Dental Anatomy & Occlusion PDF

Summary of Tooth Formation
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Dental papilla
Ectomes-
enchyme
from neural
crest
Dental follicle
95- 1
Saad Alqahtani, Twitter @saaddes

SAADDES Stratum intermedium
Inner enamel epithelium
Central cells of the dental papilla
enamel epithelium
The bell stage of tooth development, which ex hibits d ifferentiation of the too th
germ to its fim hest extent. Note the enamel organ and the dental papilla have dif-
ferentiated into various layers in preparation for the apposition of enamel and
dentin. 308AI
Reproduced \1,-ilh p~nnission from Ba1h-Balogh M, Fehrenbac-h MJ; 11/u.ftraled Demal EmhtJ'illogy. Histology. am/ A11aiMI)~ ed 2. St. Louis. 2006.
Saunders.

Stages in Tooth Development
Stageffi me Span* Micr oscopic Main Processes Description
Appearance Involved
Hlltlation stage/sixth to Induction Ectodenn lining stomedeum gives
seveth weeks rise to oral epithelium and rhen to
dental lamina. adjacent w deeper
ec1omese.nchyme, which is influ-
enced by the neural crest cells.
Both tissues are separated by a
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baseme-n t membrane.
Bud srage/e.ighth week P-roliferation Growth of dental lamina into bud

that peneuates growing ectomes-
enchyme.
Cap stage/ninth to renth Proliferation, difTe.rentia- Enamel organ fo nns into cap, sur-
weeks tion, morphogenesis rounding mass of de.ntal papilla
from the e.crome.o;endtyme and sur-
rounded by mass of dental sac also
from the eccomesenchyme. Fonna-
tion of the rooth gel'llt.
* Note that these are approximate prenatal time spans for the development of the primary dentition
3088~
R<'produccd \ltith penni$.iion (rom Ebtb-Balogh M. Fchrcnbacoh MJ; Jlill.~trale(/ Demal Emb'J'ology. Histology. om/ A11a/OP1)~ ed 2. StLouis. 2006.
Saunders.

Sta ges in Tooth development
Sta geffi me Span* Microscopic Main Processes Description
Appearance Involved
Bell stage/eleventh [0 P-roliferation, ditTerentia. Differentiation of enamel organ
twelfth weeks tion, morphogenesis into bell with four cell types and
dental papilla into two cell rypes.
Apposition stage/ varies

per tooth
SAADDES Induction. prolifermion De.ntal tissue..; secreted as marix in

successive layers.
Maturation stage/ varies Maturation Dental tissues fully mineralize [ 0

per tooth their mature levels.
* Note that these are approximate prenatal time spans for the development of the primary dentiti on
308 C.l
Reproduced with p..-nnission (rom Bath-Balogh M. Fehrenbach MJ; /1/ii.~trauNI Demo/ EmhtJ'illogy. Histology. om/ AIIOIOPIJ~ ed 2. St Ll"'Uis. 2006.
Saunders.

anterior teeth information
A stray crown is found in your office. It is an anterior tooth and has a cingulum
that is offset from center. What tooth is it most likely to be?
maxillary canine
maxillary lateral incisor
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mandibular lateral incisor
mandibular central incisor
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DENTAL ANATOMY & OCCLUSION

A cingulum (also cal led the linguocervical ridge) is the lingual lobe of an anterior
tooth. It makes up the bulk of the cervica l third of the lingual surface.
Anterior teeth that have a cingu lum located in the center of the cervica l third of the
lingual surface:
Maxillary lateral incisor
Maxillary canine
Mandibular centra l incisor
Anterior teeth that have a cingu lum which is located off center to the distal in the
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cervical third of the lingual surface:
Maxillary centra l incisor
Mandibular lateral incisor
Mandibular can ine
Note: The total number of cingula in each dentition is twelve (six maxillary anterior
teeth and six mandibular anteri or teeth).
Mandibular Right Lateral Incisor Mandibular Right Central Incisor
M D
Incisal Incisal

Which characteri stic below is common to all mandibular anterior teeth?
distinct cingula w ith grooves and pits
incisal edges that are facial to the root axis line
facial surfaces that are marked by pronounced labial ridges
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continuous convexity incisoapically on the facial surface
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continuous convexity incisoapically on the facial surface
Three characteristics common to all mandibular anterior teeth:
1. Indistinct cingula with smooth lingual anatomy without grooves and pits
2. Incisal edges lingual to the root axis line
3. Continuous convexity incisoapically on the facial surface
Specific information pertaining to mandibular central incisors:
Occlusion: they only occlude with one other tooth - the maxillary central incisor (in centric,
protrusive, and lateral protrusive as well)
Note: The alveolar process is th innest facial to both central incisors (for this reason, local infiltration
may be effective for anesthetizing these teeth).
*** Remember: The canines (both maxillary and mandibular) are the only teeth with labial ridges.
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Note: The CEJ curvat ures are greater on the mesial than the distal (see pictures below).
/ /\
I
{ ' /
I I...
... / \.
\\ \ ,./ .
l ))\ l \
....
\ '
'.: J 1
' '
v v
Mesial Distal Mesial Distal Mesial Distal
Mandibular right Mandibular right Mandibular right
central incisor lateral incisor canine

A clinical examination of your patient reveals two lower incisors centered on
the midline. The patient gives a history of a car accident when he was young
where he lost two of his lower front teeth. He says that his dentist used braces
to fill in the gaps. Which of the following criteria would be most reliable to
decide ifthe remaining teeth were lateral or central incisors?
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difference in root length
difference in ratio of crown length to root length
degree of slope of the incisal edge when viewed facia lly
difference in rotation of the crown on the root

difference in rotation of the crown on the root
*** The mandibular lateral incisor crown t ips sli ghtly to the distal relative to t he root
(facial view).
Other ways to distinguish the mandibular lateral from the mandibular central:
The lateral is larger overall (especially mesiodistally)
The lateral is not as b il aterally symm etrical as the centra l incisor
The cingulum on the lateral is slightly distal to the center
On the lateral inciso r, the mesial marginal ridge is longer than the distal marginal
ridge. On centrals, they are the same lengt h
Lateral incisors have t he distal p roximal contact s more apical t han the mes ial con-
tacts. Centrals are at the same level
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Lateral incisors have the distoincisal angles more rounded than the mesioincisal
angles. On centrals, the angles are nearly the same
Note: Both the mandibular central and lateral have a lingual cervical line t hat is posit-
ioned more apically than the facial cervical line.
Mandibular Right
Lateral Incisor Mandibular Right
Central Incisor
Labial
M
4 Incisal
D
Labial
M~
lnc.isal
D

The mesial and distal aspects oft he anterior teeth- central incisors, lateral in-
cisors, and canines, maxillary and mandibular - may be included within tri-
angles.
The base of the triangle is represented by the cervical portion of the crown
and the apex by the incisal ridge.
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both statements are true
both statements are fa lse
the first statement is true, the second is fa lse
the first statement is fa lse, the second is true

Outlines of crown forms within geometric outlines-
triangle, trapezoids, and rhomboids. The upper figure
in each square represents a maxillary tooth, the lower
figure a mandibular tooth. Note t hat the trapezoidal
outline does not include the cusp form of posteriors
actually. It does Include t he crowns from cervix to
contact point or cervix to marginal ridge, however.
This schematic drawing is intended to emphasize cer-
tain fundamentals. A, Anterior teeth, mesial or distal
{triangle). 8, Anterior teeth, labial or lingual (trape-
zoid). C, Premolars, buccal or lingual {trapezoid). 0,
Molars, buccal or lingual {trapezoid). E, Premolars,
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mesial or distal (rflombold). F, Molars, mesial and dis-
tal (rhomboid).
Summary of Schematic Outlines of the Tooth Crowns:

Triangles
Six anterior teeth, maxillary and mandibular - mesial and distal aspect
Trapezoids
Trapezoid with longest uneven side toward occlusal or incisal surface
All anterior teeth, maxillary and mandibular - labial and lingual aspect
All posterior teeth- buccal and lingual aspect
Trapezoid with shortest uneven side toward occlusal surface

All maxillary posterior teeth- mesial and distal aspect
Rhomboids
All mandibular posterior teeth- mesial and dista l aspect

Which of the following statements best describes the pulp canal of the
mandibular lateral incisor?
an elliptical shape, consistently w ider in the mesiodistal direction
an elliptical shape, consistently w ider in the facio lingual direction
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an elliptica l shape, wider in the mesiodistal direction in the pulp chamber, but wider
in the faciolingual d irection in the mid-root area
an elliptical shape, w ider in the facio lingual d irection in the pulp chamber, but w ider
in the mesiodistal direction in the m id-root area

an elliptical shape, wider in the mesiodistal direction in the pulp chamber,
but wider in the faciolingual direction in the mid-root area
Near the roof of the pulp chamber, the elli ptical form of the pulp cavity is widest in the mesiodi stal
direction; however, near mid-root the elliptical form is widest in the facio lingual d irection. A small
percentage have two canals.
-""-~):;) 1. Compared to the mandibular cent ral incisor, the mandibular lateral incisor's root is larger
in all dimensions.
2.The crown of the mandibular lateral incisor tips slightly to the distal relative to the root;
thu s, the cingulum is slightly off-center to the distal, like that of the maxillary central inci-
sor and mandibular canine, but unlike that of the mand ibular central incisor.
3. The incisa l edge of the mandibular lateral is slightly curved or rotated on the distal. For
this reason it is possible to see a small portion of this distal-incisal edge w hen viewing this
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tooth from the mesial aspect.
Mandibular Right Lateral Incisor Mandibular Right Central Incisor
Cervical Cervical
cross-section cross-section
Mesiodistal labiolingual Mesiodis1ol labiolingual

cross-section cross-section c ronsection cross-section

Which of the following line angles is least "square"?
mesioincisal of the mandibular lateral incisor
distoincisal of the mandibular lateral incisor
mesioincisal of the mandibular central incisor
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distoincisal of the mandibular central incisor

distoincisal of the mandibular central incisor
The distoincisal angle of most anterior teeth ismore rounded compared to the mesioincisal angle. An-
other way to say this is that the mesioincisal angles are more square (or acute) than the distoincisal
angles, which are more obtuse. Hint: Distal is rounded like the letter"D"; mesial is straighter like the
letter "M~
!. Important: The mandibular central is the only anterior tooth in which the distoincisal
angle is as sharp and disti nct as the mesioincisal angle. All other incisors show a more or
less rounded distoincisal angle.
2. Anterior teeth are highly important aesthetically and play an important role in the for-
mation of many speech sounds ("V~ "F: and "TH"). When viewed from the sagittal plane,
the axial inclination of the anterior teeth inclines facially.
\l:nlllaJ' and \landJb ulaJ lm1~on
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8,9 1.10 24.;25 2 3.26
Ml angle Shsrp right angle Slight rounding Shal]l right angle Some rounding
Dl angle Slight rounding Oistincc roond Sha'll right angle M ot~" rounded
Mcsialprotilc Straight Slight rounding Straight Straiglu

Dist~ll profile Ncsrlyround Oistincc round Straight Su'3iglu
Incisal outline Straight Straight Straight Straight Ol twist
Proximal contacts
Mesial lncisslthird Junction Incisal th ird l nci~al third
Distal Jun~"1ioo Middle third lncis:al tb ird Incisal third
Maxillary Right Maxillary Right Mandibular Right Mandibular Right

Central Incisor Lateral Inci sor Lateral lncisor Centrallncisor
Labial labial labial Labial

Which tooth has a pulp chamber that is least like the others?
maxillary central incisor
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The pulp chamber of the maxillary central incisor is wider in the mesiodistal dimension than in
t he labiolingual d imension. The pulp cavity conforms to the general shape of the outer surface
of the tooth. The pulp cavity is widest at the cervical level, and the pulp chamber is centered
within the dentin of the root. In young individuals, the pulp chamber is roug hly triangular in
outline with the base of the triangle at t he labial aspect of the root. As the amount of
secondary dentin increases, the pulp chamber becomes more round or crescent-shaped . Also,
the size of t he pulp chamber decreases in size.
The cervical cross sections of the pulp of permanent anterior teeth
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Max. Central Incisor Max. Lateral Incisor Max. Canine
Mand. Central Incisor Mand. Lateral Inci sor Mand. Canine

When looking at the facial or lingual aspect of all anterior teeth, they have a:
trapezoidal outline
triangular outline
rhomboidal outline
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square outline

trapezoidal outline
The trapezoidal outline has its longest uneven side toward the occlusal or incisal surface.
0
Facial view of the Facial view of the
{j {j
Lingual view of Lingual view of the
Maxillary Right Mandibular Right the Maxillary Maxillary Right
Central Incisor Lateral Incisor Right Canine Lateral Incisor
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Remember (from card #4):
1. The mesial and distal aspects of all maxillary posterior teeth have a trapezoidal outline.
The shortest uneven side is toward the occlusal surface.
2. The buccal and lingual aspects of all posterior teeth have a trapezoidal outline. The long-
est uneven side is toward the occlusal surface.
3. The mesial and distal aspects of all mandibular posterior teeth have a rhomboidal out-
line.
0Mesial view of the

Maxillary Right
First Molar
wa
Lingual view of the
Maxillary Right
First Molar
Mesial view of the
Mandibular Right
First Molar

canine teeth information
In maximum intercuspation, which anterior tooth is unique in that it contacts
with both anterior and posterior segments of the opposite arch?
maxillary first premolar
maxillary canine
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mandibular first premolar
mandibular canine

maxillary canine
There is no contact on the cusp tip. It fa lls in direct alignment with the facial embrasure
between the mandibular canine and first premolar. This anterior tooth is unique in
that it has antagonists, in the intercuspal position, in both anterior (canine) and pos-
terior (first premolar) segments of t he opposite arch.
\l:nillar~ Canines
Characteristics
FaciaULabial a spect
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Proxima l contacts
Mes ial Junction of the incisal and middle third
Distal Middle third
Mesial aspect Wider faciolingually
Lin gual a sp ect Deeper lingua l fossae
Margina l ridges Pronounced; 2 fossae
Cingu lum Large, centered MD
Lingual pi ts, grooves Common
Incisal aspect Marked symmetry of mesial/distal ha lves
Incisal/Proximal aspects Cusp tip may be at or labial to root axis line

CEJ curvature 2.5 mm (mesial)
Contour Height O.Smm

Facial/lingual Both cervical third

A hockey player comes into your office with his six upper anterior teeth in his
hand. How can you distinguish the right canine from the left canine?
the root always curves to the distal in the apical one-third
the distal surface is fuller and more convex than the mesial surface
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labially, the cusp tip is placed distal to a line which bisects the crown and root
linguall y, the cervical line slopes mesially
10

the distal surface is fuller and more convex than the mesial surface
Also remember that:

The curvature of the cervical line is greater on the mesial side than on t he d istal side
The mesial surface is straighter than the distal surface
The d istal cusp ridge is longer than the mesial cusp ridge
The mesial contact point is at the junction of t he incisal and midd le third
It usually thicker labiolingually than it is mesiodistally
The tip of the cusp is displaced labially and mesial to the central long axis of the tooth
The d istal contact is in a more cervical position (middle of the middle third)
Althoug h the apical l /3 of the root typically curves distal, t his is not always true.
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Maxillary Right Canine
C\ISP~
Facial lingual

Which of the following terms is specific to canines?
labial ri dge
lingua I fossa
mamelons
cingulum
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11

labial ridge
The labial (facial) surface of canines is marked by a pronounced labial ridge (see facial view
below). Shallow developmental depressions lie mesial and distal to t he labial ridge. On the
mandibular canines, the labial ridge and the developmental depressions are not as
pronounced.
Important: The canines (both maxillary and mandibular) are the only cusped teeth which
feature a functional lingual surface rather than a functional occlusal surface.
~ 1. Looki ng at the maxillary canine from a facial view, the d istal portion of the facial
- surface is convex in t he middle t hird and slig htly concave in the cervical third. The
mesial portion is convex in the middle third and nearly flat in the cervical third.
2. From the incisal view, the cervical line is often not visible. This is due to the convex-
ity of t he crown.
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Maxillary Right Canine Mandibular Right Canine
l a bial
ridge
labial
ridge Cusp
tip
Facial Facial

A mother brings her three kids to your office for their annual check-ups. Which
of the following statements is most likely to be true?
the m iddle ch ild is 11 and has no adult canine teeth
the youngest ch ild is 10 and has adult mandibular canines only
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the oldest child is 12 and has maxillary canines only
the youngest ch ild is 10 and has adult maxillary canines only
the oldest child is 12 and has mandibular canines only
12

the youngest child is 10 and has adult mandibular canines only
***Going by the known eruption ages, t he most plausible scenario is that the 10-year- old has
her mandibular canines but not her maxillary canines.
Remember:
Maxillary canines erupt between the ages of 11 -12 (after the premolars}
Mandibular canines erupt between the ages of 9-10 (before the premolars}
Permanent Teeth Eruption Chart
UpperTeGth Erupt
----= - - - - - - t.Mtr.tl ~isor 78yrs.
3-t )'f$.
-J:.,---- C1111ine (euspi4 u -avr'$.
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r-..st premolar {first bicuspid) 1()..11)"'$.
y :,.>_ _ Soc:ond premolllr {seeond bieuspkt) 10.12yn.
6-7yl'$.
1721yn.
LoworToeth Erupt
Third mo~r (wisdom tooth 1721yn.
U 13vrs.
6-7)"1'$.
Soc:ond premolllr {s.eeond bieuspicf) 1112yn.
Fht premolar {first bic:uspid) 1()..12)"'$.
9- IOvrs.
Lllteral ineisor 78yrs.

~tral ~isor 6-7yrs.

A hockey player comes into your office holding his friend's right canines (max-
illary and mandibular) in his hand. His friend, a lacrosse player, got hit by a
ball flying under his mask. Which of the following would you look for in the
maxillary canine as compared to the mandibular canine?
Select all that apply.
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it is narrower mesiodistally
it has a more pronounced cingulum
it is wider mesiodistally
it has a shorter root
13

it has a more pronounced cingulum
it is wider mesiodistally
Characteristics that disti nguish a mandibular canine from a maxillary canine:
On the mandibular ca nine, the mesial border is much straighter (viewed facially)
Contact areas are located more incisally (remember: IM); for the maxillary ca nine it is JM
The cusp tip is displaced lingually on the mandibular can ine, whereas on the maxillary canine
the cusp is on or labial to the root axis line (viewed proximally and incisally)
The mandibular can ine has a comparatively narrower mesiodistal dimension (viewed facially)
The mandibular canine has a continuous convex facia l surface when viewed from the mesial
or distal
The mandibular canine has a cingulum that is less pronounced and often slightly to the distal,
whereas the maxillary canine has a cingulum that is more pronounced and centered mesiodist-
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ally (viewed lingually)
Lingual ridges with mesial and distal fossae are less prominent on mandibular ca nines (viewed
incisally).
Maxillary Right Canine Mandibular Right Canine
Facial Lingual
G glnc.isal Incisal Facial Lingual

Which cusp ridge is the longest on the permanent canines?
labial
lingual
mesial
distal
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14

distal (see picture below)
The most prominent labial ridge on the permanent canines is the middle.
\1and1hula1 ( anmes
Characteristics
Facial/ Labial uptt"t
Proximal contacts
Mesial Incisal thi1d
Distal Middle third
Mesial a.spect Narrower, longe.r than maxillary canine
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Lingual aspect Flat lingual surface
Marginal ridges Parallel Ol' slightly converging
Cingulum Smalle.r. possibly off-ce.nter distally
Lingual pit~. grooves None
labial
rid~ ~usptip
lnclul aspect Greater symmerry rhan maxillary canine;
distal cusp ridge rotated
lnclui/Proximal aspe-cts Cusp tip lingual ro root axis line
CEJ curvature 1.0 mm (distal)
DCRYMCR
Contour Height < 0.5 mm
Facial/lingual Both cervical [hird
Remember:
1. The maxillary canine is the longest tooth in the mouth.
2. The faciolingual d imension of the maxillary and mandibular canines is greater
than their mesiodistal dimension.
3. The mandibular canine has the longest crown of any permanent tooth.
4. The mesial surface of the crown of a mandibular canine is nearly parallel w ith
the long axis of the tooth.

eruption sequence
Nonsuccedaneous teeth include all of the following EXCEPT one? Which one
is the EXCEPTION?
the permanent maxillary and mandibular premolars
the permanent maxillary and mandibular first molars
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the permanent maxillary and mandibular second molars
the permanent maxillary and mandibular third molars
15

the permanent maxillary and mandibular premolars
A permanent tooth that moves into a position formerly occupied by a primary tooth
is called a succedaneous tooth. In each quadrant, five permanent teeth, the incisors,
can ine, and premolars, succeed or take the place of the five pri mary teeth.
Nonsuccedaneous teeth include:

The permanent maxillary and mandibular first molars
The permanent maxillary and mandibular second molars
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The permanent maxillary and mandibular third molars
***These teeth do not move into a position formerly occupied by a primary tooth.

eruption sequence
A mother brings her 1-year-old into your office the day after his first birthday.
She says the pediatrician said to have the first dental check-up by this time.
What primary teeth are you expecting to see when the child opens?
mandibular incisors only
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maxillary incisors only
mandibular and maxillary incisors
all incisors and maxillary canines
all incisors and mandibular canines
all anteri or teeth
16

mandibular and maxillary incisors
Primary Dentition Eruption Chart
Upper Teeth Erupt Shed

Central incisor 8-12 mos. 6-7 yrs.
Lateral incisor 9-13 mos. 7-8 yrs.
Canine (cuspid) 16-22 mos. 10-12 yrs.
First molar 13-19 mos. 9-1 1 yrs.
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Second molar 25-33 mos. 10-12 yrs.
Lower Teeth Erupt Shed

Second molar 23-31 mos. 10-12 yrs.
First molar 14-18 mos. 9-1 1 yrs.
Canine (cuspid) 17-23 mos. 9-12 yrs.

Lateral incisor 10-16 mos. 7-8 yrs.
Central incisor 6-10 mos. 6-7 yrs.
*** Eruption dates are va ri able. Some infants get teeth early, others do so late.
~~ 1. Calcification of t he roots is normally completed by the age of 3 or 4.

/fJJiJ 2. Active eruption of teeth occurs after two-thirds of the root is formed.

eruption sequence
Tommy, a pediatric patient of yours, says he lost his top vampire tooth last
week and the tooth fairy gave him a dollar for it. What is Tommy's most
likely age range when he lost his maxillary canine tooth?
6-7 years old
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7-8 years old
10-12 years old
14-16 years old
17

10-12 years old
l sual t:xfoliation A~:e of 'I he Primal") 'Ieeth

Maxillary Teeth Shed
Central Incisor 6-7 years
Lateral Incisor 7-8 years
Canine 10- 12 years
First molar 9- 11 years
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Second molar I 0- 12 years
Mandibular Teeth Shed

Central incisor 6-7 years
Latera I incisor 7-8 years
Canine 9- 12 years
First molar 9- 11 years
Second molar I 0- 12 years
Primary teeth are exfoliated by the phenomenon called resorption of the primary
root. The permanent tooth in its follicle attempts to force its way in to the position
held by its predecessor. The pressure brought to bear against the primary root
evidently causes resorpti on of t he root, which continues until t he primary crown has
lost its anchorage, becomes loose, and is finally exfoliated,

eruption sequence
Which of the following are the cardinal rules regarding the eruption of
teeth?
boys' teeth usually erupt before girls' teeth of the same age
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girls' teeth usually erupt before boys' teeth of the same age
maxillary teeth usually erupt before mandibular teeth
mandibular teeth usually erupt before maxillary teeth
the teeth of slender ch ildren usually erupt before the teeth of stocky children
the teeth of stocky children usually erupt before the teeth of slender children
18

girls' teeth usually erupt before boys' teeth of the same age
mandibular teeth usually erupt before maxillary teeth
the teeth of slender children usually erupt before the teeth of stocky children
Note: You w ill probably never find these cardina l ru les in a book (we have tried but
to no avail!!!); however, if you see th is question or something similar to it asked on the
boards, answer as above.
Also remember:
1. Teeth usually erupt in pairs.
2. Often the permanent mandibular anterior teeth erupt lingual to the primary
teeth and give the appearance for awhile that there are two rows of teeth.
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Universal Tooth Numbering
Permanent Teeth
Deciduous teeth (ba by teeth)

upper left upper right
1 ~ 1 ~ lower left
~! :! H_
lower right

eruption sequence
The deciduous dental formula of man is:
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None of the above
19

1l C 1M l = 5 per quadrant = 10 per arch 20 total teeth
2 1 2 = 5 per quadrant = 10 per arch
I = Incisors
C = Canines
M =Molars
Note: There are no premolars (bicuspids) in the deciduous dentition.

For primary dentition, the crowns of all 20 teeth begin to calcify between 4 to 6
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months in utero, and on average take 10 months fo r completion. In general, the root
of a deciduous tooth is completely formed in just about one year after eruption of
that tooth into the mouth.
In the Palmer system, the arches are divided into fou r quadrants. The Palmer notation
for the primary dentition is as follows:
EDCBAIABCDE
E DCBA lA BCD E
The Federation Dentaire lnternationale (FDI) recommends a two-digit system for

both the primary and permanent dentitions. This system has been adopted by the
World Health Organization (WHO) and is accepted by other organizations and in re-
search and public health. The FDI system of notation fo r the primary dentition is as fol-
lows:
555453525116162636465 Note: Number 5 indicates the right maxillary quadrant;
number 6, the left maxillary quadrant; number 7, t he left
858483828117172737475 mandibular quadrant; and n umber 8, the right mandibu
lar quadrant

eruption sequence
The permanent dental formula of man is:
I z2 C11 s:i3 M 2z = 16 x 2 = 32
1l ( 1 M 3. =
2 1 3
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12 x 2 = 24
none of the above
20

I~ C 18 ~ M ~ = 16 x 2 = 32
2 1 2 3
12. C 1 B 2. M .l = 8 per quadrant - 16 per arch= 32 total t eeth

2 1 2 3 = 8 per quadrant - 16 per arch
I = Incisors
C = Canines
B = Bicuspids (premolars)
M =Molars
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The Palmer system for the permanent dentition divides the arches into four quad-
rants with eight teeth in each quadrant. The Palmer notation for the permanent den-
tition is as follows: 8 7 6 54 3 2 1 11 2 3 4 56 7 8
87654321 11 2345678
The FDI system of notation for the permanent dentition is as follows:
18 17 1615 14 13 12 11121 22 23 24 25 26 27 28
48 47 46 45 44 43 42 41131 32 33 34 35 36 37 38
Note: In the permanent dentition, the first digit Indicates the quadrant and the second digit Indicates the
tooth in that quadrant. The right maxillary quadrant Is 1, t he left maxillary quadrant is 2, the left mandib u-
lar quadrant Is 3, and the right mandibular quadrant is 4.

eruption sequence
As soon as a child gets his/her _ _ _ _ _ he/she is considered to be in the
mixed dentition.
permanent canines
permanent first molars
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permanent first premolars
permanent second p remolars
21

permanent first molars
The earliest indication of mixed dentition consists of t he primary dentition and the
permanent fi rst molars (usually the mandibular permanent first molars). The
mixed dentition period ends w ith the exfoliation of the last pri mary tooth (normally
the maxillary canine).
There are t hree periods of dentition in man:

1. The primary dentition (approximately 6 months to 6 yea rs)
2. The mixed dentition (approximately 6 to 12 years)
3. The permanent dentition (12 +years)
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Remember: After t he permanent teeth have reached full occlusion, small tooth
movements occur to com pensate for wea r at the contact areas (by mesial d rift) and
occl usal surfaces (by deposition of cementum at the root apex).

eruption sequence
A 15-month-old child walks into your office and begins to cry and hold his
mouth in pain. Which teeth have probably not been traumatized, as they are
not usually present at 15 months of age?
primary lateral incisors and canines
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primary can ines and first molars
primary can ines and second molars
primary central and lateral incisors
primary first and second molars
22

primary canines and second molars
Rule of four: This simplified rule will enable you to determine the number of teeth
present at any g iven time. It implies the eruption of four teeth every four months
beginning with four teeth at age seven months.
Ru k of Four
Age NumbH of Teeth Erupted Specific Teeth
(in months)
7 4 4 = mand. and max. central incisors
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II 8 8 = mand. and max. central and lateral incisors
15 12 I2 = mand. and max. central and lateral incisors, four
first molars
19 16 I6 = mand. and max. central and lateral incisors, four
first molars and four canines
23 20 20 = mand. and max. central and lateral incisors, four
first molars, four canines, and four second molars
***The above"rule of fou r" is not perfect, it is a generalization. For example, at age 23
months, the ch ild might not have their maxillary second molars yet, the same holds
true for age 7 months, the chi ld might not have their maxillary central s yet.
Example from question on front of card: At age 15 months, 12 teeth are erupted
(four centrals, four lateral s, and four first molars).

eruption sequence
A pediatric patient of yours complains of severe pain on chewing. On clinical
exam, you see an eruption cyst in the place of the mandibular second molar.
What is the most likely age of this patient?
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10
12
14
23
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***The mandibular second molar erupts between 11 and 13 years of age.
Chronolog~ of the Permanent Dentition

First Evid ence of Enamel Root
T ooth Calcification Complete Eruption Completion
Maxillarv
Central 3-4 months 4 -5 years 7-8 years 10 years
Lateral 10 months 4 -5 years 8-9 years I I years
Canine 4 -5 months 6-7 years 11-1 2 years 13-1 5 years
First pre molar I 1/2 -I 3/4 years S-6 years 10-1 1 years 12-1 3 years
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Second premolar 2 - 2 1/4 years 6 -7 years 10-1 2 years 12-14 years
First molar At birth 3-4 years 6-7 years 9- 10 years
Second molar 2 112 -3 years 7-8 years 12-1 3 years 14 -1 6 years
Third molar 7-9 years 12- 14 years 17-21 years 19-21 years
Mandibular
Central 3-4 months 4 -5 years 6-7 years 9 years
Lateral 3-4 months 4 -5 years 7-8 years 10 years
Canine 4 -S months 6 -7 years 9- 10 years 12-14 years
First pre molar I 3/4 - 2 years S-6 years 10- 12 years 12-1 3 years
Second pre molar 2 1/4 - 2 112 years 6-7 years l l - 12years 13-14 years
First molar At birth 2 112 - 3 years 6-7 years 9- 10 years
Second molar 2 112 -3 years 7-8 years 11 - 13 years 13-14 years
Third molar 8- 10 years 12- 14 years 17-21 years 19-21 years
***Apex is fu ll y developed t wo to three years after erupt ion.

eruption sequence
At 9 years of age how many primary teeth are present in the mouth?
12
18 SAADDES
24
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By age nine, the chi ld has lost the mandibular centra l (6-7 years), mandibular lateral
(7-8 years), maxillary centra l (6-7 years) and maxillary lateral (7-8 yea rs) incisors. There-
maining dentition is composed of 6 maxillary and 6 mandibular teeth.
l lsual Exfoliation Agl' of Thl' Primar~ Tl'l'th

Maxillary Teeth Shed
Centra l Incisor 6-7 years
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Lateral Incisor 7-8 years
Canine 10-12 years
First molar 9- I I years

Second molar 10-12 years
Mandibular Teeth Shed
Centra l incisor 6-7 years
Lateral incisor 7-8 years
Canine 9-12 years
First molar 9- I I years
Second molar 10-12 years

eruption sequence
A 1-year-old child is expected to have erupted which of the following primary
maxillary and mandibular teeth?
central incisors
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lateral incisors
canines
first molars
second molars
25

central inci sors
lateral inci sors
A 12 month old chil d generally has all of the primary incisors. Please refer to the primary
teeth eruption chart below. Note: Keep in mind the idea that a 6-month acceleration or
delay is considered normal.
Upper Teeth Erupt S hed
Central ii)Cisor 812 mos. 67 yrs.
Latetal ird sor 913 mos. 7-8 yrs.
Canine (cuspid) 16-22 mos. 10 12 yrs.
First molar 13-- 19 tnOS. 9 11 yrs.
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Second molar 25-33 mos. 10 12 yrs.
Lower Teeth Erupt Shed

Second molar 23-31 mos. 10 12 yrs.
First molar 1 4-- 18 tnOS. 9 11 yrs.
Canine (cuspid) 1723 mos. 912yrs.

