-palatal cusp, a portion of the disto-buccal cusp
which is more developed can be seen from palatal aspect.

Root
All three roots can be seen from this aspect, palatal being the longest.

MESIAL ASPECT

Crown
Shape of Mesial Aspect
Cervical 1/3rd of crown is much wider bucco-palatally than the occlusal
1/3rd making the occlusal table narrow.

Outlines of Mesial Aspect

Buccal outline is significantly convex at cervical 1/3rd representing the
cervical ridge. From the crest of convexity, buccal outline is flat to the
occlusal margin.
Palatal outline is more gradually curved at cervical and middle 1/3rd and flat
at occlusal 1/3rd.
Occlusal outline is represented by cusps and marginal ridge. Two cusps can
be seen from this aspect: Mesio-palatal and mesio-buccal cusp. The mesio-
palatal cusp is longer and sharper than mesio-buccal cusp. Mesial marginal
ridge is nearly as wide as cusp tips and may be crossed by a marginal groove.
Cervical line mesially shows more curvature occlusally.

Mesial Surface
Mesial surface is relatively flat except for the region of contact area.

Root
From the mesial aspect, only two roots are visible; mesio-buccal and palatal
root. Lingual root is thin and long, with a sharp curve buccally above middle
1/3rd. The disto-buccal root is not visible because mesio-buccal root is broad
enough to hide die disto-buccal root. Since the furcation is close to the
cervical line, the root trunk is very small.

DISTAL ASPECT

Crown tapers markedly towards the distal aspect and therefore is narrower
distally than medially. Crown length is lesser on distal aspect than mesial.
Disto-buccal cusp is more prominent than disto-palatal which is smaller and
may be even absent.
Cervical ridge on the buccal surface is not as prominent as on mesial aspect
Cervical line is curved occlusally to a lesser extend than mesial
Distal marginal ridge is more cervically oriented.
All three roots can be seen from the distal aspect: Mesio-buccal, disto-buccal
and palatal. Because the disto-buccal root is shorter and narrower than mesio-
lingual root, a portion of that root is also seen.

Root
Root trunk is very small with the level of bifurcation closer to the cervical
line.

OCCLUSAL ASPECT
Shape
Occlusal aspect is nearly rectangular with shorter sides represented by
marginal ridges.
Because of palatal convergence crown is wider buccally than lingually in a
mesio-distal direction. Since the crown has a distal convergence, it is wider
mesially than distally in a bucco-lingual direction. The occlusal table is
narrow in this tooth because of occlusal convergence from the proximal
aspects.

Occlusal Surface
Occlusal surface shows anatomic landmarks such as cusps, ridges, fossae,
pits, grooves, etc.

Cusps
Occlusal surface of primary maxillary first molar shows four cusps, namely
mesio-lingual, mesio-buccal, disto-lingual and disto-buccal. Mesio-lingual
cusp is largest and sharpest of all cusps, followed by mesio-buccal and disto-
buccal. Disto-lingual cusp is very small or may be even absent.

Ridges
Triangular ridges of all cusps are found extending from cusp tip towards the
center of occlusal surface.
Oblique ridge: Sometimes a well-developed oblique ridge may be seen
extending between mesio-palatal and disto-buccal cusps.
Transverse ridge may be formed between mesio-lingual and mesio-buccal
cusps.
Mesial marginal ridge forms the mesial boundary of occlusal aspect and is
well developed and is occlusally located than distal marginal ridge. The
palatal half of the mesial marginal ridge shows a distal inclination making the
palatal surface narrow.
Distal marginal ridge is straight in bucco-palatal direction and is smaller, less
developed and cervically located than mesial marginal ridge.
Fossae
Central fossa is the major fossa located at the center of occlusal aspect.
Mesial triangular fossa is a minor fossa located just inside the mesial
marginal ridge and is large and deep when compared to distal triangular
fossa.
Distal triangular fossa is located just inside the distal marginal ridge and is
less distinct.

Grooves
Occlusal surface shows both developmental and supplementary grooves.
These grooves show an ‘H’ pattern.

Developmental grooves
Central groove: Extends from the central fossa in a mesial direction to end in
the mesial triangular fossa.
Distal extension of central groove: This groove is seen in teeth in which the
oblique ridge is less prominent and this extends from central pit to the disto-
lingual developmental groove.
Buccal groove: Starts from the central pit and traverse in a buccal direction
separating the two buccal cusps and may extend onto buccal surface.
Distal developmental groove: It is present distal to the oblique ridge outlining
the disto-palatal cusp.
Lingual developmental groove: This groove is present only in four cusp types
where a disto-palatal cusp is present and this is seen as a lingual extension of
distal developmental groove between two lingual cusps.

Supplementary grooves
Supplementary grooves are found radiating from mesial pit, one in a buccal
direction, one in a lingual direction and a third one towards the marginal
ridge which may cross the marginal ridge and extend onto the mesial side.

Pits
Central, mesial and distal pits are seen at the deeper part of respective fossae.
Sometimes distal pit is absent.

DECIDUOUS MAXILLARY SECOND MOLARS

The maxillary second primary molar is similar in many respects to permanent

maxillary first molar having similar arrangement of pits, grooves and cusps.
But it differs in being smaller and more bulbous with a narrow occlusal table.
It also has prominent buccal cervical ridge, narrow cervix and divergent
roots.

BUCCAL ASPECT

Crown
Crown of deciduous second molar is considerably larger than that of first
deciduous molar with a narrow cervix. Buccal view shows two well
developed cusps: mesio-buccal and disto-buccal cusps which are separated by
a buccal developmental groove. Mesio-buccal cusp is larger than distobuccal
cusp. Buccal surface shows a prominent cervical ridge but not as prominent
as in first molar.

Root
Deciduous maxillary second molar has three roots, namely mesio-buccal,
distobuccal and palatal. All three roots can be seen from this aspect and are
long, slender and widely separated. The trifurcation is close to the cervical
line. So the root trunk is very small.

PALATAL ASPECT

Crown
From lingual aspect there are two major cusps visible: Mesio-lingual and
disto-lingual cusps. The lingual cusps are separated by lingual groove which
extends onto lingual aspect which is gradually obliterated as it reaches the
cervical 1/3rd. Mesio-lingual cusp is larger and well developed. A fifth cusp,
‘cusp or tubercle of Carabelli’ is found lingual to mesio-lingual cusp which
is separated from the mesio-lingual cusp by a developmental groove. In some
teeth, fifth cusp may be absent or is represented by traces of developmental
groove.

Root
All three roots are visible from the palatal aspect. Palatal root is thicker and
larger and same length as mesio-buccal.

MESIAL ASPECT

Crown
From mesial aspect, deciduous maxillary second molar is similar to
permanent maxillary first molar. Features observed are:

Shape of Mesial Aspect

Bucco-palatal measurement of crown is more when compared to length, so it
appears short from mesial aspect.

Outlines of Mesial Aspect

Buccal outline is almost straight, from the cervical 1/3rd where the crest of
curvature is located, to the tip of buccal cusp.
Palatal outline is smooth and round from the cervical region to the palatal
cusp tip.
Occlusal outline is represented by cusps and marginal ridge, two cusps can be
seen from this aspect: Mesio-palatal and mesio-buccal. Mesio-palatal cusp is
large when compared to mesio-buccal which is shorter and sharp. Fifth cusp,
‘cusp of Carabelli’ is also seen lingual to mesio-palatal cusp. Mesial marginal
ridge is at a higher level and is crossed by mesial groove.
Cervical line shows only a little curvature.
Mesial Surface
Mesial surface is convex cervico-occlusally and less so bucco-palatally.

Root
Only two roots are seen from this aspect: Mesio-buccal and palatal.
Bifurcation is around 2 or 3 mm above cervical line.

DISTAL ASPECT

The morphology of this aspect resembles that of mesial aspect. Differences

observed are:
Distal aspect is narrower because the crown converges distally
Disto-buccal and disto-palatal cusps are of almost same size
Cervical line is nearly straight
All three roots can be seen from the distal aspect: Mesio-buccal, disto-buccal
and palatal. Because the disto-buccal root is shorter and narrower than mesio-
buccal root, a portion of that root is also seen.

Root
Root trunk is very small with the level of bifurcation at an apical level than
other sides.

OCCLUSAL ASPECT

Occlusal aspect of deciduous maxillary second molar resembles the

permanent maxillary first molar to a greater extent, with similar shape, cusps,
ridges, groove pattern, etc.

Shape
Shape is rhomboidal. The crown is wider mesially than distally in a bucco-
palatal direction because of distal convergence. The occlusal table is narrow
in this tooth because of occlusal convergence from the proximal aspects.

Occlusal Surface
Occlusal surface shows various anatomic landmarks such as cusps, ridges,
fossae, pits and grooves.

Cusps
Occlusal surface of primary maxillary second molar shows four well
developed cusps, namely mesio-palatal, mesio-buccal, disto-palatal and disto-
buccal. Mesio-palatal cusp is largest and sharpest of all cusps and this cusp
occupies a greater portion of occluso-palatal area. Second largest cusp is
mesio-buccal followed by disto-buccal. Disto-palatal cusp is smallest of the
four major cusps. A fifth cusp, ‘tubercle of Carabelli’ is found palatal to
mesio-palatal cusp which is separated from the mesio-palatal cusp by a
developmental groove.

Ridges
Triangular ridges of all cusps are found extending from cusp tip towards the
center of occlusal surface.
Oblique ridge: A well developed oblique ridge is seen extending between
mesio-palatal and disto-buccal cusps.
Transverse ridge may be formed between mesio-palatal, mesio-buccal cusps.
Mesial marginal ridge forms the mesial boundary of occlusal aspect and is
well developed.
Distal marginal ridge forms the distal boundary of occlusal aspect and is
equally well developed as mesial marginal ridge.

Fossae
Central fossa is the major fossa, located mesial to the oblique ridge.
Distal fossa is less prominent and is located distal to the oblique ridge.
Mesial triangular fossa is well defined and is situated distal to mesial
marginal ridge.
Distal triangular fossa is less distinct and found just inside the distal marginal
ridge.

Pits
Pinpoint depressions can be seen at deepest part of the fossae where the
grooves converge. Mainly three pits are seen in deciduous maxillary second
molar: Central pit, mesial pit and distal pit.

Grooves
Both developmental and supplementary grooves are present:

Developmental grooves
Central groove extends from central pit in a mesial direction to the mesial pit.
Buccal developmental groove also begins from central pit and traverse
buccally separating the two buccal cusps.
Distal developmental groove extends from central fossa in a distal direction
across the oblique ridge to join the distal pit.
Disto-lingual developmental groove is found in the distal fossa with a mesial
inclination separating the two lingual cusps.
Lingual developmental groove is seen as an extension of disto-lingual
developmental groove which extends onto the palatal side between palatal
cusps.

Supplementary grooves
Supplementary grooves are present in mesial and distal triangular fossae.

Measurement table of deciduous maxillary first molar

Measurement table of deciduous maxillary second molar

Deciduous maxillary second molar

Deciduous maxillary first molar
 18
Deciduous Mandibular
Molars

Description of morphology of deciduous mandibular first molar and

deciduous maxillary second molar.

DECIDUOUS MANDIBULAR MOLARS

The primary mandibular molars are four in number, two on either side of the
arch, which includes the first and second molars.

DECIDUOUS MANDIBULAR FIRST MOLAR

This tooth is morphologically unique and does not resemble any other
deciduous or permanent tooth. Its outline and form differs considerably from
that of all other primary and permanent teeth. Differentiating feature is its
overdeveloped mesial marginal ridge which somewhat resembles a cusp.

BUCCAL ASPECT

Crown
Shape of Buccal Aspect
From the buccal aspect crown appears wider mesio-distally than cervico-
occlusally. Distal part of crown is shorter than mesial part. Considerable
degree of cervical convergence is observed which is more from the distal
aspect than mesial.

Outlines of Buccal Aspect

Mesial outline is nearly straight with contact area more cervical than on distal
aspect.
Distal outline is convex with contact area in the middle of the crown.
Occlusal outline is represented by cusps and cusp slopes. Two buccal cusps
are seen from the buccal aspect: Mesio-buccal and disto-buccal. Mesio-
buccal cusp is larger than disto-buccal cusp.
Cervical line on buccal surface dips apically as it joins to the cervical line on
mesial aspect so the mesial half of the crown appears to be longer.

Buccal Surface
Buccal surface is convex in mesio-distal direction but slopes abruptly
towards the occlusal surface. In the cervical region of buccal surface, a
prominent cervical ridge is seen extending in a mesio-distal direction. This
cervical ridge is more prominent at mesial half and referred to as ‘tubercle of
Zuckercandl’. On the buccal surface, two buccal cusps are separated by a
depression which may at times harbor a buccal developmental groove.

Root
Mandibular first primary molar has two roots: Mesial and distal. Furcation is
close to cervical line and the root trunk is short. Mesial root is wider and
longer than distal root. Roots are slender widely separated and the apical third
spread beyond the crown outlines.

UNGUAL ASPECT

Crown
Crown and root converges lingually on the mesial side, making mesial
surface visible from this aspect. Since there is no convergence from distal
aspect, distal surface cannot be seen. Crown length is almost equal in both
mesial and distal portions in contrast to the buccal aspect.
Two lingual cusps are seen from this aspect: Mesio-lingual and disto-lingual
cusps. Mesio-lingual cusp is larger, longer and sharper, while disto-lingual
cusp is small and rounded. The mesio-lingual cusp in some teeth is so
prominent and is almost centered over mesial root. Mesial marginal ridge is
so well developed that it resembles a cusp from lingual aspect. Along with
the lingual cusps part of two buccal cusps also may be seen from lingual side.
Cervical line is nearly straight
Lingual surface is convex mesio-distally and cervico-occlusally and the
surface is traversed by a lingual groove which separates both lingual cusps.

Root
Both mesial and distal roots can be seen from this aspect. Since the
bifurcation is slightly more apical, the root trunk may be longer lingually.

MESIAL ASPECT

Crown
Shape of Mesial Aspect
Crown appears to incline lingually as in case of permanent mandibular teeth.
Crown length is more on the mesio-buccal part than mesio-lingual part.
Cervical portion of the crown is much wider than occlusal, making the
occlusal table narrow.

Outlines of Mesial Aspect

Buccal outline shows an extreme curvature at cervical 1/3rd because of
prominent cervical ridge. The outline is flat from crest of curvature up to the
tip of mesio-buccal cusp. Buccal outline is longer than lingual outline.
Lingual outline is shorter than buccal outline and it extends beyond the
confines of lingual margin or root.
Occlusal outline is represented by cusps and marginal ridge. Two well
developed cusps, i.e. mesio-buccal and mesio-lingual cusps are visible.
Buccal cusp is well within the confines of root base, but the lingual cusp tip
may be either in line with lingual margin of root or extends beyond the
confines of lingual margin. Mesial marginal ridge is very prominent, concave
and is longer and located more occlusally than distal marginal ridge.
Cervical line on this aspect curves occlusally and is slanting occlusally from
buccal to lingual surface.

Mesial Surface
Mesial surface is relatively flatter.

Root
Only one root is visible from this aspect, i.e. mesial root. The mesial root is
flat and square with broad apex. Deep developmental depression is present,
running the entire length of root.

DISTAL ASPECT

The morphology of this aspect resembles that of mesial aspect. Differences

observed are:
The crown length on buccal and lingual aspect is uniform.
Buccal cervical ridge is not so prominent.
Disto-buccal and disto-lingual cusps are almost of same size and not as long
or sharp as mesial cusps.
Distal marginal ridge is not well developed and is cervically placed when
compared to mesial marginal ridge, so more of occlusal aspect can be seen
from distal aspect.
Cervical line is almost straight on the distal aspect.

Root
Distal root is rounded, thinner and less broad than mesial root.

OCCLUSAL ASPECT

Shape
Shape of occlusal aspect is roughly rhomboidal with an obtuse disto-buccal
angle and acute mesio-buccal angle, because of prominent buccal cervical
ridge. The occlusal surface is wider mesio-distally than bucco-lingually.
Generally the occlusal table is narrow with relatively shallow surface. The
distal half of the occlusal table is wider than the mesial half. Occlusal aspect
also shows a lingual convergence.

Occlusal Surface
Occlusal surface shows various anatomic landmarks such as cusps, ridges,
pits, fossae and grooves, etc.

Cusps
Deciduous mandibular first molar has four cusps: Mesio-lingual, mesio-
buccal, disto-buccal and disto-lingual cusps. Both mesio-lingual and mesio-
buccal cusps are larger and well developed while distal cusps are smaller.
The mesio-lingual cusp is the largest and the disto-lingual cusp is the smallest
of all cusps.

Ridges
Triangular ridges of all cusps are found extending from cusp tip towards the
center of occlusal surface.
Transverse ridge may be found between mesio-lingual, mesio-buccal cusps.
Mesial marginal ridge forms the mesial boundary of occlusal aspect and is
very prominent, long and occlusally placed.
Distal marginal ridge forms the distal boundary of occlusal aspect. It is not
well developed and is cervically placed when compared to mesial marginal
ridge.
Fossae and Pits
Central fossa is the major fossa located at the center of occlusal aspect.
Mesial triangular fossa is located just inside the mesial marginal ridge.
Distal triangular fossa is shallow and it lies inside the distal marginal ridge
Pits may be seen as pinpoint depression at deepest part of fossae where
grooves join.

Grooves
Both developmental and supplementary grooves are seen:

Developmental grooves
Central groove runs from mesial pit to central pit, separating the mesio-
buccal and mesio-lingual cusps.
Buccal developmental groove begins from central pit, traverse buccally
between the mesiobuccal and disto-buccal cusps. This groove usually does
not extend onto the buccal surface.
Lingual groove extends between two lingual cusps which also may not
extend onto lingual surface.

Supplementary grooves
Supplementary grooves are present in both mesial and distal triangular
fossae.

DECIDUOUS MANDIBULAR SECOND MOLAR

It is a five-cusped tooth closely resembling the permanent mandibular first

molar with same general contour and surface pattern, except that primary
tooth is small in all dimensions.

BUCCAL ASPECT
Mesiodistal dimension of the crown at the cervix is much less when
compared to that at contact area making the cervix narrow. Crown appears to
be tilted distally on its root base.
Three cusps are visible from buccal aspect: mesio-buccal, disto-buccal and
distal cusp. All the buccal cusps are nearly of the same size in contrast to the
permanent mandibular first molar.
Buccal surface shows two grooves: A mesio-buccal groove which separates
mesio-buccal and disto-buccal cusp and a disto-buccal groove which
separates disto-buccal cusp from distal cusp.
A well-developed cervical ridge is present on the buccal surface immediately
below the cervix extending mesio-distally.

Root
Mandibular second primary molar has two roots: Mesial and distal.
Bifurcation is very close to the cervical line and the root trunk is short. Roots
are slender widely separated and the apical third spread beyond the crown
outlines.

LINGUAL ASPECT

Lingual aspect is narrow when compared to buccal because of lingual

convergence. Crown appears to be tilted distally with a longer mesial portion
than distal.
Two cusps are present on lingual aspect: Mesio-lingual and disto-lingual
cusps both are of nearly equal size. The mesio-lingual and disto-lingual cusps
are about the same size.
Lingual surface is convex, especially at the cervical region. Lingual groove
extends onto this surface separating both the lingual cusps.

Root
From lingual aspect, both mesial and distal roots are seen. Bifurcation is very
close to the cervical line and the root trunk is short. Roots are slender, widely
separated and the apical third of the root may extend beyond the crown
outlines.
 MESIAL ASPECT

Shape of Mesial Aspect

Shape of the mesial aspect is rhomboidal with the crown tilted lingually on
the root axis. A greater bucco-lingual measurement of the crown and the root
can be appreciated from this aspect.

Outlines of Mesial Aspect

Buccal outline shows prominent curvature at cervical 1/3rd because of
cervical ridge. Thereafter outline is flat with a great lingual tilt up to the cusp
tip making the occlusal aspect narrow. Buccal outline is well within the
confines of root.
Lingual outline extends beyond the root base.
Occlusal outline is represented by cusps and marginal ridge. Two well
developed cusps i.e. mesio-buccal and mesio-lingual cusps are visible.
Mesio-lingual cusp is longer of the two. Buccal cusp is well within the
confines of root base. Mesial marginal ridge is very prominent and is crossed
by a groove. Since the mesial marginal ridge is located more occlusally,
mesio-buccal and mesio-lingual cusps appear to be short.
Cervical line is regular but slopes occlusally towards the lingual aspect.

Mesial Surface
Mesial surface is convex except for cervical region which is flat.

Root
Only one root is visible from this aspect i.e. mesial root. Mesial root is broad
and flat with blunt apex.

DISTAL ASPECT

Distal surface is convex except at cervical region.

Distal surface is narrower than mesial due to distal convergence. So part of
mesio-buccal cusp can be seen along with disto-buccal cusp.
Distal marginal ridge is short and is at a lower level so part of occlusal
surface can also be seen from distal aspect.
Disto-lingual cusp is well developed.
Cervical line is regular as in case of mesial aspect, it tilts occlusally at the
lingual part.

Root
Only one root is visible from this aspect, i.e. distal root. Distal root is flat and
almost as broad as mesial root but tapers at the apical 1/3rd.

OCCLUSAL ASPECT

General morphology is similar to that of permanent mandibular first molar.

Shape
Shape of occlusal aspect is rectangular with a lingual and distal convergence.
Because of lingual convergence crown is wider buccally than lingually.
Mesial half is wider in bucco-lingual direction than distal half due to the
distal convergence.

Occlusal Surface
Occlusal surface shows various anatomic landmarks such as cusps, ridges,
pits, fossae, grooves, etc.

Cusps
Deciduous mandibular second molar has five cusps: Three buccal cusps and
two lingual cusps. The buccal cusps are mesio-buccal, disto-buccal and distal
cusps. All the three buccal cusps are nearly of same size. Lingually there are
two cusps: The mesio-lingual and disto-lingual cusps which are also nearly of
same size. Mesio-lingual cusp is the most prominent cusp of this tooth.
Ridges
Triangular ridges are seen extending from the tips of all five cusps towards
the central part of occlusal surface. Triangular ridges of lingual cusps are
longer than that of buccal cusps.
Mesial marginal ridge: Forms the mesial boundary of the occlusal aspect and
is better developed, more pronounced and located more occlusally than the
distal marginal ridge.
Distal marginal ridge: It is located at distal margin of occlusal aspect. It is
shorter, less developed and more cervically placed.
Cusp ridges: Forms the buccal and the lingual boundaries of the occlusal
aspect

Fossae
Three fossae can be seen; one major (central fossa) and two minor (mesial
and distal triangular fossae).
The central fossa is the largest fossa located at the center of the occlusal
aspect.
Mesial triangular fossa is a triangular shaped depression located distal to the
mesial marginal ridge.
Distal triangular fossa is less distinct and is located mesial to distal marginal
ridge.

Pits
Pits are present as small pinpoint depression at the deepest part of all fossae,
where the developmental grooves converge. The pits are named according to
the fossa in which they are located: Central pit, mesial pit and distal pit.

Grooves
Both developmental and supplementary grooves are seen:

Developmental grooves
Central groove: It is the major groove seen on the occlusal aspect and is
centrally located dividing occlusal surface into buccal and lingual halves. It
starts from the mesial pit and runs in a mesial direction to end in the distal pit.
Mesio-buccal groove starting from central groove extends between two
mesio-buccal and disto-buccal cusp and extends on to buccal side.
Disto-buccal groove: Between disto-buccal and distal cusp and extends on to
buccal surface.
Lingual groove-separates two lingual cusps and extend onto the lingual
surface.

Supplementary grooves
Supplemental grooves are seen in the mesial and distal triangular fossae,
sometimes crossing over the marginal ridges.

Differences between deciduous mandibular second molar and

permanent mandibular first molar
Deciduous mandibular second Permanent mandibular first molar
molar
Smaller and more bulbous from Larger
proximal aspect

Three buccal cusps are nearly Mesio-buccal cusp is largest and

equal in size distal cusp is smallest

Prominent cervical ridge on Cervical ridge is not prominent on

mesio-buccal aspect mesio-buccal aspect

Roots are thin and longer Roots are thick and smaller relative to
compared to crown length and are crown length and are not flared
flared

Furcation is close to cervical line. Furcation is 3–4 mm below cervical

So root trunk is small line. So a distinct root trunk is seen.

Measurement table of deciduous mandibular first molar

Measurement table of deciduous mandibular second molar

Deciduous mandibular second molar

Deciduous mandibular first molar

 19
Comparison between
Deciduous and Permanent
Dentition

Difference between permanent and deciduous dentition

General differences
Features Deciduous dentition Permanent dentition
Number of 20 in number, 5 in each quadrant 32 in number: 8 in
teeth each quadrant

Type of teeth

Premolars are absent in 2 premolars are

deciduous dentition present in each
quadrant

Only two molars are present 3 molars are present

in each quadrant

Color Whiter in color due to more Yellowish white in

opaque enamel resulting from
less mineral content
color or less whiter
due to translucent
enamel resulting from
high mineral content
which reflect color of
underlying dentin
 Inter dental Natural spacing exists between Less or no spacing
spacing deciduous teeth, e.g. primate between the teeth
space

Orientation Primary incisors have got upright Undergo attrition to a

orientation than permanent teeth great extent Teeth are
more labially inclined

Attrition Undergo attrition to a great Undergo attrition but

extent to lesser extent

Shape Deciduous teeth are more Permanent teeth are

bulbous and have more less bulbous and the
consistent shape with fewer shape is less
anomalies consistent with more
anomalies

Size Smaller in all dimensions than Larger in all

permanent counterparts. dimensions
Deciduous molars are also
smaller than permanent molars
but larger than their successors,
i.e. the premolars.

In deciduous dentition second In permanent

molars are larger than first dentition first molars
molars are larger than second
molars

Contour/shape Relatively more bulbous. Crowns Less bulbous. Length

of most of deciduous teeth are of crown is more than
wider in mesio-distal direction width in mesio-distal
relative to their crown length direction

10. Contact area Contact areas are smaller Relatively larger

contact areas
11. Mamelons Absent in deciduous teeth Present

12. Cervical Less curved than that of More curved

margin permanent teeth

13. Cusps More pointed when the teeth Less sharper

erupt, becomes less sharper due
to attrition

14. Depth of Shallow occlusal surface with Deeper occlusal

occlusal less prominent fossae and ridges. surface with more
surface Only a few grooves are seen prominent fossae and
ridges. More number
of grooves are seen

15. Cervical Deciduous teeth have markedly Less pronounced

constriction pronounced cervical constriction

16. Cervical ridge Prominent cervical ridge is seen Cervical ridge is seen
in all deciduous teeth mainly in even in permanent
molars, on the buccal aspect molars but is less
especially in the mesio-buccal pronounced
portion

17. Cingulum Cingulum is more prominent Relatively less

prominent

18. Surfaces The labial and lingual surfaces The labial and lingual
are flat above the cervical ridge. surfaces are relatively
Both these surfaces converges convex. There is no
occlusally, so that the bucco- such convergence
lingual measurement near
occlusal portion is much lesser
than that of cervical region

19. Occlusal table Occlusal table is narrow Occlusal table is

relatively broad
 Morphological differences of root

20. Root length Roots of deciduous teeth are Occlusal table is

shorter and thinner wider. Longer and
larger roots

21. Root crown Root of deciduous teeth are Root is not so longer
ratio longer when relative to their when relative to
crown length crown length

22. Root flare Roots flare out beyond crown Do not flare out and
boundary are well within the
confines of crown
boundary

23. Inclination of Roots of deciduous anterior teeth Do not show labial

root show a labial inclination inclination.

24. Level of Furcation of root is closer to the Furcation is relatively

furcation of cervix in deciduous molars apically placed
roots

25. Root trunk The root trunk is very small and The root trunk is
not distinct longer and distinct

26. Apical Deciduous teeth generally have a Constricted apical

foramen large apical foramen foramen
Differences in pilpal morphology
27. Pulp chamber Large pulp chamber relative to Smaller relative to the
the crown size crown size

28. Pulp horns Pulp horns are at a higher level Pulp horns are not as
high as in deciduous
teeth

29. Pulp canal Pulp canal is wider relative to the Pulp canal is
 size of root. Less curved and narrower relative to
apically less constricted the size of root. More
tortuous and apically
more constricted

30. Accessory In deciduous teeth accessory Accessory canals are

pulp canals canals are located mainly in the located mainly in the
furcation area apical region of roots

31. Pulpal Not seen Pulpal calcifications

calcifications are seen as regressive
changes
Histological differences
32. Enamel cap Enamel cap is thinner and is of Enamel cap is thicker
more uniform thickness. Enamel and is of varying
cap ends in a marked ridge at thickness. Enamel
cervical region cap ends in a feather
edge at cervical
region

33. Direction of Enamel rods of deciduous teeth They slope cervically

enamel rods are arranged either horizontally at the neck region
or slopes occlusally at neck
region

34. Dentin thickness is limited in Dentin is thicker and

Dentin some areas but a relatively is relatively of
thickness greater thickness of dentin is uniform thickness
found over the pulp chamber in
the occlusal fossae

35. Neonatal line Neonatal lines of enamel and Neonatal lines of

dentin are seen in all the enamel and dentin are
deciduous teeth seen only in
permanent first
molars
36. Dentino- May be scalloped in deciduous Relatively smooth in
cemental teeth permanent teeth
junction

37. Cementum Cementum is thin with less Cementum is

thickness thickness of cellular cementum relatively thicker in
permanent teeth with
more thickness of
cellular cementum
 20
Permanent Maxillary Central
Incisors

Introduction to incisors
Chronology of maxillary central incisors
Measurement table
Morphology of maxillary central incisors
Developmental variations and clinical considerations

P ermanent incisors are eight in number; four in the maxilla and four in
mandible, which include two central incisors and two lateral incisors in
maxilla and mandible each. Central incisors are located on either side of
the midline with their mesial surfaces in contact. Lateral incisors are situated
distal to the central incisors on each side of the arch. As the name indicate the
incisors function in incising or cutting food. These teeth are also important in
articulation of speech and esthetics. The maxillary and mandibular incisors
guide the jaw during closure.

PERMANENT MAXILLAR/CENTRAL INCISORS

Maxillary central incisors are two in number and occupy either side of the
midline. They are the most prominent teeth in the oral cavity with a great
esthetic value and are larger in all dimensions than the lateral incisors. The
morphologic characteristics of this tooth can be described from five aspects,
namely labial, lingual, mesial, distal and incisal.
 LABIAL ASPECT

Labial aspect is the surface of the tooth facing the lip. The description of
features is categorized as features of crown and of root.

Crown
Shape
Shape of maxillary central incisor is squarish or rectangular with a slight
cervical convergence (narrower at the cervical region than incisal).
Cervicoincisal length is 2 mm more than the mesiodistal width.

Outlines from the Labial Aspect

Mesial outline is slightly convex with contact area (crest of curvature) at the
incisal third close to the mesio-incisal angle.
Distal outline is more convex than mesial outline and contact area is located
at the junction between middle and incisal third.
Cervical outline is semicircular with curvature towards the root.
Incisal outline is represented by incisal edge which is straight and regular
with sharp mesio-incisal angle and slightly rounded disto-incisal angle.

Labial Surface
Labial surface of maxillary central incisor is smooth with convexity at the
cervical third. Surface becomes relatively flat as the incisal edge is
approached. Two shallow vertical depressions may be appreciated dividing
the labial surface into three portions, each representing parts developed from
three different lobes.

Chronology of permanent maxillary central incisor

Root
Root is conical in shape, broader at cervical 1/3rd, narrows through middle
part to end in a relatively blunt apex. The apex may show a distal tilt.

MLATAL/LINGUAL ASPECT

Palatal/lingual aspect is the surface of the tooth facing the palate/tongue.

Crown
The lingual outline of maxillary central incisor is reverse of the labial outline.
The crown and the root show convergence towards the lingual side which
makes the mesial and the distal surfaces visible from this aspect.
In contrast to the smooth labial surface, the lingual surface shows
concavities and convexities.

Convexities
There is a convex area called cingulum located at the cervical third which is
placed slightly to the distal in a mesio-distal direction. Either side of the
lingual aspect is bordered by linear elevations called marginal ridges. The
ridge on the mesial side is called mesial marginal ridge and on the distal side
is called distal marginal ridge. Mesial marginal ridge is slightly longer than
the distal marginal ridge as a result of distal location of the cingulum. The
lingual surface also shows the presence of linguo-incisal ridge, which forms
the incisal boundary of the lingual surface.

Concavity
The major portion of the lingual aspect of the central incisor is occupied by a
concavity called lingual fossa. The lingual fossa is M-shaped and is bounded
superiorly by the cingulum, inferiorly by the linguo-incisal ridge and on
either side by the mesial and distal marginal ridges. A deep developmental
groove may be present on the lingual surface extending onto the cingulum.
Cervical outline is semicircular with curvature towards the root.

Root
Root is lingually converged and conical in shape with blunt and rounded
apex. Cross section of the root is triangular in shape with rounded angles.

MESIAL ASPECT

Mesial aspect is one of the proximal aspects that is closer to the midline of
the face. Morphological characteristics of crown and roots are separately
mentioned.

Crown
Shape of mesial aspect: From the mesial aspect the crown appears triangular
or wedge shaped with the base at the cervix and apex at the incisal edge.

Outlines of Mesial Aspect

Labial outline is convex and the maximum convexity (crest of curvature) at
the cervical third. Labial outline becomes relatively straight from the crest of
curvature to the incisal edge.
Lingual outline shows convexities and concavities: Cervical third is convex
representing the cingulum followed by a concavity in the region of the
lingual fossa in the middle and again followed by a convexity, the incisal
ridge. Crest of convexity on lingual aspect is located at cervical third, on
cingulum.
Cervical outline is curved with curvature towards the crown. The extent of
curvature of cervical line is more on mesial side.
The incisal edge and the root tip lies in the midline which bisects the tooth.
Mesial surface: Mesial surface of central incisor is smooth and convex.

Root
Root is cone shaped and tapered with a rounded apex. The root surface on the
mesial aspect is relatively flat and may show longitudinal developmental
depression.

DISTAL ASPECT

Distal aspect is the proximal aspect that is away from the midline of the face.
Distal aspect is similar to that of mesial aspect with slight differences.
The crown appears to be broader from this aspect than the mesial aspect.
Extent of curvature of cervical line is less on the distal aspect
The root is tapered towards the rounded apex.

INCISAL ASPECT

Incisal aspect is the cutting/biting surface of the tooth. The features described
may be appreciated when the tooth is held in such a way that incisal edge is
towards the observer, in a horizontal direction with labial aspect upwards.
When the tooth is observed in this manner, root will be visible as it
superimposed over the crown.
The shape of the maxillary central incisor is triangular from this aspect
with the base on the labial surface and the apex towards the cingulum. The
mesio-distal dimension is greater than the labio-lingual dimension. The labial
aspect shows a semicircular arch form and the lingual aspect is tapered and
more convex at the cingulum. Slight disto-lingual twist of the incisal edge
may be appreciated from this aspect because of lingual positioning of the
disto-incisal angle compared to that of mesio-lingual angle. As the incisal
edge is located at the center, equal extent of the labial and lingual halves can
be seen. The lingual fossa, marginal ridges and distally placed cingulum can
be appreciated on the lingual aspect. Root cannot be appreciated from this
aspect because it is superimposed on the crown.

DEVELOPMENTAL VARIATIONS AND

CLINICAL CONSIDERATIONS

‘Shovel shaped’ central incisors: The term shovel shaped is used to describe
an incisor that has prominent mesial and distal marginal ridges and deep
lingual fossa.
Deep lingual pit: As a developmental variation, central incisors may show a
deep lingual pit at the incisal border of cingulum. Such teeth may be prone to
develop dental caries.
Accessory lingual ridge: Rarely maxillary central incisors may show vertical
ridges extending from cingulum to incisal edge.
Talon cusp: At times in incisors, the cingulum may become very prominent
to such an extent, it resembles eagle’s talon, which is referred to as talon
cusp. In such cases chances of dental caries is considerably more. In addition,
very prominent cingulum may interfere with occlusion and may cause trauma
to tongue.
Screw driver shaped central incisor: In patients affected by congenital
syphilis which is a bacterial infection, central incisors may assume a screw
driver shape. In this condition, due to the absence of middle lobe, mesial and
distal outlines of central incisors converge incisally making incisal 1/3rd
narrower than cervical 1/3rd. In addition these teeth may also show a
notching of incisal edge.

FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Labial Aspect
Straight incisal edge with sharp mesio incisal angle and rounded disto-incisal
angle.
Relatively straight mesial outline and slightly curved distal outline.
Mesial contact area is more incisally placed (incisal 1/3rd, closer to mesio-
incisal angle) than distal (at junction of incisal and middle 1/3rd).
Distal tilt of root.

Lingual Aspect
Distal placement of cingulum.
Longer mesial marginal ridge than distal marginal ridge.

Proximal Aspect
Cervical line more curved on mesial aspect than distal.

Incisal Aspect
Disto-lingual twist of incisal edge.
Permanent maxillary right central incisor
 21
Permanent Maxillary Lateral
Incisors

Introduction to incisors
Chronology and measurement table
Morphology of maxillary lateral incisor
Differences between maxillary central and lateral incisors

L ateral incisors are the second teeth from the midline located on either side
of the dental arch, distal to the central incisors. Lateral incisors bear close
resemblance to central incisors and support them in functions. When
compared to central incisors, these teeth are smaller and appears relatively
long and narrow. The morphologic characteristics can be described from five
aspects, namely labial, lingual, mesial, distal, and incisal aspects. Further,
features on each aspect (except incisal) is described under two subheadings,
i.e. crown and root.

LABIAL ASPECT

Crown
Shape of Labial Aspect
Shape of maxillary lateral incisor is rectangular with a slight cervical
convergence. Crown is smaller in all dimensions and is less symmetrical than
that of central incisors.
Outlines of the Labial Aspect
Mesial outline is slightly convex with contact area located at the junction of
middle and incisal 1/3rd.
Distal outline is more convex from cervix to disto-incisal angle with contact
area at the middle of middle 1/3rd.
Incisal outline is represented by incisal edge which is rounded or slightly
curved with rounded incisal angles. Mesio-incisal angle is rounded in contrast
to that of central incisors. Disto-incisal angle of maxillary lateral incisor is
more rounded compared to mesio-incisal angle. More rounded disto-incisal
angle along with convex outline gives a semicircular shape to the distal
outline of the tooth.
Cervical line is semicircular, curved towards the root.

Labial Surface
Labial surface is smooth similar to that of central incisors, but is more convex
with less prominent labial depressions.

Root
Root tapers evenly from cervix to apex; apex is distally curved. Like crown,
root is 2 mm narrower than central incisor but with same length giving a long
and narrow appearance.

Chronology of permanent maxillary lateral incisor

 LINGUAL ASPECT

Crown
The lingual outline of maxillary lateral incisor is reverse of the labial outline.
The crown and the root are narrower on the lingual side because of lingual
convergence. Therefore, the mesial and the distal surfaces are visible from
this aspect.
In contrast to the smooth labial surface, the lingual surface shows
concavities and convexities.

Concavities
The lingual aspect of the lateral incisor shows a concavity called lingual fossa
which is more pronounced than that of central incisors. The lingual fossa is
inverted ‘V’ shaped and is bounded superiorly by the cingulum, interiorly by
the linguo-incisal ridge and on either side by the mesial and distal marginal
ridges. A deep developmental groove may be present on the lingual surface
extending onto the cingulum.
Cervical outline is semicircular with curvature towards the root.

