February 1<'.

2005 Daniel Travellc & Brandon Fowler's Dental Anatomy Board Review Packet 1

Everything You Wanted to Kno,w

. .

About The Shapes Of Teeth But

Were Afraid To Ask

There are 100 questions on the dental anatomy section of the' national boards. The typical

breakdown is 'approximately as follows:

-50% tooth morphology (including the crown, pulp, roots, and self-protective features)

-20% dates of calcification & eruption, surrounding structures, & clinical correlations

-33% occlusion

Part of what makes the national boards so challenging is that there's more than 100%.

Questions' on "surrounding structures" include information that we covered in our PBl Cases

(for example, the oblique fibers in the middle of the POL, Stenson's duct (aka parotid gland), or

Wharton's duct (aka submandibular gland). A clinical correlation might have to do with the only

2 teeth whose crowns have concavities. . Those concavities (on the mesi'al surface of the

maxillary first pre-molar and on the distal surface of the maxillary first molar) make it difficult to

floss, use a matrix band, or scale this area.

Remember:

-review early and often. This should be the easiest section for every one of you!

-review again before'the boards (the information leaves your brain quickly)

-review old board exams (there will be repeats, though they may be ie-worded)

Typically, a lot of tooth morphology questions focus on anterior teeth, maxillary first pre-molars,

and maxillary first molars.

The formula for the permanent dentition of man is: I 2/2 C 1/1 P 212 M 3/3'

This represents the number of maxillary/mandibular Incisors, Canines, Pre-molars, and Molars

in one half of the mouth. To calculate the total number of teeth in the mouth, add 2+2 incisors,

1+1 cahines, 2+2 pre-molars, and 3+3 molars; then multiply by 2to account for the teeth in the

other half of the mouth. If you have performed the arithmetic correctly, you will discover that.

humans have 32 permanent teeth.

The formula for the primary dentition of man is: i 2/2 c 1/.1 m 212

(Primary teeth are represented by lowercase letters.)

Be prepar~d to answer a q~estion in which we are presented the formula for the dentition of an

imaginary animal (like a fantastopotamus) and asked to answer questions about how many

teeth it has.

I
 February 1'1. 2005 Daniel Travelle & Brandon Fowler's Dental Anatomy Board Review Packet 2

~---._ . --Ge n-e ra lities:-····-·----·---------.--.-.------.- .. --.-.-.. -­

Contact Points:
Inciso- in ivai contact oints:
Mesial Distal
maxillary central incisal junction of incisal & middle
maxillary lateral jxn of incisal & mid 4Jlimt1'e J
maxillary canine jxn of incisal & mid middle

mandibular central incisal incisal

mandibular lateral incisal incisal
mandibular canine incisal mid 1/3

All posterior teeth inciso-gingival contact points are in the middle third of the crown. The
exception is the mesial surface of the maxillary & mandibular molars. (Their contact
points are at the junction of the occlusal & middle thirds.)

All teeth have facio-lingual'contact points in the middle third of the crown, but posterior teeth
have the contact points leaning toward the facial.

Heig hts of Contour and the CEJ:

Facial heights of contour are most prominent on mandibular posterior teeth. They are least
prominent on mandibular anterior teeth.

All teeth have facial heights of contour in the cervical third, except for mandibular molars
(which have facial heights of contour at the junction of the cervical and middle thirds).

Anterior teeth have lingual heights contour in the cervical third of the crown. Posterior
teeth have lingual heights contour in the middle third of the crown EXCEPT for the
mandibular second pre-molar (which has a lingual height of contour in the occlusal
third).

The CEJ dips deeper on:

-anterior teeth than posterior teeth

-the mesial side of a tooth than the distal

-maxillary teeth than mandibular teeth

Embrasures:

Facial embrasures are narrower than lingual embrasures on all teeth except the maxillary first

molar (where the facial embrasure is wider) and between the mandibular centrals (where the

facial and lingual embrasures may be the same size).

The largest incisal embrasure is between the maxillary lateral and canine.

The 2nd largest incisal embrasure is between the mandibular lateral & canine.

The 3rd largest incisal embrasure is between the maxillary central and lateral.

The 4th largest incisal embrasure is between the maxillary centrals.

The 5th largest incisal embrasure is between the mandibular central & lateral.

The 6th largest (smallest) incisal embrasure is between the mandibular centrals.

. ' The largest OVERALL occlusal embrasure is between the maxillary canine and first pre-molar,
but we shouldn't be comparing anteriors (apples) and posteriors (oranges).

----- --._---- ----- -- --- ----------------------.--------- - - - - - ­

February l't. 2005 Daniel Travelle & Brandon Fowler's Dental Anatomy Board Review Packet 3

Dates of Calcification and Eruption:

Crowns take a few years to form once calcification has begun, so it is important to take systemic
fluoride through age 12 to protect all teeth. For those who could not care less about the third
molars, fluoride need not be taken once the second molars are completely calcified at age 6-7.

Calcification dates:
Primary teeth show evidence of calcification in utero (in the 2nd trimester).
6-year molars show the first evidence of calcification at birth.
Permanent anteriors show the first evidence of calcification before age 1.
Permanent pre-molars show the first evidence of calcification around age 2.
12-year molars show the first evidence of calcification around age 3.
Wisdom teeth show the first evidence of calcification around age 7-9.

Mandibular teeth usually erupt before maxillary teeth. A tooth erupts when its root is about half­
formed. The roots of primary teeth will complete about 1.5 years after eruption; the roots of
permanent teeth will complete about 2.5 years after eruption.

Primary incisors erupt around age 6 months.

Primary first molars erupt around age 1 year (12 months).

Primary mandibular canines erupt around age 1.5 years (18 months).

Primary second molars erupt around age 2 years (24 months).

Permanent first molars erupt at age 6 years.

Permanent mandibular centrals erupt at age 6-7.

Permanent mandibular laterals erupt at age 7-8.

Permanent maxillary centrals erupt at age 7-8.

Permanent maxillary laterals erupt at age 8-9.

Permanent mandibular canines erupt at age 9-10.

Permanent pre-molars (first, then second) erupt at age 10-12

Permanent maxillary canines erupt at age 11-12.

Permanent second molars erupt at age 12.

Permanent third molars erupt at age 17-21.

Incisal Edge Orientation:

From an interproximal view:

Maxillary incisors have incisal edges that are centered over the long axis of the tooth.

Mandibular incisors have incisal edges that are lingual to the long axis of the tooth.

Maxillary canines have incisal edges that are facial to the long axis of the tooth.

Mandibular canines have incisal edges that are lingual tolcentered over the long axis.

Mandibular second pre-molars have a facial cusp centered over the long axis and a lingual cusp

in line with the lingual surface of the root.

Sha pes of teeth:

From a facial or lingual view, all teeth have a crown shaped like a trapezoid (with the short side

gingival).

From a proximal view, anterior teeth have a crown shaped like a triangle.

Fcbmary 1't. 2005 Daniel Travelle & Brandon Fowler's Dental Anatomy Board Review Packet 4
From a prQximaJ. vIew,maxiUary pQsJerior teeth have a crown shapedJike.a trapezoid (withthe
long side gingival).
From a proximal view, mandibular posterior teeth have a crown shaped like a rhombus

Trends of crowns:
Teeth with one facial cusp have a mesial cusp slope that is shorter than the distal cusp slope,
except for the primary maxillary canine and the permanent maxillary first pre-molar.

The crowns of teeth tend to get shorter from the canine to the third molar. (Possible clinical
correlation- crowns on molars are more difficult because they are so short.)

All teeth develop from 4 lobes except permanent first molars and the mandibular 2nd pre-molar
3-cusp type (which develop from 5 lobes).

The mesial side of a tooth is typically bigger than the distal side.

The largest cusp of molars is typically the mesial supporting cusp.