Lateal incisor 10.1 6 mos. 78 yrs.
Central ii')Cisor 610 mos. 6-7 yrs.
Remember: Eruption dates are variable. The timi ng of the eruption or emergence of the
teeth is due in large part to hereditary and only somewhat to environmental factors. The
mean age of eruption of the primary teeth is demonstrated schematically below.
It 11 !(I Mean age (in months) of emergence

ao ,, a of the primary dentition.

eruption sequence
A patient with erupted teeth #8, 7, C, B, A, 3 and unerupted 2 and 1 is most
likely what age?
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8
10
12
26

8
***The patient has an erupted first molar #3, so is at least 6 years old. The maxillary in-
cisors #7 and #8 are erupted, so the patient is at least 8 years old. The unerupted pre-
molars show that the patient is probably not 9 yet.
The sequence of eruption of the permanent dentition is more variable than that of
the primary dentition and does not follow the same anteroposterior pattern. In addi-
tion, significant differences in the eruption sequences between the maxillary arch and
the mandibular arch do not appear in the eruption of the primary dentition.
The most common sequences of eruption in the maxilla are 6-1-2-4-3-5-7-8 and 6-1-
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2-4-5-3-7-8. The most common sequences for the mandibular arch are (6-1)-2-3-4-5-7-
8 and (6-1)-2 -4-3-5-7-8. These are also the most favorable sequences for the
prevention of malocclusion (see the picture below). Keep in m ind that mandibular
teeth tend to erupt before their maxillary counterpart.
2 3 ~..... /
23
Favorable emergence sequence (numerical) of

permanent teeth.

heights of contour/contacts
A patient comes in with a chief complaint of, "My wife says I wake her up at
night with scraping noises from my mouth:' On clinical exam you will expect
to find which of the following characteristics of his occlusal contacts?
point-to-point
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point-to-area
edge-to-edge
edge-to-area
area-to-area
27

area-to-area
The character of occl usal contacts in the unworn dental arch are all of the following:
point-to-point
point-to-area
edge-to-edge
edge-to-area
Important: In bruxism, however, the direct tooth-to-tooth contact may resu lt in non-
physiological area-to-area contacts.
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The character of occlusal contacts makes chewing easier to perform, since there are
abundant food spillways on the occlusal table.
Note: The most difficult bruxism problem to be faced is the patient who has worn the
entire occlusion flat and has shortened the anterior teeth into an end-to-end relation-
ship. The effect of bruxism is easy to eliminate if the flat anterior guidance can be main-
ta ined, but often such a patient wishes to have the anterior esthetics improved. There
is sometimes no way to improve the esthetics w ithout steepening the anterior guid-
ance. A steepened anterior guidance almost always promotes parafunction.

All posterior teeth have proximal contacts in the:
middle third
junction of the occlusal and middle third
occlusal third
cervical third
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28

middle third
When viewed from the facial, all posterior teeth have proximal contacts in the middle third. Molars
have contacts lower in the middle third than the premolars. Also, each posterior tooth has themes-
ial contact slightly more occlusal tha n the distal contact.
Summary of contacts in the incisocervical or occlusocervical dimension:
Maxillary teeth: IJ, JM, JM, MM, MM, MM, MM, M I = Incisal third M = middle third
Mandibular teeth: II, II, IM, MM, MM, MM, MM, M J = at the junction of the incisal and middle third
A. Centrals and lateral

B. Central, lateral and canine
- ~
~
-~
C. l ateral, canine and first premolar Outline drawings of the maxillary teeth
D. canine, tim premolar, and second pre- -~- -d:b . ~
from the incisal and occlusal aspects w ith
molar cl broken line bisecting the contact areas.
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0
E. First molar. second premolar, and tim
-~-~
These illustrations show the relative posi-
molar tions of the contact areas labiolingually and
F. Second premolar, first molar, and sec-
ond molar
~~ buccolingually. Arrows point to embrasure
~
spaces.
G. First, second, and third molars
A. Centrals and lateral I I I I ~

~-~-~
B. Central, lateral and canine '<lpj'V ~ t I
C. l ateral, canine and first premolar Contact relation of mandibular teeth
A l I a I C
labio lingually and buccoling ually when
-~--~
D. canine, first premolar, and second
premolar viewed from the incisal and occlusal as-
E. First pmmolar, second premolar, D E pects. Arrows point to embrasure spaces.
and first molar
F. Second premolar and first, second, ~
-~-
and third molars 1 I I
F
Remember: 1. The more anterior the tooth, the more incisal/occlusal are the locations of the
proximal contacts.
2. For any tooth, the mesial contact area is more toward the incisal/occlusal than is the
distal contact area.

The location of the height of contour on the facial and lingual surfaces of the
crowns of teeth can best be seen from the mesial and distal views and is usu-
ally located in either the cervical third or the middle third (never the occlusal
or incisal third).
The location of the height of contour on the facial surface of all crowns is
located in or near the cervical third.
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the first statement is fa lse, the second is t rue
29

The height of contour (crest of curvature) is the greatest amount of a curve, or greatest
convexity or bulge, farthest from the root axis line. The height of contour on the facial or
lingual surfaces of the crown is where this greatest bulge would be touched by a tang-
ent line drawn parallel to the root axis line.
The location of the lingual height of contour differs, depen ding on whether the tooth is
anterior or posterior. The lingual height of contour on anterior teeth is on the cingulum,
which is in the cervical third. The lingual height of contour on posterior teeth is more likely
to be located in the middle th ird.
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Summan ul tht' lol.'alion ull adal and linJ;!ual hdJ;!hls ol contour (gn. alt'~l huiJ;!l') ol cnn\n
(hl'sl Sl'l'D Irom pruxim.ll \ il'\\)
Facial Lingual
( H ~igh tof Contour) (Height of Contour)
Anterior teeth (inciso rs and canines) Cervical third Cervical third (on cingulum)
Posterior teeth (premolars and molars) Cervical third At or ncar the middle third
The functions of the height of contour are:

It forms the contact area on the mesial and distal surfaces
It protects the gingiva surrounding the tooth
Note: There is clinical evidence that smooth and properly contoured (not too convex or
too great a contour) crown surfaces pro mote tooth cleansing and gingival health. In
other words, when fabricating a crown for a patient, make sure the height of contour is
taken into consideration.

Which three mandibular teeth are so aligned that, when viewed from the
occlusal, a straight line may be drawn that will bisect all contact areas?
central incisor, lateral incisor, and canine
can ine, first premolar, and second premolar
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second premolar, first molar, and second molar
lateral incisor, can ine, and first premolar
30

second premolar, first molar, and second molar
*** See picture below
When teeth are in ideal alignment within t he arch, the location of the mesial and dis-
ta l heights of contour (when viewed d irectly from the facia l or lingual sides) is essen-
tially the same location as contact areas. Contact areas are the greatest heights of
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contour or location of the greatest bulges on the proximal surfaces of tooth crowns,
where one tooth touches an adjacent tooth. When viewing teeth from the facial view,
contact areas are characteristically located in t he incisal or occlusal third, in the m iddle
third, o r at the junction of the incisal and middle thirds, but they are never in the cer-
vical third. When viewing posterior teeth from the occlusal view, contact points are
often slightly to the facial of the tooth m idline buccolingually.
The contact of each tooth with the adjacent teeth has important functions:
The combined anchorage of all teeth w ithin each arch making positive contact
with each other stabilizes the position of teeth within the dental arches
Contact helps prevent food impaction, which can contribute to decay, along
w ith gingival and periodontal disease
Contact protects the interdental papillae of the gingiva by shunting food toward
the buccal and lingual areas

Cervical line (or CEJ) contours are closely related to the attachment of the
gingiva at the neck of the tooth. When doing a crown prep, your margin will
slope with the contours of the cervical lines and gingival attachments. On
which surfaces will your greatest contour be found?
distal surfaces of anterior teeth
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distal surfaces of posterior teeth
mesial surfaces of anterior teeth
mesial surfaces of posterior teeth
31

mesial surfaces of anterior t eeth
Note: The m es ial surface of the maxillary central has the greatest curvature.
HHKKMMH Facial
HHHHHMN M esial
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2nd 1st 2nd 1st Canine Lateral Central
Molar Molar Premolar Premolar Incisor Inci sor
C ba r actrristic.s 8,9 7,10 24,25 23,26 6,11 22,27

C urvcatCEJ
Mesial 3.5 mm 3.0mm 3.0 mm 3.0mm 2.5mm
Distal 2.5 mm 2.0mm 2.0mm 2.0mm 1.0111111
Contour Height
facial/ lingual Cervical Cervical Ce1vical Ce1vical Cervical Cervical
third third th ird third third third
Remember: All teeth generally have a greater proxim al cervical line (CEJ) curvature on
the mesial than the distal. Also, the proximal cervica l line (CEJ) curvatures are greater on
the incisors and tend to get smaller when moving toward the last m olar, where there m ay
be no curvature at all. Facial and lingual CEJs curve apically; mesial and distal CEJs curve
coronally.

You are fabricating an interim bridge from 19 to 21. The contact areas on
the pontic when viewed from the occlusal view, should be _ _ of the tooth
midline buccolingually.
directly in line
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slightly to the lingual
slightly to t he facial
32

slightly to the facial
***Look at letter E bottom picture
Out line drawings of the maxillary teeth from the inici sal
and occlusal aspects w ith broken lines bisecti ng the con-
t act areas. These ill ustrations show the relative posit ions
of the contact areas l abiolingually and buccolingually.
Arrows point t o embrasure spaces. A, Central incisors
and lat eral incisors. B, Central and lateral incisors and ca-
nine. C, Lateral incisor, canine, and first premolar. 0 , Ca-
nine, first premolar, and second p remol ar. E, First
p remolar, second premolar, and first mol ar. F, Second
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premolar, first molar, and second molar. G, First, second,
and third molars.
-~- ~- $ Contact rel ation of mandibular teeth labiolin-

gually and buccolingually when surveyed from
A I B C t he incisal and occl usal aspects. Arrows point to
-~- -~
embrasure spaces. A, Central incisors and lateral
inci sors. B, Central and lat eral incisors and canine.
C, Lateral incisor. canine. and first premolar. 0, Ca-
D l Ef nine, first premolar, and second premolar. E. First
-~-
premolar, second premolar, and fi rst molar. F, Sec-
ond p remolar and first, second, and third molars.
' FI t

The mesial contact area of a permanent maxillary lateral incisor is usually
located:
in the incisal third
in the middle third
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at the junction of the incisal and middle thirds
33

at the junction of the incisal and middle thirds
Ctntra.l Lau~ ral Canint

Maxillary II JM JM
Mandibular II II IM
Note: IJ means that the mesial contact is located in the incisal thi rd (I) and the distal contact is located
at the junction (J) of the incisal and middle thirds. These are all from the facial aspect (incisocervical o r
occlusocervical di mension). When viewed from the occlu sal (or incisal), all anteriors have their contacts in
the middle third (M or D); thus they are centered faciolingually.
Remember: Although the mesial and distal contacts of the mandibular lateral are in the incisal third, the
distal contact is slightly cervical to the mesial contact. On the mandibular central incisor they are both
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at exactly the same level.
-n--n--n-
rrxx Xxtt
I O I t E t
I F I ~
-'!E]C -~
Outline drawings of the maxillary te-eth in contact, \VIth dotted
lines bisecting the contact a reas at the various levels as found Contact levels found normally on mandibular teeth. Arrows point
normally. Arrows point to embrasure spaces. A, Central and fat to embrasure spaces. A, Central and late ral incisors. 84 Centra l and
e ral incisors.. 8, Central and late ral incisors and canine. C., Lateral lateral incisors and canine. C., lateral incasor, canine and first prem~
inasor, camne and first ptemolar. 0, Camne and first and second lar. 0 , Camne and first and second premola rs. E. First and second pre~
premolars. E., First and second premolars and first molar. F, Sec molars and fi rst mola r. F, Second p re mola r, first molar, and second
ond premolar, fnst molar, and second molar. G, First. second. and molar. G. First. second. and third molars.
third molars.

From a facial view, mesial and distal contact area s of mandibular central
incisors are located:
in the middle third
at the junction of incisal and middle thirds
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at the junction of cervical and m iddle thirds
cervica l to the junction of incisal and m iddle th irds
incisal to the junction of incisal and middle thirds
34

incisal to the junction of incisal and middle thirds
The contact areas of mandibular central incisors are in th e incisal third of the tooth as
seen from the facial. In general, the contact area gets more cervical as you proceed
posteriorly in the arch, with the contact between all maxillary and mandibular molars
being in the middle one third of each tooth.
.a--11 # -xt -n--# Yy_ JJ("
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IAI ta l
IFI ~
-J:!]C -~
Outline d rawings of the mulllary teeth In contact. with dot
ted lines bisecting the contact areas a t the various levels as Contact levels found normally on mandibular t eeth. Ar~
found normally. Arrows point to embrasure spaces. A, Central rows point to embrasure spaces. A, Central and lateral in~
and lateral incisors. 8, Central and lateral incisors and canine. cisors. 8, Cen tral an d lateral incisors and canine. C. Lateral
C, Lateral incisor, canine and first premolar. 0, Canine and first indsor, canine and first premolar. 0 , Canine and first and
and second premolars. E, First and second premolars and first second premolars. E.. First and second premolars and first
molar. F, Second premolar, first molar, and second molar. G, molar. F, Second premolar, first molar, and second molar.
First, second, and third molars. G, f irst, second,. and third molars.

The contact area on the mesial surface of a mandibular canine is located at
the:
middle third
incisal third
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cervica l third
junction of the middle and cervical thirds
35

incisal third
The mandibular canine on its mesial surface contacts the distal surface of the lateral
incisor. The canine almost seems to tilt mesiall y towards the incisor tipping into it but
meeting it at a contact point near the incisal third. It is similar to the way in which the
mandibular incisors contact each other in the incisal th ird. The contact of the d istal of
the mandibular can ine with the mesial of the fi rst premolar is in it's middle third.
-SAADDES
n --n -
+A +
-#J()(-
Contact levels found normally on mandibular teeth. Arrows point to
embrasure spaces. A, Cent ral and lateral incisors. B, Central and lateral
incisors and canine. C, Lateral incisor, canine and fi rst premolar.

The lingual height of contour on a permanent mandibular second molar is
located:
in the middle third
in the cervical third
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in the occlusal third
at the junction of the cervical and m iddle thi rds
at the junction of the middle and occlusal thirds
36

in the middle third
*** From the cervical line, the crown bulges out ward reach ing the height of contou r at the middle
third. It then slopes more sharply inward toward the apex of the mesial lingual or distal lingual cusp
tip. In contrast on the buccal, t he height of contour is much lower and is reached almost immedi-
ately after the cervical line in the cervical or gingival third of the tooth.
The location of the crest of curvature (height of contour) on the facial (or buccal) and lingual surfaces
of the crowns of teeth can be seen from the mesial and distal aspects, and are usually in one of two
places:
l .ln the cervical third of the crown on:
Facial (or bucca l) surfaces of all anterior and posterior t eeth (maxillary and mandibular)
lingual surfaces of all anterior teeth (maxillary and mandibular) on the cingulum
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2. In the middle third of the crown on:
lingual surface of maxillary and mandibular posterior teeth
Schematic drawings of cu rvatures labially, buccally, and

lingually. A, Normal curvatures as fou nd on maxillary
molar. Arrow shows theoretical path of food during mas-
t ication. 8, If molar shows little or no cu rvature, there is
possibility for food impaction. C, Molar with curvature
in excess of normal. The significa nce of such an excess in
curvatu re has not been fi rmly established. 0, Normal
cervical curvatures as found on maxillary incisors. The
crests of curvature are opposite each other labiolin-
gually. E, Curvatures as found on mandibular posterior
I
)
teeth.

Which of the following teeth has its mesial contact located within the incisal
or the occlusal one third?
maxillary canine
maxillary first molar
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mandibular second premolar
mandibular centra l incisor
37

The mesial surface ofthe mandibular centra l incisor contacts the mesial surface of the
other mandibular centra l. They contact in the incisal third. All mandibular incisors con-
tact with each other or with the mesial of the can ine w ithin the incisal third.
Remember: Maxillary teeth - IJ, JM, JM, MM, MM, MM, MM, M
Mandibular t eeth - II, II, IM, MM, MM, MM, MM, M
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Outline drawings of the maxillary teeth in contact, with dotted lines
bisecting the contact areas at t he various levels as found normally. Ar-
rows point to embrasure spaces. A, Central and lateral incisors. B, Cen-
tra l and lateral incisors and canine. C, Lateral incisor, canine and first
premolar.
-u --n--fY
I AI
}j\-
Contact levels found normally on mandibular t eeth. Arrows point to
embrasure spaces. A, Central and lateral incisors. B, Central and lateral
incisors and canine. C, Lateral incisor, canine and first premolar.

The height of contour occlusocervically is located within the middle third of
the:
facial surface of a permanent mandibular fi rst molar
lingual surface of a permanent maxillary first molar
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distal surface of a permanent centra l incisor
mesial surface of a permanent canine
38

lingual surface of a permanent maxillary first molar
***The height of contou r of the lingual surface of the maxillary fi rst molar is in the
middle third. On the facial surface it wou ld be in the cervical third.
Remember: The location of the crest of curvature (height of contou r) on the facial
(or buccal) and lingual surfaces of the crowns ofteeth can be seen from the mesial and
distal aspects, and are usually in one of t wo places:
1. In the cervical third of the crown on:
Facial (or buccal) surfaces of all anteri or and posteri or teeth (maxillary and
mandibular)
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Lingual surfaces of all anterior teeth (maxillary and mandibular) on the cingu-
lum
2. In the middle third of the crown on:
Lingual surface of maxillary and mandibular posterior teeth

miscellaneous
For each numbered definition below, select the most closely linked term
from th e list provided.
Definition
I . A supernumerary tooth between the
T erm
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maxillary central incisors
A. Hypercementosis
2. Excessive fornultion of cementum aro und
the root of a tooth after the tooth has erupted B. Mesiodens
3. Disorder characterized by the fusion of the C. Concrescence
tooth to the bone
D. Ankylosis
4. Disorder characterized by the fusion or
growing together of two adjacent teeth at
the root through the cementum only
39

1. B, 2. A, 3. 0, 4 .C
Mesiodens is a supernumerary tooth between the maxillary central incisors.
Hypercementosis is the excessive formation of cementum around the root of a tooth

after the tooth has erupted. lt may be caused by trauma, metabolic dysfunction, or pe-
riapical inflammation.
Ankylosis is a rare d isorder characterized by the fusion of the tooth to the bone, pre-
venting both eruption and o rthodontic movement. It may be initiated by an infection
or t rauma to the periodontal ligament. The ankylosed tooth has lost its periodontal lig-
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ament space and is tru ly fused to the alveolar process or bone.
Concrescence is a fusion or growing together of two adjacent teeth at the root through
the cementum only.
Ankylosis Hypercementosis Concrescence Mesioden s

miscellaneous
The length of the mandibular arch is longer than the maxillary arch.
The difference is only about 2 mm.
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40
copyright Cl 20 13-2014 Dental Decks

the first statement is false, the second is true
Remember: The maxillary arch is slightly longer in length compared to the mandibu-
lar arch. The reason is the sum of the M-D diameter of the maxillary permanent teeth
is approximately 128 mm, whereas the sum of the M-D d iameter of the mandibular
permanent teeth is approximately 126 mm.
A'r::~~ l.Permanent teeth move occlusally and buccally while erupting.

'-< 2. Also, during active tooth eruption there is apposition of bone on all sur-
faces of the alveolar crest and on the walls of the bony socket.
3.The g rand design of the human face is the result of remodeling and dis-
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placement wh ich interact to produce the final resu lt.
4. Displacement and remodeling can occur in opposite d irections.
5. The functional matrix theory holds that:
Soft tissue is the primary determinant of growth
Bone is responsive to soft tissue
Deglutition (mandibular function) influences mandibular g rowth
The soft tissues ofthe brain expand t hus pacing growth of the flat bones
of the skull
6. The growth in width of the jaws is generally completed before the adoles-
cent growth spurt begins.
7. The growth in length of the jaws continues th rough the g rowth spurt.

miscellaneous
Which of the following is the loss of tooth structure from non-mechanical
means?
attrition
abrasion
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ankylosis
erosion
41

erosion
Erosion is the loss of tooth structure from non-mechanical means. It can result from drinking acidic
liquids or eating acidic foods. It is com mon in bulimic individualsas a result of regurgitated stomach
acids. It affects smooth (especially lingual) and occlusal surfaces.
Attrition is the wearing away of enamel and dentin from the normal function or, more commonly,
from excessive grinding of teeth together by the patient (bruxism). The most noticeable effects of at-
trition are polished facets, flat incisal edges, discolored surfaces of teeth, and exposed dentin. Facets
usually develop on the linguoincisal of t he maxillary central incisors, the facioincisal of the mandibu-
lar canines, and the linguoincisal of the maxillary canines.
Types of abrasion:
Toothbrush abrasion: most often results in V-s haped wedges at the cervica l margin in the
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canine and premolar areas. It is caused by the use of a hard toothbrush and/or a horizontal
brushing stroke and/or a gritty dentifrice.
Occlusal abrasion: results in flattened cusps on all posterior teeth and worn incisal edges. It is
caused by chewing or biting hard foods or objects or chewing tobacco.

miscellaneous
Agents (chemicals) that are capable of causing developmental abnormalities
in utero are called teratogens. For each numbered teratogen listed below,
select the most closely linked effect from the list provided.
Teratogen Effect
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I . Aspirin, vali um, dilantin, and A. Microcephaly
cigarette smoke (hypoxia)
B. Central mid-face discrepancy
2. Cytomegalovirus, toxoplasma C. Premature sutme closure
3. Ethyl alcohol D. Cleft lip and palate
4. Rubella virus E. Microcephaly, hydrocephaly,
5. X-radiation microphthalmia
6. Vitamin D excess F. Microphthalmia, cataracts,

deafness
42

1. D, 2. E, 3. B, 4. F, 5. A, 6. C
Agents (chemicals) that are capable of causing developmental abnormali ties in utero
are ca lled teratogens. The particula r type of fetal development problem is related to
not only the type of teratogen but also the time at wh ich the teratogen interacts w ith
the fetus. Since most organogenesis occurs during the first three months of gestation,
this first trimester (weeks 0-13) is the time of greatest sensitivity to teratogenic
activity.
Teratogens .\ffecting Dentof:lcial DeHlopment
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Teratogens Effect
Aspirin, va lium, dilantin, and cigarette Cleft lip and palate
smoke (hypoxia)
Cytomega lovints, toxop lasma Microcepha ly, hydrocepha ly, microphthalmia

Ethy l alcohol Centra l mid-face discrepancy
Rubella v irus Microphthalmia, cataracts, deafness
X-radiation Microcepha ly
Vitamin D excess Premature suture closure

miscellaneous
As you know, there are several kinds of teeth in the human mouth. They all
serve different functions. You are in an argument with your friend, a law
student, and you test his vocabulary. You call him a , which sim-
ply means he has teeth with different morphologies and functions.
polyphyodont
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monophyodont
heterodont
diphyodont
43

heterodont
*** Hetero means "different;" - odont means "tooth" = "different teeth"

Human dentition is also descri bed as diphyodont - to produce two sets of teeth
(primary and permanent).
Other terms to know:

"Monophyodont dentition" = having one set of teeth
"Polyphyodont dentition" = teeth continually being replaced (fish, amphib-
ians, and repti les)
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"Homodont dentition" = teeth are all alike
"Hypsodont" = long teeth
"Carnivore" = flesh eating
"Herbivore" = vegetable eating
"Omnivore" = mixed diet

miscellaneous
Which of the following refers to the congenital absence of many, but not all,
teeth?
hypodontia
anodontia
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oligodontia
hypsodontia
44

oligodontia
Anodontia is a developmental abnormality characterized by the total absence of

teeth.
Two forms:
1. Complete: is a rare cond ition in which all of the teeth are m issing. It may in-
volve both the pri mary and permanent dentitions. It is usually associated w ith
hereditary ectodermal dysplasia.
2. Partial (commonly referred to as congenitally missing teeth): is rather common.
The most common missing teeth in o rder are: thi rd molars (maxillary more often
than mandibular), maxillary lateral incisors, and mandibular second premo-
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lars.
Other terms that are sometimes used include:

Oligodontia: refers to the congen ita l absence of many, but not all, teeth
Hypodontia: refers to the absence of only a few teeth

miscellaneous
A child has maxillary incisor protrusion, an anterior open bite, crowded lower
anteriors, and a high palatal vault. Which of the following most likely caused
this problem?
mouth breathing
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thumb sucking
tongue thrusting
using a pacifier
nocturnal bruxism
45

thumb sucking (or any other sucking habit)
The pressure of the thumb against the palate and maxillary teeth during the growth and development
of the teeth and oral cavity can cause anterior open bite and overjet, labial flare of the maxillary an-
terior teeth, and a high palatal vault. Note: Most of the t ime the anterior open bite is asymmetrical
with normal posterior occlusion.
Open bite relationships are characterized by failure of the teeth in both arches to meet properly.
Open bites may be observed in t he anterior or posterior region and may be attributable to supraerup-
tion of the adjacent teeth or infraeruption of t he teeth in the area in question. In addition to thumb
sucking, open bites may be caused by deviant growth patterns or a forward tongue position.
Note: Anterior open bites are much more common in African Americans than Caucasians, whereas
deep bites are much more common in Caucasians.
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Persistent long-term thumb sucking may also result in:
Protrusion of maxillary incisors Rotation of maxillary lateral incisors
Constriction of the maxillary arch Class II malocclusions
Li ngual inclination of mandibular incisors
Remember: Mouth breathing typically presents clinically as the gingiva of the facial aspect of the
maxillary anterior being red, edematous and bleeding easily. The affected area is widest in the mid-
line and tapers laterally, the remaining gingivae are normal.
Anterior open bite can also be associated

with tongue thrust. The patient shown
here has a very prominent open bite sec-
ondary to a tongue thrust swallowing pat-
tern (note the position of the tongue).

