DSP I and II Resources 2015 - SECURED PDF

DENT 1005 and DENT 2005
School of Dentistry
Dental Science and Practice I
and II Resources
DENTAL SCIENCE AND PRACTICE I & II

RESOURCES
Prepared by
PROFESSOR GC TOWNSEND
and
ASSOCIATE PROFESSOR TA WINNING
Design, layout and format by the Sharjah Project
School of Dentistry
The University of Adelaide
Updated 2014
Contents
Introduction
Recommended Reading .............................................................................
History of Dentistry (Dr J McIntyre) .............................................................
Section I Dental Anthropology

Evolutionary Changes in Skull Form ..........................................................
Comparative Anatomy of the Masticatory System .....................................
13
Genetics and Crown Morphology ...............................................................
18
Genetics and Tooth Size ...........................................................................
22
Forensic Odontology (Dr KA Brown) ...........................................................
24
Bibliography ...............................................................................................
33
Section II Topics in Oral Anatomy

Functions of the Masticatory System I .......................................................
37
Surface Anatomy of the Oral Cavity ...........................................................
38
Structure of Oral and Dental Tissues .........................................................
48
Age Changes in Oral Tissues ....................................................................
59
Tooth Identification ....................................................................................
63
Identification of Permanent Teeth ...............................................................
64
Tooth Morphology ......................................................................................
73
Permanent Dentition ...........................................................................
74
Primary (Deciduous) Dentition ............................................................
118
Pulpal Anatomy ..........................................................................................
128
Timing and Sequence of Tooth Calcification .............................................
132
Tooth Eruption and Emergence .................................................................
138
Anatomy of the Skull ..................................................................................
142
Radiographic Anatomy ...............................................................................
146
Dental Diseases .........................................................................................
151
Preventive Dentistry ...................................................................................
159
Bibliography
165
.......................................................................................
Section III Occlusion

Morphology of the Dental Arches ...............................................................
169
Concepts of Occlusion ...............................................................................
172
Occlusal Curvatures and Axial Alignment ..................................................
174
Opposing Tooth Contacts in Intercuspal Position ......................................
179
Mandibular Movements and Positions .......................................................
185
Functions of the Masticatory System II ......................................................
191
Glossary
Introduction
This manual presents material related to oral anatomy which is mainly in the Dental Science and
Practice stream during the first and second year of the Bachelor of Dental Surgery.
The topics covered in these two years relate to the functional anatomy of the dentition and
associated structures, including the following:
evolutionary changes in skull form
comparative anatomy of the masticatory system
genetics of tooth size and morphology
oral surface features
the morphology of primary and permanent teeth
pulp cavities
timing and sequence of tooth calcification and emergence
radiographic anatomy
dental diseases
dental occlusion
Recommended Reading
The following books are recommended as sources of additional information to supplement the
information presented in this manual.
1
Nelson SJ (2010)
Wheelers dental anatomy, physiology and occlusion. 9th ed.
WB Saunders, Philadelphia.
BSL: 611.314 W56.9 (Main)
Ash GM and Nelson SJ (2003)

BSL: 611.314 W56.8 (Main)
Ash GM (1993)
BSL: 611.314 W56.7 (Joint)
Ash MM (1984)
Wheelers atlas of tooth form. 5th ed.
BSL: 611.314 W56a (Main)
Ash MM and Nelson SJ (2003)

Dental anatomy, physiology, and occlusion. 8th ed.
(BSL: 611.314 W56.8 (Main)
Introduction
1
Bath-Balogh M and Fehrenbah MJ (2006)

Illustrated dental embryology, histology and anatomy. 2nd ed.
WB Saunders, St Louis.
BSB: 611.314 B332i.2 (Reserve and main)
Bath-Balogh M and Fehrenbah MJ (1997)

Illustrated dental embryology, histology and anatomy.
BSB: 611.314 B332i (Reserve and main)
Berkovitz BKB, Holland GR and Moxham BJ (1992)

A color atlas and textbook of oral anatomy, histology and embryology.
Wolfe Medical Publications, London.
BSL: 611.314 B512c.2 (Main)
Berkovitz BB, Moxham BJ and Holland GR (2002).

Oral anatomy, embryology and histology. 3rd ed.
Mosby, Edinburgh.
BSL: 611.314 B512o.3 (Main)
10
Brand RW, Isselhard DE and Satin E (2003)

Anatomy of orofacial structures. 7th ed.
Mosby, St. Louis.
BSL: 611.31 B817a.7 (Main)
11
Brand RW and Isselhard DE (1998)

Anatomy of orofacial structures. 6th ed.
Mosby, St. Louis.
BSL: 611.31 B817a.6 (Main)
12
Carlsen O (1987)
Dental morphology
Munksgaard, Copenhagen.
BSL: 611.31 C284d (Main)
13
Dixon AD (1986)
Anatomy for students of dentistry. 5th ed.
Churchill Livingstone, Edinburgh.
BSL: 611.00246176 D619a (Main)
14
Harris NO, Garcia-Godoy F and Nathe CN (2009)

Primary preventive dentistry. 7th ed.
Pearson, Upper Saddle River, New Jersey.
BSL: 617.601 H315p.7 (Main)
15
Harris NO and Garcia-Godoy F (2004)

Primary preventive dentistry. 6th ed.
Appleton and Lange, Norwalk, Conn.
BSL: 617.601 H315p.6 (Main and Reserve)
Introduction
2
16
Harty FJ and Ogston R (1987)

Concise illustrated dental dictionary
Wright, Bristol.
BSL: 617.6003 H337c (Main)
17
Jordan RE and Abrams L (1991)

Kraus dental anatomy and occlusion.
Mosby Year Book, St. Louis.
BSL: 611.314 K91.2 (Main)
18
Kasle MJ (1989)
An atlas of dental radiographic anatomy. 3rd ed.
BSL: 617.607572 K193a.3 (Main)
19
Mitchell DA and Mitchell L (2005)

Oxford Handbook of Clinical Dentistry. 4th ed.
Oxford University Press, Oxford.
BSL: 617.6 M681o.4 (Main)
20
Mitchell L and Mitchell DA (1999)

Oxford Handbook of Clinical Dentistry
BSL: 617.6 M681o.3 (Main and Reserve)
21
Mount GJ and Hume WR (2005)

Preservation and restoration of tooth structure
Knowledge Books and Software, Brighton, Qld.
BSL: 617.6059 M928p.3 (Main and reserve)
22
Mount GJ and Hume WR (1998)

Preservation and restoration of tooth structure
Mosby, London.
BSL: 617.6059 M928p (Main)
23
Okeson JP (2003)
Management of temporomandibular disorders and occlusion. 5th ed.
Mosby, St Louis.
BSL: 617.643 041m.5 (Reserve and Main)
24
Osborn JW (1982)
A Companion to Dental Studies (Ed. Rowe, RHR and Johns, RB)
Vol 1 Book 2. Dental anatomy and embryology.
Blackwell Scientific Publications, Oxford.
BSL: 617.6 C737 (Main)
25
Posselt U (1968)
Physiology of occlusion and rehabilitation.
Blackwell Scientific, Oxford.
BSL: 617.623 P856.2 (Main)
Introduction
3
26
Ash MM and Ramfjord SP (1995)

Occlusion. 4th ed.
BSL: 617.643 R1720.4 (Main)
27
Scott, JH and Symons, NB (1982)

Introduction to dental anatomy. 9th ed.
Churchill Livingstone, Edinburgh.
BSL: 611.314 S42i.9 (Main)
28
Teaching Research: A Division of the Oregon State System of Higher Education (1982)
Dental anatomy: A self-instructional program. 9th ed.
Appleton-Century-Crofts, Norwalk
BSL: 611.314 O663d.9 (Main)
29
Thomson H (1990)
Occlusion. 2nd ed.
Wright, London.
BSL: 617.643 T482o.2 (Main and reserve)
30
Van Beek GC (1983)

Dental Morphology: an illustrated guide. 2nd ed.
Wright, Bristol.
BSL: 611.314 V218d (Main)
31
Woelfel JB and Scheid RC (1997)

Dental anatomy: its relevance to dentistry. 5th ed.
Williams and Wilkins, Baltimore.
BSL: 611.314 W842d (Reserve and Main)
32
Woelfel JB and Scheid RC (2002)

Dental anatomy: its relevance to dentistry. 6th ed.
Lippincott Williams and Wilkins, Philapdelphia.
BSL: 611.314 W842.6 (Reserve and Main)
Introduction
4
History of Dentistry
Although it is uncertain when dentistry was first practised, it is most likely that some form of
attention has been given to teeth since ancient times. There are references from as far back as
2700BC from both Egypt and China concerning remedies for toothache. Hippocrates, known as the
Father of Medicine, wrote about dental ailments, and also invented crude dental instruments
around 430BC.
Pierre Fauchard (1678-1761) has been referred to as the Founder of Modern Dentistry. The first
recorded full-time, self-trained dentists began to appear around the end of the 18th Century. During
the beginning of the 19th Century the first formal dental training courses commenced in Europe and
North America, but progress in the first hundred years was slow. However, by the beginning of the
present century, Victoria and NSW had only just established formal dental training courses. In
Adelaide, the Faculty of Dentistry came into being in 1921.
The early practice of dentistry was understandably very different from that of the present time.
Away from the cities, itinerant dentists would visit communities with portable barber chairs and set
these up as required, usually for the extraction of an aching tooth. Although dentists were first
involved in the use of general anaesthetics (Dr H Wells, 1844; Dr T Morton, 1846), local
anaesthesia did not come into common use until the beginning of the 20th Century, and then only
for the extraction of teeth.
With the relatively crude restorative and other equipment, a considerable amount of pain, and thus
fear, was associated with dentistry. It is only in the last few decades that this has begun to change.
The advent of better anaesthetics or analgesic solutions, the high speed drill for restorative
procedures, and a marked emphasis on the prevention of caries and periodontal disease before
teeth or gums become too damaged, have helped alleviate this situation.
For further reading concerning the history of dentistry, the following articles are available:
Levine S (1978) Australian dentists and dentistry around 1900. Australian Dental Journal 23(1):14.
Bremner MDK (1964) The Story of Dentistry. Henry Kimptons Medical House London. (Barr Smith
Lib. Ref. No. 617.609. B83.3)
Introduction
5
Introduction
6
Section I
Dental Anthropology
Evolutionary Changes in Skull Form

Classification of primates
Humans are members of the order Primates, which can be divided into two subgroups:
1.
the lower primates (prosimians)
2.
the higher primates (anthropoids).
The lower primates consist of 12 species, including lemurs, tree shrews and tarsiers. The higher
primates (Anthropoidea) include New World Monkeys (Ceboids), e.g. squirrel monkeys,
marmosets and tamarins of South America; Old World Monkeys (Cercopithecoids) which include
macaques and baboons; and Hominoidae (Anthropoid apes). The latter group consists of three
families of Pongidae, e.g. gorillas, chimps and orangutans; Hylobatidae (gibbons); and Hominidae
(humans) which includes the Australopithecus genus and Homo genus. The Homo family
includes various species, e.g. H. erectus (fossil), H. neanderthalensis (fossil), H. habilis (fossil)
and H. sapiens, which is the only living species remaining.
Trends in primate evolution

Early prosimians were arboreal, i.e. they lived in trees. They had prehensile digits, adapted to an
arboreal existence, assisting escape from ground predators. Tree life resulted in a number of
adaptations, such as opposability of the thumbs and big toes. The hind limbs became important
for balance and support. The forelimbs were used for exploring. There was a tendency to sit
upright and perch in trees when not moving. Hands were used for taking and putting food in the
mouth. Coupled with a freeing of the forelimbs as now these were used to gain access to food,
there was a corresponding reduction in the size of the snout as this was no longer the major site
of first contact with the environment as was the case when walking on all fours. There was a
reduced need for fine olfaction and there was a tendency for more acute vision, with the eyes
positioned more anteriorly for stereoscopic vision.
Evolution of higher primates

Monkeys became adapted for life in trees such that they developed brachiating (swinging through
trees) habits, prehensile tails and the eyes became located in a more anterior position for
stereoscopic vision which enabled judging of distances/depth.
Hominoid adaptations followed and are seen in all hominoids, i.e. Pongids, Hylobatids and
Hominids, but the changes are more advanced in humans. The probable initial changes involved
attainment of an upright posture and bipedal gait (3-4 x 106 years ago) which was accompanied
by many changes to both the bones of the trunk and lower limbs as well as the head and neck
region. Changes in the vertebrae involved alterations in the shape of the vertebrae and vertebral
column with the development of an 'S' shaped curve and loss of tails. Changes in the pelvic girdle
were required to transmit the weight of the entire body to the legs as well as assist in supporting
the weight of the thoracic and abdominal viscera, such that the pelvic girdle developed with time
into a bowl shape, with extensions of bone (sacrum) and ligaments across the birth canal.
Alterations in the head position and balance and/or musculature were needed to allow for the
head to be held in a horizontal position. In Pongids this is evident in the extensive musculature
and attachments on the posterior aspect of the skull, associated with large prominences (nuchal
crest), while in Hominids there was a change in the balance of the head with the foramen
magnum in a more inferior position, such that the head became more centred on the vertebrae.
9
This change in balance of the head is evident in the Hominid fossil record. By comparison with
other mammals, primates' eyes faced forwards and were closer together, which was
accompanied by a reduction in the simultaneous field of vision; however, this forward movement
of the eyes enabled the development of specialised vision, i.e. stereoscopic vision. In humans,
the loss of simultaneous field of vision was offset by the development of the ability of the head to
rotate, mirrored by the development of large sternocleidomastoid muscles which in turn lead to an
increased size of the mastoid process. The altered position of the eyes was accompanied by a
change in the orbital walls, with the formation of a more complete bony eye socket by the
development of a post orbital bar which lead to separation of the orbital cavity from the
infratemporal fossa.
Concomitant with the further reduction in snout and removal of the head from the site of first
contact with the environment (food and enemies), there was also a reduction in size of jaws and
teeth (used for eating and fighting in lower primates, only used for eating in higher primates, e.g.
canines decreased in size as they were no longer needed for killing). The forelimbs became the
major implement for exploring, under the control of the brain and eyes. This development
probably closely paralleled the expansion of the brain, in particular the cerebrum, because of this
greater opportunity of exploration offered by the hands and improved vision. The brain assumed
a globular shape and the face came to lie below the expanding forebrain. Approximately 2 x 106
years ago a developing social and cultural pattern was evident, with grouping of individuals into
families and the development of tools respectively.
Main trends in evolution of skull form

Many of these changes occurred concurrently due to various pressures that developed with the
attainment of an upright posture. As already noted, there was enlargement of the brain which was
more globular, recession of the snout such that the face was positioned below the forehead. The
eyes were rotated forward with an orbital ring of bone enclosing the orbit. The foramen magnum
became located inferiorly, associated with alteration in balance of the head. There was a
reduction in muscularity. (Apes have massive trapezius muscles with extensive nuchal crests to
hold the head as they are semi-erect.) The brow ridges, sagittal crest, temporal lines and occipital
protuberances all decreased in size, although in humans today there is some sexual dimorphism
in these characteristics.
Alterations associated with the dentition and supporting bones included changes in the shape of
the arch, from U-shape (e.g. Pongids) to a more parabolic shape which was associated with
decrease in the size of the snout. Other changes associated with the loss of the snout involved a
reduction in size of the alveolar arches with less alveolar prognathism and overall reduction in jaw
size. This resulted in the tendency of the brain and eyes being positioned over the teeth, i.e.
orthognathism.
In addition, there has been a reduction in tooth number (mammals - 44 teeth, Prosimians and
New World Monkeys (> 25 x 106 years ago) - 36 teeth, Old World monkeys and Anthropoids apes
(< 25 x 106 years ago) - 32 teeth) and size with a reduction in importance of teeth for survival, i.e.
with respect to killing food and fighting. For example, canines became less important for fighting
and canine size reduced markedly (compare canines of pongids and hominids).
One of the more recent changes (approximately 75,000 years ago) associated with the reduction
in size of the bones of the jaws, was the development of a chin. It is probable that rather than the
development of a bony protuberance as a chin, the marked reduction in alveolar prognathism
over time resulted in greater prominence of the anterior portion of the mandible. Development of
the chin also may have been associated with the proposed evolution of speech, such that with a
decrease in the simian shelf enabling increased movement of the tongue, increased strength for
the mandible anteriorly was provided by a chin.

10
Trends in dentition of primates

The general mammalian formula is:
3 1 4 3
I3 C1 P4 M3 = 44
Prosimians incisors tend to be elongated and procumbent. By comparison with the general
mammalian formula, they lose the third incisor and fourth premolar, so their dental formula is:
2 1 3 3
I2 C1 P3 M3 = 36
New World Monkeys do not have such long snouts as prosimians. They have spatulate incisors,
big canines and a diastema between the incisors and canines. Their dental formula is the same
as prosimians.
Old World Monkeys have only two premolars in each quadrant. The molar teeth are more
specialised with an increase in size of the molar teeth from M1 to M3. The lower third molar has 5
cusps, but molars generally have 4 cusps connected by transverse ridges. They have a
specialised lower first premolar (sectorial, i.e. blade-like tooth) with two roots and a posteriorly
tilted crown, leaving space for the upper canine when the teeth are in occlusion. This sectorial
tooth is probably of major importance in the maintenance of a knife - like posterior edge of the
upper canine. Their dental formula is:
2 1 2 3
I2 C1 P2 M3 = 32
Anthropoid apes have the same dental formula as humans. They have a massive mandible with
immense alveolar processes and no chin. The mandible has a shallow sigmoid notch and a
simian shelf instead of genial tubercles. The dental arches are U-shaped and the permanent
teeth are larger than human teeth. The incisors develop an edge-to-edge bite and canines are big
and display sexual dimorphism, such that the canines in the male are particularly large. There is a
diastema between upper lateral incisor and canine. The upper premolars have three roots while
lower premolars have two roots. The cusps of molars and premolars are more pointed than
humans and the lower first premolar is a specialised canine-like tooth (i.e. is single cusped). All
cheek teeth have short crowns relative to the total height of the teeth (brachydont). Upper molars
have four cusps, while lower molars all have five cusps.
Hominid evolution
It seems that Hominidae (the human being phylogenetic line) became separated from the
anthropoid apes at about the beginning of the Miocene period (approximately 14 x 106).
Ramapithecus may be representative of human beings' earliest ancestor. Ramapithecus is
considered to have evolved approximately 14 x 106 years ago and existed to around 9 x 106
years ago. The fossil was found in India. Characteristics of the dentition included a parabolic
dental arch (i.e. not U-shaped), anterior teeth were small compared with molars, the palate was
arched and the morphology of teeth was more like human teeth than ape teeth.

11
Australopithecus is believed to have existed approximately 5-1 x 106 years ago. A number of
species have been identified (A. afarensis, A. africanus, A. robustus, A. bosei). Australopithecines
almost certainly walked upright but were still ape-like in some respects. They had heavy brow
ridges, a relatively small brain (450-650cc), the occipital condyles more anteriorly placed than
those of apes, but were not as anterior as those of modern humans, and they possessed a small
but typically human mastoid process. They had a massive mandible but no chin, a parabolic
dental arch rather than a U-shaped one, the teeth were large and human like but there was an
increase in size from M1 to M3.
The various species of the Homo genus, including H. habilis, H. erectus, H. neanderthalensis and
H. sapiens, probably diverged from the Australopithecines approximately 2-5 x 106 years ago. H.
habilis existed alongside A. afarensis in Africa approximately 2 x 106 years ago. H. habilis had a
larger brain capacity (680cc compared with 440cc) and possessed large but human-like teeth. H.
erectus existed during the period of approximately 1.5 - 0.5 x 106 years ago. The first fossil of H.
erectus was found in Java and others have been found, e.g. a fossil found in China known as
Peking man. More human traits were present in H. erectus, e.g. they walked completely upright,
the head was better balanced on the vertebral column, the foramen magnum was more forward
and mastoid processes were prominent. The mandible was rugged, there was no chin and the
teeth were like those of H. sapiens. There also was evidence of a rudimentary culture as various
artefacts have been found.
H. neanderthalensis is believed to have evolved approximately 75,000 years ago. H.
neanderthalensis demonstrates a large variation in the degree of various characteristics, e.g.
there is a range from heavy brow ridges, flat nose, flaring zygomatic arches to more human-like
(H. sapiens) forms.
Modern humans (H. sapiens) can be dated to approximately 30,000 to 40,000 years ago, with
more archaic forms being identified to have existed more than 100, 000 years ago (e.g. H.
neanderthalensis).
Major changes between H. sapiens and H. erectus were:
a further increase in cranial capacity (1300c compared with 850-1050cc)
a reduction in the size of the jaws and teeth
an increase in height and reduction in antero-posterior length of the skull.
Today there are minor variations in the teeth and skull morphology evident between modern
ethnic groups (refer to section on Genetics and Crown Morphology).

12
Comparative Anatomy of the Masticatory System

Classification of vertebrates
Vertebrates possess a vertebral column. Fish (three classes), amphibians, reptiles, birds and
mammals belong to the subphylum Vertebrata. Mammals can be divided into primitive and
modern forms. Modern mammals include:
monotremes (subclass Protheria), i.e. egg-laying mammals that are only found in
Australia, such as the spiny ant eater (echidna) and platypus
marsupials (subclass Metatheria), i.e. opossum (found in South America) and Australian
marsupials such as the kangaroo, wombat, koala and Tasmanian tiger (Thylacine wolf)
placental mammals (subclass Eutheria), e.g.
o
primates - shrews, lemurs, monkeys, apes and humans (refer to Evolutionary

changes in skull form)
carnivores - cats, dogs, bears, seals and sea lions
rodents - rats, mice, squirrels and guinea pigs
ungulates - horses (odd-toed) and pigs, sheep and cows (even-toed)
cetacean - whales, porpoises, dolphins.
General characteristics of vertebrate dentitions

Most fish have teeth, although some have horny keratinised epidermal structures (lamprey) rather
than true calcified teeth and some are toothless (sturgeon). The method of attachment of teeth
varies from a fibrous attachment in elasmobranchs (sharks and rays) to either a fibrous or
ankylosed junction in bony fish. Teeth are usually small and conical (i.e. haplodont - simple cusp
shaped), although some bony fish have different shaped teeth (i.e. heterodont as opposed to
homodont when all teeth are the same shape). Generally, teeth are continually replaced with
successional teeth, i.e. the dentition is polyphyodont (fish have many sets of teeth); however,
some fish have a limited number of replacement dentitions. The major function of teeth in fish is
to seize or grasp prey.
Amphibians have conical (i.e. haplodont) teeth, which are all the same (i.e. homodont) and are
ankylosed and continually replaced (i.e. polyphyodont). Some amphibians do not possess teeth,
e.g. toads.
Reptiles typically have a row of only conical or only tricuspid teeth which are similar in shape
(homodont) but may vary in size, are ankylosed, simple rooted and are continually replaced.
Some reptiles have a more complex dentition, e.g. the crocodile and alligator have a periodontal
membrane, i.e. the teeth are not fused to bone but are in sockets and are attached to bone by
fibres, while in some snakes certain teeth are modified to form poison fangs that contain a canal
or groove for venom, similar to a hypodermic needle. It is probable that the primitive mammalian
dentition was derived from reptilian dentition.
No living birds have teeth, although, fossils show that they may have had teeth in former times.
Primitive mammals existed as early as 150 x 106 years ago. Different classes of teeth were
evident, namely incisors, canines and premolars which were all of a simple pattern while the
upper molars consisted of a triangular shaped trigon with a buccal amphicone (base of triangle)
and lingual protocone. The lower molars consisted of a triangular shaped trigonid (the ending 'id'
is used for terms describing lower molars), with a buccal protoconid and two lingual cusps
(mesiolingual = paraconid; distolingual = metaconid). The lower molar also possessed a talonid
13
which was attached to the distal of the triangular trigonid. It is believed that the modern
mammalian dentition evolved from this primitive form. The Cope-Osborne tritubercular theory
suggests that molars evolved as follows:
Upper molars
Amphicone developed two cusps, referred to as the paracone (mesial) and metacone (distal).
Together these formed a triangle (trigon), with the protocone (palatal). A talon (heel) with one
cusp, called the hypocone, developed on the distal of the trigon, resulting in a four-cusped upper
molar. It is this portion of the tooth that shows the greatest variability.
Lower molars
A trigonid similar to the trigon of the upper molars developed, with a buccal protoconid,
mesiolingual paraconid and distolingual metaconid. A talonid with three cusps, called the
hypoconid (buccal), hypoconulid (distal) and entoconid (lingual), developed on the distal of the
trigonid. This resulted in a six cusped lower molar tooth. During evolution this six-cusped form
evolved to a five-cusped form by loss of the paraconid from the mesiolingual, such that the
metaconid became the mesiolingual cusp. In human lower second molars, the hypoconulid (distal
cusp) is missing, resulting in a four-cusped tooth.
The complexity of the dentition in modern mammals is partly due to the fact that they have
developed the function of chewing food to a high degree. This has resulted from the requirement
to thoroughly process food because they rely on the energy produced by their bodies from
ingested food to maintain the high rate of metabolism needed to keep warm, i.e. they are
homothermic. This enables them to survive in a range of climates, which is in contrast to reptiles
that obtain heat from the environment (e.g. the sun) and become inactive when the temperature
drops. Small mammals have relatively larger surface areas compared with their volume of muscle
by comparison with larger mammals; therefore they take in relatively larger quantities of food.
In contrast to other vertebrates, mammals have flexible (muscular) lips and cheeks which are
important in the picking up of food and the positioning of food in the mouth optimal for chewing.
The development of the soft palate allows separation of the mouth and nasal cavities to enable
breathing while chewing. In reptiles, these two passages cannot be totally separated,
necessitating minimal holding and manipulation of food in the reptilian mouth. Strong muscles of
mastication and temporomandibular joints developed from the previous hinge joint, enabling
greater movement of the lower jaw and greater bite force.
The eutherian dentition is typically heterodont, i.e. teeth vary in form in different parts of the
mouth.
The typical mammalian dentition is:
3 1 4 3
I3 C1 P4 M3
However, there is considerable variation. Teeth have roots attached by a periodontal ligament to
the bony socket. Usually, there are only two sets of dentitions (diphyodont as opposed to
polyphyodont), such that successional teeth or permanent teeth replace deciduous teeth. There
are also accessional teeth, e.g. molars that emerge posterior to the deciduous dentition. The
teeth usually consist of enamel, dentine and cement and the cheek teeth are normally
multirooted. Teeth are specialised for function, e.g. fighting and defence (e.g. large canines) and
mastication such that teeth interdigitate and occlude. Associated with this latter function are
complex crown patterns of molars.

14
Specific examples of dentition of modern mammals

Marsupials show a range of dentition which may resemble carnivores, rodents and ungulates.
The adult kangaroo dental formula is:
3 0 1 5
I1 C0 P1 M5
In young kangaroos the cheek teeth series consists of six teeth on each side, the second is a
deciduous molar. This tooth and the one in front of it are replaced by a more distal molar,
reducing the cheek series to five molars. In older kangaroos, the cheek teeth continue to be shed
from the front and the molars move forward. Sometimes there is only one molar left on each side.
This process of replacement of teeth from behind is called horizontal succession.
Horizontal succession enables maximum stress to fall on those teeth below the zygomatic arch,
so that as teeth wear, they move forward. The lower incisors project forward in line with the body
of the mandible (procumbent). These teeth have pointed tips with sharp mesial and distal edges.
The cheek teeth have transverse ridges and are well-adapted for an herbivorous diet. The medial
pterygoid muscles are well-developed and attach to a deep hollowed-out fossa on the inner angle
of the mandible.
In the Eutherian subclass, the elephant also displays horizontal succession in that generally only
one molar in a quadrant is in function at any time. There is a limited number (3) of replacement
molars, such that the elephants life span is restricted by this, each molar lasting approximately 20
years of function. The dentition of pigs also shows mesial migration and this feature is present in
humans to a limited degree.
Dentitions of some members of the Eutherian subclass

Primates have many features of the dentition in common, e.g. incisors are spatulate, canines are
well-formed and the dentitions are diphyodont. The glenoid fossae and eminences generally are
poorly developed except in apes and humans.
Carnivores have a wide range of dentitions ranging from flesh-eaters (cats) through more
omnivorous, i.e. plant and animal eaters (dogs) to fish-eaters (seals and sea-lions). A
characteristic feature of flesh-eaters in particular is specialisation of one cheek tooth in each
quadrant, called carnassial teeth. These teeth consist of a blade-like upper that slices against the
buccal of the opposing lower tooth to produce a scissor-like action. These animals also tend to
have large canines. The upper lip is divided to provide mobility and possesses special sensory
hairs called vibrissae. The temporomandibular joints are purely hinge joints, i.e. only opening and
closing movements are possible.
The dental formula for the dog is:
3 1 4 2
I3 C1 P4 M3
The incisors have a high central cusp with mesial and distal lobes adapted for holding and
tearing, the canines are long and strong, while the upper fourth premolar and lower first molars
are adapted as carnassial teeth.

15
The dental formula for the cat is:
3 1 3 1
I3 C1 P2 M1
The incisors are similar to the dog but the canines are longer and stronger and the premolars and
molars are reduced in number.
Rodents have a fairly constant type of dentition. They have chisel-shaped, continually erupting
incisor teeth with a diastema between anterior and posterior teeth. There are no canines. The
muscles of mastication are complex, especially the masseter muscles which as well as closing
the jaws, work with the pterygoids and the temporalis to move the jaw back and forward. The
palatal rugae are well-developed and the upper lip is divided.
The dental formula of the rat is:
1 0 0 3
I1 C0 P0 M3
They only have one dentition, although the incisor teeth continually erupt. The labial surface of
the incisors in covered with enamel, which is pigmented due to incorporation of an iron derivative
(yellow/orange), while the lingual surface is covered with cementum.
The dental formula for the hamster is:
1 0 0 3
I1 C0 P0 M3
Hamsters have large buccal pouches that extend along the side of head and neck and open into
the oral cavity in the region of the diastema. The pouches are used for storing food.
Ungulates (hoofed animals) consist of two orders: the perissodactyls (odd-toed ungulates)
including horses and rhinoceros, and the artiodactyls (even-toed ungulates) including sheep,
cattle, pigs, hippopotamus, oxen and deer.
The dental formula of the sheep is:
0 0 3 3
I3 C1 P3 M3
The upper incisors and canines are absent while the lower incisors and canines are shovelshaped with sharp incisive edges. The lower incisors bite against a dense pad of mucous
membrane in the upper jaw. Behind the lower anteriors there is a diastema separating the
anterior teeth from the cheek teeth. The cheek teeth are termed selenodont since the unworn
cusps are crescent-shaped.
The teeth also have high crowns which are described as hypsodont. The teeth are well-adapted
for a vegetable diet because grass has a high silica content and is very destructive of tooth
substance.
The dental formula for the horse is:
3 1 4 3
I3 C1 P4 M3
16
The crowns of the incisors are columnar and covered by a thin layer of cement. When they first
emerge they show a central pit surrounded by an elevated rim, but with wear the enamel of the
rim is worn, leaving a central pit, then a circle of dentine, then enamel. The incisors develop an
edge-to-edge bite for efficient chewing. In the female horse, the canines are rudimentary or may
be absent, but they are small teeth in males. The premolars and molars are all similar in form.
The cheek teeth are hypsodont, i.e. cusps that are greatly elongated. The areas between the
cusps are filled in with cement. As the tooth wears, the various dental hard tissues, which wear at
different rates, are exposed. The glenoid fossae are flattened with no articular eminence. The
capsule of the joint is strong but somewhat lax, which allows a wide range of movements such
that extensive side-to-side movements are possible.
Cetaceans include whales, dolphins and porpoises. These are mammals that have returned to life
in the sea. The dentitions have undergone a specialised reversion towards a simpler dentition,
which is usually conical and homodont. The teeth may be lost altogether. In those members with
no teeth, a series of baleen plates suspended from the upper jaw develop. These act as sieves
for catching vegetable matter and plankton. Baleen (whalebone) represents exaggerated rugae,
i.e. derived from the epithelium of the hard palate.