Convexities
Cingulum is seen as a convexity at the cervical third. Unlike the central
incisors, the cingulum is narrower and is located at the center in a mesiodistal
direction. Mesial and distal sides of the lingual aspect are bordered by linear
elevations called marginal ridges. In most of the lateral incisors, mesial and
distal marginal ridges are more prominent than in central incisors. Incisally
the lingual surface is bounded by a prominent linguo-incisal ridge.

Root
Root is narrower lingually, conical in shape with blunt and distally tilted
apex.

MESIAL ASPECT

The mesial aspect of lateral incisor closely resembles the central incisors but
is smaller in all dimensions, than central incisors.

Crown
Shape of mesial aspect: From the mesial aspect the crown appears triangular
or wedge shaped with the base at the cervical portion and apex at the incisal
edge.

Outlines of Mesial Aspect

Labial outline is convex with crest of curvature at the cervical third, near the
cervical line. The outline becomes relatively straight from the crest of
curvature to the incisal edge.
Lingual outline shows convexities and concavities and the crest of curvature
is located at cingulum. Cervical third of lingual outline is convex in the
region of cingulum and concave at the lingual fossa. A slight convexity is
again found at the incisal ridge. Crest of convexity on lingual aspect is
located at cervical third, on cingulum.
Cervical line is curved and the curvature is marked on the mesial side,
towards the incisal edge.
The incisal edge, is thicker than that of central incisor and lies either in line
with or slightly labial to the root axis plane.
Mesial Surface
Mesial surface is smooth and convex.

Root
Root is cone shaped and tapering to a blunt apex.

DISTAL ASPECT

Distal aspect of maxillary lateral incisor resembles the mesial aspect. The
differences observed are:
The width of crown appears thicker on distal side.
Curvature of cervical line is less.
Root may show a developmental groove.

INCISAL ASPECT
Incisal aspect generally resembles that of central incisor except for its smaller
size. Labial and lingual outlines are more rounded or convex, giving ovoid or
round shape to the incisal aspect in contrast to the triangular shape of the
central incisor. The cingulum is more prominent and is centered in a mesio-
distal direction.

Differences between central and lateral incisors (type traits)

Central incisor Lateral incisor
Larger in all dimensions Smaller in all dimensions, than
central incisor

Labial surface is smooth and Labial surface is smooth but is

relatively flatter except the cervical more convex with less prominent
1/3rd labial depressions

Contact areas are more incisally Contact areas are more cervically
placed with mesial contact area at placed with mesial contact area at
 incisal third close to incisal angle junction between incisal and
and distal contact area at the junction middle third and distal contact area
between incisal and middle third at the middle of middle 1/3rd

Incisal edge is straight Incisal edge is rounded or curved

Mesio-incisal angle is sharp and Both the incisal angles are

disto-incisal angle is slightly rounded rounded: Disto-incisal angle is
more rounded than mesio-incisal
angle

Mesial outline of labial aspect is Both mesial and distal outlines of

straight and distal outline is slightly labial aspect are convex and distal
rounded outline is distinctly convex

Shallow lingual fossa and is M- More deep lingual fossa with

shaped developmental groove and is
inverted V-shaped

Cingulum is slightly off to distal, Cingulum is narrower than that of

making mesial marginal ridge longer central incisor and is at the center
and marginal ridges are of equal
length

Marginal ridges, cingulum and Marginal ridges, cingulum and

lingual fossa are relatively less lingual fossa are more prominent
prominent

DEVELOPMENTAL VARIATIONS AND

CLINICAL CONSIDERATIONS

Permanent maxillary lateral incisors are less symmetrical, and may often
show variations in the form and size.
Peg shaped laterals: This is a common developmental variation observed in
which maxillary laterals present with a characteristic conical shape. Peg
shaped lateral may also be observed as a developmental malformation caused
due to congenital syphilis.
Missing laterals: This is one of the commonest tooth that may be
congenitally absent.
‘Shovel shaped’ lateral incisors: The term shovel shaped is used to describe a
lateral incisor that has prominent mesial and distal marginal ridges and deep
lingual fossa.
Deep lingual pit: As central incisors, even lateral incisors may show a deep
lingual pit at the incisal border of cingulum. Such teeth may be prone to
develop dental caries.
Accessory lingual ridge: Rarely maxillary lateral incisors may show vertical
ridges extending from cingulum to incisal edge.
Talon cusp: At times in lateral incisors, the cingulum may become very
prominent to such an extent, it resembles eagle’s talon, which is referred to as
talon cusp. In such cases chances of dental caries is considerable more, In
addition, very prominent cingulum may interfere with occlusion and may
cause trauma to tongue.
Palatal gingival groove: Lateral incisors may show a deep groove extending
from cingulum to the root surface.

FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE

Labial Aspect
Curved incisal edge with relatively less rounded mesio-incisal angle and
more rounded disto-incisal angle.
Relatively more curved distal outline than mesial outline.
Mesial contact area is more incisally placed (at junction of incisal and middle
1/3rd) than distal (middle of middle 1/3rd).
Distal tilt of root.
Proximal Aspect
Cervical line more curved on mesial aspect than distal.
Permanent maxillary right lateral incisor
 22
Permanent Mandibular
Central Incisors

Introduction to incisors
Chronology and mandibular central incisor
Measurement table
Morphology of mandibular central incisor
Differences between maxillary and mandibular incisors

M andibular incisors are four in number; two central incisors and two
lateral incisors. Both mandibular central and lateral incisors have
similar morphology.
These teeth assist maxillary incisors in functions like cutting food,
esthetics, speech and also in guiding the mandible while closing.

PERMANENT MANDIBULAR CENTRAL

INCISORS

Mandibular central incisors are two in number located on either side of the
midline of mandibular arch, with their mesial surfaces in contact. They are
the smallest teeth in permanent dentition. The morphologic characteristics of
this tooth may be described from five aspects, namely labial, lingual, mesial,
distal and incisal. Further, features on each aspect (except incisal) is
described under two subheadings, i.e. crown and root.
 Chronology of permanent mandibular central Incisor

LABIAL ASPECT

Crown
Shape of Labial Aspect
Mandibular central incisors have a narrow long appearance from the labial
aspect. The crown is nearly bilaterally symmetrical.

Outlines of Labial Aspect

Mesial and distal outlines are relatively straight and evenly taper from contact
areas to a narrow cervix. Mesial and distal contact areas are nearly at the
same level and are located in the incisal 1/3rd close to the incisal angles.
Incisal outline is represented by incisal edge which is straight and
perpendicular to the long axis of tooth. Both mesio-incisal and disto-incisal
angles are sharp.
Cervical outline is convex and is curved towards the root.

Labial Surface
Labial surface is smooth without any developmental lines. Surface is flat at
incisal 1/3rd, but slightly convex at cervical and middle 1/3rd.

Root
Root is conical and it tapers to apex which may show a distal tilt.

LINGUAL ASPECT

Crown
Mandibular central incisor shows a lingual taper and therefore part of mesial
and distal surfaces are visible from this aspect. At cervical 1/3rd, cingulum is
present as a convexity, which is centered on the lingual aspect. Confluent
with cingulum on either side, marginal ridges are seen. Between the marginal
ridges, the lingual fossa is present as a slight concavity. In this tooth
cingulum, marginal ridges and lingual fossa are not distinct.

Root
Root is narrower lingually and conical in shape.

MESIAL ASPECT

Crown
Shape of Mesial Aspect
Mandibular central incisor is wedge-shaped from proximal aspect with the
base located at the cervix and apex at incisal edge.

Outlines of Mesial Aspect

Labial outline is slightly convex at cervical 1/3rd, where crest of convexity is
located from which the outline slopes rapidly to incisal edge.
Lingual outline is relatively straight at cervical 1/3rd, in the region of less
prominent cingulum, then becomes slightly concave till it joins to the incisal
edge. Both labial and lingual outlines show less curvature than maxillary
incisors.
Incisal outline is represented by incisal edge which is located lingual to the
midline of the tooth (arch trait of mandibular teeth).
A cervical line shows a deep curvature on the mesial aspect which extends up
to the cervical third (only feature that help in identification of side).

Mesial Surface
Mesial surface is smooth and flat except for slight convexity at incisal 1/3rd,
where contact area is located.

Root
Root outlines are straight up to middle 1/3rd, from where tapering start. Root
tip is located in the midline. Development depression may be seen on the
surface of the root.

Differences between maxillary and mandibular incisors

Maxillary incisors (arch traits) Mandibular incisors (arch traits)
Maxillary incisors are larger (both Mandibular incisors are smaller and
crown and root) and less relatively more symmetrical
symmetrical

Central and lateral incisors vary in Both central and lateral incisors are
size and in morphology nearly of same size and have
somewhat similar morphology

Mesial and distal sides are not as Mesial and distal sides are relatively
flat as in mandibular incisors, flat with contact areas located nearly
rather is convex with contact areas at the same level, closer to the incisal
located at different levels edge

Incisal angles are relatively Incisal angles are relatively sharper

rounded

Anatomic landmarks such as Less prominent anatomic landmarks.

 cingulum, marginal ridges and Lingual fossa do not show pits or
lingual fossa are more prominent. grooves, making lingual surface
Lingual fossa often shows a pit relatively smooth

When observed from proximal Labial surface is inclined lingually so

aspect, incisal edge is located in that incisal edge is located lingual to
line with root axis plane the midline

Crown is wider mesio-distally Crown is wider labio-lingually than

than labio-lingually mesio-distally

Since the difference between the The crown length is much more
crown length and width is only a relative to the mesio-distal
little the crown of maxillary measurement giving the crown of
incisors has a squarish shape mandibular incisors a thin long
appearance

Since the upper incisors have a Since the lower incisors have a
labial position in normal lingual position in normal occlusion,
occlusion, attrition leads to lingual attrition leads to labial inclination of
inclination of incisal edge incisal edge

DISTAL ASPECT

Morphology resembles mesial aspect except:

Less curvature of cervical line
More distinct developmental depression on the root.

INCISAL ASPECT

From this aspect labial and lingual surfaces of the tooth are visible. Since the
incisal edge is located lingual to midline, more of labial surface can be
appreciated. The incisal edge is straight and perpendicular to the labio-lingual
root axis plane. Bilateral symmetry of mandibular central incisor can be
better appreciated from this aspect.
Crown shows a greater labio-lingual measurement than mesio-distal. The
labial surface is broader and shows a considerable lingual inclination.
Although the cervical 1/3rd of labial surface is convex, and relatively flatter
middle and incisal 1/3rd as incisal edge is approached. The lingual surface
shows a convexity at the cingulum which is centered in a mesio-distal
direction. Middle and incisal 1/3rd are concave because of the lingual fossa.

DEVELOPMENTAL VARIATIONS AND

CLINICAL CONSIDERATIONS

Developmental variations are relatively rare in mandibular incisors

Bifurcated root: Rarely mandibular incisors may present with two roots,
labial and lingual roots.
Gemination: This is a developmental variation that occur due to an attempted
division of one tooth germ into two, resulting in incomplete division.
Affected tooth may present with a deep groove on the surface.
Fusion: At times mandibular central incisor may appear large with adjacent
lateral incisor missing. This results from fusion of two adjacent tooth germs
resulting in formation of a large tooth instead of two.

FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE

As permanent mandibular central incisor is bilaterally symmetrical, it may be

difficult to differentiate the side. However, curvature of cervical line can be a
feature that is helpful. On mesial aspect cervical line significantly more
curved than on distal aspect and may extend up to cervical 1/3rd.
Permanent mandibular right central incisor
 23
Permanent Mandibular
Lateral Incisors

Introduction
Chronology and mandibular lateral incisor
Measurement table
Morphology of mandibular lateral incisor
Differences between mandibular central and lateral incisors

M andibular lateral incisors are two in number, located distal to the central
incisors. They are larger and less symmetrical than central incisors. The
morphologic characteristics of this tooth may be described from five
aspects, namely labial, lingual, mesial, distal and incisal. Further, features on
each aspect (except incisal) is described under two subheadings, i.e. crown
and root.

LABIAL ASPECT

Crown
Shape of Labial Aspect
Mandibular lateral incisors have a narrow long appearance from the labial
aspect similar to that of central incisors. In contrast to central incisor, the
crown is larger and not bilaterally symmetrical and is tilted distally.
 Chronology of permanent mandibular lateral incisor

Outlines of Labial Aspect

Mesial and distal outlines are relatively straight and taper from contact areas
to a narrow cervix. Distal outline appears shorter and shows more
convergence towards the cervix giving an impression that a small fraction is
added to distal part of a symmetrical tooth. Crown shows a distal tilt on the
root base. Mesial and distal contact areas are not located at the same level.
Mesial contact area is close to mesio-incisal angle while distal contact area is
located at incisal 1/3rd, at a more cervical location.
Incisal outline is represented by incisal edge which shows a slope to distal
direction. Mesio-incisal angle is sharp and disto-incisal angle is slightly
rounded.
Cervical outline is convex and is curved towards the root.

Labial Surface
Labial surface is smooth without any developmental lines. Surface is flat at
incisal 1/3rd, but slightly convex at cervical and middle 1/3rd.

Root
Root is conical and it tapers to apex which may show a distal tilt.
 LINGUAL ASPECT

Crown
Morphologic features are similar to that of central incisor. Tooth shows a
lingual taper and therefore a part of mesial and distal surfaces are visible
from this aspect. At cervical 1/3rd, cingulum is present as a convexity, which
is slightly distally placed. Confluent with cingulum on either side marginal
ridges are seen. Distal placement of the cingulum makes mesial marginal
ridge longer than that of distal marginal ridge. Between the marginal ridges
lingual fossa is present as a slight concavity. Marginal ridges, cingulum and
lingual fossa may be slightly more prominent than in central incisors but not
as prominent as that of maxillary incisors.

Root
Root is narrower lingually and is conical in shape.

MESIAL ASPECT

Crown
Mesial aspect is similar to that of central incisors. Except for the difference in
size, no morphological difference is appreciated.

Shape of Mesial Aspect

Mandibular lateral incisor is wedge shaped from proximal aspects with the
base located at the cervical region and apex at incisal edge.

Outlines of Mesial Aspect

Labial outline is slightly convex at cervical 1/3rd where crest of convexity is
located from which the outline slopes rapidly to incisal edge.
Lingual outline is relatively straight at cervical 1/3rd in the region of less
prominent cingulum, and then becomes slightly concave till it joins to the
incisal edge. Both labial and lingual outlines show less curvature than
maxillary incisor.
Incisal outline is represented by incisal edge which is located lingual to the
midline of the tooth.
A cervical line shows curvature in an incisal direction and is deep on the
mesial aspect.

Mesial Surface
Mesial surface is smooth and flat except for slight convexity at incisal 1/3rd
where contact area is located.

Root
Root is conical with an apical taper. Root tip is located in the midline.
Developmental depression may be seen on the surface.

DISTAL ASPECT

Morphology resembles that of mesial aspect. While comparing the mesial and
distal aspects of a mandibular lateral incisor following differences can be
observed:
The lingual inclination of the crown appears to be more on distal aspect
because of disto-lingual inclination of the incisal ridge.

Differences between permanent mandibular central and lateral

incisors
Mandibular central incisors (type Mandibular lateral incisors (type
traits) traits)
Smallest tooth in permanent dentition Larger than central incisors

Bilaterally symmetrical Not bilaterally symmetrical

Crown is straight without any distal tilt Crown is tipped distally on the
root
 Incisal edge is straight, perpendicular Incisal edge is inclined distally
to the long axis of tooth

Contact areas are nearly at the same Contact areas are at different
level, close to incisal edge levels with more cervically
located distal contact

Both mesio-incisal angle and disto- Mesio-incisal angle is sharp and

incisal angles are sharp disto-incisal angle is rounded

Cingulum is placed at the center with Cingulum is distally placed with

mesial and distal marginal ridge of longer mesial marginal ridge
equal length

Incisal edge is straight when viewed Incisal edge is curved in a disto-

from incisal aspect and do not show lingual direction
disto-lingual twist

On the distal aspect, the degree of cervical curvature is less.

INCISAL ASPECT

Crown shows a greater labio-lingual measurement than mesio-distal. In

contrast to central incisor, lateral incisor does not appear bilaterally
symmetrical. From the incisal aspect labial and lingual surfaces of tooth can
be visible. Since the incisal edge is located lingual to midline more of labial
surface can be appreciated.
Incisal edge is not straight in a mesio-distal direction, but slightly curved
disto-lingually corresponding to the curvature of mandibular arch.
The labial surface is broader, inclines lingually. Distal placement of
cingulum, marginal ridges and lingual fossa can be better appreciated from
this aspect.

DEVELOPMENTAL VARIATIONS AND

CLINICAL CONSIDERATIONS
Developmental variations are relatively rare in mandibular incisors:
Bifurcated root: Rarely mandibular incisors may present with two roots,
labial and lingual roots.
Gemination: This is a developmental variation that occur due to an attempted
division of one tooth germ in to two, resulting in incomplete division.
Affected tooth may present with a deep groove on the surface.
Fusion: At times mandibular lateral and central incisors may fuse together
resulting in formation of a large tooth instead of two.

FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE

Labial Aspect
Incisal edge sloping distally.
Crown tipped distally on root.
Contact areas are at different level with more cervically located distal contact.
Sharp mesio-incisal angle and rounded disto-incisal angle.

Lingual Aspect
Distal placement of cingulum.
Longer mesial marginal ridge than distal marginal ridge.

Proximal Aspect
Cervical line more curved on mesial aspect than distal.

Incisal Aspect
Disto-lingual twist of incisal edge.
Permanent mandibular right lateral incisor
 24
Peermanent Maxillary
Canines

Introduction
Chronology of maxillary canine
Measurement table
Morphology of maxillary canine
Developmental variations and clinical considerations

C anines are four in number; two in maxillary arches and two in

mandibular arches. They are the third teeth from midline situated
between lateral incisor and first premolar, at the corners of mouth. Their
name is derived from the Latin word for dog (canus) because these teeth
resemble dogs’ teeth. These teeth are also called cuspids.
Canines are the longest teeth in the dental arch and usually the last one to
be lost. The selfcleansing property of these teeth resulting from their
particular shape and efficient anchorage to the jaw help in their longer
retention.
Canines help to cut or shear the food. It also functions with the incisors to
support the lips and facial muscles. These teeth have significant importance
in facial expression. Canines are important teeth in occlusion and also in
protecting the posterior teeth when the jaw moves laterally.
Class traits of canines
Permanent canines are the longest teeth in the human dentition with long,
thick root to ensure proper anchorage to alveolar bone.
Incisal edge is characterized by a pointed cusp, which is formed by mesial
and distal slope meeting at an angle. Mesial slope is shorter than distal slope.
Canines do not have mamelons but may have a notch on either cusp slopes.
Have a distinct labial ridge, extending in a vertical direction from cervical
region to the cusp tip.
Canines have greater labio-lingual measurement than mesio-distal.
A lingual ridge is present, which divides the lingual fossa into mesial and
distal fossae.

PERMANENT MAXILLARY CANINES

Maxillary canines are two in number located on either side of the dental arch,
distal to the lateral incisors. The morphologic characteristics can be described
from five aspects, namely labial, lingual, mesial, distal and incisal. Further,
features on each aspect (except incisal) is described under two subheadings,
i.e. crown and root.

LABIAL ASPECT

Crown
Shape of Labial Aspect
The crown is roughly pentagonal in shape and is narrower by 1 mm than
central incisors.

Chronology of permanent maxillary canine

Outlines of Labial Aspect
Mesial outline may be convex or slightly concave from cervix to the contact
area which is located at the junction of middle and incisal 1/3rd.
Distal outline is concave from cervix to the contact area. Contact area is more
cervically located when compared to the mesial contact area and is at the
middle of middle 1/3rd.
Cervical outline is curved in an apical direction.
Incisal edge is represented by the cusp and cusp slopes. In contrast to broadly
curved incisal edge in incisors, incisal edge in canines is divided into two
parts, i.e. mesial slope and distal slope meeting at an angle to form a point
called cusp. Distal slope of the cusp is longer than mesial cusp slope. The
junction between distal outline and distal cusp slope is rounded, while the
junction between mesial outline and mesial cusp slope is more angular. Cusp
tip is in line with root axis line and it is more mesially placed.

Labial Surface
Labial surface is convex. The middle labial lobe is well developed forming a
prominent labial ridge running cervico-incisally up to the cusp. On either side
of labial ridge shallow depressions are seen dividing the labial aspect into
mesial, middle and distal lobes.

Root
Maxillary canines have the longest root. Root is slender and conical with
bluntly pointed apex which bends distally.

LINGOAL/PALATAL ASPECT

Crown
The crown outline on the lingual aspect is similar to that of the labial aspect.
Canines show a significant lingual tapering because of which both crown and
root are narrower lingually. As in other anterior teeth, lingual aspect of
canines also shows convexities and concavities.

Convexities
The cingulum is seen as a convexity at cervical 1/3rd and is very prominent
resembling a cusp. In a mesio-distal direction, cingulum is centered over the
tooth. Mesial and distal sides of the lingual aspect are bordered by linear
elevations called marginal ridges. Both the mesial and distal marginal ridges
are prominent: Distal marginal ridge being more elevated than the mesial
marginal ridge. In addition, canines have a distinct lingual ridge running in a
cervico-incisal direction from cingulum to the cusp tip. Cingulum, marginal
ridges and lingual ridge are confluent with each other with a little evidence of
developmental grooves.

Concavities
The lingual aspect of canines shows a concavity called lingual fossa, which is
more pronounced than those of other anterior teeth. The lingual fossa is
divided into mesial and distal lingual fossae by the lingual ridge.

Root
Root is narrower lingually and much of mesial and distal surfaces are seen
from this aspect.

MESIAL ASPECT
Crown
Shape of Mesial Aspect
The crown is wedge shaped with base at cervical 1/3rd and apex at cusp tip.
The entire crown appears bulkier from this aspect because of prominent labial
and lingual ridges. A greater labio-lingual measurement of this tooth can be
appreciated from this aspect.

Outlines of Mesial Aspect

Labial outline is convex with the crest of convexity at cervical 1/3rd which is
not very close to the cervical line unlike that of incisors. The outline becomes
less convex as it proceeds incisally and becomes more or less straight as it
approaches the cusp tip. The extent of convexity of labial outline is more than
other anterior teeth.
Lingual outline is convex in the cervical 1/3rd at cingulum where the crest of
curvature is located. The outline straightens and becomes concave at middle
1/3rd and again convex in the region of incisal ridge.
Cervical line is curving towards the crown with a greater curvature on mesial
side than distal.
Cusp tip is placed labial to root axis line in most of the canines while in some
it may be in line with the root axis line.

Mesial Surface
Mesial surface is convex on all aspects except for a shallow concavity
between contact area and cervix.

Root
Root is conical with an apical taper. Mesial surface of root has a deep
developmental depression running cervico-apically.

DISTAL ASPECT
General morphology is similar to that of mesial aspect. Differences observed
are:
Curvature of cervical line is less
Distal marginal ridge is heavier and regular
Developmental depression on distal surface of the root is more pronounced
than on the mesial side.

INCISAL ASPECT

From the incisal aspect a greater labio-lingual measurement than mesio-distal

can be well appreciated. The crown is not symmetrical. The mesial half of the
tooth appears more convex and bulkier labio-lingually than distal half so that
the distal half appear as though it is pulled and stretched to make contact with
adjacent tooth. Cusp tip is located labial to midline in a labio-lingual
direction and mesial in a mesio-distal direction with the mesial and distal
cusp slopes almost in straight line mesio-distally. Although parts of labial and
lingual surfaces are visible from this aspect more of lingual surface is seen
because of the labial placement of cusp tip.
Labially, the labial ridge can be seen. The labial surface is markedly
convex near cervical region, becoming broader and flatter at middle and
incisal 1/3rd.
Lingual outline forms a shorter arc than labial outline because of lingual
taper. Lingual surface presence a prominent cingulum which is at center,
marginal ridges, lingual ridge and lingual fossae.

DEVELOPMENTAL VARIATIONS AND

CLINICAL CONSIDERATIONS

Permanent maxillary canines show wide variation in size from very small to
large.
Root division: Root may be bifurcated into labial and lingual roots.
Talon cusp: At times in canines the cingulum may become very prominent to
such an extent, it resembles eagle’s talon, which is referred to as talon cusp.
In such cases chances of dental caries is considerable more. In addition, very
prominent cingulum may interfere with occlusion and may cause trauma to
tongue.

FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE

Labial Aspect
Distal slope of the cusp is longer than mesial slope.
Relatively more curved distal outline than mesial outline.
Mesial contact area is more incisally placed (at junction of incisal and middle
1/3rd) than distal (middle of middle 1/3rd).
Distal tilt of root.

Proximal Aspect
Cervical line more curved on mesial aspect than distal.
Distal surface of the crown often shows a concavity below contact area.

Incisal Aspect
The mesial half of the tooth appears more convex and bulkier labio-lingually
than distal half.
The distal half of the crown appears stretched with greater mesiodistal width
than the mesial half.
Permanent maxillary right canine
 25
Permanent Mandibular
Canines

Introduction
Chronology of mandibular canines
Measurement table
Morphology of mandibular canine
Differences between maxillary and mandibular canines
Developmental variations and clinical considerations

M andibular canines are the third teeth from the midline situated on either
side of mandibular arch, between lateral incisor and first premolar.
They bear close resemblance to maxillary canines and assist them in
function. The morphologic characteristics are described from five aspects,
namely labial, lingual, mesial, distal, and incisal. Further, features on each
aspect (except incisal) is described under two subheadings, i.e. crown and
root.

LABIAL ASPECT

Crown
Shape of Labial Aspect
The crown of mandibular canine appears narrower and longer when
compared to bulky maxillary canine. The long thin appearance is created by
lesser mesio-distal measurement, incisally located contact areas and nearly
straight mesial and distal outlines. Crown is tilted distally on the root base.

Outlines of Labial Aspect

Mesial outline is slightly convex and is in line with mesial root outline.
Mesial contact area is located close to mesio-incisal angle.
Distal outline is somewhat parallel to mesial outline and contact area is
located at the junction of incisal and middle 1/3rd (more cervical location
than on mesial side).
Incisal outline is represented by the cusp with its ridges. Cusp has mesial and
distal cusp ridges meeting at an obtuse angle making it less sharp. Mesial
cusp ridge is nearly horizontal and is noticeably shorter than longer distal
cusp ridge which slopes in an apical direction.
Cervical line is curved towards the root.

Labial Surface
Shows a distinct ridge extending from cervical 1/3rd to the cusp tip which is
named as labial ridge and is less prominent than in maxillary canine.

Root
Root is conical in shape with an apical taper ending in a blunt apex.

LINGUAL ASPECT

Crown
Both crown and root are narrower on the lingual side because of lingual
convergence. Lingual aspect of mandibular canine resembles that of
maxillary canine and shows convexities and concavities. At cervical 1/3rd,
cingulum is present as a convexity, which is slightly distally placed.
Confluent with cingulum on either side marginal ridges are seen. Distal
placement of cingulum makes the mesial marginal ridge longer but distal
marginal ridge is bulkier. The lingual fossa is divided into mesial and distal
lingual fossae by the lingual ridge that runs from cingulum to cusp tip. In
contrast to the maxillary canine in mandibular canine various anatomic
landmarks such as cingulum, marginal ridges and lingual fossae are less
prominent. Therefore lingual aspect appears flatter and smoother.

Chronology of permanent mandibular canine

Root
Root is conical in shape with an apical taper ending in a blunt apex and is
narrower on lingual aspect throughout its length.

MESIAL ASPECT

Crown
Shape of Mesial Aspect
From the mesial aspect mandibular canine is wedge-shaped with the base
located at the cervix and apex at incisal edge. A greater bulk in labio-lingual
direction at cervical 1/3rd can be well appreciated. But the incisal portion
appears thinner and cusp appears more pointed due to less prominent lingual
ridge.
Outlines of Mesial Aspect
Labial outline is curved although the curvature is lesser than that of maxillary
canine. Crest of curvature of labial outline is more close to the cervix. From
the crest of convexity the labial outline shows a lingual inclination up to the
cusp tip.
Lingual outline is relatively straight at cervical 1/3rd in the region of less
prominent cingulum, and then becomes slightly concave till it joins to the
incisal edge. Lingual outline also shows less curvature than maxillary canine.
Cervical line is curved in an incisal direction and is to a deeper degree than in
maxillary canines.
The cusp tip is located lingual to the root axis line in most of the specimens
and in few it may be even centered over root axis line.

Mesial Surface
Mesial surface is convex on all aspects except for a shallow concavity
between contact area and cervix.

Differences between maxillary and mandibular canines (arch traits)

Maxillary canine Mandibular canine
Crown is wider with convex Crown is long and narrow with relatively
mesial and distal outlines straight mesial and distal outlines

Cusp is sharp Less sharp

Contact areas are at Nearly at same level and is more incisally

different levels and is more placed
cervically located

Mesial slope is shorter than Mesial slope is much shorter than distal
distal slope slope

Labial ridge is prominent Labial ridge is less prominent

 Cingulum, lingual ridge, Relatively smooth lingual surface with less
lingual fossae, and marginal prominent cingulum, lingual ridge, lingual
ridges are prominent fossae and marginal ridges

Cingulum is centered Distally placed

Cusp tip is located labial to Lingual to midline

midline

Both the cusp slopes are in Distal cusp slope is lingually placed
straight line

10. Crown appears less More symmetrical

symmetrical when viewed
from incisal aspect

Root
Root outlines are straight up to middle 1/3rd, from where tapering start. Root
tip is more pointed. Deep developmental depression may be seen on root
surface.

DISTAL ASPECT

Distal aspect resembles mesial aspect except for:

Lesser curvature of cervical line
Lingual placement of disto-incisal angle due to disto-lingual twist of crown
More prominent distal marginal ridge
Deeper developmental depression on root.

Incisal Aspect
Greater labio-lingual measurement compared to mesio-distal can be
appreciated from this aspect. When the tooth is viewed from this aspect the
labial and lingual surfaces and cusp can be seen. Labial contour is wider than
lingual contour because of considerable lingual convergence. When viewed
from incisal aspect crest of contour of labial outline is more mesially located.
Distal half of the crown appears more flat compared to convex mesial
portion. Crest of contour of lingual outline is located over cingulum which
may be distally located making mesial marginal ridge longer. Cusp tip is
located more mesially in a mesio-distal direction while lingual to the center in
a labio-lingual direction. The cusp ridges are lingual to the cusp which is
more so in case of distal cusp ridge. The disto-incisal line angle is located
more lingually due to disto-lingual twist of the crown to follow the dental
arch.

DEVELOPMENTAL VARIATIONS AND

CLINICAL CONSIDERATIONS

Permanent maxillary canines show wide variation in size from very small to
large.
Root division: Root may be bifurcated into labial and lingual roots.

FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE

Labial Aspect
Crown is tilted distally on the root base.
Distal slope of the cusp is longer than mesial slope.
Mesial contact area is more incisally placed, located close to mesio-incisal
angle than distal (at junction of incisal and middle 1/3rd).
Distal tilt of root.

Lingual Aspect
Cingulum is distally placed.
Mesial marginal ridge is longer than distal marginal ridge.
Proximal Aspect
Cervical line more curved on mesial aspect than distal.
Distal marginal ridge is more prominent.
Developmental depression on distal surface of root is more prominent.

Incisal Aspect
The distal half of the crown appears more flat compared to convex mesial
half.
The disto-incisal line angle is located more lingually due to disto-lingual
twist of the crown to follow the dental arch.
Permanent mandibular right canine
 26
Permanent Maxillary First
Premolars

Introduction
Chronology of maxillary first premolar
Measurement table
Morphology of maxillary first premolar
Developmental variations and clinical considerations

M axillary premolars are four in number, a first and a second premolar

located on either side of the arch. These teeth are located between
canine and molars. Premolars are the successors of deciduous molars
and there are no premolars in deciduous dentition.
They are called premolars because of their location before molars and
along with molars they are called posterior teeth. The functions include
assisting in mastication and maintenance of vertical height of face. Being a
posterior teeth, they also shares some features with other posterior teeth.
The common characteristics of posterior teeth are
Greater faciolingual measurements when compared to mesio-distal
measurements.
Broader contact areas, nearly at the same level.
Shorter crown, cervico-occlusally when compared to other anterior teeth.
Marginal ridges are in horizontal plane while in anteriors are vertical plane.
From mesial and distal aspect the crest of convexity is not as much cervically
as in case of anteriors.
General characteristics of maxillary premolars (arch traits)
Both maxillary premolars are more alike in morphology with two (one buccal
and one lingual) well developed cusps.
First premolar is larger than second premolar.
In maxillary premolars, both buccal and palatal cusps are more or less equally
developed and are functional cusps.

PERMANENT MAXILLARY FIRST PREMOLAR

Maxillary first premolars belongs to the group of bicuspids and are situated
distal to the maxillary canines on either side. The tooth resembles the canine
from the buccal aspect with a few differences.
The morphologic characteristics of maxillary first premolar can be
described from five aspects, namely buccal, palatal/lingual, mesial, distal, and
occlusal. Further, features on each aspect (except occlusal) is described under
two subheadings, i.e. crown and root.

BUCCAL ASPECT

Crown
Shape of Buccal Aspect
Shape of the crown from the buccal aspect is roughly trapezoidal with the
shorter arm of the uneven side representing the cervical portion. This
appearance is created by the cervical convergence. The mesio-distal
dimension at the cervix is 2 mm less than its width at the points of its greatest
mesio-distal measurement.

Chronology of permanent maxillary first premolar

Outlines of Buccal Aspect
Mesial outline shows a slight concavity from the cervical line to the contact
area (crest of curvature) which lies immediately occlusal to the halfway point
between the cervical line and the buccal cusp tip.
Distal outline is relatively straight or less convex than the mesial outline from
the cervical line to the contact area. The contact area (crest of curvature) on
distal side lies nearly at the same level or slightly more occlusal to the contact
area on mesial side, which is broader.
Occlusal outline is represented by the buccal cusp and cusp slopes. The
buccal cusp is long and has a pointed tip and shows mesial and distal cusp
slopes. The mesial cusp slope is straighter and longer when compared to the
distal slope which is shorter and more curved. The tip of the buccal cusp lies
distal to a line bisecting the buccal surface of the crown.
Cervical outline is semicircular with the convexity towards the root.

The Buccal Surface

Buccal surface is convex with a prominent middle lobe. This is seen as a
ridge on the buccal surface and is called the buccal ridge which runs
vertically from the cervical region to the buccal cusp tip. On either side of the
buccal ridge, i.e. mesial and distal, there may be shallow developmental
depressions which demarcate the mesio-buccal and disto-buccal lobe from
the middle buccal lobe.

Root
Although the maxillary first premolar has two roots, the buccal root
superimposes the palatal root, and therefore only the buccal root is visible
from this aspect. The buccal root is tapered apically with blunt apex.

PALATAL OR LINGUAL ASPECT

Crown
The palatal aspect of the crown is the reverse of the outline of the buccal
aspect.
The crown tapers towards the lingual and the tapering is more from the
distal aspect, so that more of the distal surface is seen from this aspect.
The palatal surface is spheroidal or smoothly convex with convex mesial
and distal outline which are in continuation with the mesial and distal cusps
slopes of the palatal cusp.
The palatal cusp is 1 to 1.5 mm shorter than the buccal cusp which makes a
portion of the buccal cusp visible from this aspect. The cusp slopes of lingual
cusp meet at somewhat rounded angle.
The cervical line is convex and regular with the curvature towards the root.

Root
In most of the cases, only the palatal root is visible as it superimposes the
buccal root. A portion of the buccal root may also be visible from this aspect.

MESIAL ASPECT

Crown
Shape of Mesial Aspect
Shape of the crown from the mesial aspect is roughly trapezoidal with the
occlusal outline representing the shorter arm of the uneven side. Bucco-
lingual dimension appears to be greater than the mesio-distal.

Outlines of Mesial Aspect

Buccal outline is convex from the cervical line to the cusp tip. The crest of
curvature is at junction of cervical and middle third from where the curvature
becomes less.
Palatal or lingual outline shows a smooth curvature from the cervical line to
the cusp tip with crest of curvature at the middle of middle third.
Occlusal outline is represented by the cusps and marginal ridge. Both the
buccal and lingual cusps are visible from this aspect and the tips of the cusps
are well within the confines of the root trunk. Buccal cusp is more prominent,
longer and the tip is in line with the center of the buccal root. Lingual cusp is
1 mm shorter and less sharp than the buccal cusp and the tip is in line with
the lingual border of the lingual root. The mesial marginal ridge is prominent,
which is located at the level of junction of occlusal and middle third. The
mesial marginal ridge is traversed by a distinct developmental groove which
crosses the marginal ridge immediately lingual to the mesial contact area.
This groove is called mesial marginal developmental groove and extends
from the central groove to a short distance on the mesial aspect.
The cervical line may be regular or irregular and is directed towards the
occlusal aspect.

Mesial Surface
Mesial surface appears to be convex at all points except for the marked
depression called the mesial developmental depression or canine fossa,
immediately cervical to the contact area which may extend up to the level of
the root bifurcation.

Root
The root begins at the cervix as a single trunk and shows bifurcation giving
rise to a buccal root and a lingual root. The level of bifurcation varies from
the middle half to apical third of root length. Because of the apical location of
the furcation area, furcation involvement of this tooth is least likely to occur
in periodontal diseases. If involved prognosis is poor.
A developmental groove and a depression are present on the root surface
below the furcation area.

DISTAL ASPECT

Gross morphology is similar to that of mesial aspect with a few differences.

Surface shows convexity from almost all points except for a small flattened
area cervical to the contact area.
No developmental groove crossing the distal marginal ridge on this aspect.
No developmental depression on this aspect.
Curvature of cervical outline is very less and is almost straight from buccal to
palatal.
Bifurcation of root is at an apical level compared to mesial aspect.

OCCLUSAL ASPECT

Shape and Outlines

Shape is hexagonal; the six sides are mesio-buccal, disto-buccal, mesial,
distal, mesio-lingual and disto-lingual. The sides are unequal and the length
of each side depends on the location of four crests.
Crest of the buccal outline (buccal crest) is located distal to the midline
while the crest of the lingual outline (lingual crest) is mesial to the midline in
a bucco-lingual direction.
Crests of both mesial and distal outlines, i.e. mesial and distal crests are
located in the buccal half, but the location of distal crest is more buccally
when compared to the mesial crest.
Distance between the buccal crest and mesial crest is more than the
distance between the buccal crest and distal crest making the mesio-buccal
outline longer than the disto-buccal outline. This is the result of distal
location of buccal crest and buccal location of distal crest when compared to
the relatively lingual location of mesial crest.
 Because of the buccal placement of distal crest when compared to the
lingually located mesial crest, the distal outline becomes longer than mesial
outline. The mesial placement of lingual crest makes the disto-lingual outline
longer than mesio-lingual outline.
Greater bucco-lingual dimension of crown than the mesio-distal dimension
can be appreciated from this aspect. Mesio-buccal cusp ridge and mesial
marginal ridge meet at an angle of 90 degree and disto-buccal cusp ridge and
distal marginal ridge meet at an acute angle.
Occlusal aspect of maxillary first premolar shows slight convergence to the
palatal aspect. The degree of lingual convergence is more from distal aspect.
Mesial outline is relatively straight and the mesio-lingual line angle is
more distinct while the disto-lingual line angle is rounded so that distal and
disto-lingual outline together forms a semicircular outline.

Occlusal Surface
Occlusal surface shows various anatomic landmarks such as cusps, ridges,
fossae and grooves.