miscellaneous
A patient of yours has enamel hypocalcification. You would expect _ _
quantity of enamel and would describe it as _ _ .
less than normal; hard
less than normal; soft
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normal; soft
normal; hard
more than normal; hard
more than normal; soft
46

normal; soft
***Enamel hypoca lcification is a hereditary dental defect in which the enamel of the teeth is soft
and undercalcified in context yet normal in quantity (qualitative enamel problem).
This condition is caused by defective maturation of ameloblasts (defect in mineralization of the
formed matrix). The teeth are chalky in consistency, the surfaces wear down rapid ly, and a yel-
low to brown stain appears as the underlying dentin is exposed.This condition affects both the
deciduous and permanent teeth.
Enamel hypoplasia is a developmental dental defect in which the enamel of the teeth is hard
in context but thin and deficient in amount (quantitative enamel problem). It is caused by
defective enamel matrix formation with a deficiency in the cementing substance. There is a
lack of contact between teeth, rapid breakdown of occlusal surfaces, and a yellowish-brown
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stain that appears where the dentin is exposed. The condition, which affects both the decidu-
ous and permanent teeth, can be transmitted genetically or caused by environmental factors,
as with vitam in deficiency, fluorosis, or metabolic d isturba nces d uring the prenatal period. It is
a common sequela in a child with a history of generalized growth failure in the fi rst six months
of life. Hypoplastic areas on teeth are seen if a child has illnesses in early childhood.
Note: Hypoplastic enamel, which is a denta l ma nifestation of hypoparathyroidism, can be
prevented by early treatment with vitam in D.
Fluorosis is t he condition that results from excessive, prolonged ingestion of fluoride.Typically
causes mottled discoloration and pitting of the enamel of permanent and deciduous teeth.
Enamel hypocalcification Fluorosis with mottled enamel Enamel hypoplasia

miscellaneous
Which ofthe following teeth have the most variability in form?
mandibular fi rst premolars
maxillary first molars
mandibular second molars
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maxillary lateral incisors
maxillary second premolars
47

The maxillary lateral incisors have the greatest va riabili ty in form ofthe entire dentition
with the exception ofthe th ird molars. Since the form of the tooth varies more than the
others listed, the maxillary lateral would more common ly be in misalignment with the
adjacent central and canine.
If the variation is too great, it is considered a developmental anomaly. A common sit-

uation is to find maxillary lateral incisors with a nondescript, pointed form; such teeth
are called peg-shaped laterals (see photo below on right).
One type of malformed maxillary lateral incisor has a large, pointed tubercle as part of
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the cingulum (see photo below on left); some have deep developmental grooves that
extend down on the root lingually with a deep fold in the cingulum; and some show
twisted roots, distorted crowns, and so on.

miscellaneous
A mental foramen would be found on X-ray closest to the root of which tooth?
19
14
29
22
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48

29
The m ental foram en carries the mental nerve, artery and vein through the mandible onto
the skin overlying the mandible from the mid line to the first premolar area. It also inner-
vates buccal soft tissue and periosteum in the sam e area, as well as portions of the lower
lip. The foram en is seen on X-ray as a lucent ova l or circle most often near the apex of the
mandibu lar second premolars. Important: It is possible in some cases to confuse the fora-
m en w ith periapical pathology.
The mental foram en has been shown to be located at practically the same level on most hu-
mans (13 -15 mm superior to the inferior border ofthe m andible). In a study of 40 skull s, the
m ental foramen was fo und to be:
Under the apex of the first premolar- never
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Between the apices of the first and second premolars - 40%
Directly under the second premolar- 42.5%
Distal to the apex of the second premolar- 17.5%
The mental foramen (arrow over apex of

the second premolar) may simulate peri-
apical disease. Continuity of the lamina
dura around the apex, however, indicates
the absence of periapical abnormality.

miscellaneous
Extreme curvature or angulation of tooth roots describes which of the fol -
lowing conditions?
fusion
gemination
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concrescence
dilaceration
dens invaginatus
49

dilaceration
Note: As a general rule, root tips tend to curve towa rd the distal (if at all).
1. Maxillary teeth seem to show the least statistica l va ri ation in root inclination.
2. Mandibular central incisors and canines usually present the greatest va riation.
Fusion is the joining of two developing tooth germs, resulting in a single large tooth
structure (may involve entire length of tooth or only the roots) .
Gemination is the fusion of two teeth from a single enamel organ (usually seen as two
crowns that share one root cana l).
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Concrescence is a form of fusion in wh ich the adjacent, already-formed teeth are
joined by cementum.
Dens lnvaginatus also known as dens in dente, is an uncommon tooth anomaly that
represents an exaggeration or accentuation of the lingual pit.

mandibular movements/positions
Pure rotation of the mandible involves which two planes of movement?
frontal
horizontal
sagittal
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50

frontal
sagittal
The mandible is moved in a number of planes:
1. Up and down (frontal plane)
2. Side to side (horizontal plane)
3. Forwards and backwards (sagittal plane)
The vert ical axis of rotation can be better visualized when one
looks at a composite of rotation because lateral rotation actu-
ally occurs around the lateral po le of the rotating condyle. As
rotation occurs, the orbiting condyle must travel down the
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slope of the eminence. The med ial pole of the rotating side
must also travel down its slope but fo r a lesser d istance. Be-
cause the condyles load against incli nes, a pure vertical rota-
tion is not possible without being combined with a sagittal
rotation of the working-side condyle.
Five factors of mandibular movement:

1. Initiating position (centric relation) 4. Degree of movement
- Most stable and most easily reproduced 5. Clinical significance of movements
position - Each patient may have different
2. Types of motion relationships
- Rotation
- Translation
3. Direction of motion (planes)
- Frontal
- Sagittal
- Horizontal

Border movements are the limits to which the mandible can move, whereas
functional movements generally occur within the border movements.
The maximum opening movement is 50 to 60 mm, depending on the age and

size of the individual.
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51

Hinge axis
1. Unassisted normal maximum lat-

eral movements are considered to be
about 10 to 12 mm.
2. The maximum protrusive move-
ment is approximately 8-11 mm.
3. The retrusive range is about 1 mm
4. Chewing function takes place usu-
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ally within a few millimeters of the ICP
or CO.
5. This diagram represents Posselt's
envelope of motion.
Schematic represent ation of mandibular movement envelope in the

sagittal plane. CR, Centric relation; CO.. Centric occlusion; F, Maximum
protrusion; R, Rest position; E. Maxi mum opening; 8 to CR, opening and
closing on hinge axis w ith no change in radius {r).
Remember:
1. If the mandible is held back and up by either the patient or the operator, a hinge movement
can be traced for the lower incisors from CR to B. This movement, called the terminal hinge move-
ment of the mandible, maintains a stationary rotation axis through the two temporomandibu-
lar joints; this axis is usually located in the condyles.
2. The anterior border movement of the mandible is from F - E.
Note: Food is masticated primarily in lateral contacting movement.

In the natural dentition, centric occlusion is, in a majority of people, _ _ to
centric relation contact and on the average approximately __ mm.
posterior; 2
anterior; 1
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medial; 2
lateral; 1
52

anterior; 1
Right mand ibular movement w i th

schematic representation of move-
ment at the inci sal point in the hori-
zontal plane (CR, ll, P. Rl) and at the
condyle (W. C, 8, P) made by a panto-
graph. Teeth are not in occlusion. CR.
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Centric relation; LL. left lateral; P. pro-
trusive; RL, right lateral; CO, centric
occlusion; IEC, incisal edge contact.
On the right side, the condyle moves
from C (centric) to right working (W).
On the balancing side, the left
condyle moves from C along li ne 8
and makes an angle 8G, called Ben-
nett angle. C toP. Straight protrusive
movement.
In lateral movements, the condyle appears to rotate with a slight lateral shift in the d irection of the move-
ment This movement is called the Bennett movement and may have immediate as well as progressive
components. If a point (the incisive point) located between the incisal edges of the two mand ibular cen-
tral incisors is tracked during maximal lateral or protrusive movements, in retrusive movement, and wide
opening movement, such movements take place within a border or envelope of movements (Posselt). Func-
tional and parafunctional movements take place within these borders. However, most functional move-
ments, such as those associated with mastication, occur chiefly around centric.

During sleep, the mandible is in its physiologic rest or postural position. The
contact of teeth is:
maximum
not present
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premature
slight
53

not present
This position results when the mandible and all of its supporting muscles (four paired
muscles of mastication plus the supra- and infrahyoids) are in their resting posture.
The term used to describe this absence of contact is "freeway space" o r
"interocclusal distance:'The interocclusal space w ith the mandible in rest position
and head in upright position is about 1 to 3 mm at the incisors but has considerable
normal va ri ance even up to 8 to 10 mm w ithout evidence of dysfunction.
Remember: When the teeth are in centric occlusion (intercuspal position), the posit-
ion of the mandible in relation to the maxilla is determined by the intercuspation of
the teeth.
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Physiological
rest position
1-3mm

Which jaw position is a ligament-guided position?
centric occlusion (CO)
centric relation (CR)
rest position of the mandible
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none of the above
54

Here are three ba sic jaw positions:

1. Centric occlusion or the intercuspal (I C) position is defined as maximum inter-
cuspation of the teeth. It is a tooth-guided position.
2. The rest position of the mandible or the postural position is determined mostly
by the musculature. The usual reflex cited as the basis for the postural position of
the mandible is the tonic stretch reflex of the mandibular levators (i.e., the
myotatic reflex). It is a muscle-guided position.
3. Centric relation or the retruded contact position (RCP) is a position (or path of
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opening and closing w ithout translation of the condyles) of the mandible in which
the condyles are in their most anterior, superior positions in the mandibular fossae
and related anteriorly to the d istal slope of the articu lar eminence. Because the
mandible appears to rotate around a transverse axis through the condyle in centric
relation movement, guidance of the jaw by the dentist in opening and closing
movements that do not have translation is referred to as hinge axis movement. In
this position (CR), the condyles are considered to be in the terminal hinge
position. It is a ligament-guided position.

A dental patient is complaining of unilateral jaw pain when chewing. You
notice that she only chews on her right side. When a mandibular movement
to the right is performed, which condyle moves forward, downward, and
medially?
working condyle (ri ght)
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non-working condyle (left)
55

non-working condyle (left)
lateral movement of the mandible is referred to as transtrusion. This movement has two
components:
1. Laterotrusion -the lateral movement of the working or rotating condyle
2. Mediotrusion -the medial movement of the balancing or nonworking condyle
In a lateral movement the balancing non- working condyle goes downward, forward, and
medially. The working condyle moves laterally (generally rotating about a vertical axis and
translating laterally). Since the mandible is a solid bone, the amount that t he non-working
condyle moves medially determines how far t he working condyle moves laterally. This lateral
movement is known as Bennett Movement (Bennett Movement is always with the working
condyle, Bennett angle is always wit h the non-working condyle).
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Remember:
1. Working side is the side that the mandible moves towards in a lateral excursion.
2. Non-working side is t he side that the mandible moves away from during a lateral excur-
sion.
3. The balancing side condyle refers to the left condyle during a right lateral jaw move-
ment and the right condyle d uring a left lateral jaw movement.
Right side contact relations of maxillary and

mandibular molars; A, Right working side. B, Cen-
tric occlusion (intercuspal position). C, Nonwork-
ing side
B c

A 7-year-old male patient with a history of thumb-sucking comes into the
orthodontist's office presenting with an anterior open bite. Doing swallow-
ing tests, the orthodontist discovers that the patient needs to involve his
tongue to close the freeway space between his teeth. During typical empty
mouth swallowing, the mandible is braced in which jaw position to allow
for proper stabilization?
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intercuspal position (IC)
retruded contact position (RCP)
protruded contact position (PCP)
56

intercuspal position (I C) - also called centric occlusion
Empty mouth swallowing occurs frequently throughout the day and is an important
function that rids the mouth of saliva and helps to moisten the oral structures. The
hourly rate of non-masticatory swallowing is apparently related to the amount of
salivary flow and, in most instances, may be an involuntary reflex activity.
1. The masseter muscles contract and the t ip of the tongue touches the
roof of the mouth during normal swallowing.
2. Tooth contacts are of longer duration in swallowing than in chewing, but
there is w ide variation in frequency and duration from one person to another.
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During a right working side movement, the right side molar teeth may
contact along the buccal inclines of the maxillary buccal cusps and the
lingual inclines of the mandibular buccal cusps.
Mandibular protrusion will result in the mesiolingual cusp of the maxillary

first molar passing through the central groove toward the distal marginal
ridge ofthe mandibular molar.
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57

From the basic contact relations occurring in maximum intercuspation, potential tooth contacts occu r
when the mandible moves laterally and protrusively:
In a normal alignment, the ML cusp of the maxilla ry first molar opposes the central fossa of the
mandibular first molar.
From thi s position, the ML cusp w ill pass through the lingual groove when a working side move-
ment occurs. During a non-working side movement. the same cusp will oppose the di stobuccal g roove.
Mandi bular protru sion will result in the ML cusp passing through the central groove toward the dis-
tal marginal ridge of the mand ibular molar.
A similar pattern exists for mand ibular movements as related to the anatomy of maxillary posterior teeth .
The DB cusps of the mandibular first molars oppose the central fossa of the maxillary first molars.
During a working side movement, the DB cusp w ill pass through the buccal groove of the maxillary
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molar. Du ring a non-working side movement. the DB cusp will oppose the maxillary ML cusp.
Maxillary suppo rting cusps and the mand ibular suppo rting cusp s oppose each other during non-
working side movements."** Look at card #55, picture Con back .
Protr u sive movements result in the mandi bular DB cusp passing through the maxillary central groove
toward the mesial marginal ridge.
During a right working side movement, the right side molar teeth may contact along the lingual incl ines
of the maxillary buccal cusps and the buccal inclines of the mand ibular buccal cusps. - Look at card #55,
picture A on back. Likewise, the lingual incli nes of the maxillary li ngual cusps may contact the buccal in-
cli nes of the mandi bular li ngual cusps. For the non-working side (left side). contact is also possible along
the buccal incl ines of the left maxillary li ngual cups and the lingual inclines of the left mandibular buccal
cusps.
Remember:
l .ln the intercuspal position, the mesiobuccal triangular ridge of the maxillary first molar opposes
the mesiobuccal groove of the mand ibular fi rst molar.
2. In a working side movement (right o r left), t he obl ique ridge of the maxillary first molar passes
through the di stobuccal sulcus of the mandibular first molar.
3. In a working side movement (right or left), the mesiobuccal cusp of the maxillary second molar
passes through the buccal groove of the mandibular second molar.

Maxillary
D D c 0 c 0
1P 2P 1M 2M
Mandibular
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l\1- Buc.cal cusp of the md. 1st premola oc.c ludes with the Me-~o;i al marginal ridgt' of the mx. 1st premola
0 - Bucc.al cusp of the. md. 2nd premolar occlude$ with the O cdu...,al embra.o;ure of the ntx. I st and 2nd premolars
0 - "-lesiobuccal ClLo;p o f d1e. nd. 1st molar Ol.'dudes with the O cclusal t -.n.brasure of the mx. 2nd prt-llOiar and mx. 1st mo lar
C-Oistobucc.al cu..o;p of the md. 1st molar ocdude~o; with the Centf<'ll fos.o;a of the nt.x. lst nolar
0 - "-lesiobul.'cal c.u..o;p o f the. nd. 2nd molar occludes with the O cclusal embrasure o f the. nx. 1st and 2nd molars
C-Oish)buccal cu..o;p of the md. 2nd molar ocdudt$ with the Central fos.o;a of the nt.~ . 2nd molar
D - Lingu al Clt..o;p of the mx. 1st premolar occludes with the D isra.l marginal ridge of the md. 1st prt-llOiar
D- Lingu al <:u..~p of the mx. 2nd preolOiar oc.cludes with the D isral marginal ridge of the md. 2nd pre1llOiar
C-Mesiolingu al <.' lL~p of the mx. 1st molar occlude.~ with the C enrrol fos..~a of the 1nd. 1st molar
0 - 0 i.stolingual c u..~p of the mx. lsr 1no lar oc.clude$ with the O cdusal embrasure of the md. 1st and 2nd mo lars
C-Mesiolingu al cu..~p of the mx. 2nd molar o..:-dudes with the C entral fOssa of the md. 2nd mo lar
0 - 0 i.stolingual <.'-lL~p of the mx. 2nd mo laroeclude$ with the O cdusal embrasu re of the md. 2nd and 3rd llOiars ( if present)
571

Retrusive movement requires the condyles to move backward and upward.
In protrusive movement, the condyles of the mandible have moved in a

downward and forward direction.
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58

Protrusive movement is accomplished when the mandible is moved straight forward until the
maxillary and mandibular incisors contact edge-to-edge. This movement is bilaterally symmet rical
in t hat both sid es of the mandible move in the same direction. Note: Incisors are most likely to
fract ure (i.e., restorations involving the incisal edge break off) during protrusive movement s.
1. Occlusal contact possi bilities occur on maxillary distal inclines and mandibular
mesial inclines.
2. Anteriorly the facial surface of the lower incisors w ill contact the guiding inclines
(lingual) of the upper incisors and canines.
3.1n protrusive movement, the condyles of the mandible have moved in a downward and
forward direction. Note: Pure translation is performed as the mandible moves from a
pure protrusive movement from maximum intercuspal position to a maximum protrud
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ed position.
4. Retrusive movement requires the condyles to move backward and upward.
Db tal Mesia l
Working
e
Balancing Balancing
Mesial Distal
Projected protrusive, working, and balancing side paths on maxillary and
mandibular first molars made by supporting cusps, that is, mesiolingual cusp
of the maxillary molar projected on the mandibular molar and distobuccal cusp
of the mandibular molar on the maxillary molar.

In regards to the picture below, the arrows indicate the path of _ __
movement of mandibular teeth over the maxillary teeth on the _ _ _ side.
right lateral; working
left lateral; working
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right lateral; non-working
left lateral; non-working
59

left lateral; non-working
Arrows indicate path of left lateral movement of

mandibular teeth over the maxillary teeth on non-
working side. Note the relationship of paths to mor-
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phological features of the teeth and embrasures.
Note: An easy way to remember if arrows are indicating working side movements is to remember
that arrows will be relatively straight, pointing buccal (if right working) or lingual (if left working).
For non-working the arrows will be slanted, pointing buccal (if right non-working) or lingual (if
left non-working - as in the picture above).
In these movements the mandible is moving towards the right or left side. The side towards which
the mandible moves is referred to as the working side. The side from which the mandible is moving
is referred to as the non-working side.
Working side contact: cusp tips pass bet ween opposing cusp tips.
Non-working side contact (interfering contact): the contact takes place on the distal of the maxil-
lary inclines and on the mesial of the mandibular inclines. The contact area possibilities here are
unique because they involve the inner aspects of supporting cusps only. This is the only time that
the inner inclines of the supporting cusps can contact outside the intercuspa l position.
Laterotrusive movement: contacts of teeth made on the side of the occlusion toward which the
mandible has been moved. Also called working movement.
Mediotrusive movement: contacts of the teeth on the sid e opposite to the side toward which the
mandible moves in articulation. Also called non-working movement.

Anterior guidance is a result of:
horizontal and vertical overlap
vertical and posteri or cusp height
horizontal overlap and posterior cusp height
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intercondylar d istance and free way space
intercondylar d istance and postural vertica l d imension
60

horizontal and vertical overlap
Anterior guidance (anterior coupling) is the guidance provided by the anterior teeth
when the mandible goes into a lateral or protrusive movement. It is determined by
the vertical overlap of the anterior teeth, termed overbite, and the horizontal over-
lap of the teeth, which is overjet.
This overl apping relationship produces disclusion of the posteri or teeth when the
mandible protrudes and moves to either side.
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Overjet Overbite
Both the condyla r guidance at the back and the

anterior guidance at the front should determine
the functional pathways of the mand ible. The pos-
terior teeth should contact in centric relation but
should be d iscluded when the mandible moves
from centric relation. Posterior teeth must not in-
terfere with condylar guidance o r anterior guid -
ance during functional jaw movement.

In a patient with a left canine protection, the mesiolingual surface of the
maxillary right first molar contacts the distofacial surface of the mandibular
right first molar during a left lateral excursion. This contact is:
normal
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evidence of group function
a wo rking side interference
a non-working side interference
normal, and a non-working side interference
61

a non-working side interference
left canine protection refers to the left side contact of the canine during a left working movement.
All other teeth of the left sid e are out of contact at this point. In a left group function, some left an-
terior teeth, the left ca nine and some left posterior teeth would contact during left side working
movement. In all cases of left working movement, however, the right side or nonworking sid e teeth
are not in contact. So in thi scase, any or all right side or nonworki ng side contacts are interferences
and are not normal.
SAADDES
A, Right lateral movement: non-worki ng side.
Multiple working side contacts (group function).
B, Right lateral movement: canine (cuspid) guid-
A
ance on worki ng side.
B
A, Patients left side showing left working side contacts (group function) and schematic of working side occlusal
contacts and guiding inclines in left lateral movement. B, Patients right side showing non-working side occlusal
contacts and guiding inclines. Nonworking contacts are not necessary except in complete dentures.

molar teeth information
An endodontist is performing root canal therapy on a permanent maxillary
first molar. Since he is a very thorough endodontist, he knows he should
look for a fourth canal. Which root of a maxillary first molar commonly has
two root canals?
the palata I root
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the d istobuccal root
the mesiobuccal root
none of the above
62

the mesiobuccal root
The maxillary first molar usually has three roots and four canals. The palatal root usually has
t he largest dimensions. The mesiobuccal root is often very wide buccolingually.
In approximately 60% of maxillary first molar teeth, a fourth root canal is present wit h its
orifice being just lingual to the orifi ce to the mesiobuccal canal. The canal is located in the
mesiobuccal root and may join the mesiobuccal canal or exit t hrough a separate foramen.
The pulp horns are usually prominent in this tooth. The mesiobuccal and mesiolingual (if
present) are higher t han the distofacial and palatal pulp horns. This should be kept in mind
during operative procedures.
Note: In all molars, root canals join the pulp chamber apical to the cementoenamel junction.
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Maxillary Right
First Molar
Mesiodistal Buccolinguol Pulp Cavity
cross-section cross- section
Cervica l Midroot
c ross-section cro ss-section

In which teeth will we most likely see a bifurcation in the apical third of the
root?
mandibular molars
maxillary first molars
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maxillary second molars
maxillary first premolars
maxillary second premolars
mandibular premolars
63

maxillary first premolars
***Bifurcations in the mandibular molars usually occur in the cervica l or m iddle th ird
of the root.
Three root types:

1. Single or one root: maxillary and mandibular incisors, maxillary and mandibular
can ines, maxillary second premolar, and mandibular first and second premolars.
2. Bifurcating or tw o roots: maxillary fi rst premolar (buccal and palatal) and
mandibular molars (mesial and distal).
3.Trifurcation or three roots: maxillary first and second molars (mesiobuccal, d isto-
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buccal, and palatal). Note: Some maxillary th ird molars have trifurcations, but they
vary too much to predict all of the time.

During a surgical extraction of the maxillary first molar, a rough oral surgeon
accidentally perforates the maxillary sinus. If he perforated the sinus with
one of the roots of the first molar, which root is the most likely candidate,
given that it is the largest, longest, and strongest ofthe three roots?
mesiobuccal
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distobuccal
palatal
64

palatal
***The distobuccal is the smallest.
The palatal root of a maxillary first molar is the third longest root (13 mm) of any of
the maxillary teeth, after the maxillary canine (1 7 mm) and second premolar (1 4 mm)
roots. It is wider buccolingually than mesiodistally (as are all maxillary molars) and
has a longitudinal depression on the lingual. It is concave on its buccal surface. When
viewed from the facial, this root apex is in line with t he buccal groove.
Remember: On the maxillary second molars, the roots are much less divergent t han
the roots of a first molar. The palatal root is straighter than the palatal root of t he first
molar.
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Note: During oral surgery if a root is forced into the maxillary sinus it is usually the
root of a permanent maxillary first molar.
Maxillary Right First Molar Maxillary Right Second Molar
Buccal Lingual Buccal Lingual

From a developmental viewpoint, all mandibular molars have _ _ major
cusps, whereas maxillary molars have only _ _ major cusps.
6; 5
5; 4
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4; 3
-3;2
65

4; 3
Permanent mandibular molars can be distinguished from permanent maxillary
molars by the following:
When viewed from the occlusal, mandibular molars appear rectangular,
maxillary molars appear rhomboidal
Mandibular molars have t wo roots, maxillary molars have three roots
Mandibular molars have pits and grooves on the occlusal and buccal surfaces;
maxillary molars have pits and grooves on the occlusal and lingual surfaces
Mandibular molars are wider mesiodistally than faciolingually; th is is the oppos-
ite of maxillary molars, wh ich are wider faciolingually
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Mandibular molars have two nearly equal-sized lingual cusps; maxillary molars
have one large and one small lingual cusp
Mandibular molars have a transverse ridge; maxillary molars have an oblique
ridge, which extends from the mesiolingual to the d istobuccal cusps
Remember: The oblique ridge is formed by the union of the distal cusp ri dge of
the mesiolingual cusp and the triangular ri dge of the distobuccal cusp.
When examined from the mesial or distal sides, mandibular molar crowns appear
to be tilted lingually (an arch trait; t rue for all mandibular teeth). This is not appar-
ent on maxillary molars. Mandibular molar crowns also tip distally relative to the
long axis of the root.
Important:
As a result of th is decided lingual inclination:
1. The height of contour of the crown is lowered apically to the middle third.
2. The placement of instruments subgingivally is more difficult on the lingual
side.

A fissured groove is most frequently found on the:
facial surface of maxillary molars
lingual surface of maxillary molars
facial surface of mandibular molars
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lingual surface of mandibular molars
66

lingual surface of maxillary molars
It is ca lled the lingual developmental groove. Due to its presence, occl usal cavity
preparations often need to be extended onto the lingual surface.
This groove originates at an occlusal pit and terminates in a pit on the lingual surface.
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Maxillary Right
Lingual developmental
Second Molar
groove
Lingual view
Remember: The parotid duct is the duct that conveys saliva from the parotid gland
to the mouth at the level of the maxillary second molar. It is also ca lled Stenson's
duct.

The photo below is a cervical cross section of the pulp cavity of a:
mandibular first molar
maxillary second molar
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mandibular second molar
67

Important points about mandibular molar roots:
Two pulp canals are usually, if not always, found in the mesial root. The distal root usually
has only one canal
If a cross section is made ju st apical to the bifurcation of the roots of a mandibular molar,
the larger, kidney-shaped canal is found in th e distal root and the smaller, more circular
canals are found in the mesial root
The MB canal curves more than the ML canal
The mesial root is typically very thin mesiodistally, much wider faciolingually, and concave
on both the mesial and d istal surfaces
The distal pu lp horn is the smallest
The pulp horn on the mesial (facially and lingually) is higher than that on the d istal (this
SAADDES
needs to be kept in mind during operative procedures)
Mandibular Right
First Molar
Pulp Cavity
Mesiodistal 8ucco&inguo1
cros.s-section cross-section
Cervical Mldroot
cross-section crou-section

A dental student is performing root canal therapy on an extracted maxillary
molar in her preclinical endodontics course. Her pre-operative radiograph
shows four canals (two canals in the MB root). She should expect the shape
of the floor of the pulp chamber in this maxillary molar to be roughly:
square
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rhomboidal
triangular
circula r
68

triangular
Maxillary Right First Molar Maxillary Right Second Molar
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Cervical
cross-section
Cervical
cross-section
Whether there are th ree root cana ls or fou r root canals (as seen often times with the
maxillary fi rst molar), the orifice of each major canal serves as a corner of the pulp
chamber. Therefore, t he shape of t he pulp chamber is roughly triangu lar. The base is
formed by t he buccal canals and the apex is formed by the palatal canal. Note: The
line connecting the mesial canal with t he palatal canal is the longest.
The cervical outline form of the pulp cavities in maxillary fi rst and second molars is
rhomboidal w ith rounded corners (see pictures above). The MB angle has an acute
angle, the DB angle is obtuse, and the lingual angles are essentially right angles.

The picture below is a buccolingual section of the pulp cavity of a:
a mandibular ri ght first molar
a mandibular ri ght second molar
a mandibular right third molar
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69

a mandibular right first molar
~~
Me-slodiJIOI
~rou -~11on
Buccoiii'J9Uol
cros.edlon
Mandibular Right First Molar Maxillary Right First Molar
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Mandibular Right Second Molar Maxillary Right Second Molar
Mandibular Right Third Molar Maxillary Right Third Molar

From a mesial or distal aspect, all mandibular posterior teeth have a:
triangular outline
rhomboida l outli ne
trapezoidal outline
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square outline
rectangu lar outline
70

rhomboidal outline
From a mesial or distal view, the crown outline of a mandibular posterior tooth is rhomboidal in
shape and tilts towards the lingual. Because of this lingual inclination, the mandibular molars have
long axes positioned with their root apices facial and their crowns lingual. Note:This design encour-
ages cusp fracture.
\fJJl H 0 ~
VA u ts:LJ B
.~ .U J?j .'RJ
SAADDES
[;Jt;j
E~ FOJ
Outli nes of crown forms w ithin geometric outlines - triangle, trapezo ids, and rhomboids. The upper fig-
u re in each square represents a maxillary tooth, the lower figure a mandibular tooth. Note thatthe trape-
zoidal outline does not include the cusp form of posteriors actually. It does include the crowns from
cervix t o contact point or cervix t o marginal ridge, however. This schematic drawing is intended to em-
phasize certain fundamentals. A, Anteriorteeth, mesial or d istal (triangle). 8, Anterior teeth, labial or li n-
gual (trapezoid). C, Premolars, buccal or li ngual (trapezoid). 0, Molars, buccal or lingual (trapezoid). E,
Premolars, mesial or d istal (rhomboid). F, Molars, mesial and distal (rhomboid).