17
Genetics and Crown Morphology

When discussing the crown morphology of teeth, consideration should be given to their size and
shape and the number of cusps, grooves, ridges etc. There are certain basic features of each
tooth which indicate that it belongs to a certain class, but there is also tremendous variability
between teeth of the same class. Some of these differences are difficult to define, but many
others can be quantified either by measurement (metric characters, e.g. mesiodistal diameter,
buccolingual diameter) and scoring (non-metric characters, i.e. the presence/absence or degree
of expression of a trait).
For metric characters, we can consider normal and abnormal variation in terms of variation about
mean values, i.e. 95% of values for normally distributed characters will fall within two standard
deviations of the mean. For non-metric characters, the concept of normality and abnormality can
be related to how frequently a character is observed. Characters which only occur in a very small
percentage of individuals may be thought of as abnormal. The crown morphology of teeth,
whether quantified in metric or non-metric terms, seems to have a reasonably strong genetic
basis. It is most likely that a polygenic system is involved in the inheritance of crown morphology.
Studies of crown morphology are useful in many fields, including:
anthropology and genetics, where differences within and between populations are
examined
forensic areas
to determine the nature and timing of developmental disturbances,
and are relevant to clinical dentistry, e.g. assessment of the likelihood of caries. (Various
morphological crown characters are discussed in more detail later in the following pages.)
Shovel shape trait

This trait occurs on incisors and canines. It is characterised by prominent marginal ridges and a
concave lingual surface, resulting in a shovel-like appearance of the teeth. It is prevalent in
Mongoloid ethnic groups; however, the degree of shovelling varies within populations. Shovelling
tends to be more marked on upper teeth than lower teeth and is more often evident in the
permanent dentition by comparison with the deciduous dentition. This trait has been noted in both
recent and early humans. Males tend to show more pronounced degrees of shovelling. Ridging
also may be found on the labial, producing a double shovelling appearance.

18
Lingual tubercles
These tubercules occur on the lingual surface of canines and incisors. They may be single,
double or multiple protuberances arising from the cingulum and they may be long pointed
projections (more common on permanent teeth) or more rounded. Occasionally, on lower canines
the lingual surface may have a double fold produced by an accessory ridge on the lingual and
separated from the distal marginal ridge by a groove.
Carabelli trait
This trait occurs on the lingual surface of the mesiolingual cusp of the upper first permanent
molar and upper second deciduous molar. It is rarely found on other molars. The expression of
the trait ranges from a pit, through a groove or double groove to a slight protuberance, small cusp
or large cusp. There is a fairly high incidence of this trait in Caucasians (up to 90%) with a lower
incidence in Mongoloid races. It is usually expressed bilaterally and appears to have a polygenic
mode of inheritance.

19
Occlusal groove pattern

Different groove patterns may be found on lower first permanent molars and lower second
deciduous molars. Generally, five cusps can be identified but the groove pattern may vary from a
Y to a + or X pattern. The Y form is sometimes called the Dryopithecus pattern because it is
characteristic of early hominoid forms.
Protostylid
The protostylid is found on the buccal surface of the mesiobuccal cusp of lower first permanent
molar and lower second deciduous molar. It is rarely found on other molars. The trait may vary in
expression from a groove to cusp. It is common in Mongoloid ethnic groups. The term paramolar
cusp has been used to refer to all anomalous cusps on the buccal surface of both upper and
lower molars, with the protostylids representing a subgroup of this general classification.

20
Accessory cusps
The lower first permanent molar and lower second deciduous molar may show extra cusps. The
sixth accessory cusp, C6, may be found on the distal aspect of the crown of these teeth between
the distal cusp and the distolingual cusp. The seventh accessory cusp, C7, occurs between the
two lingual cusps of these teeth.
The frequencies of the above characters vary between ethnic groups; therefore, they may be
useful in forensic and anthropologic studies. The shovel shape has a high frequency in
Mongoloids but a low frequency in Negroid and Caucasoid groups. The Carabelli trait has a low
frequency in Mongoloid and Negroid groups but a high frequency in Caucasoids. The protostylids
are similar in frequency to the shovel shape trait of anterior teeth, i.e a high frequency in
Mongoloids but low frequency in Negroid and Caucasoid groups.
Other characters that also may be useful include:
missing 8s which have a high frequency in Mongoloids and a very low frequency in
Negroids and Caucasoids respectively
supernumerary teeth are low in frequency in Mongoloid and Caucasoids but high in
frequency in Negroids
abnormal crown morphology that is evident in various disorders such as:
-
ectodermal dysplasia, which is an X linked recessive disorder in which missing teeth

and cone-shaped teeth are common
Down syndrome (trisomy 21) which is characterised by small teeth, a high frequency
of crown abnormalities and missing teeth
mental retardation, which may be associated with abnormal crown morphology.

21
Genetics and Tooth Size

Odontometry
Odontometry is the term given to the measurement of teeth. It is of importance in many areas,
such as clinical dentistry, human evolution, comparative and forensic odontology and genetic
studies. Tooth measurements may be obtained either directly in the clinical situation, which is
satisfactory for anterior teeth but difficult for posterior teeth, or indirectly using either radiographs
or dental casts.
In clinical dentistry (e.g. orthodontics) measurements of tooth size are often made to predict
whether there may be crowding in the arches. A mixed dentition analysis may be performed. The
combined mesiodistal diameters of the lower canine, first and second deciduous molars are about
1.7mm greater than combined diameters of lower permanent canine and premolars.
Similarly, the mesiodistal diameters of the upper deciduous canine and molars exceed the
permanent successor teeth by about 0.9mm. These differences in space occupied by the
deciduous and permanent teeth are called leeway space. In endodontics, the lengths of teeth
must be accurately estimated to enable satisfactory completion of a root canal filling.
In human evolution there has been a general reduction in tooth size over the last 100,000 years.
Professor Loring Brace has proposed that reduction in tooth size has followed the introduction of
a knife and fork culture, with less demands being placed on the dentition. It is likely that
reductions in tooth size are secondary to an overall decrease in facial morphology.
In comparative odontology, comparisons of tooth size differences between modern populations
have been applied in micro-evolutionary studies, while in forensic odontology tooth size variation
may be useful in sex determination.
Genetics
In studies of the genetic basis of various morphological features, teeth have a number of
advantages. For example, their final size is determined early in life (most crowns are complete by
about 7 years of age, refer to Timing and sequence of tooth calcification), they are virtually
indestructible, and they can be studied from dental casts. Comparisons can be made between
tooth groups, arches, sides etc. Tooth size is a metric character, and shows a continuous range
of variability that is normally distributed. The mesiodistal and buccolingual dimensions are
commonly used.
Twin and family studies suggest a polygenic mode of inheritance for tooth size. Heritability
estimates of about 60% have been determined, i.e. 60% of the total phenotypic variability in tooth
size is due to genetic differences between individuals in a population. There is some evidence
that the sex chromosomes may influence tooth size, e.g. XYY males have larger teeth than
normal.
Whilst genetic factors are important, environmental influences also play a role. This has been
demonstrated in animal studies where fluoride incorporated during tooth formation tends to
decrease tooth size and also affects tooth morphology: namely, fissure depth and cusp height are
reduced. Decreased vitamin A and increased phosphate intake also have been associated with
reduced tooth size. Human studies also indicate that environmental influences are important, e.g.
low birth weight is associated with smaller teeth, as is maternal hypertension.
Maternal hypothyroidism and diabetes have been associated with large tooth size in offspring.
There is also evidence for an interaction between developing tooth germs influencing tooth size.

22
Variability
Dahlberg has modified the concepts of Butler, resulting in the concept of a morphogenetic field
for the dentition, i.e. each tooth class is thought to represent a distinct morphogenetic field under
genetic control. Within each field the key tooth is under the strongest genetic control and tends to
be most stable with respect to size, shape, timing of emergence and presence or absence. The
key tooth is the most mesial tooth in each class, except for the lower incisors where the lateral
incisor is the key tooth. The more distal teeth frequently show greater variability.
There is no evidence of directional asymmetry in the dentition, i.e. teeth on one side are not
consistently larger than those on the other. There are, however, random, non-directional
differences in tooth size between sides, termed fluctuating asymmetry. Experimental evidence
indicates that the degree of fluctuating asymmetry is related to stress.
Other factors that influence variability are sex and ethnicity. On average, males tend to have
larger teeth than females. This is referred to as sexual dimorphism, the lower canines showing
the greatest sexual dimorphism. There also are differences in tooth size between different ethnic
groups, e.g. Australian Aborigines have large teeth.

23
Forensic Odontology
Forensic Odontology may be defined as the application of dental science to the administration of
the law and the furtherance of justice. It is the branch of dentistry that deals with the correct
professional handling, examination, interpretation, and presentation of dental and oral evidence
which may come before the legal authorities.
There are five areas in which forensic odontology has particular application.
1.
Identification of living and deceased persons
2.
Assessment of age
3.
Bite-mark identification
4.
Lip-print comparison
5.
Assessment of dental injuries
In the performance of these functions, the forensic odontologist works in close cooperation with
other members of the investigation team, including police officers, pathologists and technicians.
Evidence revealed by the teeth and mouth

Information that may provide important evidence can often be obtained by the careful
examination of the dental and oral structures and may indicate or assist in establishing the
following:
1.
Race
2.
Sex
3.
Age
4.
Occupation
5.
Dental treatment
6.
Oral hygiene habits
7.
Certain systemic diseases
8.
Certain forms of treatment of systemic disease
9.
Smoking habits
10. Behaviour habits

11. Diet

24
Age assessment
Chronological age assessment may be an important factor in establishing the identity of a living
or deceased person. It may also be a critical factor in certain legal proceedings when a specific
charge for a particular offence may depend on whether the alleged offender is a juvenile, as, for
example, in cases involving refugees or illegal immigrants. The procedures for age determination
are complex and involve the consideration of many factors which include:
eruption and emergence times of teeth
resorption of roots
attrition
oral pathology
root transparency.
The accuracy of age assessment decreases after eruption of the permanent dentition has been
completed.
Identification of dead bodies

The legal events consequent upon death are complex and have far-reaching implications. These
include:
the settlement of estates and the relief of dependants and relatives
the succession of property
payment of pensions
settlement of life assurance claims
remarriage of surviving spouse.
There are also humanitarian factors such as the performance of religious rites in association with
the disposal of the remains and the emotional reactions of surviving relations. These events
cannot proceed legally until a burial or cremation order is made by the Coroner and a Certificate
of
Registration of Death has been issued by the Registrar of Births, Deaths and Marriages. A delay
in the issue of these documents, therefore, can cause considerable hardship and distress for
relatives and dependants. Correct personal identification is thus of considerable community
importance.
Methods of identification
Personal identification may be carried out by traditional or scientific methods, as follows:
Traditional
1.
Visual recognition by a person to whom the deceased is known well.
2.
Personal property comprising identifiable items found on or about the deceased.

25
Scientific
1. Fingerprints
2.
Medical evidence
3.
Dental evidence
Limitations of identification methods

Any of the above methods may be limited by the circumstances surrounding the death. Post
mortem changes to features, as the result of severe mutilation and fragmentation of the face and
head, fire damage or decomposition, may alter or destroy the facial features. Personal property is
readily transferable and is unreliable. Fingerprints are limited by the availability of a fingerprint
record, and by the survival of the skin of the fingers.
Medical identification
Medical evidence includes information about race, sex, blood group, height, weight, certain
systemic diseases, radiographs and surgical operations.
Dental identification
Dental identification depends on the following factors.
1.
A comparison of the dental status of the deceased with dental treatment records of a
person when identity is known.
2.
The unique morphological characteristics of human teeth and dental restorations.
3.
The resistance of teeth to environmental changes.
4.
The availability of routine dental treatment records.
5.
Denture identification: identification marks on dentures.
Dental records
The dental records that may prove useful for identification include the following:
1.
Charts and treatment records
2.
Radiographs
3.
Plaster casts of impressions
4.
Wax bite records
5.
Photographs
Procedures uses in dental identification

1. Proper collection and preservation of post mortem material and other evidence at the
scene.
2.
Laboratory examinations of post mortem material, including photography, radiography

and post mortem impressions.
26
3.
Reconstruction of oral tissues.
4.
Collection and interpretation of ante-mortem data (dental records).
5.
Comparison of post-mortem and ante-mortem material.
6.
Photographic cranio-facial superimposition (if necessary).
7.
Correct preparation of reports for Coroner and/or Counsel.
8.
Presentation of evidence in court.
Disaster victim identification

National disasters include earthquakes, tornadoes, hurricanes, cyclones, floods and fires (forest
and bush fires). Artificial disasters include transportation accidents (road, rail, sea and aircraft),
explosions and fires in buildings. The potential for loss of life is very great and the existing
resources for handling all the consequences are severely taxed. Classification of a minor or major
disaster depends upon the number of victims (including deceased, injured survivors and missing).
There are six distinct steps to be carried out in dealing with the victims' remains in a mass
disaster:
1.
Recovery of the bodies from the site.
2.
Identification.
3.
Documentation.
4.
Repatriation.
5.
Disposal of the remains according to the wishes of the relatives and local authorities.
6.
Recovery and disposal of victim's property.
Each step must be completed with scrupulous concern for detail, and carried out by the most
experienced and competent experts available.
The identification team

The identification team includes police officers, forensic pathologists, forensic odontologists and
forensic photographers. Mutual trust among the team members is essential. It is important that a
forensic odontologist is included in the field team.
Organisation of the identification team

There should be two expert teams to work in liaison:
1.
a field team (for recovery)
2.
a team to collect, evaluate and transcribe the incoming data or dental records.
Standardisation of odontograms
The standard notation system is the two digit FDI system.

27
Comparison of PM and AM data

Depending on the number of victims to be identified, the comparison of the post-mortem and
ante-mortem data may be made by personal visual comparison of the two odontograms, either by
superimposing odontograms on transparencies or by computer programs.
Aircraft accidents
Aircraft accidents present special problems. In these situations the identification of victims, in
particular the air crew, and also the cause of their deaths, are vital to the investigation of the
accident and the prevention of further similar accidents.
Questions to be answered include:
1.
How many bodies are there?
2.
Who are they?
3.
What is their relationship to the accident?
The forensic dentist's role in aircraft accidents

1. Assisting in the recovery of deceased victims and significant identification material.
2.
Charting the dentitions.
3.
Examination of the oro-facial tissues.
4.
Description of head injuries.
5.
Interpretation of observations.
6.
Making identifications.
Reasons for not identifying victims

1.
Bodies not recovered due to:

(a)
fire
(b)
disintegration
(c)
lost at sea.
2.
Local difficulties, e.g. terrain, unsuitable facilities, limitation of time under pressure from
authorities.
3.
Lack of information, e.g. lack of availability of ante-mortem records.
The two golden rules

1.
Use all available means of identification.
2.
Do not release any of the bodies for burial until all the bodies have been identified as far
as is humanly possible.

28
Bite-marks
The investigation of bite-marks, which may be produced in both sexual and non-sexual assaults,
homicide, and also in non-biological materials and objects left at crime scenes, requires the
employment of specialised techniques of photography, impression taking and electric microscopy.
In all these procedures the proper collection and handling of the material to ensure the security of
the chain of evidence to comply with legal requirements for its acceptability as evidence in a court
of law, must be understood and observed. Great care must be exercised in the interpretation of
the evidence.
Classification of bite-marks of possible forensic significance

Non-human (animals).
Human:
In foodstuffs (e.g. in part-eaten foodstuffs abandoned by offenders at scene of crime).
On non-biological objects (e.g. pencils, pipe-stems, detonators etc).
In human skin:
Non-criminal (love-bites).
Criminal (malicious assaults, rape, etc).
These may be:
offensive (upon victim by assailant), or
defensive (upon assailant by victim).
Bite-mark sites
Bite-marks may be inflicted on almost any area of human skin. Some sites, however, seem more
vulnerable than others. Table 1 shows the frequency of occurrence of bite marks in specific areas
in a selection of 74 cases reported in Great Britain.
Table 1
Sites of 74 bite-marks in cases reported in Great Britain

Site
Number
Face and/or head
12
16.0
Ear
1.4
Nose
1.4
Neck
1.4
Shoulder
8.1
Breast
23
31.0
Arm
6.8

29
Hand and/or finger
6.8
Abdomen
10
13.5
Buttocks
4.1
Female genitals
2.8
Male genitals
1.4
Leg
1.4
Food
4.1
Appearance of bite-marks in foodstuff and skin

The appearance of bite-marks in foodstuff varies considerably according to the nature and
consistency of the type of food bitten. The tooth marks usually extend through the substance,
leaving a sliding appearance. The margins of the surface are therefore often well defined.
The appearance of bite-marks in skin may vary from a faint bruise, or series of bruises, to a welldefined pattern of heavy bruising and even lacerations, in the general shape of the dental arches.
Unlike the marks produced in foodstuff, teeth merely leave impression marks in skin or slight
penetration of the epithelium.
The pattern of the bite-mark bears a direct relationship to the shape and arrangement of the teeth
and associated structures (lips and tongue) that produced the injury. The bruising is produced by
the escape of blood from the subcutaneous capillaries and veins. The colour of the bruise is
related to the depth of the injured vessels, the amount of blood released, and the time since the
injury was inflicted.
The morphological changes in the skin produced by the forceful application of teeth are
permanent if death of the victim occurs at about the time of injury. Because of the elasticity of the
skin, in living victims, the morphological changes vanish within about 30 minutes, but sometimes
may last longer. It is important, therefore, to begin the examination as soon as possible after the
injury is inflicted.
Forensic significance of bite-marks

Because of the direct casual relationship between teeth and the marks they inflict on human skin,
it may be possible to establish that:
1.
a particular lesion was produced by human or animal teeth
2.
the marks were produced by a particular tooth or teeth of a suspect.
It may also be possible to exclude a suspect on the basis of the bite-mark evidence.
It may be possible to indicate the force with which the bite was inflicted. This kind of evidence
may well be important corroboration in cases of sexual assault.
There is good reason to believe that many bite-marks may not be recognised as such. Some of
these may have important significance as evidence in court.

30
Procedures used in the investigation of bite-marks

The examination, investigation and interpretation of bite-marks in skin should be carried out by an
experienced forensic odontologist.
The procedures used on victims and suspects and the procedures carried out by the dental
laboratory are outlined below.
Victim
1. Visual examination
2. Photographs - colour and black and white
3. Swab for saliva
4. Impressions of skin surface
Suspects
1. Written consent for examination
2. Clinical examination of mouth
3. Saliva swab
4. Photographs - full face and intra oral
5. Full impressions - upper and lower teeth
6. Occlusal registrations in all mandibular positions
Dental Laboratory
1. Make casts of impressions
2. Articulate casts on adjustable anatomical articulator
3. Construct transparent overlays showing occlusal contacts of teeth in various
mandibular positions
4. Compare overlays with photographs of bite marks on skin
5. Make stereo-photographic comparison of casts made from impression from skin
and casts of teeth of suspects
Recording of bite-marks
Records of bite marks are necessary for studying the marks and comparing them with the teeth
that produced the marks.
Saliva swabs
Saliva swabs should be taken prior to the impressions. These may assist in determining the
serotype of the person who produced the mark. Current research into the typing of microorganism in the saliva transmitted during a bite may provide a further means of comparison in
establishing/confirming the identity of the person who produced the bite mark.

31
Photographs
Photographs should be taken in both black and white and colour, and care should be exercised
when using a flash which might wash out a faint bruise. Low angled light is important if the marks
are deep, and the camera angle should be at 90 with the surface on which the marks appear.
Calibrated adhesive tape or a tape measure should be applied to the surface adjacent to the bitemark and within the field of the view of the camera. An adhesive identification label, showing
date, time and name or reference code, should also be placed on the skin in the field area.
Follow-up examination, with photographs, should be made at intervals of one or two days to
observe the changing pattern of the bruising until the bite-mark fades.
Impressions
Impressions are made directly onto the skin using special micro-replication impression material,
e.g. Xantopren and Optosil. The impression should be taken by the person who is to interpret the
bite-mark (a forensic odontologist). The impression may be cast to give a positive likeness of the
surface of the skin. In the case of living victims, because the marks fade relatively quickly due to
the elasticity of the skin, it is important that the impression is taken as soon as possible. The
impression should be labelled with the name and date and its orientation properly marked. This
should be photographed in situ. After it is set, it should be placed in a labelled plastic bag and
taken to the dental laboratory for casting.
Preservation of bite-marks in other materials such as foodstuffs

Foodstuffs containing bite-marks are sometimes left at the scene of a crime, and the forensic
significance of this evidence is obvious. Preservation of the material with a bite-mark is essential.
The following methods may be used according to the circumstances:
1.
Freeze in an air-tight bag in a refrigerator.
2.
Preserving fluid - equal parts of glacial acetic acid and alcohol.
(Some shrinkage may occur with both of these methods.)
Records of a suspects teeth

Consent must be obtained for the clinical dental examination and impressions. If consent is
refused, and the suspect is arrested, Section 81 of the Police Offences Act applies (in South
Australia). A forensic odontologist is not a medically qualified practitioner as is required by this
Act, and one will have to be called to make the examination with the odontologist assisting. A full
clinical examination of the suspects mouth should be carried out, and full impressions taken of
the upper and lower dentitions. Casts are then made and articulated using bite records obtained
from the suspects mouth.

32
Bibliography
Berkovitz BB, Moxham BJ and Holland GR (2002) Oral anatomy, embryology and histology, 3
ed. Mosby, Edinburgh.
rd
Hillson, S (1996) Dental Anthropology, Cambridge University Press, Cambridge.

Jordan RE and Abrams L (1992) Kraus dental anatomy and occlusion. Mosby Year Book, St
Louis.
Osborn, JW (1982) A companion to dental studies. Vol. 1, Book 2. Dental anatomy and
embryology. Blackwell Scientific Publications, Oxford. Chapter 11, pp 357-398.
th
Scott JH and Symons NB (1982) Introduction to dental anatomy. 9 ed. Churchill Livingstone,
Edinburgh.
Townsend GC (1978) Genetics of tooth size. Australian Orthodontic Journal 5(4):142-147

Townsend GC (1981) Fluctuating asymmetry in the deciduous dentition of Australian Aboriginals.
Journal of Dental Research 60:1849-1857
Townsend GC (1992) Anthropological aspects of dental morphology with special reference to
tropical populations. In Oral Diseases in the Tropics ed. Prabhu SR, Wilson DF, Daftary DK and
Johnson NW. Oxford University Press, Oxford. Pp 45-58
Townsend GC and Brown T (1981) The Carabelli trait in Australian Aboriginal dentition. Archives
of Oral Biology 26:809-814
Townsend GC, Yamade H and Smith P (1990) Expression of the entoconulid (sixth cusp) on
mandibular molar teeth of an Australian Aboriginal population. American Journal of Physical
Anthropology 82:267-274
Turner CG (1986) Dentochronological separation estimates for Pacific Rim populations. Science
232:1140-1142

33

34
Section II
Topics in Oral Anatomy
Functions of the Masticatory System I

The masticatory system is involved in incision, mastication and swallowing. Respiration and provision of
lip seal, speech and facial expression also involve the teeth.
Mastication
Masticatory movements involve movements of the mandible, lips, tongue and cheeks. The reflexes
involved in cyclic jaw movements are learned early in life and are refined as teeth emerge. Motor
impulses are directed to the masticatory muscles from the brain. Sensory receptors in the TMJs,
muscles, periodontium and oral mucosa provide feedback.
Patterns of mastication differ considerably from person to person, although for each individual they are
reasonably constant. Other factors influencing the form of the masticatory cycle include: disease,
prostheses, ageing and social customs. Generally, a typical chewing pattern consists of a few cycles on
one side, then the bolus (food) is moved to the other side by the tongue and cheeks, followed by more
chewing. There must be muscle coordination for correct positioning of the food bolus.
Deglutition (swallowing)
This process is often divided into four stages:
1. Preparation of the food bolus
2. The passage of the bolus from the mouth to the pharynx
3. The passage of the bolus in the pharynx
4. The passage of the bolus in the oesophagus
The teeth are used to stabilise the mandible in the second stage. This is called somatic swallowing. The
teeth come together in the intercuspal position (teeth interdigitate and there is maximal contact). If the
tongue is used to stabilise the mandible, e.g. before teeth erupt or in the edentulous person, it is called
an infantile or visceral swallow.
Respiration
In natural respiration the mandible is generally in the rest position with the lips together. This lip seal
helps keep the mouth moist, with breathing occurring through the nose.
Speech
Correct positioning of teeth is important in speech. The term closest speaking space is sometimes
used because while the incisors are very close when S-sounds are made, they do not generally touch.
When dentures are being made, patients are asked to say S-sounds to check on the positioning of
teeth.
Facial expression
The position of anterior teeth is important in determining facial expression.

37
Surface Anatomy of the Oral Cavity

It is extremely important to be completely familiar with the surface anatomy of the oral cavity, to be
aware of the wide variability in normal appearances, and to be able to distinguish between normal and
pathological appearance.
Examinations of the oral cavity should be carried out in a systematic manner and include both soft
tissues and hard tissues. Refer to the computer module Tour of the Mouth (available in the Health
Sciences Faculty Computer Suite Room) for examples of clinical pictures of the various regions of the
oral cavity. You will have an opportunity to work through the module in class. The structure and function
of the tissues of the oral cavity will be discussed in more detail in Dental and Health Science II. The
anatomy of the underlying regions of the oral cavity will be covered in detail in the Structure and
Function Stream, in Second Year.
General structure
The oral cavity lies between the hard palate above (roof of mouth) and the floor of the mouth below.
Anteriorly it is bounded by the lips and teeth and posteriorly it is continuous with the pharynx through
the fauces. The soft palate, at the back of the mouth, and the epiglottis, project into the oropharynx.
The oral cavity can be divided into:
an outer, smaller part called the vestibule (Figs 1a and b)
an inner, larger part called the oral cavity proper (Figs 1a and b)
Fig. 1a. Diagrammatic representation of a sagittal section

through the head and neck

38
Fig. 1b. Diagrammatic representation of a coronal section through

the oral cavity
The oral vestibule is the slit-like space bounded externally by the lips and cheeks and internally by the
alveolar tissues and teeth. It communicates with the exterior through the oral fissure (opening between
the lips) and its lateral wall is formed by the buccinator muscle lying deep to the mucous membrane
lining of the cheek.
The oral cavity proper is bounded laterally and in front by the alveolar arches and teeth. Posteriorly, it
communicates with the pharynx through an aperture called the oropharyngeal isthmus (i.e. the interval
between the palatoglossal folds, bound superiorly by the soft palate and inferiorly by the posterior third
of the tongue). The fauces is the region between the palatoglossal and palatopharyngeal folds. The
floor of the mouth is formed by the mylohyoid muscle. The oral cavity proper contains the tongue which
is attached to the mandible and the hyoid bone.
Lips
The lips contain the orbicularis oris muscle and associated elevator and depressor muscles. They are
covered externally by skin and internally by mucous membrane. Externally, the nasolabial grooves
separate the upper lip and cheeks. They run downwards and laterally from the outer aspect of the nose,
lateral to the nostrils, ending near the corners of the mouth (Fig. 2). The philtrum is the medial
depression of the upper lip extending from the base of the nose to the vermilion border of the upper lip
(Fig. 2). The location of the oral fissure when the lips are resting together generally lies opposite the
incisal edges of the upper incisors. Laterally, the lips are connected by the labial commissures at the
angles (corners) of the mouth. With the lips at rest, the commissures are normally located in front of the
first premolar tooth (Fig. 2).
The mucous membrane of the lips is thin and translucent with small mucous glands. The area where
the skin and mucous membrane meet, is the vermilion zone (red zone) and consists of modified skin
without hair follicles with few sebaceous glands. (The skin contains hair follicles, sebaceous glands and
sweat glands.)

39
Fig. 2 Nose and mouth region
Vermilion zone
Cheeks
The cheeks form a large part of the sides of the face. They are composed mainly of the buccinator
muscle, covered externally with skin and internally with mucous membrane that lines the vestibule.
They contain mucous and mixed salivary glands that open into the vestibule and fat. The opening of the
parotid duct is visible at the parotid papilla, located opposite the upper second molars (Fig 3).
Oral vestibule
The oral vestibule, as mentioned previously, is the space between the alveolar tissues and teeth on the
inside and the lips and cheeks on the outside (Figs 1a, 1b and 4). Various features of the mucous
membrane lining the oral vestibule can be identified. The upper and lower fornices (sulci) are regions of
reflection of the mucous membrane from the covering of the alveolus to the covering of the lips and
cheeks (Figs 3 and 4). The alveolar mucosa near the fornix is dark red, mobile and non-stippled. The
gingivae near the teeth are immobile, pale pink and stippled. The mucogingival junction is the line at the
junction of alveolar and gingival mucosa (Fig 4).
The oral vestibule is marked by epithelial folds called frena or frenula. In the midline are the anterior
superior and anterior inferior labial frena. There are also lateral frenula (Fig 4). The parotid duct
opening (already mentioned) is located in the cheek opposite the maxillary second molars (Fig 3). The
maxillary tuberosity is the rounded prominence of bone behind the last upper molar tooth. The region
behind the posterior mandibular molar is referred to as the retromolar area or triangle (Fig 3).