Cusps
Premolar has two equally developed cusps, one buccal cusp and one palatal
cusp. Buccal cusp is 1 mm longer and more pointed than palatal cusp.

Ridges
Triangular ridges of buccal and palatal cusps are seen extending from the tip
of cusp to the centre of occlusal aspect. Buccal triangular ridge is more
prominent than palatal triangular ridge.
Transverse ridge: The triangular ridge of the buccal cusp meets the triangular
ridge of the palatal cusp to form a transverse ridge.
Mesial marginal ridge: Forms the mesial boundary of the occlusal aspect and
is located more occlusally than the distal marginal ridge.
Distal marginal ridge: It is located at distal margin of occlusal aspect and is
more cervically placed.
Cusp ridges of buccal and lingual cusp forms the buccal and lingual boundary
of occlusal aspect.
Grooves
Developmental and supplemental grooves are seen.

Developmental grooves
Central developmental groove divides the occlusal surface into equal halves,
extending in a mesio-distal direction from mesial triangular fossa to distal
triangular fossa.
Mesio-buccal and disto-buccal developmental grooves: There are two
collateral developmental grooves extending from mesial and distal pit
respectively in a buccal direction.
Mesial marginal developmental groove: This is a distinguishing feature seen
in maxillary first premolar. This groove starts from the mesial pit as an
extension from the central groove, runs in a mesial direction across the mesial
marginal ridge immediately lingual to the mesial contact area and ends on the
mesial surface.

Supplementary grooves
Supplementary grooves may be seen in addition to the developmental
grooves, and are relatively few in number.

Fossae and Pits

Mesial triangular fossa is present as a triangular depression just distal to
mesial marginal ridge.
Distal triangular fossa is located mesial to distal marginal ridge.
Pits may be present in triangular fossae where the grooves converge.

DEVELOPMENTAL VARIATIONS AND

CLINICAL CONSIDERATIONS

Single root: In maxillary first premolars, root may remain undivided and
present as single root.
Leongs premolar/Dens evaginatus: At times an accessory tubercle may be
seen on occlusal aspect between buccal and lingual cusps. This is referred to
as Leongs premolar/Dens evaginatus. This structure may interfere with
occlusion. At times wearing away of covering enamel and dentin lead to
exposure of pulp, necessitating root canal treatment.
Mesial developmental depression on mesial aspect of crown that extends
even onto the root may increase the possibility of periodontal diseases.

FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE

Buccal Aspect
Mesial slope of the buccal cusp is longer than distal slope
Buccal surface shows prominent depression mesial to buccal ridge
Distal tilt of root

Palatal Aspect
Lingual cusp tipped to the mesial side.

Proximal Aspect
Cervical line is more curved on mesial aspect than distal.
Distal marginal ridge is more cervically located compared to mesial marginal
ridge.
Presence of mesial marginal developmental groove.
Presence of mesial developmental depression extending from crown to the
mesial surface of root.

Occlusal Aspect
Mesiobuccal cusp slope is longer.
Straight mesial outline.
Angle between mesiobuccal and mesial outline is nearly 90 degree.
Distolingual outline of occlusal aspect is curved with lingual convergence.
Longer and convex distal marginal ridge.
Large and deeper distal triangular fossa.
Permanent Maxillary First Premolars
 27
Permanent Maxillary Second
Premolars

Introduction
Chronology of maxillary second premolar
Measurement table
Morphology of maxillary second premolar
Differences between maxillary first and second premolars
Developmental variations and clinical considerations

M axillary second premolars closely resemble the first premolar in its

general morphology and supplement them in functions such as
mastication and maintenance of vertical height of face. In contrast to
first premolars, second premolars are more rounded and has single root. The
morphologic characteristics can be described from five aspects, namely
buccal, palatal/lingual, mesial, distal, and occlusal. Further, features on each
aspect (except occlusal) is described under two subheadings, i.e. crown and
root.

BUCCAL ASPECT

Crown
Shape of Buccal Aspect
Shape of the crown is squarish and is less angular. Crown shows lesser
degree of cervical convergence.

Outlines
Mesial outline is slightly curved with mesial contact area located near the
junction of middle and occlusal 1/3rd.
Distal outline is more convex than mesial outline and contact area on distal
side is slightly more cervically placed than that of mesial.
Occlusal outline is represented by buccal cusp and cusp slopes. Cusp slopes
meet at an obtuse angle making the buccal cusp tip less pointed. In contrast to
the first premolar, mesial cusp slope is shorter than the distal cusp slope.
Cervical line is only slightly curved towards the root.
Buccal surface: Buccal surface is smooth and convex. The middle buccal
lobe is well developed to form a buccal ridge that extends cervico-occlusally
up to the cusp tip. The buccal ridge is less prominent in second premolar than
in first premolar. Very shallow depression may be present on either side of
ridge.

Root
Maxillary second premolar has only one root. Root is conical in shape with
tapered apex bending distally.

Chronology of permanent maxillary second premolar

 PALATAL OR LINGUAL ASPECT

Crown
Palatal aspect is slightly narrower than the buccal due to palatal convergence,
but the degree of convergence is less compared to that of first premolar. The
palatal cusp is sharp and its height is almost same as that of buccal cusp. Tip
of the palatal cusp is slightly mesially located to the center, in a mesiodistal
direction.

Root
From palatal aspect root is smooth with a little convergence.

MESIAL ASPECT

Crown
Shape of Mesial Aspect
Shape of the crown from the mesial aspect is somewhat similar to that of first
premolar and is roughly trapezoidal with the occlusal outline representing the
shorter arm of the uneven side.

Outlines of Mesial Aspect

Buccal outline is convex from the cervical line to the cusp tip. The crest of
curvature is near to the junction of cervical and middle one third.
Palatal or lingual outline shows a smooth curvature from the cervical line to
the cusp tip with crest of curvature at the center of middle third.
Occlusal outline is represented by the buccal and palatal cusps and mesial
marginal ridge. Both the buccal and palatal cusps are visible from this aspect
and the tips of the cusps are well within the confines of the root trunk. Buccal
and palatal cusps are nearly of the same height. The intercuspal distance
between the buccal and palatal cusps is more, making the occlusal table wide.
The mesial marginal ridge is slightly concave and is located more occlusally
when compared to the distal marginal ridge. No developmental groove is
found crossing the mesial marginal ridge of second premolar.
The cervical line is directed towards the crown with a shallow curvature.

Mesial Surface
Mesial surface appears to be convex and the mesial developmental
depression observed in first premolar is not found in second premolar.

Root
Root is conical and shows shallow depression running longitudinally on
mesial surface.

DISTAL ASPECT

Morphology is similar to that of mesial aspect. Distal marginal ridge is more

cervically placed when compared to mesial. Therefore more of occlusal
aspect can be seen. (Feature common to all posterior teeth except mandibular
first premolar).

OCCLUSAL ASPECT
Shape
Occlusal aspect of maxillary second premolar is less angular and is ovoid in
shape. Greater bucco-lingual dimension of crown than the mesio-distal
dimension can be appreciated from this aspect. Because of less lingual
convergence, the buccal and palatal halves of occlusal surface are almost
equal in width. Tooth is bilaterally more or less symmetrical. When observed
from occlusal aspect contact area on mesial side is at the junction of buccal
and middle 1/3rd and on distal side is slightly lingual to the position of mesial
contact area.
Buccal ridge appears to be less prominent. Lingual crest may be slightly
mesially located.

Occlusal Surface
Occlusal surface shows various anatomic landmarks such as cusps, ridges,
grooves, fossae and pits.

Differences between maxillary first and second premolars (type traits)

Maxillary first premolar Maxillary second premolar
Larger, longer and sharper buccal Smaller, shorter and less sharp
cusps buccal cusp

Mesial slope of buccal cusp is Distal slope of buccal cusp is longer

longer than distal slope than mesial slope

Prominent buccal ridge Less prominent buccal ridge

More cervical convergence of Less cervical convergence of crown

crown on buccal aspect on buccal aspect

Crown is narrower on lingual aspect Lingual taper of crown is less

Buccal cusp is longer than palatal Both buccal and palatal cusps are
cusp nearly of same height
 Mesial developmental groove is No such groove is seen
present crossing over the marginal
ridge to the mesial surface

Mesial developmental depression on No mesial developmental

the mesial surface of crown and root depression on the mesial surface of
crown and root

Cusps are relatively closer and Cusps are spread apart and occlusal
occlusal table is narrower table is wider

10. Occlusal aspect is asymmetrical and Occlusal aspect is symmetrical and

is hexagonal in shape is oval in shape

11. Central groove is longer Central groove is shorter

12. Supplementary grooves are Supplementary grooves are many

relatively a few in number making occlusal aspect irregular or
wrinkled in appearance

13. First premolar usually has two roots Second premolar usually has only
one root

Cusps
Second premolar has two equally developed cusps: One buccal cusp and one
palatal cusp, Buccal and palatal cusps are nearly of same height. The
intercuspal distance between the buccal and palatal cusp tips is more making
the occlusal table wide.

Ridges
Triangular ridges of buccal cusp and palatal cusp are seen extending from the
tip of cusp to the center of occlusal aspect.
Transverse ridge: A transverse ridge is formed by union of the triangular
ridge of the buccal cusp and the triangular ridge of the palatal cusp.
Mesial marginal ridge: Forms the mesial boundary of the occlusal aspect and
is located more occlusally than the distal marginal ridge.
Distal marginal ridge: It is located at distal margin of occlusal aspect and is
more cervically placed.
Cusp ridges of buccal and palatal cusps forms the buccal and palatal
boundary of occlusal aspect.

Grooves
Central developmental groove is relatively short and it extends in a mesio-
distal direction from mesial triangular fossa to distal triangular fossa, dividing
the occlusal surface into buccal and lingual halves.
Supplementary grooves are many in this tooth making occlusal aspect
irregular or wrinkled in appearance.

Fossae and Pits

Mesial triangular fossa is present as a triangular depression just distal to
mesial marginal ridge.
Distal triangular fossa is located mesial to distal marginal ridge.
Pits may be present in triangular fossae where the grooves converge.

DEVELOPMENTAL VARIATIONS AND

CLINICAL CONSIDERATIONS

Leongs premolar/Dens evaginatus-at times an accessory tubercle may be seen

on occlusal aspect between buccal and lingual cusps. This is referred to as
Leongs premolar/Dens evaginatus. This structure may interfere with
occlusion. At times wearing away of covering enamel and dentin lead to
exposure of pulp, necessitating root canal treatment.

FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Buccal Aspect
Mesial slope of the buccal cusp is shorter than distal slope.
Distal tilt of root.

Palatal Aspect
Lingual cusp tipped to the mesial side.

Proximal Aspect
Cervical line is more curved on mesial aspect than distal.
Distal marginal ridge is more cervically located compared to mesial marginal
ridge.
Deeper developmental depression on distal aspect of root.

Occlusal Aspect
Lingual cusp tipped to the mesial side.
Distobuccal cusp slope is longer.
Longer and convex distal marginal ridge.
Large and deeper distal triangular fossa.
Permanent maxillary second premolar
 28
Permanent Mandibular First
Premolars

Introduction
Chronology of mandibular first premolar
Measurement table
Morphology of mandibular first premolar
Differences between maxillary and mandibular first premolars
Developmental variations and clinical considerations

M andibular premolars are four in number, two first premolars and two
second premolars located one on each side of the dental arch. They are
successors of mandibular deciduous molars. The functions include
mastication and maintenance of vertical dimension of face. Also assists
canines to shearing the teeth and support the side of mouth and cheeks.

GENERAL CHARACTERISTICS OF
MANDIBULAR PREMOLARS (ARCH TRAITS)

Mandibular premolars do not resemble each other, in contrast to maxillary

premolars of similar morphology.
Mandibular second premolar is larger than first premolar.
In mandibular premolars, buccal cusps are more developed than lingual cusp.
Lingual cusp is nonfunctional cusp in first premolar.
From buccal and lingual aspects, mandibular premolar crown appears to be
tilted distally (more significant in first premolar).
From proximal aspect both mandibular premolars are tilted lingually, with
lingual outline extending beyond the boundary of root outline.

PERMANENT MANDIBULAR FIRST PREMOLAR

Mandibular first premolar is located between canine and second premolar and
therefore bears resemblance to both, in certain features. The morphologic
characteristics of mandibular first premolar can be described from five
aspects, namely buccal, lingual, mesial, distal, and occlusal. Further, features
on each aspect (except occlusal) is described under two subheadings, i.e.
crown and root.

BUCCAL ASPECT

Crown
Shape of Buccal Aspect
From this aspect the tooth is bilaterally symmetrical and has a trapezoidal
shape with narrow cervix.
Mesial outline is straight or slightly convex from cervix to contact area.
Contact area is located slightly occlusal to midpoint of the tooth.
Distal outline is more convex and the contact area is nearly at the same level
as mesial or slightly more occlusal in its location.

Chronology of permanent mandibular first premolars

Occlusal outline is represented by buccal cusp and cusp slopes. Buccal cusp
is long and sharp and the cusp tip is located slightly mesial to the center.
Mesial cusp ridge is shorter than the distal cusp ridge. The cusp ridges meet
at an obtuse angle.
Cervical line is slightly curved towards the root.
Buccal surface: Buccal surface is convex with a well-developed buccal ridge
extending vertically from cervical region to the cusp tip. On either side of
buccal ridge, shallow depressions may be present.

Root
Mandibular first premolar has only one root. Root is conical and tapers to a
nearly pointed apex.

LINGUAL ASPECT

Crown
From this aspect mandibular premolars show many unique characteristics.
Crown and root taper considerably to the lingual side, making a part of
mesial and distal aspect visible from this aspect.
Occlusal aspect slopes lingually in a cervical direction; therefore most of
occlusal aspect can be seen from lingual aspect.
Contact areas and marginal ridges are more prominent because of narrow
cervical region.
Lingual cusp is short and poorly developed but is pointed. This cusp is a non-
occluding cusp.
Both mesial and distal marginal ridges can be seen. Mesial marginal ridge is
sloping and more cervically placed, while distal marginal ridge is relatively
straight and more occlusally placed (more cervical location of the mesial
marginal ridge is seen only in this tooth while in all other posterior teeth
mesial marginal ridge is more occlusally placed than the distal marginal
ridge).
Another characteristic feature observed in this tooth is the mesio-lingual
developmental groove which extends to lingual surface along the mesio-
lingual line angle, demarcating the mesial marginal ridge from mesial slope
of lingual cusp.

Root
Root is conical in shape and is narrow on lingual aspect.

MESIAL ASPECT

Crown
Shape of Mesial Aspect
Crown is rhomboidal in shape with noticeable tilt to the lingual side at the
cervix.

Outlines
The buccal outline is curved from cervical line to the buccal cusp tip. A
distinct inclination to lingual side is observed with the crest of curvature
located at the junction of middle and cervical 1/3rd.
Lingual outline is less curved than buccal and crest of curvature is located
nearly at middle 1/3rd. Because of extreme lingual tilting, lingual outline
extend beyond the boundary of root outline giving an impression that the
lingual side of the tooth is overhanging.
Occlusal outline is represented by buccal and lingual cusps and mesial
marginal ridge. The inclination of the occlusal aspect can be well appreciated
from mesial aspect and the lingual height of the crown is only 2/3rds of
buccal height. Buccal cusp is centered over the root and most of occlusal
portion is occupied by buccal triangular ridge which also shows a cervical
inclination. Lingual cusp is short but sharp and is nonfunctional. Lingual cusp
tip is in line with lingual outline of root. The mesial marginal ridge is at a
lower level compared to distal marginal ridge and it shows an inclination in a
cervical direction. Because of this more of occlusal surface can be seen from
this aspect. The direction of mesial marginal ridge is almost parallel to that of
buccal triangular ridge but located at a lower level.
Cervical line is slightly curved towards the crown.
Mesial surface: Mesial surface is smooth. A prominent mesio-lingual
developmental groove can be visible which demarcate the mesial marginal
ridge from mesial slope of lingual cusp and extending to lingual surface
along the mesio-lingual line angle.

Root
Root is nearly straight at cervical 1/3rd and taper at apical 1/3rd to a blunt
apex. A deep developmental groove may be present on root.

DISTAL ASPECT

Distal aspect of mandibular first premolar shows various differences from

mesial aspect.
Distal marginal ridge is longer and is more occlusal than that of mesial
marginal ridge.
Distal marginal ridge is horizontal; nearly perpendicular to long axis of tooth;
in contrast to mesial marginal ridge which shows a lingual inclination.
No evidence of developmental groove on the distal aspect of crown.
Root is more convex on distal aspect.

OCCLUSAL ASPECT

Shape
The occlusal aspect is roughly diamond shaped. Tooth is not bilaterally
symmetrical. The distal portion appears to be bulkier than mesial.
Considerable degree of lingual convergence of the tooth can be appreciated
from this aspect which is more from mesial aspect. Occlusal aspect is
broadest at the buccal half, in the region of contact; which is located
immediately lingual to buccal line angles. Because of lingual inclination
more of buccal surface is seen which shows a distinct buccal ridge. The crest
of lingual outline is located distal to center of tooth.

Occlusal Surface
Occlusal surface shows anatomic landmarks such as cusps, ridges, fossa,
grooves, and pits, etc.

Cusps
Occlusal surface of mandibular first premolar shows two cusps: One buccal
cusp and a lingual cusp. Buccal cusp and its triangular ridge make up the bulk
of the occlusal surface of the tooth. Buccal cusp tip is near the center of
crown and the cusp slopes are nearly in a straight line.

Differences between maxillary first and mandibular first premolars

(arch traits)
Maxillary first premolar Mandibular first premolar
Crown do not show lingual Crown shows a significant lingual
inclination inclination so that buccal cusp tip is in-
line with midline

Mesial slope of buccal cusp is Distal slope of buccal cusp is longer than
longer than distal slope mesial slope
 Both buccal and lingual cusps Buccal cusp is well developed but the
are almost equally developed lingual cusp is much smaller and the
crown height lingually is only 2/3rds of
the buccal aspect

Palatal cusp is occluding cusp Lingual cusp is non-occluding cusp

Occlusal aspect is hexagonal in Diamond shaped with significant lingual

shape with relatively less convergence
lingual convergence

Occlusal aspect do not incline Occlusal aspect inclines cervically

cervically

Central groove is located at the Central groove is more lingually located

center of occlusal aspect so that the buccal portion is much larger
dividing it into equal buccal than lingual portion
and palatal halves

Triangular fossae are distinct Not distinct

Mesial marginal developmental No mesial marginal developmental

groove is present groove, instead a mesio-lingual
developmental groove is seen

10. Mesial marginal ridge is Mesial marginal ridge is sloping and is

relatively straight and is at a at a lower level than that of distal
higher level than that of distal marginal ridge
marginal ridge

11. Mesial aspect of crown and No such developmental depression is

root has a developmental seen
depression

12. Usually has two roots Only one root

Lingual cusp is small, sharp and is nonfunctional. Tip is at considerably

lower level than buccal cusp. Lingual cusp occupies only a small portion of
occlusal surface.

Ridges
Triangular ridges of both buccal and lingual cusps can be seen. Buccal
triangular ridge occupies the major portion of occlusal aspect which also
shows a lingual inclination. The triangular ridge of buccal cusp forms a
transverse ridge with the small triangular ridge of lingual cusp.
Marginal ridges are well developed and prominent. The mesial marginal
ridge is at a lower level compared to distal marginal ridge and it shows an
inclination in a cervical direction. Distal marginal ridge is horizontal; nearly
perpendicular to long axis of tooth and is more occlusally placed than that of
mesial marginal ridge.

Fossa and Pits

Occlusal surface of mandibular first premolar shows two minor fossae, which
are located on either side of the transverse ridge, namely mesial and distal
fossae. The mesial fossa is linear and shallow when compared to circular and
deeper distal fossa. Pits may be seen in fossae where the grooves converge.

Grooves
A shallow central groove may be found extending from mesial to distal fossa
across the transverse ridge. The central groove is placed more lingually,
therefore, it divides the occlusal surface into two unequal parts. Mesial and
distal developmental grooves are found in the fossae, which run in a bucco-
lingual direction. Mesial groove is in continuation with mesio-lingual
developmental groove which crosses onto lingual side along the mesio-
lingual line angle, separating mesial marginal ridge and mesial slope of
lingual cusp.

DEVELOPMENTAL VARIATIONS AND

CLINICAL CONSIDERATIONS

Leongs premolar/Dens evaginatus-at times an accessory tubercle may be seen

on occlusal aspect between buccal and lingual cusps. This is referred to as
Leongs premolar/Dens evaginatus. This structure may interfere with
occlusion. At times wearing away of covering enamel and dentin lead to
exposure of pulp, necessitating root canal treatment.
Mesio-lingual developmental groove at times extends even onto the root may
increase the possibility of periodontal diseases.

FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE

Buccal Aspect
Distal slope of the buccal cusp is longer than mesial slope.
Distal tilt of root.

Lingual Aspect
Mesiolingual developmental groove.

Proximal Aspect
Cervical line is more curved on mesial aspect than distal.
Presence of mesio-lingual developmental groove.
Mesial marginal ridge is more cervically located and slopes from buccal to
lin-glial.
Distal marginal ridge is more occlusally placed compared to mesial marginal
ridge and is perpendicular to long axis of tooth.
Deep developmental depression on distal surface of root.

Occlusal Aspect
Distobuccal cusp slope is longer.
Mesiolingual developmental groove.
Permanent mandibular right first premolar
 29
Permanent Mandibular
Second Premolars

Introduction
Chronology of mandibular second premolar
Measurement table
Morphology of mandibular second premolar
Differences between mandibular first and second premolars
Developmental variations and clinical considerations

M andibular second premolars are larger than first premolars and are
located between first premolar and first molar. Except for buccal
aspect, second premolar does not resemble first premolar in
morphology. Second premolars are mainly seen in two forms; two cusp types
and three cusp types which differ from each other mainly in occlusal
morphology. The morphologic characteristics of mandibular second premolar
can be described from five aspects, namely buccal, lingual, mesial, distal, and
occlusal. Further, features on each aspect (except occlusal) is described under
two subheadings, i.e. crown and root.

BUCCAL ASPECT

Crown
Shape of Buccal Aspect
Crown appears squarish from buccal aspect. This appearance is created due to
short and less sharp buccal cusp and wider cervical 1/3rd which results from
less cervical convergence.

Outlines of Buccal Aspect

Mesial outline is curved and contact area is broader which is located occlusal
to the junction of middle and occlusal 1/3rd.
Distal outline is also slightly curved and the contact area is located relatively
in a cervical position than that of the mesial contact area.
Occlusal outline is represented by buccal cusp and cusp slopes. Buccal cusp
is short, less pointed and tip is located slightly mesial to the center. Distal
cusp ridge is longer than mesial cusp ridge. Cusp ridges meet at an obtuse
angle making the cusp less sharp.
Cervical line is curved towards the crown

Buccal Surface
Buccal surface is convex with a buccal ridge which is inconspicuous,
extending from cervical region to the cusp tip. On either side of buccal ridge
shallow depression may be present.

Root
Root is wider and longer; ending in a blunt apex which may be tilted distally.

Chronology of permanent mandibular second premolar

 LINGUAL ASPECT

Crown
From this aspect second premolar exhibits considerable morphological
variations from that of first premolar. Difference can also be observed
between two cusp type and three cusp type second premolars.
The lingual aspect is narrower than buccal aspect but, the degree of
convergence is not as prominent as in mandibular first premolar. In three
cusp type the lingual side shows only minimal convergence.
Lingual cusp is well developed and is only slightly shorter than buccal
cusp making only part of occlusal aspect visible from this aspect.
In two cusp types only one lingual cusp is seen, the cusp ridges of which
merges with marginal ridges.
In three cusp types two lingual cusps are seen separated by a groove that
extends onto lingual surface. Mesio-lingual cusp is longer and broader than
disto-lingual cusp therefore help in side identification. Lingual surface is
smooth and convex.

Root
Root is smooth and convex and taper apically to end in a blunt apex.
 MESIAL ASPECT

Crown
Shape of Mesial Aspect
From this aspect crown shows a lingual inclination, but to a lesser extent than
that of first premolar. Crown and root are wider bucco-lingually than first
premolar.

Outlines of Mesial Aspect

The buccal outline is less convex than that of first premolar and crest of
convexity of buccal outline is located at junction of middle in cervical 1/3rd.
Lingual outline is convex and it extends beyond the root boundary in the
region of crest of curvature which is located in the middle of middle 1/3rd.
Occlusal outline is represented by buccal and lingual cusps and mesial
marginal ridge. Buccal cusp is less sharp and is not so near to the midline of
the tooth. Lingual cusp is well developed and larger in both two and three
cusp types and is slightly shorter than that of buccal cusp (around 1.5 mm).
The tip of lingual or mesio-lingual cusp is almost inline with lingual outline
of the root. Because of well developed lingual lobe the occlusal surface does
not show a lingual sloping. Mesial marginal ridge is more occlusally placed
and horizontal making only a lesser portion of occlusal surface visible from
this aspect.
Cervical line is curved towards the crown.
Mesial surface: Mesial surface is smooth and convex. In contrast to first
premolar, there is no evidence of mesio-lingual developmental groove.

Root
Root is conical and tapers apically to a blunt apex.

DISTAL ASPECT
Morphology is similar to the mesial aspect. More of occlusal aspect is seen
from this aspect due to two reasons.
Distal tilt of the crown on root base
Concave and cervically located distal marginal ridge.
In three cusp types the disto-lingual cusp is smaller; therefore part of
mesio-lingual cusp is also visible from this aspect.

OCCLUSAL ASPECT

Occlusal morphology varies considerably in two and three cusp forms.

Three Cusp Type

Shape
In three cusp types, occlusal aspect is squarish with minimal lingual
convergence. In some teeth, lingual aspect is even wider than buccal portion.

Occlusal Surface
Occlusal surface shows anatomic landmarks such as cusps, ridges, fossae and
pits, grooves, etc.

Differences between mandibular first and mandibular second

premolars (type traits)
Mandibular first premolar Mandibular second premolar
Crown is longer Crown is shorter

Buccal cusp is sharp Buccal cusp is less pointed

Mesial contact area is more Distal contact area is more cervically

cervically placed than distal placed than mesial contact area
contact area

From buccal aspect cervical From buccal aspect cervical

 convergence is more with convergence is less with relatively
relatively narrow cervix broader cervix

Buccal ridge is more prominent Buccal ridge is less prominent

Crown shows considerable lingual Crown does not show much of

convergence lingual

Only one lingual cusp is seen One or two lingual cusps are seen

No lingual groove is seen In three cusp type a lingual groove is

seen

Lingual cusp is very short, narrow Lingual cusp is well developed and is
and is non-occluding cusps only lightly shorter than buccal cusp

10. Crown shows much lingual The crown is lingually inclined to a

inclination so that buccal cusp tip lesser extent and buccal cusp tip is
is in-line with root not so near to the midline

11. From the occlusal aspect crown is Square shaped

diamond shaped

12. Occlusal aspect is lingually No lingual inclination of occlusal

inclined and most of the occlusal aspect and only a little of occlusal
aspect can be seen from lingual aspect can be seen from lingual
aspect aspect

13. A transverse ridge is seen in the No transverse ridge is seen

occlusal aspect between buccal
and lingual cusp

14. Mesial marginal ridge is at a lower Mesial marginal ridge is at a high

level and is slopping lingually level and is almost straight

15. Mesio-lingual developmental No mesio-lingual developmental

groove is found extending onto groove is present
lingual surface
Cusps
In this type three cusps are seen: One buccal cusp and two lingual cusps. The
buccal cusp is largest followed by mesio-lingual cusp and disto-lingual cusp
is the smallest.

Ridges
All the three cusps have well developed triangular ridges. Mesial and distal
marginal ridges are found forming the mesial and distal boundaries of
occlusal aspect. Distal marginal ridge is slightly concave and cervically
located. Mesial marginal ridge is straight and is occlusally placed.

Fossae and Pits

There are three fossae in three cusps type:
A central fossa which is located nearly at the center of the occlusal surface
and is slightly distal to the center in a mesio-distal direction and at the center
in a bucco-lingual direction. The central fossa harbors a central pit.
Triangular fossae: Inner to the marginal ridges, on either side of occlusal
aspect mesial and distal triangular fossae are seen.

Grooves
Mesial developmental groove: Starts from central pit runs in a mesial
direction to end in the mesial triangular fossa.
Distal developmental groove: Extends from central pit to distal triangular
fossa.
Lingual groove: Extends from central pit, travel in a lingual direction
between the two lingual cusps and runs to a short distance onto the lingual
surface.
Supplementary grooves are seen radiating from developmental grooves.
All the three developmental grooves converge at the central pit giving a Y-
shaped configuration.
Two Cusps Type
In two cusp type second premolars, the occlusal aspect has a round shape
with more lingual convergence. Mesio-lingual and disto-lingual line angles
are rounded. Marginal ridges form the boundary of occlusal surface. Only
two cusps are seen: One buccal cusp and one lingual cusp, both are well
developed. Lingual cusp is located directly opposite to buccal cusp and
triangular ridges of both cusps form a transverse ridge. Mesial and distal
fossae are seen inner to marginal ridges which are roughly circular. Central
fossa is absent in two cusp types. A central groove extends from mesial to
distal fossa. This groove has a ‘U’ or crescent shape. Supplementary
grooves are also present in the fossae.

DEVELOPMENTAL VARIATIONS AND

CLINICAL CONSIDERATIONS

Leongs premolar/Dens evaginatus—at times an accessory tubercle may be

seen on occlusal aspect between buccal and lingual cusps. This is referred to
as Leongs premolar/Dens evaginatus. This structure may interfere with
occlusion. At times wearing away of covering enamel and dentin lead to
exposure of pulp, necessitating root canal treatment.

FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE

Buccal Aspect
Distal slope of the buccal cusp is longer than mesial slope.
Distal tilt of root.

Lingual Aspect
Distolingual cusp is smaller than mesiolingual cusp.

Proximal Aspect
Cervical line is more curved on mesial aspect than distal.
Distal marginal ridge is more cervically located.
Mesial marginal ridge is more occlusally placed and almost straight.
Deep developmental depression on distal surface of root.

Occlusal Aspect
Distolingual cusp is smaller than mesiolingual cusp.
Large, deeper distal triangular fossa.
Permanent mandibular right second premolar
 30
Permanent Maxillart First
Molars

Introduction
Chronology of maxillary first molar
Measurement table
Morphology of maxillary first molar
Developmental variations and clinical considerations

T here are three types of permanent molars: The first molar, second molar,
and third molar. In the permanent dentition, there are 12 molars, three in
each quadrant and are non-succedaneous teeth. The name molar comes
from the Latin word for “grinding”. Molar teeth have a major role in
mastication of food, giving support to the cheeks and also in maintaining
vertical dimension of face and fullness of cheek.

GENERAL CHARACTERISTICS OF
PERMANENT MAXILLARY MOLARS (ARCH
TRAITS)

Maxillary molars are larger than other maxillary teeth.

Crown is bucco-lingually larger in contrast to the corresponding teeth on the
mandibular arch which are larger mesio-distally. • Crown is centered over
the root and has three primary cusps and a fourth relatively smaller cusp that
is disto-lingual cusp.
All maxillary molars have an oblique ridge extending from the most
prominent mesio-lingual cusp to the disto-buccal cusp.
They have three roots, two buccal and one lingual. All the roots converge to a
root base called root trunk.

PERMANENT MAXILLARY FIRST MOLAR

There are two maxillary first molars, one on right and another on left side of
the arch located between second premolar and second molar. Permanent
maxillary molars are the largest and strongest of all maxillary teeth. Since
these teeth are the first permanent teeth in the arch to erupt into the oral
cavity, it is often the first one to be decayed. The first molars (maxillary and
mandibular) are usually referred to as sixth year molars because they erupt at
the age of 6 years. The morphologic characteristics of maxillary first molar
can be described from five aspects, namely buccal, palatal/lingual, mesial,
distal, and occlusal aspects. Further, features on each aspect (except occlusal)
is described under two subheadings, i.e. crown and root.

BUCCAL ASPECT

Crown
Shape of Buccal Aspect
Shape is trapezoidal with broader of the dissimilar outline being occlusal and
narrower the cervical outline.

Chronology of permanent maxillary first molar

Outlines of Buccal Aspect
Mesial outline is nearly straight which becomes convex at mesial contact area
located at the junction of occlusal and middle 13rd. The outline continues to
join the mesial cusp slope of mesio-buccal cusp.
Distal outline is convex with contact area in the middle of middle 1/3rd.
Occlusal outline is represented by buccal cusps and cusp slopes. From the
buccal aspect two cusps are seen; a mesio-buccal and a disto-buccal. Mesio-
buccal cusp is wider and slightly longer than the disto-buccal cusp. The
mesial and distal cusps slope of the mesio-buccal cusp meet at an obtuse
angle making it less sharp while the disto-buccal cusp is sharper.
Cervical outline is irregular and shows slight curvature to the root.

Buccal Surface
On the buccal surface a buccal groove is seen separating the two buccal
cusps. This groove extends to the middle 1/3rd and there may be a pit where
the groove ends.

Root
From the buccal aspect, a distinct root trunk (undivided part of the root) is
visible. At a point about the junction of cervical and middle 1/3rd of the root
(around 4 mm above the cervical line) the root trunk bifurcate giving rise to
two buccal roots a mesio-buccal and a disto-buccal. Both the roots are well-
separated, taper apically and often are curved distally.

LINGUAL/PALATAL ASPECT

Crown
Crown of maxillary first molar is often broader mesio-distally on the palatal
side than on the buccal side, except in the cervical 1/3rd. The outline is
reverse of that of buccal outline.
Two well developed cusps are visible from this aspect, the larger mesio-
lingual cusp and smaller disto-lingual cusp. Mesio-lingual cusp is the longest
cusp of this tooth and the cusp slopes meet at 90 degrees. The disto-lingual
cusp is smallest and is more rounded. The lingual cusps are separated by a
lingual developmental groove that extends from occlusal aspect to the lingual
surface.
Frequently a fifth cusp is found on the lingual surface of mesio-lingual
cusp which is located 2 mm cervical to the tip of the mesio-lingual cusp. This
cusp is separated from mesio-lingual cusp by a fifth cusp groove. The cusp is
named as ‘cusp of Carabelli’ after the person who first described it. The
presence or absence of this cusp is a racial characteristic and when present it
may show variation in size and shape.

Root
Only one root is present on the palatal side which is the longest of all three
roots. The palatal root tapers to a blunt apex. From the palatal aspect along
with the palatal root both mesio-buccal and disto-buccal roots are also
visible.

MESIAL ASPECT

Crown
Shape of Mesial Aspect
Crown appears to be short and broad facio-lingually. A prominent curvature
at cervical 1/3rd buccally and lingually is observed.

Outlines of Mesial Aspect

Buccal outline is convex at cervical 1/3rd, followed by slight concavity and
again convex as it progresses further to end at cusp tip. Crest of buccal
outline is usually located immediately below the cervical line.
Palatal outline is somewhat similar to buccal outline, but crest of the lingual
outline is often found at the middle 1/3rd.
Occlusal outline is represented by cusps and marginal ridge. Two cusps are
seen; a mesio-buccal cusp and a larger, longer mesio-lingual cusp. The
mesio-lingual cusp is inline with long axis of lingual root. Fifth cusp, the
cusp of Carabelli is found on the lingual surface of mesio-lingual cusp.
Confluent with the cusp ridges a distinct mesial marginal ridge is present
which is irregular and curved cervically. Mesial marginal ridge is placed at an
occlusal level than that of distal marginal ridge.
Cervical outline is irregular and slightly curved towards the crown.

Mesial Surface
Mesial surface is generally convex. A shallow concavity may be seen cervical
to the contact area which may continue onto the root surface.

Root
Two roots are visible from this aspect, mesio-buccal root and the lingual root.
The level of bifurcation on the mesial aspect is closer to (less than 4 mm)
the cervical line.
The mesio-buccal root is broad in bucco-lingual direction and the apex is
in-line with tip of mesio-buccal cusp. The palatal root is 1.5 mm longer than
mesio-buccal root but narrower in a bucco-lingual direction. The roots are
well-separated and the boundaries of the roots may extend beyond the crown.
This feature helps to differentiate this tooth from that of 2nd molar.

DISTAL ASPECT
Crown
Tooth shows a convergence distally making the buccal and palatal aspects
visible from the distal aspect.
Mainly two cusps, disto-buccal and disto-lingual cusps are visible from
this aspect. Parts of other cusps including the ‘cusp of Carabelli’ can be
seen. Of the two cusps, disto-buccal cusp is slightly larger than disto-lingual
cusp.
The distal marginal ridge is shorter, more concave and cervically placed
than mesial marginal ridge making a part of occlusal aspect visible from
distal aspect.
Cervical line is less curved on distal aspect. Distal surface is generally
convex except for a shallow concavity at cervical region which may continue
onto the root surface up to the level of bifurcation.

Roots
All the three roots are seen from this aspect. A portion of mesio-buccal root is
seen because the disto-buccal root is shorter and narrow. The level of
bifurcation on the distal side is more apical than on mesial side.

OCCLUSAL ASPECT

Shape
Occlusal outline is rhomboidal or parallelogram in shape. It has two acute
angles and two obtuse angles. Acute angles are mesio-buccal and disto-
lingual and obtuse angles are mesio-lingual and disto-buccal.
Tooth is wider bucco-lingually (1 mm) than mesio-distally. Crown shows a
buccal convergence and a distal convergence. The palatal half of the tooth is
wider mesio-distally than buccal half. Similarly, the mesial half of the tooth is
bucco-lingually wider than distal half.

Occlusal Surface
Occlusal surface shows various anatomic landmarks such as cups, ridges,
fossae, pits, grooves, etc.
Cusps
Four major cusps are seen, i.e. mesio-lingual cusp which is longest and
largest followed by mesio-buccal, disto-buccal and disto-lingual cusp. Of this
four cusps mesio-lingual, mesio-buccal and disto-buccal forms the primary
cusps of first molar. A fifth cusp the ‘cusp of Carabelli’ is also seen lingual to
mesio-lingual cusp which is located 2 mm cervical to the tip of the mesio-
lingual cusp.

Ridges
Triangular ridges of all the four major cusps are seen.
Oblique ridge: The triangular ridge of the mesio-lingual cusp is divided into
two parts by a groove named Stuart groove. The distal extension of the
triangular ridge of the mesio-lingual cusp and the triangular ridge of disto-
buccal cusp meet and form a diagonal ridge called oblique ridge.
A transverse ridge is formed by the triangular ridges of the mesio-buccal
cusp and mesial portion of the triangular ridge of the mesio-lingual cusp.
Mesial and distal marginal ridges form mesial and distal boundary of
occlusal aspect.
Cusp ridges: The buccal and lingual sides of occlusal surface are bounded by
cusp ridges.

Fossae
There are four fossae on the occlusal aspect of a maxillary first molar, two
fossae are major and other two are minor.

Major fossae
Central fossa: This is the largest fossa situated mesial to the oblique ridge,
bounded by oblique, transverse and cusp ridges of buccal cusp.
Distal fossa: This is also a major fossa, relatively smaller than central fossa,
and is located distal to the oblique ridge. It is linear in shape.

Minor fossae
Mesial triangular fossa is a minor fossa, triangular in shape and is located
adjacent (distal to) mesial marginal ridge.
Distal triangular fossa is similar to mesial triangular fossa, but smaller and is
located adjacent to distal marginal ridge.

Pits
Pits are observed at the deepest part of all fossae as pin point depression
where the grooves converge.

Grooves
Both developmental and supplementary grooves are present.