The distolingual cusp on the permanent maxillary molars is also called a:
cusp of Carabelli
talon cusp
dens evaginatus
trigone
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71

talon cusp
The distolingual cusp on permanent maxillary molars generally is the one that gets prog ressively
smaller as you go posterior in the arch. This is the most obvious characteristic that distinguishes
permanent first, second, and third molars from each ot her.
Remember: For maxillary molars, the primary cusp triangle (also called the "trigon") is formed by
the ML, MB, and DB cusps (large shaded area in center of tooth in picture below). The DL cusp is
called the talon cusp and is not a pa rt of th is primary cusp t riangle. The talon cusp might be absent
on maxillary second and third molars. Note: A cusp present abnormally is also called a talon cusp.
Someti mes a fifth cusp, the Cusp of Carabelli, is located on the ML cusp of maxillary molars.
M axillary right first molar, occlusal aspect.
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M BCR, mesiobuccal cusp ridge; CF, cent ral fossa;
MTF, mesial triangular fossa (shaded area); MM R,
Mcslol tnongulo1 mesial marginal ri dge; MLCR, mesiolingual cusp
lasso
..,.. ,. __ M esial morg!nol
ridge; OR, o blique ridge; DLCR, di stolingual cusp
ridge ridge; OF, d istal fossa; DTF, di stal triangular fossa
Meslol1nguol (shaded area); DMR, d istal marginal ri dge; DBCR.
cusp ridge
d ist obuccal cusp ridge. Note: The primary cusp
triangle i s t he large shaded area in center of
tooth.
Buccal groove
Maxillary right first molar, occlusal aspect, de-
C.t!ntrat plt vel opmental grooves. BG, buccal groove; BGCF,
~~~~~ f~~ve o f buccal g roove of central fossa; CGCF, central
Transverse groove
o f o blique ridg" Central groove of g roove of central fossa; FCG, fifth cusp g roove;
c e ntra l fossa
Olstol oblklue LG, li ngual groove; DOG, d istal oblique g roove;
groo\le _,__ __..._
TGOR, transverse groove of o bl ique ridge; CP,
f ttth cusp groovo
lingual groove - "';;;;:;:::.;"'-,; central pi t.

A dentist is completing a disto-occlusal restoration on a permanent maxillary
first molar. He is carving the distal marginal ridge. He makes sure to give it
width for support and must round it to create an embrasure. In order to get
the correct height occlusocervically, he should match the distal marginal ridge
of the maxillary first molar to the:
SAADDES
mesial marginal ridge of the maxillary second premolar
mesial marginal ridge of the mandibular first molar
mesial marginal ridge of the maxillary second molar
distal marginal ridge of t he maxillary second premolar
72

mesial marg inal ridge of the maxillary second molar
*** The marginal ridges of a tooth (M or D) are the same height as the tooth in proximal
contact to it (M or D).
Important: When restoring the marginal ridges of posterior teeth, remember to ro und
them off to form occlusal embrasures and keep them wide enough for strength.
Remember: Marginal ridges are elevation s of enamel that form the mesial and distal
margins of the occlusal surface of the molars and premolars. They also form the mesial
and distal margins of the lingual surfaces of the incisors and the canines.
SAADDES
't Marglnol
. ~ridge
Mor9inol - - - -
rid~e
Linguool ~= "'-- - - ridge

lnci$OI
~~:e-- .- r I
\j
/
foua
Sulcus
Maxillary right central incisor (lingual aspect). CL. Mesial view of maxillary right first premol ar. MR.
cervical line; Cl, cingul um (also called linguocervical marginal ridge; S, sulcus traversing occlusal surface;
ridge); MR. marginal ridge; IR, i ncisal ridge; LF, lingual CR. cusp ridge; BCR, buccocervical ridge.
fossa.

How many roots are visible from the buccal aspect of a maxillary first molar?
one root
two roots
three roots
four roots
SAADDES
73

three roots
1. The palatal, which is the longest

2. The mesiobuccal
3. The distobuccal, which is the shortest
Maxillary Right
First Molar
Buccal View
SAADDES
The two buccal roots are well separated and bent in such a way that they look like the
handles on a pair of pliers. The axes of the roots are inclined distally. Th is is in contrast to
the roots of a second molar, which are often close together and less curved. The palatal
root often has concavities both facially and lingually.
Remember: Molar roots originate as a single root at the base of the crown (called a root
trunk) near the cementoenamel j unction. The furcation is the place on multirooted teeth
where the root trunk divides into separate roots (bifurcation on two-rooted and
trifu rcation on three-rooted teeth).
1. The mesial furcation is closest to the cervical line, w hile the distal is the farthest
from the cervical line.
2. There is a deep developmental groove b uccally on the root trunk of the max-
illary first molar. It starts at the b ifurcation and terminates at the cervical line.
Remember: The distal surface of the root trunk has a concavity which requires
special attention when root p laning.
3. During surgical removal of the maxillary first molar, be careful not to force root
tips into the maxill ary sinus.

muscles
Fibers from the ventral ramus of Cl travel with the hypoglossal nerve (CN XII)
to the geniohyoid and thyrohyoid.
Fibers from the ventral rami of C1 -C3 combine to form the ansa cervicalis,
which gives off branches to the omohyoid, sternohyoid, and sternothyroid.
SAADDES
74

The infrahyoid muscles are depressors of the larynx and the hyoid bone. These
muscles are often referred to as strap muscles due to their ribbon-like appearance.
They lie between the deep fascia and the visceral fascia covering the thyroid g land,
trachea and esophagus.
lntr~th,Oid muscll's
Muscle Origin Insertion Innervation Action

Omohyoid Sc-apula (superior Hyoid bone A nsa cervic-.alis of Depresses (fixes) hyoid; draws
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(inferior belly) border, medial to ce rv i c~ l plexus (C J.C3) larynx and hyoid down for
suprasc-apular notch) phonation and tem1inal phases
of swallowing
Sternohyoid Manubrium and
sternoclavicular
joint (posterior
surface)
Sternothyroid Manubrium T hyroid
(posterior surface) cartilage
(oblique
line)
Thyrohyoid Thyroid ca1tilage Hyoid bone. Ventral ramu..o; ofC I via Depresses and fixes hyoid;
CNXII raises the larynx during
swallowing
Note: These muscles anchor the hyoid bone and depress the hyoid and larynx during
swallowing (deglutition) and speaking.

muscles
Which of the following suprahyoid muscles are innervated by the facial
nerve?
mylohyoid muscle
SAADDES
anterior belly of d igastri c muscle
posterior belly of digastric muscle
stylohyoid muscle
geniohyoid muscl e
75

posterior belly of digastric muscle
stylohyoid
Sup1 .1h\ md 'lusclcs

Muscle Origin Insertion Innervation Action
Geniohyoid Mandible (inferior Ventra] ramus ofCI v ia Draws hyoid bone fOrward
genial spine) CNXII (during swallowing); as.sist.'i in
opening the mandibJc
Mylohyoid Mandible Mylohyoid nerve (!rom Tightens and elevates ora] floor;
(mylohyoid line) CNV3) draws hyoid bone fOrward
(during swallowing); assists in
SAADDES
Hyoid bone opening the mandibJc and mov
ing it side to side (mastic-ation)
Digastric Mandible Elevates hyoid bone (during
(anterior belly) (diga..'itric fossa)) swaJlowing); assists in
depressing the mandible
Digastric Temporal bone Facial nerve (CN VII)
(poste rior belly) (mastoid notc h)
Stylohyoid Temporal bone
(styloid process)
1. The geniohyoid and mylohyoid muscles form the floor of the mouth.
8 2. The digastric, mylohyoid, and geniohyoid muscles are active during jaw open-
mg.
3. The suprahyoid muscles act as antagonists to the elevator muscles.
4. Voluntary mandibular retrusion with the mouth closed is brought about by
contraction of the posterior fibers of the temporal is muscle and by the supra-
hyoid and infra hyoid muscles.

muscles
There are two sets of lingual muscles: extrinsic and intrinsic. The extrinsic
muscles:
alter the shape of the tongue
move the tongue as a whole
SAADDES
all ori ginate from the mandible
are all innervated by the hypoglossal nerve
76

move the tongue as a whole
ln~utkln I l nntl'\'atlo n Aclion

Exlrinsk un.Uill OlUSC.If~
G~mog:lossus Mandible (superior lniCrior fibm: h)oid body Protrusion of congue
genial (menial)
spine via an inler- lmcrmediatelibers: BJ/atera/ly: makes dorsum
mcdiate tendon): posterior tongu~ concave
mor~ pos.teriorty 1hc Ullllotera/1) . deviation to
IWO genioglossi are Superior fibers: lcnlral opposite s tdc
scparatcd by the surli:u:e of tongue (mix with
lingual sepnun inlrinsic muscles)
Hyoglossus Hyoid bone (greater Lateral onj,ouc. becween Depresses the tongue
cornu and anteriot styloglossus and inferior
body) longitudmal muscle
SAADDES
Styloglossus Styloid process of Longitudinal pan: dorsolaleral Superior and poscrioc
temporal bone tongue (mix with inferior mo\emem of the longue
(anterolateral aspt.-ct longitudmal muscle)
ofapex) and stylo
mandibular ligamenl Oblique p3n:: mix with
fibcrs of the hyoglossus
Palatoglossus Palatine a1>oncurosis Lateral tongue to dorsum and Vagus nerve via Elevates the root of the
{oral surlilee) fibers of the transverse muscle he phal)ngeal tongue: closes the
plexus oropharynges! isthmus by
contracting the
palatoglossal arch
hurhuk linjlual musclts
Supcrior Thin layer of muscle inferior co the dorsal mucosa: H)pogl0$$tll Shortens tongue: m l:l."s
longitudinal fibers run anterolatemlly from the epiglottis and dorsum concave (pulls
median lingual septum apex and latl."ml margin
upward)
Infe rior Thin l ay~r of muscle superior o the geniog:los..;us Shortens tongue: m kl."s
longitudinal and hyoglossus: libers run anteriorly from the r\loC to dorsum convex (pulls api."X
the apex of the tongue d O\I,'tl)
Transverse Fibl."rs run laterally from the lingual septum to the Narrows tongue:
muscle lateral tongue elongates tongue
Vl."l1irol In lhe anterior tongue. fibers run inferiorty from the Widens and llattcns tongue
muscle dorsum of he tongue o its vcnmd surlil~

muscles
Which muscle presses the cheek against molar teeth, working with the
tongue to keep food between the occlusal surfaces and out of the oral
vestibule?
zygomaticus major
SAADDES
depressor labii inferi oris
buccinator
levator anguli o ris
77

buccinator
J\tusdt Or'tin ht$frCtoa IIUI\'t\'llt ii.Hl )hlh'l attiun. t~J
Z)')tColll:ltteu~ Zyg_unt.Sii.: IXlllw M u~do:~ at l11e 2 f'llll.i o:omtt of n)()U'Ih Sttp~Tior1y and
!USJ')I' angk of tb.:- l :lltf:lll)'
lll Oui)J
Z)')tColll:ltteu~ Uppo."11ipjus:t f'llJk Up(!O.~I lip SUpo."tiOfl)'

IU it hJI medial1,;, oome
<tfl""uth
l o:vato.)rla.bit Maxilla(fr<lontal Ul'lflo.-"1lip and BIZ Elt\':'111:~ upper lip, OilrtS noo1nl
l!upt n is J'HOCI:il!) ab1 C:lrttlag.eof
Note:
abe-que n:llli
Innervation -The muscles
l o:vato.)rla.b it Maxilla(fr<lontal Skin of upper lip Elt \':'lttl! upper lip
I!Upt n ()ti3 J'HOCtl!l!) and i n
of facial expression are i n-
ft:Wrbital l'lt.Sigill nervated by six branches of
Do:pf"d:SUr labii Ma.nd ibk(antct"iur f'llllslo'-"t ' lip uJfcrioly and latctslly. the facial nerve. Th e pos-
tnf.:-ri\lr1i portion of oblique
Ut\H""I'l!p:U
mnUint " ;.I ~ O:OOlnbuto:s w tw~i oo \J>WhftSt
SAADDES
lint)
terior muscles are inner-
vated by the posterio r
Lt-\;uor angttb Ma.xill.s (~:~niue Mu~ltsattl1e BIZ Raises angle ofnloull1.. hd ps funn
lb ssa..btlow angk of tb.: n:"lsolabial fu1row auricular (PA) nerve, w h ich
inft$01bit:"ll lll0ut11 arises before the facial
f()l:"lll\i:n)
nerve enters the parotid
D.:pteSSOI' :~ngul i Ma.nd ibl~ (oblique Ski.n :lt~'<M'tletof B/M l"ulli :~ngl t of nlout11iuftn(~tl y :lnd
gland. The anterior mus-
lin.:. b.:k>w .:-an in.:. lllOut11. blends b tt-rJ.IIy
jttei"UJat :"lnd h i witb ortneub ni cles are i nnervated by five
nlOb1 1~111 t Ofill branches of the parotid
8 uco:-u\31M AI\OObt p1 ott'S~ of Lips. otbi~-ularis B Ptessd o:-h..-ck :lilins.t nlol:lr 1~tl1.. v.urt- plexus of the facial nerve:
uu .xilla and nl:lndt- oris. !illbtl\IM:Ol:o\ 1ng w1th tunglk' to k.:o:--p foOO bi:twe.:n
bk\b)'tJ)()Iats): of lijl':land t h.:o."l: o.:dus:~ l surfaces and out of ()1al Vdllbul.:
Temporal (T), zygomatic
p.tt:tygunX!ndibut:lr (Z), buccal (B), mandibular
t:lpbe Umlato."t:ll: d1:"1ws n'll'>lllh tu ooe side
(M), and cervical (C).
Ol'bielll:lriiOni Dtepssu1illce of Mucous BIM AC IS3S()t:l)Sphil'l~'1cr:
stin nlt:ulb1an..- M Cootpt essts and protrudes hp (e.g.,
Superiorly: Maxilla lipi whistling. .>liCking. ki s~iliS,l
lnftriorty f\'l:"lndibl.:
k isonui Fasci:"l 3nd supt rfi Skill:"ll ('l()nlcrOf B Rtu:lcts .:umtr of.nout11 as in S1uilins.
ci:.tl lllusclesovcr moul11 l:lugbing. gtiulacing
Mentalis Fn.."uu1un) ofk:Mw Skill ()f d un .\1 Elev:~te s ;!.lid pl'()tt\ldo.."S luw~.., lip.
lip (dtmkiliS,t
Plal)'~ltla Skill ()v'1 lower Mandible c Deprtssei :"lnd wrinkle.i sl:in uflowc1
ncek (il1ft1teotbonkr) fact: :lnd llW'ltlth: IC'IUCUl:il'l Uf I.CCk

muscles
A new patient comes in with a history of malignant cancer. When the patient
opens, the mandible deviates to the left. You suspect a tumor blocking
nervous innervation to which muscle?
right medial pterygoid
SAADDES
left medial pterygoid
right lateral pterygoid
left lateral pterygoid
78

*..,. Important: The ma ndible will always deviate to the side of inj ury.
Remember: If the hypoglossal nerve becomes damaged from inj ury or a tumor, the tong ue w ill
also deviate noticeably toward the affected side.
Muscle Origin Insertion Innenation A(r-iOn
Lateral Superior Greater ~\ in g of tvlandible Mandibular netve (anterior Bilateral: Protrudes the.
ptt1ygoid (upper) head sphe.noid bone (pterygoid fovea) division ofCN V3) via mandible (pulls d isk
(infratemporal cre~n) and TMJ lateral pterygoid nerve forward)
SAADDES
(articular disk) Unilate-ral: Lateral
moveme-nts of the
Inferior Lateral pterygoid tvlandible mandible (ehtwing)
(lower) head plate (lateral surtaee) (pterygoid fove.a
and condylar
proc.ess)
Medial Superficial Ma:<illa (ma:<illary Pte-rygoid rugosicy Mandibular netve (anterior Elevates (adducts) the
l'lerygoid (external tuberosity) and on nedial surface division ofCN V3) via mandible
head) palatine bone of the mandibular 1nedial pterygoid nt-I'Ve
(pyramidal proc.es..~) angle
Dee,, Me.dial surface of
(internal) latetal pterygoid
head plate and pterygoid
fOssa
Note: With a fracture of the condylar neck, the condylar head remains in the mand ibular fossa due
to t he temporomandibular ligament. This ligament is the main stabilizing ligament of the TMJ.It
orig inates from the lateral surface of the zygomat ic arch and a t ubercle on its lower border, and is
directed obliquely downward and backwa rd to insert into the posterior border and lateral surface
of the neck of the mand ible. This ligament restricts downward and posterior movement of the
ma ndible and guides the for ward motion of the condyle du ring opening.

muscles
After seating a new crown on tooth #19 you need to check excursive move-
ments. You ask the patient to slide her jaw to the right to make sure there are
contacts on #19 during this movement. What muscle does the patient use to
move her jaw like this?
right medial pterygoid
SAADDES
left medial pterygoid
right lateral pterygoid
79

Lateral excursions (moving t he jaw sideways) resu lt from t he contraction of one lateral
pterygoid muscle on the opposite side.
Tht. \lusdt.s of \ J.tslic.thon \\lth \ssoci.ttcd \10\t.'OH.'Dh of the \ J.tndihlc
.
Muscles of Mastication Movements of the Mandible
Masseter
Temporal is .. Elevation of the mandible (during jaw closing)
Elevation o ftl1c mandible (during jaw closing)
Medial pterygoid . Retraction of the mandible (lower jaw backwa rd)
.
Elevation o ftl1c mandible (during jaw closing)
SAADDES
Lateral pterygoid One muscle: lateral deviation of the mandible (to
. shift the lower jaw to the opposite side)

Both muscles: protmsion o f the mandible (puJls
articular disk forwa rd)
Important: Protrusion (protruding the j aw) results only from the simultaneous
contraction of both lateral pterygoids. Th is produces forward movement of the condyle
from the mandibu lar fossa (articular fossa). They do not need assistance for th is
movement.
Unilateral contraction deviates t he mandible to the contralateral (opposite) side.
Contraction of the muscle on alternating sides prod uces the side-to-side motion required
for grinding food.
Closing the mout h (elevati ng t he mandible) res ults from t he b ilateral cont raction of three
pairs of muscles:
1. The anterior (vertical) fibers of the right and left temporal is muscles
2. The right and left masseter muscles
3. The right and left medial pterygoid muscles

muscles
Retrusion (retruding the jaw) results from:
the bilateral contraction of the anteri or (vertical) fibers of the temporalis muscle
the bilateral contraction of the posterior (horizontal) fibers of the tempo ralis muscle
the unilateral contraction of the anterior (vertica l) fibers of the tempora lis muscle
SAADDES
the unilateral contraction of the posteri or (horizontal) fibers of the temporalis
muscle
80

the bilateral contraction of the posterior (horizontal) fibers of the temporal is muscle
Retrusion results from the bilateral cont raction of the posterior (horizontal) fibers of the
temporalis muscle. They are assisted by the suprahyoid muscles, specifically the anterior and
posterior bellies of the digastric muscles.
SAADDES
Middle Zygomatic arch Mandibula ramus
head (medial aspect of (central pa11 of
anterior two-thirds} occlusal sul'fllce}
Deep Zygomatic arch Mandibula1 ramus
head (deep surface of (superio1 lateral
posterio1 third) surface) and infel'ior
coronoid
Coronoid process of Deep tempo1al Ve-rtical (anterior} fibes:
mandible (apex, nerve (anterior elevates mandible
f--- - - t - - - - - ---l medial surface, and division ofCN Hol'izontal (postel'ior) fibeno:
Deep head Tempoml fossa anterior smface of VJ) retraces (reti'Ude) mandible
(infe-riOI' remporal mandibular amus) Unilateral: late-ral movemenl
line) of mandible (chewing)
Opening of the jaw (depression of the mand ible): The lateral pterygoids do this by pulling the
articular discs and the condyles anteriorly and down onto the articula r eminences. In opening the
jaw or depressing the mand ible, the lateral pterygoids are assisted by the anterior bellies of the
digastric muscles (which are suprahyoid muscles) and the omohyoid muscles (which are infrahyoid
muscles) . These muscles help fix or hold the hyoid bone.

occlusion information
A 22-year-old female dental student comes into your dental practice for a
regular check-up. She states that she has never had any problems with her
teeth, and upon examination you notice that only one pair of teeth seem to
have contact during lateral movements ofthe mandible. Which teeth should
ideally provide the predominant guidance through the full range of
movement in lateral mandibular excursions?
SAADDES
premolars
first molars
incisors
canines
81

canines
This is called canine or cuspid protected ocdusion. It is an occlu sal relationship in which the
vertical overlap ofthe maxillary and mandibular canines produces a disclu sion (separation) of all of
the posterior teeth when the mandible moves to either side. All other teeth, once they move from
centric relation, do not contact. If there is contact of other teeth, it is termed a working side" or
"non-working side" interference depending on which side the mandible moves towards.
Group function (someti mes called unilateral balanced occlusion) is an occlusal relationship in
which there is contact of one or more teeth on the working side duri ng a lateral working movement.
SAADDES
A, Right lat eral movement: non-working side.
Multiple working side contacts (group function).
8, Right lateral movement: cani ne (cuspid) guid-
ance on worki ng side.
A, Patients left side showing left working side contact s
(group function) and schematic of worki ng side oc-
clusal contacts and guid ing incli nes in left lateral move-
ment. 8, Patient's right side showing non-working side
occlusal contacts and guiding incli nes. Nonworking
contacts are not necessary except in complete den-
tures.
1. Some relationships are not conducive to cu spid protected occlusion, such as Class II or
''itj end to end relationship.
2. Some relationships are not amenable to group fu nction, such as Class II, deep vertical
overlap.
3. Regardless of what lateral concept is used, it is essential to have no non-working side
contacts (except in complete dentures) because:
(1) They are damaging
(2) They are difficult to control due to mandibular flexure
(3) They deliver more force to the teeth than other contacts

In an ideal intercuspal position, the mesiobuccal cusp of the permanent
maxillary first molar opposes the:
the d istobuccal g roove of the mandibular first molar
the buccal groove of the mandibular second molar
SAADDES
the mesiobuccal groove of the mandibular first molar
the developmental groove between the d istobuccal and the d istal cusps of the
82

the mesiobuccal groove of the mandibular first molar
Normal intercuspation of
maxillary and mandibu lar
teeth.
A. First molars (buccal as-
pect).
B. First molars (mesial as-
pect).
C. First molars(distal aspect)
Important:
SAADDES
The mesiobuccal cusp (specifically, the triangular ridge of the MB cusp) of the maxillary first
molar opposes the mesiobuccal groove of the mandibular first molar. This relationship is a
key factor in the definition of Class I occlusion.
The distobuccal cusp of the maxillary first molar opposes the distobuccal groove of the
mandibular first molar. Note: This distobuccal groove also serves as an escapeway for the ML
cusp of the maxillary first molar during non-working excursive movements.
When the mandible moves to the right. the ML cusp of the maxillary right first molar passes
through the lingual groove of the mandibular right first molar.
The oblique ridge of the maxillary first molar opposes the developmental groove bet ween
the distobuccal and distal cusps of the mandibular first molar.
Remember: The maxillary buccal (facial) and the mandibular lingual cusps are guiding cusps. The
inner occlusa l inclines leading to these cusps are called guiding inclines because in contact
movements they guide the supporting cusps away from the midline. Thus, there are bucco-ocdusal
inclines (lingual inclines of the buccal cusps) of the maxillary posterior teeth and linguo-ocdusal
inclines (buccal inclines of the lingual cusps) of the mandibular posterior teeth.

Identify the following pictures of dental arch relationships as being either
Class I, Class II Div I, Class II Div. II, or Class Ill.
A B c D
SAADDES
83

A - Cla ss II pjv II
In the Class II relationship, the maxillary arch is positioned mesially, with the mesio-
buccal cusp above or approaching the embrasure between the mandibular first molar and
the second premolar. In addition, the maxillary canine is seated anterior to the mandibular
canine. The Angle Class II Division II incisors are retroclined and have less anterior overjet,
but a deeper vertical overbite, than Class II Division I.
B =Class Ill
In the Class Ill relationship, the mandibular first molar is mesial to the maxillary first
molar and there is concomitant mandibular prognathism reflected in the patient profile.
The mandibular arch is displaced mesially or the maxillary arch is displaced distally, w ith
SAADDES
the mesiobuccal cusp of the maxillary first molar occluding distal to the buccal groove
of the mandibular first molar.
C= Class I
In the Class I relationship, the mandibular first permanent molar is slightly anterior to the
maxill ary first permanent molar. If there are no irregularities elsewhere, this wou ld be
termed a Class I occlusion. If there were irregularities elsewhere, it wo uld be termed a Class
I malocclusion. The Class I relationship is a normal permanent molar relationship. In this
condition the mesiobuccal cusp of the maxillary first molar is placed over the buccal groove
of the mandibular first molar. In addition, the maxillary canine is p laced in the embrasure
between the mandibular canine and the first premolar in a normal canine relationship.
D = Class II Di v I
In the Class II relationship, the maxillary arch is positioned mesially, with the mesio-
buccal cusp above or approaching the embrasure between the mandibular first molar and
the second premolar. In addition, the maxillary canine is seated anterior to the mandibular
canine. The Ang le Class II Division I incisors normally display excessive anterior overj et.

An archaeologist consults a dentist about some findings he had on a dig. The
teeth the archeologist finds have four cusps - two of them taller and pointed,
two of them shorter, rounded, and dull. The dentist tells the archaeologist
that these teeth are similar to our human molars. The broader, more rounded
cusps are:
SAADDES
non-supporting and working
supporting and balancing
supporting and working
non-supporting and balancing
84

supporting and w orking
Five common characteristics of supporting cusps:
1. They contact the opposing tooth in the intercuspal position
2. They support the vertical dimension of the face
3. They are nearer the faciolingual center of the tooth than the non-supporting
cusps
4. Their outer incline has a potential for contact
5. They have broader, more rounded cusp ridges than non-supporting cusps
Remember: The supporting cusps are the maxillary lingual cusps and the
mandibular buccal cusps. These cusps do grinding work because they occlude in a
SAADDES
fossa or marginal ridge and are also called working cusps. They are sometimes cal led
centric cusps because they hold the occlusion in a middle position (centric position).
The non-supporting cusps are the maxillary buccal cusps and the mandibular
lingual cusps. These cusps do not occl ude or fit into fossae or marginal ri dge areas
and are ca lled balancing or non-centric cusps. These cusps allow the dentition to
move apart, out of occlusion. They allow the teeth to "unlock" and move back and
forth and side to side.
Non-supporting cusps Supporting Cusps
Maxillary Right Mandibular Right

First Molar First Molar
Supporting Cusps Non-supporting Cusps

Which permanent teeth occlude with only one tooth in the opposite jaw,
assuming ideal relations exist?
maxillary can ines
maxillary central incisors
SAADDES
mandibular central incisors
mandibular th ird molars
85

mandibular central incisors
Oppose the maxillary central incisors only (right or left)

Will also contact the maxillary incisors in protrusive and lateral protrusive
movements
Important: In an ideal intercuspal position, the distoincisal aspect of the mandibular
central incisor opposes t he lingual fossa of the maxillary central incisor.
Normally a tooth has contact with two teeth in the opposing arch. The only except-
ions are the lower central incisors and the upper third molars. In the mandible, a
tooth is situated more mesially and lingually t han its counterpart in the maxilla.
Accord ingly, each mandibular tooth in the intercuspal position contacts two maxillary
SAADDES
teeth (its class counterpart and the tooth immediately mesial to it. For example, t he
mandibular first molar makes contact with t he maxillary first molar and second
premolar).
Normal intercuspation of maxil-

lary and mandibular teeth.
A. Central incisors (labial aspect).
B. Central incisors (mesial as-
pect).

In an ideal intercuspal position, the facial cusp tip of a maxillary first
premolar opposes the:
facial embrasure between the mandibular first and second premolars
facial embrasure between the mandibular second premolar and the mandibular
SAADDES
first molar
opposing central fossa
opposing mesial marginal ri dge
86

facial embrasure between the mandibular first and second premolars
Remember: The facial cu sp tips of permanent maxillary premolars oppose the facial embrasure
bet ween their class counterpart and the tooth distal to it.
Examples:
1. The facial cusp tip of a maxillary first premolar opposes the facial embrasure between the
mandibular first and second premolars (see note below).
2. The facial cusp t ip of a maxillary second premolar opposes the facial embrasure between the
mandibular second premolar and mandibular first molar.
1P 2P 1M 2M
SAADDES
0 0 C 0 C
D D C 0 C 0
1P 2P 1M 2M
Important: For further explanation of the above schematic refer to the illustration for card 57.
Note: During lateral excursive movements, the facial cusp ridge of the maxillary first premolar on
the working side opposes the distal cusp ridge of the first premolar and the mesial cusp ridge of
the second premolar.

In the intercuspal position, where does the mesiolingual cusp of a permanent
maxillary first molar occlude?
the distal triangular fossa of f irst p remolar
the distal triangular fossa of second premolar
SAADDES
the central fossa of the mandibular fi rst molar
the distal marginal ri dge of mandibular first molar
87

the central fossa of the mandibular first molar
Cuntach in lhl' lntcn:usp.d Pus1tmn
Maxillary Occludes into Area of Mand ibular Teeth

Lingual Cusps (Class counterpart or counterpart and tooth distal to it)
First premolar Distal triangular fossa of the first premolar
Second premolar Distal triangular fossa of the second premolar
First molar
Mesiolingual Central fossa of the first molar
Distolingual Distal marginal ridge of the first molar and the mesial
marginal ridge of the second molar
SAADDES
Second molar
Mesiolingual Central fossa of the second molar
Distolingual Distal marginal ridge of the second molar and the mesial
marginal ridge of the third molar
Example of idealized cusp-fossa

relationship.
A. Mesiolingual cusp of maxillary
first molar occludes in the cen-
tral fossa of the mandibular first
molar. Distal buccal cusp of
mandi bula r first mola r occludes
in the central fossa of the maxil-
lary first mola r.
B. Concept of occlusion in which
all supporting cusps occlude in
fossae.

In the intercuspal position, where does the distal cusp of a permanent
mandibular first molar occlude?
the d istal triangular fossa of the maxillary second premolar
the distal fossa of the maxillary fi rst molar
SAADDES
the centra l fossa of the maxillary second molar
the mesial marginal ridge of the maxillary first molar and distal marginal ridge of the
maxillary second premolar
88

the distal fossa of the maxillary first molar
( ont~u.ts m the Intel cusp~1l Position
Mandibular Occludes into Ar ea of Maxillary Teeth

Buccal Cusps (Cias.s counterpatt or counterpart and tooth me.sial to it)
First premolar Mesial triangular fOssa of the first premolar and distal marginal ridge of the canine
Second premolar Mesial triangular fos.sa of the second premolar
Firs t molar
Mesiobucc-al Mesial marginal ridge of the first molar and the dista l marginal ridge of the second premolar
Distobucca l Central fossa of the first molar
Distal Distal fossa o f the fi rst molar
SAADDES
Second molar
Mesiobuccal Mesial marginal ridge of the second molar and the distal marginal ridge o f the first molar
Distobuccal Central fossa of the second molar
Example of idealized cusp-fossa ~

~
relationship.
A. Mesiolingual cusp of maxillary ,,
,,
first molar occludes in the cen-
tral fossa of the mandibular first
molar. Distal buccal cusp of
mandibular first molar occludes
in the central fossa of the maxil- ''
~
lary first molar.
B. Concept of occlusion in which
all supporting cusps occlude in
fossae.
A

Match the following diagrams on the left with the proper Angle's
classification on the right.
A. Class I
B. Class II
C. Class Ill
SAADDES
2
89

1. C, 2. A, 3. B
Classification of Human Occlusion !Angle's)
Class 1: most common (about 70% of the population). The mesiobuccal cusp of the maxillary first molar
lines up ap proximately with the mesiobuccal groove ofthemandibular first molar. The maxillary central in-
cisors overlap the mandibulars. Maxillary canine lies between the mandi bula r canine and fi rst premolar.
Class II: less common(about 25%). The mesiobuccal cusp of the maxillary first molarfall s approximately
between the mandibular fi rst molar and second premolar. The lower jaw and chin may al so appear small
SAADDES
and retruded. The mandib ular incisors occlude even more posterior to the maxillary incisors so that they
may not touch at all. Maxillary canine is mesial to mandi bul ar canine. The subclassificati ons of the Angle
Class II relationship are based on the posit ion of the inci sors in ind ividual s with Class II relationships, and
are referred to as Class II Division I and Class II Divi si on II relationship s.
I
Class Ill: the l east common (less than 5%). The mesiobuccal cusp of the maxi llary fi rst molar fall s ap-
p roximately betw een the mandibular first molar and second molar. The chin may also protrude li ke a b ull-
dog's d oes. The mand ibul ar incisors overlap anterior to t he maxillary inci sors. The maxillary canine is distal
'"" ~"'""""'"'" I I

A dental student is finalizing the temporary crown he fabricated for his
patient. The patient's occlusion is in an ideal relationship, and the crown
has ideal centric contacts. The student has a bad habit of forgetting about