40
Fig 3. Intraoral view of the buccal vestibule and cheek
Fig 4. Intraoral view of the vestibule

41
Gingiva
The gingiva can be divided into free and attached gingiva. The free gingiva is the gingiva that is
associated with the gingival sulcus, while the attached gingiva is attached to both the tooth and bone.
Between adjacent teeth, the gingiva that is triangular in shape, is referred to as the interdental papilla
and may consist of both free and attached gingiva (Figs 5 and 13). Between the labial and lingual
interdental papilla is the region of the interdental col, whose surface lining consists of junctional
epithelium. In health, the shape of the col follows the contour of the contact point, i.e. it has a concave
surface between the interdental papilla. There is a gingival crevice or sulcus surrounding every tooth
which in health is about 0.5-2mm deep (Figs 5 and 13). Healthy gingivae attach to the tooth in the
region of the cementoenamel junction (Figs 5 and 13) and are pink, firm, well contoured and stippled. In
contrast, inflamed gingivae are red, swollen, puffy, non-stippled and bleed readily.
The transition of the gingiva to the alveolar mucosa is demarcated by the mucogingival junction.
Fig 5. Anterior and cross-sectional view of gingiva

42
Palate
The palate is composed of the hard palate and soft palate. The hard palate consists of the palatal
processes of the maxillae and the horizontal plates of the palatine bones. It is covered by dense
mucous membrane. The soft palate is a mobile muscular attachment at the posterior border of the hard
palate. Located on the surface of the palatal mucosa are various anatomical features, including:
the oval or pear-shaped incisive papilla situated behind the incisors (Fig 6)
palatine raphe which extends back from the papilla and forms a midline ridge (Fig 6)
rugae (transverse palatal folds) which are located anteriorly. They form transverse
ridges on the hard palate and are more developed in carnivorous animals (Fig 6).
Other features associated with the palate are the hamular notch, which is located between the maxilla
and the pterygoid plate of the sphenoid bone. The hamular process is the process from the medial
pterygoid plate, which can be palpated posterior to hamular notch. The pterygomandibular fold is the
fold of mucosa produced by a raphe running from the hamular process to the posterior part of the
mylohyoid line on the mandible.
Fig 6a. The hard palate
Fig.6b. Diagrammatic representation of the hard palate.

43
Fauces
The fauces or oropharyngealisthmus is the area or space between the palatoglossal (from palate to
tongue) and palatopharyngeal (from palate to pharynx) arches (folds) located laterally and the soft
palate superiorly and base of the tongue interiorly. It separates the oral cavity proper from the
oropharynx (Fig 7). The folds are formed by muscles (with the same names) located underneath the
mucosa. The palatine tonsil lies in the tonsillar fossa located between the pillars (Fig 7). The uvula
hangs down at the back of the soft palate (Fig 7) and is continuous laterally with the folds that bound
the fauces.
Fig 7. Diagrammatic representation of an open mouth
Pharynx
The pharynx constitutes the area behind the nasal and oral cavities and larynx. It is the superior portion
of the gastrointestinal tract which connects inferiorly with the oesophagus (Fig 8). It is involved in the
passage of food to the oesophagus and air from the nose/mouth through to the larynx and to the lungs.
Usually the pharynx is divided into three parts: nasopharynx, oropharynx, laryngopharynx, i.e. those
parts lying behind the nasal cavity, oral cavity and larynx respectively (Fig 8).

44
Fig 8. Diagrammatic representation of a sagittal section through the head and

neck region
Tongue
The tongue is a muscular organ with both intrinsic (contained within the tongue) and extrinsic muscles
(extensions of muscles outside the tongue, attaching to various bones and soft tissue structures).
Openings of minor salivary glands are located posteriorly on the dorsal surface. It can be divided into
an anterior 2/3 and a posterior 1/3 by the V-shaped sulcus terminalis (Fig 9). These parts of the tongue
have different embryological origins and different nerve supplies. The apex of the sulcus terminalis
faces posteriorly and is marked by a pit, the foramen caecum (Fig 9). A shallow median groove extends
from the tip of the tongue to foramen caecum. The top/superior surface of the tongue is referred to as
the dorsal surface (Fig 9). The ventral (inferior) surface of the tongue is discussed below. The anterior
2/3 of the dorsal surface of the tongue is covered by small projections called papillae, while the
posterior 1/3 contains lymphoid tissue.
There are four types of papillae found on the dorsal surface of the tongue:
1.
Circumvallate or vallate, which are located immediately anterior to the sulcus terminalis, are 812 in number. They are mushroom-shaped, surrounded by deep troughs and taste buds are
found on the lateral borders (Fig 9).
2.
Fungiform, which are smaller and more numerous, are bright red spots located on the tip and
margins of the tongue and carry taste buds (Fig 9).
3.
Filiform are minute pointed projections, arranged in rows and covering the dorsal surface of
the tongue. Filiform papilla impart the velvety texture of the tongue (Fig 9).
4.
Foliate are approximately five short vertical folds on the sides of the tongue near the junction
of the anterior 2/3 and posterior 1/3. They also possess taste buds (Fig 9).

45
Fig 9a. Part of the dorsum of the tongue
Fig 9b. Diagrammatic representation of the dorsal surface of the tongue
Floor of the mouth

This includes two areas:
1. Sublingual sulcus, which lies between the tongue and the inner surface of the lower teeth.
The position and shape of the sulcus constantly changes with movement of the tongue.
2. Inferior (ventral) surface of the tongue.
Various features of the ventral surface of the tongue can be identified. The lingual frenum, located in
the midline, is a crescentic fold of mucous membrane connecting the under-surface of the anterior part
of the tongue to the floor of the mouth (Fig 10). The fimbriated folds are fringed folds of mucous
membrane on either side of the lingual frenum (Fig 10). Deep lingual veins are located medial to the
fimbriated folds. They are bluish in colour and follow a tortuous path (Fig 10).
Prominent features of the sublingual sulcus include the sublingual glands that bulge on either side of
the floor of the mouth. On top of each bulge is a delicate fold called the sublingual fold which contains
the duct of the submandibular gland. The fold ends medially close to the lingual frenum in a small
papilla that is referred to as the sublingual papilla. The submandibular duct opens at the sublingual
papilla (Fig 10). Deep to the mucosa in the floor of the mouth is a muscular sling formed by the
mylohyoid muscle.
46
Fig 10. Ventral surface of the tongue and the anterior floor of the mouth
Fig. 10b. Diagrammatic representation of the ventral surface of the tongue
Teeth - These will be described in detail in the following sections.

47
Structure of Oral and Dental Tissues

This section contains some more detailed information about the histological appearance of the oral and
dental tissues. During First Year you are expected to have a good understanding of the basic
histological structure of the oral hard and soft tissues. To assist in developing your understanding of
this area, refer to histology texts from the Human Biology stream, or refer to oral histology texts, e.g.
Avery JK (1992) Essentials of oral histology and embryology. The more detailed aspects of cell types in
epithelium and connective tissue will be discussed further next year. Nevertheless, you might like to
read about them now!
Oral mucosa
Oral mucosa lines the oral cavity. It consists of a covering of stratified squamous epithelium and
underlying connective tissue. It is important in protecting the underlying structures from damage such
as trauma, bacteria and noxious substances.
Oral mucosa can be divided according to the type of epithelial covering in the various parts of the oral
cavity:
Lining mucosa, which has a non- keratinised epithelial covering and is found on the
cheeks, lips, soft palate, floor of mouth and ventral surface of tongue.
Masticatory mucosa, which has a keratinised epithelial covering and is distributed

over the hard palate and gingiva.
Specialised mucosa, which is a mix of keratinised and non-keratinised epithelium

and is located on the tongue (papilla have keratinised epithelium and intervening areas are
covered with non-keratinised epithelium) and vermilion border of lip.
Epithelium
The epithelial covering of the oral mucosa consists of layers of epithelial cells and can be divided into
various layers or strata depending on the morphological and functional characteristics of the cells. The
deepest layers of cells of the different types of epithelium have similar properties, while the more
superficial cell layers differ. These differences depend on the differentiation pathway of these cells, i.e.
non-keratinising or keratinising. Other non-epithelial cells that are found in the epithelium include
Langerhans cells, lymphocytes, Merkel cells and melanocytes.
The epithelium of lining mucosa is non-keratinised; therefore, it is less able to resist damage but is
capable of distension. The basal layer (stratum basale) is the layer/s of cells closest to the underlying
connective tissue. These cells are the least differentiated of the epithelial cells. They are the smallest
cells and are cuboidal or columnar in shape. This stratum is the site of cell division and production.
The spinous/prickle layer (stratum spinosum) is the next layer and these cells are larger cells by
comparison with the cells in the basal layer. Cells in the prickle cell layer are polyhedral in shape. Cell
junctions (i.e. desmosomes) are prominent in this layer. Keratin proteins, in the form of tonofilaments,
become evident in this layer. The next layer is the intermediate layer, in which the cells become
flattened and there is an increasing percentage of tonofilaments. The last layer of cells forms the
superficial layer. These cells demonstrate membrane thickening. The permeability barrier develops in
this layer of cells. There are decreased desmosomes between the cells and the nuclei persist. In this
layer the cells are desquamated, i.e. they are shed from the surface.
The epithelial covering of the masticatory mucosa is keratinised and, therefore, is mechanically tough.
The basal layer is similar to lining mucosa. The next layer is also called the spinous layer. In this layer
there is an increase in tonofilaments, increased desmosomes and increased cell volume. The granular
layer (stratum granulosum) is so-called because of the presence of basophilic keratohyalin granules.
The cells in this layer are flattened cells and there is a decrease in the size of the nucleus. Membranecoating granules increase in number in this layer. They contribute to the permeability barrier that is
found in the adjacent superficial layer, the keratinised layer. In the keratinised layer (stratum corneum)
48
the cells have thickened plasma membranes, densely packed tonofilaments, few desmosomes and no
organelles. When there is no nucleus present, the epithelium is referred to as ortho-keratinised.
If a pyknotic (shrunken, darkly staining) nucleus is retained, the epithelium is referred to as parakeratinised. This layer provides a permeability barrier. The cells at the surface of this layer are shed
into the environment.
Basal complex
At the junction of epithelium and connective tissue is a basal complex, the majority of which is produced
by the epithelium. It attaches the epithelium to the connective tissue and acts as barrier to diffusion in
both directions. At the light microscope level it appears as a 1m thick structureless layer and is
referred to as the basement membrane.
Under the electron microscope two layers can be seen: the lamina lucida and the lamina densa.
The lamina lucida is electron-lucent, is adjacent to basal layer and contains fine filaments, laminin and
heparan sulphate. Hemidesmosomes (half-desmosomes) are present in the basal cells and are
important in the attachment of the basal cells to the basal lamina. The lamina densa is electron dense
and is beneath the lamina lucida. It consists of a granular material and type IV collagen. Attached to the
lamina densa and looping into the connective tissue are anchoring fibrils.
Connective tissue - lamina propria
The underlying connective tissue of oral mucosa can be divided into the superficial lamina propria and
submucosa. The lamina propria consists of connective tissue including fibroblasts, mast cells,
macrophages, lymphocytes and other inflammatory cells, extracellular matrix (collagen types I & III,
elastic, oxytalan fibres and proteoglycans), blood and lymph vessels and nerves. It can be divided into
two layers:
1.
The papillary layer which is the thin and most superficial area associated with the undulating border
with the epithelium; it contains loosly arranged collagen,
2.
and the deeper layer, referred to as the reticular layer, that consists of a dense network of collagen
fibres found in many areas of the oral mucosa
The deeper layer may border directly onto periosteum as in gingiva, or muscle as in tongue, or submucosa as in cheek.
Connective tissue - submucosa
The submucosa contributes to the ability of oral mucosa to return to the resting state after deformation.
It varies in thickness in different regions, such that loose connective tissue is found in lining mucosa
and dense connective tissue which is firmly attached to periosteum is found in masticatory mucosa.
The submucosa contains neurovascular bundles and may possess salivary glands as in soft palate and
lip, or possess fibro-adipose tissue as in hard palate and lips.

49
Fig. 11a. Keratinised masticatory oral mucosa gingiva, hard palate
Fig. 11b. Non-keratinised lining oral mucosa - cheeks, lips, alveolar mucosa.
Note that the lining mucosa has a thicker epithelium and reduced undulations at
the junction between the epithelium and connective tissue.

50
Enamel
Enamel is found covering the crown of teeth and is a hard, acellular, non-vital tissue. In fact, it is the
hardest tissue found in the human body. It may be considered an inert tissue; however, ion exchange
between the outer enamel and the saliva does occur. For example, fluoride ions in the saliva can be
exchanged for other inorganic ions that form part of the enamel. This capacity for ion exchange
indicates that the enamel is permeable and this can occur in the outer layer of enamel to a depth of
approximately 20-30m and also through pores which consist of greater organic or water content.
As already noted, enamel is the hardest tissue, due to its very high mineral content, and so it is also the
most mineralised tissue in the body. It consists of:
96% by weight of inorganic substances in the form of hydroxyapatite crystals
approximately 2% organic substances
and 2% water.
Despite the hardness of the enamel it is susceptible to acid attack, i.e. dissolution in the presence of
acid. It also is a brittle substance and relies on the support of the resilient dentine to withstand the
forces of function. Once it is no longer adequately supported by dentine, e.g. when caries has
destroyed the dentine, it can fracture under masticatory load.
Enamel varies in thickness, with the thickest portions covering incisal edges and occlusal surfaces
(areas under the greatest functional load). It has a knife-like edge at the cervical margin. It has a
whitish/grey semi-translucent appearance such that the yellow colour of dentine is visible through the
enamel, except at the incisal edge where there is no underlying dentine.
The cells responsible for the production of enamel are ameloblasts, which are derived from the oral
epithelium. They form the inner layer of the structure called the dental organ that is responsible for the
formation of teeth. These cells produce enamel initially as an organic matrix, but this quickly
mineralises. The secretion of the enamel organic matrix occurs in a cyclic pattern, with the ameloblasts
actively secreting matrix, followed by a period of rest.
Various features can be found in the enamel as a result of this rhythmic pattern of secretion, e.g. cross
striations are found at 5m intervals along the enamel rods (prisms) and striae of Retzius are
incremental lines and delineate the successive front of secreting ameloblasts (Fig 12).
A pronounced incremental line is found in teeth in which the enamel is forming at birth. This is referred
to as the neonatal line and is said to be a result of the environmental differences between the intrauterine environment and the post-natal environment and marks birth. This will, of course, be evident in
most deciduous teeth (refer to the section Timing and Sequence of Tooth Calcification). The striae of
Retzius extend to the enamel surface to form perikymata, which are slight depressions on the surface
of the enamel and can be visualised on newly emerged teeth.
With function, however, these tend to be worn away. In some conditions, e.g. fluorosis, that are
associated with alterations in the formation of the enamel, the perikymata can be exaggerated.
Maturation phase
Once the enamel of the crown has been completely formed, a maturation phase follows where there is
a reduction in the organic content of the enamel and further incorporation of mineral with growth of the
apatite crystals. After this phase the ameloblasts become quiescent cells and are now referred to as the
reduced enamel epithelium. These cells remain closely opposed to the enamel surface until the tooth
emerges into the oral cavity. They then are replaced by adjacent cells and eventually form the junction
between the gingiva and the enamel, i.e. dentogingival junction (refer to section Supporting Tissues Periodontium).

51
The maturation phase of the enamel actually continues once the tooth has emerged into the oral cavity,
with further ion exchange with ions in the saliva as noted above. This continues for approximately 2-3
years post emergence of the teeth into the oral cavity. It is during this time that the application of topical
fluoride is particularly beneficial to the tooth with respect to increasing resistance to acid attack.
Obviously, this mainly has an effect on the 20-30 m of outer enamel.
Structure of enamel
Enamel has a very characteristic structure related to the stage of differentiation of the cells responsible
for producing it, i.e. ameloblasts. The initially formed enamel closest to the dentine and in the outer
30m of deciduous teeth and the gingival third of permanent teeth, has no rod structure. This is due to
the fact that the ameloblasts have not yet developed their special cone-shaped processes extending
from their secreting end, i.e. Tomes' process. It is the development of this process that leads to the
characteristic formation of rods (prisms) in which mineral (hydroxyapatite) crystals form, with one
ameloblast primarily being responsible for one rod. Within the rods, the crystals have varied orientation,
depending on the orientation of adjacent Tomes' processes and the path the ameloblasts follow as they
move away from the dentino-enamel junction (DEJ). Within the head of a rod, the crystals are
approximately parallel with the long axis of the rod. The junction of adjacent rods of apatite crystals are
regions referred to as the rod sheath (prism sheath). These are areas where there is an abrupt change
in orientation of crystals within the rods, which results in greater spacing between the crystals of
adjacent rods. These pores are filled with organic enamel components and it is along these regions that
substances can diffuse, and so these areas contribute a major part to the permeability of enamel.
Cross section of enamel rods demonstrate the characteristic shape of rods: namely, a shape similar to
a keyhole that interlocks with heads of adjacent rods located between two tails. (Refer to Ten Cate
[2003] Oral histology pp 147 - 154). The appearance of these 'keyholes' is due to different orientations
of crystals within each rod which, as already noted, is related to the Tomes' process and path of the
ameloblasts.
Dentine
Dentine forms the major part of the tooth, and is covered by enamel in the crown and cementum on the
root. It can be described as a specialised connective tissue consisting of approximately:
10% water
20% organic
and 70% mineral content by weight.
Dentine is a hard yellowish avascular tissue with elastic properties and a tubular structure, but in
contrast to enamel, it is a vital tissue.
Odontoblasts
As discussed below in the section on pulp, there are cellular processes of odontoblasts that project
through the tubules of dentine (Fig. 12). The odontoblasts are the cells responsible for the production of
the dentine. These cells differentiate from cells found initially in the dental papilla and once the tooth
has formed, from cells in the dental pulp. These cells lay down dentine during the formation of the
crown and root of the tooth (primary dentine) and continue to lay down dentine throughout the life of the
tooth (secondary dentine) which results in a gradual decrease in the size of the pulp chamber. They
also will produce dentine in response to stimuli (tertiary dentine) such as attack by caries; therefore,
odontoblasts are capable of repair.
Odontoblasts initially secrete an organic dentine matrix which consists of collagen fibres and ground
substance. With further secretion of the dentine matrix, the odontoblasts recede away from the DEJ
and matrix vesicles are released from the secreting border of the odontoblast. It is these matrix vesicles
that are involved in the initiation of mineralisation of dentine with growth of apatite crystals that rupture
the vesicles. This results in the formation of clusters of crystallites that continue to grow and coalesce to
mineralise the initially formed organic matrix.
52
Fig. 12. Mandibular first molar displaying features found in dental tissues in either ground
sections (undecalcified) (a) and decalcified (b) sections.
With the continual secretion of organic dentine matrix, mineralisation spreads from this initially
mineralised dentine, with the deposition and growth of apatite crystals. As a result of this process of
mineralisation, where it is preceded by matrix production, there is always a layer of predentine
(unmineralised dentine matrix) that lies between the odontoblasts and the mineralised front of dentine.
Similar to enamel, dentine is deposited in increments and mineralises in phases.
Evidence of this fast - slow process of deposition are the incremental lines of von Ebner which are
approximately at 90o to the tubules, while the contour lines of Owen indicate variations in
mineralisation.
The contour lines of Owen are more widely spaced than the incremental lines of von Ebner and usually
are considered as exaggerated incremental lines of von Ebner. An example of a wide contour line of
Owen is the neonatal line that marks the junction of the dentine formed prenatally and dentine
deposited postnatally. It will only be present in the deciduous teeth and possibly the first permanent
molars (refer to section Timing and Sequence of Tooth Calcification).
53
Associated with the secreting border of the odontoblast is a short process that initially forms as the
odontoblast begins to produce the first secreted collagen and moves away from the DEJ. This cellular
extension continues to lengthen and becomes the odontoblastic process that occupies the tubules
found in dentine. The odontoblastic process is bathed in dentinal fluid and is often surrounded by
peritubular dentine, that lines the dentinal tubules and has a higher mineral content that the adjacent
dentine. Nerve fibres also may be located within tubules, adjacent to the odontoblast processes, and
may extend to the near the dentinoenamel junction. It has been proposed that it is the movement of
dentinal fluid in response to, for example, thermal stimuli, that leads to depolarisation of these nerves,
thus imparting the sensory characteristics of dentine.
Cementum
Cementum is the mineralised layer that covers the roots of teeth. Although it is one of the dental hard
tissues, it will be discussed in the following section on Supporting Tissues, because functionally it is
involved in the Periodontium.
Dental pulp
Dental pulp is the soft tissue component that occupies the central part of the tooth and is enclosed by
the dentine of the tooth. It is composed of loose connective tissue which originates from the
mesenchyme of the dental papilla.
Histology
Histologically, the pulp consists of cells and intercellular substance. The cells include: odontoblasts,
fibroblasts and defence cells. Odontoblasts are highly differentiated columnar shaped cells derived from
the dental papilla. They have cytoplasmic processes which extend into dentinal tubules. The cell
nucleus is at the pulpal end. These are the cells that are responsible for the laying down of dentine, not
only during the development of the teeth but throughout the life of the teeth. Fibroblasts are long flat
cells with oval nuclei involved in collagen formation. Defence cells, such as histiocytes, undifferentiated
mesenchyme cells and lymphocytes, are all important in the inflammatory response of the pulp to
noxious stimuli.
The intercellular substance consists of ground substance and fibres that include collagen and silverstaining fibres. There also are blood vessels as the pulp has a rich blood supply. Arterioles run in the
long axis of the tooth and form many anastomoses (connections). These vessels form a rich
subodontoblastic plexus. There are lymph vessels around the blood vessels and nerve fibres are
present also. There are unmyelinated nerve fibres of the autonomic nervous system, which run along
blood vessels and control the contraction of smooth muscle and there are myelinated nerve fibres
which are sensory fibres (pain) and therefore respond to hot, cold and painful stimuli.
Functions
The pulp has a number of functions:
1.
Formative
Odontoblasts lay down dentine, both pre-emergence (primary) and post-emergence (secondary).
They can also respond to stimuli, e.g. attrition and caries, by laying down tertiary dentine. Both
secondary and tertiary dentine result in a reduction in the size of the pulp chamber.
2.
Nutritive
Blood vessels carry nutrients to the pulp and dentine. While the pulp is vital, the tooth is vital.

54
3.
Sensory
Nerve endings can evoke a response to stimuli, e.g. pain.
4.
Defensive
The inflammatory process is a defensive mechanism. In response to noxious stimuli or insults, the
inflammatory response ranges from hyperaemia (an increase in blood flow) which may resolve, or
it may persist and lead to acute and chronic inflammation of the pulp (pulpitis). As the pulp is
totally enclosed in dentine, these changes in the pulp can result in an increase in the pressure
within the pulp, with associated pain.
Supporting tissues - periodontium

The term periodontium is derived from peri - around (Latin/Greek) and odont - tooth (Greek).
The periodontium is a functional system of different tissues that invest and support the teeth. It includes
cementum, periodontal ligament, alveolar bone and gingiva, specifically the dentogingival junction (Fig
13). The dentogingival junction consists of the portion of gingiva that faces the tooth and includes the
junctional and sulcular epithelium and the associated underlying connective tissue attachment. The
peridontium develops mainly from the dental follicle, while the dentogingival junction is derived from
dental organ, namely the reduced enamel epithelium. The formation of the periodontium occurs soon
after the root begins to develop and continues over the time of eruption of the tooth. It undergoes
continual remodelling as fibres are formed and remodelled as the tooth moves closer to the oral cavity,
into occlusion and then is maintained in occlusion.
Figure 13. Diagrammatic representation of canine and its supporting

tissues

55
Cementum
Development and structure
Once dental follicle cells come in contact with the root dentine, they differentiate into cementoblasts and
begin to lay down cementum. The first cementum is formed pre-eruptively. While post-emergence, it
continues to be formed in layers in the apical portions of roots.
Cementum is less densely mineralised (45-50% weight) than dentine (70%). Cementoblasts which are
typical protein secreting cells initially secrete an organic matrix consisting of intrinsic collagen fibres and
ground substance. The cementoblasts may not recede after laying down cementum, but rather can
become incorporated into the cementum similar to osteocytes. The matrix mineralises in a similar
fashion to dentine with deposition of matrix vesicles containing apatite crystals.
Once the cementoblast becomes incorporated into cementum, it is referred to as a cementocyte.
Overlying this layer of cementum, multiple layers of cementum will form in which extrinsic fibres will
become embedded. These extrinsic fibres are called Sharpey's fibres and are arranged at right angles
to the long axis of the tooth. Cementum is avascular and does not have the same ability to remodel that
alveolar bone displays.
Morphology at cementoenamel junction
The cementoenamel junction may be characterised by
cementum and enamel bordering each other (generally most common)
overlapping of enamel by cementum
gap between the enamel and cementum with exposed dentine.
A combination of all forms of junction is found on all teeth. There is a variation in the percentage of the
different junctions present on each tooth.
Function
Cementum anchors the teeth as it attaches periodontal ligament via the extrinsic fibres to teeth. This
attachment changes due to continual turnover of periodontal ligament, occlusal forces on teeth and
changing positions of teeth (mesial drift). Changes in cementum with cementocytes allow for limited
adaptation of the teeth to changes in the alveolus, root lengthening in response to occlusal wear, and
reparative functions
Alveolar bone
Development
The development of the alveolar bone is dependent on the presence of teeth. The tooth socket walls
develop from the cells of the dental follicle, while the remaining portion of the alveolar bone is derived
from the bone forming the body of the jaws. It has been noted that in children with total anodontia, no
alveolus develops and with loss of the teeth the alveolus is resorbed.
Once eruption begins, the bone of the socket walls begins to be formed, at the same time as the
appearance of the periodontal ligament and cementum, and is completed before the tooth has emerged
into the oral cavity. The crestal regions and apical regions of the alveolar bone develop once the teeth
are in occlusion. For the secondary incisors, canines and premolars, there is marked remodelling of the
socket wall and alveolar process as the deciduous teeth are shed and the permanent teeth erupt and
emerge and the sockets remodel to fit around these teeth.

56
Structure
Alveolar bone is another mineralised connective tissue and consists of approximately 60 % mineral
(slightly less than dentine) and 25% organic matrix and 15% water by weight. In contrast, to the other
mineralised connective tissues that have been discussed, bone is a vascular tissue. Another
distinguishing feature of bone is its ability to remodel. In fact, bone is a tissue that is constantly
undergoing periods of deposition, followed by periods of resorption, in response to functional or other
demands, e.g. mesial drift of the teeth or orthodontic forces. As a result of this deposition/resorption
pattern, lines marking these phases are visible in the bone when viewed under the microscope.
Alveolar bone surrounds the teeth and consists of outer cortical plates, inner spongy bone and bone
lining the sockets. The bone lining the sockets that is seen radiographically as the more radio-opaque
line around the tooth root, is referred to as the lamina dura. The socket walls consist of thin compact
bone with many openings that carry blood vessels, lymphatics and nerves from the bone marrow to the
periodontal ligament. High numbers of periodontal ligament collagen fibres (Sharpey's fibres) insert into
the bone of the socket wall and provide the attachment of the tooth to the bony socket.
Periodontal ligament
Development and structure
The development of the periodontal ligament parallels that of the formation of cementum and alveolar
bone lining the sockets.
The periodontal ligament consists of dense connective tissue with cells, connective tissue fibres, matrix,
vessels and nerves. The cells that are present include:
fibroblasts, which are the most numerous cells that produce and remodel collagen fibres
and are located between the collagen fibres in three-dimensional network
cementoprogenitor and osteoprogenitor cells, which closely resemble inactive

fibroblasts and are precursor cells to cementoblasts and osteoblasts
cementoblasts, which are oval to cuboidal in shape and line the cemental surface of the
root and are responsible for the production of cementum
osteoblasts and osteoclasts which are located adjacent to bone and are arranged in an
irregular distribution dependent on areas of deposition (osteoblast) and resorption
(osteoclast)
epithelial cells (rests of Malassez), which are the remnants of Hertwig's root sheath,
form a net-like arrangement close to cementum and are characteristically seen as
isolated clusters of epithelial cells
a few lymphocytes and macrophages.
Other components of the periodontal ligament include:
connective tissue fibres, which constitute the greatest part by volume of the periodontal
ligament: namely, collagen fibres and bundles that are arranged in groups and are
continuously remodelled and oxytalan fibres which are similar to elastic fibres
matrix, which is composed of a highly viscous gel that confers some of the stress
withstanding properties of periodontal ligament
blood and lymph vessels

nerve fibres, both autonomic (regulate blood flow) and sensory (pain and pressure
associated with muscles of mastication).