Enamel is the hardest substance in the human body. It is about 96-97% calcified. Dentin
contains about 20-25% organic material.

Trends of Roots, Canals and Pulp:

The roots of all teeth are inclined distally, except for the mandibular canine (which leans to the
mesial).

If one root has 2 canals, they will be oriented facially and lingually.

Teeth erupt with as many pulp horns as they have cusps. The pulp follows the outline of the
tooth, so it will be widest aUhe widest pOliion of the tooth.

Permanent Teeth:
(I've tried to organize the organize the information on each tooth by first listing its unique traits,
then by discussing the more common characteristics of its crown, roots, and pulp. Some of the
most distinctive traits are re-capped at the end of these notes. I think it's helpful to look at either
your typodonts or pictures of the teeth as you read about them. But since my prize-winning
artwork doesn't translate very well over the computer, I'll offer the next best solution and refer to
pages in Wheeler's Dental Anatomy, Physiology & Occlusion.)

Maxillary Central Incisors:

(For a diagram of the following, see page 134 of Wheeler)
The maxillary central incisor:
-is the widest ANTERIOR tooth mesio-distally
(the widest tooth in the mouth is the mandibular first molar)
-is the only tooth with a pulp wider mesio-distally than facio-lingually
-is the only tooth with a cross section thru the CEJ that appears triangular
(the base of the triangle is facial; the apex points lingual)

--~--::---
 February 1,to 2005 Daniel Travelle & Brandon Fowler's Dental Anatomy Board Review Packet 5
_ _ -has.thasecand_tallestcrawnJnthe__mQuth.- .--------~----------- -­
(the mandibular canine has the tallest crown in the mouth; the maxillary canine has the third
tallest crown in the mouth)

From a facial or lingual vlew, the crown shape of every tooth in the mouth is a trapezoid
(with the long side incisally/occlusally and the short side gingivally). The maxillary central is flat
facially and wide mesio-distally. It has a ridge (like the elevations which soldiers hid behind in
the civil war) in the middle of the facial surface. It has a fairly straight mesial outline nearly
parallel to the root. The distal outline is more convex. Like all incisors, it has a fairly straight
incisal ridge. The mesial inciso-gingival contact location is in the incisal third of the crown; the
distal contact point is at the junction of the incisal and middle thirds. This is due to the sharp
mesio-incisal corner and the round disto-incisal corner.

Mamelons are the bumps that are found on the incisal edges of permanent incisors. All
permanent incisors (but not canines or primary incisors) erupt with 3 mamelons. (C do not erupt
with mamelons.) The mamelons (one mesial, one distal, and the smallest one in the middle)
represent 3 of the 4 developmental lobes (the cingulum represents the 4th lobe).

An embrasure is a V-shaped space around a contact area. There are 4 embrasures around
each anterior contact area ,(incisal, gingival, facial, and lingual). Teeth are narrower lingually
than they are facially, so the lingual embrasure is always wider than the facial embrasure.
The exceptions are the maxillary first molar (which is wider facially and has a smaller lingual
embrasure) and between the mandibular centrals (where the facial and lingual embrasures
are equal).

The maxillary central has well-developed lingual anatomy (though not as well-developed as that
of the maxillary lateral). There are a series of elevations around the lingual fossa. There is a
mesial marginal ridge (MMR), distal marginal ridge (DMR), cingulum, and incisal ridge.

All anterior teeth have a wedge-shaped (triangular) crown from a proximal view. The
facial height of contour reflects the cervical ridge. The CEJ is considered a self-protective
feature of the dentition because (in a young mouth) the epithelial attachment is here and
prevents bacteria from invading deeper structures. The interproximal bone is parallel to the
CEJs of adjacent teeth.

From an incisal view, the- tooth has a triangular shape. The cingulum appears to the distal
half of the tooth. That means that the mesial leg of the triangular shape is longer than the distal
leg.

All maxillary anteriors have one root and one root canal. The maxillary central's root is
straight, has a blunt apex, and is short (no longer than that of the maxillary lateral).

Maxillary Lateral Incisors:

(For a diagram of the following, see page 143 of Wheeler)
The maxillary lateral:

-has the best developed lingual anatomy

-is the most likely to have dens-in-dente

-is the 2nd most congenitally malformed or missing (second to the third molars)

 Febmary 1SI. 2005 Daniel Travelle & Brandon Fowler's Dental Anatomy Board Review Packet 6
.._**.... NOTE~~~.Often. times. boardquestiofis_(lasLyears. e:xam)_ba~e.. the_.Maxillary.LateraLlncjsor
as being the #1 most congenitally missing tooth. This is one question that many of us debated
up until the day of boards. Different resources contradict each other.

The maxillary lateral is just like a maxillary central but squashed mesio-distally (making it
rounder) and with better developed lingual anatomy. Surrounding the lingual fossa are the
mesial marginal ridge, distal marginal ridge, cingulum, and incisal ridge. When malformed, the
maxillary lateral tends to be peg-shaped. It might have a groove running onto the distal
side of the root from the lingual pit. This anatomy makes scaling difficult (possible clinical
correlation question).

The shape of the crown is trapezoidal from the facial. The mesial inciso-gingival contact point is
at the junction of the incisal and middle thirds; the distal contact point is in the middle third. The
mesio-incisal corner is sharper than the distal. There is one root (which is inclined distally and is
as long or longer than that of the maxillary central) and there is one root canal. The bulky incisal
ridge is in line with the long axis of the tooth. From an incisal view, the maxillary lateral appears
oval shaped. It is as wide or wider facio-lingually as it is mesio-distally.

Mandibular Central Incisors:

(For a diagram of the following, see page 156 of Wheeler)
The mandibular central incisor:
-is the smallest tooth
-is the narrowest mesio-distally tooth
-is the most symmetrical tooth
-is the first succedaneous tooth (6 year molars are the first permanent teeth but do not
replace primary teeth and qo not qualify as "succedaneous")

Like all permanent incisors, the mandibular central erupts with 2 pulp horns, 3 mamelons, and
lingual anatomy. The crown is fan-shaped, which makes the inciso-gingival contact points both
in the incisal third of the tooth. (The mandibular lateral also has mesial and distal contact points
in the incisal third, but the distal contact point is LOW in the incisal third. The mandibular canine
has a mesial contact point in the incisal third and a distal contact point in the middle third.
According to a nit-picky board question, the mandibular central is the only mandibular
anterior which has both its mesial and its distal contact points at the same level.)

The smallest facial embrasure in the mouth is between the mandibular centrals. It might
be the same size as the lingual embrasure, making it an exception to the rule that lingual
embrasures are always larger than facial.

Mandibular incisors have smooth lingual anatomy. They usually have one root and one root
canal, but maybe 40% have 2 root canals. The root is flat mesio-distally with a mesial and a
distal concavity. (The deeper concavity is on the distal and faces the deep mesial concavity on
the mesial surface of the adjacent lateral).

From an interproximal view, the facial CEJ is at a different level from the lingual CEJ on
mandibular anterior teeth. The incisal edge is lingual to the long axis of the tooth, so from
an incisal view less of the lingual side is visible than the facial surface. The pulp appears
narrower from the facial view than from the interproximal view. The facial heights of contour
protrude least on mandibular anteriors (they are biggest on mandibular molars).
 Febmary 1'1, 2005 Daniel Travelle & Brandon Fowler's Dental Anatomy Board Review Packet 7

.. ----_._---------~---._--~----_._------_._-----~--------_._-~----

Mandibular Lateral Incisors:

(For a diagram of the following, see page 164 of Wheeler)
The mandibular lateral is similar to the mandibular central but larger and not as symmetrical. (In
contrast, the maxillary central is bigger than the maxillary lateral.) Right and left mandibular
laterals can be distinguished because each has an incisal edge that appears twisted on its
apex (as it goes from mesial to distal, it curves lingually) and an incisal ridge that is not at a
right angle to the mesial and distal sides (as it goes from mesial to distal, it slightly slopes
gingivally), The mandibular lateral is oval in cross section.