working and balancing contacts. He does remember the rule that he should
avoid laterotrusive contacts on the guiding cusps on posterior teeth. Which
two of the following are considered to be guiding cusps?
SAADDES
maxillary lingual cusps
maxillary buccal cusps
mandibular lingual cusps
mandibular buccal cusps
90

maxillary buccal cusps
mandibular lingual cusps
These cusps are also called balancing, non-supporting, non-centric or shearing cusps. These
cusps do not occlude or fit into fossae or marginal ridge areas on the opposit e arch. They all ow the
dentition to move apart, out of occlusion.They all ow the teeth to unlock" and move back and forth
and side to side.
Supporting cusps are the maxillary lingual cusps and the mandibular buccal cusps. These cusps are
also called working, stamp, or centric cusps. The three areas of centric contacts or centric stops,
between the two arches are height of cusp contour, marginal ridges, and central fossae. are areas of
contact that a supporting cusp makes with opposing teeth. For example, the mesial lingual cusp of
the maxillary first molar (a supporting cusp) makes contact with the central fossa (central stop) of
the mandibular first molar.
SAADDES
Supporting cusps contact the opposing teeth in their corresponding faciolingual center on a
marginal ridge or a fossa. Non-supporting cusps overlap the opposing tooth without contacting it.
The ideal centric stops be-

tween the two a rches are
highlighted. Note that the
stops include the height of
contour, marg inal ridges,
and central fossae of the
teeth.
Note: In posterior cross-bite situations, the supporting and guiding cusps are opposite.
*** The maxillary buccal and the mandibular lingual would be supporting and the maxillary
lingual and the mandibular buccal would be guiding.

In an ideal intercuspal position, the mesiolingual cusp of a permanent
mandibular molar opposes:
the opposing central fossae
the lingual embrasure between their class counterpart and the tooth d istal to it
SAADDES
the opposing distal marginal ridge
the lingual embrasure between their class counterpart and the tooth mesial to it
91

the lingual embrasure between their class
counterpart and the tooth distal to it
Examples:
1. The mesiolingual cusp of t he mandibular first molar opposes t he lingual
embrasu re between the maxillary first molar and second premolar.
2. The mesiolingual cusp of t he mandibular second molar opposes the lingual
embrasure between the maxillary second molar and first molar.
Note: The distolingual cusp of the mandibular first molar fits into (opposes) the
lingual groove of the maxillary first molar.
SAADDES
Remember: The lingual cusp of permanent mandibular first premolars does not
occlude with anything.
Important: Duri ng mandibular movements (working, non-working, etc.), the outer

aspects of the lingual cusps of the mandibular molars will not contact their maxillary
antagonists. Al l other areas of buccal and lingual cusps may contact during mandib-
ular movements (this is assuming that all occlusal relationships are normal).
Note: In unilateral balanced occlusion, contact between mandibular buccal cusps

and maxillary buccal cusps, along w ith simultaneous contact between mandibular
lingual cusps and maxillary lingual cusps, w ill most likely occur in laterotrusive
movements.

Which of the following positions would yield the smallest measurement of
vertical dimension?
reverse overlap
edge-to-edge
SAADDES
retruded contact
maximum intercuspation
92

maximum intercuspation
Maximum intercuspation or centric occlusion is the position in which the teeth are
most fully contacted w ith each other. As such, the jaws are most fully closed and there-
fore the vertical dimension is the least.
SAADDES Teeth in intercuspal position/centric occlusion

A patient presents to the dentist for examination and bites into centric
occlusion. The permanent maxillary canine is found to be mesial to the
mandibular canine. This type of occlusion is classified as:
cl ass I
SAADDES
cl ass II
cl ass Ill
cl ass IV
93

cla ss II
In normal occlusion, the mandibular canine would be slightly mesial to the maxillary
can ine. In th is question, the maxillary tooth is mesial to the mandibular, and the max-
illa is therefore protruding and/or the mandible is retruding. This is an Angle Class II re-
lationship and results in a "buck tooth" appearance.
SAADDES
Normal occlusion Class I malocclusion
Class II malocclu sion Class Ill malocclusion

occlusion terms
There are four theoretical determinants needed to restore a complete and
functional occlusal surface. They include all of the following EXCEPT one.
Which one is the EXCEPTION?
the amount of vertica l overlap of the anterior teeth
SAADDES
the contour of the articu lar eminence
the relative strength of the muscles of mastication
the amount and d irection of lateral shift in the working side condyle
the position of the tooth in the arch
94

the relative strength of the muscles of mastication
The four theoretical determinants needed to restore a complete and functional

occlusal surface of a tooth are:
1. The amount of vertica l overlap of the anterior teeth.
2. The contou r of the articular eminence.
3. The amount and direction of lateral shift in the working side condyle.
4. The position of the tooth in the arch.
SAADDES

occlusion terms
The basic principles for occlusal adjustment include all of the following
EXCEPT one. Which one is the EXCEPTION?
the maximum d istribution of occlusal stresses in centric relation
the forces of occlusion should be borne as much as possible by the long axis of the
teeth
SAADDES
when there is surface-to-surface contact of flat cusps, it should be changed to a
point-to-surface contact
once centric occlusion is established, never take the teeth out of centric occlusion
when a slide from CR to ICP is natural, it should never be modified
95

when a slide from CR to ICP is natural, it should never be modified
Occlusal adjustment (equilibration) is the reshaping of the occlusal surfaces of teeth to create har-
monious contact relationships between the maxillary and mandibular teeth. Occlu sal adjustment
enhances the healing potential of tissues affected by the lesions of occlusal trauma. lt may involve:
Disking
Odontoplasty
Enameloplasty
Coronoplasty
The basic principles for occlu sal adjustment include:

The maximum distribution of occlusal stresses in centric relation
The forces of occlusion should be borne as much as possible by the long axis of the teeth
SAADDES
When there is surface-to-surface contact of flat cusps, it should be changed to a point-to-
surface contact
Once centric occlusion is established, never take the teeth out of centric occlusion
Equilibration Procedures in a Nutshell:

1. Find and verify centric relation or adapted centric posture (ACP). Rule out intracapsular disorders.
2. Mount casts with a facebow and a centric relation or adapted centric bite record.
3. Analyze casts to make sure that equilibration is the best choice of treatment.
4. Eliminate al l deflective inclines that interfere with complete closure in centric relation or ACP.
5. Verify simultaneouscontact on both posterior teeth and anterior teeth if arch alignment permits.
6. Verify that maximum intercuspation occurs in perfect harmony wi th centric relation or ACP.
7. Eliminate all excursive contact on posterior teeth. The only posterior tooth contact is in centric
relation or ACP.
8. Refine anterior guidance for all excursions (may need to do more reduction of excursive inclines
on posteriors as anterior guidance is altered).
9. Recheck posterior teeth while firmly clenching and grinding. There should be no contacts on in-
clines.
10. Verify dots in black....lines in front

occlusion terms
The determinant factors of occlusion include all of the following EXCEPT
one. Which one is the EXCEPTION?
the temporomandibular joint
the masticato ry muscles
SAADDES
the tongue and buccal mucosa position
the biomechanics of the tempo romandibular joint
the dentition and the occlusal table
96

the tongue and buccal mucosa position
Determinants of occlusion:
1. The right and left temporomandibular joints and their suspensory ligaments as well as the
right and left condyles of the mandible.
*"'*These are the posterior determinants of occlusion and are fixed .
2. The teeth- consist of the inter-occlusal contacting points and inclines of cuspsof the opposing
arches; they are variable.
**'*This is the anterior determinant of occlusion and is variable.
3. The neuromuscular system is programmed by the second determinant (the teeth and what
nature and man do to them).
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Five requirements for occlusal stability:
1. Stable stopson all teeth when the condyles are in centric occlusion.
2. Anterior guidance in harmony with the border movement of the envelope of function.
3. Disclusion of all posterior teeth in protrusive movements.
4. Disclu sion of all posterior teeth on the nonworking (ba lancing) side.
5. Noninterference of all posterior teeth on the working side, with either the lateral anterior guid-
ance, or the border movements of the condyle. The working-side posterior teeth may contact in
lateral group function if they are in precise harmony with anterior guidance and condylar guidance,
or they may be discluded from working-side contacts by the lateral anterior guidance.
Five requirements for equilibrium of the masticatory system:

1. Stable, comfortable TMJs (even when loaded).
2. Anterior guidance in harmony with functiona l movements of the mandible.
3. Noninterference of posterior teeth:
Equal intensity contacts in centric relation
Posterior disclusion when the condyle leaves centric relation
4. All teeth in vertical harmony with the repetitive contracted length of the closing muscles.
5. All teeth in horizontal harmony with the neutral zone.

occlusion terms
The centric relation (CR) is the most unstrained, retruded anatomic and
functional position of the heads of the condyles or the mandible in the
_ _of the temporomandibular joints. This is a relationship of the _ _ of
the upper and lower jaws _ _tooth contact. The presence or absence of
teeth, or the type of occlusion or malocclusion, _ _ factors.
SAADDES
mandibular fossae/ bones/independent of/ are not
mandibular fo ramen/teeth/dependent on/are
mandibular fossae/bones/dependent on/are
mandibular fossae/teeth/dependent on/are
mandibular fo ramen/bones/independent of/ are not
97

mandibular fossae/bones/independent of/are not
The centric relation (CR) (also called the retruded contact position) is the most
unstrained, retruded anatomic and functional position of the heads of the condyles
or the mandible in the mandibular (glenoid) fossae of the temporomandibular joints.
This is a relationship of the bones of the upper and lower jaws independent of tooth
contact. The presence or absence of teeth, or the type of occl usion or malocclusion,
are not factors. Important: Centric occlusion is typica lly slightly anterior to centric
relation.
Note: The mandible cannot be forced into centric relation from t he rest position
because the patient's neuromuscular defense reflex wou ld resist the applied force.
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The mandible should be relaxed and gently guided into centric relation.
Centric occlusion (also ca lled the intercuspal position) is the relationship between
maxillary and mandibular occlusal surfaces t hat provides t he maximum
intercuspation between the teeth. This position is independent of condyla r position,
it is a "tooth-guided" position.
Functional occlusion:
Functional occlusion consists of all contacts duri ng chewing, swallowing, or nor-
mal actions
Functional contacts: normal contacts made during chewing and swallowing
Parafunctional contacts: t hose made outside the normal range, may create wea r
facets or attri tion and result from habits (i.e., bruxism, clenching, nail biting, t humb
sucking, cheek biting, etc.)

occlusion terms
Anterior guidance (anterior coupling) is the guidance provided by the anterior
teeth when the mandible goes into a lateral or protrusive movement.
If anterior guidance can be accomplished, the least amount of force will be

placed on the posterior teeth during lateral and protrusive movements.
SAADDES
both statements are t rue
both statements are false
the first statement is true, the second is false
98

Anterior guidance (anterior cou pling) is the g ui dance provid ed by the anterior teeth when
the m andible goes into a lateral or protrusive movement. It is determined by the vertical
overlap of the anterior teeth, termed overbite, and the horizontal overlap of the teeth,
which is overjet.
Anterior teeth have a mechanical advantage over posterior teeth because they are farther
away from the fulcrum (condyles), g iving them better leverage to offset the closing
musculature. Th is is apparent when one tries to occlude maximally w ith anterior teeth
as opposed to occluding maximally in the molar region. The further away from the site
of muscle action, the less force is exerted.
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Important point of all this: If anterior guidance is accomplished, the least amo unt of
force w ill be placed on the posterior teeth during latera l or protrusive m ovem ents.
Fulcrum:The pressure point of support on

which a lever rotates. Because all upward
force is applied behind the teeth, between
the fulcrum and the teeth, the fulcrum is al-
ways under pressure (compression) when
the elevator muscles contract. Th is is a very
important fact to understand, as it affects
both the TMJs and the teeth.
Force: Exertion of power that starts or stops

movement. Can result in compression
(load ing) .... or tension.

occlusion terms
A patient's mother comes in to complain that her child's upper front teeth rest
in front of his lower lip. You explain to her that this is called _ __
overjet
overbite
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underjet
open bite
99

overjet
Overbite: t he vertical d istance by w hich maxillary incisors overlap the mandibular

incisors
*** Normal = incisal edges are w ithin the incisal third of mandibular incisors
Overjet: the horizontal distance between the labia-incisal surfaces of the mandib-
ular incisors and the lingua-incisal surfaces of the maxillary incisors
Underjet: maxillary teeth are lingual to mandibular teeth
Open bite: lack of occlusal o r incisal contact between maxillary and mandibular
teeth. The teeth can not be brought together. Also can be cal led negative overbite.
SAADDES Horizontal
overlap
Vertical
overlap
Overjet Overbite

occlusion terms
Generally, the deeper the curve of Spee, the more difficult it is to make and
adjust interocclusal appliances that are used in the treatment of bruxism.
Increasing the curve of Spee can reduce the vertical overlap of the teeth.
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100

the first statement is true, the second is fal se
*** Reducin g the curve of Spee can reduce the vertical overl ap of the teeth.
There are t wo curves of the occlusal plane observed from a buccal and a proximal
view:
1.Curve of Spee - refers to the anteroposterior curvatu re ofthe occlusal surfaces,
beginning at the tip of the lower canine, following the buccal cusp tips of the pre-
molars and molars and continu ing to the anterior border of the ramus. An ideal
curve of Spee would be aligned so that a continuation of its arc would extend
through the condyles.
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2.Curve of Wilson- refers to the mediolateral curve that contacts the buccal and
lingual cusp tips on each side of the arch. It results from inward inclination of the
lower posteri or teeth, making the lingual cusps lower than the buccal cusps on the
mandibular arch; the buccal cups are higher than the lingual cusps on the maxil-
lary arch because of the outward inclination of the upper posterior teeth. For
mandibular teeth the curve is also concave and for maxillary teeth it is convex.
Remember: Combined, the Curve ofSpee and Curve of Wilson form a plane termed the
"Sphere of Monson or the Monson Curve:
Note: From a frontal view, the plane of occlusion of the mandibular arch in a normal
dentition is a concave curve, wh ile the maxillary arch is a convex curve.

occlusion terms
The mandible functions as a:
class I lever
class II lever
class Ill lever
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101

class Ill lever
***The cranium is fixed and t he mandible is movable.
In t his system (Class Ill):

Fulcrum = condyle
Force = muscles
Workload = teeth
In a Class Ill lever system the fulcrum is at one end, t he workload at the other end
and the force (effort) lies between the workload and the fulcrum.
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Fulcrum: The pressure po int of support on
which a lever rotates. Because all upward force
is applied behind the teeth, between the fu l-
crum and the teeth, the fulcrum is always
under pressu re (compression) when the ele-
vator muscles contract. This is a very important
fact to understa nd, as it affects both the TMJs
and the teeth.
Force: Exertion of power that sta rts or stops

movement. Can result in compression (load-
ing) .... or tension.
Force

periodontal ligament/gingiva
Which of the following types of oral mucosa are keratinized under normal
conditions?
verm illion border of the lips
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hard palate
gingiva
buccal mucosa
dorsal surface of the tongue
102

vermillion border of the lips
hard palate
gingiva
dorsal surface of the tongue
The three functional t ypes of oral mucosa are masticatory, lini ng, and specialized mucosa. These terms
p rovide functional descriptions of the oral mucosa in specific locations.
Masticatory mucosa: covers the g ingiva and hard palate.
- Epithelium: it has a keratinized or para kerati nized stratified squamous epitheli um.
- Lamina propria: has t w o layers: a thick papi llary layer of loose connective tissue and a deep retic-
ular layer of dense connective tissue.
Lining mucosa: covers all of soft tissue of the o ral cavity except the g ingiva, hard palate, and dor-
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sal surface of t he tongue.
- Epithelium: generally, t he epithelium of the li ning mucosa is nonkeratinized. On the vermillion
border of the lip, however, it is keratinized. If subject to unusual frictional stress, the epithelium may
become parakeratinized or keratinized . Other cells found in the epitheli um of the li ning mucosa are
Langerhans cells, melanocytes, and Merkel cells.
- Lamina propria: under the epitheli um of the li ning mucosa, a loose conn&tive tissue with thin col-
lagen fibers forms a papillary lamina propria that carries blood vessels, lymphatic vessels, and nerves.
- Submucosa: a d istinct submucosa underl ies the lining mucosa, except on the inferior of the
tongue. The submucosa contains large bands of collagen and elastic fibers t hat bind t he mucosa to
t he underlying muscle. The submucosa also contains the larger nerves, blood vessels, and lymphatic
vessels t hat supply the neurovascular networks of the lamina propria throughout the oral cavity. In
t he lips, tongue, and cheeks, the submucosa contains many minor salivary glands.
Specialized mucosa: is restricted to the dorsal surface of the tongue, and is characterized by the
p resence of surface papillae of several types and by taste buds in the epithelium. The epitheli um is ker-
ati nized.
Important: All oral mucosa, whet her kerati nized, non kerati nized or parakeratinized, is of the stratified
squamous type of epithelium and the underlying central co re of connective tissue. Although the ep-
ithelium is predominantly cellular in nat ure, the connective tissue is less cell ular and composed primar-
ily of collagen fibers and ground substance.

The principal fibers of the periodontal ligament are arranged in four groups.
The molecular configuration of collagen fibers in the periodontal ligament

provides them with a tensile strength greater than that of steel.
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the fi rst statement is true, the second is false
103

The most important element s of the periodontal ligament are the principal fibers, which are collagenous
and arranged in bund les and follow a wavy course when v iewed in longitudi nal section. The terminal por-
tions of the principal fibers that are insert ed into cementum and bone only are t ermed Sharpey's fibers.
The principal fibers of the periodontal ligament are arranged in f ive groups that develop sequentially in
the developi ng root:
The alveolar crest group of the alveolodent al ligament: originates in the alveolar crest of the alveolar
bone proper and fans out to insert int o the cervical cementum at various angles. The function of this
g roup is t o resist tilting, intrusive, extrusive, and rotational forces.
The apical (periapical) group of the alveolodentall igament: radiates from the apical region of the
cementum to insert into the surroundi ng al veolar bone proper. The function of t his group is to resist
extrusive forces, which try t o pull the t ooth outward (in an occlusal d irection), and rot ational forces.
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The oblique group of the alveolodentall igament: the most numerous of the fiber groups and covers
the apical t wo-thirds of the root . This group originates in the alveolar bone proper and extend s apically
to insert more apically into the cementum in an oblique manner. The function of this g roup is to resist
intrusive forces, which try t o push the tooth inward, as well as rot ational forces.
The horizontal group of the alveolodentalligament: originates in the alveolar bone proper apical to
its alveolar crest and inserts into the cementum horizontally. The function of this g roup is to resist til ting
fo rces, which work t o force the tip either mesially, distally, lingually, or f acially, and t o resist rot ational
forces.
The interradicular group of the alveolodent al ligament: found only between the root s of multiroot ed
teeth (furcation area). Run from the cementum int o bone, forming the crest of the interrad icular
septum. The function of this group is to work t ogether w ith the alveolar crest and apical g roups t o resist
intrusive, extrusive, til ti ng, and rotational forces.
Note: Another principal fiber group (called transseptal fibers) inserts mesially or interdent ally into the
cervical cementum of neighboring teeth over the alveolar crest of the alveolar bone pro per. Thus, the fibers
travel from cementum t o cementum w ithout any bony attachment. The function of this group is t o resist
rot ational forces and thus hold the t eeth in interproximal cont act.
Important: The molecular configuration of collagen fibers provides them w ith a t ensile strength g reater
than that of steel. Conseq uently, collagen imparts a unique combination of flexibility and strength to the
ti ssues.

The gingival fibers are arranged in five groups. Which of the following is
NOT one of those groups?
circular group
dentogingiva l group
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apical g roup
transsepta l group
dentoperiosteal group
alveologingival group
104

apical group
The connective tissue of the marginal gingiva is densely collagenous, containing a prominent sys-
tem of collagen fiber bundles called the gingival fibers. They consist of type I collagen.
The gingival fibersare arranged in five groups:
Circular group - this fiber subgroup of the gingival fiber group is located in the lamina propria
of the marginal gingiva. The ci rcular ligament encircles the tooth and helps maintain gingival
integrity. They resist rotational forces.
Dentogingival group- this fiber subgroup of the gingival fiber group inserts in the cementum
on the root, apical to the epithelial attach ment, and extends into the lamina propria of the mar-
ginal gingiva. Thus, this ligament has only one mineralized attachment to the cementum. The
dentogingivalligament works with the ci rcular lig ament to maintain gingival integrity.
Alveologingival group -this fiber subgroup of the gingival fiber group extend s from the alv-
SAADDES
eolar crest of the alveolar bone proper and radiates coronally into the overlying lamina propria of
the marginal gingiva. These fibers may possibly help to attach the gingiva to the alveolar bone
because of their one mineralized attachment to bone.
Dentoperiosteal group - this fiber subgroup of the gingival fiber group courses from the
cementum, near the cementoenamel j unction, across the alveolar crest These fibers possibly
anchor the tooth to the bone and protect the deeper period ontal ligament.
Transseptal group - this fiber subgroup of the gingival fiber group are located interproximal ly
and form horizontal bundles that extend between the cementum of approxi mating teeth into
which they are embedded.They lie in the area between the epithelium at the base of the gingival
sulcu sand the crest ofthe interdental bone and are sometimes classified with the pri ncipal fibers
of the periodontal ligament.
1. The attachment apparatus is a term used to describe these gingival fibersand the ep-
ithelial attachment.
2. Some studies have also descri bed two more gingival fiber groups: (1) a group of semi-
circular fibersand (2) a group of transgingival fibers.
3. Tractional forces in the extracellular matrix produced by fibroblastsare believed to be
the forces responsible for generating tension in the collagen. This keeps the teeth tightly
bound to each other and to the alveolar bone.

The junctional epithelium consists of a collar-like band of stratified squamous
keratinized epithelium.
The reduced enamel epithelium is not essential for its formation.
SAADDES
105

The junctional epithelium consists of a collar-like band of stratified squamous non keratinized
epithelium. It is three to four layers th ick in early life, but the number of layers increases with age
to 10 or even 20 layers. Also, the j unctional epithelium tapers from its coronal end, which may
be 10 to 29 cells wide to one or two cells at its apical termination, located at the CEJ in healthy
t issue. These cells can be grouped in two strata; the basal layer facing t he connective tissue and
the suprabasallayer extending to the tooth surface. Note: The length of the junctional epithe-
lium ranges from 0.25 to 1.35 mm (average is 0.97 mm}.
The junctional epithelium is formed by the confluence of the oral epithelium and the reduced
enamel epithelium duri ng tooth eruption. However, the reduced enamel epithelium is notes-
sential for its formation; in fact, the junctional epithelium is completely restored after pocket in-
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strumentation or surgery, and it forms around an implant.
The j unctional epithelium is attached to the tooth surface (epithelial attachment} by means of
an internal basa l lamina. It is attached to the gingival connective tissue by an external basal
lamina. The internal basal lamina consists of a lamina densa (adjacent to the enamel} and a
lamina Iucida to which hemidesmosomes are attached. Hemidesmosomes have a decisive
role in the firm attachment of the cells to the interna l basal lamina on the tooth surface.
In order for a new attachment to form after periodontal treatment the following must occur:
1. Complete removal of calculus, altered cementum, d iseased j unctio nal epi thelium, and
pocket epithelium
2. Need for undifferentiated mesenchymal cells
Important: The junctional epithelium in disease (which is referred to as a long j unctional ep-
ithelium} is different from the junctional epithelium in health. In disease, migration of t he junc-
t ional epithelium occurs, along wit h degeneration in the connective t issue under the attach-
ment; as t he j unctional epithelium proliferates along t he root surface (gets longer} the coronal
portion detaches. Barrier membranes, which are often used to treat bony defects, help to pre-
vent t his long junctional epith elium from forming.

Bone consists of:
two-thirds organic matter and one-third inorganic matrix
one-third o rganic matter and two-thirds inorganic matrix
one-half organic matter and one-half inorganic matrix
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two-thirds inorganic matter and one-third organic matrix
106

two-thirds inorganic matter and one-third organic matrix
The alveolar process is the portion of the maxilla and mandible that forms and supports the tooth
sockets (alveoli).lt forms when the tooth erupt s to provid e the osseousattachment to the forming
PDL; it disappears gradually after the tooth is lost. The alveolar process consists of the following:
An external plate of cortical bone formed by haversian bone and compacted bone lamellae.
The inner socket wall of thin, compact bone called t he alveolar bone proper, which is seen as
the lamina dura in radiographs. Histol ogically, it contains a series of openings (cribriform plate)
through which neurovascular bundles link the PDL with the central component of the alveolar
bone, the cancell ous bone.
Cancellous trabeculae, between these two compact layers, which act as supporting alveolar
bone. The interdental septum consists of cancellous supporti ng bone enclosed within a com-
pact border.
SAADDES
In addition, the bones of the jaw include the basal bone, which is the port ion of the jaw located api-
cally, but unrelated to the teeth.
Most of the facial and lingual portions of the sockets are formed by compact bone alone; cancellous
bone surround s the lamina dura in apical, apicolingual, and interradicular areas.
Osteoblasts, the cells that produce the organic matrix of bone, are differentiated from pluripotent
follicle cells. Alveolar bone is formed during fetal growt h by intramembranousossification and con-
sists of a calcifi ed mat rix with osteocytes enclosed within spaces call ed lacunae.
Bone consistsof two-thirds inorganic matter and one-third organic matrix. The inorganic matrix
is composed principally of the minerals calcium and phosphate, along with hydroxyl, carbonate, cit-
rate, and trace amounts of other ions, such as sodium, magnesium, and fl uoride. The mineral salts
are in the form of hydroxyapatite crystalsand constitute approximately two thirdsof the bone struc-
ture.
The organic mat rix consists mainly of collagen type I (90%), with small amounts of noncollagenous
proteins such as osteocalcin, osteonectin, bone morphogenetic protein, phosphoproteins, and pro-
teoglycans.

Although the average width of the periodontal ligament space is docu-
mented to be about , considerable variation exists.
0.002mm
0.2mm
SAADDES
2.0mm
20mm
107

0.2mm
***The periodontal space is diminished aroun d teeth t hat are not in function and in
unerupted teeth, bu t it is increased in teeth subjected to hyperfunction.
The periodontal ligament is composed of a complex vascular and highly cellular connective tis-
sue that surrounds the tooth root and connects it to the inner wall of the alveolar bone. It is
continuous with the connective tissue of the gingiva and communicates with the marrow spaces
th rough vascular channels in t he bone.
The periodontal ligament is abundantly supplied with sensory nerve fibers capable of trans-
mitting tactile, pressure, and pain sensations by the trigeminal pathways. Nerve bund les pass
into the periodontal ligament from the periapical area and through channels from the alveolar
bone that follow the course of the blood vessels. The bundles divide into single myelinated
SAADDES
fibers, which ultimately lose their myelin sheaths and end in one of fou r types of neural term i-
nation:
1. Free endings, which have a t ree-like configuration and carry pain sensation.
2. Ruffini-like mechanoreceptors, located primarily in the apical area.
3. Coiled Meissner's corpuscles, also mechanoreceptors, found mainly in t he mid root
region.
4. Spindle-like pressure and vibration endings, which are surrounded by a fibrous
capsule and located mainly in the apex.
Note: Orthodont ic treatment is possible because the PDL cont inuously responds and changes
as a result of the functional req uirements imposed upon it by externally applied forces.
PDL and its hard tissue anchorage in terms of resisting occlusal force:
1. Anterior teeth have slight or no contact in the intercuspal position.
2. The occlusal table is less t han 60% of the overall faciolingual wid th of the tooth.
3. The occlusal table of the tooth is generally at right angles to the long axis of the tooth.
4. Crowns of mandibular molars are inclined about 15-200 toward the lingual. For t his reas-
on, the root apices of mandibular molars are positioned more facially and the crowns are
position ed more lingually.

_ _ _ are the most common cells in the periodontal ligament and appear