Developmental grooves
Central groove: Extends mesially from the central fossa, over the transverse
ridge and ends in mesial triangular fossa.
Transverse groove of the oblique ridge: This groove extends from the central
fossa in a distal direction across the oblique ridge to the distal triangular
fossa.
Distal oblique groove: Extends from the distal triangular fossa, along the
distal aspect of oblique ridge in a lingual direction between the mesio-lingual
and distolingual cusps.
Buccal groove: Extends from the central fossa, traverse in a buccal direction
between the mesio-buccal and disto-buccal cusps and continues onto the
buccal aspect of the tooth.
Lingual groove: This is seen as a continuation of the distal oblique groove
and extends onto the lingual surface of the tooth between mesio-lingual and
disto-lingual cusps.
Fifth cusp groove: This groove separates the fifth cusp from the mesio-
lingual cusp.
Stuart groove: This is a small groove which extends from central groove to
separate the two portions of triangular ridge of mesio-lingual cusp.

Supplementary grooves
In addition to developmental grooves, supplementary grooves are also
present in triangular fossae extending to a buccal and a lingual direction.

DEVELOPMENTAL VARIATIONS AND

CLINICAL CONSIDERATIONS

First molars are the teeth most often get decayed and the first tooth in
permanent tooth to be lost, as they may be mistaken as primary teeth and
neglected by parents. The deep pits and grooves present may act as the site of
initiation of caries.
The maxillary first molars may have an additional cusp on the buccal
surface of the mesio-buccal cusp, which is termed as paramolar
tubercle/parastyle.
Taurodontism is a term used for developmental variation of molar teeth
where the crown of the tooth is enlarged at the expense of root. This term is
given as this tooth resembles that of a cud chewing animal. Bifurcation of the
root will be shifted apically. This condition may exist as an isolated trait
(autosomal dominant) or as part of several syndromes. Endodontic treatment
of teeth affected by taurodontism needs special consideration.
Concrescence is the fusion of cementum of adjacent teeth, a good reason
to have radiographs before extraction of a tooth.
Mulberry molar is dental defects specifically involving first molars, in
congenital syphilis and caused by direct invasion of tooth germs by
Treponema pallidum which can pass through the placenta. In mulberry
molars the cusps are replaced by many globular masses of enamel, giving
resemblance to mulberry fruit.
Dens in dente/Dens invaginatus is a condition characterized by deep
invagination in crown portion of tooth resulting in enamel being reflected
into the tooth giving an appearance, tooth within a tooth. In affected teeth,
caries may develop in the invagination and escape detection.
Enameloma or enamel pearl is ectopic formation of enamel appear as
small droplets of enamel on the root surface, mostly close to bifurcation.

FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Buccal Aspect
Mesio-buccal cusp larger than disto-buccal cusp.

Palatal Aspect
Mesio-lingual cusp is largest cusp.
Cusp of Carabelli is present on lingual aspect of mesio-lingual cusp.

Proximal Aspect
Cervical line is more curved on mesial aspect than distal.
Distal marginal ridge is more cervically located.
Mesial marginal ridge is placed at an occlusal level than that of distal
marginal ridge.
Deep developmental depression on distal surface of root.

Occlusal Aspect
Distal and buccal convergence of occlusal aspect.
Mesiolingual cusp is largest cusp and distolingual the smallest.
Oblique ridge running from mesio-lingual to disto-buccal cusp.
Permanent maxillary right first molar
 31
Permanent Maxillary Second
Molars

Introduction
Chronology of maxillary second molar
Measurement table
Morphology of maxillary second molar
Differences between maxillary first and second molars
Developmental variations and clinical considerations

M axillary second molars are situated distal to the first molars. Although
they are relatively smaller, they assist first molars in function. These
teeth may show considerable variation in morphology. The
morphologic characteristics of maxillary second molar can be described from
five aspects, namely buccal, palatal/lingual, mesial, distal, and occlusal.
Further, features on each aspect (except occlusal) is described under two
subheadings, i.e. crown and root.

BUCCAL ASPECT

Crown
Crown is shorter and less wider than first molars and is tipped distally on the
root trunk.
Mesial outline is slightly convex with contact area located at the junction
of occlusal and middle 1/3rd.
Distal outline is shorter than the mesial outline. Distal contact area is
located at the middle of middle 1/3rd.
Two cusps can be seen on this aspect, mesio-buccal and disto-buccal.
Mesio-buccal cusp is longer and wider than disto-buccal cusp. Smaller disto-
buccal cusp and distal tilting of the crown allows a part of the disto-lingual
cusp visible from this aspect. Buccal groove present on buccal surface
separates two buccal cusps, which is shorter than that of the buccal groove of
first molar and only rarely end in a pit.

Root
The maxillary second molar has two buccal roots and a palatal root and all
three roots are visible from this aspect. The root trunk is distinct and the level
of bifurcation is more apical when compared to that of the first molar making
the root trunk longer.
Both the buccal roots are nearly parallel, not spread apart and may show a
distal tilt. The mesio-buccal root apex is in-line with buccal groove.

LINGUAL/PALATAL ASPECT

Crown
General outline of palatal aspect is reverse of that of buccal outline.
Two cusps can be seen from this side, the mesio-lingual and disto-lingual
cusps. The mesio-lingual cusp is longer and the disto-lingual cusp may be
very small or even absent in some teeth. Part of the disto-buccal cusp may be
visible. In contrast to maxillary first molars in this tooth a fifth cusp is not
seen. Lingual groove separates both the lingual cusps.

Chronology of permanent maxillary second molar

Root
Only one palatal root is present which is almost of same length as that of
buccal roots. Apex of the palatal root is in-line with disto-lingual cusp tip.
Along with this palatal root, other two buccal roots are also visible from this
aspect.

MESIAL ASPECT

From the mesial aspect second molars resemble first molars. The differences
observed are:
Cusp of Carabelli is not present
Roots are less separated
Buccal and palatal roots are of equal length
Buccal and palatal roots generally do not extend beyond the crown boundary.

DISTAL ASPECT

From the distal aspect also the second molar shows similarity to first molar.
The tooth is converging to the distal aspect; therefore buccal and lingual
surfaces are visible. Since the tooth shows a distal tilt and a cervical
placement of the marginal ridge, the tooth appears shorter from this aspect
and also much of occlusal aspect is seen.
All the three roots are seen; palatal, mesio-buccal and disto-buccal. Apex
of the palatal root is often in-line with that of disto-lingual cusps.

OCCLUSAL ASPECT

Second molar shows similar morphological features as 1st molar with a few
differences.
Rhomboidal shape is more prominent with acute angles (mesio-buccal and
disto-lingual) are less and obtuse angles (mesio-lingual and disto-buccal) are
greater. It appears as though the lingual portion is pushed distally. Crown
shows a lingual convergence and a distal convergence which is more
pronounced than in the first molars. Tooth is bucco-lingually wider than
mesio-distally with a difference of around 2 mm.
There are four cusps, i.e. mesio-lingual, mesio-buccal, disto-buccal and
disto-lingual. Greater difference in the cusp size is observed in this tooth.
Mesio-buccal and mesio-lingual cusps are nearly of the same size and are
noticeably larger than disto-buccal and disto-lingual cusps. Disto-lingual cusp
is very small or even may be absent. No fifth cusp is observed. Occlusal
surface shows more pits and grooves and the oblique ridge is less prominent
than in first molar.

Differences between maxillary first and second molars (Type traits)

Maxillary first molar Maxillary second molar
Larger in size Smaller in size

Difference between bucco- Difference between bucco-lingual and

lingual and mesio-distal mesio-distal diameter is more than in
diameter is less (around 1 mm). first molar (around 2 mm)

Buccal convergence of crown is Lingual convergence of crown is

observed observed
 Crown appears squarish or Because the mesio-distal diameter is
rhomboidal from occlusal lesser, crown appears more oblong from
aspect occlusal aspect

Crown do not show distal Crown is tipped distally on root trunk

tipping

Disto-lingual cusp is relatively Disto-lingual cusp is very small or

larger than that of second absent
molars

The mesio-buccal cusp is Both the mesio buccal and disto-buccal

notably larger than disto-buccal cusps are notably larger
cusp

Cusp of Carabelli is present Cusp of Carabelli is absent

Prominent oblique ridge Less prominent oblique ridge

10. Relatively longer buccal Short buccal groove, may not end in pit
groove, may end in a pit

11. Root trunk is relatively shorter Root trunk is longer

12. Roots of maxillary first molars Roots do not spread out and all roots
are spread out show adistal tilt

Similarities between Maxillary First and Second Molars

Tooth is bucco-lingually broader
Four major cusps as in the first molar
Presence of oblique ridge and transverse ridge
Fossae and groove pattern are similar
Presence of 3 roots
 DEVELOPMENTAL VARIATIONS AND
CLINICAL CONSIDERATIONS

Maxillary second molar may be prone to dental caries due to deep pits and
fissures. Rarely cusp of Carabelli may be present on lingual aspect of mesio-
lingual cusp. Chances of concrescence with maxillary third molar is
considerably more due to crowding of teeth in maxillary posterior region.

FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE

Buccal Aspect
Mesio-buccal cusp larger than disto-buccal cusp.

Palatal Aspect
Disto-lingual cusp is the smallest cusp.

Proximal Aspect
Cervical line is more curved on mesial aspect than distal.

Occlusal Aspect
Distal and lingual convergence of occlusal aspect.
Mesio-lingual cusp is the largest and disto-lingual cusp is the smallest.
Oblique ridge running from mesio-lingual to disto-buccal cusp.
Permanent maxillary right second molar
 32
Permanent Maxillary Third
Molars

Introduction
Chronology of maxillary third molar
Measurement table
Morphology of maxillary third molar

T hird molars are the last tooth in the arch and erupt by the age of 17 to 21
years or later. These teeth show maximum variation in size and shape.
The third molars are sometimes referred to as the “wisdom” tooth
because they erupt last.
The characteristics of maxillary third molars are:
Smaller than 1st and 2nd molars.
Crown shows significant convergence.
Oblique ridge is less prominent.
Disto-lingual cusp is much smaller or absent.
Occlusal aspect may have many supplementary grooves giving wrinkled
appearance.
Root trunk is longer with point of bifurcation located more apically.
Three roots, i.e. mesio-buccal, disto-buccal and lingual are seen. The roots
are shorter than other maxillary molars and are less separated or often fused.
Chronology of permanent maxillary third molar

Permanent maxillary right third molar

 33
Permanent Mandibular First
Molars

Introduction
Chronology of maxillary second molar
Measurement table
Morphology of maxillary second molar
Differences between maxillary first and second molars
Developmental variations and clinical considerations

P ermanent mandibular molars are the largest group of teeth in the

mandibular arch and are three in number on either side of the arch; 1st,
2nd and 3rd molars. Like maxillary molars, these teeth are also non-
successor teeth. Permanent mandibular molars help in mastication of food, to
maintain proper vertical dimension of face, maintaining continuity of dental
arches and also to provide fullness to the cheek. Unlike maxillary molars, all
the mandibular molars are wider mesio-distally than bucco-lingually and
have two roots.

GENERAL CHARACTERISTICS OF
MANDIBULAR MOLARS (ARCH TRAITS)

Shorter than other mandibular teeth but greater in other dimensions,

Crown is broader mesio-distally than bucco-lingually.
Crown tapers distally and lingually.
Crown tilts distally and lingually on the root base.
Lingual cusps are relatively of same size,
Two roots are present: Mesial and distal
Root trunk is shorter.

PERMANENT MANDIBULAR FIRST MOLARS

The mandibular first molars are the largest and strongest of all the mandibular
teeth and have the widest crown of all teeth in the dentition. The mandibular
first molar is the first permanent tooth to erupt into the oral cavity and is
referred to as the “six-year-molar” as it erupts at 6 years. It normally erupts
slightly before the maxillary first molar and is considered as the key of
occlusion. Normally there are five functioning cusps on the occlusal surface
of this tooth. The morphologic characteristics of mandibular first molar can
be described from five aspects, namely buccal, lingual, mesial, distal, and
occlusal. Further, features on each aspect (except occlusal) is described under
two subheadings, i.e. crown and root.

BUCCAL ASPECT

Crown
Shape of Buccal Aspect
Shape is roughly trapezoidal with the cervical and occlusal outlines
representing the uneven sides. Crown is broader mesio-distally than cervico-
occlusally.

Chronology of permanent mandibular first molar

Outlines of Buccal Aspect
Mesial outline is relatively straight or slightly concave from the cervical line
to the contact area which is located at the junction of occlusal and middle
third.
Distal outline is straight or slightly convex from cervix to the contact area
which is at the middle of middle third beneath the distal cusp.
Occlusal outline is represented by the buccal cusps and the cusp slopes. On
this aspect mainly three buccal cusps can be seen; the mesio-buccal cusp,
disto-buccal cusp and a distal cusp. The mesio-buccal cusp is the longest and
widest, followed by disto-buccal cusp which is smaller and shorter and a
distal cusp which is the smallest and the pointed than the other buccal cusps.
The smallest cusp on the buccal aspect is called the distal cusp because the
major portion of the cusp is located on the distal part of the crown and only a
small portion is seen on the buccal aspect. From the buccal aspect, a portion
of mesio-lingual and disto-lingual cusps are also seen, as they are longer than
the buccal cusps.
Cervical line is nearly straight, regular and curves slightly to the root.

Buccal Surface
Buccal surface of first molars is smooth and convex and shows two
developmental grooves. The groove that separates the mesio-buccal and
disto-buccal cusp is the mesio-buccal groove which extends up to the middle
third and ends in a pit. The disto-buccal groove separates disto-buccal and
distal cusp, which ends at the cervical third without a distinct pit. The
cervical portion of buccal aspect may show a prominent ridge running in a
mesio-distal direction which is referred to as buccal cervical ridge.

Roots
Mandibular first molar has two roots; mesial and distal. The level of
bifurcation is 3 mm below the cervical line. Since the bifurcation is closer to
the cervical line, the root trunk is short. The mesial root is the wider and the
stronger of the two. The mesial and distal roots show a distal tilt. The tip of
mesial root is almost in-line with the mesio-buccal cusps and of the distal
root is often in-line or distal to the distal surface of crown.

LINGUAL ASPECT

Crown
Shape of Lingual Aspect
From the lingual aspect the tooth shows a convergence lingually, making a
part of mesial and distal surfaces visible. The degree of lingual convergence
is more prominent distally. Tooth also tapers to the cervical region.

Outlines of Lingual Aspect

Mesial outline is slightly convex. With the crest of contour located at the
junction of occlusal and middle third.
Distal outline is relatively straight with the crest of curvature located on the
distal surface of the distal cusp.
Occlusal outline is represented by the cusps and the cusp slopes. On this
aspect mainly two cusps are seen; mesio-lingual and disto-lingual. Because of
the lingual convergence, the distal portion of the distal cusps may be visible
from this aspect. The mesio-lingual and the disto-lingual cusps are the
longest and the sharpest of the five cusps. The mesio-lingual cusp is longer
than the disto-lingual cusp and the width may be equal or slightly more than
that of the disto-lingual cusp.
Cervical line is slightly irregular and relatively flat.

Lingual Surface
Lingual surface is smooth and convex at the coronal 1/3rd and almost flat at
the cervical region. Lingual developmental groove extends onto a short
distance onto the lingual surface demarcating both the lingual cusps.

Root
From this aspect both the mesial and distal roots are seen which show a
lingual convergence. The root trunk appears to be longer because of the
occlusal placement of cervical line. The level of bifurcation is 4 mm above
the cervical line.

MESIAL ASPECT

Crown
Shape of Mesial Aspect
Shape is rhomboidal with the crown tilted lingually on the root axis (arch
trait). A greater bucco-lingual measurement of the crown and the root can be
appreciated from this aspect.

Outlines of Mesial Aspect

Buccal outline is noticeably convex at the cervical third where the crest of
convexity is located, in the region of the buccal cervical ridge. As the buccal
outline continues occlusally it becomes less convex and shows a lingual
inclination.
Lingual outline is relatively straight in the cervical third, becomes convex at
the middle third where the crest of convexity is located.
Occlusal outline is represented by the cusps and the marginal ridges. Two
cusps can be seen from mesial aspect: Mesio-buccal and mesio-lingual.
Mesio-lingual cusp is longer and sharper and is in-line with the lingual
surface of mesial root. A well developed mesial marginal ridge is seen which
is slightly concave and is placed occlusally.
Cervical line is irregular and slightly convex towards the occlusal aspect. The
cervical line on the lingual surface is at a higher level than the buccal by
about 1 mm. This difference in the level of cervical line can be appreciated
from the mesial aspect.

Mesial Surface
Mesial surface is smooth and relatively convex except for a slight concavity
cervical to the contact area.

Root
Only mesial root is visible from this aspect because the broad mesial root
superimposes the narrower distal root. The outline of mesial root is relatively
straight up to the junction of cervical and middle third and from there it tapers
to a blunt apex. The apex is located directly below the mesio-buccal cusp.

DISTAL ASPECT

Crown
The general morphology of distal aspect is similar to that of mesial aspect.
The crown is shorter distally than mesially. Due to the distal convergence of
the crown, a part of buccal and lingual surface is also seen from this aspect.
The distal convergence of the buccal surface is more pronounced than that of
the lingual surface.

Differences are
The distal marginal ridge is short, curved and is more cervically located than
the mesial marginal ridge.
Because of the distal tilt of the crown and cervical placement of the marginal
ridge most of the occlusal surface and all cusps are seen from this aspect.
Curvature of cervical line is less than on mesial aspect.

Root
The distal root and a part of the mesial root are visible from this aspect. The
distal root is narrower than the mesial root and ends in a pointed apex.

OCCLUSAL ASPECT

Shape
The occlusal aspect is roughly quadrilateral in shape with the mesio-distal
dimension more than bucco-lingual with a difference of 1 mm or more. The
lingual and the distal convergence of the crown can be well appreciated.
Because of the lingual tilt when tooth is viewed from occlusal aspect much of
buccal surface also can be seen. The mesial outline is slightly convex and the
contact area is centered in a bucco-lingual direction. The distal contact area is
located buccal to the center point of distal marginal ridge.

The Occlusal Surface

Occlusal surface shows various anatomic landmarks such as cusps, ridges,
fossae, pits, and grooves.

Cusps
Mandibular first molar has five cusps: Three buccal cusps and two lingual
cusps. The buccal cusps are mesio-buccal, disto-buccal and distal. Of the
three buccal cusps, the mesio-buccal cusp is the largest followed by disto-
buccal and the distal cusp. The distal cusp is the smallest and the sharpest and
is located at the disto-lingual line angle. Lingually there are two cusps: The
mesio-lingual and disto-lingual. The mesio-lingual and the disto-lingual
cusps are the longest and tht sharpest of the five cusps. The mesio-lingual
cusp is longer than the disto-lingual cusp and the width may be equal or
slightly more than that of the disto-lingual cusp.

Ridges
Triangular ridges are seen extending from the tips of all five cusps towards
the central part of occlusal surface. Triangular ridges of lingual cusps are
longer than that of buccal cusps.
Transverse ridge: The triangular ridge of the mesio-buccal cusp meets the
triangular ridge of the mesio-lingual cusp to form a transverse ridge.
Similarly, a transverse ridge is also formed by the triangular ridges of both
the disto-buccal and disto-lingual cusps.
Mesial marginal ridge: Forms the mesial boundary of the occlusal aspect and
is located more occlusally than the distal marginal ridge. It is placed 1 mm
below the level of the cusp tips.
Distal marginal ridge: It is located at distal margin of occlusal aspect. It is
shorter, concave and more cervically placed.
Cusp ridges: Forms the buccal and the lingual boundaries of the occlusal
aspect.

Fossae
Three fossae can be seen; one major (central fossa) and two minor (mesial
and distal triangular fossae).
The central fossa is the largest fossa located at the center of the occlusal
aspect. Central fossa is bounded by the distal slope of the mesio-buccal cusp,
mesial and distal slope of the disto-buccal cusps, mesial slope of the distal
cusp, triangular ridges of distal and disto-lingual cusps, mesial slope of disto-
lingual cusp, distal slope of mesio-lingual cusp and the transverse ridge.
Mesial triangular fossa is a triangular shaped depression located inner (distal)
to the mesial marginal ridge.
Distal triangular fossa is less distinct and is located inner (mesial) to distal
marginal ridge.

Pits
Pits are present as small pinpoint depression at the deepest part of all fossae,
where the developmental grooves converge. The pits are named according to
the fossa in which they are located: Central pit, mesial pit and distal pit.
Grooves
Developmental and supplemental grooves are seen.

Developmental grooves
Central groove: It is the major groove seen on the occlusal aspect and is
centrally located dividing occlusal surface into buccal and lingual halves. It
starts from the central pit and runs in a mesial direction between the mesio-
buccal and mesio-lingual cusps to end in the mesial triangular fossa. The
distal extension of the central groove runs between the disto-buccal and disto-
lingual cusps to end in distal triangular fossa. The central groove follows a
zigzag pattern.
Mesio-buccal groove: This groove starts from the central fossa, slightly
mesial to the origin of central groove and traverse in a buccal direction
between the mesio-buccal and disto-buccal cusps and extend onto the buccal
surface.
Disto-buccal groove: It starts from the distal portion of the central groove
and traverse in a buccal direction between the disto-buccal and distal cusps
and extends onto the buccal surface.
Lingual groove: It starts in the central pit, extends lingually between the two
lingual cusps and onto the lingual surface.

Supplementary grooves
In addition to the developmental groove there are supplementary grooves in
triangular fossae extending to a buccal and lingual direction. Supplementary
grooves are less distinct in the distal triangular fossa.

DEVELOPMENTAL VARIATIONS AND

CLINICAL CONSIDERATIONS

First molars are the teeth most often get decayed and the first tooth in
permanent tooth to be lost, as they may be mistaken as primary teeth and
neglected by parents. The deep pits and grooves present may act as the site of
initiation of caries.
 Differences between maxillary first and mandibular first molars (arch
traits)
Maxillary first molar Mandibular first molar
Crown is bucco-lingually broader than Crown is mesio-distally
mesio-distally broader than bucco-
lingually

Have four major cusps: Two buccal and two Have five cusps: three
lingual buccal and two lingual

One accessory cusp, i.e. ‘cusp of Carabelli’ No such cusp is seen

is also present and is seen lingual to mesio-
lingual

Lingual cusps are of different size; large Lingual cusps are nearly of
mesio-lingual and a smaller disto-lingual equal size

Buccal surface is relatively flat Buccal surface is convex

and inclined lingually

Occlusal aspect is rhomboidal in shape Occlusal aspect is

quadrilateral

Occlusal aspect shows buccal convergence Occlusal aspect shows a

lingual convergence

A prominent oblique ridge is seen on No such oblique ridge is

occlusal aspect extending from mesio-lingual seen on occlusal aspect
to disto-buccal cusps

Occlusal aspect has four fossae: Two major Occlusal aspect has only
and two minor three fossae: One major
and two minor

At times mandibular first molars may have only four cusps as in second
molar with distal cusp missing. Sometimes an additional cusp on the buccal
surface of the mesio-buccal cusp may be present, at the middle third of the
crown which is termed as paramolar tubercle/protostylid. An extra cusp,
when located on distal marginal ridge between distal cusp and disto-lingual
cusp, it is referred to as tuberculum sextum and when present between two
lingual cusp, it is termed as tuberculum intermedium.
Root division: Occasionally mesial root of mandibular molar may be divided
into mesio-lingual and mesio-buccal roots making it three rooted.
Taurodontism is a term used for developmental variation of molar teeth
where the crown of the tooth is enlarged at the expense of root. This term is
given as this tooth resembles that of a cud chewing animal. Bifurcation of the
root will be shifted apically. This condition may exist as an isolated trait
(autosomal dominant) or as part of several syndromes. Endodontic treatment
of teeth affected by taurodontism needs special consideration.
Concrescence is the fusion of cementum of adjacent teeth, a good reason to
have radiographs before extraction of a tooth.
Mulberry molar is dental defects specifically involving first molars, in
congenital syphilis and caused by direct invasion of tooth germs by
Treponema pallidum which can pass through the placenta. In mulberry
molars the cusps are replaced by many globular masses of enamel, giving
resemblance to mulberry fruit.
Dens in dente/Dens invaginatus is a condition characterized by deep
invagination in crown portion of tooth resulting in enamel being reflected
into the tooth giving an appearance, tooth within a tooth. In affected teeth,
caries may develop in the invagination and escape detection.
Enameloma or enamel pearl is ectopic formation of enamel appears as
small droplets of enamel on the root surface, mostly close to bifurcation.

FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE

Buccal Aspect
Crown tilted distally
Mesio-buccal cusp largest and distal cusp smallest
Distal tilt of root

Lingual Aspect
Disto-lingual cusp is smaller than mesio-lin-gual cusp.

Proximal Aspect
Cervical line is more curved on mesial aspect than distal.
Distal marginal ridge is more cervically located.
Mesial marginal ridge is more occlusally placed and almost straight.
Deep developmental depression on distal surface of root.

Occlusal Aspect
Disto-lingual cusp is smaller than mesio-lin-gual cusp.
Large, deeper distal triangular fossa.
Distal convergence of the crown.
Smallest distal cusp.
Permanent mandibular right first molar
 34
Permanent Mandibular
Second Molars

Introduction
Chronology of mandibular second molar
Measurement table
Morphology of mandibular second molar
Differences between mandibular first and second molars
Developmental variations and clinical considerations

M andibular second molars are two in number, one on either side of the
arch, situated distal to the mandibular first molars. They supplement
the first molar in function. Although the second molar resembles the
first molar in its general morphology, a few differences can be observed. The
morphologic characteristics of mandibular second molar can be described
from five aspects, namely buccal, lingual, mesial, distal, and occlusal.
Further, features on each aspect (except occlusal) is described under two
subheadings, i.e. crown and root.

BUCCAL ASPECT

Crown
Shape of Buccal Aspect
Shape is roughly trapezoidal with the cervical and occlusal outlines
representing the uneven sides. Tooth is wider mesio-distally than the crown
length. The degree of cervical convergence is less therefore, the tooth appears
to be wider at the cervix. Crown tilts distally so the distal side appears to be
shorter.

Outlines of Buccal Aspect

Mesial outline is straight with the contact area located at the junction of
middle and occlusal 1/3rd.
Distal outline is more convex and the contact area is at the middle of middle
1/3rd.
Occlusal outline is represented by the buccal cusps and the cusp slopes. On
this aspect mainly 2 buccal cusps can be seen: Mesio-buccal cusp and disto-
buccal cusp. Lingual cusps are also visible because they are longer than the
buccal cusps.
Cervical line is relatively straight or may curve sharply towards the root.

Buccal Surface
Buccal surface is smooth and convex. The buccal groove extends between the
mesio-buccal and disto-buccal cusps, which ends at the middle third of the
surface in a pit. The cervical portion of buccal aspect may show a prominent
ridge running in a mesio-distal direction which is referred to buccal cervical
ridge (sometimes called buccal cingulum).

Root
Two roots are present; mesial and distal. The level of bifurcation is more
apical when compared to that of first molar. Both mesial and distal roots are
usually closer together, nearly parallel and ending in a pointed tip.

Chronology of permanent mandibular second molar

 LINGUAL ASPECT

Crown
Tooth shows convergence lingually but to a lesser extent than that of first
molar.
Mesial and distal outlines are more convex.
Occlusal outline is represented by the lingual cusps and the cusp slopes. Two
lingual cusps are seen; mesio-lingual cusp and a disto-lingual cusp. The
mesio-lingual cusp is slightly wider and longer of the two.
Cervical line is regular.
Lingual surface is smooth and convex. The lingual groove extends between
the mesio-lingual and disto-lingual cusps, which is shorter than the buccal
groove.

Root
Two roots, mesial and distal roots are seen which end in a pointed apex.

MESIAL ASPECT
Crown
Shape of Mesial Aspect
From this aspect shape of second molar resembles that of first molar except
for the differences in measurement.

Outlines of Mesial Aspect

Buccal outline is noticeably convex at the cervical third (crest of convexity)
in the region of the buccal cervical ridge. As the buccal outline continues
occlusally it becomes less convex and shows a lingual inclination.
Lingual outline is nearly straight or slightly convex with crest of convexity at
the middle third.
Cervical line is regular and straight with a slight curvature occlusally.
Occlusal outline is represented by the cusps and the marginal ridge. Two
cusps are seen: mesio-lingual and mesio-buccal cusps. Mesio-lingual cusp is
longer. The mesio-buccal cusp tip is lingual to the buccal outline of mesial
root. Mesial marginal ridge is concave and more occlusally placed.

Mesial Surface
Mesial surface is smooth and convex.

Root
Only mesial root is visible from this aspect because the mesial root is broad
enough to hide the distal root.

DISTAL ASPECT

General morphology of distal aspect resembles that of mesial aspect.

Differences are:
The distal convergence of the tooth makes a portion of buccal and lingual
surfaces visible from this aspect.
In addition to disto-buccal and disto-lingual cusps, a part of mesial cusps are
also seen.
The distal marginal ridge is concave and more cervically located.
Distal tilt of the crown and cervically located marginal ridge allows most of
the occlusal aspect also to be visible from this aspect.

OCCLUSAL ASPECT

Shape
The occlusal aspect of mandibular second molar differs considerably from
mandibular first molar.
The tooth when viewed from occlusal aspect has a roughly rectangular
shape which is wider in a mesio-distal direction than the bucco-lingual.
The occlusal outline shows a distal and lingual convergence. The extent of
the lingual convergence is lesser than the first molar.
Mesial outline of the tooth is straight while distal outline is convex.
Because of the lingual tilt when tooth is viewed from occlusal aspect much
of buccal surface also can be seen. The mesio-buccal portion of the buccal
surface shows a prominent bulge, representing the cervical ridge.

Occlusal Surface
The occlusal surface shows various anatomic landmarks such as cusps,
ridges, fossae, pits and grooves.

Cusps
Four cusps are present; the mesio-lingual, disto-lingual, mesio-buccal and
disto-buccal. The mesio-buccal and mesio-lingual cusps are larger than disto-
buccal and disto-lingual cusps. Unlike the mandibular first molars, distal cusp
is absent in second molar.

Ridges
Triangular ridges are seen extending from the tips of all the four cusps
towards the central part of occlusal surface.
Transverse ridges-triangular ridges of mesio-buccal and mesio-lingual cusps
meet to form a transverse ridge. Similarly, a transverse ridge is also formed
by the triangular ridges of both the distal cusps.
Mesial marginal ridge forms the mesial boundary of the occlusal aspect and
is located more occlusally than the distal marginal ridge.
Distal marginal ridge is located at distal margin of occlusal aspect. It is
concave and more cervically placed.
Cusp ridges forms the buccal and the lingual boundaries of the occlusal
aspect.

Fossae
The central fossa is the largest fossa located at the center of the occlusal
aspect.
Mesial triangular fossa is a triangular shaped depression located inner (distal)
to the mesial marginal ridge.
Distal triangular fossa is less distinct and is located inner (mesial) to distal
marginal ridge.

Pits
Pits may be present in any of the fossae where the grooves converge.

Grooves
Occlusal surface shows both developmental and supplemental grooves.

Developmental grooves
Central groove: Begins from central fossa and extends in a mesial and distal
direction to end in the mesial triangular fossa and distal triangular fossa
respectively. The central groove is relatively straight in second molar when
compared to zigzag pattern in first molar.
Buccal groove runs from the central fossa in a buccal direction separating two
buccal cusps which also extends to the buccal surface.
A lingual groove extends from central fossa between the two lingual cusps.
These developmental grooves arising from central fossa give a criss-cross
pattern.

Differences between mandibular first and second molars (type traits)

Mandibular first molar Mandibular second molar
Larger in all dimensions Smaller in all dimensions

Has five cusps, three buccal Has only four cusps, two buccal cusps and
cusps and two lingual cusps two lingual cusps. Distal cusp is absent

Buccal surface shows two Only one buccal groove

buccal grooves

Less cervical constriction More cervical constriction

Crown has a quadrilateral Rectangular

shape from the occlusal
aspect

Roots are widely separated Roots are close together

Grooves on occlusal aspect Grooves on occlusal aspect show a cross

show a zigzag pattern pattern

Supplementary grooves
There may be many supplementary grooves radiating from the developmental
grooves making the occlusal surface irregular.

DEVELOPMENTAL VARIATIONS AND

CLINICAL CONSIDERATIONS

The deep pits and supplementary grooves make the mandibular second molar,
prone to caries.
The mandibular first molars may have an additional cusp on the buccal
aspect similar to distal cusp of first molar.
There is possibility of concrescence with third molar, i.e. the fusion of
cementum.
Enameloma or enamel pearl is ectopic formation of enamel appear as small
droplets of enamel on the root surface, may be seen in this tooth, mostly close
to bifurcation.

FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE

Buccal Aspect
Crown tilted distally.
Occlusal surface appears to be slopping cervically from mesial to distal.
Mesio-buccal cusp wider than a disto-buccal cusp.
Distal tilt of root.

Lingual Aspect
Disto-lingual cusp is smaller than mesiolingual cusp.

Proximal Aspect
Cervical line is more curved on mesial aspect than distal.
Distal marginal ridge is more cervically located.
Mesial marginal ridge is more occlusally placed.
Deep developmental depression on distal surface of root.

Occlusal Aspect
Distal convergence of occlusal surface.
Mesial outline of occlusal aspect nearly straight while distal is more convex.
Disto-lingual cusp is smaller than mesio-lingual cusp.
Permanent mandibular right second molar
 35
Permanent Mandibular Third
Molars

Introduction
Chronology of mandibular third molar
Measurement table
Morphology of mandibular third molar

M andibular third molars are extremely variable in morphology which

may resemble a second molar (4 cusps) in most of the cases. A few
specimens may also resemble a first molar (5 cusps). It supplements the
mandibular second molar in function. Mandibular third molars are most
likely to be impacted or congenitally missing.

General features are

Rounded occlusal outline with a narrow occlusal table.
Crown is bulbous and is tilted distally on root axis.
Larger and longer mesio-lingual cusp, with short and rounded buccal cusps.
Occlusal surface has irregular groove pattern.
Roots are shorter, either fused or separated with more distal tilt.

Chronology of permanent mandibular third molar

Permanent mandibular right third molar
 36
Occlusion
Dr Ajeesha Feroz

Occlusion
Deciduous dentition
Mixed dentition
Permanent dentition
– Compensating curves
– Occlusal relationship between maxillary and mandibular posterior
teeth

O cclusion is defined as the contact of masticating and incising surfaces of

opposing maxillary and mandibular teeth in function or in parafunction.
The alignment and occlusion of the teeth are important in masticatory
function.

OCCLUSION IN DECIDUOUS DENTITION

At birth, teeth are not present in the mouth and over a period of time they
erupt into the oral cavity. The maxillary and mandibular alveolar ridges,
before the tooth eruption are called gum pads. The maxillary gum pads are
wider than mandibular gum pads. The first deciduous tooth erupts into the
oral cavity by six months of age and the dentition is completed by the age of
20–30 months. Natural spacing is seen in deciduous dentition and is more
distinct in maxillary arch mesial to canine and in mandibular arch distal to
canines. This space is called primate space, anthropoid space or simian
space. Spacing in deciduous dentition is necessary for the proper alignment
of permanent dentition.
Deciduous teeth are more or less upright in their arrangement in alveolar
bone. The contact relations between the teeth vary in deciduous dentition
with degree of bruxism present in the child. Normally, deep bite may be seen
in deciduous anterior region which is reduced later by gradual attrition of
incisors, forward movement of mandible and by the eruption of molars.
The mesio-distal relationship between distal surfaces of deciduous second
molars may be:
Flush terminal plane (Fig. 36.1a): In this type of relation, the distal surface
of maxillary second molar is in the same plane as that of distal surface of
mandibular second deciduous molar. This type of relation results due to
larger mesio-distal measurement of mandibular second molar when compared
to maxillary second molar. This is considered as ideal relation which favors
the development of proper occlusion of permanent molars.
Mesial step terminal plane (Fig. 36.1b): In this type the distal surface of
mandibular molar is anteriorly (mesially) located compared to distal surface
of maxillary second molar. This causes a step directed mesially.
Distal step terminal plane (Fig. 36.1c): When the maxillary second molar is
in an anterior location than the mandibular second molar, the distal surface of
mandibular second molar is located more distal to that of distal aspect of
maxillary second molar resulting in a distal step.

Fig. 36.1: Molar relation in deciduous dentition

The mesial and distal step relations in a deciduous dentition suggest the
possibility of disturbed occlusion in permanent dentition.

MIXED DENTITION
The mixed dentition begins with the emergence of the mandibular first molar
at the age of 6 years and last up to 11–12 years, till all the deciduous teeth are
replaced by permanent successors. Initially when the permanent first molars
erupt distal to the deciduous molars they also show a flush terminal plane but
the mesial movement of mandibular first molar results in class I molar
relation. The space for the mesial shift of mandibular first molar is obtained
by growth of mandible and by utilizing primate space and leeway space.
At about the age of 8–9 years, by the eruption of larger anterior teeth
crowding occur for a short period of time. The difference between the space
available and space required to accommodate larger permanent incisors is
called incisor liability. This liability is overcome by increase in width of
dental arch in the intercanine region, by utilizing primate space and also by a
labial inclination of permanent incisors which increase the dental arch
circumference.
Posterior successor teeth have a relatively lesser mesio-distal diameter than
deciduous predecessors. Therefore the total mesio-distal measurements of
deciduous canine and deciduous first and second molars are more than the
total mesio-distal measurements of permanent canine, and two premolars.
The difference between these two measurements is called leeway space of
Nance. This space is around 0.9 mm on either side making up a total of 1.8 in
maxillary arch and 1.7 on either side of mandible with a total of 3.4 mm in
mandibular arch. This space is utilized by the permanent first molars to drift
mesially to develop a class I molar relation.

PERMANENT DENTITION

Alignment of Permanent Teeth in Dental Arch

All the teeth in maxillary and mandibular arches are aligned with an
angulation with respect to the alveolar bone. In the mandibular arch, both
anterior and posterior teeth show a mesial inclination. Second and third
molars are more inclined than the premolars. In the maxillary arch the
anterior teeth are mesially inclined while the posteriors are distally inclined.
A line drawn along the buccal cusp tips and the incisal edges of the
mandibular teeth, is a curved line. By broadening this curved line to include
the lingual cusp tips and extending it across the arch to the opposite side, a
curved plane can be established. This curved plane is called plane of
occlusion. The curvature of occlusal plane is primarily due to the positioning
of dental arch at varying degrees of inclination and this curved plane of
occlusion permits maximum contact during function.

Compensating Curves
The natural dentition shows compensating curves.
Antero-posterior compensating curve runs in an antero-posterior
direction, which can be appreciated from lateral (buccal) aspect.
Curve of Spee (Fig. 36.2a): It is defined as anatomic curvature of occlusal
alignment of teeth beginning at the tip of lower canine and following buccal
cusp tips of the premolar and molar and continues to the anterior border of
the ramus of mandible. This curve of dental arch was first described by von
Spee. This imaginary curve is concave for mandibular arch and convex for
maxillary arch. When the dental arches are placed into occlusion these
concave and convex lines matches perfectly.
Lateral compensating curve runs in bucco-lingual direction one side of the
arch to other, which can be appreciated from frontal view.
Wilson curve (Fig. 36.2b): When dental arch is observed from the anterior
(front) region with mouth slightly open, a lateral (medio-lateral)
compensatory curves can be appreciated in the maxillary molar region.
Generally the posterior teeth in the maxillary arch have a slight buccal
inclination while mandibular posterior teeth have a slight lingual inclination.
If a line is drawn through the buccal and lingual cusps tips of both the right
and left posterior teeth, a curved plane of occlusion is observed. The
curvature is convex in the maxillary arch and concave in mandibular arch.
When the arches are brought to occlusion both these curvatures match
perfectly. This curvature in occlusal plane observed from frontal view is
called curve of Wilson.