57
Function
Fibroblasts play a role in eruption and emergence of teeth. All the other components support the teeth
during mastication by acting as a hydraulic shock absorber. The periodontal ligament acts as a whole in
withstanding forces with fluid movement possible due to matrix, tissue fluid and blood in vessels which
together act as a viscoelastic system. The nerve fibres involved in pressure detection are important in
the masticatory cycle providing proprioceptive information and feedback, i.e. information regarding
location and position of various components of the masticatory apparatus such as the muscles of
mastication and the temporomandibular joint.
Dentogingival junction/complex (marginal periodontium)

This complex forms the junction between tooth and gingiva and consists of junctional epithelium,
sulcular epithelium and underlying connective tissue. The junctional epithelium is derived from the
reduced enamel epithelium of the dental organ.
Junctional epithelium and epithelial attachment

The junctional epithelium provides a seal around the tooth to prevent bacteria resident in the sulcus
from penetrating to the underlying connective tissue. It is only a few cells thick at its apical aspect,
increasing to 15-30 cells at the base of the sulcus/junction with the sulcular epithelium and covering the
interdental col.
The epithelial cells are immature/undifferentiated cells that are continually lost and replaced by division
of the cells located adjacent to the connective tissue. Via the epithelial attachment, the junctional
epithelium is bound to the tooth in the region of the cervical region. This attachment of the epithelium to
the teeth is stronger than the bond between adjacent epithelial cells.
The presence of the sulcular epithelium is dependent on the state of health of the gingiva, such that in
clinically healthy gingiva there is a 0.5 mm deep sulcus around necks of teeth, from interdental papilla
to interdental papilla (labial/buccal and lingual aspects of the teeth). Generally, it is lined by a nonkeratinised stratified squamous epithelium; otherwise, the sulcular epithelium is similar in appearance
to oral gingival epithelium, i.e. keratinised stratified squamous epithelium. Supporting the epithelium is a
dense connective tissue and fibre system, similar in appearance and components to the periodontal
ligament.
Function
The fibre network within the connective tissue contributes to attachment and stabilisation of teeth to
alveolar process (fibres to bone) and unites the teeth together as a continuous dental arch (transseptal
fibres). Via the junctional epithelial attachment to the tooth, the integrity/continuity of the epithelial
lining/covering of body is maintained in areas where teeth protrude through it.
The keratinised oral gingival epithelium and fibre network in the connective tissues enable the tissues
to withstand the shearing and tearing forces experienced during mastication and maintain the gingival
tissues in close approximation to tooth. Structure of the junctional epithelium enables provision of a
peripheral defence against infection.
Function of periodontium as a unit
As discussed above, these tissues function as a structural unit which is involved in attaching teeth to
jaws, enabling teeth to withstand forces of mastication as well as having a sensory ability that is
important in the control of mastication. It also plays an important role in the eruption and emergence of
teeth.
58
Age Changes in Oral Tissues

Numerous changes associated with age have been reported to be found in the oral hard and soft
tissues. It should be remembered, however, that the various changes attributed to increasing age may
be a result of various physiological processes as well as changes associated with intervening factors,
e.g. disease and treatment. It is generally very difficult to dissect these factors when describing age
changes.
An example of changes that occur with age which are modified by intervening factors is the changes
that occur in the appearance of the face. Increased wrinkling, open-pored and sagging skin result from
changes in the epithelium and underlying connective tissue, but many of these changes are
accelerated by exposure to sun. (A comparison of different sites of skin from the same individual that
are exposed or protected from the sun demonstrates marked differences in appearances, with the
unexposed skin having a more 'youthful' appearance.)
Enamel
As already noted, enamel is a relatively inert tissue with no cellular component. Changes in enamel do
occur with age. Some of these changes are due to attrition and alterations in the physicochemical
structure of enamel. Attrition of enamel depends on its composition. Examples include deciduous teeth
often wearing very quickly with wear of incisal edges and loss of cusp tips, the type of occlusion, the
diet, and bruxism, with the frequency, duration and severity of the grinding resulting in variable attrition.
Attrition can occur both on incisal and occlusal surfaces and interproximally. The enamel surfaces of
teeth which initially have incremental lines (perikymata, refer Enamel) tend to be smoothed with time
and mamelons are also worn away.
Use of dyes and radioactive isotopes have shown that the enamel is slightly permeable, an exchange
of ions occurring between saliva and enamel. As noted, this is restricted to the outer 20-30 m of
enamel and along the rod sheaths. Permeability decreases with age, with a decrease in water and
organic content. Young teeth tend to show high permeability and therefore this is a good time for
maximal benefit from fluoride therapy.
The permanent teeth tend to become darker and more yellowish with time. This may be related to
increased pigmentation of organic material that fill cracks and pores that develop posteruptively, or due
to increased thickness of dentine (secondary and tertiary).
Dentine
Dentine is a vital tissue and demonstrates marked changes with age by comparison with enamel. As
noted, dentine is laid down throughout the life of the tooth as regular secondary dentine, or it may be
laid down in an irregular pattern in response to a stimulus, e.g. attrition, abrasion or caries. With
increasing age, the production of secondary and tertiary dentine decreases. Other changes include the
formation of translucent dentine in the tooth root, which results from the occlusion of tubules with
mineralised tissue (peritubular dentine). This is particularly common in the root region and progresses
from the apex towards the crown. Dead tracts may be present and represent regions where the
odontoblasts have degenerated, possibly in (increased peritubular dentine) response to noxious stimuli.
In response to chronic noxious stimuli, sclerotic dentine may be produced. It is found occluding dentinal
tubules of dentine, e.g. in areas deep to carious lesions. With these changes in the dentine, it is
understandable that older teeth tend to be less sensitive.

59
Pulp
As noted above, continual deposition of dentine occurs with age. This leads to a reduction in the size of
the pulp, with reduction in pulp horns and coronal pulp chamber and a narrowing of the root canals.
Young pulp contains many fibroblasts; however, with increasing age, there is an increase in collagen
fibre bundles, with a moderate and continual reduction in fibroblast numbers. There are reduced neurovascular components, which in conjunction with the changes in dentine result in a reduction in
sensitivity of teeth with age and contribute to a reduced defence capacity of the pulp. The incidence of
calcification of the pulp (pulp stones) may increase with age.
Cementum
Cementum is deposited slowly throughout life, especially at the root apex. The amount of cementum is
loosely correlated with age but it is also influenced by the functional stress applied to the tooth.
Increased cementum is located near the apex of the tooth related to passive eruption of the tooth to
maintain occlusal relationships (in conjunction with increased alveolar bone height). Systemic (e.g.
Paget's disease) or local conditions (e.g. chronic periapical inflammation) are associated with abnormal
thickening of cementum, either diffuse or circumscribed. This is referred to as hypercementosis.
Periodontal ligament and gingiva
The periodontal ligament is about 0.2mm wide and may become narrower with age. Gingival recession
occurs with age and although it has been considered to be a normal process, it may be a result of
inflammation.
Jaws
Alveolar bone reduces markedly if teeth are lost, due to the remodelling characteristic of bone, such
that loss of function results in resorption. Extensive resorption may occur, producing a loss of vertical
dimension of the face. There is a decreased blood supply to the mandible in particular, while in the
maxilla, extensive loss of the alveolar process can result in very close proximity of the floor of the
maxillary sinus to the oral cavity.
Oral mucosa
Age changes of the oral mucosa involve both the epithelium and the connective tissue. There is a
thinning of the epithelium with a reduction in cell division. In the connective tissue there is a reduction in
number, size and activity of fibroblasts with a reduction in collagen turnover. There are thickened dense
bundles of collagen and reduced elasticity due to alterations (cross linking) of the elastic fibres with
decreased vascularisation of the connective tissue. The mucosa tends to become more fragile with age
and it has been suggested that healing is slowed. There are varied reports about a diminution of the
ability to taste with age. Recent reports indicate that although there may be some reduction in
perceived taste intensity in specific locations of the oral cavity and there can be increases in the
threshold for taste, these changes have little impact on taste for the whole mouth.
Other factors can influence taste, including:
various medications
wearing of dentures
poor oral hygiene
and the olfactory system whose function has been found to decrease with age.
Salivary glands
There is conflicting evidence about age changes in salivary glands. Although histological changes
associated with ageing may be present, e.g. atrophy of saliva producing cells (acinar cells) with
60
replacement with adipose (fat) tissue and fibrosis, the impact of these changes at the clinical level is
unclear. Certainly, dry mouth is more prevalent in older individuals; however, medications and systemic
disease are major factors that contribute to altered salivary flow. The viscosity of saliva may decrease
with age, resulting in changes in the properties of saliva. The defence capacity of saliva appears
relatively unchanged with age.
Temporomandibular joints
Changes may occur in the articulating surfaces of the condyle and glenoid fossa with age. These
changes to the cartilaginous surfaces of the bones may be important in the initial defects that are
reported to occur with osteoarthrosis. Factors that are known to increase with age may be aetiologic
factors in the development of osteoarthrosis, eg. marked attrition which may be associated with
overloading, in particular, asymmetrical loading associated with bruxism. There are mixed reports on
the association between loss of teeth and osteoarthrosis as tooth loss also increases with age.
Implications of age changes to oral tissues

Caries
Caries rate tends to decrease with age, which may be related to maturation of enamel resulting in
decreased enamel permeability. Due to this maturation, fluoride should be applied to teeth early when
the enamel is most permeable to gain optimal protection. However, risk of root caries and secondary
coronal decay is increased with age. Decreased saliva flow (commonly associated with medication) can
result in decreased antibacterial effects and increased plaque formation, which in turn can result in an
increased caries rate. Effective preventive regimes are necessary to combat this problem.
Clinical dentistry
The decrease in size of pulp chambers and root canals with age is relevant to operative work and
endodontics. These changes may alter restorative procedures and may increase the complexity of
endodontic treatment. Changes in the dentine and cementum can lead to complications associated with
extractions. Reduced bony support for dentures or more advanced prosthetic appliances can interfere
with restoration of function. Changes in the oral mucosa and saliva may influence prosthetic treatment.
For example, dentures for patients with atrophic mucosa and reduced salivary flow may experience
greater difficulties with retention as well as an increased risk of trauma to the mucosa.
Forensic odontology
For medicolegal reasons and archaeological purposes, an estimate of the age of skulls, jaws and teeth
may be required. Various features of the skull may be used in age estimation, e.g. the state of closure
of fontanelles or sutures of the skull and the closure of synchondroses, e.g. spheno-occipital.
Dental features also can be used, e.g. which teeth are present, the extent of root formation, presence of
attrition, translucency of roots and size of pulp chamber. Generally, up to 14 years of age, dental
development is the best indicator of age. (Refer to Timing and Sequence of Tooth Calcification and
Tooth Eruption and Emergence p 132 141, these areas will be discussed in more detail in DSP2).

61
Notes:

62
Tooth Identification
Notation
Fdration Dentaire Internationale (FDI) Notation
This notation provides an international standard for describing teeth using a two-digit system.
The first digit identifies the quadrant in which the tooth is found. Quadrants are numbered 1-4 for
the permanent teeth and 5-8 for the deciduous teeth. Numbering proceeds in a clockwise direction,
beginning at the patient's upper right (1-permanent or 5-deciduous), upper left (2-permanent or 6deciduous), lower left (3-permanent or 7-deciduous) and lower right (4-permanent or 8-deciduous).
The second digit identifies the tooth within the quadrant. Teeth are numbered from 1-8 for the
permanent teeth and 1-5 for the deciduous teeth. The teeth in each quadrant are numbered from
the midline backwards.
The numbers are pronounced separately, such that the upper right permanent central incisor is
called 11 and pronounced as one-one.
The reasons for adoption of this notation were ease of understanding and teaching this notation. It
is simple to communicate when speaking, is succinct for recording in printed documentation and
entry of data into computers. It also can be readily applied to standard dental practice charts.
Palmers notation
Palmers notation is based on the division of the teeth into quadrants. The Palmers notation uses a
diagrammatic representation of the quadrants as a cross. The permanent teeth are numbered from
1-8 for each quadrant, beginning at the midline and the deciduous teeth are identified by the first
five letters of the alphabet, beginning at the midline. Individual teeth or groups of teeth are
designated by their numbers and are enclosed in the two sides of the cross to differentiate left from
right and upper from lower, e.g. upper right central incisor is represented by:
Patient's Left
Patient's Right
Permanent
87654321
Deciduous
ABCDE
Comparative dental anatomy - general mammalian formula

Due to differences in the number of the various classes of teeth in the upper and lower jaws of
some animals, e.g. mammals, the notation for the dentition indicates the class of teeth that are
present and then the number of that class that are found in both the upper and lower jaws.
Abbreviations that are used are: I - incisors; C - canines; P -premolars; M - molars. Using this
formula, the number of teeth for different animals can be calculated by adding the number of teeth
listed and multiplying by two (formula is representative of the right or left side of the jaws).
The following are examples of this formula for various animals:
Cat:
3
3
Rat:
Sheep:
I 1 C0 P
I
0
3
C 1 P2 M 1
0
0
C 01 P
M
3
3
3
3
3
3

63
Identification of Permanent Teeth

Initial questions
There are five basic questions to ask when identifying a tooth:
1.
Is it an incisor, canine, premolar or molar?
2.
Is it a maxillary or mandibular tooth?
3.
Is it a deciduous or a permanent tooth?
4.
Does it come from the right or left side of the jaw?
5.
If it is an incisor, is it a central or a lateral?

If it is a premolar, is it a first or second?
If it is a molar, is it a first, second or third?

64
Incisors
Is it an upper or lower incisor?
Upper incisors are wider mesiodistally than lower incisors.
The mesiodistal diameter of uppers is greater than the labiolingual diameter - the
reverse is true for lowers.
Marginal ridges and cingula are more prominent in upper incisors.
The roots of upper incisors are rounded or triangular in cross-section, whereas lower
incisor roots are flattened mesiodistally.
Is it an upper central or upper lateral incisor?
The upper central incisor is wider mesiodistally than the lateral. The length/breadth
ratio of the lateral is greater.
The lateral is more rounded.
The lateral is more asymmetrical.
Is it a lower central or lower lateral incisor?
The central is symmetrical, whereas the lateral is not.
The lateral is slightly larger.
The lateral is more fan-shaped when viewed from the labial aspect.
The incisal edge of the central is perpendicular to the labiolingual axis when viewed
from the incisal aspect, whereas the lateral's incisal edge is twisted to the distal.
Is the tooth from the right or left side of the jaw?
The mesioincisal angle approximates 90; the distoincisal angle is more rounded.
When viewed from the incisal aspect, the incisal edge tends to twist to the distal.
Root tends to curve distally.
Cingulum tends to be slightly distally placed.
Curve of the cervical line is generally more pronounced on the mesial than the distal.
The distal contact area tends to be more cervical than the mesial contact area.

65
Canines
Is it upper or lower canine?
The upper canine is bell-shaped when viewed from the labial, whereas the lower has
mesial and distal margins which are more parallel.
The incisal margin of the upper canine occupies 1/3 to 1/2 of the height of the crown,
whereas the incisal margin of the lower occupies only 1/4 to 1/3.
The lingual surface of the lower canine is flatter; less distinct marginal ridges and
cingulum.
The cusp of the lower is generally less pointed.
The root of the lower canine is more flattened mesiodistally.
Is the tooth an upper right or left canine?
The distal cusp slope is greater than the mesial slope.
Root tends to curve distally.
The crown is asymmetrical; the distal portion is wider and more concave.
Is the tooth a lower right or left canine?
The mesial profile of the crown is in a straight line with the mesial surface of the root.
The mesial cusp ridge forms a high shoulder, the distal being lower.
Note: The root may curve mesially.

66
General features for identification of anterior teeth

1. Size
Uppers are larger than lowers.
Upper central incisors are larger than upper laterals.
Lower central incisors are smaller than lower laterals.
2. Symmetry
Lateral incisors are more asymmetrical.
The distoincisal angle is rounded.
3. Lingual surfaces
Flatter lingual surfaces in lowers than uppers.
4. Contact areas
Distal contact areas tend to be more cervical than mesial contacts.
5. Wear facets
Wear facets tend to occur on the lingual of upper incisal edges and the labial of lower
incisal edges.
6. Roots
Upper anterior teeth have roots which are triangular or rounded in cross-section.
Lower anteriors have roots flattened mesiodistally.
Roots tend to curve to the distal (the root of the lower canine may incline mesially).

67
Premolars
Is it an upper or lower premolar?
Upper premolars have two cusps which are approximately equal in size, whereas the
lingual cusp of lower premolars is smaller than the buccal.
Upper premolars are hexagonal in outline when viewed from the occlusal (they are
wider buccolingually than mesiodistally). Lower premolars are round or square in
outline from the occlusal aspect.
Uppers are trapezoidal in outline from the proximal view, whereas lowers are
rhomboidal with a lingual tilt.
Lower premolars are single rooted.
Is it an upper first or second premolar?
The upper first premolar has a mesial developmental groove and depression.
The upper first premolar has an angular outline from the occlusal aspect, whereas the
second premolar is more rounded.
The upper first premolar usually has two roots, while the second premolar usually has
one root.
The upper first premolar has a well-defined occlusal, the second premolar is less
definite with more supplemental grooves.
The upper second premolar has a "narrow-shouldered" appearance when viewed
from the buccal aspect.
Is it a lower first or second premolar?
The lower first premolar has a small lingual cusp. The buccal and lingual cusps are
more equal in the lower second premolar.
The lower first premolar has a mesiolingual groove and flattening.
The lower second premolar is generally larger than the first premolar.
The lower first premolar has two cusps with a transverse ridge, the second premolar
may have two or three cusps.
Is the tooth an upper right or left premolar?
The roots tend to curve distally.
The upper first premolar has a mesial developmental groove and depression.
The mesial slope of the buccal cusp is longer than the distal slope for the first
premolar, whereas the reverse is true for the second premolar.
The crown of the first premolar is twisted from the occlusal view.
a)
The tip of the buccal cusp is distal to the tip of the lingual cusp.
b)
The buccal cusp ridge is inclined mesiolingually.
c)
The distolingual contour is greater than the mesiolingual contour.
d)
The crest of the distal contact is buccal to the crest of the mesial contact.
The distal contact area is more cervical than the mesial contact area.

68
Is the tooth a lower right or left premolar?

The lower first premolar has a mesiolingual groove and flattening.
The mesial marginal ridge of the first premolar is lower than the distal (the reverse is
true for the lower second premolar).
The distal occlusal fossa of the first premolar is larger than the mesial fossa.
The mesial slope of the buccal cusp is shorter than the distal slope.
If the lower second premolar has three cusps, the distolingual cusp is smallest.

69
Molars
Is it an upper or lower molar?
Upper molars have three roots (two buccal and one lingual); lower molars have two
roots (one mesial and one distal).
Upper molars have four cusps (in a characteristic pattern); lower molars have four or
five cusps.
Upper molars are rhomboidal in outline from the occlusal view; lower molars are
rectangular.
Upper molars are trapezoidal in outline from the proximal view; lower molars are
rhomboidal with a lingual tilt.
Is it an upper first, second or third molar?
Upper first molar:
four well developed cusps,
may have a cusp of Carabelli,
distinct occlusal pattern,
divergent roots; two buccal roots often like plier handles.
Upper second molar:
more rhomboidal than first molar,
often has extra grooves,
distolingual cusp smaller.
Upper third molar:
often only 3 cusps; heart-shaped,
roots often fused,
often has extra occlusal grooves; variable.
Is it a lower first, second or third molar?
Lower first molar:
five cusps; three buccal and two lingual,
definite occlusal pattern,
divergent roots.
Lower second molar:
four cusps in typical "hot-cross bun" pattern.

70
Lower third molar:

more rounded occlusal outline,
variable morphology; may resemble a lower first or second molar,
often has extra occlusal groove,
often has fused roots.
Is it an upper right or left molar?
Occlusal form.
Root structure.
Is it a lower right or left molar?
Mesial portion bulkier than distal.
Occlusal form.
Root structure.
Crown shows lingual tilt from proximal view, with buccal roll.

71
General features for identification of molars

Upper molar trend:
Size - first molar is largest, third molar smallest.
Distolingual cusp - becomes progressively smaller.
Roots - greater distal curvature, less divergent.
Lower molar trend:
Size - first molar largest, third molar smallest.
Cusps - first molar has five cusps, second has four cusps, third may have four or five
cusps.
Roots - greater distal curvature, less divergent.
Morphological differences between deciduous and permanent teeth:
Deciduous teeth are smaller than corresponding permanent teeth.
Crowns are wider mesiodistally compared with their crown height (anteriors appear
cup shaped and molars appear squat).
Cervical ridges more prominent (constricted necks) more bulbous.
Roots narrower, relatively longer, flare more (no root trunk).

72
Tooth Morphology
The descriptions of tooth morphology in the following section include for each tooth:
average dimensions,
description: including general, labial, lingual, proximal (mesial, distal), incisal or
occlusal view of crowns; root morphology; variations,
photographs of the labial, lingual, mesial, distal, occlusal and apical views for each
tooth in the permanent dentition.

73
Permanent dentition
Permanent Maxillary Right Central Incisor (11)
Average length 23.5 mm, range 21 mm - 26 mm
Mesiodistal diameter 8.5 mm
General
Largest of the incisors
Labial
Smooth convex surface, trapezoidal

Two faint vertical developmental grooves, demarcating three lobes
Mamelons - rounded prominences on incisal edge, corresponding to the
incisal extensions of the mesial, central and distal lobes
Mesioincisal angle approximately 90, distoincisal angle rounded
Incremental lines on surface give a natural appearance
Incisal edge straight
Maximum diameter in the incisal 1/3
Lingual
Tapers lingually
Lingual fossa with mesial and distal marginal ridges
Large cingulum
Point of maximum convexity of cervical line tends to be distal of centre
Proximal
(mesial &
distal)
Triangular
Incisal edge is in the long axis of tooth ie. The long axis bisects the incisal
edge and root apex
Curvature of cervical line tends to be greater on the mesial than the distal
Incisal
Triangular
Broad, flat labial surface
Fairly symmetrical
Cingulum located slightly to the distal
Incisal edge bisects the tooth labiolingually
Root
Single, tapering, conical, blunt apex

Tilts to the distal
Triangular in cross-section at the cervix, more rounded at the apex
Variations
Labial outline may be tapering, square, ovoid

Shovel-shaped incisors common in mongoloid ethnic groups

74
Permanent Maxillary Right Central Incisor (11)
Palatal/
Lingual view
Labial view
Incisal view
Mesial view
Distal view

75
Permanent Maxillary Right Lateral Incisor (12)
Average length 22 mm, range 21 mm - 25 mm
General
Smaller than central incisor, except in root length

Ratio length/breadth is greater than for central
Less symmetrical, more rounded
Labial
More curved outline, incisal edge curved

Incisal edge slope to short distal surface
Distal outline more rounded than central
Lobes not as obvious as central
Lingual
Marked marginal ridges, more prominent than central

Prominent cingulum
Lingual pit may be present
Lingual fossa more concave than central
Proximal
(mesial &
distal)
Triangular outline, similar to central

Root appears longer
Incisal
Distal twist of incisal edge
Root
Single, tapering, pointed root; curves to the distal
Variations
Great variability, e.g. diminutive laterals, peg laterals, or agenesis

76
Permanent Maxillary Right Lateral Incisor (12)
Labial view
Palatal/
Lingual view
Incisal view
Mesial view
Distal view

77
Permanent Mandibular Right Central Incisor (41)
Mesiodistal diameter 5 mm
General
Smallest of the permanent teeth

Lower incisors are wider labiolingually than mesiodistally (opposite to
upper incisors)
Labial
Symmetrical, trapezoidal, tapering

Incisal edge straight, perpendicular to long axis
Mid groove pattern, mamelons
Mesioincisal and distoincisal angles almost 90
Lingual
Smooth surface, inconspicuous marginal ridges

Very few lines or grooves
Proximal
(mesial &
distal)
Triangular
Incisal
Incisal edge is perpendicular to a line bisecting the crown labiolingually
Incisal edge inclined to lingual
Labial surface is not as rounded as the maxillary central

Root
Single, tapering, flattened mesiodistally

Tends to curve distally, groove on distal more marked than mesial

78
Permanent Mandibular Right Central Incisor (41)
Labial view
Lingual view
Incisal view
Mesial view
Distal view

79
Permanent Mandibular Right Lateral Incisor (42)
General
Very similar morphology to lower central incisor except:
Root
slightly larger than the lower central

not symmetrical; distoincisal angle rounded, incisal
edge has twist to distal, incisal edge slopes down in
distal direction
more fan-shaped than central
Longer than central

80
Permanent Mandibular Right Lateral Incisor (42)
Labial view
Lingual view
Incisal view
Mesial view
Distal view

81
Permanent Maxillary Right Canine (13)
Total length 27 mm, range 23 mm - 29 mm
General
Single cusp in line with centre of the root; longest tooth
Labial
Single cusp, bell-shaped, three developmental lobes

Incisal ridge is 1/3 to 1/2 crown (height of cusp from mesial and distal
incisal angles is approximately 1/3 to 1/2 of crown height)
Distal slope of cusp is longer than mesial
Lingual
Large cingulum, sometimes pointed

Mesial and distal marginal ridges
Lingual ridges, from cusp tip to cingulum, is often present producing
mesial and distal lingual fossae
Proximal
(mesial &
distal)
Wedge-shaped, greater bulk than maxillary central
Incisal
Labiolingual dimension greater than mesiodistal

Distolabial and distolingual outlines slightly concave
Root
Long, single, rounded triangular in cross-section

Distopalatal and mesiopalatal surfaces often grooved
Distal tilt
Variations
Shows high degree of sexual dimorphism in size

May be crowded out of dentition and require orthodontic treatment

82
Permanent Maxillary Right Canine (13)
Labial view
Palatal/Lingual
view
Incisal view
Mesial view
Distal view

83
Permanent Mandibular Right Canine (43)
Total length 27 mm, range 23 mm -28 mm
Mesiodistal diameter 7 mm
General
Narrower mesiodistally than upper and approximately the same

length, therefore crown seems longer
Not as well developed as upper canine
Labial
Cusp less pointed than upper

Mesial surface of the crown flattened by comparison with the
maxillary canine resulting in approximately a straight line
Height of cup from mesial and distal incisal angles is confined to
incisal 1/4 of tooth
Lobes less obvious than upper
Lingual
Flatter, less distinct marginal ridges, cingulum
Proximal
(mesial &
distal)
Tendency for cusp to tilt lingually, less curvature labially
Incisal
From this view more of the labial is visible since the incisal edge tilts
to the lingual
More symmetrical than upper
Root
Oval, flattened mesiodistally, may be mesial curvature of root

Bifurcated sometimes
Variations
Sexual dimorphism in size greatest for this tooth

Bifurcated root

84
Permanent Mandibular Right Canine (43)
Lingual view
Labial view
Incisal view
Mesial view
Distal view

85
Alignment in arch of maxillary and mandibular incisors and canines
In both views, note position of contact areas on mesial, distal, labial and lingual of each
tooth and on adjacent teeth.

86
Notes
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87
Notes

88
Premolars
Premolars usually have two cusps: buccal and lingual.
They are sometimes called bicuspids but it is preferable to use the term
premolar.
Follow the deciduous molars after exfoliation of these teeth.
First premolars may be extracted as part of orthodontic treatment for

crowding in the dentition.

89
Maxillary Permanent First Premolar
Mesiodistal diameter 7.0 mm, Buccolingual diameter 9.0 mm
Buccal
Roughly bell-shaped, like the canine

Mesial slope of the buccal cusp is rather straight and longer than the
distal slope which is shorter and more curved; the tip of the buccal cusp
is distal to a line bisecting the buccal surface
Mesial edge is sometimes notched
There is a semblance of three lobes, the middle one being most
prominent and often forming a buccal ridge
The contact areas (with canine and second premolar) are at about the
same level in the middle 1/3 of the tooth
Lingual
Crown tapers lingually

Both cusps are visible from this view as the buccal cusp is about 1mm
longer than the lingual
Mesial
Roughly trapezoidal
Distinguishing feature of tooth occurs on mesial
On mesial surface is a well-defined mesial developmental groove which
crosses the mesial marginal ridge and is continuous with the central
groove
Cervical to the mesial contact area, centred on the mesial surface, is a
marked depression which continues up to and includes the cervical line.
This is called the mesial developmental depression or sometimes the
canine fossa
Mesial developmental depression continues and joins a deep
developmental depression between the roots which ends at the root
bifurcation
Distal
No developmental groove is present
Occlusal
Hexagonal shape, angular, twisted appearance

Well defined grooves, no supplemental grooves
Occlusal has a twisted appearance that results from several interrelated
features:
Buccal cusp ridge is inclined mesiolingually
Buccal cusp peak is distal to lingual cusp peak
Distolingual contour is greater than mesiolingual contour
The maximal convexity of the mesial contour generally is more lingually
placed than the maximal convexity of the distal contour
Root
Usually two roots, often bifurcated halfway up the root

Long root trunk
May be single root, compressed on mesial and distal surfaces
Clinically
Long thin roots, close to maxillary sinus; care during extraction

90
Permanent Maxillary Right First Premolar (14)
Buccal view
Palatal/Lingual
view
Occlusal view
Mesial view
Distal view

91
Permanent Maxillary Right Second Premolar (15)
Length 22.5 mm, range 19 mm - 23 mm
Mesiodistal diameter 6.8 mm. Buccolingual diameter 8.8 mm
General
Similar to first premolar but more rounded

Crown smaller except for mesiodistal diameter at the cervix
Buccal
Less bell-shaped
Buccal cusp smaller, more rounded and nearly equal in height with the
lingual cusp
Distal slope of buccal cusp is longer than mesial (like canine)
Buccal ridge and labial lobes are not very prominent
Proximal
(mesial &
distal)
Usually no mesial developmental groove or depression

Occlusal sulcus shallower (height of cusps above marginal ridges less
than that for the first premolar)
Cusps more equal in size than first premolar
Occlusal
Oval, not angular, occlusal outline

Central developmental groove is shorter and more irregular
Many supplemental grooves traversing in a buccal and lingual direction
from the central groove
Crown occlusal area smaller than first
Mesial and distal profiles more parallel (do not converge) such that the
occlusal table is more rectangular
Root
Usually single root

92
Permanent Maxillary Right Second Premolar (15)
Palatal/Lingual
view
Buccal view
Occlusal view
Distal view
Mesial view

93
Permanent Mandibular Right First Premolar (44)
Mesiodistal diameter 7.0 mm, Buccolingual diameter 7.5 mm
General
Two cusps, buccal larger than lingual
Buccal
Bell-shaped profile with a buccal ridge

Mesial slope of buccal cusp shorter than distal slope
Lingual
Tapers lingually
Lingual cusp small
Mesiolingual developmental groove on lingual surface
Proximal
(mesial &
distal)
Rhomboidal outline, with a lingual tilt
Occlusal
Diamond-shaped in outline, flattened and grooved on mesiolingual

Two occlusal fossae, distal larger than mesial
Two cusps joined by transverse ridge (formed by buccal and lingual
triangular ridges)
Most of buccal surface is visible from occlusal view because of the
lingual tilt of the crown
Root
Single root, curves distally

Grooved, more so on the mesial
Variations
Extremely variable
Buccal surface of crown is convex, lingual almost straight

Lingual border of mesial marginal ridge merges with developmental
depression mesiolingually to give mesiolingual developmental groove
Mesial marginal ridge is lower than distal and inclines cervically at 45
angle to the long axis of the tooth
Occlusal plane is tilted at 45 to horizontal
Size of lingual cusp variable, also mesiolingual groove

94
Permanent Mandibular Right First Premolar (44)
Lingual view
Buccal view
Occlusal view
Mesial view
Distal view

95
Permanent Mandibular Right Second Premolar (45)
Mesiodistal diameter 7.2 mm. Buccolingual diameter 8.0 mm
General
Larger than lower first premolar

Extremely variable occlusal morphology
May have two or three cusps
Buccal
Shorter buccal cusp, more rounded than first premolar

Similar shape to lower first
Lingual
Lingual cusp larger than in lower first

Mesiolingual and distolingual profiles do not converge as much on the
lingual
Proximal
(mesial &
distal)
Crown and root are wider buccolingually than lower first premolar
No mesiolingual groove
Mesial marginal ridge is 90 to long axis of tooth, so less of occlusal
surface can be seen from this view
Distal marginal ridge is lower than mesial
Occlusal
Not tilted lingually like first premolar, instead it is oriented horizontally

If two-cusped type:
Buccal and lingual cusps joined by transverse ridge
Round outline
Central developmental groove may be straight or U-shaped
Usually distolingual depression
If three-cusped type:
One buccal, two lingual cusps
Square outline
May have Y-shaped groove pattern, with grooves converging
on a central pit
Distal groove, mesial groove and lingual groove (lingual groove
located towards distal)
Of the three cusps, the buccal cusp is the greatest in height,
the mesiolingual next and the distolingual cusp is smallest in
height
Many supplemental grooves
Root
Single root, flattened mesiodistally

Apex blunter than first premolar, maybe longer too

96
Permanent Mandibular Right Second Premolar (45)
Lingual view
Buccal view
Occlusal view
Mesial view
Distal view

97
Alignment in arch of maxillary and mandibular permanent first and second premolars
In both views, note position of contact areas on mesial, distal, buccal and lingual of
each tooth and on adjacent teeth,

98
Molars
Maxillary molars
General
Mesiodistal diameters M1 = 10.7 mm, M2 = 9.8 mm, M3 = 8.6 mm

Upper molars generally have 4 cusps, 3 roots (2 buccal and one
palatal).
They are trapezoidal in outline when viewed from the buccal or
lingual.
They are rhomboidal in outline when viewed from the occlusal.
Trends
There is a decrease in size from M1 to M2 to M3.