Maxillary Canines:
(For a diagram of the following, see page 176 of Wheeler)
The maxillary canine:
-is the widest ANTERIOR tooth bucco-lingually
(All posterior teeth are wider bucco-lingually, especially the maxillary first molar- which is the
widest in the mouth.)
-is the longest tooth inciso-apically
-has the longest root
-has the third longest crown (behind the maxillary central and the mandibular canine)

Canines do not erupt with mamelons. The lingual anatomy is different from that of incisors; it
still has a mesial marginal ridge, distal marginal ridge, and cingulum. But it does not have a
lingual fossa because it has a lingual ridge which splits the lingual fossa into a mesial
fossa and a distal fossa.

The maxillary canine erupts with 1 pulp horn and a prominent facial ridge on the (pointy) facial
cusp. The mesial contact point is at the junction of the incisal and middle thirds; the
distal contact point is in the middle third. (On both the maxillary and mandibular canines,
the distal side reaches out more to make contact with the adjacent tooth than the mesial side
does.) The maxillary canine bulges out mesio-distally from the CEJ more so than does the
mandibular canine.

The facial cusp has a mesial cusp slope that is shorter than the distal cusp slope. (This
is true of all teeth except for the primary maxillary canine and the permanent maxillary
first pre-molar.) The mesial side is straighter than the distal. There is a concavity on the distal
side of the root (the mandibular canine has a concavity on the mesial side of its root).

From an interproximal view, the cusp tip is facial to the long axis of the tooth. (So from an
incisal view, more of the lingual surface is visible than the facial surface.) It is widest facio­
lingually in the cervical third (since the facial and lingual heights of contour are in the cervical
third) so the pulp canal is also widest facio-lingually in the cervical third.

Mandibular Canines:
(For a diagram of the following, see page 188 of Wheeler)
The mandibular canine:
-has the longest crown
-is the second longest tooth (next to the maxillary canine)
-has the second longest root (next to the maxillary canine)
-is the only tooth with a root that is inclined mesially (not always)

I
 Febmal)' l't. 2005 Daniel Travelle & Brandon Fowler's Dental Anatomy Board Review Packet 8
-------- . ~is_tnaanteriortooth most-Hkel¥- ta-havaa bifurcated root-------------------------------------­

The mandibular canine has a duller cusp tip than does the maxillary canine. The mesial inciso­
gingival contact point is in the incisal third. The distal contact point is in he middle third (but
leaning toward the occlusal). A lingual ridge separates the mesial and distal fossa.

From an interproximal view, the mandibular canine has its incisal edge centered over or
slightly lingual to the long axis of the tooth. The facial side makes a smooth arc due to its
subtle crest of curvature.

From an occlusal view, the mandibular canine appears to have an oval shape.

Maxillary Pre-Molars:
Maxillary pre-molars have roots that are longer than incisors but shorter than canines; they have
crowns that are shorter than canines but longer than molars. They have inciso-gingival contact
points in the middle third. Like all maxillary posteriors, they have a trapezoidal shape when
viewed interproximally.

(For a diagram of the following, see page 200 of Wheeler)

The maxillary first pre-molar:

-has a mesial concavity in its crown gingival to the contact area

-on the facial cusp, has a longer mesial cusp slope than distal cusp slope

-has a mesial marginal ridge developmental groove

-has the shape of a kidney in cross-section

-bifurcates halfway down the root

-has the greatest demarcation between the pulp chamber and the pulp canals

From a lingual view, the the maXillary first pre-molar's lingual cusp appears to the mesial of the

facial cusp, rounder than the facial cusp, and shorter than the facial cusp.

From the occlusal view, the maxillary first pre-molar is hexagonal in shape. There is a

prominent facial ridge, a distal ridge, a mesial ridge, and a triangular ridge. There are triangular

ridges from the facial and lingual cusps; these two triangular ridges meet perpendicular to the

central developmental groove and form a transverse ridge which separates the mesial and distal

pits.

The maxillary first pre-molar has 2 pulp horns, 2 roots and 2 root canals (the lingual canal is

bigger than the facial canal).

(For a diagram of the following, see page 211 of Wheeler)

The maxillary 2nd pre-molar is similar to the maxillary first pre-molar. Unlike the first pre-molar,

the lingual cusp is the same height as the facial cusp, but still to the mesial. There is no

concaVity on the crown. Instead of a long central groove with few supplemental grooves, it has

a short central groove with a lot of supplemental grooves that make it look wrinkly. The

mesial cusp slope is shorter than the distal cusp slope. From an occlusal view, it is rounder

than the first pre-molar, but still hexagonal in shape. The maxillary second pre-molar has 1 root;

about 50% have 2 canals.

Mandibular Pre-Molars:

/~--
 Fcbmary 1'1, 2005 Daniel Travelle & Brandon Fowler's Dental Anatomy Board Review Packet 9
. __-fEor a diaQLamill.lheJ1Jl1owlogo-_SJ3e_P8ga224-DiWheeLer) ._
The mandibular first pre-molar:
-is the only tooth with its MMR at a grossly different angle than its DMR
- functionally it is most like a canine because the lingual cusp is not a functional cusp.
- is the smallest pre-molar
-has the narrowest and smallest root of all the pre-molars
-has the most prominent transverse ridge of all the pre-molars
-is the only tooth with a mesio-Iingual groove from the occlusal to the lingual

Except in terms of crown h~ight, the mandibular first pre-molar is smaller than the
mandibular second pre-molar in all dimensions. From an interproximal view, the facial
cusp appears centered over the long axis; the lingual cusp tip is in line with the lingual
surface of the root.

The mandibular first pre-molar has a tall facial cusp with a mesial slope shorter than the distal
slope. From a lingual view, 4 surfaces (distal, mesial, occlusal and lingual) are visible because
the tooth narrows facio-lingually. From an interproximal view, the mesial marginal ridge
slopes cervically as it goes from occlusal to apical. The triangular ridges come together
and separate the mesial and distal pits. The occlusal view has a diamond shape. It has one
root and usually one root canal. 30% have a second root canal.

(For a diagram of the following, see page 233 of Wheeler)

The mandibular second pre-molar:

-is the pre-molar most likely to be congenitally missing

-is the pre-molar most likely to have a central pit

-is the pre-molar most likely to have 1 root and 1 canal.

The mandibular second pre-molar is a transition between the first pre-molar and the first molar.
Its lingual cusp is higher than that of the first pre-molar, but still not as high as that of the first
molar.

If a mandibular second pre-molar is congenitally-missing, the roots of the primary mandibular

second molar will not be resorbed and the primary tooth may be retained.

There are 2 types of mandibular second pre-molars. The 3 cusp type has three pulp horns.
From an occlusal view, it has a square occlusal form and grooves that form a "Y." The 2-cusp
type has a crescent-shaped appearance from an occlusal view.

The mesio-lingual cusp of the 3-cusp type is bigger than the disto-lingual cusp. There is a
groove on the lingual surface between. them. A cross-section of the root appears oval-shaped
or round. The pulp is shaped like a funnel and has a dramatic constriction (though not as
dramatic as that of the maxillary first pre-molar).

Maxillary Molars:
The "Rule of Singh" is designed to help determine whether a MAXILLARY tooth viewed from
the occlusal is from the right or the left side of the mouth. Arrange the diagram so the lingual
side is closer to your chest and the buccal side is away from your chest. If the mesial side is
now on your left. the tooth is from the left side of the mouth. If the mesial is on your right, the
tooth is from the right side of the mouth.