as ovoid or elongated cells oriented along the principal fibers, exhibiting
pseudopodia-like processes.
cementoblasts
SAADDES
osteoblasts
fibroblasts
macrophages
108

fibroblasts
Types of cell s identified in t he periodontal ligament:
Connective tissue cell s: fibroblasts, cementoblasts, and osteoblasts. Fibroblasts are the
most common cells, they synthesize collagen and possess the capacity to phagocytose "old"
collagen fibers. Note: Cementoclasts and osteoclasts are also seen in the cementa I and os-
seous surfaces of the POL.
Epithelial rest cells: the epithelial rests of Malassez form a latticework in the periodontal lig-
ament and are considered rem nants of Hertwig's root sheath, which disintegrates d uring root
development. They are distributed close to the cementum throughout the POL of most teeth
and are most numerous in t he apical and cervical areas.
Defense cells: include neutrophils, lymphocytes, macrophages, mast cells, and eosinophils.
These cell s, as well as those associated with neurovascular elements, are similar to the cells
SAADDES
in other connective tissues.
The functions of the periodontal ligament are categorized into:
Physical: attachment of t he tooth to the bone via principal fibers and t he absorption of
occlusal forces.
Formative: formation of connective t issue components by activities of connective tissue
cells (cementoblasts, fibroblasts and osteoblasts).
Remodeling: by activities of connective t issue cells that are able to form as well as resorb
cementum (cementoblasts or cementoclasts), the periodontal ligament (fibroblasts or
fibroclasts), and the alveolar bone (osteoblasts or osteoclasts).
Nutritive: through blood vessels that maintain the vitality of its various cells.
Sensory: carried by the trigeminal nerve, proprioceptive and tactile sensit ivity is imparted
t hrough POL (sensation of contact between teeth).
Note: The periodontal ligament also contains a large proportion of ground substance, filling
the spaces between the fibers and cells. It consists of two main components: glycosaminogly-
cans (such as hyaluronic acid and proteoglycans), and glycoproteins (such as fibronectin and
laminin). The POL may also contain calcified masses called cementicles, which are adherent to
or detached from t he root surfaces. These develop from calcified epithelial rests.

Of the choices listed below, which one describes the boundaries that define
the attached gingiva?
from the gingiva l margin to the interdental groove
from the free gingiva l groove to the gingiva l margin
SAADDES
from the mucogingival junction to the free gingiva l groove
from the epithelial attachment to the cementoenamel junction
109

from the mucogingival junction to the free gingival groove
In an adult, normal gingiva covers the alveolar bone and tooth root to a level j ust coronal to the CEJ.
The gingiva is divided anatomically into marg inal, attached, and interdental areas.
Marginal or unattached gingiva: is the terminal edge or border of the gingiva surrounding the
teeth in colla r-like fash ion. In about SO% of cases, it is demarcated from the adjacent attached gingiva
by a shallow linear depression, the free gingival groove. Usuall y about 1 mm wide, the marginal
gingiva forms the soft tissue wall of the gingival sulcus.
Attached gingiva: is continuous with the marginal gingiva. It is fi rm, resilient, and tightly bound to
the underlying periosteum of alveolar bone.The facial aspect of the attached gingiva extend sto the
relatively loose and movable alveolar mucosa and is demarcated by the mucogingival junction.
**'* The width of the attached gingiva is an important clinical pa rameter. It is the distance be-
t ween the mucogingival j unction and the projection on the external surface of the bottom of the
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gingival sulcus or the periodontal pocket. It should not be confused with the width of the kerat-
inized gingiva because the latter also includes the marginal gingiva .
**'*The width of the attached gingiva on the facial aspect differs in different areas of the mouth.
It is generally greatest in the incisor reg ion and narrower in the posterior segments.
*"'*Because t he mucogingival junction remains stationary throughout adult life, changes in the
width of the attached gingiva are caused by modifications in the position of its coronal portion.
The width of the attached gingiva increases with age and in supraerupted teeth.
Note: "Stippling" of the attached gingiva refers to the irregular surface texture of the attached gin-
giva, similar to the surface of an orange peel. Stippling occurs at the intersect ion of epithelial ridges
that causes the depression and the interspersing of connective tissue papillae bet ween these inter-
sections giving rise to the small bumps.
Interdental gingiva:occupies the gingival embrasure, which is the interproximal space beneath the
area of tooth contact. The interdental gingiva can be pyramidal or can have a "col" shape. The shape
of the gingiva in a given interdental space depends on the contact point between the two adjoining
teeth and the presence or absence of some degree of recession.
Remember: In the absence of periodontal disease, the configurations of the crest of the interdental
alveolar septa are determined by the relative positions of the adjacent CEJs. The width is deter-
mined by the tooth form present.

The attachment apparatus is composed of all of the following EXCEPT one.
Which one is the EXCEPTION?
peri odontal ligament
cementum
SAADDES
alveolar process of the maxillae and mandible
gingiva
110

gingiva
The t issues that surround and support the teeth are co llectively called the periodon-
tium. Their main functions are to support, protect, and provide nourishment to
the teeth. It has been divided into two parts:
l.Gingiva
2. Attachment apparatus - composed of the:
Periodontal ligament
Cementum
Alveolar process of the maxillae and mandible
The cementum is considered a part of t he periodontium because, with the bone, it
SAADDES
serves as the support for the fibers of t he periodontal ligament.
The gingival fluid (sulcular fluid) contains components of connective t issue, epithe-
lium, inflammatory cells, serum, and microbial flora inhabiting t he g ingival margin or
the sulcus (pocket). In the healthy sulcus the amount of gingiva l fl uid is very small.
Duri ng inflammation, however, the gingival flu id flow increases, and its composition
starts to resemble that of an inflammatory exudate.
The main route of the gingival fluid diffusion is th rough the basement membrane,
throug h t he relatively wide intracellular spaces of the junctional epithelium, and then
into the sulcus.
The gingival fluid is believed to:
Cleanse material from t he sulcus
Contain plasma proteins that may improve adhesion of the epithelium to the tooth
Possess antimicrobial properties
Exert antibody activity to defend t he gingiva

The principal fibers of the periodontal ligament are composed mainly of col-
lagen type I.
The amount of collagen in a tissue can be determined by its glycine content.
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111

Collagen is synthesized by fibroblasts, chondroblasts, osteoblasts, odontoblasts, and

other cells. The several types of collagen are all d istinguishable by their chemica l com-
position, d istribution, function, and morphology. The principal fibers of the peri -
odontal ligament are composed mainly of collagen type I, whereas reticu lar fibers are
composed of collagen type Ill. Collagen type IV is found in the basal lamina.
Collagen is a protein composed of different amino acids, the most important of which
are glycine, proline, hydroxylysine, and hydroxyproline. The amount of collagen in a
tissue can be determined by its hydroxyproline content. Collagen is responsible for
maintenance of the framework and tone of tissue.
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1. Less regu larly arranged co llagen fibers are found in the interstitial connec-
t ive tissue between the pri ncipal fiber groups; this t issue conta ins the blood
vessels, lymphatics, and nerves.
2. Although the periodontal ligament does not conta in mature elastin, two
immature forms are found; oxytalan and eluanin. The so-called oxytalan
fibers run parallel to the root surface in a vertical direction and bend to attach
to the cementum in the cervica l th ird of the root. They are thought to regu-
late vascu lar flow.
3. The principal fibers are remodeled by the peri odontal ligament cel ls to
adapt to physiologic needs and in response to different stimuli.

Because of the high turnover rate, the connective tissue of the gingiva has a
remarkably good healing and regenerative capacity.
The reparative capacity of the gingival connective tissues is better than that
of the periodontal ligament and the epithelial tissue.
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112

*** The reparative capacity of the gingival tissues is not as great as that of the POL and ep-
ithelial tissue.
The dominant cellular element in the gingival connective tissue is the fibroblast. Numerous
fibroblasts are found bet ween the fiber bundles. Fibroblast s are of mesenchymal origin and
play a major role in the development, maintenance, and repair of gingival connective tissue.
Mast cells are numerous in the connective tissue of the oral mucosa and the gingiva. Fixed
macrophages and histiocytes are present in the gingival connective t issue as component s
of the mononuclear phagocyte system and are derived from blood monocytes. Adipose cells
and eosinophils, although scarce, also are present in t he lamina propria.
In clinically normal gingiva, small foci of plasma cells and lymphocytes are found in the con-
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nective ti ssue near the base of t he sulcus. These inflammatory cell s usually are present in
small amounts in clinically normal gingiva.
Three sources of blood supply to the gingiva are as follows:
1. Supra periosteal arterioles: along t he facial and lingual surfaces of the alveolar bone,
from which capillaries extend along t he sulcular epithelium and between the rete pegs of
the external gingival surface.
2. Vessels of the POL: which extend into the gingiva and anastomose with capillaries in the
sulcus area.
3. Arterioles : which emerge from t he crest of the interdent al septa and extend parallel to
the crest of t he bone to anastomose w ith vessels of the POL.
The lymphatic drainage of t he gingiva brings in the lymphatics of the connective tissue
papillae. It progresses int o the collecting network external to t he periosteum of the alveolar
process, then to the regional lymph nodes, particularly the submaxillary group.
Within the gingival connective tissues, most nerve fibers are myelinated and are closely as-
sociated with the blood vessels. Gingival innervation is derived from fibers arising from nerves
in the POL and from the labial, buccal, and palatal nerves.

The narrowest band of attached gingiva is found:
on the lingual surfaces of maxillary incisors and the facia l surfaces of maxillary first
molars
on the facial surfaces of mandibular second premolars and the lingual surface of
canines
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on the facial surfaces of the mandibular canine and first premolar and the lingual
surfaces adjacent to the mandibular incisors and can ines
none of the above
113

on the facial surfaces of the mandibular canine and first premolar and
the lingual surfaces adjacent to the mandibular incisors and canines
* ** Narrow gingiva l zones may occur also at the mesiobuccal root of maxillary first
molars, associated w ith prominent roots and sometimes w ith bony dehiscences and
at the mandibular t hird molars.
The width of the attached gingiva is determ ined by subtracting t he sulcus or pocket
depth from the total w idth of t he g ingiva (gingiva l margin to mucogingiva lline). This
is done by stretching the lip or cheek to demarcate the mucogingivalline w hile the
pocket is being probed. The amount of attached gingiva is generally considered to be
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insufficient when stretching of the lip or cheek induces movement of the free gingival
margin.
The w idth of the attached gingiva on the facial aspect differs in different areas of the
mouth. It is generally greatest in the incisor region (3.5-4.5 mm in the maxilla, 3.3-3.9
mm in t he mandible), and narrower in the posteri or segments (1.9 mm in maxillary
fi rst premolars and 1.8 mm in mandibular first premolars).
Important: A "functionally adequate" zone of g ingiva is defined as one that is kera-

tinized, firm ly bound to tooth and underlying bone, about 2.0 mm o r more in width,
and resistant to probing and gaping when the lip or cheek is distended.
1. The "attached" gingiva is structured to w ithstand fri ctional stresses of mas-
B tication and brushing.

2. The alveolar mucosa appears to be well-adapted to permit movement but
is not able to withstand frictional stresses.

premolar teeth information
Which tooth is most likely to be unnecessarily endodontically treated by a
novice dentist who sees a radiolucency on the radiograph?
mandibular canine
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mandibular f irst molar
maxillary first p remolar
114

Note: When viewing an x-ray of th is area, the mental foramen is sometimes misdiagnosed
as a premolar abscess. Therefore, before performing root canal therapy, make sure all
diagnostic tests confirm your find ing.
Important: When performing endodontics on this tooth, care must be taken to avoid an
overfi ll that may impinge on the mental foramen.
Remember: This tooth can show three types of occlusal surfaces (pit and groove patt-
erns). The three types of occlusal surfaces (pit and groove patterns) are:
=
1. Y-type 5 lobes, 3 cusps (most common type)
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=
2. H-type 4lobes, 2 cus ps
=
3. U-type 4lobes, 2 cusps; central developmental groove w ill appear crescent
shaped.
~uccol ~
~~
/. ~
Meslollngual Oistolingual ~dol pit
cusp cusp
UShoped HShoped
ThreeCusp Two Cusp Groove Groove
Occlusal view of two types of permanent mandibular Occlusal view of twocusp type of permanent
right second premolars: threecusp type and twocusp mandibular right second premolar. showing the U and
type. Hshaped groove patterns.

Which tooth has a mesial marginal ridge that is distinctly shorter in length
and less prominent in height than the distal marginal ridge?
mandibular fi rst premolar
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115

The distal marginal ridge forms a prominent elevation on the distal portion of the crown and meas-
ures nearly twice the length of the mesial marginal ridge.
Both mesial and distal marginal ridges of this tooth have little or no contact in the ideal intercuspal
relationship. The contacts are ideally on the mesial or distal triangular fossae, which are found
slightly mesial or distal to the marginal ridges.
This tooth has a small, non-functioning lingual cusp. For this reason, the masticatory function most
closely resembles that of the mandibu lar can ine.
1. The mandibular first premolar shows evidence of crown completion at 5 to 6 years of
age.
2. The mandibular second premolar shows evid ence of crown completion at 6 to 7 yearsof
age.
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3. The maxillary premolars show crown completion at the same approximate time as the
mandibular premolars.
auccol
triangular rtdge
Mtsloltosso
Mesial
morginOI Iktg
lingual cusp lip
Melfol nguol
groove Ungual cusp Mandibular Right
First Premolar
Lingual view

On mandibular premolars, the lingual cusps are much smaller than the buc-
cal cusps.
On maxillary premolars, the buccal cusps are smaller than the lingual
cusps.
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the first statement is t rue, the second is false
the first statement is fa lse, t he second is true
116

Three characteristics of mandibular premolars that clearly distinguish them from their
maxillary counterparts:
1. From a proximal view, the mandibular premolar crowns tilt lingually.
2.0n mandibular premolars, the lingual cusps are much smaller than the buccal cusps.
On maxillary premolars, the lingual cus ps are small er; however, they are on ly slightly
smaller.
3.From an occlusal view, mandibular premolars are more square, wh ile maxill ary pre -
molars are more rectangular (in that they are wider buccolingually).
Important: The com mon characteristic that all mandibular first premolars have
when viewed f rom the occ lusal as pect is that the buccal lobe makes up the majority of
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the tooth.
Remember: A lobe is one of the prim ary sections of formation in the development of the
crown of a tooth. It is represented by a cusp on posterior teeth, and mamelons and
cing ula on anterior teeth.
Mandibular Right First Premolar Mandibular Right Second Premolar
M D M D
Mesial Distal Occlusal Occlusal Mesial Distal

The pulp cavity shown below is the:
maxillary right first premolar
maxillary left second premolar
mandibular right first premolar
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mandibular left second premolar
Cervical
cross-section
Mesiodistal Buc colingual

cross-section cross-section
117

maxillary right first pre molar
Remember: Maxill ary first premolars:

Often times both the root outli ne and pulp chamber are kidney-shaped
They are the only pre molar with two roots
Buccal root and canal a re the largest
Maxillary Right
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First Premolar
Mesial view
Mesial
developmen1ol
d8'pnus.lon
Meslol morglnol
groove
Meslol marginal
ridge
;?~:;~ 1. Premolars are most difficult to do root canal treatment on because they are
: . J~J easy to perforate (especially maxillary first premolars).
2. Maxill ary p remolar roots occasionally penetrate the antrum.
3. The key to determining right from left maxillary first premolars is that there is
a more pronounced developmental groove and developmental depression on
the mes ia l crown and root surface.

Which premolar is the only one that has a mesial buccal cusp ridge that is
longer than its distal buccal cusp ridge?
mandibular first p remolar
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maxillary first p remolar
118

Remember also: That this tooth has a pronounced cervical concavity on the mesial
surface of its crown, as does the distal surface of the maxillary first molar.
Maxillary Right First Premolar
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~ lmbrica ~on
Mesial
lines developmental
depression
Mesial marginal
groove
Distal cusp Mesial cusp Mesial marginal

51 ope slope ridge
Buccal features Mesial features

The largest of all the premolars are the _ _ _ and the smallest are the
maxillary first, mandibular first
maxillary first, mandibular second
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maxillary second, mandibular first
maxillary second, mandibular second
119

maxillary first, mandibular first
The maxillary first and second premolars are more alike than the mandibular p re-
molars and, unlike the mandibular premolars, the maxillary first premolar is larger t han
the second. The mandibular first premolar is usually the smallest of all premolars.
Remember: Both maxillary and mandibular premolars have their long axis most per-
pendicular to the horizontal plane when the teeth are in maximum intercuspation. In
other words, they are the most closely vertically aligned of all the teeth.
Max illary Right Maxillary Right Mandibular Right Mandibular Right

First Premolar Second Premolar First Premolar Second Premolar
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~ .._____.//
Important:
1. In a mediotrusive movement (nonworking, right or left), the lingual cusp of a
maxillary second premolar passes through the facial embrasure between the
mandibular second premolar and the first molar.
2. In a mediotrusive movement (working, right or left), the lingual cusp of a
maxillary second premolar passes through t he lingual embrasure between the
mandibular second premolar and the first molar.

A hockey player comes into your office with both of his maxillary right pre-
molars in hand. Which ofthe following characteristics would you NOT use to
distinguish the first from the second maxillary premolar?
number of roots
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symmetry (one is more symmetrical t han the other)
mesial to d istal cusp ridge ratio
presence of mesic-lingua l developmental groove
central groove size and supplemental groove number
120

presence of mesio-lingual developmental groove
***This is found on the mandibular fi rst premolar, not on either maxillary premolar.
The maxillary second premolar has the following characteristics compared to the max-
illary first premolar:
One root; the first premolar has two roots
Much more symmetrical and less angular (more ovoid ) than the first premolar
DBCR (disto-buccal-cusp-ri dge) is longer than MBCR; opposite of first premolar
Buccal and lingual cusps are almost equal in height; on the first premolar they are
not
Has no mesial developmental depression; first premolar does
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Has a less prominent buccal ridge; first premolar has a prominent buccal ri dge
Has a shorter central groove with more supplemental grooves; first premolar has
a long central groove with minimal supplemental grooves
Maxillary Right Second Premolar
Buccal Lingual Occlusal Mesial Distal

tooth components
The dental lamina is a horseshoe-shaped band of epithelial tissue that arises
from the and is surrounded by mesenchymal cells.
basement membrane
basal lamina
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ectomesenchyme
oral epithelium
Irefer to AS 308 B-1, 308 C-1for illustration] 121


Appearance Involved
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enchyme.
3088~
Saunders.

Appearance Involved

per tooth

successive layers.

308 C.l
Saunders.

oral epithelium
Important information to remember:
1. During the sixth to seventh weeks of embryonic development, the oral epithelium (ectoderm)
thickens along the future dental arches to form the dental lamina.
2. Around the eighth week of embryonic development. the mesenchymal neural crest (which
contains ectomesenchyme) induces the development of tooth buds at ten locations in the upper
and lower dental lamina.
3. Duri ng the bud stage, the dental lamina grows into the mesenchyme in the shape of a bud.
4. During the ninth to tenth weeks of embryonic development, the tooth bud di fferentiates
into a cap-shaped enamel organ extending from the dental lamina. A vestibular lamina devel-
ops to sepa rate the gum from the lip/ cheek. Duri ng the cap stage, an unequal growth of epithel-
ial cells grows down to form a concavity around the mesenchyme, forming the dental papilla.
Other mesenchymal cells encircle the enamel organ, form ing the dental sac.
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By the end of the cap stage (third stage of odontogenesis) the tooth germ is complete and con-
sists of:
1. The enamel organ, which is formed from oral epithelium. It is derived from the ectoderm.
It has four disti nct cell layers: (1) Outer enamel epithelium
(2) Inner enamel epithelium
(3) Stratum intermedium
(4) Stellate reticulum
*"*The enamel organ will give rise to enamel and will eventually form Hert wig's epithelial
root sheath .
2. The dental sac surrounds the developing tooth germ and will give rise to the cementum, the
POL, and the alveolar bone proper.
3. The dental papilla will give rise to the dentin and dental pulp.
Note: The outer layer of cells of the dental papilla differentiates into the odontoblasts (denti n-
forming cells).
*** Bot h the dental papilla and dental sac are formed from the mesenchymal neural crest (which
contains ectomesenchyme).

tooth components
Enamel matrix is an ectodermal product because ameloblasts are derived
from the inner enamel epithelium of the enamel organ, which was originally
derived from the ectodermal layer of the embryo.
Enamel matrix is first formed in the incisal/occlusal portion of the future

crown near the forming DEJ.
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122

Ena mel is the hardest calcified tissue in the human body and the richest in calci um. Enamel is
highly mineralized and is totally acellular. It consists of approximately 96% inorganic material
(primarily calcium and phosphorus as hydroxyapatite), 1% organic material. and 3% water. Enamel
is of ectodermal origin. The organic matrix consists mainly of protein, which is rich in proline.
The fundamental morphologic unit of enamel is the enamel rod or prism w hich is bound together
by an interprismatic substance (interred substance). Each is formed in increments by a single
enamel-forming cell, the ameloblast. Most enamel rods extend the width of the enamel from the
DEJ to the outer enamel surface. Consequently, each enamel rod is oriented somewhat
perpendicular to the DEJ and the outer enamel surface. The specific shape of the enamel rod is
dictated by the Tomes' process of the ameloblast. In most cases, each enamel rod is cylind rical in
the long itudinal section. In most areas of enamel, the enamel rod is about 4 micrometers in
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diamet er. Note: The oldest enamel in a fully erupted tooth is located at the DEJ und erlying a cusp
or cingulum.
Important: An important event for the production and organization of t he enamel is t he develop-
ment of a cytoplasmic extension on ameloblasts, Tomes' process, that j uts into and interd igitates
with the newly forming enamel. In sections of forming human teeth, Tomes' processes give the j unc-
tion between the enamel and the ameloblast a picket-fence or saw-toothed appea rance. Note:
Tomes' processes are distinctly different from Tomes' fibers (odontoblastic processes that occupy
dentinal tubules).
Other important facts about enamel:
It has no power of regeneration - the ameloblasts lose their functional ability when the crown
of the tooth has been completed
It has no power of metabolism
It has no means of combating bacterial invasion - the susceptibility of the mineral component
to dissolution in an acid environment is the basis for dental decay
It has no nerve supply
It is a good thermal insulator
The acid solubi lity of the surface enamel is reduced by fluoride (this is the basis for the topical
application of fluorides in dental caries prevention)

tooth components
Mature enamel is by weight:
74% minerali zed or inorganic materi al, 20% o rganic material, and 6% water
SAADDES
123

96% mineralized or inorganic material, 1% organic material, and 3% water
Enamel is a highly m ineralized structure conta ining approximately 96% inorganic

material. This inorganic component consists of mainly (90-95%) calcium hydroxyap-
atite with the chemica l formula of Ca 10(P0 4) 6(0H) 2. Other m inerals, such as ca rbon-
ate, magnesium, potassium, sodium, and fluo ride are also present in smaller amounts.
Note: Due to the high inorganic content, enamel appears optically clear on a histo-
logic section of the human tooth.
Enamel also consists of an organic matrix (1%) and water (3%). This organic matrix
and water content decreases as enamel matures. At the same time, the inorganic
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content increases. Note: The organic portion of enamel does not contain collagen,
whereas dentin and bone do. Instead, it has two unique classes of proteins cal led
amelogenins and enamelins. The role of these proteins is not understood fully at
this time, but it is believed that these proteins aid in the development of enamel as a
framework support and other mechanisms.
Enamel is extremely brittle but can endure crushing pressure of approximately

100,000 pounds per square inch. A layering of dentin and peri odontium, coupled
with the hardness of the enamel, produces a cushion ing effect on the tooth's d ifferent
structures, enabling it to endure the pressures of mastication.
Enamel is semitranslucent and turns various shades of yel low-white because of the
underlying dentin. The enamel on primary teeth has a more opaque crystalline form
and thus appears wh iter than on permanent teeth. Note: Enamel is a selectively
permeable membrane, allowing water and certain ions to pass via osmosis.

tooth components
Which of the following are partially calcified vertical defects in the enamel
resembling cracks or fractures that traverse the entire length of the crown
from the surface to the DEJ.
enamel tufts
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enamel spindles
enamel rods
enamel lamellae
124

enamel lamellae
Enamel formation begins at the future cusp and spreads down t he cusp slope. As the
ameloblast s ret reat in increment al steps, the ameloblasts create an artifact in the enamel
called the lines of Retzius. Where these lines terminate at t he toot h surface they create t iny
valleys on the tooth surface that t ravel circumferenti ally around the crown known as
perikymata or imbrication lines of Pickerill. One of t he lines of Retzius is accentuat ed and
is more obvious t han the others. It is t he neonatal line that marks the division bet ween
enamel formed before birth and t hat which is produced after birth (this neonatal line is
found in all deciduous teeth and in the larger cusps of the permanent first molars).
1. Enamel tufts are fan-shaped, hypocalcified structures of enamel rods that
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project from the dentinoenamel junction into the enamel proper. They are found
in the inner one-third of enamel and represent areas of less mineralization. Enamel
tufts are an anomaly of crystallization and seem to have no clinical import ance.
2. Enamel spindles represent short denti nal t ubules near t he DEJ. They result from
odontoblasts t hat crossed the basement membrane before it mineralized int o the
DEJ. These dentinal tubules become trapped during the apposition of enamel
matrix, and enamel becomes mineralized around them. They may serve as pain
receptors.
3. Enamel lamellae are partially calcified vertical defects in the enamel resembling
cracks or fractures t hat traverse the entire length of the crown from the surface to
the DEJ. They are narrower and longer than enamel tuft s. Enamel lamellae are an
anomaly of crystallization and seem to have no cl inical importance.
The term Hunter-Schreger bands refers t o the alt ernating light and dark lines seen in
dental enamel t hat begin at the DEJ and end before t hey reach the enamel surface. They
represent areas of enamel rods cut in cross-section dispersed between areas of rods cut
longit udinally.

tooth components
The mesenchymal cells in the dental papilla adjacent to the inner enamel
epithelium differentiate into:
ameloblasts
odontoblasts
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cementoblasts
fibroblasts
[refer to AS 95-1for illustration[ 125


Summary of Tooth Formation
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Dental papilla
Ectomes-
enchyme
from neural
crest
Dental follicle
95- 1

odontoblasts
*** Remember: During the bell stage, the mesenchymal cel ls in the dental papilla adjacent to the
inner enamel epithelium differentiate into odontoblasts, which produce predentin and deposit it
adjacent to the epithelium. Later, the predentin calcifies and becomes dentin. As the dentin thickens,
the odontoblasts regress toward the center of the dental papilla; however, their fingerlike cytoplas-
mic processes (odontoblastic processes or Tomes' fibers) - remain embedded in the dentin.
Inner enamel epithelium cells continue their differentiation into ameloblasts that produce organic
matrix again st the newly formed dentinal surface. Almost immediately, this organic matrix mineral-
izes and becomes the initial enamel layer of the crown. Thus although enamel protein secretion oc-
curs before mantle dentin is visible on the crown, these proteins do not assemble as a layer until
dentin is formed.The enamel-forming cells, the ameloblasts, move away from the dentin, leaving be-
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hind an ever-increasing thickness of enamel.
For these events to take place normally, differentiating odontoblasts must receive signals from dif-
ferentiating ameloblasts (inner enamel epithelium), and vice versa- an example of reciprocal in-
duction.
Usual events in the histogenesis of a tooth:
1. Elongation of the inner enamel epithelial cells of the enamel organ; this influences mesenchy-
mal cells on the periphery of the dental papilla to differentiate into odontoblasts (#2 below)
2. Differentiation of odontoblasts
3. Deposition of the first layer of dentin
4. Deposition of the first layer of enamel