Interarch Tooth Relationship

The relationship of teeth in one arch to those in the other arch is called
interarch relationship. The maxillary and mandibular teeth occlude in a
precise and exact manner. Since the arch width of mandible is slightly lesser
than that of maxillary arch when the teeth occlude, maxillary teeth are more
facially placed than the occluding mandibular teeth.

Occlusal Relationship between Maxillary and Mandibular

Posterior Teeth
Centric relation refers to the relationship of the mandible to the skull as it
rotates around the “hinge-axis” before any translatory movement of the
condyles from their “uppermost and midmost position” in the mandibular
fossa. In simple term centric relation can be defined as the position (or path
of opening and closing without translation of the condyles) of the mandible in
which the condyles are in their uppermost, midmost position in the
mandibular fossae. It is irrespective of tooth position or vertical dimension.

Fig. 36.2a: Curve of Spee

Fig. 36.2b: Curve of Wilson

 Centric occlusion refers to the relationship of the mandible to the maxilla
when the teeth are in maximum occlusal contact, irrespective of the position
or alignment of the condyle-disk assemblies. In other words, centric
occlusion is the occlusion of opposing teeth when the mandible is at centric
relation. This may or may not coincide with maximal intercuspation.
The complete intercuspation of the opposing teeth independent of condylar
position is referred to as maximum intercuspation.
In complete occlusal closure (centric occlusion) the palatal cusps of the
maxillary molars are seated in the central fossa of mandibular molars and
buccal cusps of the mandibular teeth are seated in the central fossa of the
maxillary molars. Therefore the buccal cusp of the mandibular posteriors and
palatal cusps of maxillary posteriors are called supporting
cusps/centric/functional/stamp cusps and are primarily responsible for
maintaining the distance between maxilla and mandible. This distance
supports the vertical facial height and is called vertical dimension of
occlusion.
The buccal cusp of the maxillary posteriors and lingual cusps of
mandibular posteriors are called guiding or noncentriclnonfunctional cusps.
The centric cusps are broad mid-rounded whereas noncentric cusps are sharp.
When the teeth are in maximum intercuspation, only a small area of centric
and noncentric cusps contact or remain in close relation and have functional
significance. This area is located in the inner inclines of noncentric cusps
near the central fossa and on the outer aspect of opposing centric cusps. The
noncentric cusps give mandible stability so that when the teeth are in full
occlusion, a tight definite occlusal relationship results.

Mesiodistal Occlusal Contact Relationship

When the centric cusps contacts the opposing tooth, the occlusal contact can
be observed in one of the two areas: 1. central fossa, 2. marginal ridge and
embrasures. In the first type, when the cusp tip contacts with the central fossa
only certain portions come in contacts at a given time, leaving other areas
free of contact. In the second type, cusp tip contacts with the marginal ridge
of the opposing tooth. Two variations in the occlusal contact patterns can
result with respect to marginal ridge areas in some cases, the cusp contacts
the embrasure area and the adjacent marginal ridges, resulting in two contacts
on one area of cusp tip. In contrast, in some teeth cusp tip contacts only on
marginal ridge, resulting in only one contact on cusp tip.
 Normally each tooth occludes with two opposing teeth except for two
teeth: Mandibular central incisors and maxillary third molars which occlude
with only one tooth. Throughout the arch any given tooth is found to occlude
with its counterpart in the opposing arch plus an adjacent tooth. This is
described as one tooth to two teeth relationship.
When the teeth are not in contact in mastication, swallowing, or speech,
the lips are at rest and the jaws are apart. This is termed the postural position
of the mandible, a term that is more appropriate than physiologic rest
position. To maintain the mandible in this position, it is necessary to support
it against the force of gravity. Thus, the masticatory muscles are in a mild
state of contraction. The postural position is not constant; it varies with the
position of the head and body and is affected by proprioceptive stimuli from
the dentition, by prior jaw movements, and by emotional factors. Thus, there
is no single, constant position of the mandible when the subject is at rest. The
space between the mandibular and maxillary teeth when the mandible is in
the postural position is called the free way space or the vertical dimension of
rest. The average free way space ranges between 0 and 3 mm with an average
of 1.7 mm.

Common Occlusal Relationships of the Posterior Teeth

The molar relation of permanent posteriors can be class I, II or III as
described by Angle. The key teeth for this classification are permanent first
molars.
Class I relation (Fig. 36.3a): Class I is the most typical molar relationship
found in natural dentition and is considered as normal occlusion in permanent
dentition. In this type of molar relation, the mesio-buccal cusp of the
maxillary first molar is aligned directly over the mesio-buccal groove of the
mandibular first molar. The mesio-buccal cusp of the mandibular first molar
occludes in the embrasure area between the maxillary second premolar and
first molar, whereas the mesio-lingual cusp of the maxillary first molar is
situated in the central fossa area of the mandibular first molar.
Class II relation (Fig. 36.3b): This type of molar relationship occurs when
the mandibular arch is small or posteriorly positioned or the maxilla is large
or anteriorly positioned. In this type of molar relationship, the mesio-buccal
cusp of the maxillary first molar is aligned directly over the embrasure area
between the mandibular second premolar and the first molar. The disto-
buccal cusp of maxillary first molar is inline with mesio-buccal groove of the
mandibular first molar. The mesio-buccal cusp of the mandibular first molar
occludes with the central fossa of maxillary first molar whereas the disto-
lingual cusp of the maxillary first molar occludes in the central fossae area of
the mandibular first molar.
Class III relation (Fig. 36.3c): This type of molar relationship corresponds to
a predominant growth of the mandibular arch. Here, the mandibular molars
are mesial to maxillary molar as compared to class I relation. Therefore
mesio-buccal cusp of the maxillary first molar is found to be situated over the
embrasure area between the mandibular first and second molars. The disto-
buccal cusp of the mandibular first molar is situated in the embrasure
between the maxillary second premolar and first molar whereas the mesio-
lingual cusp of the maxillary first molar is situated in the mesial pit of the
mandibular second molar.

Common Relationships of the Anterior Teeth

Maxillary anterior teeth also show a labial placement compared to
mandibular teeth. Both maxillary and mandibular teeth are aligned with slight
labial inclination.
In normal arch relation, when teeth are brought to occlusion, the anterior
teeth of the maxillary arch overlaps the teeth of the mandibular arch. A
horizontal overlap of approximately 2–4 mm, referred to as overjet is seen
because the incisal edges of the maxillary anterior teeth are labial to the
incisal edge of mandibular anterior teeth. The over jet is measured from the
labial surface of the mandibular central incisor to the mid point of incisal
edge of maxillary incisors. In normal relation, when viewed from labial
aspect 3 to 4 mm of mandibular incisors are hidden because the incisal edge
of maxillary incisors extend below the incisal edge of mandibular anteriors.
This vertical overlap is called overbite and is measured as a distance between
a horizontal line drawn between incisal edge of mandibular central to a point
on labial aspect of maxillary incisors and a similar horizontal line drawn from
maxillary incisor’s mesial edge and a point on mandibular incisor (Fig. 36.4).
 Fig. 36.3: Molar relation in permanent dentition

Theories of Occlusion
a. Bonwill Theory of Occlusion
According to this theory of occlusion, the teeth move in relation to each other
as guided by condylar and incisal guidance. The condylar guidance refers to
the path that the trans-cranial rotation axis of the condyles travel during
mandibular opening. The incisal guidance is a measure of amount of
movement and angle at which the lower incisors and mandible must move
from the overlapping position in centric occlusion to an edge to edge
relationship with maxillary incisors.

Fig. 36.4: Overjet and overbite

 Bonwill theory is also known as theory of equilateral triangle. According
to this, the distance between the condyle is equal to the distance between the
two condyles and the midpoint of mandibular incisors (the incisal point). A
line drawn between the two condyles and from each condyle to the incisal
point forms an equilateral triangle. The length of each arm of the equilateral
triangle being 4 inches. Later, Monson, used Bonwill’s triangle and proposed
a theory that sphere existed with radius of 4 inches, with centre that was an
equal distance from occlusal surfaces of posterior teeth and from centres of
condyles. The sphere formed is known as ‘Sphere of Monson’. ‘Curve of
Monson’ can be defined as an ideal curve of occlusion in which each cusp
and incisal edge touches the surface or confirms to a segment of an imaginary
sphere 8 inches in diameter. Curve of Spee and Curve of Wilson form
portions of the sphere of Monson.

b. Conical Theory of Occlusion

This theory is proposed by RE Hall. According to this theory the lower teeth
move over the surface of the upper teeth as over the surface of cone
generating an angle of 45° with central axis of the cone tipped 45° to the
occlusal plane.

c. Spherical Theory of Occlusion

Proposes that the lower teeth move over the surface of upper teeth as over the
surface of a sphere with a diameter of 8 inches. The surface of the sphere
passes through the glenoid fossa along with articular eminences and the
center of the sphere is located in the region of glabella.
Section 4

Oral Physiology

37. Eruption
38. Shedding
39. Saliva
40. Physiology of Taste and Speech
41. Mastication
42. Deglutition
43. Calcium Phosphorus Metabolism
44. Mineralization
45. Hormonal Influence on Orofacial Structures
46. Age Changanses of Oral Tissues
 37
Eruption

Introduction
Types of physiological tooth movements
– Pre-eruptive movements
– Eruptive movements
– Post-eruptive movements
Mechanism of tooth movement
Clinical considerations

T eeth undergo complex movements within the jaw bones during its
development, as it moves from jaw bone to the functional position and
also later to compensate for masticatory wear and to maintain their
position in growing jaws. All these movements of teeth together are referred
to as physiological tooth movements. The physiological movements of teeth
are described under three headings.
Pre-eruptive movements: The movements made by the developing tooth
germ within the jaw bone.
Eruptive tooth movements: The movements made by a developed tooth as it
moves from the jaw bone to the functional position in the oral cavity.
Post-eruptive movements: The movements made by a fully erupted tooth to
compensate for occlusal wear and to maintain the occlusal plane as the jaw
bone continues to grow.

Pre-eruptive Tooth Movements

Pre-eruptive tooth movements are preparatory to the eruption phase. These
movements help in positioning the tooth germs within the jaw bone as the
bone grows in length, width and height and also to position the tooth germs in
a position favorable for eruption.

Pattern of Pre-eruptive Tooth Movement

Deciduous teeth undergo pre-eruptive tooth movements to adjust their
position in the developing jaw. As the jaw bone increases in length, anterior
teeth drift forward and molars drift posteriorly to relieve the crowding of
expanding tooth germs. Again as the jaw height increases, maxillary teeth
move downwards and mandibular teeth move upwards to adjust their
position. Tooth germs also move slightly outwards as the bone grows in
thickness or width.
Permanent successors also move in a complex fashion before it reaches its
position from where they erupt. During initial stage of development,
permanent anterior teeth are situated lingual and near to the occlusal level of
its deciduous predecessor teeth in the same bony crypt. As the deciduous
teeth erupt, they move apically to occupy their own bony crypt. Similarly,
developing premolar tooth germs also move from a lingual position to the
region between the divergent roots of deciduous molars.
Permanent molar tooth germs also move considerably from the site of their
initial development. Permanent maxillary molars develop with their occlusal
aspect facing distally and mandibular molars with the occlusal aspect facing
mesially. These teeth gradually become upright, only after sufficient space is
created by distal growth of the jaw bones.

Histology of Pre-eruptive Tooth Movements

Pre-eruptive tooth movements are combination of eccentric growth and total
bodily movement. Eccentric growth results when the tooth germ increases in
size and changes the shape. During this, only bone resorption occurs in the
bony crypt to accommodate the growing tooth germ.
Bodily movement is characterized by the movement of entire tooth germ
which is brought about by selective resorption and deposition of the bony
crypt wall. Bone resorption is observed on the side to which the tooth germ
has to move followed by deposition on the opposite side. (For example, a
tooth germ moving in a mesial direction, show resorption of mesial aspect of
crypt wall creating space. After the tooth germ moves mesially the bone is
deposited on the distal aspect to fill in the space created by the movement of
tooth germ.)

Eruptive Tooth Movements

Eruption is defined as the axial or occlusal movement of the tooth from its
developmental position within the jaw bone to its functional position in the
occlusal plane. The term eruption is derived from a Latin word ‘erumpere’
which means ‘to breakout’.
Although the breaking out of the tooth through the gingiva is the first
clinical sign of eruption, eruptive tooth movements begin much earlier.

Pattern of Eruptive Tooth Movements

Eruptive tooth movements are primarily in the axial or occlusal direction and
ends when the tooth reaches the occlusal plane. During this phase,
movements in other direction is also observed to position the teeth in the
growing jaw bone.

Histology of Eruptive Tooth Movements

During eruption along with movements of tooth, important events like root
formation, orientation of periodontal ligament fibers and establishment of
dento-gingival junction take place. Therefore histologically features related to
these events are observed during eruptive tooth movements.
Root formation: As a part of root formation, proliferation of Hertwig’s
epithelial root sheath and dental papilla, formation of radicular dentin and
cementum is observed. During initial stages of root formation, to
accommodate the developing root, bone is resorbed at the base of bony crypt.
During eruption, since the space is created for developing root by the occlusal
movement of tooth, bone resorption stops and sometimes even bone
formation is seen.
Changes in periodontal ligament: As the root develops, organization of
periodontal ligament takes place. During this phase periodontal ligament
shows important changes that are required for eruptive tooth movement,
These changes include: (a) presence of contractile elements in fibroblasts, (b)
formation of intercellular attachment between fibroblasts, (c) development of
fibronexus (morphological relationship between intracellular microfilaments
in the fibroblast and extracellular collagen fibers, mediated through a sticky
glycoprotein called fibronectin), and (d) active remodeling of collagen fibers.
Establishment of dento-gingival junction: After the erupting tooth comes
out of the bone significant changes are observed in the overlying soft tissue
such as: (a) degeneration of the connective tissue between reduced enamel
epithelium and oral epithelium, (b) proliferation of both epithelia to form a
solid plug of cells, and (c) degeneration of central cells of this epithelial plug,
forming a canal through which tooth erupt without bleeding. Once the tooth
erupts part of reduced enamel epithelium remain attached to the tooth and
helps in establishment of dento-gingival junction. This part of epithelium is
called junctional epithelium.
Once the tooth break through mucosa it continues to move at the same rate
till it reaches the occlusal plane to meet the antagonist tooth. Even after the
tooth reaches the occlusal plane the major portion of tooth is covered by the
soft tissue. Further exposure of the crown takes place by the apical shift of
junctional epithelium. This is called passive eruption (for details refer page
124 and 125).
In addition to the above mentioned changes, permanent successor teeth
show an additional feature called gubemacular canal and guber-nacular
cord. After the initial phase of development within the same bony crypt of
deciduous teeth, permanent teeth move apically to occupy their own bony
crypt. This bony crypt has a small opening or canal that contains connective
tissue along with some remnants of dental lamina which connect the dental
follicle to the lamina propria of overlying mucosa. The canal is called
gubemacular canal and the connective tissue content of the canal is called
gubemacular cord or gubernaculum dentis. In dry skull, this canal may be
seen as small openings lingual to the deciduous teeth. This canal is widened
by osteoclastic resorption as the tooth erupts and therefore may guide these
teeth in eruption.

Post-eruptive Tooth Movements

The teeth undergo physiologic movement even after it reaches the occlusal
plane and this continues as long as the tooth remains in the oral cavity.
Posteruptive tooth movements mainly occur due to three reasons.
To adjust their position in a growing jaw: This is seen up to the age of 18
years and stops once the growth of condyle is completed. As the condyle
increases in length jaw get separated. To maintain the occlusal contact the
upper and lower teeth move axially into a new occlusal plane. The same
mechanism involved in eruptive movement is helping in this movement
To compensate for occlusal wear—due to continuous tooth to tooth contact as
in mastication, occlusal aspect of teeth undergoes continuous wear and tear.
To compensate for this, the teeth move in axial direction which is also caused
by the same mechanism as tooth eruption.
To compensate for proximal wear due to wear and tear in the region of
proximal contact, the teeth tend to drift mesially to maintain their contact.
This is brought about by selective remodeling of bony socket wall and
remodeling in periodontal ligament and contraction of transseptal fibers.

Histology of Post-eruptive Tooth Movement

Histological changes observed during post-eruptive tooth movements include
deposition of cellular cementum around the root apex; bone deposition at
alveolar crest and base of socket and remodeling of collagen in periodontal
ligament.

MECHANISM OF TOOTH MOVEMENT

(THEORIES OF ERUPTION)

The mechanism involved in eruption of teeth is not fully understood. It is

considered that the eruptive tooth movement is brought about by multiple
factors. Many factors have been considered to be playing significant role in
tooth eruption. Accordingly, different theories have been put forward to
explain the phenomenon of eruption. No single theory can be considered as
complete explanation of eruption process.

1. Root Formation Theory

According to this theory, the eruption of the tooth is brought about by the
occlusal movement of the tooth that occurs to accommodate the growing
root.
 The increasing length of root during its formation can be accommodated
either by an occlusal movement of the tooth or by resorption of bone at the
base of the socket. It has been observed that the root growth produces force
that is sufficient to move the tooth. But it is possible only if this apically
directed force is translated to an occlusal direction for which a fixed base is
essential.
People who support this theory consider the existence of a strong base at
the bottom of the socket in the form of a ‘cushion-hammock ligament’ that
extends from one bony wall to other like a sling. But the histologic
examination of developing tooth germs do not reveal any such structure.
Instead only the pulp delineating membrane is observed that separates dental
pulp from periapical tissue which do not have a bony attachment and is
therefore unable to function as a fixed base.
Although it would be possible to consider that the growing root pushes the
tooth into the oral cavity, there are some clinical observations which question
the importance of this theory.
Some teeth move to a greater distance during eruption than the actual length
of roots.
Eruptive movement is observed even after the root completion.
Experimental resection of developing root does not stop the eruption process.
‘Rootless teeth’ are found to be erupting.
Although there are some demerits for this theory, root formation has an
important role in helping in tooth eruption.

2. Bone Remodeling Theory

This theory proposes that the eruption of tooth is brought about by selective
deposition and resorption of bone that occur around the developing tooth.
According to this theory, the resorption of bone in front and deposition of
bone behind the erupting tooth, results in tooth movement.
Results of some experimental studies have shown supporting evidences for
this theory.
In experimental studies where the tooth germ was removed and the dental
follicle was left behind, the eruption pathway was created. In a similar
experiment when a silica replica was placed after removal of developing
tooth, it erupted normally like a tooth. But when the dental follicle was
removed, eruption pathway was not formed.
It is observed that the tooth eruption is prevented in animals that have genetic
deficiency of osteoclasts, the cells responsible for bone resorption.
The supporters of this theory say that bone remodeling that occurs lead to
formation of an eruption pathway through which the tooth erupts. The role of
dental follicle could be indirect through the presence of blood vessels which
provide a pathway for the osteoclasts that are derived from monocytes.
Possible role of osteoblasts in bone remodeling is also been considered. The
osteoblasts can secrete the collagenase and other proteolytic enzymes which
can remove the osteoid layer to expose the mineralized bone; which in turn,
can attract the osteoclasts to the site to cause bone resorption.
Since the developing tooth is situated within the bony crypt, resorption and
deposition of bone is very essential for tooth movement. But it is debatable
whether the bone remodeling is the cause of tooth movements or the effect.
Growth of alveolar bone: Growth of alveolar bone by apposition at the
alveolar crest, was also thought to be helping in eruption process by the
pulling action of periodontal ligament.

3. Vascular Pressure/Hydrostatic Pressure Theory

According to this theory the local increase in tissue fluid pressure in the
periapical region of the tooth causes the occlusal movement of tooth.
The periapical tissue contains many blood vessels. The active fluid
movement from these fenestrated capillaries into the local periapical tissue
can cause swelling of the tissue to around 50%. Since the periapical tissue is
in a closed space, swelling of tissue can cause local increase in the pressure
and this pressure is exerted onto the tooth resulting in eruptive tooth
movement. Since this pressure difference created is transient, it is doubtful
whether this factor only is sufficient to cause a significant tooth movement as
in eruption.
Reduced eruption rate following severance of blood vessels to the
periapical region has been observed. The role of vascular pressure in eruption
cannot be confirmed only with this observation because lack of blood supply
may affect other factors such as tissue growth, which could be even
responsible for decrease in eruption rate.
4. Constriction of Pulp
As the root formation continues, radicular dentin thickness increases resulting
in decrease in size of the pulp cavity. It has been suggested that the pressure
created within the constricting pulp is adequate to cause eruption of tooth.
There is not much experimental evidence for this theory.

5. Pulp Growth
The role of growing pulp in providing eruptive force has been suggested by
Sicher. The supporters of this theory suggest that in the apical end of
developing root there is active mitotic division of cells which bring about
pulp growth and may provide at least a part of eruptive force.
Rate of eruption is found to be decreased after injection of antimitotic
drugs. This observation is insufficient to confirm the role of pulp growth
alone, because the antimitotic drugs can adversely affect proliferation of
other tissues that would be influencing eruption.

6. Periodontal Ligament Traction Theory

This is the most accepted theory of eruption and it proposes that the
contractile force created by the cells and fibers of the periodontal ligament is
helping in pulling the tooth into occlusion.
The fibroblasts in the developing periodontal ligament show intracellular
contractile filaments, increased number of intercellular junctions and also a
specialized structure called fibronexus providing connection between
collagen fibers and intracellular filaments of the fibroblasts.
Since the fibroblasts of periodontal ligament contain contractile filaments
such as actin and myosin, they are called as myofibroblasts. These
myofibroblasts contract and these contractile forces created by many cells are
summated because of the intercellular attachments. These summated forces
are transferred through fibronexus onto the collagen fibers, which are
attached onto the tooth on one side. These forces applied onto an obliquely
arranged collagen bundles are sufficient to pull the tooth upwards. The rapid
remodeling of the collagen fibers and root elongation helps to maintain the
oblique orientation of fibers when the teeth move occlusally. Force created by
the fibroblasts and collagen fibers is able to pull the tooth only if the oblique
orientation of periodontal ligament is maintained.
 The activity of fibroblasts in pulling the tooth has been compared to a
sailor (fibroblasts) pulling on a rope (collagen) attached to the sail (tooth). To
move the sail (tooth) the sailor (fibroblasts) must remain stationary and pull
on the rope (contraction) and coil it onto the deck (collagen remodeling).
Many experimental evidences support the role of fibroblasts in eruption.
Eruption process was stopped or slows down when periodontal ligament
destruction was induced by injecting lathyritic agents or by denying vitamin
C, which is an essential vitamin for development of collagen fibers of
periodontal ligament.
When fibroblasts were implanted on silicone rubber, they were found to be
crawling on it and while doing so created wrinkles on the rubber indicating
that traction forces have been created by moving fibroblasts.
When fibroblasts of periodontal ligament were embedded in collagen gel, the
fibroblasts were found to be aligning themselves parallel to collagen fibers
and establishing a connection between each other and to collagen fibers
thereby converting the collagen gel to a three-dimensional structure.
Experiments in animals have showed the persistent movements of the tooth
when only periodontal ligament was available to move the tooth and the
possible effect of root growth and vascular pressure were eliminated.
The force created by shrinkage of collagen fibers of periodontal ligament
that occur during its development and maturation has also been considered as
a source of eruptive force.

7. Dental Follicle Theory

According to this theory dental follicle plays a very important role in eruption
of teeth by:
Playing important role in development of root
Giving rise to periodontal ligament
Providing a pathway for osteoclasts which is required for bone remodeling
Acting as a source of osteoblasts
Although many other mechanisms such as hormonal theory, foreign body
theory, blood vessel thrust theory, pressure from muscular action, growth of
periodontal tissues, and resorption of the alveolar crest, etc. have been
suggested by various investigators, these have not gained much importance.
In conclusion, the eruption of the tooth is a multifactorial process initiated
by pulling action of fibroblasts and periodontal ligament, facilitated by bone
remodeling, root formation, vascular pressure, etc.

Clinical Considerations
There are a number of clinical conditions, where eruption process is
disturbed.
1. Premature eruption: Tooth erupts into oral cavity much earlier than
normal time of eruption. Frequently involved tooth are deciduous
mandibular central incisors. The term ‘natal’ teeth is used when the
deciduous teeth are present at the time of birth. Deciduous teeth which
erupt within first 30 days of life is termed as neonatal teeth. Premature
loss of deciduous teeth causes premature eruption of permanent teeth
which may be related to hormonal disturbances.
2. Delayed eruption: Tooth erupts into oral cavity much later than normal
time of eruption. Both deciduous and permanent dentition may be
affected.
3. Impacted teeth: Teeth which are prevented from eruption into oral
cavity by some physical barrier in eruptive path or nonavailability of
space.
4. Embedded teeth: It refers to those teeth that are unerrupted due to lack
of eruptive forces
5. Ectopia: Remote location of a tooth away from its normal position. For
example: Maxillary canine erupting in nasal cavity/maxillary sinus/at
the inner canthus of eye, or mandibular 3rd molar erupting at angle of
mandible/lower border of mandible/through the skin of cheek.
6. Transposition: Condition wherein 2 teeth exchange position. For
example: Exchange of position between maxillary canine and
premolar.
7. Rotation: Developmental anomaly wherein a tooth turns
partially/completely.
 38
Shedding

Introduction
Mechanism of shedding
Histology of shedding
Pattern of shedding
Clinical considerations

S hedding is defined as a physiological process by which the deciduous

teeth are removed to allow the succeeding permanent teeth to take their
functional position in the oral cavity. In simple words, shedding is the
physiological process of eliminating the deciduous dentition. Shedding of the
deciduous teeth is necessary as the teeth do not grow after they are formed
and therefore they need to be replaced by more number of larger teeth, which
can resist greater masticatory force and also, esthetically pleasing in a large
jaw of adults.

Mechanism of Shedding
Shedding of the deciduous teeth occur as a result of resorption of roots of the
teeth and destruction of supporting periodontal ligament. The factors
suggested to be playing role in shedding are:
Pressure from erupting permanent successors: This pressure helps in the
differentiation of odontoclasts that can resorb the dental hard tissues. In case
of congenitally missing permanent successor, the deciduous tooth is retained
for a longer time, supporting the role of pressure from the successor teeth in
exfoliation.
Force of mastication: Although the deciduous tooth is retained for sometime
when permanent successor is missing, ultimately it exfoliates suggesting the
role of other factors on shedding. As individual grows, force of mastication
increases and become greater than what deciduous periodontal ligament can
withstand. This leads to trauma to the periodontal ligament, followed by
destruction, initiating resorption and ultimately shedding.
Combination of these two factors may be deciding the rate and patterns of
resorption. When the root is resorbed, supporting tissue decreases making the
tooth unable to bear the masticating forces. This makes the tooth mobile and
accelerates the process of shedding.

Histology of Shedding
Shedding is brought about by resorption of dental hard tissues and destruction
of supporting periodontal ligament. The cells responsible for resorption of
tooth are odontoclasts.
Odontoclasts are highly specialized cells responsible for resorption of dental
hard tissue including cementum, dentin and enamel. They are structurally and
functionally similar to osteoclasts, the bone resorbing cells. Origin of
odontoclast is from circulatory monocytes that are capable of giving rise to
all different tissue macrophages.
Light microscopically odontoclasts can be readily identified as large,
multinucleated giant cells, occupying the irregular bays on the surface of
resorbing dental hard tissue. They may also be found in the pulp.
Electron microscopically these cells have a ruffled border adjacent to the
resorbing hard tissue. This is formed by folding of cell membrane into a
series of invaginations of 2–3 mm in depth. Mineral crystallites may be seen
in the depth of these invaginations. Cytoplasm has large number of
mitochondria and vacuoles which are seen close to the ruffled border.
Histochemically the cells have increased levels of enzyme acid phosphatase.
The mechanism by which odontoclasts actually resorb the hard tissues of
teeth is not understood. Possibly during the initial stage, the crystallites are
removed exposing the organic matrix. As a second step, organic matrix is
removed by extracellular dissolution into smaller molecules and phagocytosis
by odontoclasts.
 Vacuoles in the odontoclasts, rich in acid phosphatase suggest that they are
phagosomes causing break down of ingested materials.
Histological sections show that periodontal ligament degeneration may be
through apoptotic cell death or through a mechanism that interfere with
formative function of fibroblasts.

Pattern of Resorption and Shedding

The pressure exerted by the successor tooth leads to resorption. The
developmental position and the physiological movement of the successors are
very important factors in determining pattern of resorption and shedding.
The developmental positions of permanent incisors are lingual to
deciduous incisors, and later they occupy an apical position. Because of this,
for deciduous anteriors first sign of resorption is on the lingual aspect of the
root followed by resorption of the apical region. If the permanent tooth fails
to take an apical position, it may erupt lingual to deciduous tooth which is
still in function.
The developmental position of premolars is between the roots of deciduous
molars. So the first evidence of resorption is observed along the inner aspect
of deciduous molar roots. Later the developing tooth occupies an apical
position and slowly resorbs the root from its apex and continues till the root
is completely resorbed and exfoliated.
The process of resorption is not continuous but has periods of rest and
repair. Overall the process of resorption predominates, over repair leading to
exfoliation of tooth. If repair predominates it can lead to retention of
deciduous tooth.
The pattern of shedding is symmetrical for right and left side. Mandibular
teeth exfoliate before their counterparts in maxillary arch. Maxillary and
mandibular second deciduous molar exfoliate almost simultaneously. Girls
exfoliate teeth earlier than boys. This discrepancy is most observable in case
of mandibular canine. The sequence of shedding in mandibular follows
anterior to posterior order of teeth in the jaw. In the maxilla, the sequence is
disrupted by first molars exfoliating before canines.

Clinical Considerations
1. Retained deciduous teeth: Deciduous teeth remaining in the oral cavity
 for longer time than the normal exfoliation period are referred to as
retained deciduous teeth.
The causes of retained deciduous teeth may be
• Congenital absence of permanent successor
• Failure of eruption of permanent successor
• Ankylosis of deciduous tooth (fusion of tooth to alveolar bone).
• Eruption of permanent tooth in a lingual or labial position so that
the deciduous tooth escape from the pressure exerted by them.
2. Remnants of roots of deciduous tooth
Remnants of roots of deciduous tooth is commonly seen in maxillary
premolar region. The roots of deciduous molars are so divergent that
the distance between roots is more than the diameter of the developing
permanent tooth. This allows a portion of root to escape from
resorption. These unresorbed root pieces may get resorbed and
replaced by bone. The remnants closer to the surface extrude through
the mucosa and ultimately exfoliate,
3. Submerged tooth
Submerged tooth is the one which remains below the level of normal
occlusal plane of other teeth. This can occur if the tooth is ankylosed
(fused) to the alveolar bone. Ankylosis may be due to trauma resulting
in damage to periodontal ligament. Imbalance between resorption and
repair that occur during the process of exfoliation may also lead to
ankylosis of deciduous teeth. An ankylosed tooth is unable to undergo
physiological tooth movement to compensate for increased height of
alveolar bone. When adjacent teeth continue eruption, the ankylosed
tooth remains submerged with occlusal plane of this tooth at a lower
level. When the deciduous tooth is ankylosed, it fails to exfoliate and
therefore prevent eruption of its successor. A submerged tooth should
be extracted, after a radiographic confirmation of presence of
permanent successor.
 39
Saliva

Introduction
Composition
Function
Synthesis
Control of secretion

S aliva is the fluid secreted by the salivary gland that keeps the oral cavity
moist. Saliva is secreted by three pairs of major salivary glands, namely
parotid, submandibular and sublingual glands and numerous minor
salivary glands which are widely distributed in the oral mucosa. The total
volume of saliva secreted varies from 600 to 700 ml per day or even may be
up to 1 to 1.5 liters/day. pH of saliva varies from 6.2 to 7.6. During rapid
secretion the saliva becomes more alkaline because of high bicarbonate
content. Specific gravity of saliva is 1.002 to 1.012.

COMPOSITION OF SALIVA

Saliva contains various constituents such as inorganic salts, both enzymatic

and non-enzymatic proteins, dissolved gases, etc. Composition of saliva
varies from unstimulated to stimulated saliva.

Saliva Contains
Water-99%
Organic and inorganic components-1%

Organic Components
Mucin or carbohydrate rich glycoproteins
Antibacterial components
– Lactoferrin
– Kallikrein
– Lysozymes
– Peroxidase
– Thiocyanate
Digestive enzymes
– Ptyalin or amylase
– Maltase
– Lipase
Free amino acids, fatty acids, urea, uric acid, free glucose, peptides, blood
clotting factors, blood group substances, epidermal growth factors, etc.

Inorganic Component
Sodium, chloride, potassium, calcium, bicarbonates, phosphates, ammonia,
magnesium, fluoride, iodine, etc.

Dissolved Gases
Carbon dioxide, oxygen, nitrogen, etc.
In addition, the whole saliva obtained from the mouth also contains
desquamated epithelial cells and a few leukocytes from crevicular fluid and
oral micro-organisms.

FUNCTIONS OF SALIVA

Mechanical Function
Lubrication: Because of water and mucin content, saliva helps to keep oral
cavity wet and helps in speech, mastication and deglutition.
Salivary glycoproteins forms a lining of oral tissues and therefore prevent
adhesion of microbes, microbial products and various other materials.
Lavage: Saliva helps to flush out food debris and micro-organisms from the
oral cavity.
Saliva helps to dilute hot and other irritant materials therefore preventing
trauma to mucosa.

Antimicrobial Actions of Saliva

The high molecular weight glycoproteins in the saliva aggregate the micro-
organisms and therefore help in rapid clearance from oral cavity thereby
preventing their adhesion to the oral tissue.
Immunoglobulins: Saliva contains immunoglobulins mainly IgA, IgG and
IgM also may be present. These immunoglobulins prevent the adhesion of
micro-organisms to oral tissues. (Salivary IgA [sIgA] in contrast to serum
IgA are always seen as diamers, i.e. two IgA molecules joined by a J chain.
In addition, salivary IgA also has an additional protein called secretory
component that helps in the transfer of IgA through the parenchymal cells
and gives resistance to hydrolysis.)

Fig. 39.1: Functions of saliva

The antibacterial activity of sIgA can be
• By binding to specific antigens responsible for adhesion.
• By agglutination or clumping of bacteria which are then easily
 washed off.
• By affecting specific enzymes necessary for bacterial metabolism.
Peroxidase: This enzyme present in the saliva can catalyze the reaction
between thiocyanate and hydrogen peroxide produced by micro-organisms,
leading to formation of hypothiocyanate which oxidizes the bacterial
enzymes and is bactericidal.
Lysozymes: Saliva contains the enzyme lysozymes that can break down
bacterial cell wall leading to lysis of bacteria.
Lactoferrin is an iron binding protein present in the saliva that can combine
with free iron; therefore depriving micro-organisms of iron which is essential
for their multiplication.

Digestive Function
Saliva contains amylase or ptyalin which can act on starch and split it into
disaccharides. Lipase present in the saliva secreted by von Ebner’s gland is
important in lipid digestion in newborn. Saliva also contains some maltase
enzyme.

Buffering Action of Saliva

The components that impart a buffering action to saliva are mainly
bicarbonates and phosphates. When bicarbonate ions come in contact with
acid ions, weak carbonic acid is formed which is rapidly dissociated into
water and carbon dioxide. The glycoproteins having negatively charged
residues and Sialin, a salivary polypeptide also reported to have buffer
capacity.
Buffering action of saliva is helpful in two ways
It denies the optimum pH required for multiplication of micro-oganisms.
Salivary buffers helps to neutralize the acids produced by micro-organisms
therefore preventing demineralization of enamel and dental caries.

Taste Sensation
Taste sensation can be perceived only when the substance is dissolved and
therefore the solvent action of saliva is very important in perception of taste.
Saliva also helps in cleaning the taste buds to ready them for the next taste
perception. ‘Gustin’ present in saliva helps in development and maturation of
taste buds.

Tissue Repair and Blood Coagulation

Tissue repair function of saliva is considered because of the presence of
epidermal growth factors which stimulate epithelial growth and therefore
could be helping in wound healing. Saliva also contains blood coagulating
factors such as IX, VII and platelet factor that reduces the clotting time.

Water Balance
When the water content in the body is reduced, salivary secretion is
decreased and mouth becomes dry. The nerve endings in the posterior aspect
of tongue are stimulated and a dry mouth reflex is initiated which stimulate
the salivary flow. If the body tissue is short of water, reflex does not occur
leading to drying of mouth. Thus, encourages the individual to drink water
and water balance is maintained.

Endocrine Function
Saliva contains some biologically active materials. For example, parotin
secreted by parotid gland. Parotin is reported to promote mesenchymal tissue
growth, decreases serum calcium level, promoting the mineralization of
dentin, etc. in animals. The status of parotin as a true hormone has not been
identified.

Excretion
Saliva act as a route through which certain substances are excreted such as
mercury, lead, thiocyanate, ethyl alcohol, some drugs, etc. (Excretion of ethyl
alcohol in saliva can be used as a method to determine whether the individual
has consumed alcohol in case of medico legal cases.) Certain viruses like
viruses of rabies, mumps and poliomyelitis are also excreted through saliva.

Tooth Integrity
Saliva contains calcium and phosphate ions. Due to ionic exchange between
saliva and tooth, enamel undergoes maturation. Due to this, enamel becomes
harder, less permeable and more resistant to caries. Ionic exchange can also
lead to remineralization of initial caries lesion preventing further progression.

Nerve Growth Factor

In experimental animals it has been observed that submandibular gland
secretions contain rich nerve growth factor which greatly increases the
growth of sympathetic ganglia and sensory nerves.

Temperature Regulation
This function of saliva is significant in animals.

SYNTHESIS AND SECRETION OF SALIVA

The organic components of the saliva are synthesized by the secretory cells
of salivary gland utilizing the substrate provided by the nutrients that reach
the cell from the blood vessels and stored in secretory granules. When the
secretory unit is stimulated the stored products are expelled out.
Water and electrolyte required for the sava reaches the cell from
circulation and from tissue fluid. When there is nerve stimulation, chloride
ions are actively transported into the cell. This increased electronegativity
induces the influx of sodium ions. This increased sodium and chloride ions in
the cell create an osmotic force resulting in transport of water into the cell
causing cell swelling. The pressure in the cell results in minute rupture of
secretory border of cell, expelling water and electrolytes. Kallikrein presents
in saliva act upon plasma proteins to produce bradykinin. This produces the
vasodilatation resulting in seepage of water into the tissue fluid, during active
secretion of saliva.

Decision for protein synthesis is taken in the nucleus

↓
Messenger RNA in ribosomes carry the message to the cytoplasm through
ribosomes
↓
Ribosomes translates the message and initiate protein synthesis by adding
 amino acids in required sequence. Thus, form a preprotein with a signal
sequence attached to it
↓
With the help of signal sequence, protein synthesized enters the PER
where the signal sequence is removed and protein assumes a helical
structure
↓
Protein synthesized is transferred to Golgi complex
↓
Structural modification of protein in the Golgi complex by addition of
carbohydrates
↓
Packing of secretory product into secretory granules (pro secretory
granules)
↓
Further addition of molecules resulting in maturation of secretory granules
↓
Storage of secretory granules in the apical cytoplasm
↓
Secretion of stored material by a process of exocytosis

Control of Salivary Secretion

Secretion of saliva is under nervous control. An increased secretion of saliva
may result from thought, sight or smell of food, talking about food or even by
the noise of food being prepared.
Increased salivary secretion can be caused by:
Taste: different tastes have varying capacities in stimulating salivary
secretion.
Smell
Mechanical stimulation of oral mucosa
Mechanical irritation of gingiva during dental treatment procedures
Mastication: Stimulate salivary secretion by stimulating sensory impulses.
Chemical irritation of oral mucosa by acids such as citric acid, salt, etc.
Irritation of esophagus, like in case of foreign bodies or pathology like
carcinoma.
Pregnancy: An increased salivary flow rate is reported.
Irritation of the stomach wall leading to nausea.