I
r

February 1".2005 Daniel Travellc & Brandon Fowler's DenIal Anatomy Board Review Packet 10
-~-.--_. __ --_._.------ -_ . . -._ _----­ - ----- --- - ---- -- -------
-------~--------------------~------------- - ----­

Try the "Rule of Singh" on the above diagram. This may seem simple, but trust me, these are
the type of questions you do not want to miss because you messed up what side of the mouth
they are talking about.

(For a diagram of the following, see page 250 of Wheeler)

The maxillary first molar:
-is the subject of a lot of board questions
-is the only tooth that is wider lingually than facially
-is the widest tooth facio-lingually
-is the only tooth with 2 triangular ridges on 1 cusp (the mesio-lingual cusp)
-has a concavity on the distal surface of its crown
.
The maxillary first molar has a cusp of Carabelli lingual to the mesio-Iingual cusp. The cusp of
Carabelli reminds us that this tooth formed from 5 lobes. (The other teeth to form from 5 lobes
are the mandibular first molar and the 3-cusp form of the mandibular second pre-molar. The
mandibular first molar has one lobe form each of the 5 cusps. The mandibular second pre­
molar has one lobe for the mesial-marginal ridge, one for the distal marginal ridge, one for the
mid-facial lobe, one for the facial lobe, and one for the lingual lobe.)

The mesio-Iingual cusp has 2 triangular ridges; one heads down the cusp to the central
groove, where it meets the triangular ridge from the mesio-buccal cusp to form the transverse
ridge. The other triangular ridge heads down the mesio-Iingual cusp to meet the triangular ridge
of the disto-buccal cusp and form the oblique ridge. The transverse groove of the oblique
ridge connects the distal fossa and central fossa.

There are 4 grooves on the maxillary first molar. There is a lingual groove; it extends onto
the occlusal surface and becomes the distal oblique groove and ends in the distal pit. There
is also a facial groove and· a transverse groove of the oblique ridge.

There are 4 major functional cusps (the cusp of Carabelli is not functional). But there are
only 3 major cusps from a developmental standpoint (the disto-lingual cusp gets
progressively smaller on the maxillary second and third molars). The 3 major developmental
cusps are the mesio-buccal, the mesio-lingual, and the disto-buccal.

Even though we all agree the facial surface of the maxillary first molar has a trapezoidal form, it
has 5 sides from the facial view (according to an old board question). It has a lingual groove in
the middle of the tooth. (On the second and third molars, the lingual groove is positioned more
distally.)

The maxillary first molar has a tri-furcation with all its roots centered above the crown (the
second and third maxillary molars have a more distal inclination to their roots). The palatal root

/
 Fcbmary 1",2005 Daniel Travelle & Brandon Fowler's Dental Anatomy Board Review Packet II
__ j~thJ~jQngest arldjs th~Qnl~-IQot..lnJbJLrn~LLtb_~ith.both a facial and. a linQ..ual concavity. Th~L .__
mesio-buccal root is the widest facio-lingually. The disto-buccal root is the shortest. It has a
large root trunk.

The occlusal view has a rhomboidal shape with acute angles at the disto-lingual and mesio­
buccal corners. It has obtuse angles at the disto-buccal and mesio-lingual corners. The height
of the distal marginal ridge is the same as the height of the mesial marginal ridge and the height
of the oblique ridge. The distal cusp of the mandibular first molar occludes with the distal fossa.

The mesio-Iingual cusp is the biggest and tallest of all the cusps of the maxillary first molar.
The mesio-buccal cusp is second largest; the disto-Iingual cusp is third largest; the disto-buccal
cusp is 4th largest. (On the second and third molars, the disto-lingual cusp is smaller and
becomes the 4th largest cusp.)

When preparing a maxillary first molar for endo, the access should be made in triangular form to
include 3 orifices. The longest leg. of the triangle should be between the palatal and mesio­
buccal orifices; the most acute angle should be at the mesio-buccal ori'flce; the most obtuse
angle should be at the disto-buccal orifice.

There are 4 functional cusps, so there are 4 pulp horns. There are usually 3 canals, but 40% of
the time, a 4th canal is in the mesio-buccal root.

(For a diagram of the following, see page 260 of Wheeler)

The maxillary second molar is similar to the first molar. But it has 2 types; there is a 4-cusp type

(which has a lingual groove on the distal half of the lingual surface) and a 3-cusp type (in which

the disto-lingual cusp is non-existent); From an occlusal view, the 3-cusp type has the occlusal

shape of a heart. Both types have a large root trunk and 3 roots which are more fused and

more inclined distally than those of the first molar. It rarely has more than 3 canals.

(For a diagram of the following, see page 268 of Wheeler)

Third molars are the teeth most frequently congenitally missing or malformed, The maxillary

third molar has short crowns and long roots. (Mandibular molars have big crowns and short

roots). Root length is important because longer roots are more easily anesthetized (possible

clinical correlation).

Mandibular Molars:

The mandibular molars all have 2 roots. The mesial root is always bigger and wider facio­

lingually than the distal. The biggest and straightest canal is in the distal root, which is better

designed for paraposts. (There are 2 canals in the mesial root and they have to be small to both

fit. )

(For a diagram of the following, see page 282 of Wheeler)

The mandibular first molar:

-is the widest tooth mesio-distally

-has 5 major functioning cusps

-erupts with 5 pulp horns

I
,

Febmary 1".2005 Daniel Travelle & Brandon Fowler's Dental Analomy Board Review Packet 12
---The mandibular first molar-is-1mm-widet: mesio",distall-y-tnanJacio,.Jjngually---ILhas-2-roots- ina­
broad furcation. It is likely to have decay on the facial surface because of its buccal groove and
buccal pit.

All 5 functioning cusps of the mandibular first molar can be seen from the facial or the distal
aspect. The biggest cusp is the mesio-facial (the mesial supporting cusp). The tallest cusp is
the mesio-lingual cusp. The smallest is the distal cusp.

The mandibular first molar has 4 grooves; it has a central developmental groove, mesio-facial
groove, disto-facial groove and lingual groove.

(For a diagram of the fol/owing, see page 293 of Wheeler)

The mandibular second molar has roots which are more fused, more distally inclined, shorter in
height, and shorter in width. In contrast to the mandibular first molar, the mandibular second
molar has 4 cusps and only 3 grooves (a facial groove, lingual groove and central
developmental groove). The occlusal view has a rectangular shape and grooves which form a
plus (+) sign. The mesial side is wider than the distal, a helpful identification trait.

(For a diagram of the fol/owing, see page 303 of Wheeler)

Mandibular third molars have big crowns and short roots. They are frequently missing or
malformed. They have fused roots with a distal inclination.

(for a diagram that isn't particularly germane but displays the skull of a pretty cool Mississippi
alligator, see page 91 of Wheeler)

Primary Teeth:
I know what your thinking - we didn't learn about primary teeth at all in our PBL cases. Although

that is very true, the boards love questions about Pedo teeth. Know them well and know the

differences when compared to there permanent counterparts.

Primary teeth can be grouped into 3 categories- anteriors, second molars, and first molars. All

of them are different from permanent teeth in the following ways:

A- Primary teeth have thinner, whiter, less calcified enamel that is more uniform in depth than

the enamel of permanent teeth.

8- Primary teeth have a thinner DEJ (so it's easier to have a pulp exposure).

C- Primary teeth have more prominent pulp horns. ~

0- Primary teeth have bigger cervical bulges (especially the first molars). LA .•Alr "t .ll£:~~oAI\aL1a~
E- Primary teeth have enamel rods which go from the DEJ occlusally.~ ~ ,/Io..,V\P77 w·'<N()""

F- Primary teeth have a more narrow cervix.

G- Primary teeth have a narrower root trunk.

H- Primary teeth have roots which are more flared and skinny.