The distolingual cusp becomes progressively smaller from M1 to M3,
and may be absent in M3.
The roots are less divergent and slope more to the distal from M1 to
M3.

99
Permanent Maxillary Right First Molar (16)
Buccal
Average length (varies depending on root - palatal root longer) 19.5 mm

(B) 20.5 mm (P), range (varies depending on root) 18 mm - 22 mm
Trapezoidal outline, two cusps with mesiobuccal cusp larger than
distobuccal cusp
Buccal groove separates the two cusps
Lingual
Trapezoidal outline, two cusps, lingual groove
Proximal
(mesial &
distal)
Trapezoidal
Occlusal
Rhomboidal outline, mesiodistal diameter less than buccolingual

Four cusps - mesiobuccal, distobuccal, mesiolingual distolingual
Central pit and fossa evident
Oblique groove traverses the oblique ridge at right angles to this ridge
which connects the distobuccal and mesiolingual cusps
Regular appearance, no crenations
May have marginal ridge tubercles on the mesial
Root
Three roots, two buccal and one lingual

Divergent roots, buccal roots shaped like pair of pliers from buccal;
mesiobuccal root is broader and a bit longer than distobuccal
Lingual root is broad when viewed from buccal and is shaped like a
banana when viewed from the proximal
Variations
May be an extra cusp on the lingual surface of the mesiolingual cusp,

called the Carabelli Trait which is common in Caucasians and generally
only found on the permanent first molars or deciduous second molars.
The expression of this trait varies in form from a groove to a large cusp
Clinically
First molar is important tooth to maintain

Prone to decay
Emerges at about 6 years of age behind deciduous molars

100
Permanent Maxillary Right First Molar (16)
Buccal view
Palatal/Lingual
view
Occlusal view
Mesial view
Distal view

101
Permanent Maxillary Right Second Molar (17)
General
Average length (varies depending on root - palatal root longer) 18 mm

(B), 19 mm (P); range (varies depending on root) 18 mm - 22 mm.
Same general morphology as first molar except:
smaller overall, especially in mesiodistal diameter
distolingual cusp smaller and so tooth looks more

rhomboidal
roots less divergent, with more tilt to the distal
no Carabelli trait
may have only three cusps
tends to have extra grooves on occlusal surface.

102
Permanent Maxillary Right Second Molar (17)
Buccal view
Palatal/Lingual
view
Occlusal view
Mesial view
Distal view

103
Permanent Maxillary Right Third Molar (18)
General
Clinically
Average length 17.5 mm

Often called wisdom tooth
Same general morphological features as other upper molars but:
may be heart-shaped, with only three cusps
often has extra grooves and is very variable
roots often fused, shorter with distal inclination.
Third molars may be congenitally missing (agenesis) or impacted

(crowded)
Variable in relation to size, shape, time of emergence

104
Permanent Maxillary Right Third Molar (18)
Buccal view
Palatal/Lingual view
Occlusal view
Mesial view
Distal view

105
Notes
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__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
__________________________________________________________
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________________________________________________

106
Mandibular molars
General
Mesiodistal diameters M1 = 11.3 mm, M2 = 10.6 mm, M3 = 10.6 mm

Lower molars have 4 or 5 cusps, 2 roots (mesial and distal)
Trapezoidal in outline from the buccal view
Rhomboidal in outline from the proximal view
Rectangular from the occlusal view
Trends
Generally decrease in size from M1 to M2 to M3 or may be M2 = M3

Roots less divergent and tilt to distal from M1 to M3

107
Permanent Mandibular Right First Molar (46)
Buccal

Trapezoidal outline, three buccal cusps; mesiobuccal, distobuccal,
distal
Cusps decrease in size from mesiobuccal to distobuccal to distal
The two lingual cusps are higher than the buccal cusps
Lingual
Two cusps, mesiolingual and distolingual
Proximal
(mesial &
distal)
Rhomboidal outline, with lingual tilt

Buccal surface shows buccal roll
Occlusal
Rectangular, not symmetrical; mesial part is bulkier than distal

Five cusps, three buccal and two lingual
Mesiobuccal and distobuccal grooves separate the buccal cusps
Central or transverse groove
Variations
Position of the distal cusp may vary

Groove pattern can vary
May possess extra cusps eg. Cusp 6 (between distal and distolingual
cusps) or cusp 7 (between the two lingual cusps)

108
Permanent Mandibular Right First Molar (46)
Buccal view
Lingual view
Occlusal view
Mesial view
Distal view

109
Permanent Mandibular Right Second Molar (47)
General

Similar morphology to first molar except:
four cusps, two buccal and two lingual

hot cross bun arrangement of occlusal grooves
often extra grooves on occlusal

mesial part of tooth bulkier than distal when
viewed from the occlusal

110
Permanent Mandibular Right Second Molar (47)
Lingual view
Buccal view
Occlusal view
Distal view
Mesial view

111
Permanent Mandibular Right Third Molar (48)
General
Average length 18 mm
Similar morphology to other lower molars except:
more rounded
may have occlusal pattern either like M1 or M2
often extra grooves on occlusal

often fused roots
often impacted, need surgical extraction; care

needed due to proximity of mandibular canal
and contents

112
Permanent Mandibular Right Third Molar (48)
Buccal view
Lingual view
Occlusal view
Mesial view
Distal view

113
Alignment in arch of maxillary molars
In both views, note position of contact areas on mesial, distal, labial and lingual of each
tooth and on adjacent teeth.

114
Alignment in arch of mandibular molars
In both views, note position of contact areas on mesial, distal, labial and lingual of
each tooth and on adjacent tooth.

115
Alignment in arch of maxillary and mandibular permanent teeth
Note location and shape of contact areas.
Occlusal view

116
Suggested Reference Texts
There are many Oral Anatomy texts which include descriptions of tooth morphology, for
example:
Ash MM (1993) Wheelers dental anatomy, physiology and occlusion.
Saunders, Philadelphia. BSL: 611.314 W56.7 (Reserve)
Ash MM (1984) Wheelers dental anatomy, physiology and occlusion.
611.314 W56.6 (Main and Short Term)
7th ed.
6th ed.
WB
BSL:
Ash MM (1984) Wheelers atlas of tooth form. 5th ed. WB Saunders, Philadelphia. BSL:
611.314 W56a (Main)
Ash MM and Nelson SJ (2003) Dental Anatomy, physiology, and occlusion. 8th ed. WB
Saunders, Philadelphia. (check BSL catalogue for call no)
Bath-Balogh M and Fehrenbach MJ (1997) Illustrated dental embryology, histololgy and
anatomy. WB Saunders, Philadelphia. 611.314 B332i (Reserve and Main)
Carlsen O (1987) Dental morphology Munksgaard, Copenhagen. BSL: 611.31 C284d
(Main)
Jordan RE and Abrams L (1991) Kraus' Dental Anatomy and Occlusion. Mosby Year
Book, St. Louis. BSL: 611.314 K91.2 (Main and Reserve)
Teaching Research: A Division of the Oregon State System of Higher Education (1982)
Dental anatomy: A self-instructional program. 9th ed. Appleton-Century-Crofts,
Norwalk. BSL: 611.314 O663d.9 (Main)
Van Beek GC (1983) Dental Morphology: an illustrated guide. John Wright and
Sons Ltd., Bristol. BSL: 611.314 V218d (Reserve)
Woelfel JB and Scheid RC (1997) Dental Anatomy: its relevance to dentistry. 5th ed.
Williams and Williams, Baltimore. 611.314 W842d (Reserve and Main)
Woelfel JB and Scheid RC (2002) Dental anatomy: its relevance to dentistry. 6th ed.
Lippincott Williams and Wilkins, Philapdelphia. BSL: 611.314 W842d (Reserve
and Main)

117
Primary (Deciduous) dentition

There are twenty primary teeth (milk teeth/deciduous teeth) with five teeth in each
quadrant, i.e. two incisors, one canine and two molars per quadrant (there are no
premolars). The primary teeth serve extremely important functions, namely:
mastication,
speech,
growth of jaws,
maintenance of space,
aesthetics.
Primary teeth emerge between 6 months and 2.5 years of age, while primary molars may
be retained till 12-13 years of age. The natural loss of primary teeth is called exfoliation and
results from resorption of the roots.
Morphological differences between primary and permanent dentition
Morphologically, the primary teeth are similar in many ways to their permanent successors
but there are differences. Generally the incisors and canines are similar in morphology to
their permanent successors, the primary second molars are similar in morphology to the
permanent first molars; however, the primary first molars are unlike any other tooth and can
be described as being midway between premolars and molars.
Notable differences include the following:
Primary teeth are smaller than their successor teeth, except for primary
molars which are larger than the premolars that replace them. The difference
in the size of the primary molars by comparison with the premolars is referred
to as leeway space and provides some space for permanent teeth in the
developing dentition. (The canines are included by some in the calculation of
leeway space.)
The crowns of primary teeth are wider mesiodistally compared with their
crown height. This makes the anterior teeth appear more cup-shaped and
gives molars a squat appearance.
Cervical ridges are more prominent in primary teeth, which make them
appear more bulbous. The enamel retains its thickness at the cervical region
and then stops abruptly rather than thinning down as in the permanent teeth.
Due to this abrupt junction of the enamel of the crown and the root, the teeth
seem to have constricted necks. In anteriors, there is a bulge in the cervical
1/3 on both the lingual and the labial, while in molars only the buccal surface
is bulged.
The roots of primary teeth differ by comparison with the roots of permanent
teeth - anterior teeth have narrower roots that are comparatively longer in
relation to the crown. Molars have roots that are relatively longer and more
slender. Molar roots flare more to accommodate the developing premolars
and do not possess a root trunk.

118
Other differences are as follows:
Cusps tend to be more pointed in primary canines and molars but they
wear quickly.
The enamel is thinner, more opaque and more even in thickness, giving
primary teeth a whiter appearance.
The pulp horns of primary teeth are prominent, especially in the mesial
portion of molars.

119
Primary Maxillary Right Central Incisor

(51)
Smaller than permanent
Increased mesiodistal diameter which is
greater than the height of the crown
Round full shape resulting in a bulbous cup
shape
Smooth labial surface, straight incisal edge
Lingually there are well-defined marginal
ridges and a large cingulum
Constricted at the neck
Sharp mesioincisal angle and rounded
distoincisal angle
Root tilts distally
Primary Maxillary Right Lateral Incisor

(52)
Smaller than central, especially mesiodistally

Cingulum not as prominent
Rounded distoincisal angle
Not nearly as variable as the permanent lateral
Relative sizes
Relative sizes
Labial
Mesial
Mesial
Labial
Occlusal view
Occlusal view

120
Primary Mandibular Right Central Incisor

(81)
Primary Mandibular Right Lateral Incisor

(82)
Larger than lower central

Not symmetrical, incisal edge follows line of
arch, distal twist
Rounded distoincisal angle
Single root
Smallest tooth in the primary dentition

Bilaterally symmetrical
Lingual surface flatter than uppers
Cervical constriction
Bulge on labial and lingual
Single root
Relative sizes
Relative sizes
Labial
Mesial
Labial
Occlusal view
Mesial
Occlusal view

121
Primary Maxillary Right Canine

(53)
Diamond shaped when viewed from the
labial
Cusp very pointed initially, more so than the
permanent canine
Cervical bulge
Mesial and distal contact areas are on the
same level (by comparison with permanent
canines)
Mesial cusp slope longer than distal cusp
slope ((by comparison with permanent
canines)
Primary Mandibular Right Canine

(83)
Smaller, slimmer than upper
Crown height is greater than mesiodistal
diameter
Sides do not converge as much as upper
canine
Distal cusp slope longer than mesial cusp
slope
Relative sizes
Labial
Relative sizes
Mesial
Occlusal view
Labial
Mesial
Occlusal view

122
Primary Maxillary Right First Molar

(54)
Primary Maxillary Right Second Molar

(55)
Occlusal divided into buccal and lingual

halves by central groove
Generally described as having four cusps;
mesiobuccal, distobuccal, mesiolingual,
distolingual
But often only three cusps (no distolingual
cusp) or sometimes only two cusps (no
distobuccal)
Mesiolingual cusp is largest
Squat appearance from the buccal or
lingual; no obvious cusps
On the mesial side of the buccal surface
there is a pronounced bulge (sometimes
called the Tubercle of Zuckerkandl)
When viewed from the occlusal, the outline
converges lingually and distally
Three roots - two buccal and one lingual
Morphologically like the permanent first

molar
Smaller than the permanent first molar, but
larger than the primary first molar
Roots more slender and diverge compared
with permanent
Prominent bulge on the cervical part of the
buccal surface
Four cusps, oblique ridge etc. Like
permanent first molar
Cusp of Carabelli often present
Relative sizes
Palatal
Buccal
Occlusal view
Buccal
Palatal
Occlusal view

123
Primary Mandibular Right First Molar

(84)
Four cusps; two buccal and two lingual
Joining the two mesial cusps is a ridge of
enamel called the buccolingual crest or
transverse ridge
Pronounced cervical bulge
Buccal cusps are compressed labiolingually
with no clear separation between them, no
groove just a depression
Lingual cusps clearly defined
From the occlusal view the tooth outline
converges lingually, especially on the mesial
From the occlusal view there is a
rhomboidal outline, with the mesiodistal
diameter greater than the buccolingual
There are two roots - one mesial and one
distal
The mesial root is longer and does not taper
much and so appears rectangular
Primary Mandibular Right Second

Molar (85)
Morphologically like the permanent lower
first molar
Five cusps; three buccal, two lingual
The three buccal cusps are approximately
equal in size (by comparison with the
permanent second molar)
Smaller than permanent molar
Prominent bulge on buccal surface
Rectangular occlusal outline
Relative sizes
Buccal
Linguall
Occlusal view
Buccal
Lingual
Occlusal view

124
Primary
Mesiodistal crown diameters
Average lengths
Tooth
Maxilla (mm)
Mandible (mm)
Maxilla (mm)
Mandible (mm)
1 (A)
2 (B)
3 (C)
4 (D)
5 (E)
6.6
5.3
6.9
7.1
9.0
4.0
4.7
5.9
7.8
9.8
16.0
15.8
19.0
15.2
17.5
14.0
15.0
17.0
15.8
18.8
It is important to know and appreciate the differences in morphology between permanent and
primary teeth, especially in paedodontics (children's dentistry). Differences in anatomy are relevant
to treatments such as the placement of stainless steel crowns and pulpotomies.
The concept of leeway space is important in orthodontics, because in cases of crowding, the first
permanent molar may be held in position and prevented from drifting in a mesial direction during
the exfoliation of the primary molars and emergence of the premolars. This can be used to alleviate
some crowding problems, e.g. if the space deficiency in an arch is approximately 1.5 mm in the
maxilla or 2.5 mm in the mandible. Obviously, this is dependent on the differential in the size of the
primary and secondary teeth.

125
Alignment in arch of maxillary and mandibular primary teeth

126
Notes
_______________________________________________________________
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127
Pulpal Anatomy
General pulp anatomy
The pulp cavity consists of:
pulp chamber (coronal)
pulp horns (cornua)
pulp canals (root canals, radicular pulp)
lateral canals
apical foramen
accessory foramina.
The shape of the pulp cavity generally follows the external contour of the tooth. Shape changes do
occur, however. For example, in a young tooth where the root is still developing, there is a wide
open apex, while in older teeth, with the laying down of secondary and tertiary dentine, particularly
on the floor of the chamber and pulp horns, the pulp cavity decreases in size.
Calcification may occur within the pulp and may result in the formation of pulp stones. Pulp stones
may be free or attached and their frequency increases with age.
Methods of studying pulp anatomy

The pulp anatomy may be studied by:
sectioning teeth,
taking radiographs, but it must be remembered that this provides only a twodimensional representation,
injection techniques. (The pulp cavity is injected with a red resin compound and
then the tooth is replaced with clear resin. These specimens are immersed in
paraffin oil which prevents optical distortion and allows ease of viewing the root
canal morphology in relation to the external form of the tooth.)
Clinical applications
An understanding of the pulp, both in terms of its anatomy and its response to stimuli, is imperative
in restorative dentistry. For example, in cavity preparation or placement of pins for a restoration,
knowledge of the pulp anatomy is needed to ensure the pulp is not compromised and that its
vitality is maintained.
The impact of thermal and chemical stimuli on pulp vitality also needs consideration. For example,
heating of the tooth when cutting tooth structure should be avoided and adequate precautions
taken when applying noxious chemicals.
In endodontics, the length and number of root canals must be determined accurately.
Access cavities are needed to provide access to the pulp and as the main apical foramen and the
anatomical root apex generally do not correspond, an accurate knowledge of pulp cavity
morphology is necessary to complete successful endodontic treatment. In diagnosing pain, one
must understand the process that can occur in pulp degeneration, the type of pain and location of
the pain.

128
Pulpal anatomy of individual teeth

Maxillary
Upper incisors and canines are generally single rooted with single root canals.
Upper first premolars usually have two roots, one buccal and one lingual and usually
two root canals, with the buccal canal being thin and curved.
Upper second premolars are usually single rooted but may have two canals.
Upper molars generally require access cavities of triangular shape and are located
on the mesial half of the tooth. Generally, there are three root canals, although the
mesiobuccal root may have two canals.
Mandibular
Lower anterior teeth have roots that are flattened mesiodistally and may have two
canals.
Lower premolars generally have single root canals.
Lower molars require access cavities that are generally triangular to rectangular in
shape. The mesial root most commonly has two canals, with one canal in the distal
root. Variations in the number of canals include the lower second permanent molar
that may have only one mesial canal, while some lower molars have four root canals.
In the primary dentition, pulp horns are relatively prominent and pulp chambers are proportionally
larger in comparison to the permanent dentition. The roots of primary teeth are long and slender.
Pulp treatments are generally pulpotomies (removal of the parts or the whole pulp chamber with
treatment of the pulp in the root canals) rather than pulpectomies (removal of the pulp from both
the pulp chamber and canals).

129
Access cavity outlines for permanent maxillary and mandibular teeth
Occlusal view
Access cavities are used to gain entry to the pulp chamber and root canal/s of teeth. The
cavity outlines follow the general shape and positions of the pulp chambers.

130
Notes
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_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
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131
Timing and Sequence of Tooth Calcification

The term chronology is often used to refer to the timing of developmental events, while sequence
refers to the order of development.
Knowledge of the development of the dentition can be applied in many areas: dentistry
(paedodontics, orthodontics); physical anthropology; endocrinology; nutrition; forensic science.
There is considerable variation in developmental timing which tends to follow a normal distribution.
Development of the dentition can be studied by a number of means:
1.
Histological - examination of sections of developing teeth
2.
Radiological - use of radiographs
3.
Clinically - tooth emergence
Histological assessment is the only method available for prenatal studies. Material that is studied is
obtained from non-pathological aborted foetuses; therefore all the material is postmortem. Bertram
Kraus (Kraus Dental Anatomy and Occlusion) has carried out a lot of work in this area.
Radiological assessment is used to study postnatal development. Several longitudinal studies have
been carried out, e.g. Fels growth study at Yellow Spring, Ohio. Radiographs are taken of the
same individual over a period of time to determine how much tooth mineral is present. There is a
set sequence of events in dental development, which can be studied on radiographs:
1.
Formation of dental crypt (dental follicle formed)
2.
Calcification of cusps
3.
Calcification of crown
4.
Calcification of roots
5.
Emergence
6.
Closure of the apical canal of roots.
Clinical assessment can be studied directly in the mouth by examination of dental casts that are
made from impressions recorded at regular intervals (refer Examination of Dental Casts, p 191).
Using a stylised method, one can study these stages, i.e:
1.
crown (tips of cusps, crown complete)
2.
roots (R1/4, R1/2, R3/4, root complete)
3.
apex (1/2 open, closed)
Primary tooth formation

The first radiological evidence of development of tooth germs is round radiolucent areas in the
bone at about 8-10 weeks in utero. The primary central incisors start to mineralise at about 3-4
months in utero, while the last tooth to begin to mineralise at approximately 6 months are the
primary second molars. In other words, all primary teeth have started to calcify by about 6 months
in utero.
The sequence of calcification of the primary teeth is:
1.
central incisor
2.
first molar
3.
lateral incisor
4.
canine
5.
second molar
132
At birth:
approximately 3/4 of the crown of central incisor has calcified
1/2 of the crown of lateral incisor has calcified
1/3 of the crown of canine has calcified
cusps have united on the first molar
and cusps are isolated on the second molar.
The varied stages of development of teeth are relevant to fluoride therapy and the question of
whether women should take fluoride during pregnancy. The evidence is equivocal. It has been
suggested that there is placental control of fluoride blood levels in the foetus, although more recent
evidence suggests that fluoride passes freely from mother to foetus, within physiological levels, but
the rapid renal excretion and uptake by the skeletal system of the mother may be important in
restricting the availability of fluoride to primary teeth. This is supported by the reported low levels of
fluorosis in primary teeth, although the whiter appearance of primary teeth may result in an
underestimation of the numbers of affected primary teeth. It should be noted that the areas of the
teeth that are most often carious are the contact point regions of the first molar and second molar,
and these areas are not yet calcified at birth.
All crowns of the primary dentition have completed calcification by 12 months post-natally. The
canine is slow to calcify.
Root formation, generally, is not completed until the teeth have been in the mouth for about 12
months.
Root completion occurs as follows:
1.
central incisor - 18 months
2.
lateral incisor - 24 months
3.
canine - 40 months
4.
first molar - 30 months
5.
second molar - 42 months.
Permanent tooth formation

These teeth calcify post-natally.
The first permanent molar (6) starts to calcify at about birth, although, radiographically it is rare to
find a mineralised 6 at birth.
In the newborn, the mesiobuccal cusp is first seen generally at 2-3 months after birth.
The central incisors and lower lateral incisors start to calcify at 3-5 months.
The upper lateral incisors do not start to mineralise until 12 months.
The third molars show tremendous variation and may commence to calcify between 7 to 12 years
Crown development takes about 4 years and by 8 years of age all the crowns (except 8) are
completely formed.
With respect to root development, the 6 forms more rapidly than the other molars and it completes
its root development by about 9 years of age. The 6 is intermediate in its development between the
primary and permanent dentitions.
Root development for the remaining permanent teeth takes 4-5 years for the incisors and 7-8 years
for canines, premolars and molars.

133
Variability
Variability in development and mineralisation occurs between individuals, sexes, and ethnic
groups.
In individuals, agenesis (lack of development of a tooth) may occur. It is more common in the
permanent dentition.
Between sexes, variable differences generally are found. There is not much difference between
males and females in development of the primary dentition; however, with an increase in age, teeth
in males tend to develop later, in that females get their permanent teeth earlier than males.
The crowns are generally smaller and roots are shorter in females. The lower canine shows the
greatest difference, developing earlier in females.
Between ethnic groups some differences include a more orderly sequence of development in
Aboriginals and Negroids by comparisons with Caucasians. The third molar tends to develop earlier
in Aboriginals (about 9 years), while the late appearance of the third molar in Caucasians may be
partial expression of an agenesis gene.
Application of tooth formation knowledge

Various methods for dental age estimation are used to determine whether an individual is an early
or late developer, sometimes termed physiological age assessment.
These include:
1.
the Fanning method (each tooth assessed separately)
2.
the Demirjian method (tooth scores are combined)
Individuals can be compared with norms of tooth development and decisions regarding early or late
development of the patient can be made. This is useful for orthodontists because age, growth and
development are important in the diagnosis and treatment of malocclusions.
The paedodontist is interested in knowing whether teeth are going to be present or not, e.g. the
upper lateral incisors or second premolars may be missing. This will influence treatment planning,
e.g. with respect to retention of primary predecessors.
The endocrinologist may use dental development in the assessment of glandular function because
accelerated dental development may indicate altered function. Generally, however, the teeth are
not affected as much as other body systems.
Tetracyclines may be given for upper respiratory tract infections. They have few side effects, but if
given during dental development, staining of teeth may result. If this staining affects the permanent
teeth, there may be very important consequences in terms of possible defects in the mineralisation
of teeth and aesthetics.
During the early 1960s there was a flurry of reports of human and animal studies on the effects of
tetracyclines on teeth. One of these studies by a research group in Melbourne Australia reported
on human primary teeth affected by tetracyclines. Tetracyclines are absorbed by the placenta and
pass this barrier, and they may be ingested during breast-feeding.
In relation to the primary dental development, tetracyclines should not be prescribed during the last
trimester of pregnancy. Tetracycline is deposited mainly in the inorganic component of dental
tissues during formation. Following exposure to light, the complex deposited in dentine may oxidise
and discolour, or coloured degradation products of tetracycline may bind to the mineralised
component of dentine. Permanent anterior teeth start to form in the first few months after birth until
4-5 years; therefore, use of another drug, if possible, is important during this time. Tetracycline
affected teeth will fluoresce under UV light.
Insults during development may affect tooth formation. For example, trauma to a primary tooth may
cause dilaceration of the permanent successor, or viral diseases may influence calcification.
134
These insults may result in bands, pits, (hypoplastic areas) and/or hypomineralised areas (e.g.
white/discoloured areas).
If fluoride is available during tooth formation, it is incorporated into enamel in the form of
fluorapapite. Excess fluoride (greater than 1 ppm) may cause fluorosis or mottling of teeth i.e.
hypomineralised areas (mild = white/opaque; severe = brown). Tooth formation chronology can be
used to determine when these insults occurred on tooth crowns.
Archaeologists use dental information in aging remains and determining the severity and timing of
environmental insults, while forensic odontologists use knowledge of dental calcification for age
determination.

135
Primary tooth calcification

Sequence
1
2
3
4
5
51, 61, 71, 81

54, 64, 74, 84
52, 62, 72, 82
53, 63, 73, 83
55, 65, 75, 85
(A)
(D)
(B)
(C)
(E)
upper before lower

upper before lower
upper before lower
lower before upper
upper before lower
Calcification at birth
51, 61, 71, 81
52, 62, 72, 82
53, 63, 73, 83
54, 64, 74, 84
55, 65, 75, 85
(A)
(B)
(C)
(D)
(E)
3/4 crown
1/2 crown
1/3 crown
Cusps united
Cusps isolated
Approximate age of crown completion

51, 61, 71, 81
52, 62, 72, 82
53, 63, 73, 83
54, 64, 74, 84
55, 65, 75, 85
(A)
(B)
(C)
(D)
(E)
2 months post-natally
Approximate age of root completion

51, 61, 71, 81
52, 62, 72, 82
53, 63, 73, 83
54, 64, 74, 84
55, 65, 75, 85
(A)
(B)
(C)
(D)
(E)
18 months
24 months
40 months
30 months
42 months
Permanent tooth calcification

Initial calcification
1
3 months
2 (Mand.) 5 months
(Max.)
1 year
5 months
1- 2 years
2- 3years
birth
2- 3years
7 -12 years
Crown development takes approximately 4 years.

By 8 years of age, the crowns of all teeth, except M3, are completed.
Root development takes 4-5 years for incisors and 7-8 years for canines, premolars and molars.
The permanent first molar forms more rapidly than the other molars and has completed
development in 9 years (intermediate between primary and permanent development (i.e crown =
3y; root = 6y)).
136
Notes

137
Tooth Eruption and Emergence

Eruption refers to the movement of a developing tooth and emergence refers to its appearance in
the oral cavity. The initiation of the eruption of teeth is accompanied by the initial formation of the
root. The mechanisms of tooth eruption are discussed in Dental and Health Science II.
Primary dentition
Primary teeth, which form more quickly than permanent teeth, emerge when their roots are about
1/2 formed. The tooth, therefore, is present in the mouth some time before development is
complete.
A baby may be born with primary teeth (natal teeth) or teeth may erupt into the mouth during the
first month (neonatal teeth). Often, there is a familial history of natal or neonatal teeth. Sometimes
babies are born with structures that appear to be erupted teeth, usually in the mandibular incisor
region. These are often hornified epithelial structures without roots that are found on the gingiva
over the crest of the ridge. They may be easily removed, whereas prematurely erupted true primary
teeth generally are not extracted.
Primary teeth generally emerge into the oral cavity between 6 months and 2.5 years. The
sequence can be quite erratic, although there are no sex differences and there usually is symmetry
between sides in the timing of emergence.
Although it is often altered, the order of primary tooth emergence is generally:
1.
the central incisor
2.
lateral incisor
3.
first molar
4.
canine
5.
second molar.
Premature children tend to have fewer teeth present in the oral cavity prior to approximately 5
years. As they catch up quickly, by 5 years there is little difference by comparison with a full-term
child.
After the crown and root have completely formed, root resorption begins. Resorption occurs at
about 2 years in incisors, and continues for 4-5 years, while resorption begins at 3-4 years for
canines and molars and continues for 6-8 years.
Root resorption begins at the root apex. Initially the apical area is rounded off to a blunted shape
and gradually the root is resorbed towards the crown. Eventually the tooth becomes loose and is
lost from the oral cavity. In primary molars, the mesial portions of roots are first to resorb.
In the absence of pathology, the primary tooth is exfoliated at the right time for the permanent tooth
to emerge. Extraction of a primary tooth may alter the pattern of emergence of the permanent
successor. If a tooth is decayed, resorption may be affected. For example, decay on the distal of
the crown is associated with accelerated resorption on the distal portion of the root; however, if the
tooth is restored, resorption slows down. Resorption is related to the developing permanent tooth,
but even if there is no permanent tooth, resorption still occurs, usually at a slower rate.
Resorption can be considered in various stages, eg. R1/4, R1/3, R1/2, R2/3, R3/4. The tooth is
usually lost at or after R3/4, i.e. 3/4 of the root has been resorbed.
Girls tend to exfoliate their teeth before boys, which is accompanied by earlier emergence of
permanent teeth in girls.