Tooth development is dependent on a series of sequential cellular interactions bet ween epithelial
and mesenchymal components of the tooth germ. Once the ectomesenchyme influences the
oral epithelium to grow down into the ectomesenchyme and become a tooth germ, the above
events occur.
Remember: Histogenesis means the formation and development of the tissues of the body, in
this case the tooth.

tooth components
Which structure is the central core and fills the bulk of the enamel organ?
outer enamel epithelium
inner enamel epithelium
stratum intermedium
SAADDES
stellate reticu lum
126
Irefer to AS 308 Al for illustrationl copynght 0 20 132014 Dental Decks

SAADDES Stratum intermedium
Inner enamel epithelium
Central cells of the dental papilla
enamel epithelium
The bell stage of tooth development, which ex hibits d ifferentiation of the too th
germ to its fim hest extent. Note the enamel organ and the dental papilla have dif-
ferentiated into various layers in preparation for the apposition of enamel and
dentin. 308AI
Reproduced \1,-ilh p~nnission from Ba1h-Balogh M, Fehrenbac-h MJ; 11/u.ftraled Demal EmhtJ'illogy. Histology. am/ A11aiMI)~ ed 2. St. Louis. 2006.
Saunders.

stellate reticulum
Four layers ofthe enamel organ:

1. Outer enamel epithelium (OEE) - the outer cellular layer of the enamel organ
(very thin). This layer outlines the shape of the future developing enamel organ.
2.1nner enamel epithelium (lEE)- the innermost cellular layer of the enamel organ
(very thin). The cells in this layer w ill become ameloblasts and produce enamel.
3. Stratum intermedium - this area lies immediately lateral to the inner enamel
epithelium (thicker than both the OEE and lEE). This layer of cells seems to be
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essential to enamel formation (prepares nutrients for the ameloblasts of the lEE).
4. Stellate reticulum -this area is the central core and fills the bulk of the enamel
organ. This layer contains a lot of intercellular fluid (mucus-type fluid ri ch in
albumin) that is lost just before enamel deposition.
After enamel formation is completed, all ofthe above structures of the enamel organ
become one and form the reduced enamel epithelium. This is important in the for-
mation of the dentogingival junction, which is an area where the enamel and ep-
ithelium come together as the tooth erupts into the mouth. This forms the initial
junctional epithelium (epithelial attachment), which later migrates down the tooth to
assume its normal position.

tooth components
A patient comes into your dental clinic holding a bag of ice to the side of his
face and a sliver of ice tucked between his cheek and teeth. He says the cold
relieves the pain in his tooth. This is almost indicative of partial necrosis of
the structure which innervates the whole tooth. This structure is a connec-
tive tissue that develops from the:
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enamel organ
dental papilla
epithelial rests of Malassez
dental sac
127

dental papilla
The pulp is t he innermost tissue of t he tooth. The pulp as well as dentin are formed from the
central cells of the dental papilla.
Anatomy of the Pulp:

Coronal pulp - located in the pulp chamber and forms pulp horns
Radicular pulp - located in t he pulp canals (root portion of tooth)
Apical foramen - communicates wit h the POL
*** Accessory canals may also be associated with t he pulp. Remember: These form when
Hertwig's epithelial root sheath encounters a blood vessel during root formation. Root
structure then forms around the vessel, forming the accessory canal.
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Architecture of the Pulp:
The peripheral aspect of dental pulp, referred to as the odontogenic zone, different iates
into a layer of dentin-forming odontoblasts. Immediately subjacent to the odontoblast
layer is the cell-free zone (of Wei I). This region contains numerous bundles of reticular
(Korff's) fibers. These fibers pass from the central pulp region, across the cell free zone and
between the odontoblasts, their d istal ends incorporated into the matrix of the dent in layer.
Numerous capillaries and nerves are also found in this zone.
Ju st under the cell-free zone is the cell-rich zone containing numerous fibroblasts, t he
predominant cell type of pulp. Since odontoblasts themselves are incapable of cell division,
any dental procedure that relies on the formation of new dentin after destruction of odont-
oblasts, depend s on the differentiation of new odontoblasts from these multipotential cells
of the pu lp. Lymphocytes, plasma cells and eosinophils are other cell types also common in
dental pulp.
Medial to the cell-rich zone is the deep pulp cavity that contains the subodontoblastic
plexus of Raschkow.
*** If cold relieves the pain, then there is almost always partial necrosis of the dental pulp.

tooth components
Which ofthe following statements concerning dentin are true?
it is hard, elastic, 70% inorganic, 20% organic, and 10% water
the main cell type is the odontoblast, which is derived from ectomesenchyme
SAADDES
the inorganic component consists of mainly calcium hydroxyapatite
it is less m ineralized than cementum or bone but more mineralized than enamel
128

it is hard, ela stic, 70% inorganic, 20% organic, and 10% w ater
the main cell type is the odontoblast, w hich is derived from ectomesenchyme
the inorganic component con sists of mainly calcium hydroxyapatite
Dentin is the specialized connective tissue that m akes up the b ulk of the tooth, extending
for almost its entire length. Dentin is hard, elastic, 70% inorganic, 20% organic, and 10%
water. The inorganic component consists of m ainly calcium hydroxyapatite w ith the
chemical formula of Ca10(PO,V6 (0H) 2. This calciu m hydroxyapatite is simil ar to that fo und
in higher percentages in enamel and in lower percentages in bone and cem entum.
Sm all er amounts of other minerals, such as carbonate and fl uoride, are also present.
SAADDES
1. Unlike enamel, which is acellul ar, dentin has a cellu lar component that is
retained after its form ation by odontoblasts.
2. Dentin and p ulp t issue are both formed by the dent al papilla. Pulp t issue is a
loose, very vascu lar, and non-calcified connective t issue while dentin is ava scu-
lar and a calcified t issue.
3. The m ain cell type in dentin is the odontoblast, which is derived f rom ecto-
mesenchyme.
4. Dentin is much softer than enamel but harder than bone. Dentin is more
flexible (lower modulus of elasticity) than enamel. Dentin's compress ive
strength is m uch h igher than its tensile strength.
5. Dentin is more mineralized than cementum o r bone but less mineralized
than enamel. Morphologically and chemically, dentin has many characteristics in
comm on with bone.
6. The major organic component of dentin is type I coll agen fi bers (91% to 92%),
w ith type Ill fibers being present in m antle dentin, and type V and VI fibers being
found in t races throughout the dentin.

tooth components
A 3-year-old boy is being rushed by his mother to finish up his ice-cream. He
is unwilling to bite into it because it hurts his teeth. The reason the teeth of
children are more sensitive to thermal changes than those of an adult is that:
newly erupted teeth have more dentin than older teeth
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newly erupted teeth have larger dental pulps
newly erupted teeth have more differentiated mesenchymal cells
newly erupted teeth have less ground substance
129

newly erupted teeth have larger dental pulps
When a tooth is newly erupted, the dental pulp is large; it becomes progressively smaller as
root formation is completed. The entire pulp and apical foramen are relatively large in primary
teeth and also in young permanent teeth. For this reason, the teeth of children and young
people are more sensitive to thermal change and dental operative procedures than the teeth
of older people.
The dental pulp is a connective tissue, and thus has all of the components of such a tissue: in-
tercellular substance, tissue fluid, cells, lymphatics, vascular system, nerves, and fibers (mainly
collagen and some reticular fibers).
Cells found in the pulp:
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Fibroblasts: most numerous
Odontoblasts: only cell bodies are located in the pulp
Undifferentiated mesenchymal cell s
Lymphocytes, plasma cells and eosinophils
Several large nerves enter t he apical foramen of each molar and premolar with single ones en-
tering the anterior teeth. A young premolar may have as many as 700 myelinated and 2,000 un-
myelinated axons entering t he apex. These nerves have two pr imary modalities:
1. Autonomic Nerve Fibers. Only sympathetic autonomies fibers are found in t he pulp. These
fibers extend from the neurons whose cell bodies are found in t he superior cervical ganglion
at the base of the skull. They are unmyelinated fibers and travel with t he blood vessels. They
innervate the smooth muscle cells of the arterioles and therefore function in regulation of
blood flow in the capillary network.
2. Afferent (Sensory) Fibers. These arise from the maxillary and mandibular branches of t he
fifth cranial nerve (trigeminal). They are predominantly myelinated fibers and may termi-
nate in the central pulp. From this region some will send out small individual fibers that form
t he subodontoblastic plexus (of Raschkow) just under t he odontoblast layer.

tooth components
Gemination and fusion occur during which stage of tooth development?
initiation
bud stage
cap stage
bell stage
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appositional stage
maturation stage
130
Irefer to AS 308 B-1, 308 C-1for illustration] copyngh t 0 20 132014 Dental Decks

Appearance Involved
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enchyme.
3088~
Saunders.

Appearance Involved

per tooth

successive layers.

308 C.l
Saunders.

cap stage
Stages oftooth development (odontogenesis):

1. Initiation (sixth to seventh weeks) - Ectoderm lining stomodeum gives rise to oral
epithelium and then to dental lamina, adjacent to deeper ectomesenchyme, wh ich is
infl uenced by the neural crest cells. Induction is the main process involved. Congenital
absence of teeth (anodontia) and supernumerary teeth result from an interruption in
this phase.
2. Bud stage (eighth week) - Growth of dental lamina into bud that penetrates growing
ectomesenchyme. Proliferation is the main process involved.
3. Cap stage (n inth to tenth weeks)- Enamel organ forms into a cap, surrounding the
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mass of the dental papill a from the ectomesenchyme and surrounded by the mass of
the dental sac also from the ectomesenchyme, thus forming the tooth germ. Prolifer-
ation, differentiation, and morphogenesis are the main processes involved. Dens in
dente, gemination, fusion, and tubercle formation occur during this phase.
4. Bell stage (eleventh to twelfth weeks) - final shaping of tooth, cell s differentiate into
specific tissue forming cells (ameloblasts, odontoblasts, cementoblasts, and fi broblasts)
in the enamel organ. Hist odifferentiation and morphodifferentiation are the main
processes involved. Macrodontia/microdontia occur during this stage.
5. Apposition (varies per tooth) - cell s that were differentiated into specific t issue-form-
ing cells begin to deposit the specific dental tissues (enamel, dentin, cementu m, and
pulp). Enamel dysplasia, concrescence, and the formation of enamel pearls occur during
this stage.
6. Maturation (varies per tooth)- mineralization
7. Eruption (varies per tooth)
8. Attrition (varies per tooth)

tooth components
A 14-year-old boy comes into the dental office for a prophylaxis. A diet eval-
uation reveals that he consumes 3-4 cans of soda a day and eats a box of fruit
snacks every week. Radiographs show multiple incipient interproximal cari-
ous lesions and one cavitated carious lesion in his premolar. The cavitated les-
ion in the premolar is beginning to encroach on the pulpal tissue. Reparative
dentin is usually formed in response to injury. The primary function of which
tissue is responsible for forming this reparative dentin?
enamel
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hertwig's epithelia l root sheath
dental pulp
cementum
131

dental pulp
***The life span of the odontoblasts generally is believed to equal that of the viable
tooth because the odontoblasts are end cells, which means that, once differentiated,
they cannot undergo fu rther cell division. This fact poses an interesting problem. On
occasion, when the pulp tissue is exposed, repair can take place by the formation of
new dentin. This means that new odontoblasts must have differentiated and migrated
to the exposure site from pulp tissue, most likely from the cell-rich subodontoblast
zone.
Remember: The dental pulp is the soft-tissue component of the tooth. It is a connect-
ive tissue originating from the mesenchyme of the dental papilla and performs mult-
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iple functions th roughout life. In addition to being the formative organ of the den-
t in, it also has the following functions:
Nutritive - the pulp keeps the o rganic components of the surrounding mineral-
ized tissue supplied w ith moisture and nutrients
Sensory - extremes in temperature, pressure, or t rauma to the dentin or pulp
are perceived as pain
Protective - the formation of repa rative or tertiary dentin (by the odontoblasts)
Important clinical information:

Pulp capping is more successful in young teeth because:
The apical foramen of a young pulp is large
The young pulp contains more cells (odontoblastic)
The young pulp is very vascular
The young pulp has fewer fibrous elements
The young pulp has more tissue fluid
***The young pulp lacks a col lateral circu lation

tooth components
The dental tissue which most closely mimics bone is:
enamel
dentin
dental pulp
cementum
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132

cementum
Cementum is composed of a mineralized fibrous matrix and cells (cementocytes). The

fibrous matrix consists of both Sharpey's fibers and intrinsic nonperi osteal fibers.
Sharpey's fibers are t he terminal portions of t he principal fibers of the POL that are
each partially inserted into the outer part of the cementum at 90 degrees (or a right
angle) to t he cementa I surface, as wel l as the alveolar bone on their other end.
Remember: Cementum is the bone-like mineralized tissue covering t he anatomical

roots of teeth. The two basic types are acellular and cellular.
Other functions of cementum incl ude the following:
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Compensates for t he loss of tooth surface due to occl usal wea r by apical deposit-
ion of cementum throug hout life
Protects the root surface from resorption duri ng vertical eruption and tooth
movement
1. Histologically, cementum differs from enamel in the following ways:

Cementum has collagen fibers
Cementum has cellular components in the mature tissue
2. Cementoid is t he peripheral layer of developing cementum that is laid
down by cementobl asts undergoing cementogenesis. Cementoid is uncalci-
fied or immature.
3. When the cementoid reaches t he fu ll th ickness needed, t he cementoid
surrounding the cementocytes becomes ca lcified or matured and is then
considered cementum.
4. Cementocytes are cementoblasts entrapped by the cementum they pro-
duce.

tooth components
Which of the following statements concerning cementum are true?
it is formed by cementoblasts from the periodontal ligament
the organic portion is primarily composed of co llagen and protein
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cellular cementum occurs more frequently on the coronal two-thirds of the root
it is avascular
133

it is formed by cementoblasts from the periodontal ligament
the organic portion is primarily composed of collagen and protein
it is avascular
Cementum is the bone-like mineralized tissue covering the anatomical roots of teeth. The primary
function of cementum is to attach Sharpey's fibers. It has the following characterist ics:
Slightly softer and lighter in color (yellow) than dentin
Formed by cementoblasts from the POL, as opposed to dentin, which is formed from odonto-
blasts of the pulp. It develops from the dental follicle (aka dental sac)
Most closely resembles bone (more so than dentin), except there are no haversian systems or
blood vessels- it is avascular
Mature cementum is by composition 45-50% mineralized inorganic material (mainly calcium
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hydroxyapatite), and 50% organic material, namely collagen and noncollagenous matrix protein.
The organic portion is primarily composed of collagen and protein
Has no nerve innervation
Thickest at the tooth's apex and th innest at the CEJ at the cervix of the tooth
Important in orthodontics. Cementum is more resistant to resorption than alveolar bone,
permitting orthodontic movement of teeth without root resorption
Two types of cementum (functionally there is no difference):

1. Acellular (someti mes called primary cementum) - consists of the first layers of cementum
deposited at the DCJ; acellular cementum is formed at a slow rate and contains no embedded
cementocytes, usually predominate on the coronal two-thirds ofthe root. Thinnest at the CEJ.
2. Cellular (someti mes called secondary cementum) - consists of the last layers of cementum
deposited over the acellular cementum; cellular cementum is formed at a faster rate than acell-
ular cementum and contains embedded cementoblasts. Cellular cementum occurs more fre-
quently on the apical third of the root. Cellular cementum is usually the thickest to compensate
for occlusal/incisal wear and passive eruption of the tooth.
Note: The composition of bone is roughly 50% inorganic, 25% collagen, and 25% water.

tooth components
The junction between primary and secondary dentin is characterized by a
sharp change in the direction of dentinal tubules.
Tertiary dentin is the dentin formed in a tooth before the completion of the
apical foramen of the root.
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134

Reparative dentin or tertiary dentin is dentin formed very rapidly in localized regions
in response to a localized injury to exposed dentin. The injury could be caries, cavity
preparation, attrition, or recession. Odontoblasts in the area of the affected tubu les
might die because of the injury, but neighbori ng undifferentiated mesenchymal cells
of the pulp move and become odontoblasts. Tertiary dentin tries to seal off the
injured area, thus the term reparative dentin.
Primary dentin is the dentin formed in a tooth before the completion of the apical
foramen of the root. Pri mary dentin is characterized by a regula r pattern of tubules.
Secondary dentin is the dentin that is formed after completion of the apical
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foramen. Secondary dentin is formed at a slower rate than pri mary dentin and is less
mineralized. Secondary dentin is a regula r and somewhat uniform layer of dentin
around the pulp cavity. Secondary dentin is made by t he odontoblastic layer t hat
lines the dentin-pulp interface.
Note: The junction between pri mary and secondary dentin is characterized by a
sharp change in t he direction of dentinal tubules.
When dentin is damaged, usually by the chronic injury of ca ri es, odontoblastic
processes die or retract, leaving empty dentinal tubules. Areas w ith empty dentinal
tubu les are called dead tracts and appear as dark areas in ground sections of tooth.
With time, these dead t racts can become completely filled with mineral. This region is
called blind tracts and appears white in sections of g round tooth. A certa in type of
tertiary dentin called sclerotic dentin fills the blind tracts. The adaptive advantage of
blind tracts is the sealing off of the dentinal tubu les to prevent bacteria from entering
the pulp cavity. Clinically, this scl erotic dentin appears dark, smooth, and shiny.

tooth components
Which of the following is formed inside the walls of the dentinal tubules?
tertiary dentin
mantle dentin
peritubular dentin
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intertubular dentin
135

peritubular dentin
Dentin is not a uniform tissue in the tooth but differs from region to region. Dentin that creates
t he wall of the dentinal t ubules is called peritubula r dentin. Peritubular dentin is highly min-
eralized after dentin maturation. The dentin that is found between the t ubules is called inter-
tubular dentin.lntertubular dentin is highly mineralized, but less so t han peritubular dentin.
Mantle d ent in is t he first predentin that forms and matures within the tooth. Mantle dentin
shows a difference in the direction of t he mineralized collagen fibers compared with the rest
of dentin, with the fibers perpendicular to the DEJ. Mantle dentin also has more peritubular
dentin than the inner portions of the dentin and thus has higher levels of mineralization.
SAADDES
I ' pes ot L>entm
Type Location/Chronology Description

Peri tubular Formed in J*.ripht.ra l parts o f the 11ighly mineral i.~:ed and it also c.onlains liule c.ollagen
(intralubular) m ineralized de nlin in..'> ide the walls o f
dentin tubules
Intertubular Formed by odontoblasts through Dense c ollagen matrix

predentin mineralization between th e
t u bu le~.::
Man11e O utc-nnost layer of prima ry dentin FirlU dentin formed. slightly le~.:;s mineralized than
other layers o f the primary dentin (i.e. cir<:umpulpal)
Circumpulpal Layer around outer pulpal wall Dentin fonued afler mantle de ntin
Primary Fonnt.d rapidly during tooth More mineraliz ed than secondary

formation. h outl ine~~: the pulp chamber
and constitute~.:: the main part oftht
dentin nta.liS
Se.c.ondary Formed afler completion of the apical Le~.::s mineralized than primary
foramen; fonns slower than prima ry
T crtiary Formed a.'> a result o f injury Irregular pauern of tubules

(reparative o r
reactionary den1jn)

tooth components
After the lEE differentiates into preameloblasts, the outer cells of the dental
papilla are induced by the preameloblasts to differentiate into:
fibroblasts
osteoblasts
SAADDES
odontoblasts
cementoblasts
136

odontoblasts
After the lEE differentiates into preameloblasts, the outer cells of the dental papilla are induced by the
preameloblasts to differentiate into odontoblasts.These cells also undergo repolarization, which re-
sults in their nuclei moving from the center to a position in the cell farthest from the basement mem-
brane. These repolarized cells are also lined up adjacent to the basement membrane but in a
mirror-i mage orientation compared with the preameloblasts. The odontoblasts now begin dentino-
genesis, which is the apposition of denti n matrix, or predentin, on their side of the basement mem-
brane. Thus the odontoblasts start their secretory activity some time before enamel matrix product-
ion begins. This explain s why the dentin layer in any location in a developing toot h is slightly thicker
than the corresponding layer of enamel matrix.
After the differentiation of odontoblasts from the outer cel ls of the dental papilla and their forma-
tion of predentin, the basement membrane between the preameloblasts and the odontoblasts dis-
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integrates. This disintegration of the basement membrane all ows the preameloblasts to come into
contact with the newly formed predenti n. This induces the preameloblasts to differentiate into
ameloblasts. Ameloblasts begin amelogenesis, or the apposit ion of enamel matrix, laying it down
on their sid e of the now disintegrating basement membrane. The enamel matrix is secreted from
Tomes' process, a tapered portion of each ameloblast that faces the disintegrating basement mem-
brane.
With the enamel matrix in contact with the predentin, mineralization of the disintegrating basement
membrane now occurs, forming the dentinoenamel junction (DE)), the inner junction between the
dentin and enamel tissues. Apposition of both types of dental matrix becomes regular and rhythmic,
as the cellular bod ies of both the odontoblasts and ameloblasts retreat away from the DEJ.
The odontoblasts, unlike the ameloblasts, will leave attached cellular extensionsin the length of the
predentin called the odontoblastic process (Tomes' fiber). Each odontoblastic process is contained
in a mineralized cylinder, the dentinal tubule.
~ 1. The DEJ is also the area at which caldfication of a tooth begins.
-~~ 2. The morphology of the DEJ 1s determmed at the bell stage.
-~ 3. The oldest enamel in a fully erupted molar is located at the OEJ underlying a cusp.
4. Research has shown that in order for ameloblasts to form enamel, cells from the
stratum intermedium must be present.

tooth components
The application of excessive heat to a tooth results in pain because:
excessive stimulation of a heat receptor always resu lts in pain
heat receptors in the pulp have a low threshold to pain
all stimuli to the pulp resu lts in a pain sensation
SAADDES
blood vessels of the pulp expand and cause strangulation of the t issue
137

all stimuli to the pulp results in a pain sensation
Remember:
1. The only type of nerve ending found in the pulp is the free nerve ending, wh ich
is a specific receptor for pain. These pain receptors are located in the plexus of
Raschkow. Rega rdless of the source of stimulation (heat, co ld, pressure), the only
response w ill be pain.
2. The nerve bundles that enter the tooth pulp consist principally of sen sory
afferent nerves of the trigem inal (fifth crania l) nerve and sympathetic branches
from the superior cervica l ganglion.
3. Each bundle contains myelinated and unmyelinated axons.
4. Although most of the nerve bundles terminate in the subodontoblastic plexus
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(of Raschkow) as free, unmyelinated nerve endings, a small number of axons pass
between the odontoblast and sometimes extend into dentinal tubules.
Note: Proprioceptors (which respond to stimuli regarding movement) are not found
in the pulp.
Important: As the dental pulp ages, the following changes take place:
Decreased:
-intercellular substance, water, and cells
*** Major decrease in the number of undifferentiated mesenchymal cells
-size of the pulp cavity due to the addition of secondary or tertia ry dentin
Increased:
-number of collagen fibers
-calcifications with in the pulp (called denticles or pulp stones)
Important point: As the pulp ages, it becomes more fibrotic, leading to a reduction in
the regenerative capacity of the pulp.

tooth terms
Which of the following is a shallow groove or line between the primary parts
of the crown or root?
fossa
sulcus
SAADDES
developmental groove
supplemental groove
138

developmental groove
A sulcus is a long depression or va lley in the surface of a tooth between ridges and
cusps, the inclines of which meet at an angle. A sulcus has a developmental groove at
the junction of its inclines (the term sulcus should not be confused with the term
groove).
A developmental groove is a shallow groove or line between the primary parts of the
crown or root. A supplemental groove, less distinct, is also a shallow linear depression
on the surface of a tooth, but it is supplemental to a developmental groove and does
not mark the junction of primary parts. Buccal and lingual grooves are developmen-
SAADDES
ta l grooves found on the buccal and lingual surfaces of posterior teeth .
1. Pits are small p inpoint depressions located at the junction of develop-

mental grooves or at term inals of those g rooves.
2. A fissure is a narrow channel or crevice, sometimes deep, formed at the
depth of a developmental groove.
3. Dental caries (decay) often begins in deep fissures or pits.
A fossa is an irregular depression or concavity. lingual fossae are on the lingual sur-
face of incisors. Central fossae are on the occlusal surface of molars. They are formed
by t he convergence of ridges term inating at a central point in the bottom of the de-
pression w here there is a junction of grooves. Triangular fossae are found on molars
and premolars on the occl usal surfaces mesial or distal to marginal ridges. They are
sometimes found on t he lingual surfaces of maxillary incisors at the edge of the lin-
gual fossae where t he marginal ridges and t he cingulum meet.

tooth terms
When two teeth in the same arch are in contact, their curvatures adjacent to
the contact areas form spillway spaces called embrasures.
The design of contact areas, interproximal spaces, and embrasures varies

with the form and alignment of the various teeth; each section of the two
arches shows similarity ofform.
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139

When two teeth in the same arch are in contact, their curvatures adj acent to the contact areas
form spillway spaces called embrasures. The spaces that widen out from the area of contact
labially or buccally and lingually are called labial or buccal and lingual interproximal
embrasures. These embrasures are continuous with the interproximal spaces between the teeth.
Above the contact areas incisally and occlusally, the spaces, w hich are bounded by the ma rginal
ridges as they join the cusps and incisal ridges, are called the incisal or occlusal embrasures.
These embrasu res, and the labial or buccal and lingual embrasures, are continuous. The curved
proximal surfaces of the contacting teeth roll away from the contact area at all points, occlusally,
labially, or buccally, and lingually and cerv ically, and the embrasures and interproximal spaces are
continuous, as they surround the areas of contact. Note: For esthetics and function, embrasu res
must be symmetrical.
SAADDES
Three functions of embrasures:
1. Function as spillways to direct food away from the gingiva.
2. Make the teeth more self-cleansing.
3. Protect the gingival tissue from undue frictional trauma, but at the same time provide the
proper degree of stimulation to the tissue.
The lingual embrasures are ordinari ly larger than the facial embrasures because most teeth are
narrower on the lingual side than on the facia l side, and also because their contact points are
located in the facial third of the crowns.
The design of contact areas, interproximal spaces, and embrasures va ries with the form and
alignment of the various teeth; each section of the two arches shows simila rity of form. In other
words, the contact form, interproximal spacing, and the embrasure form seem rather consistent
in sectional areas of the dental arches.
~ 1. Pronounced developmental grooves are usually associated with embrasures between
Notes7 permanent maxillary o;anines and first premolars, and between permanent mandibu-
lar canines and first premolars.
2. The largest incisal/occlusal embrasure is found between the maxillary lateral incisor
and canine.

tooth terms
When viewed from the facial, all posterior teeth have proximal contacts in
the middle third.
The more posterior teeth (the molars) have contacts higher in the middle
third than the premolars.
SAADDES
140

When viewed from the facial, all posterior teeth have proximal contacts in the middle third. The
more posterior teeth (the molars) have contacts lower in the middle third than the premolars.
Also, each posterior tooth has the mesial contact slightly more occlusal tha n the distal contact.
Note: Four teeth have mesial surfaces that contact each other. They are the maxillary and
mandibular central incisors. In all other instances, the mesial surface of one tooth contacts the
distal surface of its neighbor, except the distal su rfaces of permanent third molars and t he distal
surfaces of primary second molars.
The loss of proximal contact may result in periodontal disease, malocclusion, food impaction, or
drifting of teeth.
-11 XX- -n--n-xx

_fi-SAADDES
I A I I BI 1C I
Outline d rawings of the maxillary teeth in contact, with dotted lines

bisecting the contact a reas a t the various levels as found no rmally. As
-t3c- -~
Contact levels found normally o n mandibular te-eth. Arrows
rows point to embrasure spaces. A. Central and lateral incisors. 8, Cen pomt to e mbrasure spaces. A. Central and lateral incisors. B. Cello
tral and lateral incisors and canine . c . late ral incisor, a nine and 6rst tral and late ral mcisors and canine. C, Lateral incasor. canine and
premolar. 0, Canine a nd fi rst and second p remolars. E, First and second first premolar. 0 , Canine and first and se<ond ptemolars. E, First
premolars and tirst mola r. F, Second premola r, first molar, and second and se<ond premolars and tirst molar. F, Second premolar, fi rst
molar. G, First. second. and third molars. molar, and second mola r. G, First. second. a nd third molars.

tooth terms
A 16-year-old patient is referred to the orthodontist's office needing work to