Most of the other traits that are exhibited by permanent teeth are held by the corresponding

primary teeth. (For example, the widest anterior primary tooth mesio-distally is the maxillary

central; the widest anterior'tooth facio-lingually is the maxillary canine; the smallest tooth is the

mandibular central.)

Febmary 1st • 2005 Daniel Travellc & Brandon Fowler's Dental Anatomy Board Review Packet 13
~~-------------------------------_.-

There are generally diastemas between the crowns of primary ~th,which appear short and fat.

That makes the roots appear longer in comparison. By age~all primary teeth should be in

occlusion.

Primary Anteriors:

The primary maxillary canine is one of only 2 teeth to have a longer mesial cusp slope than

distal cusp slope on its incisal edge. (The permanent maxillary first pre-molar is the other.)

From the facial view, the primary maxillary canine appears to have a diamond-shaped

crown (unlike the trapezoidal-shaped crowns of all other teeth).

The mandibular lateral has a more exaggerated slope on its incisal edge than does the

permanent lateral.

Primary Second Molars:

Primary second molars resemble the permanent first molars that will erupt adjacent to them.

The primary maxillary second molar is the widest primary tooth facio-lingually. It has 3

roots; the palatal is longest; the mesio-buccal is widest facio-lingually and has 2 canals. It has a

rhomboidal occlusal outline.

The primary mandibular second molar is the widest primary tooth mesio-distally. It has 5

cusps; the smallest is the distal cusp (barely). It has two roots; the mesial root is bigger and has

2 canals.

Primary First Molars:

The primary first molars -are the most unique deciduous teeth. They have 4 cusps and very

prominent cervical bulges.

The primary maxillary first molar has a crown that resembles a permanent maxillary pre-molar

and 3 roots that resemble a maxillary 6 year molar. It has occlusal grooves which form an "H".

The primary mandibular first molar is a very primitive looking tooth. It is probably the best

answer when you're not sure how to answer a question about primary teeth. It has a mesio­

lingual cusp shaped like an ice-cream cone that is the tallest cusp of the tooth. From the

facial view, the mandibular first molar has a CEJ that curves up toward the distal.

Don't forget; it's us against the national boards. Good luck everyone-

Biggest, Tallest,. Widest, Best, Only, Fastest,

and Most Likely Teeth:
The widest mesio-distally: mandibular first molar
The widest ANTERIOR mesio-distally: maxillary central
The only tooth with a pulp wider mesio-distally than facio-lingually: maxillary central
The widest facio-lingually: maxillary first molar

I
 Fcbmary 1",2005 Daniel Travelle & Brandon Fowler's Dental Anatomy Board Review Packet 14
___The wid estANI ERIQRfaciil-linguali~:
__ maxHJa[~_cani 08.--- ------------------- -----------------­ ..-.
The only tooth that is narrower facially than lingually: maxillary first molar

The tallest tooth inciso-gingivally: #1 = maxillary canine

#2= mandibular canine

The tallest crown inciso-gingivally: #1 = mandibular canine

#2= maxillary central

#3= maxillary canine

The longest root inciso-gingivally: maxillary canine

The most symmetrical: mandibular central

The smallest: mandibular central

The narrowest mesio-distally: mandibular central

The narrowest and smallest-rooted pre-molar: mandibular first

The most congenitally malformed or missing: #1 = third molars

#2= maxillary lateral

it 3::: tv\~}i\)\ VNL+\\Z 2~ '?..etV'l":::'\c~(' s

The pre-molar most likely to be congenitally missing= mandibular second pre-molar

The best developed lingual anatomy: maxillary lateral

The most likely to have dens-in-dente: maxillary lateral

The greatest constriction from pulp chamber to canals: maxillary first pre-molar

The pre-molar most likely to have 1 root and 1 canal: mandibular second

The anterior tooth most likely to have a bifurcated root: mandibular canine

The only tooth with 2 triangular ridges on 1 cusp: maxillary first molar

The only tooth with a mesio-Iingual groove: mandibular first pre-molar

The only tooth with a root tRat is inclined mesially: mandibular canine

The only teeth with crown concavities: maxillary first pre-molar (mesial)

maxillary first molar (distal)

The only teeth with a longer mesial maxillary first pre-molar

cusp slope than distal:

primary maxillary canine

"''''''''''NOTE'''''''''

When we began to study for the Dental Anatomy Section of Boards, we felt that we were very
unprepared. Don't worry, this section will become easier and easier as time goes on. In fact, this is
the section that all of you should ace. However, having said that... do not put this section off until
the week before the exam. Start studying dental anatomy now and review it as you see fit. It is our
opinion that with this packet alone and the diagrams we have shown you ... you will all not only
pass the Dental Anatomy Section, but should do quite well.
I February I"t, 2005 Daniel TraveIle & Brandon Fowler's Dental Anatomy Board Review Packet
---- D~ntal--Ana tom¥-. and. OcclusiOR---- . . -- ---.-_ . .
If you can reproduce the picket fence below, then you will be able to answer almost 100% of MIP questions, as well as
._-.------..---.--__.
15

occlusion/lateral excursion questions. The exceptions to this diagram are listed below**.

First let's concentrate on Supllorting Cusp questions: TIle Lingual Cusps of Max, TIle Buccal Cusps of Man.
So Look at the diagram in this maruier:

Lingual CUSI)S
(Buccal ~ Cen Lat Can IPM 2PM 1M 2M 3M
Embmsures)

BuccaJ Cusps 1M 2M 3M
(Lingualu::=:==> Cen Lat Can IPM 2PM
Embrasures)

So How do you interpret these Supporting Cusp picket-teeth? BuccaJ Embrasure Lines
CF: Central Fossa

MMR: Mesial Marginal Ridge

DMR: Distal Marginal Ridge Distal

~ = MR or Cusp Tip/InciSal Ridge Mc~ial

Buccal
Cu~p +- Lingual Embrasure Lines
============= - -- -
- ---- - ==== - - -
--­
OK. - Then what about the Non-Supllorting CusJ)s? Usc the Same diagram with a mini-change in rules.
Non-Supporting Cusps arc. as you know, the Maxillary Buccals. and the Mandibular Linguals
BuccaJ Cusps
(Lingual ~ Cen Lat Can IPM 2PM 1M 2M 3M
Embrasures)

Lingual Cusps IPM 2PM 1M 2M 3M

Cen Lat Can
(Buccal ~
Embrasures)
Lingual Embrasure Lines .
G: Groove

+- BuccaJ Embrasure Lines

====== -- = = = = ============

**EXCEPTIONS:
'2 No MaxiIlary Cusp Contacts tlle MMR or the Lingual Cusp of the Man IPM
:2 TIle Distal Fossa of the Max 1M Opposes the Distal Cusp of the Man 1M
'2 TIle Distofacial Groove of the Man IM opposes the oblique ridge of the Man 1M
=====================--==-­
One Other Diagram:
February 1'\ 2006 Daniel Travelle & Brandon Fowler's Dental Anatomy Board Review Packet

Glossary of Dental Terms

Balancing Contacts
see Mediotrusive Contacts

Centric Cusps
see Supporting Cusps

Centric Occlusion
1) The maximal intercuspation of the teeth.

2) The relationship of the mandible to the maxilla when the teeth are in maximum occlusal contact,

irrespective of the position or alignment of the condyle-disk assemblies.

3) The occlusion of opposing teeth when the mandible is in centric relation.

Centric Relation
1) The position of the mandible when the condyles are in an orthopedically stable position. This
occurs when the condyles are in their most superoanterior position, resting on the posterior slopes of
the articular eminences with the disks properly interposed.
2) The maxillomandibular relationship in which the condyles articulate with the thinnest avascular
portion of their respective disks with the complex in the anterior-superior position against the slopes
of the articular eminences. This position is independent of tooth contact.
syn. retruded contact position

Compensating Clirve
The anteroposterior curvature'On the median plane) and the mediolateral curvature (in the frontal
plane) in the alignment of the occluding surfaces and incisal edges of artificial teeth that are used to
develop balanced occlusion.