Nervous Control of Salivary Secretion

The salivary glands are innervated by both sympathetic and parasympathetic
secreto-motor nerve fibers. The parasympathetic innervation is secretory and
vasodilatory while sympathetic innervation is mainly vasoconstrictive which
also promote secretion in some cases.
Secretory activity of secretory cells is mediated by cholinergic agents in
parasympathetic system and by adrenergic agents in sympathetic system. The
secretory motor nerve endings are seen in relation to secretory cells, cells of
striated and intercalated ducts, myoepithelial cells, smooth muscles of
arterioles, etc.
In relation to secretory cells, two types of association with nerve endings
can be observed.

Intraepithelial or Hypolemmal Type

In this type axons split off from the nerve bundle and penetrate the basal
lamina to reach the space between two adjacent secretory cells. Here the
nerve endings are in close proximity to the secretory cells and the distance in
between is only 10–20 nm.

Subepithelial Type or Epilemmal Type

In this type the nerve axons instead of penetrating the basal lamina, remain in
the nerve bundle in the connective tissue. The distance between the secretory
cell and the nerve axon is more and is around 100–200 nm.
In both intraepithelial and subepithelial type of innervations, nerve axons
show varicosities or thickening. These varicosities are called the
neuroeffector sites. They contain chemical neurotransmitters such as
norepinephrine and acetylcholine. When the nerves are stimulated, these
neurotransmitters are released which stimulate secretory cells to synthesize
and secrete saliva.
The arterioles in the connective tissue component of the salivary gland also
get sympathetic and parasympathetic innervations. Stimulation of
parasympathetic system causes vasodilatation while the sympathetic system
causes vasoconstriction. Parasympathetic stimulation results in secretion of
large volumes of watery saliva by the secretory cells. Sympathetic
stimulation produces less quantity of thicker saliva. Sympathetic stimulation
also has a greater influence on the composition of saliva and results in a
higher concentration of organic substances due to increased exocytosis in the
cell with decreased movement of water caused by vasoconstriction.
There is no direct inhibition of salivary secretion by nerves.

Clinical Considerations
• Sialorrhea is the term used to describe a condition where there is an
excessive flow of saliva. This may be associated with various
conditions, such as acute inflammation of the mouth, mental
retardation, mercury toxicity, teething, etc. Sialorrhoea is called
hypersalivation or ptyalism.
• Xerostomia is the term used for dry mouth due to a lack of saliva.
Xerostomia can be caused due to a number of reasons: Psychological
causes like anxiety and depression; dehydration due to diarrhoea,
sweating, vomiting, diabetes mellitus and diabetes insipidus; use of
antihistaminic drugs; diseases affecting salivary glands such as
Sjogren’s syndrome, tumors or salivary gland aplasia. Xerostomia can
cause difficulty in speech and eating. It also leads to halitosis (bad
breath), dramatic increase in dental caries and infections.
 40
Physiology of Taste and
Speech
Dr Usha Balan

Physiology of taste
– The sensation of taste
– Mechanism of taste stimulation
Physiology of speech
– Speech process
– Integration of speech
– Perception of speech

PHYSIOLOGY OF TASTE

The Sense of Gustation or Taste

Taste is a mixture of four elementary taste qualities salty, sweet, sour and
bitter. Recently a fifth taste sensation called umami also has been identified.
Taste depend on activation of chemoreceptors located in the taste buds (refer
page 122 for details). Taste buds are widely distributed on the tongue, palate,
pharynx and larynx, epiglottis, etc. The taste buds of the tongue are found on
the dorsal and lateral aspects and are associated with specialized structures
called papillae. The fungiform papillae contain up to five taste buds per
papillae. The lateral walls of the circumvallate papillae contain large number
of taste buds up to 100. Adults have a total of approximately 3000 to 10000
taste buds which decreases by as much as 60% in old age. Taste bud cells
undergo rapid turnover with half life of 10 days. The sensitivity of tongue for
different taste qualities vary with regions of tongue. Sweet sensations are
detected best at the tip, salty and sour along the sides and bitter in the
posterior region. When the taste substance is low in concentration each taste
bud usually respond to one of the four primary taste stimuli, but at high
concentrations taste buds can be excited by various primary taste stimuli.

Mechanism of Stimulation of Taste Buds

The gustatory receptor cells are chemoreceptors that respond to substances
dissolved in oral fluids. These substances act on exposed microvilli in the
taste pore to evoke generator potentials in the receptor cells which generate
action potential in the sensory neurons. The membrane of taste receptor cells
are negatively charged on inside with respect to the outside. When a taste
substance is applied, the taste chemical in the substance binds to the protein
molecules in the microvilli. This in turn opens ion channels which allow
sodium ions to enter and depolarize the cell. The type of receptor protein in
microvilli determines the type of taste that will elicit the response. This
change in potential in the taste cell leads to the receptor potential and the
release of an excitatory neurotransmitter. This neurotransmitter evokes a
generator potential in the primary afferent nerve fibers and cause a discharge
that is transmitted to central nervous system.
The taste buds are innervated by three cranial nerves. The chorda tympani
branch of facial nerve supplies the taste buds of anterior 2/3rd of tongue and
glossopharyngeal nerve supplies the taste buds of posterior 1/3rd of the
tongue. A few taste buds on the posterior region such as pharynx (areas other
than tongue) are innervated by vagus nerve.
On each side, the taste fibers in these three nerves unite in the medulla
oblongata to enter the nucleus of the tractus solitarius. Here they synapse on
the second order neurons, the axons of which cross the midline and join the
medial lemniscus ending with fibers of touch, pain and temperature, in the
specific sensory relay nuclei of thalamus. The impulses are relayed from
there to the taste projection area in the cerebral cortex.
On first application of the taste stimulus, the rate of discharge of nerve
fibers rises to the peak and comes down to a lower steady level. Thus, the
taste is characterized by a strong immediate signal followed by weaker
continuous signal as long as the taste bud is exposed to the taste stimulus.
 PHYSIOLOGY OF SPEECH

Speech is an ordered utterance of language. Speech is human achievement

and is a signal output process through which an individual communicates
with his or her surroundings.
The development, maturation and maintenance of good speech depends
greatly upon the integrity of the structural, neurological, physiological,
psychological, social, and cultural processes.

Speech Process
Speech is often described as “an overlaid process” secondary to vegetative
functions. Phenomenon of speech process includes four mutually dependent
divisions.
Respiration
Phonation
Resonation
Articulation
These process co-ordinate to produce dynamic acoustic modulation of
speech.

Respiration or Power Division

First step in speech producing process is respiration where in the energy
source for speaking is provided by the respiratory system.
Exhaled air stream moves through the resonating cavities and is shaped
into discrete sounds.

Phonation
Second step in speech process is phonation. Breath stream emitted from the
lungs strikes the vocal folds housed in the larynx. Phonation results from
vibratory activity of vocal folds. Exhaled air stream is interrupted by
vibratory pattern of vocal folds, and air puffs emerging from this process
create sound. This sound is referred as source excitation which serves as an
acoustic material from which speech sounds are later developed.
 Processes concerned with shaping or modifying source sounds into
identifiable speech sounds are resonance and articulation.

Resonation
Resonation is the third step in speech process. Resonance system gives a
distinguishing quality which is characteristic of each voice. Sounds are
modified by selective alteration of size and shape of vocal tract. Depending
on the configuration of vocal tract, certain frequencies are amplified whereas
others are attenuated.

Articulation
Articulation is the fourth step in speech producing sequence. Articulators and
articulatory valves are responsible for this act. Vocal organs are the
articulators and the articulatory valves are the place at which airstream is
modified to produce speech sounds. When vocal organs assume a certain
position they produce sound, simultaneously articulatory valves stop,
constrict and narrow the air-stream, thus producing speech sounds.
Articulation thus refers to placement and movement of lips, teeth, tongue,
mandible, soft palate and associated structures during speech to produce
speech sound.

Integration of Speech
Processes of respiration, phonation, resonances and articulation are co-
ordinated and integrated by the nervous system to produce the complex and
dynamic behavior known as speech production.

Perception of Speech
Speech is studied in terms of both production as well as perception of sound.
Properties of each sound is influenced by speech sounds that preceed and
succeed it. Perception of sound depends not only on factors like acoustic
signals but also on adequacy of listeners auditory system, nature of
perceptual environment and linguistic orientation of both speaker and
listener.
 41
Mastication

Introduction
Objectives of mastication
Forces of mastication
Masticatory cycle/chewing cycle
Changes in various structures during mastication
Control of masticatory cycle

M astication is the act of chewing food whereby the ingested food is cut
or crushed into small pieces, mixed with saliva and formed into a bolus
in preparation to swallowing.

Objectives of Mastication
Mastication helps in deglutition by
• Breaking the large food particles into smaller particles which
otherwise may cause irritation to gastrointestinal tract.
• Forming a bolus that can easily be swallowed.
Mastication helps digestion by
• Stimulating salivary secretion
• Causing break down of food particles thereby increasing surface area
for enzymatic action.
• Facilitating mixing of food with saliva and initiating digestion by
salivary enzymes.
 • Exposing the digestible components present inside in some food
materials.
Mastication also ensures healthy growth and development of oral tissues.
The act of mastication is a complex process that uses masticatory muscles,
teeth, periodontal supportive structures and also the lips, cheeks, tongue,
palate and salivary glands. During mastication well coordinated functioning
of masticatory muscles move the mandible to bring the teeth together. During
this process of contact between teeth considerable force is exerted on the food
particles resulting in reduction in size of food particles.

Forces of Mastication
The maximum biting force that can be applied to the teeth varies from
individual to individual. Males are able to exert more masticatory force than
females. The masticatory force exerted on anterior teeth is 55 pounds (10–15
kg) and on molars is 200 pounds (around 50 kg) approximately. Biting force
can be increased by exercise. Maximum biting force up to 150 kg has been
recorded in traditional Eskimos who have lived on very tough diet requiring
vigorous mastication.

Masticatory Cycle/Chewing Cycle

Mastication is made up of rhythmic well-controlled separation and closure of
maxillary and mandibular teeth. Each opening and closing movement of
mandible represents a chewing stroke. During mastication similar chewing
strokes are repeated over and over as the food is broken down. Along with
straight opening and closing movements, the jaw also show protrusive,
retrusive and lateral movements. Each chewing cycle lasts for approximately
0.8–1.0 second.

Chewing cycle comprises two phases

An opening phase
A closing phase
The closing phase has been further subdivided into:
Crushing phase which is at the first phase of closure during which food is
trapped between the teeth.
Grinding phase which is at the later phase of closure which permit the
shearing and grinding of food.
Mastication is a complex process which causes rhythmic opening and
closing movements of the jaws brought about by masticatory muscles and
TMJ. The structures involved in masticatory cycle include masticatory
muscles, temporomandibular joint, mandible, teeth and soft tissues such as
tongue, cheeks and lips.

Changes Observed in Masticatory Muscle during

Chewing Cycle
During the opening phase and in the beginning of closing phase masticatory
muscles undergo isotonic contraction (shorten to produce jaw movements
against a constant load) and relaxation. In the latter part of closing phase and
occlusal phase, tension builds up in the elevator muscles which undergoes
isometric contraction (produce contractile tension with no change in length);
when the teeth are in contact or when there is a hard object in between the
teeth.
During the opening phase the lateral pterygoid muscle is active and also
the suprahyoid muscles (digastric, geniohyoid and mylohyoid). During the
initial closing phase the depressor muscles are first activated, then gradually
relaxed to allow the mouth to be closed by the passive tension in the elevator
muscles. In the closing phase, first the temporalis on the working side
become active followed by masseter and temporalis muscle of the non-
working side.
Masseter and medial pterygoid are active during incisive movement and
lateral pterygoid during protrusive movement.

Jaw Movement during Masticatory Cycle

Both condylar head and the mandibular body move during masticatory cycle.
The mandibular and condylar movements associated with mastication are the
coordinated result of sequenced mandibular muscle contractions.
When the movement of mandible is traced during masticatory stroke ‘a
tear drop’ shaped tracing is observed. In the opening phase, the mandible
drops downward from the intercuspal position to a point where the incisal
edge of the teeth are about 16 to 18 mm apart. The mandible then moves 5 to
6 mm laterally from the midline as the closing movement begins. The first
phase of closure traps the food between the teeth and is called crushing
phase. As the teeth approach each other the lateral displacement is lessened
and the jaw occupies a position only 2 to 4 mm lateral to the starting position
of the chewing stroke. As the mandible continues to close the bolus of the
food is trapped between the teeth and the grinding phase starts. During
grinding the mandible is guided by the occlusal surface of teeth which has
come back to the intercuspal position.
In early stages of mastication where the food has to be incised, the
mandible moves forward to a greater distance. In later stages, the crushing of
food is concentrated and very little anterior movement occurs. Similarly, the
lateral movements are also greater when the food is initially introduced into
the mouth and then becomes lesser as the food is broken down. The lateral
movement also varies according to the consistency of food. The harder the
food the more the lateral closure stroke becomes.
Condylar heads rotate and translate to allow the jaw to open and close
during masticatory movements. During opening phase the condyle on the
working side move laterally whereas the opposing condyle on the balancing
side moves medially downward and forward. These condylar movements
make the mandible shift to the working side.
In early closing phase the condyle of the working side resumes its position
within the articular fossa whereas balancing side condyle returns only in late
period of closing phase. The mandible swings back to intercuspal position.

Position of Teeth during Chewing Cycle

In the opening phase, the incisal edges of teeth are about 16 to 18 mm apart.
During the closing phase, the teeth approach each other with a distance of 2
to 3 mm in between. At this point teeth are so positioned that the buccal
cusps of mandibular teeth are almost directly under the buccal cusps of
maxillary teeth on the side, the mandible has been shifted. During grinding
phase mandibular and the maxillary teeth come to intercuspal position and
allows the cuspal inclines to move across each other permitting grinding of
teeth similar to the action of pestle and mortar.
During mastication most of the food particles are crushed by vertical
movement of mandible and then sheared to make a bolus. Teeth do not come
into occlusion in the initial period. The frequency of tooth increases after the
food particles are softened. In the final stage of mastication, just prior to
swallowing, contacts occur during every stroke. Two types of contacts have
been identified: Gliding, which occurs as the cuspal inclines pass by each
other during opening and grinding phase of mastication, and single, which
occurs in maximum intercuspal position.
Occlusal contacts occur in centric occlusion in at least 90% of all chewing
cycle, especially towards the end of the masticatory cycle. The number of
teeth which may contact vary with food type and increases towards the end of
chewing cycle. In some cases tooth contact occur only on one side.

Role of Soft Tissues (Lips, Cheeks, Tongue) in

Mastication
The lips, tongue and cheek play an essential role in mastication. As the food
is introduced into the mouth, the lips guide and control intake. By sealing the
oral cavity, the lips prevent the loss of fluid and food to outside. The lips are
especially necessary when liquid is being introduced. When the food is
introduced, the tongue often initiates the breaking up process by pressing the
food against the hard palate. The tongue then pushes the food onto the
occlusal surfaces of teeth where the food can be crushed. During the opening
phase of next chewing cycle, the tongue repositions the partially crushed food
onto the teeth for further break down. While the tongue is repositioning, the
food from the lingual side the buccinator muscles of the cheek position food
from the buccal side. The food is thus repositioned continuously until the
particle size is small enough to be swallowed. Once the food is crushed and
chewed it is moved back below the soft palate by squeezing action of tongue.
Tongue is also important in collecting and sorting food that is suitable for
swallowing while larger food particles are returned to occlusal table for
further reduction. Tongue also has a hygienic function by removing the
residues of food from, between the teeth and from the oral vestibule by
sweeping action.

Control of Masticatory Cycle

Mastication is a functional activity that is generally automatic and practically
involuntary. Yet when desired, it can be readily brought under voluntary
control. Mastication is controlled by nuclei in the brainstem and also areas in
hypothalamus and cerebral cortex. The masticatory muscles are supplied by
the trigeminal nerve.
The cyclic activity of the masticatory muscle is generated by the chewing
center (neural pattern generator) in the brainstem and is influenced by
peripheral afferents from face, mouth, etc. Sensory input generated by closing
on a hard food initiate the generation of rhythmic activity; whereas closure on
a softened bolus initiates a swallowing reflex and may consequently
terminate rhythmic activity. Afferent fibers innervating the periodontal
mechanoreceptors, mechanoreceptors at the corners of the mouth and jaw
spindle afferent fibers exert peripheral control on masticatory cycle.
The process of chewing is caused by chewing reflex that is repeated many
times. When food is placed in the mouth the mandible drops down due to
inhibition of muscles of mastication. This drop initiates a stretch reflex of
muscles leading to rebound contraction. This leads to closure of jaw and
compression of food between teeth and oral mucosa. This once again causes
inhibition of muscles leading to drop of jaw which rebounds again. This
process continues repeatedly till the food is sufficiently softened.
 42
Deglutition

Introduction
Phases of deglutition
Infantile and adult swallow

D eglutition or swallowing is a series of coordinated muscular contractions

that move the ingested food and pooled saliva from the oral cavity
through esophagus into the stomach.
Swallowing consists of voluntary, involuntary and reflex muscular activity.
Over a period of 24 hours swallowing occurs approximately 1000 times;
which is highest while eating.
Although swallowing is a continuous process, it can be divided into three
basic phases:
Oral phase during which a voluntary transfer of material from the mouth to
pharynx takes place.
Pharyngeal phase, which involves an involuntary or reflex mechanism that
transfers material from the pharynx to the upper esophagus.
Esophageal phase in which contents of the upper part of the esophagus are
transferred into the stomach by involuntary peristaltic contraction of the
esophageal muscles.
In addition to these three phases, a preparatory phase can also be
appreciated which merges with the terminal phase of mastication.

Preparatory Phase
During this phase, the bolus is prepared and positioned on the tongue as a
preparation to swallowing. The tip of the tongue presses against the maxillary
incisors or anterior part of palate and lateral aspect rises against posterior
teeth and palate so that tongue develops a spoon-like depression. Posteriorly
the pharyngeal part of the tongue arches up to the soft palate. At the same
time, soft palate is depressed to create a glossopalatine seal, which prevent
the bolus from escaping into the pharynx.

Oral Phase
During oral phase, bolus is propelled from the oral cavity to the pharynx. The
tongue muscles and the muscles of floor of the mouth play an important role
in this phase. The oral phase starts after the bolus is positioned on the tongue.
During this phase, the lips are closed and upper and lower teeth come in
contact. This is followed by elevation of the anterior 2/3rds of the tongue,
which presses against anterior part of the hard palate. Mean while the
glossopalatine seal is opened by elevation of the soft palate with depression
of posterior part of tongue. This allows the passage of food to pharynx. The
entry of food into the nasopharynx is prevented by the elevation of the soft
palate. The inward and forward constriction of posterior pharyngeal wall
closes the palatopharyngeal isthmus.
Oral phase of deglutition is under voluntary control and it lasts for 0.5
seconds. During this phase, airway is open and breathing continues normally.

Pharyngeal Phase
In pharyngeal phase, the bolus is transported from the oropharynx into the
esophagus by a peristaltic wave caused by contraction of the pharyngeal
constrictor muscle. The pharyngeal phase begins, when the bolus makes
contact with the posterior part of oral mucosa and mucosa of the pharynx.
These contacts on sensitive areas act as stimuli for a series of reflexes that are
responsible for the bolus being transferred into the esophagus and not into
trachea or nasopharynx.
In the beginning of pharyngeal phase tongue makes a rapid piston-like
movement to propel the bolus through oropharynx to hypopharynx. The
whole pharyngeal tube is elevated by stylopharyngeus and palatopharyngeus
muscles. The entry of bolus to the esophagus is facilitated by the upward
movement of larynx which stretches the opening of esophagus and elevation
of larynx that lifts the glottis away from the food passage. Simultaneous
relaxation of the upper esophageal sphincter occurs followed by a wave of
peristalsis caused by contraction of pharyngeal muscles propels the bolus into
the esophagus.
During this phase, there are possibilities of food entering back into oral
cavity, upward into nasopharynx, forward into larynx and downward into
esophagus. Due to co-ordinated movements of various structures, the entry of
food to other passages is prevented.
Bolus is prevented from moving back to oral cavity by the tongue which
takes a position against the roof of the mouth and also by increased intraoral
pressure created in the oral cavity by the movement of tongue.
Entry of bolus to nasopharynx is prevented by upward movement of soft
palate which becomes triangular in shape and contacts the adjacent
pharyngeal wall.
Several mechanisms operate to prevent aspiration of food to the larynx.
a. Larynx rises and is pulled up under the tongue.
b. Epiglottis folds down from an upright to horizontal position over the
laryngeal opening.
c. The intrinsic muscle of the glottis approximate the vocal cords and
the pyriform sinus create lateral food channels so that the bolus
deviates around the laryngeal opening.
Temporary arrest of breathing occurs during the pharyngeal phase of
swallowing and is referred to as deglutition apnea. The pharyngeal phase of
deglutition takes around 0.7 seconds. The second phase of deglutition ends
when the bolus is transferred from the pharynx into the upper part of
esophagus and then the muscles of the tongue, palate, pharynx and larynx
relax, the mandible is moved into rest position and respiration resumes.

Esophageal Phase
During this phase, the bolus moves down the length of esophagus to the
stomach. This is an involuntary stage. Esophagus helps to move food from
pharynx to the stomach. The peristaltic movements (the alternative
contraction and relaxation of muscle fibers of GIT) help in the movement of
food in esophagus. When the bolus reaches esophagus these peristaltic waves
are initiated which propel the food from pharynx to stomach.
 The distal 2–5 mm is the lower esophageal sphincter. When bolus enters
this part of the esophagus, the sphincter relaxes and the contents enter into
the stomach. Later this sphincter contracts to prevent movement of food back
to esophagus. This phase is somewhat longer, liquids take 3 seconds whereas
solids take 9 seconds.

Immature Swallow/Infantile Swallow

Swallowing in infancy prior to the establishment of occlusion has been
termed as infantile swallow or visceral swallow. This type of swallowing is
based on unconditioned reflex system in which facial and circumoral muscles
initiate swallowing.
Newborns and infants feed by a process called suckling. In infants, soft
palate is large and more compact. During suckling, mouth acts as a piston
within a cylinder. A negative pressure or suction is created in the mouth by
lowering the jaw while the lips are sealed around the nipple to prevent entry
of air to oral cavity. Respiration continues during the burst of suckling. As
the infant grows, the soft palate becomes more mobile and orofacial
structures develop. The epiglottis descends and assumes its mature functional
role in swallowing. The duration of suckling becomes prolonged as the infant
grows which is followed by deglutition.

Features of Infantile Swallow

Alveolar ridges or teeth are apart and the tongue will be positioned between
them.
Mandible is stabilized by both tongue and facial muscles which are supplied
by the 7th cranial nerve.
Because of anatomic relationship of newborn pharynx and larynx, infants can
swallow without interruption of breathing.
With the eruption of teeth and emergence of canines at age of 12 years, there
is transition to a teeth together swallowing which is termed as adult or
somatic swallowing. Occasionally the transition from infantile swallow to
adult swallow does not occur. This may be due to lack of tooth support
because of poor tooth position or arch relationship. The infantile swallow
also may be maintained when discomfort occurs during tooth contact because
of caries or tooth sensitivity. Over retention of the infantile swallow can
result in labial displacement of anterior teeth by powerful tongue muscle,
which may be presented clinically as anterior open bite.

Features of Adult Swallow

Teeth are in contact and tongue does not come in between.
Tongue will be positioned behind the teeth
Mandible is stabilized by occluding teeth and masticatory muscles which are
supplied by the 5th cranial nerve.
Temporary arrest of respiration is observed during swallowing.
 43
Calcium Phosphorus
Metabolism

Calcium metabolism
Phosphorus metabolism
Hormonal control of serum calcium level
Other hormones that have role in serum calcium level
Functions of calcium and phosphorus
Clinical considerations

C alcium and phosphorus are considered as two essential elements required

for normal growth and development. Adult human body contains
approximately 1.1 kg calcium, of which 98 to 99% is in the bone and
teeth.
Normal serum calcium level varies from 9 to 11 mg%. 50% of serum
calcium is in free or ionic form while 40% is bound to proteins and another
10% complexed with citrate phosphate or bicarbonate. The ionized calcium
found free in the plasma performs its biological functions.

Requirement and Absorption

Source
Milk, diary products, egg, etc.

Daily Requirement
200 mg/day for infants
1000–1300 mg/day for children and adolescents
1000 mg/day for adults
1300 mg/day for pregnant and lactating females
Absorption is mainly in jejunum and ileum and only about 1/3rd of the
dietary intake of calcium is absorbed under normal circumstances.

Local Factors Increasing Absorption of Calcium

Vitamin D
Fat
Citrates lower the pH of alimentary tract and produce calcium citrate which is
relatively soluble.
High protein diet produces soluble calcium compounds.
Low pH of alimentary tract.

Local Factors Decreasing the Calcium Absorption

Phytic acid present in cereals: Form insoluble calcium phytate with ingested
calcium and make it nonabsorbable.
Oxalic acid: Produces insoluble calcium oxalate.
Hypochlorhydria or achlorhydria decreases calcium absorption because pH of
intestine becomes high in the absence of hydrochloric acid.

Excretion
Calcium is excreted both in urine and feces. In urine it is excreted as calcium
chloride and calcium phosphate. Renal threshold is 7 mg/dl of serum calcium.
Not only non absorbed calcium, even absorbed calcium is excreted through
feces.

Phosphorus
Normal serum phosphorus level
2–4 mg/dl in adults
3–5 mg/dl in children

Daily Requirement
240 mg for infants
800 mg for adults
1200 mg for pregnant and lactating females.
Absorption of phosphorus takes place in small intestine in the form of soluble
inorganic phosphate. Approximately 70% of dietary phosphate is absorbed in
the form of orthophosphate. By the action of intestinal phosphatases food
bound phosphorus is released during digestion.
An excess of calcium, iron or aluminum may interfere with absorption.
Excretion: Occurs primarily through urine in the form of phosphates of
various cations. Fecal phosphorus is usually excreted as calcium phosphate.

Regulation of Serum Calcium Level/Hormonal Control

of Serum Calcium
Plasma calcium level is maintained with remarkable constancy despite with
variation in calcium intake. Any gross decrease in plasma calcium leads to
severe metabolic disturbances which may even lead to death. Calcium taken
through the diet is absorbed from the intestine to the blood and distributed to
various parts of the body. While passing through the kidney large amount is
filtered in the glomerulus. 90% of calcium in this filtrate is reabsorbed in the
renal tubules and only a small quantity of it is excreted. In the bone, calcium
may be deposited or resorbed depending upon the level of calcium in the
plasma. Therefore the serum calcium is maintained by regulating its
absorption in intestine, reabsorption in the kidney and mobilization from the
bone. All these processes are finely regulated by hormones. The level of
blood calcium is maintained by action of two hormones: Parathyroid
hormone and calcitonin and vitamin D (Fig. 43.1).

PARATHYROID HORMONE (PTH)

The parathyroid hormone is secreted by chief cells of parathyroid gland and
its main function is to increase the serum calcium level. PTH performs this
function by its direct effect on bone and kidney and also by an indirect effect
on intestine through vitamin D. PTH secretion varies inversely with the level
of ionized calcium in the plasma.
Effect on kidney
• Increases the calcium reabsorption
• Enhances phosphate excretion
• Accelerates the conversion of 25-hydroxy-cholecalciferol to its
active metabolic form 1, 25-dihydroxycholecalciferol which has a
role in calcium absorption in the intestine.
Effect on bone
• Enhances osteoclastic activity in skeleton, thereby mobilizing the
calcium from bone to the plasma.
• Increases net bone mass by its anabolic effect on bone.
• Decreases osteoblastic activity so new bone formation and
utilization of serum calcium is decreased.
Effect on intestinal tract
Enhances the absorption of calcium and phosphorus which is probably
indirectly associated with the increased renal production of 1, 25-
dihydroxycholecalciferol (calcitriol).

VITAMIN D

The most active metabolite of vitamin D is calcitriol which is formed in

kidney. This calcitriol is considered as hormone like substance and is
responsible for all the biological effect of vitamin D on calcium metabolism.
Through the effect on intestine, kidney and bone, vitamin D increases the
serum calcium level (Fig. 43.2).
 Fig. 43.1: Hormonal control of serum calcium

Fig. 43.2: Schematic representation of metabolism and actions of vitamin D

Actions of Calcitriol
Effect on intestinal tract
Increases the intestinal calcium uptake: Calcitriol increases the transcription
of calcium binding protein. This calcium binding protein acts as a carrier
protein which facilitates the intestinal absorption of calcium and its transport.
Other mechanisms by which calcitriol increases intestinal absorption of
calcium may be by formation of calcium stimulated ATPase in the lining
cells of intestine and by formation of alkaline phosphatase.
Effect on bone
Vitamin D enhances osteoclastic activity and increases mobilization of
calcium from bone. Thus, increases serum calcium level.
Effect on kidney
Increases the reabsorption of calcium in kidney and decreases phosphate
reabsorption.

CALCITONIN

Calcitonin is a hormone produced by ‘C’ cells or parafollicular cells of

thyroid gland. This hormone counteracts the actions of PTH and helps to
decrease the serum calcium level. Although the main effect of calcitonin is on
bone, it also acts on intestine and kidney to some extent. The level of this
hypocalcemic hormone depends on plasma calcium level.

Actions of Calcitonin
Effect on bone
• Acts directly on the osteoclasts causing an immediate inhibition of
bone resorbing activity.
• Decreases development of new osteoclasts.
• Facilitates bone formation.
Effect on kidney
Acts on kidney and increases excretion of calcium and decreases the
reabsorption.
Effect on intestine
Prevents absorption of calcium.

Other Hormones Playing Role in Serum Calcium

Prolactin: Prolactin stimulate 1, 2-hydroxylase activity; thus increasing
production of calcitriol, which in turn, increases the calcium absorption in
lactating period.
Growth hormone: Also have shown to have some influence on production of
calcitriol.
Sex hormones: Influence calcium and phosphate metabolism by increasing
calcium absorption, decreasing calcium excretion and promoting
mineralization of bone. Estrogen has a direct effect in reducing bone
resorption.
Thyroid hormone: Hyperthyroidism is accompanied by osteoporosis and
increased excretion of calcium in urine. Fecal calcium is also increased
indicating that this hormone decreases the absorption of calcium. This could
be due to increased peristalsis, moving the gut contents too quickly
preventing normal absorption.

Functions of Calcium
Hemostasis: Calcium is necessary for activation of clotting factors in plasma.
Calcium plays important role in formation of bone and teeth and in its
maintenance.
Calcium is essential for neurotransmitter release and helps in neuromuscular
excitability.
Calcium is bound to cell surface and has role in stabilization of cell
membrane, normal membrane permeability and adhesion between cells.
Calcium is essential for all secretory processes such as release of hormone by
endocrine cells and release of secretory products of exocrine glands.
Calcium is essential for activation of certain enzymes involved in
inflammation and also acts as secondary messenger of hormonal action.
Functions of Phosphorus
Phosphorus is important for formation of bone and teeth.
Phosphates by their function in phosphorylation, is important in the
metabolism of fat and carbohydrate.
Phosphorus is used in building the more permanent organic phosphates
including some catalyst essential for the structure and functions of cells.
Phosphates are utilized for the formation of phosphoproteins, nerve
phosphatides and nucleoproteins of cells.
They provide energy rich bonds in such compounds as adenosine
triphosphate and is important in muscle contraction.
Phosphate form part of coenzymes as pyridoxal phosphate which is necessary
for decarboxylation and transamination of certain amino acids such as
tyrosine, tryptophan and arginine.

Clinical Considerations
A low concentration of serum calcium which is less than 8 mg% produces
hyperirritability of nerves and neuromuscular junction, leading to
contraction of muscle spontaneously. This condition is called tetany which
is characterized by carpopedal spasm and convulsions.
 44
Mineralization

Introduction
Booster theory
Seeding theory
Matrix vesicle theory

M ineralization is the process of deposition of minerals in the organic

matrix, which is capable of accepting the minerals. The process of
mineralization is an important step in formation of hard tissue of the
body.
The synthetic cells are responsible for deposition of calcifiable organic
matrix with alkaline phosphatase enzyme activity.
The mineral component of all hard tissues of the body are chiefly calcium
hydroxyapatite crystals which is represented as Ca10 (PO4)6 (OH)2. The
biologic apatite crystal has the shape of stubby rhombic prism which varies in
size. The crystallites of mesenchymal hard tissues are approximately 100 ×
200 × 50 × 50 A dimensions, whereas hydroxyapatite of enamel forms a
considerably larger crystal which is 1,400 A long and 800 A wide.
Although, tissue fluid contains calcium, phosphate and other minerals,
spontaneous crystallization do not take place. This is probably because of
presence of substances inhibiting crystal formation, requirement of energy for
mineralization and formation of unstable insufficient amount of crystal,
which is unable to cause mineralization.
In this situation, mineralization can occur under following circumstances:
If there is local increase in concentration of minerals which allows formation
of sufficient ionic crystallites required for mineralization. Such process that
leads to mineralization is called homogenous nucleation.
In presence of nucleating substances, mineralization process can be initiated
even in the absence of increase in ionic concentration. This is called
Heterogenous mineralization. These nucleating substances act as a template
for crystal formation and therefore decrease the energy requirement for
mineralization.
The above mechanism will be effective if there are means to remove the
inhibitors of mineralization.
Once crystal formation is initiated, mineralization progresses rapidly,
utilizing the calcium and phosphate ions from the tissue fluid even at a low
concentration of ionic content. Based on above observations, theories have
been put forward to explain the process of mineralization.

1. Booster Theory or Robinson’s Alkaline Phosphatase

Theory
This theory is put forward by Robinson in 1923 based on some of his
experimental evidences. He proposed that, alkaline phosphatase enzymes
present in the organic matrix of calcifying matrix can hydrolyze organic
phosphates such as pyrophosphate or glucose 1,6-phosphate, etc. present in
plasma and calcifying tissue fluid, and release inorganic orthophosphate
resulting in local increase in phosphate ion concentration. This local increase
in ionic component has a boosting effect which would increase the proportion
of phosphate ions sufficient to cause spontaneous precipitation. The
phosphate ions combine with the calcium ions available in tissue fluid to
form hydroxyapatite crystals. According to him initially unstable amorphous
calcium phosphate is formed which is then converted into stable calcium
hydroxyapatite.
He has evolved his theory based on his experiments on alkaline
phosphatase.
Robinson has observed in his studies that calcifying cartilage contains more
alkaline phosphatase than noncalcifying cartilage.
When slices of cartilage removed from bone of rachitic animals (affected by
richets) were incubated with calcium and organic phosphates, hydroxyapatite
crystals were formed. From this experiment Robinson came to a conclusion
that rachitic bone contains alkaline phosphatase which is capable of splitting
organic phosphate to release inorganic phosphates. This phosphate combines
with calcium to produce apatite crystals.
Robinson’s theory of mineralization is not widely accepted and is criticized
for various reasons.
Robinson’s studies were on rachitic bone which is an abnormal tissue.
Whether the result obtained in these studies can be applied to normal bone is
doubtful.
Alkaline phosphatase is observed in other tissues whith do not calcify.
Inhibitors of certain other enzymes which do not inhibit alkaline phosphatase
activity are found to be preventing mineralization.
Experimental studies have shown that presence of inorganic phosphate and
calcium is not sufficient to induce mineralization. Rather this also requires
action of some other enzymes.
The organic phosphate presents in tissue fluid of calcifying matrix is
insufficient to produce sufficient inorganic phosphate ions to induce
mineralization (Fig. 44.1).
Although this theory is been criticized by various authors, the role of
alkaline phosphatase in mineralization can’t be excluded.
Alkaline phosphatase is a group of enzymes that can cleave phosphate
ions from organic phosphates at an alkaline pH. This enzyme is found in cell
membrane of hard tissue forming cells and in organic matrix of calcifying
tissue. In addition to providing phosphate ions, alkaline phosphatase may also
be involved in ion transport. Neumann has proposed that alkaline
phosphatase may be playing important role in mineralization by hydrolyzing
pyrophosphate which is a known crystal poison which prevents
mineralization, therefore helping in crystal growth (Fig. 44.1).
 Fig. 44.1: Alkaline phosphatase and mineralization
The possible role of alkaline phosphatase in mineralization can be:
Hydrolyzing organic phosphates to provide inorganic phosphate ions required
for mineralization.
Ion transport
May help in removing crystal poisons.

2. Collagen Seeding Theory/Nucleation

Theory/Collagen Template Theory
Some nucleating substances which have spatial arrangement as that of
hydroxyapatite crystals, can act as a mould on template upon which crystals
can be laid down. Nucleating substance can initiate mineralization even when
the ionic, concentration is less and also reduce energy required for
mineralization.
Collagen is the most important seed playing a significant role in
mineralization. It is suggested that certain amino acid residues in collagen
with charged side chains, provide a specific, spatial arrangement that
constitute a template matching for hydroxyapatite.
Calcium and phosphate ions present in the extracellular fluid binds to these
sites to form hydroxyapatite crystals which grow further by addition of ions.
It has been observed that lysine and hydroxylysine groups are specific ion
binding sites for phosphate ions, while carboxyl sites associated with aspartic
acid and glutamic acid residues act as calcium binding sites to initiate
nucleation of hydroxyapatite crystals.
The role of collagen in mineralization was suggested based on some
experimental evidences. When tendon collagen was added to a solution
containing calcium and phosphate, crystal formation was found even when
the concentration of ions were lower than what is required for spontaneous
mineralization and it was suggested that this had happened due to seeding
capacity of collagen. Only the collagen with 64 nm periodic banding with
three dimensional organization of collagen macromolecule has the capability
of functioning as a seed. The gaps between the collagen molecules are filled
with proteoglycans which bind to calcium. Calcium is released by enzymatic
degradation of proteoglycans. After the removal of proteoglycans,
phosphoproteins are attached to the collagen which is broken down by
alkaline phosphatase to give rise to phosphate ion. These ions combine to
form apatite crystals in the gap zone of collagen.
Support for this template theory can be achieved from electron microscopic
observation of parallel arrangement of hydroxyapatite crystals and collagen
fibers.
This theory is unable to explain mineralization in all tissues. For example,
enamel is a highly mineralized tissue, but does not contain collagen.
Mineralization of cartilage begins in ground substance and not in association
with collagen.
Therefore possibility of other mechanism should be considered.
Similarly, another important question to be answered is why collagen does
not initiate mineralization in all connective tissue. Possible explanation for
this include:
Collagen in connective tissue that does not calcify, may have spatial
arrangement of charges that is different from the collagen in calcifiable tissue
therefore unable to act as a suitable template.
In collagen of soft tissues, the charged site could be protected by some
ground substance components which prevent the attachment of the ions to
initiate mineralization. These substances are called crystal poison. In
calcifiable tissue these substances may be removed by certain mechanism
leading to exposure of these charged sites, followed by binding of ions to
initiate mineralization. Pyrophosphate is a known crystal poison which is
hydrolyzed by alkaline phosphatase enzyme to expose the binding sites.
Collagen exhibits intrafibrillar pores through which the calcium and
phosphate ions should pass through to reach the nucleating sites located
inside the fibrils. The gap between tropocollagen molecules in calcifiable
tissues is 0.6 nm which is large enough to allow the passage of phosphate
ions which are of 0.4 nm diameter. The gap in soft tissue collagen is only 0.3
nm through which the phosphate ions cannot pass, therefore cannot act as a
template for hydroxyapatite crystals.