138
Permanent dentition
The first permanent teeth to emerge are usually the first molars, which are important teeth. They
emerge behind the primary second molar and tend to be prone to decay. The lower first molars
(36, 46) are usually first to emerge. Parents should be informed when these teeth emerge.
With respect to dental development, bone maturation and sexual development, girls tend to be
more advanced than boys. With increasing time, this difference increases. Sex differences vary
from approximately 2 months for the first molar, to 6 months for other teeth, and approximately 12
months for the lower canine. Differences in the timing of emergence can be related to tooth size the mesiodistal crown diameters of teeth are smaller in females, and roots of teeth are shorter.
Permanent teeth start to move shortly after crown completion. As the root starts to form they erupt
more quickly; therefore, eruption is slow at first but speeds up subsequently. The tooth is moving at
its fastest when it emerges.
For incisors, approximately 1/2 the root is formed at emergence. For other teeth, approximately 3/4
of the root is formed at emergence. (The canine and second molar tend to have more root formed
when they emerge.)
After teeth have been present in the mouth for about 3 years, apical closure is complete. The teeth
have a very extensive blood supply prior to apical closure. This period of completion of root
formation following emergence of the teeth is an optimal time for fluoride therapy because the
enamel undergoes maturation when ionic transfer can occur between the crown and saliva
following any topical fluoride application and between the pulp and root dentine and periodontal
ligament and cementum.
Variability
Patterns of tooth emergence vary between individuals in a group and also between different ethnic
groups with respect to timing and sequence. Patterns of tooth emergence can be affected by both
general and local factors.
General factors
Permanent tooth emergence can be considered to consist of two active phases:
1.
Phase one, when the first molars and incisors are emerging, i.e. a quiescent period.
2.
Phase two, when the canines, premolars and remaining molars emerge.
Genetic factors play a role in variations in emergence patterns between ethnic groups. There also
appears to be a genetic polymorphism for the emergence sequence of the second premolar and
second molar (P2M2).
Other pairs of teeth that vary in their timing of emergence between individuals are the first molars
and central incisors (M1I1), as well as the maxillary canine and second premolar (CP2).
Socioeconomic factors are also relevant in that earlier tooth emergence is associated with higher
socioeconomic groups.
It has been suggested that the timing of emergence of anterior teeth reflects general physical
status, whereas later developing teeth are influenced by the superimposed effects of the oral
environment, function and the state of preservation of primary precursors.

139
General disturbances that may influence tooth emergence include:
congenital hypothyroidism (cretinism) - delayed tooth emergence
cleidocranial dysostosis - multiple unerupted teeth
infantile rickets - delayed eruption
Down syndrome - delayed eruption
Usually, dental development is not retarded unless there is a severe disturbance.
Local factors
Premature extraction of primary teeth usually accelerates eruption of the permanent successor;
however, if the primary tooth is extracted very early, the permanent successor may be delayed.
Early extraction of the permanent first molar or permanent second molar tends to accelerate
eruption and emergence of the third molar.
The amount of space available in the arch will influence eruption. For example, leeway space or
lack of it may mean there is insufficient space for the teeth to emerge.
The inclination of the tooth during its eruption is important as well as the presence of obstacles
such as supernumerary teeth or cysts that may influence emergence.
Bibliography
Brown T (1978) Tooth emergence in Australian Aboriginals. Annals of Human Biology 5(1):41-54.
Falkner F and Tanner JM (1978) Human Growth, 2. Postnatal Growth. Plenum Press, New York.
Chapter 15, pp. 413-44. BSL: 612.65 H918 (Main)

140
Emergence of primary teeth

Tooth
Maxillary
Mandibular
Median age in months
95th percentile
51,
52,
53,
54,
55,
61 (A)
62 (B)
63 (C)
64 (D)
65 (E)
10.1
12.0
19.9
15.6
29.0
14.5
17.2
26.2
20.6
36.6
71,
72,
73,
74,
75,
81 (A)
82 (B)
83 (C)
84 (D)
85 (E)
6.7
13.6
20.4
16.3
27.7
13.6
20.3
26.5
21.0
37.6
Shedding of primary teeth

Tooth
51,
52,
53,
54,
55,
61,
62,
63,
64,
65,
71,
72,
73,
74,
75,
Maxillary (years)
Mandibular (years)
67
78
10 12
9 11
10 12
57
78
9 12
9 11
10 12
81 (A)
82 (B)
83 (C)
84 (D)
85 (E)
Emergence of permanent teeth

Male
Maxillary
Mandibular
Female
Tooth
1
2
3
4
5
6
7
1
2
3
4
5
6
7
Tooth
75th percentile
25th percentile
7.4
8.6
11.8
11.3
12.1
6.7
12.7
8.0
9.5
12.7
12.2
12.9
7.3
13.6
6.8
7.8
10.9
10.4
11.2
6.1
11.8
5.8
6.4
9.5
8.9
9.7
5.1
10.3
9.1
10.9
14.2
13.6
14.4
8.4
15.1
6.6
7.8
11.0
11.2
12.1
6.6
12.2
7.3
8.4
11.8
12.0
13.0
7.3
13.0
6.0
7.1
10.2
10.4
11.2
6.0
11.3
5.0
6.0
8.9
9.0
9.7
5.0
9.8
8.3
9.6
13.1
13.3
14.5
8.3
14.5
Median
n
Median
75th percentile
25th percentile
5th to 95th percentile
5th to 95th percentile
Maxillary
1
2
3
4
5
6
7
7.2
8.2
11.2
10.8
11.7
6.6
12.3
7.7
9.1
12.1
11.6
12.6
7.2
13.2
6.6
7.4
10.3
10.0
10.7
5.9
11.4
5.6
6.0
8.8
8.6
9.2
4.8
9.9
8.7
10.5
13.6
13.0
14.2
8.3
14.7
Mandibular
1
2
3
4
5
6
7
6.4
7.5
10.1
10.6
11.7
6.4
11.7
7.0
8.2
10.9
11.4
12.6
7.0
12.6
5.8
6.8
9.3
9.8
10.7
5.8
10.9
4.8
5.7
8.0
8.5
9.1
4.9
9.4
8.0
9.3
12.2
12.7
14.2
8.0
14.1
Reference: Halikis, SE. (1961) The variability of eruption of permanent teeth loss of deciduous teeth in
Western Australian children. I. Times of eruption of permanent teeth. Australian Dental Journal, 6:
137-143
Population: Diamanti, J and Townsend, G (2003) New standards for permanent teeth emergence in Australian
children. Australian Dental Journal, 48: 39-42
141
Anatomy of the Skull

Components of the skull
The skull is made up of a number of bones, most of which are separated by fibrous joints called
sutures.
The skull may be subdivided as follows:
Skull
Cranium
Mandible
(Fixed)
(Moveable)
Calvaria
Calva
Upper Face
Cranial Base
Facial Skeleton
(Fixed)
There are 22 bones in the adult skull. Some are paired bones and some are single.
Calvaria (No. of bones)
Parietal (2)
Temporal (2)
Facial skeleton (No. of bones)
Frontal (1)
Ethmoid (1)
Sphenoid (1)
Occipital (1)
Nasal (2)
Lacrimal (2)
Inferior concha
(turbinate) (2)
Maxilla (2)
Zygomatic (2)
Palatine (2)
Vomer (1)
Mandible (1)
The mandible is attached to the cranium via a synovial joint, called the temporomandibular joint
(TMJ).
Variability in form of the skull

Variability in skull morphology can be considered in relation to the following:
Age
There are differences in size and proportions of the skull between children, adolescents, adults,
elderly (edentulous), e.g. sinuses develop and remodelling occurs in relation to muscle
attachments.
Sex
There are differences between males and females, for example:
mastoid process is longer and more robust in males
upper orbital margins are sharper in females
forehead is more vertical in females
muscle markings, e.g. angles of mandible, are more prominent in males
cranial capacity is less in females

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Ethnic group
Differences occur, e.g. Aboriginal skulls are robust; Caucasian skulls are often gracile.
Evolutionary changes
Hominid changes include a decrease in prognathism, alterations in dental arch shape and tooth
size, lowering of F. magnum and decreased robusticity.
The skull should not be considered to be static; rather it is a labile structure that shows
considerable variability.
Functions of the skull

The skull provides both support and protection for the brain and special sense organs, e.g. sight,
hearing, smell, and enables food to be obtained and chewed.
The skull protects the brain from external impacts. The brain is surrounded by meninges and
cerebrospinal fluid (CSF) which act as a cushion or buffer within the rigid skull. Space occupying
lesions can cause a rise in intracranial pressure, however, with devastating effects.
The skull is also well designed to absorb the stresses and forces exerted by the powerful muscles
of mastication.

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Lateral view of skull
Frontal view of skull

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Interior of base of the skull

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Radiographic Anatomy
Material covered in this section is an introduction to Dental Radiology, which is studied in greater
depth in Dental Clinical Practice I and II, Aspects of Basic Physics and Dental and Health Science
II. Normal anatomical features are considered and related to their radiographic appearance.
Radiography describes the technique of producing radiographs. Radiology refers to the science of
ionising radiation, including the therapeutic use of X-rays, diagnosis and treatment. Radiographs
are obviously an important diagnostic aid in dentistry, e.g. to look for evidence of decay,
periodontal disease, unerupted teeth, root morphology, cysts, supernumerary teeth and agenesis.
Briefly, a source (X-ray machine) produces X-rays that pass through the object to a film.
Radiopaque structures appear as white areas on the film; radiolucent areas appear dark.
Good quality radiographs without elongation or distortion of the object image are needed in
dentistry and a thorough understanding of normal anatomy is essential.
Radiographs can be either:
1.
Intraoral: bitewings, periapical, occlusal
2.
Extraoral: lateral head, oblique lateral, panoral, e.g. OPGs (orthopantomographs)
Bitewing radiographs are commonly used to detect dental caries and to show the contour of
restorations, gross calculus and pulp chamber anatomy.
Dosage of radiation to the patient must always be carefully considered, especially the gonadal
dose. A safe technique is needed, e.g. lead apron, thyroid shield and good equipment that is
checked regularly.
It must be realised that the film obtained is only a two-dimensional representation of a threedimensional object and so there will often be superimposition of structures which must be
interpreted.
Dense dental structures that will appear radiopaque include:
amalgam fillings
enamel
cortical bone.
Less dense structures which appear radiolucent (to varying degrees) include:
dentine
cancellous bone
cementum
soft tissues.
Maxilla
Radiographic landmarks on the base of the skull include:
the incisive foramen
and the median palatine suture.

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Other landmarks that are visible are:

the zygomatic process of the maxilla
zygomatic arch
maxillary tuberosity
and pterygoid hamulus (hamular process).
On an occlusal radiograph the incisive foramen, median palatine suture and zygomatic process of
maxilla can be identified. A lateral view of the maxilla shows the zygomatic process, zygomatic
bone, tuberosity and hamulus.
The alveolar process of the maxilla (bone related to the roots of the teeth) is composed of
cancellous bone. The sockets are enveloped by a dense cortical layer of bone which appears
radiopaque on radiographs and is called the lamina dura. A radiolucent line, which represents the
periodontal ligament, is between the root of the tooth and the lamina dura. The zygomatic process
may obscure roots and surrounding tissues of upper molars.
In a radiograph of upper central incisors, images of the nasal fossae may appear as elliptical
radiolucent areas of various sizes separated by a radiopaque band representing the nasal septum.
Sometimes, images cast by the nasal fossae are very large and may approach the apices of the
upper central incisors. The incisive foramen is seen in the midline of the hard palate immediately
above and behind the central incisors and is often related to the apices of upper incisors in
periapical films. Its radiographic appearance is a roughly circular or elliptical radiolucent area. The
degree of radiolucency depends on the vertical angulation and alignment of the incisive canal; the
more closely the central ray coincides with the canal, the greater is the degree of radiolucency.
Radiographically, the median palatine suture may be indiscernible or it may appear as a
radiolucent line.
The most important structure in the premolar-molar area is the maxillary air sinus. This sinus
occupies a large part of the body of the maxilla in the adult. Although not completely visible in a
periapical film, it may appear as a radiolucent area that varies greatly in dimension.
The radiopaque line representing the floor of the sinus usually appears near the apices of the
premolar and molar teeth, but extensions may occur into the alveolar process, especially in older
persons and following loss of teeth. The position of the floor of the sinus varies considerably, being
approximately on a level with the floor of the nasal fossae at puberty, and well below this level in
the adult. If pneumatisation is incomplete, the sinus floor may be so high that it will not be evident
on a radiograph. The maxillary sinus may have bony partitions or septa that divide the sinus into
compartments. In distinguishing the sinus, look for the inverted Y appearance formed by the
confluence of the lateral wall of the nasal fossa and the anteromedial wall of the sinus.
The plexuses from which the nerve and blood supply of the upper teeth are derived and found in
minute canals referred to as nutrient canals. These nutrient canals may appear as small
radiolucent dots in cross-section, termed nutrient foramina.
The maxillary tuberosity is a rounded eminence of bone behind the last molar tooth. It usually
contains cancellous bone, but may be pneumatised by an extension of the maxillary sinus. The
coronoid process of the mandible may be superimposed on radiographs of upper molars when the
mouth is wide open.
Variations of maxillary landmarks that could be misinterpreted include the following:
Incisive foramen - confused with periapical pathology of upper central incisors.
Differentiation may be made by retaking the radiograph at a different angle. If the
teeth are not involved they will be vital and the lamina dura will be intact.
Median palatine suture - may be so wide and radiolucent that it is mistaken for a fracture.
Extension of the maxillary sinus - may confuse with cystic involvement.

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Tuberosity extension of the sinus results in thinning of the posterior inferior wall of the
sinus, making it very fragile. This is very important if planning tooth extraction as
fracture of the tuberosity and opening of the sinus to the oral cavity can occur.
The image of the coronoid process may or may not be superimposed on the maxilla.
Mandible
The following can be identified from a view of the lateral surface of the mandible
mental protuberance
mental foramen
external oblique ridge
ramus.
A radiograph of the mandible from the lateral aspect will show the above landmarks. On the medial
surface of the mandible note
the genial tubercles (mental spine)
mylohyoid ridge (internal oblique ridge)
and mandibular foramen.
The above landmarks are also visible on a radiograph.
The periodontal ligament appears as a radiolucent band around the roots of lower teeth. The
lamina dura surrounds the tooth root outside the periodontal ligament space. The interproximal
alveolar bone crest can be seen between adjacent teeth.
The cancellous bone of the mandible produces a characteristic picture:
1.
the trabeculae produce radiopaque lines of varying widths
2.
the radiolucent areas between represent the medullary spaces.
The trabecular pattern should be visualised as a three-dimensional lattice and not the chicken wire
appearance it has in a two-dimensional radiograph. The pattern of cancellous bone varies such
that medullary spaces may be large or small and trabeculae may be coarse or thin.
The external oblique ridge is a continuation of the anterior border of the ramus. It passes
downwards and forwards over the lateral surface of the mandible, appears as a radiopaque band
in the molar region and may overlap the crown of the third molar. The mylohyoid ridge begins
posterior to the third molar on the medial surface of the mandible and extends downwards and
forwards. It provides an origin for the mylohyoid muscle which forms the floor of the mouth and
appears as a radiopaque line of varying width that often overshadows the roots of the molar teeth.
It is located in a more inferior position than the external oblique ridge.
The inferior alveolar artery and nerve that supply the lower teeth run through the mandibular canal.
The mandibular canal runs forward through the body of the mandible to the region of the premolar
teeth. At this point the inferior alveolar artery and nerve divide into incisive and mental branches.
The mandibular canal occupies various locations, ranging from adjacent to the border of the
mandible to close to the apices of the teeth. It has a tramline appearance due to denser cortical
bone around the canal. The location of the canal must be established, especially prior to extraction
of teeth (e.g. third molar).
The mental foramen appears as a roughly round or oval radiolucent area in the premolar region.

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The exact location varies radiographically with its anatomical location and the angulation of the Xrays. It usually lies between and just below the apices of the premolars and is directed outwards,
upwards and backwards. The foramen may appear higher than the apices of the premolars on
some radiographs. Tracing the outline of the mandibular canal will usually determine whether a
radiolucency at the apex of a premolar is, in fact, the mental foramen. It may be necessary to take
another radiograph from a different angle to establish if the radiolucency is the mental foramen. In
a normal vital tooth the lamina dura continues as an unbroken line around the apex.
In the centre of the radiopaque circle representing the genial tubercles a radiolucent dot may be
seen. This represents the lingual foramen. The genial tubercles, two on either side of the
symphysis, are located on the lingual surface of the mandible, a short distance above the inferior
border. They are small spines that appear as a radiopaque circle.
The mental process or protuberance is located on the anterior aspect of the mandible. It varies
considerably in density and prominence.
Nutrient canals are evident in the bone and may be misinterpreted as evidence of fracture or
infection. The incisive nerve and blood vessels supply the anterior teeth and supporting tissues.
Branches may leave the bone through nutrient foramina near the alveolar crest, lingual to the
incisors and terminate in the gingiva.
The temporomandibular joint articulates the mandible to the base of the skull. The condyle of the
mandible articulates with the mandibular fossa (glenoid fossa) of the temporal bone. Interposed
between the two articulating surfaces is a fibrous disc: the articular disc or meniscus. The joint is
enclosed by a fibrous cuff or capsule. Radiographs may be taken with the mouth open and closed
to show the relationship of the condyle to the mandibular fossa and articular eminence.
There are areas of possible misinterpretation of mandibular landmarks:
Large medullary spaces (internal point of bone), which may be mistaken as cysts.
Concavity on the lingual surface of the mandible between the mylohyoid ridge and
the inferior border of the mandible. It is occupied by the submandibular gland,
which may be mistaken as a cyst.
Mental foramen varies in position and may be mistaken for periapical pathology.
Always trace around the lamina dura and perhaps take another radiograph
from a different angulation.
Must be able to recognise incomplete root development of teeth, especially molar
teeth, where the crown has calcified but no root formation has occurred - may
be mistaken for pathology.
There are numerous nutrient canals that may appear in both edentulous and dentate
areas. They may resemble fracture lines.
The hyoid bone may be superimposed on the mandible in lateral oblique jaw
extraoral radiographs.

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Dental Diseases
The most common dental diseases, which affect most of us, are dental decay (caries) and gum
disease (gingivitis).
Dental caries
Dental caries refers to the progressive localised demineralisation and destruction of tooth tissues.
(LATIN caries = rottenness)
Theories of the aetiology (or cause) of caries
th
th
From as early as the 7 Century BC until the 18 Century it was commonly believed that worms
caused dental caries. Treatments were aimed at fumigating the tooth. For example, Guy de
Chauliac (1300-1368), a famous surgeon, advocated fumigation with seeds of leek and onions!
By the late 19th Century the chemo-parasitic theory of caries was established. This theory of caries
aetiology basically states that dental caries is caused by acids produced by micro-organisms of the
mouth. Whilst there have been other theories proposed subsequently, it is generally agreed now
that acid produced by oral bacteria in dental plaque is an important factor in producing dental
caries.
Rather than thinking of caries as a one-way process of progressive demineralization of tooth
structure, however, emphasis is now placed on a demineralisation-remineralisation cycle of
chemical reactions that occur on tooth structure.
Caries results from a prolonged imbalance of factors that favour demineralisation over those that
favour remineralisation.
Factors to consider include:
the host (particularly saliva and teeth)
the microflora (i.e. plaque bacteria in the mouth)
diet (the substrate of bacterial plaque).
A fourth factor, time, should also be considered.
Let us look at the evidence for each of these factors.
Bacteria
It has been clearly established that dental caries is an infectious disease. In germ-free animals,
dental caries cannot be initiated. Also dental caries can be transmitted from caries-active animals
to caries-free animals.
The bacteria responsible for dental caries are concentrated at the tooth surface in the form of an
adherent film called bacterial plaque or dental plaque. (The formation of dental plaque is
discussed in more detail later.)
Bacteria in dental plaque can rapidly ferment sugars, e.g. sucrose, glucose, fructose, producing
acid. This causes a drop in the pH of plaque (pH values range from 0 to 14. Values below 7 are
acidic; those above alkaline). If the pH in plaque falls below a certain critical level (usually
considered to be pH = 5.5), microscopic demineralisation of the enamel can occur. Enamel is
hydroxyapatite crystal Ca 10 (PO 4 ) 6 (OH) 2 and will break down in an acid environment.
Repeated cycles of acid generation can, in time (say 18 6 months), cause an early or incipient
carious lesion, an opaque white or brown spot beneath the plaque layer. As more demineralisation
occurs, the surface enamel loses hardness, bacteria penetrate into the enamel, and a macroscopic
cavity appears.
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The series of events may be as follows:

Initial demineralisation - remineralisation due to Ca and P ions in saliva may occur.
Further demineralisation - continued drops in plaque pH will cause further demineralisation,
which tends to be more extensive below the surface layer of enamel. A lesion can
therefore be quite advanced before it can be detected clinically. Radiographs may
show early carious lesions, especially in interproximal areas.
Surface breakdown - continued pH drops will eventually lead to surface breakdown and
cavity formation.
Progression of lesion - caries may progress through enamel to dentine and then to the
pulp. Pulpitis (or inflammation of the pulp) may follow and produce pain. Pulp
necrosis or death may follow and toxic products from the pulp can then produce
pathology in the periapical tissues, e.g. an abscess.
The results of experimental studies in animals indicate that one of the most cariogenic organism(s)
is Streptococcus mutans, a gram positive acidogenic organism. Studies in humans support the
view that S. mutans plays a very important role in human caries. Other microorganisms are also
likely to be involved too, e.g. Lactobacillus. S. mutans seems to be particularly important in smooth
surface caries, e.g. interproximally, whereas Lactobacillus and others play a role in pit and fissure
caries.
Streptococcus mutans has a number of properties that make it such a likely candidate in caries
production.
It can rapidly form lactic acid and other acids from carbohydrates, e.g. sucrose, glucose.
It can survive in a low pH environment.
It can produce extracellular polysaccharides from sucrose. Two important extracellular
polysaccharides are fructans and glucans (homopolymers of fructose and glucose
respectively). Glucans form the bulk of the plaque matrix. They are sticky and
insoluble and enable bacteria to stick to the tooth and also stick to each other, e.g.
aid in colonisation of bacteria. They also protect bacteria and retain an acid
environment at the tooth surface. Fructans can be metabolised to acid even after
sucrose is cleared from the mouth.
Diet
There is overwhelming evidence that rapidly fermentable carbohydrates, especially sucrose (which
is a disaccharide consisting of fructose and glucose), are associated with dental caries.
The evidence comes from many areas, for example:
1.
The prevalence of decay in native populations, e.g. Australian Aboriginals, was very low prior
to their exposure to European-type diets with high amounts of refined sugar. Similar patterns
have been noted in other countries: as sucrose intake increases, dental caries increase.
2.
Controlled human studies.

Vipeholm Study
Patients at a mental institution in Sweden were divided into groups to compare the effects of
carbohydrate intake. As sucrose intake increased, so did caries. More particularly, as more
sucrose was taken between meals, caries experience was even greater. The form of sucrose
was important also. Sticky, adhesive forms of sucrose-containing foods that maintain high
sugar levels in the mouth were more cariogenic.

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Hopewood House
This study involved institutionalised children in NSW. Sugar and other refined carbohydrates,
e.g. white bread, were excluded from the diet and there was virtually no decay. When the
children left the home and were examined, later many had a number of decayed teeth.
3.
Hereditary fructose intolerance

This is a genetic disorder in which affected individuals cannot eat substances containing
fructose or sucrose without becoming ill. These people have virtually no decay.
Apart from fermentable carbohydrates, there are other sources of acid that may lead to
demineralization of teeth, e.g. soft drinks, fruit juices.
Host (saliva and teeth)

There is a tremendous amount of variation between individuals in susceptibility to dental caries.
Differences in dietary patterns and exposure to fluoride account for a good deal of this variation
but, despite these factors, some people seem more resistant than others to dental decay.
There is good evidence that genetic factors can account for some of this observed variation in
caries susceptibility. For example, there is a tendency for relatives of individuals with low caries
experience to also show low levels of caries. Similar patterns of caries attack have also been noted
in identical twins. A very interesting recent study considered the genetic contribution to dental
caries in twins reared apart. Although most of the subjects had been separated for over 40 years,
they showed very similar patterns of decay and restorations despite the fact that they had
presumably been exposed to different dietary patterns and oral hygiene practices, and had also
attended different clinics for treatment.
Two specific factors associated with caries susceptibility that display genetic bases are saliva and
tooth morphology.
Saliva
Saliva is a very important determinant in the aetiology of dental caries.
Saliva has the ability to buffer plaque acids, i.e. resist changes in pH. Phosphate ions and
bicarbonate ions are important buffering agents.
Saliva is supersaturated with respect to calcium and phosphate ions and can therefore contribute
to remineralisation of surface enamel. The fluoride content of saliva is low, but still contributes to
protection of the tooth.
Saliva flow is important. As flow decreases, caries tends to increase (e.g. in patients who have had
radiation therapy for cancer and some damage to salivary glands has occurred). Also, saliva flow
tends to decrease at night.
Saliva contains antibacterial factors, e.g. lysozyme and lactoperoxidase.
Salivary glycoproteins are important in colonisation of tooth surfaces by bacteria. Bacteria must
adhere to a surface first, and then they can multiply.
A group of salivary proteins, designated proline rich proteins (or PRPs) because of their high
content of the amino acid proline, have been associated with early plaque formation. These
proteins have a similar composition to enamel matrix proteins and bind tightly to hydroxyapatite
crystals. At least eight different forms of PRPs have been identified and they are all coded for by a
block of genes located on chromosome No. 12. There is some evidence that certain individuals
may be inherently more susceptible to caries because of their salivary protein make-up.

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Tooth morphology
Tooth size and shape, which is under moderately strong genetic control, also influences dental
caries. The general arrangement of teeth in the dental arches, crowding of teeth, the number of
grooves and fissures on teeth, all influence the likelihood of caries.
It is interesting that one of the effects of fluoride incorporated during formation is to alter tooth
morphology, reducing fissure depth and cusp height of teeth. Other trace elements apart from
fluoride, e.g. selenium, also seem to influence dental caries but it is not completely clear how they
act.
Summary
Dental caries has a multifactorial aetiology.
Bacteria in plaque and refined carbohydrate interact with protective factors, including saliva
and good oral hygiene to determine the balance between demineralisation and
remineralisation.
Repeated pH drops in plaque can lead to demineralisation of enamel. The frequency of pH
drops in plaque is very important.
We have considered the aetiology of dental caries and discussed dental plaque. Since plaque
plays a basic role in the aetiology of the other common dental disease, gingivitis, it is worth
considering plaque formation in more detail.
Plaque formation
Saliva, which is derived from the salivary glands (e.g. parotid, submandibular, sublingual and minor
glands), consists mainly of water (approximately 99%). It also has some organic components
including substances called glycoproteins. These substances consist of a protein core with
carbohydrate side-chains, and give saliva its viscosity.
Glycoproteins are important in plaque formation as they are selectively adsorbed to enamel in the
presence of bacteria to form a thin film. This film, which forms within 30 minutes of brushing, is
called the acquired pellicle (1-10 microns thick). Bacteria can attach to the pellicle and
subsequently multiply and produce extracellular polysaccharides which make the plaque bulkier
and sticky. Bacteria rarely attach directly to teeth, i.e. they need the pellicle to enable them to
attach to the tooth surface.
Plaque composition changes with time. Generally, plaque consists of cocci and bacilli but as
plaque gets older differences in the types of cells occur between those at the tooth surface and
those near the salivary interface.
Plaque composition also differs in different parts of the mouth, e.g. occlusal grooves compared
with subgingival areas.
Plaque + fermentable carbohydrates can dental caries
And
Plaque around the necks of teeth (especially in the gingival crevice) can
inflammation of gums (gingivitis).

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The gingival crevice represents a unique environment for bacteria that can colonise it. Subgingival
plaque differs from supragingival plaque because:
saliva rarely enters the crevice and therefore the pellicle and interbacterial matrix is
different
the crevice is a relatively retentive and stagnant area so less adherent bacteria may
accumulate
conditions favour anaerobic bacteria
crevicular fluid is produced and provides nutrients for certain bacteria.
Plaque that has been present for some time may become calcified to produce calculus or tartar.
This may occur supragingivally or subgingivally and once formed is not easy to remove by
brushing. The calculus provides a good site for further plaque formation.

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Periodontal disease
Virtually everyone suffers from some form of periodontal disease. In many people this may involve
very mild inflammation of the gingival tissues which may bleed slightly during brushing or when
probed by a dentist. There may be more severe inflammation resulting in puffy, swollen, red,
bleeding gums together with a bad taste in the mouth. In a fairly small percentage of individuals,
the process may extend to involve the supporting tissues (periodontitis) causing:
loss of attachment of the gingivae
apical migration of the epithelial attachment
pocket formation
recession
loss of alveolar bone
mobility of teeth and possible loss of teeth.
As with dental caries, periodontal disease has a complex aetiology.
Basically, bacteria in plaque around the necks of teeth can produce toxic products that may cause
inflammation of the periodontal tissues. The balance between bacteria and the body's defence
system is very important, however; that is, bacteria are essential agents, but their presence is in
itself insufficient. Host factors must be involved if the disease is to develop and progress.
There is a difference then between caries and periodontal disease: tooth enamel is relatively inert
whereas the periodontal tissues are vital (living tissues).
In the gingival region the body responds to the growing bacterial mass. White blood cells called
polymorphonuclear leucocytes (PMNs) emigrate out from the blood vessels in the gingival
tissues into the sulcus or crevice where they phagocytose (engulf) and kill bacteria. They form a
protective barrier which tries to prevent or control plaque extension. If there is a build-up of plaque,
toxic products produced by bacteria may cause acute inflammation in the tissues.
This initial stage is followed by the early lesion that is characterised by persistence of acute
inflammation but also with infiltration of lymphocytes, macrophages and plasma cells (part of the
body's immune system). With time, the established lesion develops with mainly plasma cells,
characteristic of chronic inflammation.
The established lesion may:
disappear
remain stable
transform to become destructive, with destruction of alveolar bone - periodontitis.
In chronic periodontitis there is gingival or periodontal pocket formation with ulceration of the
pocket epithelium. Bacteria can then invade the periodontal tissues. The body mounts all of its
defence mechanisms against the bacteria which can produce various antigenic substances
including enzymes, exotoxins and endotoxins.