Cross-Bite
1) When the teeth occlude in such a manner that the maxillary buccal cusps contact the central fossa
area of the mandibular teeth.
2) An occlusal relationship in which the mandibular teeth are located facial to the opposing maxillary
teeth; the maxillary buccal cusps are positioned in the central fossae of the mandibular teeth.
syn. reverse articulation

Curve of Monson
archaic see Compensating Curve

Functional Occlusion
The contacts of the maxillary and mandibular teeth during mastication and deglutition.

Guiding Cusps
The puccal cusps of the maxillary and the lingual cusps of the mandibular teeth

syn. non-centric cusps, shearing cusps

Habitual Centric Occlusion

see Centric Occlusion
J- February 1,1; 2006 Daniel Travelle & Brandon Fowler's Dental Anatomy Board Review Packet 17

Intercuspal Position
see Maximum Intercuspation and Centric Occlusion

Laterotrusive Contacts
see Working Side Contacts

Laterotrusive Movement
Contacts of teeth made on the side of the occlusion toward which the mandible has been moved.
syn. working movement

Maximal Intercuspal Position

1) A tight definite occlusal relationship when the teeth are in full
occlusion
2) The complete intercuspation of the opposing teeth independent of condylar position
syn. intercuspal position

Maximum Intercuspation
syn. maximimal intercuspal position

Mediotrusive Contacts
Contacts of the teeth on the side opposite to the side toward which the mandible moves in articulation
syn. non-working contacts and balancing contacts

Non-centric Cusps
see Guiding Cusps

Non-working Contacts
see Mediotrusive Contacts

Normal Occlusion
Angle's Class I occlusion

Retruded Contact Position

see Centric Relation

Reverse Articulation
see Cross-Bite

Shearing Cusps
see Guiding Cusps

Supporting Cusps
When the lingual cusps of the maxillary arch and the buccal cusps of the
mandibular arch occlude with the central fossa of the opposing teeth
syn. centric cusps .

Working Movement
see Laterotrusive Movement
February 1S\ 2006 Daniel Travelle & Brandon Fowler's Dental Anatomy Board Review Packet

Working Side Contacts

Contacts of teeth made on the side of the articulation toward which the mandible is moved during
working movements.
syn. laterotrusive contacts

- - - = ' " ---­ =-=­ -

_ _--=--_­ - - ­ -__---_­
-~---

_~7~_---=~: ~~=--==---c:-_~-=-_ -­ __~-

__ -~
I
Development of Dental Lamina
th
At the 6 embryonic week, the embryonic oral epithelium begins thickening. As the
epithelium thickens, it grows downward into the underlying connective tissue and does
not create a visible ridge in the oral cavity at this time. This thickened oral epithelium is
known as the 2~ll!~l~ It's a U-shaped thickening of the epithelium of the primitive
oral cavity and is found in a position corresponding to the future arch-shaped
arrangement of the upper and lower teeth. This thickening is first seen in the anterior
midline, slowly spreading posterior toward the molar region. It takes several weeks for
this thickening to extend to the position of the primary molars.
At about the.§: embryonic weekjl.£:J-1!nlUtl tb~JULqline~~agin~l~ri.Qfly., there's
a £9PJi.!2JJ~<1-tlJick~g i~Jhe ~eI}talJ~iE! in 10 areas of the upper arch and 10 areas of
the lower arch. These 1~l2saJlsgJhL«.JsE1j,U-g§correspond to the position of the future
primary dentition and will form the enamel of the future teeth;
t~m,IU 1 WI. . -- ......

Enamel Organ Development

Bud Stage
STAGES OF TOOTH DEVELOPMENT
The initial budding from the dental lamina
Tune Scale
(week.! in ulelOl at the 1.9 thickened areas in each arch is
PP~MARY E?ITHEUAL called the bud stage, the first stage in
BMID development of the enamel organ that
fOrrriS the enamel of the teeth. The cells in
the middle of the buds come from the outer
VESTIBULAR LAMINA DENTAL LAMINA layers of the oral epithelium, and the cells
~ in the periphery of the bud come from the
BUD STAGE .a deep or basal layers of the oral epithelium.
. ~ The buds seem to stretch out from the
CAP STAGE ~U dental lamina as they grow. As
~ E.:RLY 14
development continues, the deepest parts of
the buds become slightly concave, and this
BELl STAGE ~
~ ,ATE ,8 is the point where the cap stage starts.
ROOT DEVELOPMENT
Cap Stage
As the enamel organ moves into the
,,,... : - ~ ~ ~ ~ ~ _ . ~ = , , , v . ; : ~ ~ ~ , - - - , . ~
~

~r.0tOG~rJ~:·lIC
~t~£SI:'~~t
. £~£,~~Z~ c~.!be f£g£\ViEg~
compartments:
~:~~~~ .o--·:;:'7~..._ _

(D Outer enamel epithelium (OEE)

The outermost part of the structure of the cap stage. It's a direct continuation of the basal
layer of oral eptiherliaL thse are lOW colmnnar OF cuboidal cells.
""~:r~~~""'~~.-'''''~~~~'?~~~~~~~~~,~
 3~~~~~I~~~f
.. ~.·h·-Bosal cell loyer
of oral epithelium

Sfellcle reticulum

~~) Inner enamel epithelium (ffiE)

Outer enamel
These cells outline the concavity in the epithelium
Outer enamel
epithelium
deepest part of the cap stage. The cells are

continuous with the GEE cells and also

come from the basal layer of the oral

Inner enamel
epithelium. epithelium

FIG. 4-3. Cap stage. Basal layer 01 the cells olthe oral epithelium is continu­

(D Stellate reticulum ous with the inner and outer enamel epithelium. Dividing points of IE.E and
OEE (arrows). Stellate reticululll can be seen as a continuation of tl1e superfi­
These are cells between the lEE and the cial layers 01 the oral epithelium.

GEE. They ".~~'cl<,--.:~.<

originate from the sunerficial
,:,_",ir..~~_""-=,....",,.-,;;:.=-c.=S',...,r,:- "~"~''''''''''.-.-.' .t:;::~.'O""-~"'''3., ....,->y~~
..

l~X~~r..s..g.tth~.QL~L~ElE.~~.!i.I,!_m. Although they may resemble embryonic mesenchymal

cells, they're really ectoderamal cells, as are other part of the enamel organ.

As the concavity of the cap grows more pronounced, enamel organ reaches the bell stage.

Bell Stage
The ~_.':';.".~
differentiation between the cap and bell stap-es is made when a fourth laver of
!~_"~"-=,;~."]::"".J~B~~'.':';il·"";;'·Z-I.:r~~.5~~o;.·~"-.?-,;,:,-;;c~.",,, "-:"'_."~%J'''';:::1S"''t,~,7;· ~!.C~""Iti:"-,,,,'O,!·;~:.Q:;:·~-,-~:...r,'''''O';··'''Oo:-;'::\''''':i'!:oS':~(''''''-~~<'''''''_~~':'';~!.:'_''~·'l,;';;:--;;''-'''';~'''~i,~'u~:~~·.,·-; ../<''':f.,~·~,",~
. .

,e£~!h,~ltYm"lb,~"~tr~_tuIl},i~,t~~_e,d,i u_I11L~11l?S~<w:~i!1~~&q,~El,il?~",!£}"h.~~!bJ,~,~,"~ll~~.s!l,"!D~}l!iS)~,~£t
The stratum intermedium comprise several layers of flattened squamous cells lying
between the lEE and the stellate reticulum.
As development continues in the bell stage, two process occur. gix§,~ the future
outline of formof the crown of
the tooth is determined by the
way in which the cell layers
expand as the enamel organ
grows. Second, there are
'~:~~;';:~;f~

changes in the various cells,

particularly the IEE cells,
that'll lead to the production of
A
GEE SuceeBLonol lamina enamel.