Other Nucleating Materials

Lipids: Lipids have been identified as an important factor associated with
mineralization process. Although the exact role of lipids in mineralization is
not identified, experimental evidences suggest that phospholipids can act as a
seed or a template for hydroxyapatite crystal formation. Phospholipids are
also capable of stabilizing amorphous calcium phosphate which will later be
transformed into hydroxyapatite crystals. Phospholipids are also found in
matrix vesicle, which can participate in mineralization.
Protein polysaccharides: It has been suggested by some investigators that
protein polysaccharides act as a seed for mineralization. Experimental
evidences show that proteoglycans and glycosaminoglycans have the
capability of binding to calcium ions. Probably these protein polysaccharides
regulate the rate of mineralization rather than initiating mineralization.

Matrix Vesicle Theory

Matrix vesicles are membrane bound vesicles isolated from areas of
calcification. These structures bud off from the synthetic cells and are
released into the organic matrix. It has been observed that the matrix vesicles
induces precipitation of hydroxyapatite crystals in vitro from solutions
containing calcium and phosphate ions and also are capable of crystal
formation even when the solubility of product of calcium and phosphate are
as low as 2 millimoles2. The above factors suggest that the matrix vesicles
have a capacity to initiate mineralization.

Two Types of Matrix Vesicles have been Identified

Type I matrix vesicles are round or ovoid in shape resembling lysosomes.
They contain enzymes such as acid phosphatase and aryl phosphatase. These
enzymes can break down proteoglycans and glycosaminoglycans which are
inhibitors of mineralization.
Type II matrix vesicles are irregular membrane bound structures having
enzymes such as ATPase, alkaline phosphatase, pyrophosphatase,
proteoglycans and metalloproteinases but relatively less acid phosphatase.
These vesicles are also rich in phospholipids with great affinity for calcium
and a large amount of annexin V.

Role of Matrix Vesicle in Mineralization

Matrix vesicles provide a local environment for initial crystal formation.
They have all the characteristics needed for the induction of calcification.
Freshly isolated vesicles contain a relatively high Ca2+ content bound to
phospholipids which act as a nucleating site within the vesicle. By being
extremely rich in alkaline phosphatase activity, the vesicles have the capacity
to hydrolyze a variety of organic phosphate substrates, to increase
substantially the local availability of free phosphate ions which binds to
calcium ions to initiate apatite crystallization. Such enzymatic activity may
also remove putative inhibitors of mineralization, including pyrophosphate.
In addition the vesicles also contain a large amount of annexin V, a
membrane-associated protein which mediates the influx of Ca2+ into matrix
vesicles, enabling intraluminal crystal growth. In addition, annexin V binds
directly to type II and X collagen which may be important for anchoring the
vesicles to the fibrous components of the matrix. Thus, the first crystal is
formed in the matrix vesicle. Crystal growth continues in the vesicle by
further addition of ions which is followed by rupture of vesicle membrane.
The crystals are released into the organic matrix, where they grow by using
ions in the tissue fluid and mineralization spreads to surrounding matrix. The
mineralization progresses in the form of spherical or calcospheric masses
which fuses with each other forming uniformly mineralized matrix.
In summary, all the three mechanisms are involved in mineralization.
Collagen acts as a seed and helps in intrafibrillar calcification. Similarly
matrix vesicles help in extrafibrillar calcification. Alkaline phosphatase helps
in providing more phosphate ions and also removing crystal poisons.
 45
Hormonal Influence on
Orofacial Structures

Introduction
Effect of thyroid hormone
Effect of parathyroid hormone
Effect of pituitary hormones
Effect of sex hormones
Effect of adrenal hormones
Effect of pancreatic hormone

T he endocrine system consists of several glands which secrete hormones.

Hormones are biologically active substances produced by these glands,
directly released into the blood-stream in which it circulate continuously
and exert their biological effect on different systems of our body. Hormones
have a vital role in growth and development of orofacial structures and their
functional activities and therefore altered levels of these can cause variety of
manifestations in orofacial structures.

THYROID HORMONE

Thyroid hormone is secreted by thyroid glands situated in the lower part of

anterior region of neck. The hormone secreted by thyroid gland, i.e. thyroxin
plays an essential role in regulation of metabolic activities of the body and
also in physical and intellectual development. Calcitonin produced by ‘c’
cells of thyroid gland is also important in maintaining serum calcium level.
Abnormal functioning of the thyroid gland may cause hyperthyroidism or
hypothyroidism, which can adversely affect growth by accelerating or
retarding the growth.
Hyperthyroidism causes increased metabolic activity. Affected persons are
abnormally energetic. This condition, if occurs in early stages of life can lead
to formation of large teeth, accelerated eruption of deciduous and permanent
teeth and premature loss of deciduous teeth. Experimental studies have
shown that excessive thyroid hormone can have a toxic effect on odontoblasts
resulting in disturbed dentin formation. In advanced cases alveolar atrophy
occurs.
Hyperthyroidism in adults does not show any orofacial manifestations, but
they may have increased sensitivity to epinephrine and due to
hyperthyroidism they become poor dental patients.
Hypothyroidism: This condition results from decreased functioning of
thyroid gland. Congenital hypothyroidism or cretinism affects the mental and
physical developments of a child depending upon severity of deficiency.
Affected children have a characteristic facial appearance with depressed nasal
bridge and flared nose. Face is wide and fails to develop in a longitudinal
direction. The mandible is underdeveloped while maxilla is overdeveloped.
Tongue is enlarged due to edema fluid and it protrudes out. Enlarged tongue
exerts pressure on the teeth leading to malocclusion.
In hypothyroidism, generalized retardation of skeletal growth takes place
which also affect the jaw bones. Poor development of the jaw bones leads to
anterior open bite and receded chin. In addition to skeletal development, teeth
development is affected leading to decreased size of the tooth, delayed
eruption, delayed exfoliation of deciduous teeth, etc.
Hypothyroidism in children and adults leads to myxedema, a condition
characterized by subcutaneous edema. Clinical and orofacial findings of
myxedema are limited to soft tissues of face and mouth. Tongue is large and
edematous, interfering with speech and mastication. Lips, nose, eyelids and
suborbital tissue also show edema.

PARATHYROID HORMONE (PTH)

Parathyroid hormone is secreted by parathyroid gland situated on the
posterior aspect of thyroid gland. This hormone has a significant role in
maintaining the serum calcium level and therefore plays a vital role in
orofacial development.
Hypoparathyroidism: Dental changes can be observed in teeth which have
formed during the time of PTH deficiency such as defective matrix
deposition and mineralization of enamel and dentin. Delayed eruption also
has been reported in individuals suffering from hypoparathyroidism which
could be due to inhibitory effect on osteoclasts. A tooth cannot erupt without
osteoclastic bone resorption, Exaggerated incremental lines and areas of
interglobular dentin also have been reported in teeth of hypoparathyroid
patients.
Hyperparathyroidism: Parathyroid hormone can mobilize the calcium from
bone causing bone resorption. This effect is applicable only on bone and not
in fully formed teeth. Therefore in hyperparathyroidism, no visible changes
occur in dental tissue. But the alveolar bone undergoes resorption. Loss of
lamina dura is a very important observation in this condition. Alveolar bone
becomes osteoporotic and soft leading to drifting of teeth and malocclusion.
The jaw bones also may show areas of bone resorption which may be evident
in the radiographs as large areas of radiolucencies. The areas of bone
resorption will be filled with highly vascular connective tissue. These lesions
are termed as brown tumor.

PITUITARY HORMONES

Pituitary gland is the master endocrine gland, secretions of which control the
functioning of many other glands and many body functions. Anterior
pituitary produces at least six hormones: The somatotropic, the thyrotropic,
the adrenocorticotropic and the lactogenic hormone. The posterior pituitary
produces antidiuretic hormone. Decreased activity of this hormone results in
excessive production of urine and general dehydration of the body. The main
effect of pituitary hormones on teeth and orofacial structures are mainly
through the effect of growth hormone and partly by thyroid stimulating
hormone.
Hypopituitarism can occur due to congenital defects or due to destructive
diseases. If it occurs before puberty it leads to a condition called dwarfism. In
pituitary dwarf the eruption of teeth is delayed and the shedding time of
deciduous teeth is also delayed, as is the growth of body in general. The size
of the crown and root of the tooth is smaller than normal. The supporting
structures of the teeth also show retardation of development. Because of
incomplete eruption, clinical crown of the teeth may be smaller.
Decreased growth hormone also causes retardation of development of
maxilla and mandible. The dental arch is smaller than normal, therefore
results in crowding of teeth and malocclusion. Pituitary dwarfs are reported
to have a decrease in caries rate.
Hypopituitarism in adults does not show any specific dental changes.
Hyperpituitarism that occurs before the closure of epiphysis of long bones
leads to a condition called gigantism and if it occurs later in life after
epiphyseal closure, leads to acromegaly.
Gigantism is characterized by symmetric overgrowth of the body. As a part
of general overgrowth of bones, both mandible and maxilla are larger than
normal. The teeth, both crown and root are larger and is in proportion to the
size of the jaws. The eruption of both deciduous and permanent teeth is
accelerated with premature shedding of deciduous teeth.
In acromegaly, mandible continues to grow leading to abnormally long
face and mandibular prognathism. Supra-eruption of teeth may occur leading
to overgrowth of alveolar bone. Increase in length of mandibular arch may
lead to malocclusion. The lips become thick and the tongue enlarged with
indentations on the sides of the tongue. The enlarged tongue exerts pressure
on the teeth leading to buccal or labial displacement of teeth and
malocclusion.

SEX HORMONES

The effect of sex hormones on oral tissues is not well understood.

Experimental studies have confirmed that female sex hormones influence the
growth of oral epithelium and its keratinization. They also cause dilatation of
blood vessels in underlying connective tissue and increase their permeability.
Tendency for gingivitis has been observed in females during puberty,
menstruation and pregnancy. Hormonal alterations do not initiate the
inflammation but exaggerate the existing inflammation by altering the
reaction of gingival tissue to inflammation.

ADRENAL HORMONES

Various hormones have been secreted by adrenal cortex and medulla. The
main secretions from adrenal medulla are epinephrine (adrenaline) and
norepinephrine. Adrenaline is very essential for a quick physiological
response to crisis situations. Adrenal cortex is concerned with liberation of
steroids which involve in carbohydrate, mineral, fat and protein metabolisms
and fluid electrolyte balance. Hydrocortisone also has a marked anti-
inflammatory effect.
Chronic insufficiency of adrenal cortex leads to a condition called
Addison’s disease which is characterized by pigmentation of oral mucous
membrane involving buccal mucosa, tongue, gingiva and lip.
Hyperfunctioning of adrenal cortex causes Cushing’s syndrome. The
changes in orofacial region could be related to osteoporosis. Cortisone causes
osteoporosis by suppressing the activity of osteoblasts resulting in defective
matrix deposition.

PANCREATIC HORMONE—INSULIN

Insulin is mainly concerned with carbohydrate metabolism and deficiency

leads to diabetes mellitus.
Diabetic patients have less resistance to infections, therefore these patients
may show increased tendency to develop gingivitis and periodontitis. They
also have delayed woundhealing and may complain of dryness of mouth.
 46
Age Changes of Oral Tissues

Age changes in dental tissues

Age changes in tooth supporting tissues
Age changes in oral mucosa
Age changes in salivary glands

T he term age changes refer to all the changes that occur in the body from
birth to death. However, it is usual to consider age changes as those
which are evident in later life. Effects of aging in relation to the oral
tissues can be discussed in the following headings:
Changes in dental tissues
Enamel
Dentin
Cementum
Dental pulp
Changes in supporting structures of teeth
Periodontal ligament
Alveolar bone
Changes in oral mucosa
Changes in salivary glands
 ENAMEL

Enamel is the hardest calcified tissue in the human body which forms the
resistant covering of the teeth, rendering them suitable for mastication.
Enamel being a nonliving tissue it is incapable of repair. But its surface can
however be modified at a crystal level by ion exchange or grossly by
attrition, abrasion, erosion or by dental caries.
Age changes observed in enamel are
Attrition: Attrition is the physiological wearing away of the teeth resulting
from masticatory movements of teeth and friction from food particles. It is
the most conspicuous change in the teeth with advancing age and can be
appreciated on both occlusal and proximal surfaces. The amount of wear
differs a great deal, due to variations in the type of occlusion present, habit,
and muscular power, type of food and tooth loss. Attrition causes loss of
vertical dimension of the crown, loss of enamel from the occluding surfaces
of the teeth to produce polished attrition facets and flattening of proximal
contour.
Modification in surface layer: The enamel of newly erupted teeth are
covered with pronounced rod ends and perikymata. With increasing age,
these surface structures disappear. The rates at which they are lost depend on
the location of the surface of the tooth and on the location of tooth in the
mouth. Facial and lingual surfaces lose their structure more rapidly than
proximal surfaces. Anterior teeth lose their structure more rapidly than
posteriors.
Increase of inorganic content: Due to exchange of ions with the oral
environment during aging, superficial enamel surface of older teeth have
increased inorganic content. The thickness of hypermineralized surface zone
increases in older teeth and exhibits more resistance to decay. A steady
increase in nitrogen and fluoride level in enamel with age has also been
reported.
Decrease permeability: Permeability of enamel decreases with age, possibly
as a result of surface consolidation of crystals, formation of fluoroapatite and
a reduction of matrix between individual crystals.
Decrease in water content: The crystals in enamel acquire more ions and the
pores between them decreases. As the major portion of water in enamel lie in
these pores, reduction in the pores in older enamel, results in decrease in their
water content.
Change in color of teeth: Color of the teeth becomes darker with age due to
deepening of the color of the dentin. It is also possible that enamel itself
either becomes darker with age or more translucent contributing to change in
color of tooth.

DENTIN

The dentin provides the bulk and general form of the tooth. Unlike enamel,
dentin is deposited throughout life and is a vital tissue that can react and
respond to various stimuli to which it is exposed.
Age changes of dentin can be
Changes in physical properties: Color of dentin becomes darker with age.
Density and mineralization and hardness of dentin of both crown and root
increases with age.
Vitality of dentin: The vitality of dentin is decreased in advancing age
probably due to decrease in the odontoblastic activity.
Thickness of dentin: Although at a slower rate, dentin is laid down
throughout life, resulting in gradual increase in thickness as age advances.
Dentin tend to be deposited in greater amounts in certain areas of pulp such
as in the floor of the pulp chamber.
Secondary dentin deposition: This is the type of dentin formed after root
completion and in the absence of obvious trauma to the tooth, such as
attrition, abrasion, erosion, etc. Deposition of secondary dentin is a normal
aging process that continues throughout life.
Dead tracts: Dead tracts are empty dentinal tubules that are formed due to
degeneration of odontoblast processes in the dentinal tubules. This usually
occurs due to exposure of dentin following attrition, abrasion or erosion.
These empty dentinal tubules are filled with air; thereby appear dark under
transmitted light. Dead tracts may also develop in unerupted teeth and in
teeth with a little or no visible damage, especially in the region of cusp or
incisal edges due to death of odontoblasts occurring as a result of
overcrowding. Therefore dead tract can also be considered as an age change.
Sclerotic or transparent dentin: Mild stimuli induce protective changes in
the existing dentin. Continued deposition of intratubular dentin occurs in the
tubules and this leads to gradual reduction in tubule diameter or even
complete closure of tubules. The refractive indices of dentin in which the
tubules are occluded are equalized and therefore such areas appear
translucent or transparent in the transmitted light and dark in reflected light.
 Sclerotic dentin is frequently found near the root apex in the teeth of
elderly people as an age change. The sclerotic dentin is more brittle and less
permeable.
Reparative dentin: This is the type of response seen due to severe irritation
caused by extensive abrasion, erosion, caries or operative procedures.
Majority of the odontoblasts in this affected area degenerates, but a few may
survive and continue to form dentin at a rapid rate to seal off the exposed
tubules from the pulp. This dentin produced by survived odontoblasts is
called reparative dentin. Dead odontoblasts are replaced by new odontoblasts
differentiated from undifferentiated mesenchymal cells present in the pulp.
The dentin produced by these new odontoblasts is called reactionary dentin.

CEMENTUM

Cementum is the vital calcified tissue covering the periphery of root.

Age changes of cementum can be
Thickness of cementum: Cementum deposition is a continuous process that
occurs throughout life. Cementum is deposited intermittently and its
deposition in later life is mainly in response to stresses to which the tooth is
subjected. It is said that, there is a triple increase in the thickness of
cementum between 11 and 76 years of age. There is certainly a correlation
between the thickness of cementum and age. Relatively thick layers of
cementum are found on the roots of unerupted teeth in aged persons.
Surface irregularity: Smooth surface becomes irregular due to calcification
of periodontal ligament fiber bundles where they are attached to cementum.
Local injuries and mechanical stress cause resorptive changes which may be
also responsible for surface irregularity.
Reduced permeability: It becomes less permeable to dye molecules and ions.
As the permeability reduces the nutritive molecules may not reach the deeper
layers of cementum thus these deeper layers have less cementocytes in them.
The fluoride content of cementum increases with age particularly in the
acellular cementum of the cervical region, probably because this tends to be
exposed to the oral environment.
Structural changes: Resorption of root may occur with aging which will be
repaired by cementum. Cementum also may show alternate periods of
resorption and deposition creating reversal lines.

PULP

Pulp is the soft tissue component of the tooth situated in the pulp cavity.
Age changes in the dental pulp are
Size and morphology: With age a progressive reduction in pulp size occurs
due to secondary dentin deposition. The pulp horn becomes less prominent or
may disappear. Similarly, the radicular dentin becomes narrow or even
obliterated.
Cellular and fibrous components: The pulp in older teeth becomes more
fibrous with appreciable amount of mature collagen with proportionate
reduction in the cellular components and ground substances. The collagen
fibers of aged pulp is more resistant to enzymatic degradation. The number of
cells in the pulp including fibroblasts and odontoblasts decreases with age.
The odontoblast layer may show intercellular edema and vacuolation in
sections of pulp, which could be even because of poor fixation.
Changes in blood supply and innervations: Loss and degeneration of
myelinated and unmyelinated axons occur which can be correlated with an
age related reduction in sensitivity. As these progresses, the number of nerves
gets greatly diminished. There is a decrease in the blood supply as the apical
foramen is almost obliterated by secondary dentin and cementum which
initiates most of the other changes in the pulp. Blood vessels decrease in
number may also show decrease in size of lumen, thickening of vessel walls
with fibrosis and calcifications. Arteriosclerotic changes begin to develop
from the age of 40 years.
Reduction in sensitivity and healing potential: As age advances the
sensitivity and healing or reparative capacity of pulp decreases. Decreased
sensitivity can be directly related to nerve degeneration. Overall reduction in
vascular supply and cellular component could be responsible for decreased
reparative capacity of pulp.
Pulpal calcifications: Calcification may occur in pulp tissue as a result of
aging or external stimuli. These may be nodular, calcified masses referred to
as pulp stones or diffuse calcifications.
They are seen in functional as well as embedded, unerupted teeth.
Although pulp calcifications are seen in young individuals, the incidence
increases with age: 66% between the age group of 10 to 30 years, 80%
between 30 to 50 years and 90% above 50 years.

Pulp Stones are Classified Based on its Relation to

Adjacent Dentin into Three Groups
Free pulp stones are those calcified structures lying free in the pulp without
being attached to the dentin.
Attached pulp stones: Those which are attached to the dentin.
Embedded pulp stones: When pulp stone is completely surrounded by dentin
it is called embedded pulp stone. They are believed to be formed as free pulp
stones which later becomes attached or embedded due to progressive dentin
formation.

Depending On Structure Pulp Stones can be Grouped into

True denticles: True denticles are localized masses of calcified tissue having
tubular structure containing odontoblast processes and thereby resembling
dentin. They are very small and are seen only rarely. The true denticles are
thought to be formed due to entrapped remnants of root sheath in pulp. These
cells may induce the differentiation of odontoblasts which form calcified
structures resembling dentin.
False denticles: False denticles are localized masses of calcified tissue
having a laminated structure made of concentric layers of calcium deposited
around a central nidus, which could be dead cells. They do not have a tubular
structure or structural resemblance to dentin. They are larger than the true
denticles and may fill the entire pulp chamber.

Diffuse Calcification
Diffuse calcification is composed of small calcified particles with a few
larger masses. The calcified structures are arranged as linear strands parallel
to the long axis of pulp. They are found to be closely associated with blood
vessels with an orientation parallel to the vessels and nerves. It is usually
seen only in radicular pulp.

PERIODONTAL LIGAMENT

Periodontal ligament is a soft tissue component that helps in the attachment

of tooth to the bone. The age changes seen are:
Width: The width of periodontal ligament is narrower in older individuals,
due to continuum deposition of cementum and bone on either side of
ligament.
Vascularity: As age advances there is a decrease in vascularity of periodontal
ligament.
Cellular and fibrous components: The number of fibroblasts, collagen fibers
and mucopolysaccharides content decreases with age, while the elastic fibers
increases. Mitotic activity of cells of periodontium also decreases.

ALVEOLAR BONE

It is that part of the maxilla and mandible that forms and supports the socket
of the teeth. As age advances alveolar bone facing periodontal ligament
becomes irregular. Bone also shows osteoporotic changes and decreased
metabolic rate, vascularity, healing capacity, etc. Cancellous bone becomes
dense with coarse trabecular pattern. Since the existence of alveolar bone
greatly depends on teeth, when the teeth are lost, it undergoes gradual
atrophy.

ORAL MUCOSA

It is defined as a moist lining of the oral cavity and shows various age
changes such as:
Clinically, the oral mucosa of an elderly person relatively has a smooth and
dry surface than that of a youngster and may be described as atrophic or
friable. Permeability of mucosa to water is reduced in older individuals.
Histologically, the epithelium appears thinner and more or less regular
epithelium-connective tissue interface resulting from the flattening or
shortening of epithelial ridges. In the lamina propria, there is decreased
cellularity with increased amount of collagen, which is reported to become
more highly cross linked. The number of blood vessels decreases resulting in
reduced blood flow to the oral tissues and decreased rates of metabolic
activity. This leads to thinning of the mucosal layer and thus the oral mucosa
is more susceptible to damage and infections as age advances.
Gingiva may show a decrease in degree of keratinization.
Sebaceous glands (Fordyce’s spots) of the lips and cheeks also increase with
age.
A striking and relatively common feature in elderly persons is nodular
varicose veins on the undersurface of the tongue.
The number of taste buds decreases as much as 60% in old age resulting in
decrease or loss of taste perception. Threshold for salt and bitter tastes
increases with age.
The dorsum of the tongue may show a reduction in the number of filiform
papillae. The reduced number of filiform papillae may make the fungiform
papillae more prominent.

SALIVARY GLANDS
The salivary glands show various age changes which include:
Structural changes: The salivary glands become less active with age due to
relative decrease of acinar tissue with increase in fibrous and adipose tissue.
Replacement of parenchyma with fatty tissue is more apparent in parotid
gland. Salivary glands also show a progressive accumulation of lymphocytes.
Quantity and quality of saliva: Since parotid is the major source of watery
saliva, with advancing age the viscosity of saliva increase with a total
reduction in the salivary secretion.
Oncocytes: Altered epithelial cells found in the salivary glands that can be
identified by their marked granularity and acidophilia under light microscope
are thought to represent an age related change. The number of oncocytes
increases with age.
Section 5

Allied Topics

47. Tissue Processing

48. Microscope
49. Muscles of Orofacial Region
50. Vascular and Nerve Supply of Orofacial Region
 47
Tissue Processing
Dr Rajeesh Mohammed PK and Dr Girish KL

Introduction
Soft tissue processing
Hard tissue processing
– Decalcification
– Ground sectioning

M icroscopic examination is the method used to study the histological

structure of the oral tissues. To study the histology or histopathology,
the tissue should be appropriately prepared for microscopic
examination. The tissue specimen received in the laboratory may be soft
tissue, hard tissue or a combination of both which is taken from a living or
dead organism.
Tissues taken from the body for diagnosis of disease processes must be
processed in the histopathology laboratory to make microscopic slides that
can be viewed under the microscope by pathologists. For microscopic
examination, the tissue specimen must be thin enough (4–6 (i) to permit the
passage of transmitted light. The aim of tissue processing is to embed the
tissue in a solid medium firm enough to support the tissue and give it
sufficient rigidity to enable thin sections to be cut, which can be viewed
under microscope.
Depending on nature of specimen, preparation of tissue for microscopic
study includes: Soft tissue processing and hard tissue processing. Hard tissue
sections can be made either by grinding (ground sections) or by
decalcification procedure (decalcified sections).
 SOFT TISSUE PROCESSING

The most commonly used method of preparing soft tissue for the light
microscopic study is by embedding the tissue in paraffin and cutting and
mounting the section on slides and staining. The procedure for soft tissue
processing can be either manual or automatic. In manual method, all the
procedures of soft tissue processing have to be done manually and require
constant vigil. In automatic tissue processing, the tissue specimens are
automatically transferred through all the processing solutions in the automatic
tissue processor in which the time for the tissue to pass from one solution to
the other can be preset.

Steps in Routine (Paraffin Embedded) Tissue

Processing (Fig. 47.1)
Obtaining the specimen
Specimens for microscopic study are obtained through either biopsy or
autopsy.
Biopsy is the removal of tissue from a living organism for the purpose of
microscopic examination and diagnosis. If tissue is taken for the same
purpose from dead organisms it is called autopsy.
After removal, the specimen should be kept in sufficient volume of fixative
solution at the earliest and sent to the lab for tissue processing.
Regardless of the type of tissue, the specimens received in the lab should
be examined for: Relevant details about the patient and the lesion, adequate
size of the tissue, labeling of the specimen bottle and fixative used.
In the lab, steps should be taken to ensure complete fixation, before
proceeding with further steps of tissue processing. Large tissues should be cut
into smaller pieces. Care should be taken to send representative areas for
processing. To avoid interchanging the specimen, a piece of paper with
graphite pencil labeling is to be put in the tissue capsule in which the
specimens are kept while processing.
Fixation
Fixation is the foundation in the sequence of events in tissue processing. It is
a process involving series of chemical events which results in the
stabilization of proteins and makes the tissue resistant to damage during
subsequent stages of processing and visualization.

The aims of fixation are

To preserve the cells and tissue constituents in life like condition as closely as
possible without loss or derangement.
To prevent the process of autolysis and bacterial action or putrefaction of
tissues.
To coagulate the proteins, thus reducing the change in shape or volume
during further processing of tissue and to make the tissue more readily
permeable to the subsequent application of reagents.
After fixation the specimen is washed in running water.
10% formalin is the most commonly used fixative. Formalin increases the
cross linking and results in the stabilization of proteins.

Other fixatives used

Glutaraldehyde
Osmium tetroxide
Chromic acid
Methyl alcohol and ethyl alcohol
Mercuric chloride
Picric acid
The amount of fixative should be 25 times more than the size of the
specimen. Depending on the size and density of the specimen, the fixation
time can vary from a few hours to days. Usually 24 hrs is sufficient for small
specimens. Various factors which can influence the rate of fixation are
specimen size (3–4 mm ideally), pH, agitation, heat, viscosity, vacuum,
ultrasonic, etc.
Dehydration
Dehydration is done to remove the water content from tissues to allow the
penetration of paraffin wax and is achieved by passing the tissue through
ascending grades of alcohol. Ascending grades of alcohol is used to prevent
sudden shrinkage of tissue as a result of rapid leaching of water from the
tissue.
Example 50%, ... 70%, 90% and 100%

Solutions used
Methyl and ethyl alcohol
Isopropyl alcohol
Acetone
Clearing
Paraffin and alcohol are not miscible. So impregnation of tissue by paraffin is
not possible unless alcohol is replaced by a fluid that is miscible with both
alcohol and paraffin. This process is called clearing. Xylene is one of the
solutions that is miscible with both paraffin and alcohol. The term “clearing”
comes from the fact that the clearing agents often have the same refractive
index as proteins in the specimen. As a result, when the tissue is completely
infiltrated with the clearing agent, it becomes translucent or clear. The
presence of opaque areas after clearing indicates incomplete dehydration.

Ideal requirements of a clearing solution

Speedy removal of alcohol
Minimum tissue damage and toxicity
Cost factor

Choice of a clearing agent depends on

The type of tissues to be processed
The type of processing to be undertaken
The processor system to be used
Processing conditions like temperature, vacuum and pressure
Safety factors
Cost and convenience
Reagents used
Xylene (most commonly used)
Chloroform
Toluene
Benzene
CNP 30; inhibisol
Food oil derivatives
Cedar wood oil

Xylene
Xylene is a colorless, clear, oily, liquid aromatic hydrocarbon (sweet-
smelling), used as a solvent and clearing agent in the preparation of tissue
sections for microscopic study. Also called xylol; di-methylbenzene C6H4
(CH3)2 and has a molecular weight of 106. Xylene is obtained from coal tar
and sometimes from petroleum. Xylene is insoluble in water and is soluble in
alcohol.
Xylene is an organic solvent which is miscible with both alcohol and
paraffin and is the most commonly used clearing agent in lab. It is widely
used as a solvent and thinner for paints and varnishes, often in combination
with other organic compounds and as a solvent in glues and printing inks, etc.
Xylene is stable under ordinary conditions of use and storage, but is highly
flammable under adverse conditions and can form explosive mixtures in air.
Xylene is an irritant to the eyes and mucous membranes at low
concentrations, and is narcotic at high concen trations. Although the
carcinogenic effect of xylene is suggested, there is no direct evidence of
carcinogenicity in humans.
Impregnation
Impregnation is the procedure where there is saturation of tissue cavities and
cells by a supporting substance, which is generally, but not always, the
medium in which they are finally embedded. Impregnation procedure
replaces the xylene with paraffin and is achieved by immersion in molten
paraffin wax (60°C).
Factors affecting impregnation
Size and type of tissue
Clearing agent employed
Vacuum embedding
Embedding or blocking
Embedding is the process by which tissues are surrounded by a medium such
as agar, gelatin, or wax, which when solidifies will provide sufficient external
support during section. Impregnated tissue is transferred from wax bath to a
mould filled with molten wax to get a block of wax with the tissue specimen
at the center with the cutting surface facing the base of the block.

Procedure
Embedding is done using Leuckhart’s L-shaped pieces, ice trays, paper boats
or embedding cassette. The L-shaped block or paper boat is arranged to form
a cube on a clean, flat surface. The cube is then filled with molten wax and
the specimen is embedded into this with the help of a warm forceps. Make
sure that there are no air bubbles trapped between the tissue and the molten
wax. Care should be taken while embedding, so that the tissue to be
embedded has proper orientation. The wax-filled mould containing the tissue
is then allowed to cool. The wax blocks are labeled for easier identification.
The hardened wax block is removed from the mould and trimmed using a
sharp knife.
 Fig. 47.1: Steps to be followed in tissue processing
Sectioning
To view the specimen under microscope, the embedded tissues are to be cut
into thin sections of 3–5 μ with a microtome. The microtome is a device used
to cut the tissue into thin sections of specified thickness. The preparation of
sections using a microtome also can be manual or automatic. The wax block
is to be fixed onto a wooden or metal block to prevent wax block from
crumbling during sectioning and the metal or wooden block is clamped onto
the microtome for sectioning.
The cut sections are transferred and floated on a warm water bath. The
temperature of the water bath is to be maintained at 10° less than the melting
temperature of wax. The inside of the water bath should be preferably of
black color. This helps in easy visualization of the floated specimens against
a dark background. The water bath helps to remove wrinkles and spread the
specimen. Floated sections are picked up on an adhesive coated glass slide.
Egg albumin with additives is the commonly used section adhesive. Glass
slide should be kept on a slide warmer at 58° temperature for 20 mins to
ensure complete adhesion.
Staining
Staining is the biochemical technique of adding a class-specific dye to a
substrate (DNA, proteins, lipids, carbohydrates) to qualify or quantify the
presence of a specific compound.
Hematoxylin and eosin (H and E) staining is the routinely used method in
histopathology lab.
Other commonly used staining procedures in histopathology tab are
Gram staining
Papanicolaou staining (Pap stain)
Periodic acid-Schiff staining (PAS stain)
H and E stain/hematoxylin and eosin stain Hematoxylin and eosin stain is
the most popular staining method in histology and is the most widely used
stain in medical diagnosis. The staining method involves application of the
basic dye hematoxylin, which colors basophilic structures with blue-purple
hue, and alcohol-based acidic eosin-Y, which colors eosinophilic structures
bright pink. The basophilic structures are usually the ones containing nucleic
acids, such as the ribosomes and the chromatin-rich cell nucleus, and the
cytoplasmic regions rich in RNA. The eosinophilic structures are generally
composed of intracellular or extracellular protein. Most of the cytoplasm is
eosinophilic. Red blood cells are stained intensely red.
Hematoxylin is a natural dye which is extracted from the logwood of the
tree, Haematoxylon campechianum. Oxidation of this extract produces a
colored substance hematein, which itself is a poor dye. This dye when used in
conjunction with a mordant becomes a powerful dye. The color of dye is red
which turns into blue when the tissue section is treated with weak alkali
(blueing) following hematoxylin staining.
Eosin is the second component of the H and E and is the counter stain.
Eosin is a red dye formed by the action of bromine on fluorescein and is both
water and ethanol soluble. Eosin-Y is the commonly used form of eosin.
Eosin is used to stain cytoplasm, collagen and muscle fibers.
Hematoxylin and eosin staining procedure can be carried out manually or
using automated equipment.
Methods of hematoxylin and eosin staining
Remove wax with xylene.
Rehydrate the tissues using descending grades of alcohol
Wash sections in water
Stain with hematoxylin
Differentiate in acid alcohol
Wash in water
Blueing by using tap water or Scott’s tap water substitute
Rinse in water
Stain with eosin
Wash in running water
Dehydrate using ascending grades of alcohol
Removal of alcohol and clearing in xylene
Mounting
The stained section on the slide must be covered with a thin glass coverslip to
protect the tissue from being scratched, to provide better optical quality for
viewing under the microscope, and to preserve the tissue section for years to
come. The mounting medium is used to adhere the coverslip to the slide.
There are two types of mounting media: Water based mounting media and
resinous mounting media. Distrene dibutyl phthalate xylene (DPX) and
Canada balsam are the commonly used mounting media which are resinous
mounting media.

Procedure
Apply drops of mounting medium upon tissue section.
Hold the coverslip at an angle of 45°. Allow the edge of the coverslip to
contact the drop so that the drop spreads along the edge of the coverslip.
Let go off the coverslip and allow the medium to spread slowly.
Allow it to dry and the section is ready for viewing under microscope.
Although paraffin embedded tissue processing is the one carried out
routinely in a histopathology laboratory, another method termed as frozen
section/cryosection procedure is performed, when rapid microscopic
analysis of a specimen is required. In this case tissue to be examined is placed
on a metal tissue disc which is then secured in a chuck and frozen rapidly to
about –20 to –30°C. The entire process is done in a cryostat machine, which
is a microtome inside a freezer, which is then used to cut thin sections. The
sections are taken on to a glass slide and stained with H and E stain. The
preparation of the sample is much more rapid; however, the technical quality
of the sections is much lower than formalin fixed paraffin embedded tissue
processing. It is used most often in oncological surgery to ensure that the
entire tumour and its surrounding borders are removed.

HARD TISSUE PROCESSING

To study the structure of hard tissues of the body, two procedures can be
adopted: Ground sections and decalcified sections.

Decalcified Sections
Decalcification is the process by which calcium in the mineralized tissue is
removed, so that the tissue becomes soft enough to make thin sections. The
structure of all hard tissues of the body except enamel can be studied in
decalcified sections. Enamel cannot be studied by this procedure because it is
highly mineralized (96%) and is lost during decalcification.
Decalcification is usually carried out between the fixation and processing
steps. A variety of agents or techniques have been developed to decalcify
tissues, each with advantages and disadvantages. Immersions in solutions
containing mineral acids, organic acids, or EDTA are the commonly used
methods. Electrolysis has also been tried.
Mineral acids such as nitric acid and hydrochloric acids are used to
decalcify dense cortical bone and teeth because they will remove large
quantities of calcium at a rapid rate. Frequently used acid for decalcification
is 5% nitric acid. Nitric acid may cause yellowing of the tissue, that may
interfere with further staining procedure. To avoid this 0.1% urea is added to
nitric acid. 10 to 15% formic acid is one of the best decalcifying agents. The
use of EDTA is limited by the fact that it penetrates tissue poorly and works
slowly. Electrolysis is slow and is not suited for routine daily use.

Procedure
Hard tissue to be decalcified should be fixed in 10% formalin or formal
saline. To reduce the time for decalcification, tissue can be cut into smaller
pieces. Then, place the tissue in a container with decalcifying solution. The
solution should be changed daily for few days and then the specimen should
be tested for completion of decalcification.

Methods to Check the Completion of Decalcification

Checking the consistency of the tissue: Completely decalcified tissue will be
soft without any hardness being felt. (Experienced hand can tell by the feel of
the tissue.)
Pressing the tissue with a needle: If it enters the tissue without resistance,
the tissue is completely decalcified. This is not recommended because it may
cause damage to tissue.
Judicious bending or trimming of the tissue: This can be done to ensure
completion of decalcification.
Taking radiograph of the specimen: In the radiograph, if radiopaque specks
are found, tissue is not completely decalcified.
Chemical test: The basis of this test is to identify calcium in the decalcifying
solution in which the specimen was kept. Sodium hydroxide or strong
ammonia is added to 5 ml of decalcifying fluid, to neutralize the solution.
Then 5 ml of saturated ammonium oxalate solution is added. After this,
turbidity is checked. Absence of turbidity after 5 minutes indicate the fluid is
free from calcium and thereby decalcification is complete. Turbidity is
observed due to precipitation of calcium. If precipitation is observed after
addition of sodium hydroxide, it indicates large amount of calcium is present
in fluid. Precipitation seen only after addition of ammonium oxalate suggests
decalcification is nearly complete.
Checking the end point of decalcification is important because incomplete
decalcification makes further cutting of specimens difficult. Prolonged
decalcification is also not desirable because it may affect the staining
procedure. Once the decalcification is complete the tissue should be washed
in running water to remove all the acids. Hard tissue specimens after
decalcification are treated like routine soft tissue specimens. The steps of
processing can be continued like soft tissue processing, which include
dehydration, embedding, sectioning and staining.

Ground Sections
Ground sections are of particular importance in the study of structure of
dental hard tissues especially enamel. This method can also be used to study
the structure of bone. In this method the hard tissue specimen is made into
thin sections of desirable thickness by grinding, using abrasive stones.