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There are certain factors that may predispose to gingivitis. These factors may be general or local.
1.
General factors
Apart from natural variation in susceptibility between individuals, certain disease or hormonal
changes may predispose to or modify gingivitis, e.g. pregnancy, diabetes.
2.
Local factors
Areas where plaque can accumulate are likely to be affected, e.g. malaligned teeth, faulty
restorations (overhangs), dentures, orthodontic appliances.

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Preventive Dentistry
Prevention of dental disease
We have discussed the aetiology of the two common dental diseases and theoretical methods of
prevention. Now we will see what we can do to prevent them.
These diseases are preventable!
We know that:
plaque + dietary sugar may decay
NB: It's plaque that causes decay, not food particles.
We know that:
plaque (around the necks of teeth) may gingivitis
NB: The nature of the diet is of less importance in periodontal disease, although the build-up of
plaque is increased with high sucrose diets. Tough, fibrous foods appear to have some beneficial
effect on gingival tissues; however, they have little to no impact on plaque removal around the
necks of the teeth and the gingival crevice, which is critical for prevention of gingivitis.
Obviously:
1.
If there is no plaque there will be no decay and no gingivitis.
2.
If there is no dietary sugar there will be no decay.
(Plaque without sugar won't cause decay; however, consumption of a sugar-free [natural and
added] diet is not practical or realistic.)
Let us consider dental caries in more detail.
If we consider the nature of dental plaque, where it builds up and the fact that it needs to mature
before it can produce acid, we could say that if we completely removed plaque once a day we
should be free of caries. It shouldn't matter when the plaque is removed and it shouldn't matter
how, provided all the plaque is removed.
It is impossible to remove all plaque mechanically, e.g. in grooves and interproximally, but we can
reduce it substantially.
We also know that
constant pH drops cause decay
certain foods produce greater and more prolonged pH drops
sugar between meals is worst, whereas during meals it is not so bad.
If we had no dietary sugar there would be no decay, but this is impossible to achieve. We can
reduce sugar intake overall, however, and particularly in between meals. That is, we should limit
the amount and particularly the frequency of sugar intake not only for our dental health but also our
general health. A sensible approach is to limit sugar in food and drink to meal times only and eat
only foods with no added sugar between meals.

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Approaches to the prevention of dental disease (dental caries and gingivitis) can be considered
under the following headings in order of importance:
Increasing resistance of the tooth:
pre-eruptive
adequate nutrition
systemic fluoride
post-eruptive
topical fluorides
fissure sealants
remineralising solutions.
Dietary control:
reduced frequency of carbohydrate intake
sucrose substitutes
additives.
Plaque control:
mechanical
chemical
immunological
alteration of plaque flora.
All three methods are relevant in the prevention of dental caries, particularly increasing the
resistance of the tooth, whereas the last and, to a lesser extent the second, are relevant in
prevention of gingivitis.
1.
Increasing resistance of the tooth

Fluoride
The aim of fluoride use in increasing the resistance of the tooth and preventing caries is to
provide a continuous low concentration of fluoride in the immediate vicinity of the tooth
surface, so enabling enhancement of remineralisation and inhibition of demineralisation of
the tooth surface.
a)
Water fluoridation
This has proved to be the most effective public preventive approach to dental caries,
providing up to 60% reduction in decay. This arises from incorporation of fluoride
into the tooth during development as well as acting as a provision of fluoride
immediately adjacent to the tooth surface resulting in a continuous source of fluoride
in the oral cavity.

160
b)
Topical fluorides
This approach involves the deposition of fluoride in the surface layer of enamel to
form fluorapatite, which is caries-resistant. The chemicals used include sodium
fluoride, stannous fluoride and acidulated phosphate fluoride. They may be used as
rinses or in gel or paste form.
c)
Remineralising solutions (professionally applied)

Various solutions can be used clinically to encourage remineralisation of
demineralised enamel.
Fissure sealants
These materials, which are synthetic resins, are bonded to the tooth enamel and physically
occlude the pits and fissures of teeth, areas where fluoride has least effect and mechanical
plaque removal is ineffective.
2.
Dietary control
Reduced frequency of carbohydrate intake - we will discuss this method in more detail
later.
Sucrose substitutes
Various substitutes have been tested which are non-cariogenic, e.g. sorbitol, mannitol,
xylitol; however, these may have some side effects. Other non-caloric sweeteners include
aspartame (Nutrasweet), saccharin and cyclamates. Numerous synthetic and natural
derivatives, many of which are much sweeter than sucrose, are currently being tested.
Additives
Many natural foods contain sugar, but they also contain natural protective factors. During
the refining of sugars, a number of protective factors are removed, e.g. phosphates.
Attempts have been made to add protective substances to foods, e.g. calcium sucrose
phosphate (Anticay).
Fluoride can also be added to food, e.g. salt or milk.
Summary
Fluoridation of foods is likely to be effective, but less desirable than fluoridation of water.
The use of substitutes and additives has still not proven practical.
3.
Plaque control
Mechanical plaque control methods - tooth brushing and flossing (with particular
reference to control of gingivitis).

161
Tooth brushing is the most commonly used method to reduce the level of active plaque
around teeth. Efficient removal of plaque is the most important way of preventing or
controlling initial gum disease.
Disease tends to occur where plaque grows thickly; therefore, it is essential to remove it as
much as possible from these areas.
If plaque can be clearly seen, eg. disclosing stain, then
a)
a person can see how adequate their brushing method is in removing plaque
b)
a person can learn to alter his brushing to make it more effective.
It is impossible to remove all plaque with a toothbrush, or in fact any cleaning aid. With
careful brushing, however, a considerable amount of plaque which would potentially
cause gingival disease can be removed. NB: Eating apples or swishing with water won't
remove plaque.
A multi-tufted soft bristle brush is best. This allows maximum penetration of the bristles into
remote areas, whilst causing minimal damage to gingival tissues. There are many
satisfactory brushes now available, including electric toothbrushes. Shaggy-dog
brushes are less effective at removing plaque and should be replaced.
The method of brushing is in itself not crucial to success. In general it is best not to attempt
to radically change a person's brushing method, but rather look for modifications to
improve efficiency. Disclosing agents are helpful in making this assessment. The
modified scrub method is recommended by many. The bristles should just touch the
gum and small movements are used. Tooth brushing should be done systematically
and will take 3-5 minutes to do properly. Overzealous brushing may damage gingival
tissues and/or wear away root surfaces of teeth.
If efficient brushing is carried out, brushing twice a day should be sufficient (say, morning
and night). It is recommended that a fluoride-containing toothpaste is used; however, all
toothpastes contain abrasives so care is needed not to damage tooth structure.
Interproximal cleaning is not completely effective with brushing only. To supplement
brushing for more efficient removal of interproximal plaque (for adults), dental floss may
be used. Dental floss is a thin cord of multiple fine strands of fine nylon thread that
squashes to a fine tape when drawn between tight contacts. Floss may be waxed or
unwaxed, but there is little evidence to demonstrate that one is better than the other.
Mint flavour is also provided. Dental tape is now available also, together with various
accessories, e.g. floss-holders. It is essential that floss is used correctly or damage to
the gingival tissues may result. Patients should always be shown how to use it properly.
Use of floss is not recommended in children as it has not been shown to be useful in
reducing gingivitis in children.
Other oral hygiene aids
There are many other devices available including interdental sticks (Interdens) and
interspace brushes (for interdental regions) that may be beneficial in certain instances.
Chemical plaque control methods
1.
Antibiotics. Antibiotics have been tried in toothpastes but there are problems of
sensitisation with prolonged use, the development of resistant strains and the
overgrowth of unwanted organisms. Recently, antibiotics such as spiromycin,
vancomycin and kanamycin have been used to treat severe gingival and periodontal
disease.
2.
Fluorides. Fluoride in various forms, including fluoride-containing toothpastes and

mouth rinses, has a chemical effect on plaque organisms by inhabiting bacterial
metabolism, including their metabolism of carbohydrates.
3.
Chlorhexidine. This substance does inhibit supragingival plaque formation. It is

adsorbed to tooth surfaces and soft tissues. It is effective if used continuously but
162
may cause mucosal erosions, it reacts with certain substances in the diet to stain
teeth and soft tissues, and has a bitter taste. It does have a place in treatment of, for
example, disabled people, trauma victims and in periodontal surgery.
4.
Dextranase. Theoretically enzymes which degrade dextran (glucan) should be

valuable but as yet no really encouraging results have been obtained.
5.
Mouth rinses. Various substances in mouth rinses have been tried. Whilst some are
effective in the short-term, their long-term effects are not known.
Immunological plaque control methods

There is evidence to suggest that a caries vaccine against S. mutans can prevent caries. It
does not seem to be 100% effective, however, and side effects may occur in humans.
Research continues in this area.
Alteration of plaque flora
Replacing cariogenic organisms by non-cariogenic bacteria, i.e. strains that do not produce
acid, is also the subject of continuing research.
Summary
Regular mechanical removal of plaque can theoretically prevent or reduce dental disease
but it is difficult to achieve on a community basis. Evidence to support that mechanical
plaque removal alone prevents caries is very limited. There is good evidence that the
combination of mechanical removal with a toothbrush plus a fluoride toothpaste can
prevent caries
Many chemical agents have been tested for anti-plaque activity including antibiotics,
antiseptics and enzymes. None has yet been shown to be a completely effective, safe and
acceptable method of controlling plaque in humans.
Prevention of caries by immunisation with S. mutans has been shown in animals. Further
studies are ongoing before this method can be tested safely in humans.
Some aspects of preventive dentistry philosophy

1.
To motivate people you must really believe in what you are saying.
2.
The dental assistant, as well as the dentist, therapist or hygienist, can play a vital role in
educating and motivating patients. The use of models, slides, books, pamphlets etc. often
helps.
3.
Advice on plaque and its control with use of a fluoride toothpaste can be reinforced using
disclosing solutions or tablets, and keeping plaque scores.
4.
Dietary advice should include information on particular problems and also provide
alternatives, e.g. effects of chronic intake of paediatric syrups, constant sucking of sweets,
honey on the dummy, sweetened drinks in baby bottles.
5.
Patients should know the warning signs of disease, e.g. bleeding gums.
6.
Regular check-ups, radiographs to detect early carious lesions, and fluorides are all
important. If the water supply is not fluoridated and after checking for other sources of
fluoride in the patient's diet, fluoride tables may be indicated.
7.
Patients should be properly instructed in tooth brushing with a fluoride toothpaste and
flossing (for adults) and be aware of what they are trying to achieve with these devices.

163
Summary
Fluoride application, e.g. fluoride in drinking water. is the most important factor to consider in dental
caries prevention in conjunction with a reduction in sugar intake. Mechanical plaque removal once
or twice a day should be used as a means to enable application of fluoride toothpaste.
We know that plaque is the culprit in gingivitis, and also that it needs to be mature before it will
cause inflammation. It probably takes 2-3 days before inflammation occurs.
To prevent gingivitis we need to remove plaque at least once a day from around the necks of the
teeth and also between the teeth (interproximally). Perhaps in the future a safe and effective
chemical means of plaque control will be discovered.

164
Bibliography
Berkovitz BKb, Holland GR and Moxham BJ (2002) Oral Anatomy, Histology and Embryology.
Mosby, St. Louis.
Bevelander G, Rolle GK and Cohlan SQ (1961) The effect of the administration of tetracycline on
the development of teeth. Journal of Dental Research 40: 1020-1024
Brand RW and Isselhard DE (1998) Anatomy of Orofacial Structures. 6th ed. Chapter 1, pp2-1`6.
Mosby, St. Louis.
Diamanti JA and Townsend G (2003) New standards for permanent tooth emergence in Australian
children. Australian Dental Journal 48: 39-42
Dixon AD (1986) Anatomy for Students of Dentistry. 5th ed. Churchill Livingstone, Edinburgh.
th
DuBrul E (1988) Sicher and DuBruls Oral Anatomy. 8 ed. Ishiyaku EuroAmerican Inc, St. Louis.
Harcourt JK, Johnson NW and Storey E (1962) In vivo incorporation of tetracycline in the teeth of
man. Archives of Oral Biology 7: 431-437
Jordan RE and Abrams L (1992) Kraus Dental Anatomy and Occlusion. Mosby Year Book, St.
Louis.
Lunt RC and Law DB (1974) A review of the chronology of calcification of deciduous teeth. Journal
of American Dental Association 89: 599-606
th
Nanci, A. (2003) Ten Cates Oral Histology: Development, Structure and Function. 6 ed. Mosby,
St. Louis.
Schroeder H (1991) Oral Structural Biology: Embryology, Structure and Function of Normal Hard
and Soft Tissues of the Oral Cavity and Temperomandibular Joint. Thieme Verlag Thieme Medical
Publishers, Stuttgart.
Skinner MF (1986) An enigmatic hypoplastic defect of the deciduous canine. American Journal of
Physical Anthropology 69: 59-69

165

166
Section III
Occlusion
Morphology of the Dental Arches

Introduction
We have considered the morphology of individual teeth in some detail and will now discuss the
morphology of the dental arches leading on to a study of dental occlusion. The teeth are
arranged in arches. You can form an idea of the shape of dental arches by looking at the
general arrangement of teeth; cusp ridges, e.g. buccal cusp ridges or central grooves; maximum
convexities of buccal surfaces of teeth; alveolar bone; and basal bone (e.g. assessing the shape
of the lower border of the mandible).
Classification
Arch shape in classified in geometric terms. For example:
parabolic (half an oval)
hyperbolic (relatively broader than a parabola)
ovoid (converges in molar segments)
trapezoidal (flat in the incisor region)
omega shaped (restricted in the premolar region)
U-shaped (parallel-sided in posterior segments).
This approach is quite subjective. In order to classify arch shape more objectively various
methods have been proposed.
In 1905, de Terra developed a dental arch index, DA, where
DA = dental arch breadth (M2 - M2) x 100
dental arch length (I1 - M2)
Such an index is of some value in interpopulation comparisons, but individuals could have
different arch shapes but still obtain the same DA score.
Arne Bjrk, a well-known researcher from Denmark, has developed a method of describing arch
shape in terms of a polygon shape, connecting the contact point of incisors, to canines and first
molars.
Functional considerations
We would expect that upper and lower arches would normally fit, i.e. be similar in shape. In fact,
although there are large variations in the ratio of arch breadth/arch length in populations, there
is a tendency for these measures (arch breadth and arch length) to be highly correlated within
individuals. If there is a lack of coordination between the size and shape of the maxillary and
mandibular arches, then malocclusions are likely.
The maxillary arch, generally, is larger than the mandibular arch (it overlaps the lower). This
overlap is referred to as overjet, i.e. the distance that the maxilla projects outside the arch of the
mandible, and is measured in a horizontal plane. The mandible is, therefore, the contained arch.
This overjet arrangement allows for more efficient mastication, it provides for more extensive
movement of the mandible including lateral movements whilst maintaining some tooth contact,
and it provides some protection for the soft tissues, minimising biting of tongue and cheeks.

169
General arrangement
As noted, there is an overjet arrangement (horizontal direction) of the maxillary and mandibular
arches. There is also an overbite arrangement, such that upper teeth bite over the lower teeth
(i.e. overlap the mandibular teeth in a vertical direction). The mandibular teeth tend to be
positioned about half a tooth anterior to their maxillary counterparts in an anteroposterior
direction.
Discrepancies
Discrepancies in arch shape and size may occur and these can be grouped into those in an
anteroposterior or mediolateral direction.
Discrepancies in the anteroposterior direction have been classified by Angle into Class I, Class
II and Class III (Angle's classification), while mediolateral discrepancies are referred to as
crossbites (refer next section for more details).
Features of an intact arch

In an intact arch there is a continuous series of occlusal surfaces of adjacent teeth and there is
continuity of marginal ridges. With a full dentition there are normally no spaces between teeth.
The contact areas between teeth tend to provide a stabilising effect and protect the gingival
papillae.
Embrasures are the V-shaped spaces between teeth, formed where the teeth diverge from their
contact points. There are lingual, labial, gingival and occlusal embrasures between all teeth.
The embrasures form spillways for food and are important as a self-cleansing mechanism.
There is some evidence that gingival tissues which receive functional stimulation tend to retain a
healthy character, whilst if there is a lack of stimulation, plaque may accumulate and be
associated with inflammatory change in the tissues. Poorly contoured fillings may predispose to
food impaction and plaque accumulation.
In clinical dentistry consideration must be paid to contact areas, embrasures, marginal ridges
and overhangs. Loss of teeth may also lead to change in the dental arches, including tilting of
teeth, mesial migration and overeruption.
Determinants of arch morphology

Both genetic and environmental factors are relevant in the development of arch morphology.
Genetic factors are important in determining arch shape variability. Variations in arch shape
between ethnic groups are found, e.g. Negroes tend to show a bimaxillary prognathism
(protrusion of alveolar arches in both upper and lower jaws). Arch shape also is correlated with
the shape of the face which, in turn, is under genetic control. Environmental factors also play an
important role, e.g. thumb-sucking and tongue thrusting may lead to alterations in arch shape.
Obviously, loss of teeth due to extraction may also alter arch morphology due to subsequent
drifting and movement of teeth.
The concept of a neutral zone refers to the region where the teeth lie, being a zone where
pressures from the lips and cheeks on the outside are balanced by pressures from the tongue
on the inside. Professor Proffit, an American orthodontist, studied oral pressures in Australian
Aborigines using small pressure transducers and found that the large dental arches of the
Aboriginals were associated with low lip pressures.
Changes in arch morphology with age

The dental arches show a number of changes in shape with age. Prior to the emergence of the
deciduous teeth, the developing tooth germs lie on a curved arch described as catenary. Upon
170
emergence of the deciduous teeth between 6 months and 2 years of age, there is alveolar bone
growth. The deciduous dental arches are generally ovoid in shape and there appears to be less
variation than in the shape of arches once the permanent teeth have emerged. There is often
spacing in the anterior region of the deciduous arches. This is usually located mesial to the
upper canines and distal to the lower canines. These spaces are sometimes called primate
spaces.
At about 6-7 years of age, when the permanent incisors and first molars begin to emerge, the
shape of the arches alter due to the eruption paths of the teeth. There is an increase in breadth
of the incisor region at this time.
At about 10-12 years, when the deciduous molars are exfoliated and the permanent premolars
emerge, there is some gain in space since the combined mesiodistal diameter of the deciduous
molars is greater than the permanent premolars. This relationship is referred to as leeway
space and may be associated with a reduction in arch length.
When the permanent canines erupt they may be crowded out if there is a discrepancy between
tooth size and jaw size. The tooth size/jaw size relationship becomes important again when the
second and third molars emerge. In the late teens there is a tendency for some uprighting of the
lower incisors which may be accompanied by lower incisor crowding (imbrication).
As previously mentioned, loss of teeth may be associated with changes in arch shape. Even
after the jaws are edentulous the arches are still subject to changes in shape due to resorption
of bone.
Clinical implications
Dental arch shape is a very important concept clinically. In orthodontics, determining the cause
of discrepancies (genetic or environmental), understanding the changes in arches with age and
ensuring the stability of the relationship after treatment, are all very important. In prosthodontics,
bone resorption may alter jaw relations; however, teeth generally are positioned in the neutral
zone.

171
Concepts of Occlusion
Occlusion in its simplest sense merely refers to the contact between upper and lower teeth.
There are obviously several types of occlusion possible depending on the position of the
mandible; therefore the term needs to be qualified.
The occlusion where there is maximum contact between opposing occlusal surfaces is called
intercuspal occlusion. In so-called normal dentitions all the teeth make contact with opposing
teeth by means of:
a)
cusps, fossae and marginal ridges in posterior teeth
b)
incisal edges and lingual surfaces in anterior teeth
but only approximately 60% of dentate individuals have so-called normal dentitions. If there is
an anterior open bite, contact only occurs between the molars in the intercuspal occlusion. The
position of the mandible when the teeth are in the intercuspal occlusion is called the
intercuspal position.
The mandible is capable of many movements and positions and a limited occlusion is possible
in certain of its positions other than intercuspal occlusion. Terms such as lateral occlusion,
protruded occlusion and retruded occlusion are used to describe contact between teeth in
lateral, protruded or retruded positions of the mandible respectively.
Occlusion in its simplest sense is therefore a static concept referring to the moment and place of
contact of teeth. Articulation is the term given to the contact that exists between teeth while the
mandible is moving.
Although one usually examines occlusion and articulation in the empty mouth, obviously one
must consider what happens during function, e.g. during mastication and swallowing. Occlusal
function refers to contact between teeth and between teeth and food during the functions of
mastication and swallowing. Parafunction (wrong or irregular function) refers to non-functional
contact between teeth during habits such as clenching, tapping, grinding, holding pencils, etc.
If we combine all these concepts we can define occlusion as follows:
Occlusion in the broad sense refers to the study of tooth contacts, both stationary and mobile,
both functional and parafunctional, of the tissues that provide these functions, of disturbances
that can affect tissues, and of the treatment procedures devised to restore them.
We must consider the whole of the masticatory system: i.e. the teeth, muscles and
neuromuscular function, the periodontium and the temporomandibular joints. Since the
masticatory system is subject to adaptation, abuse, wear, ageing and disease, it is clear that
occlusion is a changing condition. Responses to these changes will vary from individual to
individual, and from healthy adaptation to total disorder.
As a basis for the study of occlusion we need to understand the morphology of the masticatory
system including individual tooth form, form of the dental arches, opposing tooth contacts,
muscles, temporomandibular joints and neuromuscular activity.
Neuromuscular activity governs movement of the mandible. Movement patterns are
remembered by the neuromuscular system provided signals from occlusal contacts are
constantly reinforced. Sensory receptors are located in the periodontal ligament, muscles of
mastication and TMJs. These sensory receptors convey information about movements and
positions of the mandible and are called proprioceptors.

172
During chewing the following events occur:

1.
2.
3.
4.
5.
The mouth opens. (The degree of opening depends on the amount to be eaten.)
The mouth closes; proprioceptors in the periodontal ligament, muscles and TMJs act.
Proprioceptors transmit information to the mesencephalic nucleus of the Vth cranial nerve.
A crossover of information occurs to the motor nucleus.
Information is directed to the muscles of mastication to close the mandible with the
necessary power and proper function.
Occlusion is basic to dentistry and must be considered in all areas.

In restorative dentistry, occlusion, articulation and occlusal function need to be considered for all
restorations involving the occlusal surfaces of teeth. The presence of high spots and
overcontouring also need consideration in the restoration of an optimal occlusal surface. In
exodontia, loss of teeth may lead to overeruption, tilting and drifting of remaining teeth. The
impact of these and prevention must be considered.
In prosthodontics, the stability of complete dentures is very important. Stability refers to the
property of dentures to resist displacement when subjected to vertical or horizontal forces. The
concept of balanced occlusion and articulation is relevant in prosthodontics and refers to the
simultaneous contact of upper and lower teeth on the right and left hand and posterior and
anterior occlusal areas when the mandible is moved in various positions. If occlusal forces
cause a denture to tilt, the denture loses retention and the supporting tissues may be damaged.
In orthodontics, the orthodontist is concerned with function and aesthetics in relation to
occlusion. The Angle classification of malocclusion is often used to describe the anteroposterior
relationship of upper and lower teeth, i.e:
(a)
Class I -the mesiobuccal cusp of the upper first permanent molar occludes in the
mesiobuccal groove of the lower first permanent molar. This is associated with
malpositioning/crowding of some teeth.
(b)
Class II -the upper first permanent molar is anteriorly placed by comparison with (a)
above.
(c)
Class III -the upper first permanent molar is posteriorly placed by comparison with (a)
above.
In periodontics, the forced generated from occlusion, particularly during parafunction, may affect
the periodontal tissues.
The term occlusal trauma is used to refer to injury to the periodontal tissues of the tooth as a
result of occlusal forces by an opposing tooth or teeth. Primary occlusal trauma refers to the
effect of abnormal forces on healthy periodontium and may be reversible. Secondary occlusal
trauma refers to the effect of forces on diseased periodontal tissues. Factors such as tooth-tooth
contact or overloading by dental appliances may lead to occlusal trauma. The signs include
wear patterns on teeth, mobility of teeth and migration of teeth.
Occlusion can be considered optimal for an individual if it allows the masticatory system to carry
out physiological function whilst maintaining the health and integrity of the associated structures.
Reference
Thomson, H (1990) Occlusion, 2nd ed. Wright, London.

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Occlusal Curvatures and Axial Alignment

Occlusal curvatures
The occlusal surfaces of the dental arches do not conform to a flat plane. In the horizontal
plane, the mandibular arch conforms to curved planes that appear concave, while the maxillary
arch conforms to convex planes. If the dentition is viewed from the lateral aspect (about
opposite the first molars), the cusps and incisal edges of the teeth tend to follow a curve, called
the Curve of Spee, which curves upwards generally from anterior to posterior. This curve is
confined to the sagittal plane (plane oriented in an anteroposterior direction).
b
Fig 1a & b. Curve of Spee

174
If the dentition is viewed from the coronal plane (plane passing from left to right), we find that in
the posterior region there is another occlusal curve that is concave for the mandible. The cusps
of teeth on the right and left hand side lie on this curve, called Monson's (Wilson's) Curve.
b
Fig 2a & b. Monsons (Wilsons) curve
The occlusal curvatures, Curve of Spee and Monson's Curve, allow tooth contact in various
movements of the jaws. If the planes were flat, teeth would soon come out of contact during
mandibular movements. The curvatures also may enable teeth to better withstand masticatory
forces.
The pull of the masseter is perpendicular to the Curve of Spee and therefore the teeth are in
direct line of contraction of masseter. Occlusal curvatures and alignment (or inclination) of teeth
are inter-related: each relies on the other. The teeth themselves must adapt to the occlusal
curvatures. This adaptation provides for axial loading rather than unfavourable loading of the
teeth. For the teeth to fit into the arches there is a need for axial curvatures. The axial curvatures
enhance stability in the dental arches.

175
It is very important to realise that variations occur. Not all occlusal curvatures are the same; some are
more convex, others more concave. There may be a reverse Curve of Spee or a reverse Monson's
Curve (anti-Monson's curve). In Australian Aboriginals, or other groups with marked attrition, the form
of the coronal occlusal plane can vary from an anti-Monson Curve in the M1 region (due to wear on
the buccal cusp of these teeth), to a flat plane in the M2 region, to a normal Monson's Curve in the
M3 region. This produces the so-called helicoidal plane of the molar occlusal surfaces when viewed
from the anterior.
Axial alignment
Teeth are inclined in both mesiodistal and buccolingual directions. The degree of inclination varies
from tooth to tooth. In general, each tooth is placed at an angle that best withstands the lines of
forces brought against it during function. The relationship of the incisors when viewed from the
proximal does not appear to be optimal; however, incisors are generally used for momentary biting
and shearing. Generally, additional support is provided by posterior teeth and the lips tend to oppose
forces. The lower incisors appear to be better aligned to resist forces than the uppers, and this may
be evidenced in cases of secondary occlusal trauma where posterior tooth support has been lost and
upper incisors tend to drift before lowers. The interincisal angle is generally about 130-135 and is
important for aesthetics, allowing gliding contact between incisors in protrusion and for phonetics
(speech).
Fig 3. Incisors when viewed

from the proximal
Fig 4. Molars when viewed from the proximal view.

176
When the dentition is viewed from the front (coronal plane) there is a general tendency for the roots of
teeth to curve distally. In the molar and premolar region in the coronal plane, the upper tooth crowns
are inclined buccally and the lower crowns lingually. From the lateral view (sagittal plane), the teeth
show the tendency for a distal curve of the roots. There is also variation in the axial alignment of teeth
between individuals and also within individuals with age.
Fig 5. Dentition viewed from the front (coronal plane).
Fig 6. Dentition viewed from the lateral (sagittal) view.

177
In the deciduous dentition, the incisors tend to be quite vertical, leading to a marked overbite. This
relationship is generally corrected when the permanent teeth emerge. In the mixed dentition, there is
often an ugly duckling stage with splaying and concomitant spacing of the incisors; however, as the
canines erupt the anterior teeth generally tend to move into correct alignment. In the late teens there
is often a tendency for the lower incisors to become more upright with an increase in interincisal
angle. This may be associated with lower incisor crowding.
Contacts between teeth

Contact between teeth can be described as those located between adjacent teeth and those that
occur when opposing teeth contact in occlusion. The contact areas between adjacent teeth help to
stabilise the dentition and protect the periodontium. The V-shaped areas related to contact areas, i.e.
areas that diverge from the areas of contact, are termed embrasures.
There are four embrasures at each interproximal region:
1. labial
2. lingual
3. occlusal
4. gingival.
When viewed from the labial or buccal view, the level of the contact areas in the maxilla and mandible
tend to move from the incisal 1/3 to the middle 1/3 of teeth as one moves from the anterior to
posterior teeth. When viewed from the occlusal, the lingual embrasures tend to be larger than the
labial in the anterior region, but are of more equal size in the posterior region.
Fig 7. Contact areas when viewed from the occlusal view.

178
Opposing Tooth Contacts in Intercuspal Position

Basic concepts
Lower incisors are narrower mesiodistally than uppers; therefore the lower teeth are located in a
more anterior position in the arch by comparison with the corresponding upper teeth.
Each tooth in one arch contacts two teeth in the other, except for lower central incisors and
upper third molars. The lower teeth occlude anterior to the corresponding upper tooth but they
are not completely offset by half a tooth, i.e. the upper first permanent molar mainly contacts the
lower first permanent molar, but also part of the lower second permanent molar. This system
serves to equalise the forces of impact and distributes load. It preserves the integrity of the
arches such that if one tooth is lost there is still contact for the opposing teeth with the teeth on
either side of the space. (Of course, this may change with drifting of teeth.)
Fig 8.
The upper teeth occlude outside the lower teeth, i.e. there is an overjet of the maxillary teeth
over the mandibular teeth. This serves to protect the lips and cheeks and allow movements of
the mandible with some tooth contact.
Detailed description
Considering contacts from all aspects, e.g. opposing contacts, the relevant occlusal anatomy of
the teeth should be reviewed (refer Tooth Morphology).
Incisors:
Lingual surfaces, cingula, inclinations, incisal guidance, interincisal angle.
Fig 9. Mesial view of maxillary and

mandibular permanent central incisor.
Fig 10. Palatal and mesial views of central

incisor.