A. Function of the Four

Layers of the Enamel Organ

1. The GEE can be considered

a protective layer for the entire
Strotum inter medium enamel organ. Later it'll playa
Sletlole reliculum
role in attaching the gingival to
the tooth

FIG. 4-4. Bell stage. A, Concavity of lEE cells has increased in the bell st.ge.
Successional lamina can be seen developing to the lingual side of the primary
tooth. B, Enlargement of the boxed section of A. There arc s<veraJ layers of
"_ •• ~_~A ,.... 11 .... ,h;,·h ....... c.c .... ",,., ;n ...... rn .. .4i"rn .,,, \&,.. 11"'0: 11:1= ()1='r.' ::tn,l li:rl"l.

__ .w. ~ _ · _ ~ ·~ - ••• - _.--- ... - ~._--._------_ .. - _ _..

... .. ~._---_.-
__--_._---_._---------._--­
..

3. The s1~m functions as a cushioned protection for IEE cells and also plays
a role in !lQ.U~..Qf the stratym.intermedW..m by allowing vascular fluids to move
between the loosely packed cells

4. The cells of the stratum intermedium probably help provide nourishment for IEE cells.
They're also producers of protein and may receive products from and provide products
for the ameloblasts.

IV. Successional Lamina

In the developing primary teeth the dental lamina develops an extension to the lingual
side of each tooth, known as the successional lamina. Successional laminae go through a
bud, cap, and bell stage just like the primary teeth to f~the p~rmanent i;cisors, .
canines, and premolars. The permanent molars develop from a posterior growth of the
dental lamina and are non successionaL The permanent teeth develop at a much slower
rate than the deciduous ones.

V. Vestibular Lamina
This is a thickening of oral epithelium in a facial or buccal direction from the dental
lamina. This epithelium thickens, and then a c1efting/splitting can be seen in the
thickened area. ~~lJW:~£l~1L{~~~~Lgr.P'W~X~,,~JJ)~J:.Q~~tb~"~~a,{}ttne.
m.1L~,g,bJl~al~C1tcmll~91qbiaLt:Q..ld.luL~~X~~~stib"ut!:6. Without the· vestibular lamina,
the vestibule would end at the level of the alveolar ridge, and denture construction would
be very difficult or impossible.

VI. Dental Papilla and Dental Sac

The dental papilla is a small area .
of condensed cells arising from
the mesoderm and located next to
or deep to the IEE. It's first seen
in late bud stage, and grows .~,,:,,-,=~~--,---,;......:o.-Permanent tooth forming
through the bell stage. During
~7-~~';-~~ Dental lamina
the bud stage, the cells of the
embryonic connective tissue B ~""",,=--~---'--:--Enamel organ

deep to the bud resemble

mesenchymal cells. As the
~,---''-'-----:'-,----=-- Denfal papilla
enamel organ goes into the cap
stage, the mesenchymal cells
adjacent to the cap become more
rounded and condensed and are \
. ""­
then called dental papilla cells.
The condensation continues into FIG.5-1. A, General condensation of dental papilla. B, Later stage. Conden­
the bells stage. The dental sation of the cells in dental papilla is more pronounced. (From Bevelander G:
Outline of histology, ed 8, St Louis, 1979, Mosby.)
papilla forms the dentin and
pulp of the tooth. As it develops, its cells becomes more compact and the area enlarges.
It sits within the conical shape of the IEE cells and becomes very pronounced, bulging

r----..'~---------
:­

out from the enamel organ. The mesodenn of the dental papilla detennines the shape of
the developing crown of the tooth.
The dental sac comprises several rows of flattened cells surrounding the part of the dental
papilla not in contact with lEE cells and also surround part of the enamel organ. It froms
the cementum of the tooth, the periodontal ligament, and some al veolar bone.B()th.the
d~nt~.l£(lpilla and dentalsac arise frornED~§.<:l.g~,rrn. ~'~'"~'~''"'''''''
.~ ,'-"" _.~:rl:::;.":,f;r~""-"""~'" ".'~ ''':·-'''<!'~~.CcL'~''''~~;~'''~';;:<>'-1 '...~·,';:,;7~i'c:,.~~·,·.··,.. "...."'-"';:,"";:'.'<:!'.Y~ ......:':.;~.~;: ::>';",<.,.~~ .. -~. _~._ ...,.... 1_" """,..•''''-'''- ."-~

VII. Enamel and Dentin formation

1. During bell stage, the IEE cells become taller, increasing from 12 to 40um in length.
These taller cells are now called preameloblasts. As they enlarge, their organelles are
multiplying making more mitochondria, ERs, and more obvious Golgis.

2. The E~liJ?h~F~!"Se.lJ~,.,Htlb"~,,,g~[lS(l1..b1~pJ!1.g.
adjacent to the preameloblasts become lo~
columnar cubOIdal cells called odontohlasts.
,.
or
.,~...:~~~~~"~..o:,,,"-.i:;:;;:'~~,~~'<-;<'~~;y.,<::"";~"""~"'';:.;
.•)::<I:i'

3. The odontoblasts move away from the preameloblasts toward the center of the dental
11a and secrete a matrix of mucopolysaccharide ground substance and collagen fibers.

4. The secretion of this dentin matrix causes the preameloblast ~9'£d~i\.~ll;~~.j~B;21,qUl~by

• 'UP....Yin~rr.om the cell's c~nter to th~ end_nearestJhe..s..ttatumjnt.ermedium:
Wit!" :arity change, the cell becomes an ameloblast and i.§ ready to begin secretion
L~,t:
l .lel matrix.

.), '0loblast lasys down a matrix of mucopolysaccharide and organic fiber next to
the ,,__,Jtrix, and the ~~~IJ",illJl~jHJ1~1j,g111~~~J2!!ll~~ As the ameloblast
secretes .,le matrix, it moves away from the dentin toward the GEE.

6. II..:ntin beings to lay down hydroxyapatite crystals and calcify (crystals begin

groWillg)

7. The enamel begins to lay down hydroxyapatite crystals and calcify too.

Within any single tooth, this type of interrelatiqI1shjp.

i~>!!r<~t~~~.?~~.t.!h~..!~.a~L~~£~2~f~~:i§"21E;:~~n~i~i:
'spreads'f()waicfS"tne cervical line: This process is
idenncarfor'~anMQeveTopin'gteeti1, whether primary or
permanent. The pennanent molars develop as a
budding off of a posterior extension of the dental
lamina, whereas the anterior pennanent teeth and the
pennanent premolars develop from a budding off of
the dental lamina of the primary teeth developing in
that position.

Development of Enamel

---~
 ~ -~,. -----,~------ ._----_. __._-.-_._­
Enamel structure comprises two parts: the rod sheath and the enamel rod. The rod sheath
outlines the rod and contains most of the fibrous organic substance. However, .!!2~~,
~,f_of ~~",~ll'lliJ~~!X~S~.,k~~~u~_tmiJJ2t~l~§lU1£l~. The rod is a

column of enamel that runs all the way from the DEJ to the tooth surface. It's somewhat

perpendicular to the DEI and to the crown surface. It is still debatable about how the

enamel rod and its shape actually develops. A typical enamel rod has a keyhole shape,

with a wide upper end and a narrowed bottom end.

There are two stages of enamel development:

(f) Mineralization Stage
.>:.-~

Ameloblasts begin to lay down their matrix, and in a

few days deposit millions of hydroxyapaptite crystals
into the small area of matrix.