Procedure
The tooth to be examined should be cut into 2–3 sections using dental hand
piece and diamond impregnated or carborundum disc. These sections should
be ground using an Arkansas stone or by simply rubbing on a glass plate
using abrasive slurry. Grinding should be continued till it is approximately
25–50 microns thickness. Fine abrasives should be used for final polishing.
Most suitable abrasive is domestic scouring powders followed by soapy
water. Once the desirable thickness is attained the section should be washed
and dehydrated and mounted on a glass slide using synthetic resin or Canada
balsam as mounting medium and is allowed to dry.
Grinding of the tooth can also be done using a laboratory lathe. Initial
grinding is done by holding the tooth in fingers and pressing it against the
rotating course abrasive wheel of the lathe. When the tooth is thin, it is
difficult to hold with fingers. Therefore a wooden block wrapped with
adhesive plaster with sticky side directed outward can be used. Stick the tooth
onto the plaster and press the wooden block to the rotating wheel of the lathe
so that the tooth becomes thinner. Then change the coarse wheel to fine
wheel and continue grinding till the section is sufficiently thin. To remove the
adhesive plaster the sections can be soaked in water. The section removed
from the plaster is then mounted on a glass slide using a mounting medium.
Precision equipment like hard tissue microtomes are now available for the
preparation of ground section.
 48
Microscope

Types of microscopes
Light microscopy

A microscope is an important instrument used in histopathology laboratory

to observe the tissues. The magnification it provides enables us to see
the structures otherwise invisible to the naked eye.
Robert Hooke developed an instrument that could truly be referred to as
the forerunner of the modern day microscope.

Types of Microscopes
Microscopes are broadly classified as: Simple microscopes and compound
miroscopes.
Simple microscopes
It has a single lens system through which the upturned image of the object is
seen.
Compound microscopes
These are again classified into two types:
Light microscope
Electron microscope
Light microscopes
They are of the following types
Bright field microscope
Dark field microscope
Phase contrast microscope
Fluorescence microscope
Ultraviolet microscope
Interference microscope
Electron microscopes
They are of two types
Transmission electron microscope (TEM)
Scanning electron microscope (SEM)

Light Microscopy
Microscope in which the final magnified image of the object, illuminated by
visible light is seen through glass lenses is called optical or light microscopes
or bright field microscope.
The ordinary microscope is called a bright field microscope because it
forms a dark image against a brighter background.
The bright field microscope used in histopathology lab today is a
compound microscope that uses multiple lens system to magnify the object, it
has a light source, a condenser lens that focuses the light on the specimen and
two sets of lenses—objective and ocular—that contribute to the
magnification of the image.
Through the refraction or bending of light rays by the system of
microscope lenses, an image of the specimen is formed that is larger than the
object itself, permitting the structures of the specimen to be seen.

Magnification
The magnifying capability of a compound microscope is the product of the
individual magnifying powers of the ocular lens and the objective lens.

Resolving Power
Resolving power is the ability to distinguish two points as separate and
distinct. Resolving power of the microscope depends upon the wavelength of
light and the numerical aperture of the lens (light gathering ability of the lens
system).

Construction of Compound Light Microscope (Fig. 48.1)

The compound microscope consists of a strong metal stand with a broad base
or foot, from which rises a short, stout pillar supporting an upright, curved
arm.
Situated in the base is a strong light source either an adjustable, built in
electric lamp or a mirror.
Attached to the pillar, above the light source is a system of one or more
horizontal iris diaphragms which regulate the passage of light and eliminate
undesirable peripheral rays from the light source.
Attached to the pillar above the iris diaphragm is one or two lenses vertically
adjustable sub-stage condenser which concentrates the light rays on the
object.
Above the condenser is the horizontal working platform or the stage about 3
or 4 inches square or circular with an opening in the center to admit light
from the condenser below.
Attached to the curved upright arm is the vertical barrel or body tube.
Modern binocular microscope contains a system of prism and reflectors that
permit tilting of the barrel for ease in viewing. The barrel is mounted on a
rack and pinion mechanism for vertical coarse and fine adjustment or
focusing.
 Fig. 48.1: Light microscope
At the lower end of the body tube is the objective lens system which consists
of low power (10X, 45X) and oil immersion (100X) objectives. These are
mounted on a “nose piece” on which they may be rotated into position under
the body tube correctly aligned. The low power objectives are commonly
used without immersion oil and are spoken of as “high-dry” objectives. The
objective lens produces a real image within the instrument.
At the top of the body tube is the ocular lens system or the eyepiece usually
containing 2 or 3 lenses. These magnify the real image which then appears as
a greatly enlarged virtual image seeming to be projected to a position just
above the light source and below the iris diaphragm.
Light rays from below the iris diapragm are refracted through the condenser
and emerge from the top surface of the slide, at the plane of the object as a
cone of light with the apex downwards.
 49
Muscles of Orofacial Region

Muscles of mastication
Muscles of soft palate
Muscles of facial expression
Muscles of pharynx
Suprahyoid muscles
Muscles of tongue

Muscles of mastication (Figs 49.1a to d)

Fig. 49.1a: Temporalis

Fig. 49.1b: Messetei

 Fig. 49.1c: Medial pterygoid

Fig. 49.1d: Lateral pterygoid

Muscles of the soft palate

Muscles of the facial expression (Fig. 49.2)
 Muscles of the pharynx

Fig. 49.2: Muscles of facial expression

Suprahyoid muscles
Muscles of tongue
 50
Vascular and Nerve Supply of
Orofacial Region

Vasculature and nerve innervations of:

– Face
– Teeth and supporting structures
– Palate
– Tongue
– Gingiva
– Cheek and lips

Face
The facial artery is the chief artery of the face which is the branch of external
carotid artery. This artery gives off anterior branches and posterior branches.
Anterior branches include: Inferior labial supplying lower lip, superior labial
supplying upper lip and lateral nasal supplying ala and dorsum of the tongue.
The anterior branches anastomose with similar branches of opposite side.
Posterior branches are smaller and anastomose with transverse facial artery
which is a branch of superficial temporal artery.
Other arteries supplying face include transverse facial artery, infra-orbital
and mental branches of maxillary artery and dorsal nasal branch of the
ophthalmic artery.
Facial vein is the main vein draining the face. It begins at the medial corner
of the eye by the confluence of supra-orbital and supratrochlear veins. The
facial vein passes across the face following the course of facial artery. Below
the mandible this vein joins to the retromandibular vein to form the common
facial vein which drains into internal jugular vein.
The lymph from major part of forehead, lateral halves of eyelids, lateral
part of the cheeks and parotid region is drained into pre auricular lymph
nodes. The central part of lower lip and the chin drain into submental lymph
nodes. The remaining region of face which include midportion of forehead,
external nose, upper lip, lateral part of lower lip, medial part of eyelids,
greater part of the lower jaw drain into the submandibular lymph nodes.
The trigeminal nerve is the sensory nerve of the face. The ophthalmic
division supplies the forehead, upper eyelid, and the nose. The upper lip, ala
of the nose, lower eyelid, upper part of the cheek are supplied by maxillary
division of trigeminal nerve. Mandibular division of trigeminal nerve
provides sensory supply to lower lip, chin, lower part of cheek, lower jaw
except for angle, lower margin, etc. Skin over the angle and lower margin of
the lower jaw and parotid region are supplied by cervical plexus.
The motor nerve supply of face is through the five branches of facial
nerve: Temporal, zygomatic, buccal, mandibular, and cervical.

Teeth and Supporting Structures

Mandibular teeth and supporting structures are supplied by inferior alveolar
artery which is a branch of maxillary artery. Inferior alveolar artery passes
through the mandibular foramen to enter into the mandibular canal and
terminate as mental and incisive arteries.
Maxillary teeth receive arterial supply from three different sources;
posterior superior alveolar artery supplies the molars and premolars while
anterior superior alveolar artery supplies anterior teeth.
The veins related to the mandibular teeth may be collected into one or
more inferior alveolar veins which may drain anteriorly into facial vein or
posteriorly to pterygoid plexus of veins. In the maxilla also veins drain either
into facial vein or pterygoid plexus of veins.
The lymph vessels from teeth usually run directly into the submandibular
nodes on the same side. Lymph from lower incisor teeth may drain into
submental nodes. Sometimes molars may drain directly into jugulodigastric
group of nodes.
Inferior alveolar nerve innervates the mandibular premolars and molars
while anterior teeth are innervated by incisive nerve. In the maxillary arch,
anterior superior alveolar nerve supplies the anterior teeth and middle
superior alveolar nerve supplies the premolars and mesio-buccal root of first
molar. The posterior superior alveolar nerve supplies all the molars except for
mesio-buccal root of first molar.

Palate
The palate receives its arterial supplies from greater and lesser palatine
branches of maxillary artery.
The veins of hard palate drain into pterygoid plexus while those of soft
palate drain into pharyngeal plexus. The venous drainage of cheek is to
pterygoid venous plexus via buccal veins. The veins of the lips drain into
facial vein via superior and inferior labial veins.
Lymphatic channels from the major part of palate drain into jugulodigastric
group of nodes. Lymph vessels from posterior part of palate terminate in
retropharyngeal lymph nodes.
The nerve supply to most of the palate is from the maxillary division of
trigeminal nerve. Anterior part of the palate is supplied by the nasopalatine
nerve which emerges through the incisive foramen. The remaining part of the
hard palate is supplied by greater palatine nerve while lesser palatine nerve
supplies the soft palate. All muscles of soft palate except for tensor palati are
supplied by pharyngeal plexus. The tensor palati is supplied by mandibular
nerve.

Tongue
The arterial supply of the tongue is from lingual artery, a branch of the
external carotid artery.
The veins of dorsum and sides of the tongue form the lingual veins which
follow the course of lingual arteries to drain into internal jugular veins. The
deep lingual veins from ventral surface of the tongue join the facial, internal
jugular or lingual veins.
The lymphatic vessels from the tip of the tongue drain into the submental
nodes. The remaining part of anterior two-thirds of the tongue drain
unilaterally into submandibular lymph nodes. The posterior one-third drains
bilaterally into jugulo-omohyoid node.
The sensory innervations of tongue are from three different sources. The
anterior one-third of the tongue is supplied by lingual nerve although the taste
sensation is mediated by chorda tympani. The posterior one-third including
the circumvallate papillae are supplied by glossopharyngeal nerve which
carries taste and general sensations. The posterior most part of the tongue is
innervated by vagus nerve via internal laryngeal branch. Lingual nerve
supplies the mucosa on the ventral aspect of the tongue. The motor supply to
intrinsic and extrinsic muscles of the tongue is hypoglossal nerve except for
palatoglossus which is supplied by cranial part of accessory nerve through the
pharyngeal plexus.

Gingiva
The labial gingiva around the mandibular anterior teeth are supplied by
mental artery and perforating branches of incisive artery. The buccal artery
and perforating branches from inferior alveolar artery supplies the posterior
buccal gingiva. The lingual gingiva is supplied by the lingual artery and
perforating branches from the inferior alveolar artery. The arterial supply to
the buccal gingiva around maxillary posterior teeth is by gingival and
perforating branches from posterior superior alveolar artery and by buccal
artery. The labial gingiva of anterior teeth is supplied by labial branches of
infraorbital artery and by perforating branches of the anterior superior
alveolar artery. The palatal gingiva is primarily supplied by branches of
greater palatine artery.
The venous drainage of gingiva could be via buccal, lingual, greater
palatine and nasopalatine veins which drain into internal jugular vein or to
pterygoid plexus of veins.
The lymphatic drainage from labial and buccal gingivae of both maxillary
and mandibular teeth drain into submandibular lymph node though the
gingiva in the labial region of mandibular incisors drain to the submental
node. The palatal and lingual gingiva drain into jugulodigastric nodes directly
or indirectly through submandibular node.
In the mandibular arch the entire lingual gingiva is innervated by lingual
nerve. The labial and buccal gingiva in relation to the anterior teeth and
premolars are supplied by mental nerve while the gingiva of molar region
receives nerve supply from long buccal nerve. The labial gingiva in relation
to maxillary anterior teeth is innervated by anterior superior alveolar nerve
and infra-orbital nerve. The buccal gingiva of premolars gets the nerve
supply from middle superior alveolar nerve and infraorbital nerve. The
posterior superior alveolar nerve supplies the posterior buccal gingiva in
relation to molars. The major portion of palatal gingiva is innervated by
greater palatine nerve except for the anterior gingiva which is supplied by
nasopalatine nerve.

Cheek and Lips

The cheek is supplied by buccal branch of maxillary artery, and the floor of
the mouth by lingual arteries. The superior and inferior labial branches of
facial arteries provide arterial supply to the lips.
The buccal vein of the cheeks drains into pterygoid venous plexus. The
venous blood from the lip drains into the facial veins via superior and inferior
facial veins.
The lymphatics of cheek mainly drain into submandibular and preauricular
nodes. Lymphatics from the lips except for central part of the lower lip drain
into submandibular lymph nodes. The central part of the lower lip drains into
submental lymph nodes. The submandibular nodes also drain the anterior part
of floor of the mouth.
The mucosa of upper lip is supplied by infraorbital branch of maxillary
division of trigeminal nerve. The mental branch of mandibular division of
trigeminal nerve innervates the mucosa of the lower lip. The cheek mucosa is
supplied by buccal branch and floor of the mouth by lingual nerve.
 Appendix
Test Yourself
(Expected Questions)

SECTION 1: ORAL EMBWOLOGY

Chapter 1: General Embryology

Short Answers for 4–5 marks
Derivatives of germ layer (Page 4)
Neural crest cells (Page 4)
Branchial arches and pouches (Page 5)
Short Notes for 2–3 marks
Morula (Page 3)
Blastocyst (Page 3)

Chapter 2: Development of Orofacial Structures

Short Answers for 4–5 marks
Formation of palate (Pages 9–10)
Formation of tongue (Pages 11–13)
Formation of mandible (Pages 12–13)
Formation of salivary glands (Page 14)
Meckel’s cartilage and its role in development of mandible (Page 12)
Development of face (Page 8)

SECTION 2: ORAL HISTOLOGY

Chapter 3: Development of Tooth

Essay Questions of 10 or more marks
Enumerate the stages of development of teeth. Discuss in detail cap stage of
tooth development. (Both morphological and physiological stages should be
enumerated. (Pages 22–24)
Enumerate the stages of development of teeth. Discuss in detail bell stage of
tooth development (Pages 20 and 25–28)
Enumerate the stages of development of teeth. Discuss in detail various
physiological stages of tooth development and its clinical importance. (Pages
19–21)
Discuss in detail development of roots (Pages 28–30)
Short Answers for 4–5 marks
Dental lamina (Pages 17–19)
Tooth germ in bud stage (Pages 21–22)
Enamel organ in cap stage (Pages 22–24)
Enamel organ in early bell stage (Pages 25–26)
Tooth germ in late bell stage (Pages 27–28)
Hertwig’s epithelial root sheath and its role in root formation (Pages 28–30)
Functions of enamel organ (Pages 30)
Stellate reticulum (Pages 23)
Transitory structures/temporary structures of enamel organ seen in cap stage
of tooth development (Page 24)
Short Notes for 2–3 marks
Vestibular lamina (Page 17)
Primary epithelial band (Page 17)
Cell rests of Serres’ (Page 19)
Successional lamina (Pages 26–27)
Components of tooth germ and derivatives of each components (Pages 19–
20)
Enamel knot and enamel cord (Page 24)
Cervical loop (Page 26)
Cell rests of Malasses (Pages 30 and 85–86)
Stratum intermedium (Pages 25–26)

Chapter 4: Enamel and Amelogenesis

Essay Questions of 10 or more marks
Enumerate and discuss in detail stages of life cycle of ameloblasts (Pages 33–
36)
Enumerate stages of life cycle of ameloblasts and discuss in detail
Amelogenesis (Pages 33 and 36–38)
Describe the light microscopic and electron microscopic characteristics of
enamel rods (Pages 38–40)
Discuss in detail various structures observed in ground section of enamel
under light microscope. (Answer should include light microscopic structure
of enamel rod, structural lines, Gnarled enamel, Hunter Schreger bands,
enamel lamellae, tufts and spindles, DEJ, etc.) (Pages 38–47)
Discuss in detail the hypocalcified structures of enamel. (Answer should
include enamel lamellae, tufts, spindles and various structural lines.) (Pages
41–42, 44–46)
Short Answers for 4–5 marks
Unique features of enamel (Page 32)
Chemical composition and physical properties of enamel (Pages 31 and 32)
Secretory stage of ameloblasts (Page 35)
Ameloblast modulation (Page 35–36)
Enamel proteins (Page 36)
Light microscopic characteristics of enamel rods (Pages 38 and 39)
Electron microscopic/submicroscopic characteristics of enamel rods (Pages
39 and 40)
Structural lines of enamel (Pages 41–42)
Striae of Retzius (Pages 41–42)
Hunter Schreger bands (Pages 43–44)
Dentinoenamel junction (Page 44)
Enamel lamellae and tufts (Pages 45–46)
Surface structures of enamel (Pages 46–47)
Age changes of enamel (Pages 320–321)
Short Notes for 2–3 marks
Tomes’process (Page 35)
Reciprocal induction (Page 34)
Reversal of polarity (Page 34)
Reduced enamel epithelium (Page 36)
Immediate partial mineralization of enamel (Page 38)
Direction of enamel rods (Pages 40–41)
Cross striation (Page 41)
Neonatal lines of enamel (Page 42)
Enamel spindles (Pages 44–45)
Enamel tufts (Page 45)
Perikymata (Page 47)
Nasmyth’s membrane/enamel cuticle (Page 47)
Chapter 5: Dentin and Dentinogenesis
Essay Questions of 10 or more marks
Discuss in detail various structures observed in ground section of dentin
under light microscope. (Answer should include description of dentinal
tubules, peri- and intertubular dentin, interglobular dentin, Tomes’ granular
layer, structural lines and functional changes) (Pages 54–62)
Discuss in detail dentinogenesis (Pages 51–53)
Enumerate and discuss in detail various types of dentin. (Answer should
include description of primary (mantle and circumpulpal), secondary, tertiary
dentin, interglobular dentin, sclerotic dentin, predentin, osteodentin, etc.)
(Pages 53–54, 56–58, 60–62)
Short Answers for 4–5 marks
Chemical composition and physical properties of dentin (Pages 49–50)
Differences between enamel and dentin (Page 50)
Primary dentin (Pages 53–54)
Dentinal tubules (Pages 54–55)
Peritubular and intertubular dentin (Pages 56–57)
Hypocalcified structures of dentin (answer should include interglobular
dentin, structural lines of dentin and Tomes’ granular layer) (Pages 58–59)
Interglobular dentin (Page 58)
Structural lines of dentin (Page 59)
Age and functional changes of dentin (Pages 60–62)
Dead tracts (Pages 60–61)
Reparative dentin (Pages 61–62)
Sclerotic dentin (Page 62)
Theories of dentin sensitivity (Pages 62–63)
Short Notes for 2–3 marks
Mantle dentin (Page 53)
Circumpulpal dentin (Pages 53–54)
Secondary dentin (Page 54)
Tomes’ granular layer (Pages 58–59)
Incremental lines of dentin (Page 59)
Contour line of Owen (Page 59)
Neonatal lines of dentin (Page 59)
Predentin (Page 60)
Hydrodynamic theory of dentin sensitivity (Page 63)

Chapter 6: Pulp
Essay Questions of 10 or more marks
Discuss in detail histological/microscopic structure of pulp. Add a note on
functions of pulp (Pages 67–71)
Discuss in detail structural components of pulp (Pages 68–70)
Short Answers for 4–5 marks
Pulp stones/pulp calcifications (Pages 72–73)
Age/regressive changes of pulp (Pages 71–73)
Histological zones of pulp (Pages 67–68)
Functions of pulp (Pages 71)
Odontoblasts (Pages 68–69)
Short Notes for 2–3 marks
Morphological characteristics of pulp (Pages 65–66)
Accessory canals (Pages 66–67)
Zone of Weil (Page 68)
Plexus of Rashkow (Page 68)
Undifferentiated mesenchymal cells of pulp (Page 69)

Chapter 7: Cementum
Essay Question of 10 or more marks
Classify cementum and discuss in detail structure of cementum (Pages 76–
81)
Short Answers for 4–5 marks
Physical properties and chemical composition of cementum (Pages 74–75)
Cementogenesis (Pages 75–76)
Structure of acellular cementum (Pages 77–78)
Structure of cellular cementum (Pages 78–79)
Cementoenamel junctions (Page 80)
Differences between acellular and cellular cementum (Page 80)
Hypercementosis (Page 82)
Functions of cementum (Pages 81–82)
Short Notes for 2–3 marks
Classification of cementum (Page 76–77)
Cementocytes (Page 78)
Acellular afibrillar cementum (Page 79)
Intermediate cementum (Page 79)
Cementodentinal junction (Page 81)
Mixed stratified cementum (Page 79)
Age changes of cementum (Page 322)

Chapter 8: Periodontal Ligament

Essay Questions of 10 or more marks
Discuss in detail microscopic structure of PDL (Pages 84–89)
Discuss in detail cellular components of PDL (Pages 84–86)
Discuss in detail extracellular components of PDL (Pages 86–89)
Discuss in detail principal fibers of PDL add a note on functions of PDL
(Pages 86–88)
Short Answers for 4–5 marks
Epithelial cell rests of Malassez (Pages 85–86)
Principal fibers of PDL (Pages 86–87)
Gingival group of fibers (Page 87)
Functions of PDL (Pages 89–90)
Age changes of PDL (Page 323)
Short Notes for 2–3 marks
Progenitor cells of PDL (Page 85)
Intermediate plexus (Pages 88–89)
Oblique fibers of PDL (Page 87)
Sharpey’s fibers (Page 88)
Cementicles (Page 89)
What is periodontium and what are the various components (Page 83)

Chapter 9: Alveolar Bone

Short Answers for 4–5 marks
Briefly describe parts of alveolar bone (Pages 91–93)
Histology of bone (Pages 94–97)
Cells of bone (Pages 95–97)
Osteoclasts (Pages 96–98)
Bone remodeling (Pages 98–99)
Short Notes for 2–3 marks
Alveolar bone proper/lamina dura/cribriform plate (Page 92)
Bundle bone (Page 92)
Define alveolar bone and enumerate the parts (Page 91)
Resting lines and reversal lines (Page 98)
Osteon/Haversian system (Page 95)
Chemical composition of bone (Page 93)
Supporting alveolar bone (Pages 92–93)

Chapter 10: Oral Mucosa

Essay Questions of 10 or more marks
Define and classify oral mucosa. Describe in detail structure of keratinized
mucosa (Pages 100 and 103–106 and brief mention of basal complex and
desmosomes)
Define and classify oral mucosa. Describe in detail structure of
nonkeratinized mucosa (Pages 100 and 107–109 and brief mention of basal
complex and desmosomes)
Describe in detail structure of buccal mucosa (Pages 107–109 and brief
mention of basal complex and desmosomes)
Describe in detail microscopic and macroscopic structures of gingiva (Pages
115–117 and 103–104 and brief mention of basal complex and desmosomes)
Discuss in detail microscopic and macroscopic structures of tongue (Pages
120–123)
Discuss in detail microscopic and macroscopic structures of palate (Pages
118–120 and brief description of keratinized epithelium)
Discuss the differences between keratinized and nonkeratinized mucosa
(Page 110)
Short Answers for 4–5 marks
Light microscopic structure of keratinized epithelium (Pages 103–104)
Light microscopic structure of nonkeratinized epithelium (Page 107)
Nonkeratinocytes of oral epithelium (Pages 112–113)
Papillae of tongue (Page 121–122)
Basal complex (Page 112)
Desmosomes (Page 109)
Vermilion border of lip (Pages 114–115)
Taste buds (Pages 122–123)
Dentogingival junction (Pages 124–125)
Passive eruption (Pages 124–125)
Lamina propria (Page 102)
Junctional epithelium (Page 117)
Short Notes for 2–3 marks
Classification of oral mucosa (Pages 100–101)
Function of oral mucosa (Page 100)
Submucosa (Page 102)
Mucoperiosteum (Pages 102 and 118)
Odland bodies (Pages 106 and 108)
Keratohyaline granules (Page 106)
Melanocytes (Pages 112–113)
Langerhans cells (Page 113)
Merkel cells (Page 113)
Circumvallate papilla (Page 122)

Chapter 11: Salivary Glands

Essay Questions of 10 or more marks
Classify salivary glands. Discuss in detail structure of parotid/serous gland
(answer should include detailed description of serous acini, and brief
description of myoepithelial cells, ductal system and connective tissue
component. Pages 127, 129–130, 135, 137–138)
Classify salivary glands. Discuss in detail structure of sublingual/mucous
gland (answer should include detailed description of mucous acini, and brief
description of myoepithelial cells, ductal system and connective tissue
component. Pages 127, 133–134, 135, 137–138)
Classify salivary glands. Discuss in detail structure of submandibular/mixed
gland (answer should include brief description of mucous, serous and mixed
acini, myoepithelial cells, ductal system and connective tissue component.
Pages 127, 129–134, 135, 137–138)
Classify salivary glands. Discuss in detail structure of serous acini (answer
should include detailed description of light and electron microscopic structure
of serous cells with a mention of arrangement of cells into acinus and
myoepithelial cells)
Classify salivary glands. Discuss in detail structure of mucous acini. Add a
note on differences between serous and mucous acini (answer shoul include
detailed description of light and electron microscopic structure of mucous
cells and myoepithelial cells with a mention of arrangement of cells into
acinus and difference with serous acini)
Classify salivary glands. Discuss in detail structure of parenchymal
components of serous/mucous/mixed glands. (Answer should include
description of mucous/serous/mixed acini, myoepithelial cells and ductal
system)
Short Answers for 4–5 marks
Ductal system of salivary glands (Pages 137–138)
Myoepithelial cells (Pages 135–136)
Short Notes for 2–3 marks
Differences between serous and mucous acini (Page 140)
Functions of salivary ductal systems (Pages 138–139)
Mixed acinus (Page 135)
Striated ducts (Page 137)
Excretory ducts (Page 138)
Lingual glands (Page 128)
von Ebner’s glands (Page 128)
Synthesis and secretion of saliva (Pages 130–132)

Chapter 12: Temporomandibular Joint

Short Answers for 4–5 marks
Histology of articular fibrous covering (Page 142)
Articular capsule (Pages 142–143)
Synovial membrane (Page 143)
Articular disc (Pages 144–145)
Functions of articular disc (Pages 144–145)
Ligaments of TMJ (Page 145)
TMJ movements (Pages 145–146)
Short Notes for 2–3 marks
Histology of condyle (Page 141)
Bennett movement (Page 146)

Chapter 13: Maxillary Sinus

Short Answers for 4–5 marks
Anatomy of maxillary sinus (Pages 148–149)
Histology of maxillary sinus lining (Page 149)
Functions of maxillary sinus (Pages 149–150)
Short Notes for 2–3 marks
Pseudostratified ciliated columnar epithelium (Page 149)
Goblet cells (Page 149)
Oro-antral fistula (Page 150)

SECTION 3: ORAL AND DENTAL ANATOMY

Chapter 14: Introduction to Dental Anatomy

Short Answers for 4–5 marks
Tooth numbering systems (Pages 161–163)
Ridges and grooves (Pages 166–167)
Fundamental curvatures of teeth (Pages 169–171)
Chronology of human dentition (Page 159)
Short Notes for 2–3 marks
Dental formula for deciduous and permanent dentition (Pages 157–158)
Sequence of eruption of deciduous and permanent dentition (Page 159)
Mamelons (Page 168)
Embrasures/spillway spaces (Page 170)
Line angles and point angles of anterior and posterior teeth (Pages 164–165)

Chapter 15: Deciduous Maxillary Anterior Teeth

Short Answers for 4–5 marks
Morphological features of deciduous maxillary central incisor (Pages 172–
173)
Morphological features of deciduous maxillary canine (Page 173)

Chapter 16: Deciduous Mandibular Anterior Teeth

Short Answers for 4–5 marks
Morphological features of deciduous mandibular central incisor (Page 176)
Morphological features of deciduous mandibular canine (Pages 176–177)

Chapter 17: Deciduous Maxillary Molars

Essay Questions of 10 or more marks
Discuss in detail morphology of deciduous maxillary first molar (Pages 180–
183)
Discuss in detail morphology of deciduous maxillary second molar (Pages
183–185)
Short Answers for 4–5 marks
Occlusal aspect of deciduous maxillary first molar (Pages 182–183)
Occlusal aspect of deciduous maxillary second molar (Pages 184–185)

Chapter 18: Deciduous Mandibular Molars

Essay Questions of 10 or more marks
Discuss in detail morphology of deciduous mandibular first molar (Pages
187–189)
Discuss in detail morphology of deciduous mandibular second molar (Pages
189–191)
Short Answers for 4–5 marks
Occlusal aspect of deciduous mandibular first molar (Page 189)
Occlusal aspect of deciduous mandibular second molar (Page 191)
Differences between deciduous mandibular second molar and permanent
mandibular first molar (Page 192)

Chapter 19: Comparison between Deciduous and

Permanent Dentition
Essay Questions of 10 or more marks
Discuss in detail differences between deciduous and permanent dentition
(Pages 194–196)

Chapter 20: Permanent Maxillary Central Incisors

Essay Question of 10 or more marks
Describe in detail morphology of permanent maxillary central incisors. Add a
note on its chronology (Pages 197–200)
Short Answer for 4–5 marks
Class trait of permanent maxillary central incisors (Page 204)

Chapter 21: Permanent Maxillary Lateral Incisors

Short Answers for 4–5 marks
Briefly describe morphology of permanent maxillary lateral incisors (Pages
202–204)
Class trait of permanent maxillary lateral incisors (Page 204)
Morphologic differences between of permanent maxillary central and lateral
incisors (Page 204)

Chapter 22: Permanent Mandibular Central Incisors

Short Answers for 4–5 marks
Morphological characteristics of permanent mandibular central incisors
(Pages 207–209)
Class trait of permanent mandibular central incisors (Page 214)
Class trait of permanent mandibular incisors (Page 209)
Morphologic differences between of permanent maxillary and mandibular
incisors (Page 209)

Chapter 23: Permanent Mandibular Lateral Incisors

Short Answers for 4–5 marks
Morphological characteristics of permanent mandibular lateral incisors
(Pages 212–214)
Class trait of permanent mandibular lateral incisors (Page 214)
Morphologic differences between of permanent mandibular central and
lateral incisors (Page 214)

Chapter 24: Permanent Maxillary Canine

Essay Question of 10 or more marks
Describe in detail morphology of permanent maxillary canine. Add a note on
chronology (Pages 216–219)
Short Answers for 4–5 marks
Class trait of permanent canines (Page 216)
Class trait of permanent maxillary canine (Page 223)
Short Note for 2–3 marks
Anatomic landmarks on lingual aspect of permanent maxillary canine (Pages
217–218)

Chapter 25: Permanent Mandibular Canine

Essay Question of 10 or more marks
Describe in detail morphology of permanent mandibular canine. Add a note
on chronology (Pages 221–225)
Short Answers for 4–5 marks
Class trait of permanent mandibular canine (Page 223)
Differences between maxillary and mandibular canines (Page 223)

Chapter 26: Permanent Maxillary First Premolar

Essay Question of 10 or more marks
Describe in detail morphology of permanent maxillary first premolar. Add a
note on its chronology (Pages 226–231)
Short Answers for 4–5 marks
Class trait of permanent maxillary first premolar (Page 234)
Occlusal morphology of permanent maxillary first premolar (Pages 229–230)
Mesial aspect of permanent maxillary first premolar (Page 228)
Short Note for 2–3 marks
Canine fossa (Page 228)

Chapter 27: Permanent Maxillary Second Premolar

Essay Question of 10 or more marks
Describe in detail morphology of permanent maxillary second premolar. Add
a note on its chronology (Pages 232–235)
Short Answers for 4–5 marks
Class trait of permanent maxillary second premolar (Page 234)
Occlusal morphology of permanent maxillary first premolar (Pages 234–235)
Morphological differences between maxillary first and second premolars
(Page 234)

Chapter 28: Permanent Mandibular First Premolars

Essay Question of 10 or more marks
Describe in detail morphology of permanent mandibular first premolar. Add a
note on chronology (Pages 237–241)
Short Answers for 4–5 marks
Class trait of permanent mandibular first premolar (Page 240)
Occlusal morphology of permanent mandibular first premolar (Pages 239–
241)
Mesial aspect of permanent mandibular first premolar (Page 239)
Differences between permanent maxillary and mandibular first premolar.
(Page 240)

Chapter 29: Permanent Mandibular Second Premolars

Essay Question of 10 or more marks
Describe in detail morphology of permanent mandibular second premolar.
Add a note on chronology (Pages 243–247)
Short Answers for 4–5 marks
Class trait of permanent mandibular second premolar (Page 245)
Occlusal morphology of three cusp type/two cusp type permanent mandibular
second premolar (Pages 245–246)
Differences between permanent mandibular first and second premolars (Page
245)

Chapter 30: Permanent Maxillary First Molars

Essay Question of 10 or more marks
Describe in detail morphology of permanent maxillary first molar. Add a note
on its chronology (Pages 248–252)
Short Answer for 4–5 marks
Occlusal morphology of permanent maxillary first molar (Pages 251–252)
Short Note for 2–3 marks
Ridges in occlusal aspect of permanent maxillary first molar (Page 251)

Chapter 31: Permanent Maxillary Second Molars

Essay Question of 10 or more marks
Describe in detail morphology of permanent maxillary second molar. Add a
note on chronology (Pages 254–257)
Short Answer for 4–5 marks
Differences between permanent maxillary first and second molars (Page 256)

Chapter 32: Permanent Maxillary Third Molars

Short Note for 2–3 marks
Morphological characteristics of permanent maxillary third molar (Page 258)

Chapter 33: Permanent Mandibular First Molars

Essay Question of 10 or more marks
Describe in detail morphology of permanent mandibular first molar. Add a
note on chronology (Pages 260–264)
Short Answer for 4–5 marks
Occlusal morphology of permanent mandibular first molar (Pages 263–264)
Short Note for 2–3 marks
Anatomic landmarks in the occlusal aspect of permanent mandibular first
molar (Pages 263–264)

Chapter 34: Permanent Mandibular Second Molars

Essay Question of 10 or more marks
Describe in detail morphology of permanent mandibular second molar. Add a
note on chronology (Pages 267–271)
Short Answer for 4–5 marks
Differences between permanent mandibular first and second molars (Page
270)

Chapter 35: Permanent Mandibular Third Molars

Short Note for 2–3 marks
Morphological characteristics of permanent mandibular third molar (Page
272)

Chapter 36: Occlusion

Short Answers for 4–5 marks
Molar relation in permanent dentition (Pages 277–278)
Molar relation in deciduous dentition (Pages 247–275)
Compensating curves (276)
Theories of occlusion (Page 279)
Centric relation and centric occlusion (Pages 276–277)
Short Notes for 2–3 marks
Leeway space of Nance (Page 275)
Primate space (Page 274)
Curve of Spee (276)
Curve of Wilson (276)
Overjet and overbite (Page 278)
Bonwill theory of occlusion (Page 279)
Centric and concentric cusps (Page 277)

SECTION 4: ORAL PHYSIOLOGY

Chapter 37: Eruption
Essay Question of 10 or more marks
Enumerate and discuss in detail the various theories of eruption (Pages 285–
288)
Short Answers for 4–5 marks
Define eruption and describe pattern of pre-eruptive movements (Pages 283–
284)
Histology of eruptive tooth movement (284–285)
Post eruptive tooth movements (Page 285)
Enumerate theories of eruption and discuss the most accepted one (Pages
283–284. Answei should include names of all theories and detailed
description of PDL traction theory)
Root formation theory of eruption (Pages 285–286)
Bone remodeling theory of eruption (Pages 286–287)
Role of dental follicle in eruption (Page 288)
Short Notes for 2–3 marks
Gubernacular canal and cord (Page 285)
Enumerate and define types of physiological movements of teeth (Page 283)
Pre-eruptive movements of permanent molars (Page 284)
Histological changes observed in PDL during eruption (Page 284)
Cushion hammock ligament (Page 286)
Importance of pre-eruptive tooth movements (Pages 283–284)

Chapter 38: Shedding

Short Answers for 4–5 marks
Mechanism of shedding (Page 289)
Histology of shedding (Pages 289–290)
Odontoclasts (Pages 289–290)
Pattern of shedding (Page 290)
Short Notes for 2–3 marks
Submerged tooth (Page 291)
Causes of retained deciduous teeth (Page 291)
Definition of eruption and shedding (Pages 284 and 289)

Chapter 39: Saliva

Short Answers for 4–5 marks
Composition and functions of saliva (Pages 292–294)
Antimicrobial functions of saliva (Page 293)
Factors controlling the secretion of saliva (Page 295)
Synthesis and secretion of saliva (Pages 294–295)
Short Notes for 2–3 marks
Salivary IgA (Page 293)
Buffering action of saliva (Page 293)

Chapter 40: Physiology of Taste and Speech

Short Answers for 4–5 marks
Physiology of taste/mechanism of taste perception (Pages 297–298)
Physiology of speech (Pages 298–299)

Chapter 41: Mastication

Short Answer for 4–5 marks
Masticatory/chewing cycle (Pages 300–303)
Short Note for 2–3 marks
Definition and objectives of mastication (Page 300)

Chapter 42: Deglutition

Short Answer for 4–5 marks
Phases of deglutition (Pages 304–305)
Short Notes for 2–3 marks
Enumerate and define various phases of deglutition (Page 304)
Infantile swallow (Page 306)

Chapter 43: Calcium Phosphorus Metabolism

Short Answers for 4–5 marks
Factors affecting calcium absorption (Page 307)
Role of hormones in serum calcium level (Pages 308–311)
Short Notes for 2–3 marks
Role of parathyroid hormone in serum calcium level (Page 308)
Role of vitamin D in serum calcium level (Pages 308–309 )
Role of calcitonin in serum calcium level (Page 310)

Chapter 44: Mineralization

Short Answers for 4–5 marks
Booster theory/Robinson’s alkaline phosphatase theory (Pages 312–313)
Seeding theory/nucleation theory/role of collagen in mineralization (Pages
314–315)
Matrix vesicle theory/role of matrix vesicle in mineralization (Pages 315–
316)
Short Note for 2–3 marks
Alkaline phosphatase (Page 313)

Chapter 45: Hormonal Influence on Orofacial

Structures
Short Answers for 4–5 marks
Effect of hormones on oral tissues (Pages 317–320)
Effect of thyroid hormone on oral tissues (Page 317)
Effect of parathyroid hormone on oral tissues (Page 318)
Effect of pituitary hormones on oral tissues (Page 318)

Chapter 46: Age Changes of Oral Tissues

Short Answers for 4–5 marks
Age changes of enamel (Pages 320–321)
Age changes of dentin (Pages 321–322)
Age changes of pulp (Pages 322–323)
Age changes of cementum (Page 322)
Age changes of oral mucosa (Page 324)
Age changes of salivary glands (Page 324)
Short Note for 2–3 marks
Oncocytes (Page 324)

SECTION 5: ALLIED TOPICS

Chapter 47: Tissue Processing

Short Answers for 4–5 marks
Enumerate the steps in routine tissue processing (name various steps in order)
(Pages 327–331)
Ground sectioning (Pages 327–328)
Decalcification techniques/preparation of decalcified section (Pages 326–
327)
Short Notes for 2–3 marks
Frozen section (Page 331)
Fixation and fixatives (Page 322)
Dehydration (Page 322)
Clearing (Pages 322–323)
Hematoxylin and eosin stain (Page 325–326)

Chapter 48: Microscope

Short Answer for 4–5 marks
Compound microscope (Pages 335–336)

Chapter 49: Muscles of Orofacial Region

Short Answer for 4–5 marks
Muscles of mastication (Page 337)

Chapter 50: Vascular and Nerve Supply of Orofacial

Region
Short Answers for 4–5 marks
Nerve supply of orofacial region (Pages 342–344)
Vasculature of orofacial region (Pages 342–344)