179
Canines:
Upper canines are bell-shaped, cingulum, lingual ridge divides the lingual surface
into two surfaces, mesial and distal. These slopes are important as they provide
guidance in articulation.
Lower canines have more parallel-sided mesial and distal profiles and a flatter
lingual surface.
Fig 11. Lingual and occlusal

view of canines.
Premolars:
Uppers are hexagonal in outline from the occlusal, trapezoidal from the proximal,
two cusps, two triangular fossae, two marginal ridges, cusp tips are at the summit
of three ridges - mesial cusp ridge, distal cusp ridge, triangular ridge.
Lower premolars are rhomboidal in outline from the proximal with a lingual tilt,
and tend to be oval-shaped from the occlusal. The buccal cusp is larger than the
lingual cusp. The lingual cusp of the lower first premolar has no occlusal function.
Transverse ridge joins buccal and lingual cusps.
Fig 12. Occlusal view of premolars

180
Molars:
Uppers have typical four-cusped arrangement with central fossae, central pit,
oblique ridge.
Lowers tend to be rectangular in outline with five or four-cusped occlusal, central
fossae.
Fig 13. Buccal, occlusal and mesial views of molar teeth.
Fig 14. Mesial view of first molars

181
Proximal view
The relationship between the upper and lower incisors can be described in terms of overjet,
overbite and the interincisal angle. The incisal edge of lower incisors occludes on the lingual
surface of the upper incisors in the cingulum area.
An overjet relationship exists between the maxillary and mandibular posterior teeth, such that
the buccal cusp of the lowers occludes in central sulcus region of uppers whilst the lingual cusp
of the uppers occludes in the central sulcus region of the lowers.
The buccal cusps of the lower posterior teeth and the lingual cusps of the upper posterior teeth
are referred to as supporting cusps. These cusps occlude wholly within the opposing occlusal
table. They support the mandible and keep forces in line with root bases. These cusps are also
more rounded in shape, more centrally placed and the outer facing surface is called the
functional outer aspect.
The lingual cusps of the lower posterior teeth and buccal cusps of the upper posterior teeth are
referred to as guiding cusps. These cusps occlude outside the opposing occlusal table, they
influence gliding movements and they occlude lightly with the inner surfaces against the
functional outer aspect of opposing supporting cusps. These cusps also are sharper and the
outer aspect of the guiding cusps has no opposing tooth contact.
Labial (or buccal) view

The anterior teeth show an overbite relationship, with the lower incisors being narrower than the
upper incisors. The distal cusp ridge of the lower canine occludes on the mesial slope of the
upper canine. The mesial cusp ridge of the lower first premolar occludes on the distal slope of
the upper canine. The lingual ridge of the upper canine divides the occlusion between the lower
canine and first premolar and also provides guidance in articulation. The mesiobuccal cusp of
the upper first molar occludes in the mesiobuccal groove of the lower first molar (Class I).
Fig. 15 Anterior view of permanent dentition intercuspal position.
Fig. 16 Buccal view of permanent dentition in intercuspal position.

182
Occlusal view
Basically, contact occurs between cusps and fossae and cusps and marginal ridge/triangular
fossa areas. Only two upper and two lower supporting cusps occlude in central fossae, the
mesiolingual cusp of upper first and second permanent molars and the distobuccal cusp of
lower first and second permanent molars. The remaining cusps occlude in opposing marginal
ridge areas. Since the supporting cusps are rounded they generally do not act as plunger cusps.
There is considerable variation in opposing tooth contacts between individuals.

183
Fig. 17 Occlusal view. Distobuccal cusp ridges of lower first and second molars
in opposing fossae. Mesiolingual cusp ridges of upper first and second molars in
opposing fossae.

184
Mandibular Movements and Positions

In studying occlusion we must understand mandibular movements and positions since the type
of occlusal contacts depends on the position of the mandible, e.g. intercuspal occlusion or
protruded occlusion. If we consider occlusion from a dynamic point of view, we also must
consider function. Obviously, mandibular movements are involved. Muscles, teeth and
temporomandibular joints (TMJs) all need to be considered. These components are often
referred to as comprising the temporomandibular articulation, i.e. all the structures
concerned with the suspension of the mandible from the cranium. Each of these components is
functionally interrelated.
Temporomandibular articulation is similar to other synovial joint systems except there are two
temporomandibular joints that are joined. Movements in one will therefore be associated with
movements in the other. Teeth tend to limit movements of the mandible and also guide
movements when the teeth are in contact. Proprioceptors in the periodontium may influence
movements. The TMJ ligament (strengthened lateral part of capsule) tends to limit movements.
Anatomical structures also may limit mandibular movements, e.g. the coronoid process and
zygomatic arch.
Methods used to study movements and positions of the mandible

Intrajoint movements and movements of the mandible can be considered as a whole or from a
fixed point of the mandible, e.g. the incisor point. Studies of intrajoint movements have included
cadaver inspection and cineradiography (intrajoint movements are discussed in more detail in
Structure and Function, second year).
Various methods have been used to study mandibular movements, e.g. the classical work of
Posselt who examined movements of the mandible as a whole by attaching a stylus to the
mandible (between the lower centrals) and then inscribing movements on waxed plates placed
either in the sagittal or horizontal plane. Other methods of studying jaw movements have
included the use of cinematography records of mastication. Digital encoders (transmitters) also
have been attached to teeth. These give out signals/impulses that vary according to the position
of the mandible in space. These impulses are recorded on a computer.
The limitation of most studies of jaw movement is the need to attach something to the mandible
that may well interfere with normal function. Often the incisal point (point between the lower
central incisors) is used to study movements of the mandible. When the mandible is made to
follow extreme paths limited by the constraints mentioned before, the incisal point moves along
border paths. The border paths enclose a total movement space or envelope of motion. Normal
movements, e.g. during chewing and swallowing, lie well within the border paths.

185
Posselt's classical work

We will consider movement in the vertical and horizontal planes and then combine these to
present a three-dimensional concept. There is obviously considerable individual variation in
movement envelopes. In the sagittal plane the following positions may be noted:
Intercuspal position
Contact path determined by the teeth, including an incisal path determined by the
interincisal angle
Edge-to-edge bite
Reversed vertical overlap, with the lower teeth anterior to the uppers
Maximum protruded contact, determined by posterior tooth contacts
Retruded contact position, a position posterior and inferior to intercuspal position.
Posselt estimated that 90% of individuals could retract their mandibles by approximately 1 mm
from intercuspal to retruded contact.
From the retruded contact position, the jaws can be opened until incisal separation is about 20
mm. This is called the retruded hinge path. The condyles are prevented from moving forward
and only rotation occurs in the joints. Eventually (after about 20 mm), a maximum hinge opening
is reached. The condyles then move forward due to the pull of the lateral pterygoid muscles,
until maximum opening is reached. The retruded opening path is sometimes referred to as
diphasic, representing the two aspects of this border movement, i.e. rotation then translation.
There is also an opening path from maximum protrusion to maximum opening. These
movements are all border movements. They need conscious effort to attain or guidance by
another person. All other movements will be intra-border movements. For instance, a normal
opening will produce an habitual opening path which will be an intraborder movement.
The mandible can move from intercuspal position, to rest position, to maximum opening. The
curvature of this path is determined by a combination of the roll and slide of the condyles. Rest
position is discussed in more detail later. It is usually between 2-4 mm from intercuspal position,
slightly forwards and downwards. The space between the intercuspal and rest positions is called
the freeway space or interocclusal distance.
Horizontal movements also can be traced. These can be studied during contact of teeth and at
any degree of jaw separation. The horizontal areas of the movement envelope will decrease as
the jaws open further. Intercuspal position, retruded contact and maximum right and left lateral
movements lie on the upper surface of the movement envelope. Lateral movements can be
traced from retruded contact. The patterns generated from recordings of lateral movements are
sometimes called Gothic arch tracings.
In lateral movements the side to which the mandible moves is called the working side and the
condyle on this side is called the working (side) condyle. The working condyle shows a small
lateral shift called the Bennett movement. The bodily lateral shift is about 1.5 mm. The
opposite side to the working side is called the non-working side or balancing side. The condyle
on the non-working side moves most, such that it moves downwards, forwards and medially.
The angle traced by the non-working side condyle in relation to the sagittal plane has been
called the Bennett angle. In lateral movement, the non-working side molars and premolars
move obliquely forward and medially and the working side teeth move buccolingually, i.e. the
anterior component of movement is minimal.

186
Fig. 18 Mandibular movements and positions, showing envelope of motion (Posselt) and
Gothic Arch tracing.
The sagittal and horizontal components of the movement envelope can be combined to form a
three-dimensional movement space. This space includes movements made by the incisal point
during all possible mandibular movements.

187
The total movement space displays considerable dimensional variability. Average values for the
incisal point in adults include:
maximum opening
= 50-60 mm
protrusion from intercuspal to edge-to-edge
= 5 mm
protrusion from retruded contact to protruded contact
= 10 mm
retruded hinge opening
= 20-25 mm
side to side lateral slide
= 20 mm
The ranges are generally less in children.
Basic positions of the mandible

Basic positions of the mandible are mandibular positions used frequently during function or
alternatively reference positions against which other positions or movements can be compared.
Three important basic positions are: the intercuspal position, rest position and retruded position
(which may be retruded contact).
Intercuspal position
Intercuspal position also can be called tooth position or centric occlusion. This is the position of
the mandible when the teeth are in maximum contact; therefore it is determined by the teeth. It
is not a static position as it changes as teeth erupt or are lost, and also may change due to
attrition or restoration placement in the teeth. Once the intercuspal position is established, it is
maintained by a neural reflex. Initially it is a learned position, but with repeated closures it
becomes reflex; however, constant reinforcement from receptors is needed to maintain the
reflex. If an occlusal splint (mouthguard) is continually worn for a few days, the ability to close
quickly into intercuspal position is lost. In edentulous people there are no periodontal receptors;
however, people with full upper and lower dentures derive impulses from sensory nerve endings
in the oral mucosa. The occlusal vertical dimension is defined as the height of the face when
the mandible is in intercuspal position.
Fig. 19 Three dimensional combined

lateral and vertical patterns of combined
lateral and vertical patterns of mandibular
movements.

188
Rest position
Rest position also may be called postural position or endogenous postural position. It is not
determined by teeth and is maintained by sustained contraction of temporalis muscle acting to
counteract the effect of gravity. It is analogous to other postural positions of the body, e.g.
suboccipital muscles keep the head up and the erector spinae keep the body upright. Posselt
has defined rest position as the relationship of the mandible to the skull assumed most
frequently when a person stands or sits in an upright position in a state of relative passivity.
(Passivity implies quiet respiratory rate and relative emotional and psychic tranquillity.) Rest
position is a fairly stable position. In rest position, there is minimal contraction of muscle fibres.
The position can be maintained indefinitely without fatigue. Because the position is fairly stable,
it is useful in clinical situations, e.g. in constructing dentures. Factors that may influence rest
position include head and body posture, sleep, disease and spasm and TMJ disease.
The distance between intercuspal and rest position is termed freeway space or interocclusal
distance and is usually 2-4 mm. If there is a large interocclusal distance, a person may be
overclosed, with reduced occlusal vertical dimension, e.g. when a person has old dentures that
do not adequately replace the alveolar bone loss that occurs following extraction. If there is a
small interocclusal distance, bone resorption may occur, e.g. incorrectly made dentures that
intrude into the freeway space.
Retruded contact position
Retruded contact position is determined by the teeth and TMJ ligaments. It does not depend on
posture or state of emotion; consequently, it is used clinically in the construction of dentures as
it is a stable reproducible position.

189
Notes
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190
Functions of the Masticatory System II

In addition to the functions noted in Functions of the Masticatory System 1 (i.e. incision,
mastication, swallowing, respiration, speech and facial expression) the following aspects should
be noted, namely, occlusion and articulation are involved in all the above activities and it should
be remembered that articulation refers to contact between the teeth while the mandible is
moving. These movements may include retrusive, protrusive and right or left lateral.
Mastication
The form of the chewing cycle may be bilateral, unilateral, mainly vertical or more side-to-side.
Obviously, the type of food being eaten and the time devoted to chewing is relevant. Telemetry
experiments suggest that some tooth contact occurs during chewing near the intercuspal
position. The cycle consists of an opening phase and crushing phase.
The opening phase begins from the intercuspal position, approximately along the median line,
with an opening movement gradually approaching the food bolus side, although there may be
slight deviation to the non-food side initially. The opening is usually about 18 mm.
The crushing phase involves jaw deviation to the food side with the pressure and velocity of
movements depending on the size, shape and hardness of food. There may be a slide into
intercuspal position. The cycle of opening and crushing usually lasts one second approximately.
Deglutition (swallowing)
In some malocclusions, e.g. Class II division 1 where the upper teeth protrude, the tongue may
be used in swallowing to block the anterior space between the teeth.
Respiration
In Class II malocclusions there may be no lip seal, and the mandible may need to be protruded
to assume an habitual rest position in an attempt to provide a lip seal. The muscles are then no
longer minimally contracted and may become fatigued.
There is minimal contact between the teeth in all these functions, so even though the teeth,
occlusion and articulation need to be considered, in a good functional occlusion there will be
very little tooth contact normally.
Parafunctional habits such as grinding and clenching produce more tooth contacts and may
lead to other symptoms. Stress can lead to bruxism (grinding and clenching) which may lead to
the symptoms of myofascial pain dysfunction syndrome, i.e. pain, limitation of movement,
muscle tenderness and clicking TMJs.

191

192
Glossary
GLOSSARY
ABRASION
the wear of teeth by physical agencies apart from

normal use.
ACCESSORY FORAMINA -
located on the root surface, these are additional or

extra openings of lateral/accessory canals. These
canals and openings contain blood vessels, nerves
and lymphatics that branch from the main root canals.
AGENESIS
missing tooth due to lack of development.
ANKYLOSIS
fusion of tooth with surrounding bone.
APEX
the tip of a tooth root.
ARBOREAL
adapted to living and moving about in trees.
ARTICULATION
contact between maxillary and mandibular teeth

during mandibular movements.
ATTRITION
the wear of teeth produced by use.
AVULSION
when a tooth is completely knocked out from its

socket as a result of accidental trauma.
AXIAL
pertaining to the long axis of the tooth.
BIFURCATION
division of a root into two parts.
BRACHIATE
swing from branch to branch using the limbs.
BRUXISM
grinding or clenching of teeth that is not part of the

normal function of chewing, ie. parafunctional activity
that may occur when awake or asleep.
BUCCAL
next to or toward the cheek.
CARABELLI TRAIT
an extra cusp sometimes present on the lingual

surface of the mesiolingual cusp of upper first
permanent molars and upper second deciduous
molars. The expression of the trait varies from a
groove to a large cusp.
CEMENTO-ENAMEL
JUNCTION
the line formed by the division between the enamel of

the crown and the cementum of the root (cervical
line).
CERVICAL
area near the cemento-enamel junction.

Glossary
195
CERVIX
narrow part of the tooth where root and crown join.
CINGULUM
a bulbous convexity on the cervical third of the lingual

surface of an anterior tooth.
COL
the gingival tissues located in the interproximal area,

below the contact areas of adjacent teeth, ie. located
between labial/buccal and lingual aspects of the
interdental papilla. The col may have a flattened or
concave contour and has an epithelial covering
similar in to junctional epithelium.
CONGENITAL
born with, especially relating to defects or diseases.
CONTACT AREA
CORNU
area of the mesial or distal surface of a tooth which

touches its neighbour in the same arch.
a projection of the pulp; also called a horn.
CORONAL
pertaining to the portion of a structure associated with

the tooth crown, eg. coronal pulp = pulp within the
crown of a tooth.
CRENATIONS
fine notches on a tooth surface.
CROWN, ANATOMICAL
the enamel-covered part of the tooth.
CROWN, CLINICAL
the part of the crown above the gingiva.
CURVE OF SPEE
when viewed from the lateral, the occlusal surfaces of

the teeth in the buccal segments are aligned along a
curve (mesial-distal direction), with the distal marginal
ridge of a molar being positioned in a more superior
position than the mesial marginal ridge.
CURVE OF MONSON
the orientation of the occlusal surfaces of the

posterior teeth form a concave curve if viewing the
mandibular molars from the anterior, such that the
slope of the occlusal surface has a lingual tilt.
Conversely, for the maxillary molars, the occlusal
surfaces have a buccal tilt and therefore a convex
curve can be drawn through the occlusal surfaces of
the maxillary teeth.
CUSP
a peak on the crown of a tooth making up a divisional

part of the occlusal surface.
Glossary
196
CUSP RIDGE
a ridge that extends in a mesial and distal direction

from the tip of the cusp. The crest of the cusp ridge
delineates the buccal or lingual boundaries of the
occlusal surface (Fig 14).
Figure 14.
Sketch of maxillary first permanent molar
DIASTEMA
a space between adjacent teeth in the same jaw.
DILACERATION
deviation in the root of a tooth at an angle to the long

axis such that long axis of the crown and root are no
longer aligned.
DISTAL
the proximal surface of a tooth farther from the

midline.
EMBRASURES
the V-shaped spaces formed where teeth diverge

from contact points, eg. buccal, lingual, gingival and
occlusal (Fig. 15).
Figure 15.
Sketch of maxillary permanent first and

second molars
Glossary
197
EPIGLOTTIS
a cartilaginous 'flap' that closes over the opening to

the larynx when swallowing, thus preventing food
from entering the larynx, trachea and lungs.
EVULSION
intentional removal or knocking out of tooth from its

socket.
EXFOLIATION
the loss of primary or deciduous teeth due to

resorption of the deciduous tooth root. This generally
occurs prior to the emergence of the associated
permanent tooth.
EXODONTIA
study and practice of extraction of teeth.
FACIAL
collective term for both labial and buccal.
FAUCES
communication/junction of the oral cavity proper with

the oropharynx. It is bounded laterally by the pillars
of the fauces, ie. the palatoglossal fold (anterior) and
palatopharyngeal fold (posterior) and superiorly by
the soft palate and inferiorly by the posterior of the
tongue.
FISSURE
a development fault or cleft, usually found on the

occlusal or buccal surface of a tooth (Fig 16).
Figure 16.
Sketch of cross section of occlusal enamel.
FORAMEN
i) opening in a bone through which nerves, blood

vessels, etc. pass.
ii) opening at or near apex of the tooth root through
which nerves, blood vessels, etc. pass.
FORNIX (CES)
trough located at reflection of oral mucosa from inner

aspect of lips and cheeks to alveolar mucosa
(sulcus).
Glossary
198
FOSSA
a rounded or angular depression or concavity on the

surface of a tooth. There are three common types:
1 lingual fossa - on the lingual surface of incisors
and canines (Fig. 17)
2 central fossa - on the occlusal surface of molars
3 triangular fossa - on the occlusal surface of molars
and premolars mesial or distal to marginal ridges
(Fig. 14).
Figure 17.
Sketch of maxillary permanent canine.
GINGIVA
the gum surrounding the tooth. Gingiva can be either

free (forming a cuff around the tooth at the level of the
gingival sulcus) or attached to the tooth and alveolar
bone of the tooth.
GLOBULAR
in the shape of a globe, spherical.
GLOSSAL
with reference to/associated with/part of the tongue.
GRACILE
slender, thin.
GROOVE
a shallow linear depression on the surface of a tooth.

There are two common types:
i) developmental groove - marks the boundaries
between adjacent cusps and other major lobes/
divisional parts of a tooth
ii) supplemental groove - an indistinct linear
depression, irregular in extent and direction and is
not related to developmental lobes or divisions.
HARD PALATE
consists of the paired maxillary and palatine bones

covered by dense mucous membrane. It forms the
roof of the mouth.
INCISAL EDGE
the biting edge of anterior teeth.
INCISAL RIDGE
the incisal part of an anterior tooth. In the canine, the

incisal ridge is similar to the cusp ridge of cusps of
posterior teeth.
Glossary
199
INCISIVE PAPILLA
oval or pear shaped soft tissue prominence situated

in the midline behind the maxillary central incisors. It
is located adjacent to the opening of the incisive
canal, namely, the incisive foramen.
INCREMENTAL LINES
lines that encircle teeth and are formed as a result of

the 'stop/start' process of laying down of enamel.
These lines become indistinct in areas of continuous
wear.
LABIAL
next to or toward the lips.
LATERAL CANALS
canals that branch from the main root canal. These

are most commonly found in the apical third of the
root.
LEEWAY SPACE
difference in size between deciduous molars and

successional premolars, providing some space for the
permanent dentition during development of the
dentition.
LINGUAL
next to or toward the tongue.
LINGUAL RIDGE
linear elevation located on the lingual surface,

extending from the cusp tip to the cingulum, eg.
maxillary canine (Fig. 17).
LINE ANGLE
that angle formed by the junction of two surfaces

along a line.
LOBE
developmental portions of a tooth. The junction of

adjacent lobes in a fully developed tooth is often
demarcated by a developmental groove (Fig 18).
LUXATION
dislocation or displacement of a tooth from its socket,

as a result of trauma.
MAMELONS
rounded prominences on the incisal edge of newlyerupted incisors (Fig 18).
Glossary
200
Figure 18.
Sketch of a labial view of a maxillary

permanent central incisor.
MARGINAL RIDGES
elevations that form the mesial and distal boundaries

of the lingual surfaces of anterior teeth and the
occlusal surfaces of posterior teeth (Figs. 14 and 17).
MAXILLARY SINUS
air space, lined with mucous membrane, located

within the maxillae, on either side of the nasal cavity.
MEDIAN
middle figure
MESIAL
the proximal surface of a tooth nearer the midline.
MUCOUS MEMBRANE
moist linings (epithelium and connective tissue) of

internal cavities that are continuous with the outer
body covering, e.g, lines gastrointestinal tract,
including the mouth, which is continuous with skin at
the lips.
OCCLUSAL
the surfaces of premolars and molars which come into

contact with those in the opposing jaw during closure.
OVERBITE
distance that the maxillary anterior teeth overlap the

mandibular teeth in a vertical plane.
OVERJET
distance that the maxillary anterior teeth are

positioned anteriorly or posteriorly (reverse overjet) to
the mandibular anterior teeth, ie. distance between
anterior maxillary and mandibular teeth in a horizontal
plane.
PALATAL
next to or toward the palate.
PERCENTILE
division of group into 100 equal-sized parts.
PERIDONTIUM
functional system of different tissues that surround

and support teeth. It consists of cementum, alveolar
bone, periodontal ligament and the dentogingival
complex.
PHARYNX
mucous membrane lined muscular tube that lies

posterior to and continuous with the nasal and oral
cavities and the larynx and connects inferiorly with
the oesophagus.
PIT
a small, pinpoint depression at the junction of

developmental grooves or at the termination of a
single groove.
Glossary
201
POINT ANGLE
the angle formed by the junction of three surfaces at

a point.
PROCUMBENT
lying down in a flat plane.
PROXIMAL
the surface of a tooth facing an adjoining tooth in the

same arch. May refer to mesial or distal surface.
PULP CANALS
a narrow tube that is located within the dentine of a

tooth root. It travels from the pulp chamber (see
below) to the apex of the root and contains pulpal
tissues.
PULP CHAMBER
a cavity containing pulpal tissues. It is located in the

coronal portion of a tooth and varies in size and
shape from the incisors to the molars. The position
and shape of the pulp chamber dictates the location
and shape of access cavities which are specific for
each tooth (see p.102-104).
PULP CAVITY
the space inside a tooth containing dental pulp.

Consists of pulp chamber and pulp canal(s).
PULPECTOMY
removal of the entire pulpal tissues from the pulp

chamber and root canals.
PULPOTOMY
removal of part or all of the pulp contained in the pulp

chamber. The remaining pulp in the root canals is
then treated with one of a range of medicaments.
The aim of a pulpotomy is to preserve viability of the
pulpal tissue within the root canals.
QUADRANT
the teeth and jaws can be divided into quarters, with

the upper and lower jaws providing one division and
the midline dividing patients right from left. This
results in the designation of upper right, upper left,
lower left and lower right quadrants.
RADICULAR
portion of tissue or structure associated with a tooth

root, eg. radicular pulp=pulp within root canals.
RHOMBOIDAL
shaped like a diamond found on playing cards.
RIDGE
a linear elevation on the surface of a tooth. May refer

to marginal ridges, triangular ridges, cusp ridges,
incisal ridges, oblique ridges or transverse ridges
(Figs. 14 and 17).
ROOT TRUNK
that part of the root between the cervix and the point
of separation of the roots.
Glossary
202
SEXUAL DIMORPHISM
two different forms/arrangements of structure that are

found in the males and females of a species.
SOFT PALATE
moveable soft (muscular) mucous membrane covered

extension from the hard palate. It is raised superiorly
to seal off the nasopharynx during swallowing.
SUBLINGUAL FOLDS
elevation of mucous membrane that extends laterally

and distally from the sublingual papilla in the floor of
the mouth.
SUTURE (BONY)
a rigid fibrous joint between bones that are closely

united.
SULCUS
an elongated valley. This may be found on a tooth

and is formed by the inclines of adjacent cusps which
meet at an angle. It also describes the trough formed
by the reflection of the oral mucosa from the lips and
cheeks to the alveolar mucosa, ie. vestibular sulcus
and the trough located between the junctional
epithelium of the gingiva and the tooth, ie. gingival
sulcus.
SYNCHONDROSES
a cartilaginous joint between the bones in which the

joining substance is hyaline cartilage.
TEMPOROMANDIBULAR JOINT
(TMJ)
joint formed by the articulation of the condyle of the

mandible and the glenoid fossa of the temporal bone.
TONSIL
irregular bulges of lymphoid tissue at the rear of the

mouth, i.e, the lingual tonsil - located on the posterior
third of the tongue; palatine tonsil - located between
the pillars of the fauces; pharyngeal tonsil - located in
the nasopharynx, adjacent to the opening of the
eustachian tube.
TORUS (TORI)
rounded elevation/prominence, eg. mandibular tori

are bony prominences that are located on the lingual
aspect of the mandible in the premolar region.
TRANSVERSE RIDGE
formed by the buccal and lingual triangular ridges of

the buccal and lingual cusps, resulting in a generally
continuous elevation that is positioned crosswise on
the occlusal surfaces of posteriors, eg. lower first and
second premolars.
TRAPEZOIDAL
a four sided figure that has two opposite sides that

are parallel and the remaining sides are not.
Glossary
203
TRIANGULAR RIDGES
ridges that extend from the cusp tips in a labial/buccal

or lingual direction that are triangular in cross section,
eg. buccal triangular ridge of the buccal cusp of the
lower first premolar.
TUBERCLE
a small, rounded elevation on the surface of a tooth.
UVULA
drop shaped extension of soft muscular tissue located

in the midline of the free posterior border of the soft
palate.
VESTIBULAR
collective term for both labial and buccal.
VESTIBULE
space located between the inner aspects of the lips

and cheeks and the buccal and labial aspects of the
teeth and mucosa overlying the alveolus.
Glossary
204
References:
Ehrlich A and Torres HO (1992) Essentials of Dental Assisting. WB Saunders
Company, Philadelphia.
Harty FJ and Ogston R (1987) Concise Illustrated Dental Dictionary. Wright, Bristol.
Hiatt JL and Gartner, LP (1982) Textbook of Head and Neck Anatomy. Williams
and Wilkins, Baltimore. BSL: 611.91 H623t (Main)
Jordan RE and Abrams, L (1992) Kraus' Dental Anatomy and Occlusion. Mosby
Year Book, St. Louis.
Martin EA (Ed) (1983) MacMillan Dictionary of Life Sciences (2
Press, London. BSL: 574.03 D554.2 (Reference)
nd
ed). MacMillan
Mitchell L and Mitchell DA (1995) Oxford Handbook of Clinical Dentistry (2nd ed).
The Oxford Paperback Dictionary. (1984) Oxford University Press, Oxford. BSL:
433 O984 (Reference)
Zwemer TJ (1993) Bouchers Clinical Dental Terminology. A Glossary of Accepted
Terms in all Disciplines of Dentistry. (4th ed.) Mosby Year Book Inc., St.
Louis. BSL: 617.6003 B753.4 (Reference)
Glossary
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DENT 1005 and DENT 2005

DENTAL SCIENCE AND PRACTICE I & II

Design, layout and format by the Sharjah Project

History of Dentistry (Dr J McIntyre) .............................................................

Section I Dental Anthropology

Comparative Anatomy of the Masticatory System .....................................

Genetics and Crown Morphology ...............................................................

Genetics and Tooth Size ...........................................................................

Forensic Odontology (Dr KA Brown) ...........................................................

Section II Topics in Oral Anatomy

Surface Anatomy of the Oral Cavity ...........................................................

Structure of Oral and Dental Tissues .........................................................

Age Changes in Oral Tissues ....................................................................

Tooth Identification ....................................................................................

Identification of Permanent Teeth ...............................................................

Tooth Morphology ......................................................................................

Permanent Dentition ...........................................................................

Primary (Deciduous) Dentition ............................................................

Pulpal Anatomy ..........................................................................................

Timing and Sequence of Tooth Calcification .............................................

Tooth Eruption and Emergence .................................................................

Anatomy of the Skull ..................................................................................

Radiographic Anatomy ...............................................................................

Dental Diseases .........................................................................................

Preventive Dentistry ...................................................................................

Section III Occlusion

Concepts of Occlusion ...............................................................................

Occlusal Curvatures and Axial Alignment ..................................................

Opposing Tooth Contacts in Intercuspal Position ......................................

Mandibular Movements and Positions .......................................................

Functions of the Masticatory System II ......................................................

Ash GM and Nelson SJ (2003)

Ash MM and Nelson SJ (2003)

Bath-Balogh M and Fehrenbah MJ (2006)

Bath-Balogh M and Fehrenbah MJ (1997)

Berkovitz BKB, Holland GR and Moxham BJ (1992)

Berkovitz BB, Moxham BJ and Holland GR (2002).

Brand RW, Isselhard DE and Satin E (2003)

Brand RW and Isselhard DE (1998)

Harris NO, Garcia-Godoy F and Nathe CN (2009)

Harris NO and Garcia-Godoy F (2004)

Harty FJ and Ogston R (1987)

Jordan RE and Abrams L (1991)

Mitchell DA and Mitchell L (2005)

Mitchell L and Mitchell DA (1999)

Mount GJ and Hume WR (2005)

Mount GJ and Hume WR (1998)

Ash MM and Ramfjord SP (1995)

Scott, JH and Symons, NB (1982)

Van Beek GC (1983)

Woelfel JB and Scheid RC (1997)

Woelfel JB and Scheid RC (2002)

Evolutionary Changes in Skull Form

the lower primates (prosimians)

the higher primates (anthropoids).

Trends in primate evolution

Evolution of higher primates

Main trends in evolution of skull form

Section I Dental Anthropology

Trends in dentition of primates

Section I Dental Anthropology

Section I Dental Anthropology