{~ Maturation Stage
Crystals grow until they're tightly packed together.
~"!H~1221~~~"£[9.ill~ mm'!JIL~illl"<j!<n".~~lEl_L~ Proliferation
,4~~l' ~1, d-~~h:?l~J~e~~s..!p.!?~e~ c.~,~Jr; zone

~ deve1op~t, and ~.2!:?~~~h~eyel~,lU.J.~

enarnei': caned striae of Retzius. These lines curve
~~!~~'''if'e''' 'f'7'~

o~~.rt~Y and 0S:~~1h.~.

\=3. Beginning of dentinocnamel junction [DE])
Fate of Enamel Organ fotm;tion. Amelob1::lsts have already moved away
. frclm the DE] in the upper section but not in the lower
As the ameloblast moves away from the DEI towards section. Modified frolO Bhaskar SN: Orban's oral his­
the GEE, it begins to compress the 2 layers in the tology and embry'ology, cd 10, St Louis, 1986, Mosby.
middle-the stratum intennedium and the stellate
reticulum, causing the 2 layers to eventually lose their identity. The final job of the
ameloblast is to lay down apE~.~~i~~~J:~~£!l~Illdb~aLkst!P~~~:n~~~s.l
cuticle or Nasmyth's membrane. This layer covers the crown and remillns"fnere for many
",-$'~_~;;>-;.~J.f~$~~"!:o-'1l:",,",,~,,~~~~~

months after eruptIon untifworn away by toothbrushing and other abrasion.

After the ameloblast produces the primary cuticle, it begins flattening out and blending
with the GEE cells in what is called reduced enamel epithelium. This produces an
adhesive like secretion called the secondary enamel cuticle or epithelial attachment,
which functions to hold the gingival to the tooth. This epithelium adheres to the tooth
and is know as the attachment epithelium, found at the base of the gingival sulcus:
~r ~7
JDentin Formati0l!l
Dentin comprises of the following 3 distinct areas:
1) Dentinal tubule-long tube containing odontoblastic process running from
DEI or DCl to pulp
2) Peritubular dentin-an area of~lz!l~l£EX~~~mf1~~t immediately
surrounding the dentinal tubules
3) Intertubular dentin-bulk of dentin material

I
 As the odontoblast begins to secrete
Occlusal wear
dentin matrix at the future DEI, the cell
begins to move toward the pulp. The
Caries
odontoblast differs from the amelobalst in
that it leaves part of the cell behind and Reparative dentin
Enamel
secretes matrix around it. The secreted
matrix from an odontoblast spreads
eripherally until it meets wi other dentin
matrices and eventually calcifies and ~~~-Secandarydentin

forms ':",.
intertubl!lqr
.
<;lentil). Later, the
-:;...~_;",;;~ ~,e<"'_~"·'''·_ ,J",; ' ..c·!-~-.....·;"," ;>,;:;-.>,..,.'t.:!
-N---- Primary dentin
odontoblast process contained within the
intertubular dentin shrinks in diameter, -'+--+--- Pulp
and the space that it formerly occupied is
filled wi a highly calcified dentin known
as p~Ijl1!J:?IlJ?I*g~.!lttU. When the tooth FIG. 5-13. Primary, secondary, and reparative dentin. Notice how rhe sec­
erupts:--the dentin that has formed by that ondary dentin has decreased the size of the enrire pulp chamber, whereas re­
parative dentin is formed only beneath traumatic areas, such as a carious re­
time is known as primary dentin or gion and an area of occlusal wear.
regular dentin. Dentin continues to be
fonned as either secondary or reparative dentin.

Pulp Formation ./
Pulp develops form the me§oderm of the dental papilla. As dentin grows inward, it
compressed the inner tiss;k of the dental papilla. At this point, blood vessels, lymphatic
channels, nerves, and c~nective tissue cells are very evident. Many of the mesenchymal
cells become fibroblasts and being forming collagen. The nerves of the pulp are sensory
and only tran;:m]Tine'"pain sensation. With the aging of the tooth, the pulp becomes
smaller because of the production of secondary and reparative dentin and is less able to
resist trauma because it loses its reserve cells.

Root Formation
This part will be a brief overview, because it's a whole other chapter, and I've already
tried to cover 3 chapters prior to this.
This begins after the outline of the crown has
Orol epithelium
been established but before the full crown is
calcified. The point where the OEE and IEE
cells meet is the £~. The OEE and
IEE cells here undergo rapid division,
...... - .. _­
/ , * , , - - - Enomel
~
growing deep into underlying connective
---Dentin
tissue-the beginning of root formation. The Crown of
Reduced enomel
tooth
tip of the epithelial root sheath turns epithelium

horizonatally inward; this portion is called the

_~pithelial diaphragm of the root sheath, and it
guides the shape and number of roots. The Epitheliol
way
"
in which the epithelial
.',~._,z..~.:":. "'_-f~"":!"'::';""'"""";""""._~-~~:~;":;';".c·::_
:-;
diaphraom
.:.-_.oth'~
<e-,"<.,"'" rool sheath
-', ..,,,., :,·ct:.· -:>;,"'..:",.." ,..,.,?. -, ' ...;;. ••..;.,.:-..;

cgD!j,~1J~.§Jg"gm\X.in~,~r£tp~t~,rmiu~s.-,wh~th_t;l
the tooth will have one, two, or three roots.
__:'_~:~;,.iJ,~i:_r,:,,,~,,,~:-:~~·_,;,:;,,,,,t';'."i-: ...:;~-'&:IG~:i:"J:~~«,~~r..<$.i,?f~;"'i::L,.;':""'-'~~'~"~'6.~r':-"·,160<1~:i:;:t:1,.- ;jC,,~ ;;';':?e
FIG.6-1. Beginning roor developmenr. The epithehaJ roor shearh interposed
berween the dental papilla and rhe denr~j sac.

I
 ----- ----- ----------------------------

1 ::-te vertical epithelial root sheath grows longer, forming root length, the horizonatal
.--'-_3
::;il:helial diaphragm continues to grow in toward the middle of the tooth.

Symptoms of Tooth Eruption

Teething describes the physiologic process of tooth eruption through the gums of the
mouth.

Teething usually begins between the 6th and 8th month of life. Further tooth eruption
occurs periodically until all 20 teeth of infancy and childhood, or deciduous teeth, are in
place. All the deciduous teeth are normally in place by the 30th month of life.
These teeth include 4 incisors, 2 canines, and 4 molars in each jaw for the total of 20. The
2 lower incisors usually erupt first followed by the 2 lower incisors, upper lateral incisors,
lower molar, upper molar, lower canine, upper canine, lower lateral molar, and finally the
upper lateral molar. Note that some children do not show any teeth until much later than
8 months, and this is perfectly normal.

The signs of teething are:

• Drooling
• Irritability
• Gum swelling and sensitivity
• Sleeping problems
• Refusing food
• Biting on hard objects
• Low grade fevers (but NOT over 100 degrees)
The discomfort that results from teething is due to the pressure exerted on the tissue in
the mouth, called the periodontal membrane, as the teeth erupt. This discomfort may be
eased by a cool object such as a firm rubber teething ring or a cold apple. Gently rubbing
the gums with a cool, wet washcloth may also provide comfort.
The gums should not be cut to facilitate the eruption of teeth since infection can result.
Teething powders and aspirin should also be avoided. Medications such as children's
Tylenol or over-the-counter teething medications containing a topical anesthetic can be
helpful.
Note: I had a hard time finding the symptoms for tooth exfoliation, which our patient
would be experiencing, but figured if anything it would be similar to what is mentioned
above.
References:

Brand, R, Isselhard, D. Anatomy of Orofadal Structures, 6 th ed.1998.

http://www.temple.edu/dentistry/perio/periohistology/gu0301m.htm

http://www.uic.edu/classes/orla/orla312NariationlnToothMorphology.htm

www.umm.edu/ency/article/002045.htm- 23k