fix her malocclusion. Before the patient's first appointment, the orthodon-
tist reviews the clinical photographs of the patient and notices mamelons.
Mamelons are unusual in older patients and would indicate that the patient
most likely has which ofthe following malocclusions?
SAADDES
posterior cross bite
posterior open bite
anteri or open bite
edge-to-edge class Ill dental occlusion
141

anterior open bite
Mamelons usually develop in groupsof three. They resemble rounded protuberances and they are
found on the incisal edges of newly erupted incisor teeth, both maxillary and mandibular. When
each of the anterior teeth develops, they originate from four lobes- mesial, labial, distal, and lingual
(or cingulum).
Each one of these lobes terminates formation incisally in these rounded eminences. They are usually
t he most profound right after eruption, but with time they usually wear down after the tooth comes
into functional position. Note: The presence of mamelons in a teenager or adult is indicative of
malocclusion. Most likely there is an anterior open bite relationship where the incisors do not
touch (see picture below).
Part of the reason that the mamelons are so not iceable is because these extensions are made of
SAADDES
pure enamel wi th no dentin layer underneath. This and their thinness contributes to their transluc-
ent appearance as opposed to the rest of the clinical crown which is almost always more opaque
than the mamelons. With this translucent quality, they oft en appear to be a different shade than the
rest ofthe tooth and therefore are sometimes much more distinct
Remember: Maxillary and mandibular incisors characteristically have three mamelons which are
centered beneath the three facial lobes.
Photo shows mamelons

present on maxillary and
mandibular incisors as well
as an anterior open bi te.

tooth terms
Which ofthe following are true concerning developmental grooves?
they are formed during tooth development
they usually separate the primary parts of the crown or root
SAADDES
they are important escape ways for cusps during lateral and protrusive jaw motions
and for food particles during mastication
they are broad, deep, linear depressions
142

they are formed during tooth development
they usually separate the p rimary parts of the crown or root
they are important escape ways for cusps during lateral and protrusive
jaw motions and for food particles during mastication
A developmental groove is a shallow groove or line between the primary parts of

the crown o r root. A supplemental groove, less distinct, is also a shallow linear
depression on the surface of a tooth, but it is supplemental to a developmental groove
and does not mark the junction of pri mary parts. Buccal and lingual groov es are
developmental g rooves found on the buccal and lingual surfaces of posterior teeth.
SAADDES
Remember: Pits are located at the junction of developmental grooves or at termi-
nals of these grooves.
Developmental
groove
Occlsal
developmental
pit
Marginal ridge
Supplemental
groove
Occlusal View of a Permanent Mandibular First Molar

tooth terms
In many older individuals, gingival recession leads to an unaesthetic problem
affectionately known as "black triangle disease:' This is caused by the Joss of
gingival tissue in the interdental space. The interdental space is the:
occlusal (incisal) border at which the gingiva meets the tooth
SAADDES
portion of the gingiva that fil ls the interproximal space
col lar of t issue that is not attached to the tooth or alveola r bone
band or zone of gray to light or cora l pink keratinized masticatory mucosa that is
firmly bound down to the underlying bone
143

portion of the gingiva that fills the interproximal space
This interproximal space is triangular. The sides of the triangle are the proximal sur-
faces of the adjacent teeth, the apex of the triangle is the area of contact of the two
teeth, and the base of the t riangle is the alveolar bone.
The interdental gingiva which occupies this space (papilla) between the facia l and ling-
ual papillae conforms to the shape of the contact area.
-~<+ 1. The gingival margin is the occlusal (incisal border) at which t he gingiva
es- meets the tooth.
SAADDES
2. The free gingiva (marginal gingiva) is the collar of tissue that is not attached
to the tooth or alveolar bone. lt surrounds the root of each tooth from the gin-
gival margin to form the col lar of space o r gingival crevice or sulcus (where
dental floss can fit).
3. The attached gingiva is a band or zone of gray to light or coral pink kera-
tinized masticatory mucosa that is firm ly bound down to the underlying bone.
It is present between the free g ingiva and the more movable alveolar mucosa.

tooth terms
Which of the following types of ridges is unique to permanent maxillary
molars?
a labial ridge
a marginal ri dge
SAADDES
an oblique ri dge
a t ransverse ri dge
144

an oblique ridge
*** It crosses the occlusal surface obliquely and is formed by the union of the distal cusp ridge of
t he mesiolingual cusp and the tria ngular ridge of the distobuccal cusp. It normally forms the
dista l boundary of the central fossa.
A labial ridge is a ridg e runn ing cervico-incisally in approximately the center of the labial sur-
face of the canines
A buccal (cusp) ridge is a ridge running cervico-occlusally in approximately the center of the
buccal surface of premolars (more pronounced on the first premolars than second premolars)
A cervical ridge is a ridge run ning mesiodistally on the cervical third of the buccal surface of the
crown . It is found on all primary teeth, but only on the permanent molars.
A marginal ridge; on incisor and canine teet h, it is located on the mesial and distal border of the
lingual surface; on posterior teeth, it is located on the mesial and distal border of the occlusal sur-
SAADDES
face
A triangular ridge is a ridge that projects from the cusp tip to the central groove. It is found on
posterior teeth. Note: The ML cusp on maxillary molars has two triangular ridges.
A transverse ridge is a ridge formed by the union of a lingual tria ngular ridge of a buccal cusp
and a buccal triangular ridge of a lingual cusp. It runs from the buccal surface to the lingual sur-
face across the occlu sal surface of most posterior teeth.
Dislobuccol
cusp
Oblique
ridge
Dlslollnguol Mesiolinguol
cusp cusp
Occlusal view of a permanent maxillary molar

tooth terms
Transverse ridges are very common on which of the following?
mandibular premolars
mandibular molars
SAADDES
maxillary premolars
maxillary molars
145

mandibular molars
maxillary premolars
A transverse ridge is the union of the buccal and lingual triangular ridges. Th is ridge crosses the
occlusal surface of most posterior teeth in a buccolingual direction. They occur between the ML
and MB or between the DL and DB cusps on molars or between buccal and lingual cusps on pre-
molars.
Important: Transverse ridges are very common on mandibular molars and maxillary premolars.
Triangular ridges descend from the tips of the cusps of molars and premolars toward the central
part of the occlusal surface. They are called tria ngular because the slopes of each side of the ridge are
inclined to resemble two sides of a t riangle. They are named after the cusps to which they belong
(e.g., the tria ngular ridge of the buccal cusp of the maxillary second premolar).
SAADDES
Remember: Maxillary molars have a characteristic oblique ridge. An oblique ridge is the union of
two ridges runn ing obliquely across the occlusal su rface. Oblique ridges always run between the dis-
tobuccal cusp and the mesiolingual cusp. They are formed by the union of the distal cusp ridge of the
Ml cusp and the triangular ridge of the DB cusp.
Central pit Buccal groove
Mesial pit Distal pit
Transverse ridge
Occlusal features of the permanent mandibular right second molar

tooth terms
A 7-year-old patient comes into your pediatric practice for a routine prophyl-
axis. When conducting an intra-oral exam you comment to him that you
notice that he has just eaten something sticky like gummy worms or fruit
snacks. The chewing surface of posterior teeth, and the likely location of
sticky food deposits in this patient, is referred to as the:
SAADDES
cl inical crown
incisal edge
occlusal surface
anatomic crown
146

occlusal surface
It consists of cusps, ridges, and grooves and is bounded mesiodistally by the mar-
ginal ridges and buccolingually by the cusp ridges. Note: Incisors and can ines do not
have an occl usal surface.
1. The incisal edge is the cutting edge or biting surface of anteri or teeth.
2. The anatomic crown is that part of the tooth covered by enamel.
*** The anatomical crown and root are separated by the CEJ; the anatom-
ical crown does not include cementum, and the anatomical root does not
include enamel.
SAADDES
3. The clinical crown is that part of the tooth that is visible in the oral cavity.
It may be larger or smaller than the anatomic crown.
***The cl inical crown and root are separated by the gingival margin; the
clinical crown or root may be composed of both enamel and cementum.

tooth terms
All anterior teeth show traces of:
one lobe
two lobes
three lobes
fou r lobes
SAADDES
147

four lobes
Tooth development begins with increased cell activity in growth centers in the tooth
germ. A growth center (lobe) is an area of the tooth germ where the cells are
particu larly active. These lobes are primary centers of ca lcification and are primary
sections of formation in the development of the crown of a tooth. They are
represented by a cusp on posteri or teeth and mamelons and cingula on anterior
teeth. They are always separated by developmental grooves, wh ich are very
prominent in the posteri or teeth and form specific patterns. With anteri or teeth, their
presence is much less noticeable and these lobes are separated by what are known
as development al depressions.
SAADDES
Summary of number of lobes:
All anterior teeth: three labial and one lingual (cingulum)
Premolars: three buccal and one lingual
Exception: The mandibular second premol ar has three buccal and two lingual
lobes.
First molars: maxillary- four lobes (or five if Carabelli); mandibular- five lobes
Second molars (maxillary and mandibular): fou r lobes
Third molars: at least fou r lobes. Variations are seen.
***The number of lobes forming molars is one per cusp, including the cusp of Cara-
belli.
Important: The minimum number of lobes from wh ich any tooth may develop is
four.

tooth terms
A young patient comes to the clinic complaining that he gets too much food
stuck behind his front tooth when he bites. On examination, the dentist notes
an anomalous, claw-shaped cusp which projects from the cingulum of tooth
#9. This small elevation of enamel found on the crown portion of a tooth
would be classified as a:
SAADDES
tubercle
mamelon
ridge
developmental depression
148

tubercle
It is an extra formation of enam el. The m ost comm on example would be the cusp of Cara-
belli, which is located on the lingual surface of the m esiolingual cusp of the maxillary first
perm anent mo lar. Note: The maxill ary prim ary second m olar may even have a cusp that re -
semb les the cusp of Carabelli.
Dens evaginatus is an extra cusp, usually in the central groove or ridge of a posterior tooth
and in the cingulum area of the centra l and lateral incisors. In incisors, these cusps appear
talon-shaped and can approach the level of the incisal edge. This extra portion conta ins
not only enamel but also dentin and p ulp t issue, and therefore pulp exposure can result
from radica l equilibration.
SAADDES Dens evaginatus

- Talon cu sp
A cusp is an elevation or mound on the crown portion of a tooth making up a d ivisional part
of the occlusal surface.
A tubercle is a small er elevation on so me portion of the crown produced by an extra for-

m ation of enamel.
A cingulum is the lingual lobe of an anterior tooth. It makes up the bulk of the cervical
third of the lingual surface.
A ridge is any linear elevation on the surface of a tooth and is nam ed according to its lo -
cation (e.g., buccal ridge, incisal ridge, marginal ridge).

tooth terms
Each tooth has:
two point angles
four point angles
six point angles
SAADDES
eight point angles
149

four point angles
A point angle is an angle formed by the junction of three surfaces. The point angle
derives its name from the combination of the names of the surfaces form ing it. For
example, the junction of the mesial, buccal, and occlusal surfaces of a molar is cal led
the mesiobuccal-occlusal point angle. All teeth have four point angles.
A line angle is an angle formed by the junction of two surfaces. They are named
according to the surfaces which form them. Note: The mesiobuccal and distobuccal
line angles protect the interdental papilla by their deflective nature.
The line angles (8 of them) of the posterior teeth are:
SAADDES
mesiobuccal mesiolingual mesio-occlusal bucca-occlusal
distobuccal distolingual disto-occlusal lin guo-occlusal
Because the mesial and d istal incisal angles of anterior teeth are rounded, mesioin-
cisalline angles and distoincisal line angles are usually considered nonexistent. They
are spoken of as mesial and distal incisal angles only.
The line angles (6 of them) of the anterior teeth are:

mesiolabial mesiolingual labioincisal
distolabial distolingual linguoincisal

tooth terms
Any linear elevation on the surface of a tooth is called:
an incline
a prominence
a ri dge
a tuberosity
SAADDES
150

a ridge
A ridge is any linear elevat ion on the surface of a tooth that is named according to its location and
form, such as a buccal ridge, incisal ridge, or marginal rid ge.
Remember: Two ridges that are present on all teeth are the mesial and distal marginal ridges. They
form the mesial and distal margins of the occlusal surfaces of premolars and molars and the mesial
and distal margins ofthe lingual surfaces of the incisors and canines.
Note: The marginal ridges are more prominent on the lingual surface of the maxillary lateral inci-
sors as compared to the maxillary central incisors or mandibular incisors (centralsand laterals).
Cusp ridge: Each cusp has four cusp ridges radiating from its tip. They are named according to the
direction they take away from the cusp tip (for example, mesial. distal. buccal, or lingual).
SAADDES
Lingual ridge: The ridge of enamel that extends from the cingulum to the cusp tip on the lingual sur-
face of most can ines.
Buccal cusp ridge

of the buccal cusp
Distal cusp ridge Mesial cusp ridge

of the buccal cusp of the buccal cusp
Lingual cusp ridge Mesial marginal

of the buccal cusp groove
(buccallrlongular rtdgc)
Central groove
Permanent Maxillary Right First Premolar: Occlusal view

permanent teeth
Which tooth in the mouth has the greatest axial inclination relative to the
occlusal plane?
maxillary canine
SAADDES
151

Maxillary Right
Central Incisor
~1...---------J~L-....:.,...__,L...____...J
SAADDES
Labial Lingual Incisal Mesial
Crown: largest of all incisor t eeth. The distal outline is more convex than the mesial outline.lt
is the most prominent tooth in th e mouth. It has the w id est crown mesiodistally of any per-
manent anterior tooth.
Root: one root w ith a sin gle root canal. It is conica l with a blunt apex. This root is the only max-
illary tooth that is as thick at the cervix mesiod istally as faciolingually (the others are thicker fa-
ciolingually than mesiodistally).lt is not unusual to find definite pulp horns in the in cisal region
of t he tooth.
Surfaces:the mesial curvature of the cervical line is larger than any other tooth. The d istoincisa l
corner is more rounded (convex) than the mesioincisal corner. The mesial and distal contact
areas are centered faciolingually (as are all permanent incisors). The cingulum is well-devel-
oped and is located off-center toward the distal.
Occlusion: occludes in centric w ith the mandibular central and lateral incisors (same in pro-
trusive and there is no contact in retrusive).
Distinguishing features: compared to other in cisors, t hey have the greatest axial inclination
relative to t he occlusa l plane. They usually have three mamelons and four developmental
grooves.

permanent teeth
Which teeth have the most variable crown shape of all permanent teeth?
mandibular lateral incisors
maxillary third molars
SAADDES
mandibular second premolars
152

maxillary third molars
SAADDES
Occlusal
Characteristics of maxillary third molars:
They have greater morphological variance t han any other tooth
They are the shortest permanent tooth
They are often congenitally missing or non-functional - may be present but unerupted
(this is also true of the mandibular third molar)
Crown tapers more from buccal to lingual
They frequently have only t hree cusps. It is sometimes difficult to ident ify them individ-
ually (MB, DB, and lingual cusps). The DL cusp is frequently absent. Obl ique ridge is poorly
developed and often absent.
Roots are unpredictable (usually short and fused)
Sometimes a small fourth molar (para molar) will be fused to thi s molar
They occlude only with the mandibular t hird molars (all other teeth occlude with two teeth
except the mandibu lar central incisors)
Remember: The mandibular third molar is often anomalous as well, but not as often as the
maxillary t hird molar.

permanent teeth
Which of the following statements concerning the mandibular lateral incisor
are true?
the mandibular lateral incisor is a little larger in all dimensions than the mandibular
centra l incisor
SAADDES
the crown of the mandibular lateral incisor is not as bilaterally symmetri cal as the
the cingulum is directly in the center of the lingual surface
the single root is usually straight, slightly longer and wider than that of a mandibular
centra l
153

the mandibular lateral incisor is a little larger in all dimensions than the mandibular central
incisor
the crown of the mandibular lateral incisor is not as bilaterally symmetrical as the mandibu-
lar central incisor
the single root is usually straight, slightly longer and wider than that of a mandibular central
nr---.,
J
Mandibular
SAADDES
Right Lateral
Incisor
~
Lab1al
\ Lmgual Incisal
'----:-:-"'-:- ~
Crown: not as bilaterally symmetrical as the mandibular central incisor. The crown is tilted distally on
the root . The d istoincisal angle is more rounded than the mesioincisal angl e. It is broader labiolin-
gually than mesiodistally.
Root: one root; usually straight, slightly longer and wider than that ofa mandibular central. Pronounced
p roximal root concavities, especially on the distal surface.
Surfaces: lingual surface is smooth. The cingulum is sli ghtly off-center to the d istal. Mesial marginal
ridge is slightly longer than the d istal margi nal ridge.
Important: The mesial and d istal contact areas of the lateral incisor are not at exactly the same level, a
condition d ifferent from that found on the central incisor. The mesial and d istal contacts are both in the
incisal third; however, the d istal contact is slightly cervical to the level of the mesial contact a rea.
Note: In an anterior cross-bite relationship (Class Ill ), as the mand ible retrudes, the maxillary lateral
contacts the mandibular canine and late ral.

permanent teeth
Which tooth is considered the "cornerstone" ofthe permanent dentition?
maxillary canine
mandibular canine
SAADDES
154

SAADDES
Crown: it is the largest mandibular tooth . It has the largest mesiodistal dimension of any
tooth. Mesiodistal dimension is slightly greater than the faciolingual dimension. This tooth pres-
ents a pentagonal"home plate" occlusal outline that is distinctive for this tooth.
Roots: two roots with three canals (a second canal is in the mesial root) Note: A fourth canal
(in the d istal root) is found 30% of the t ime. The roots are widely separated and the root trunk
is relatively short.
Cusps: five cusps (three buccal- MB, DB, and distal; two lingual- DL and ML). The mesiobuccal
cusp is the largest of the five and the distal cusp is the smallest. Ungual cusps are higher and
more pointed t han the buccal cusps (flattened bucca l cusps are typical of all mandibular
molars).
Occlusal pattern: two transverse ridges, three fossae with pits. The central groove is crooked
in its mesiodistal course.
Distinguishing features: first permanent tooth to erupt (known as six-year molar), it is con-
sidered t he "cornerstone" of the permanent dentition. Has two buccal grooves (MB and DB).
Note: The mandibular first molar is the most often restored, extracted and replaced tooth.

permanent teeth
A patient walks into your office holding three crowns in her hand and claims
that they fell out during a car accident. You notice that one of the crowns has
a mesiolingual developmental groove. This is a dead giveaway that this
tooth is a:
SAADDES
155

Mandibular Right First Premolar
SAADDES
Occlusal
Crown: from the buccal, it is longer and has a more prominent buccal ridge t han the second
premolar. It is bell-shaped and the cervical is very constricted.
Root: one; it is shorter and has a pointed apex (the second premolar is longer with a blunt apex).
It is broader facially than lingually and may have slig ht concavities on the mesial and distal.
Cusps: has a large pointed buccal cusp which occupies almost two-thi rds of the occlusal sur-
face and has a prominent triangular ridge. lt has a small (about two-thirds the heig ht of buccal
cusp), non- functioning lingual cusp (does not occl ude with anything).
Occlusal pattern: small, non-functioning occlusal surface which converges toward the lingual.
The prominent triang ular ridge of the buccal cusp and the small buccal ridge of the ling ual cusp
unite to form a transverse ridge. Usually there is no central groove (may have mesial and dis-
tal pits). The mesial marginal ridge is more cervical than the distal marginal ridge.
Distinguishing feature: A developmental groove, the mesiolingual groove, usually separates
the mesial marginal ridge from t he mesial cusp slope of the small lingual cusp.
Note: The masticatory function of a mandibular first premolar is similar to that of a mandibu-
lar canine.

permanent teeth
You are sifting through extracted teeth to practice a root canal. Since you will
rarely do a third molar root canal in practice, you throw those out right away.
What is the most reliable distinguishing feature of the mandibular third
molar?
fused and compressed root system
SAADDES
short, bulbous outline of the crown
marginal ridge forming a smooth circle
marked distal inclination of the root trunk
great morphologic resemblance to the first molar
156

marked distal inclination of the root trunk
Mandibular RightThird Molar
r----------,r---~----~ r----~~~ r--~-----,
./--~.,..,_,_ . ,<;-/ .\ . .,.i....'.
SAADDES
Most mandibular third molars have two roots, one mesial and one distal. These roots are usually
shorter, generally with a poorer development than the roots of the first and second molars, and
their distal inclination in relation to the occlusal plane of the crown is greater. This is the most
distinguishing feature of the mandibular third molars.
Characteristics of mandibular third molars:

Bulbous crowns that taper from mesial to distal
The crown can resemble the mandibular second molar (four cusps) or the mandibular first
molar (five cusps)
The mesial-distal dimension of the crown is greater than the buccal-ling ual dimension
Short roots that are often fused. long root trunk.
MB cusps are usually wider and longer than DB cusps
Irregular groove pattern with many supplemental grooves and pits (very shallow)
Note: Oversized anomalies are more common with the mandibular third molar, while under-
sized anomalies are more common with the maxillary third molar.

permanent teeth
The most distinguishable difference between the maxillary first and second
permanent premolars is:
the size of the crown
the number of roots
SAADDES
the curvatu re of the facial surface
the length of the lingual cusp
157

the number of roots
Maxillary Right First Premolar
Occlusal
SAADDES
Mesial
Maxillary second premolar:
Dista l Occlusal Mesial Distal
Crown: smaller than first premolar. From the occlusal, it is much more symm etrical
and Jess angular (more ovoid) than the first premolar. The crown is wider faciolingually
than mesiodistally.
Root: one
Cu sps: two, the buccal and lingual are almost equal in height. M esial inclination of
lingual cusp (same as fi rst premolar). The distobuccal cusp ridge (DBCR) is longer than
the mesiobuccal cusp ridge (MBCR)- opposite of maxillary fi rst premolar.
Surfaces: has no mesial developmental depression (as seen on maxillary first premol-
ars). less prominent buccal ridge; maxillary first premolar has prominent buccal ridge.
Occlusal pattern: shorter central groove with more supplemental grooves (com-
pared with maxillary first premolar).

permanent teeth
The maxillary first molar is the largest tooth in the maxillary arch and also has
the largest crown in the permanent dentition.
All maxillary molars are wider buccolingually than mesiodistally; in compar-

ison, the mandibular molars are wider mesiodistally.
SAADDES
158

Maxillary Right First Molar
SAADDES
Crown: it is the largest maxillary tooth. From the occlusal, all maxillary molars are rhomboidal,
with obtuse angles at t he Ml and DB (the other two angles are acute- MB and Dl). Like all maxillary
posterior teeth, the crown outline is trapezoidal from each proximal view. In addition, the crown is
also centered over the root and shows no lingual inclination, like all maxillary molars and unlike
mandibular molars.
Roots: three; MB root often has two canals (MBand Ml). These pulp horns are often higher than the
distal and palatal.
Cusps:fou r, t wo buccal (MBisusually longer and wider than DB) and two lingual (Ml and Dl). Ml is
always the largest and highest on any posterior tooth.The cusp of Carabelli (when present) is seen
lingual to the ML cusp.
Occlusal pattern: ha san oblique ridge (as do all maxillary molars) which run s from the ML cusp to
the DB cusp and meets near the center on a level with the marginal ridges.
Note: The distal surface has a pronounced cervical concavity that needs special attention when
root plan ing. It is the second permanent tooth to erupt (after the mandibular fi rst molar). These
two teeth form t he cornerstone of the arch.lt has a long lingual groove which has a pit.

permanent teeth
The are the only teeth in the permanent dentition with a vertical
and centrally placed labial ridge.
central incisors
lateral inci sors
SAADDES
canines
premolars
159

canines
SAADDES
Crown:has a prominent labial ridge. The cingulum is large and centered mesiodista lly.lt represents
a transition from anterior to posterior teeth; the mesial resembles the incisors and the distal resem-
bles the premolars. It is wider labio-lingually than mesiodistally. From the proxima l view, it appears
to be positioned vertically in the arch.
Root: one root with one ca nal. It is the longest root The heavy root results in a bony labial ridge
called the canine eminence.
Cusp: when viewed from the incisal, the cusp tip is located on the mesiofacial of the crown . The
mesial cusp ridge is shorter than the distal cusp ridge.
Surface:the lingual surface contains all of the following: a pronounced cingulum, lingual ridge (lo-
cated between mesio and distolingual fossa), mesio and distolingual fossa, and mesial and distal mar-
ginal ridges.
Pits and grooves: has a shallow lingual groove. This groove may contain a lingual pit near its center.
Distinguishing features: least often extracted (together wi th the mandibular canine).

permanent teeth
A linguogingival groove may be present on the root (and possibly on the
crown) of the maxillary lateral incisor.
A maxillary lateral incisor has a single conical root that is relatively smooth
and straight but may curve slightly to the distal.
SAADDES
160

Maxillary Right
Lateral Incisor
urement. SAADDES
Crown: resembles the maxillary central incisor; however, it is smaller in all dimensions except the
root (root lengths are equal). The mesiodistal measurement is greater than the labiolingual meas-
Root: single conical root that is relatively smooth and straight but may curve slightly to the distal.
Surfaces: lingual pit is common (more pronounced tha n mandibular lateral). lingual surface is the
most concave of any of the incisors (maxillary and mandibular). The linguoincisal ridge is well de-
veloped. The distoi ncisal corner or angle is more rounded (convex) than that of the central incisor.
Pits and grooves:a linguogingival groove may be present on the root (and possibly on the crown)
Note: It is prone to decay and also may complicate root planing.
Occlusion: in the intercuspal position, it opposes the incisal edge of the mandibular lateral and the
canine. It is the tooth that is most often in an abnormal relation and contact with adjacent teeth in
the same arch.
Distinguishing features:may be congenitally absent (most often of the permanent anterior teeth).
It is the last anterior tooth to begin calcification (1 0 months). Displays greater variation in form
than any other permanent tooth, except the third molars. It may appearpeg-shaped " or manifest as
"dens in dente.

permanent teeth
When filling a Class II amalgam you are having trouble fitting the matrix band
perfectly and keep getting an overhang in the cervical area. What surfaces
are you preparing?
mesio-occlusal of a maxillary first premolar
SAADDES
disto-occlusal of a maxillary first premolar
mesio-occlusal of a maxillary second premolar
disto-occlusal of a maxillary second premolar
mesio-occlusal of a mandibular first premolar
disto-occlusal of a mandibular first premolar
161

mesio-occlusal of a maxillary first premolar (the mesial surface has a pronounced
mesial concavity that can be hard to adapt to with a matrix band)
***Immediately cervical to the mesial contact area, centered on the mesial surface, is a marked de-
pression, called the mesial developmental depression, which continuesup to and includes the cer-
vical line.
f\ ~
Mesial developmental
depression Maxillary Right
First premolar
. I
.i i.
SAADDES
{ ) !
'
....
,..../ ''\, __ ,
Buccal Lmgual Occlusal
Crown: widest of all premolars (maxillary and mandibular). The oblong crown outline is greater
buccolingually than mesiodistally. They are longer cervico-occlusally than the second premolar,
first molar, or second molar.
Roots: two roots, one buccal and one lingual, each with one ca nal. This is the only premolar that has
two roots. When viewed from the proxima l, the axial inclination of the roots appears vertical.
Cusps:two; the lingual cusp is shorter than the buccal cusp. The buccal cusp tip is sharp and is placed
slightly to the distal. The mesial buccal cusp ridge is longer than the distal buccal cusp ridge. The
lingual cusp tip is located toward the mesial half ofthe lingual surface. Cusp inclines are very steep.
Surfaces: mesial surface has a pronounced (deep) cervical concavity (developmental depression)
that requires special consideration when performing periodontal maintenance. Has a prominent
buccal ridge.
Occlusal pattern: has a deep sulcus and long central groove. Also has a mesial marginal develop-
mental groove. Usually few supplemental grooves and no pits.
Comparison:resembles the second premolar, except it is larger and more angular; the MBCR is longer
than the DBCR, the buccal ridge ismore prominent and it has a longer central groove.

permanent teeth
A mandibular canine is wider labiolingually and mesiodistally than a maxill-
ary canine.
The crown of the mandibular canine can be as long or even longer than that
of a maxillary canine.
SAADDES
162

***The mandibular canine is narrower labiolingually and mesiodistally tha n a maxillary can ine.
Mandibular Right
Canine
~~~
SAADDES Incisal
Crown: labial surface is smooth and convex. Labial ridge is not as prominent as the maxillary ca-
nine. The greatest faciolingual measurement is greater tha n the greatest mesiodistal measurement.
Root:one; may be bifurcated into labial and lingual parts. A developmental depression may appear
on the mesial root surface. In cross-section, the root is ovoid, but wider mesiodistally at the labial.
Cusps: the cusp tip is displaced lingually. The mesial cusp ridge is shorter than the distal cusp rid ge
(more so than on maxillary can ines).
Surfaces: the mesial surface of the crown is almost parallel to t he long axis of the tooth. The cingu-
lum is less bulky and less prominent than the maxillary can ine.
Comparisons: it appears more slender and is smoother tha n the maxillary canine in al l respects;
the labial and lingual ridges are less well developed. This feature allows them to be very caries re-
sistant.
***All can ines have a mesiolabial developmental depression that is fou nd on the labial crown
surface in the incisal third, just mesial to the labial ridge.

permanent teeth
Which tooth has two forms: the three-cusp type and the two-cusp type?
SAADDES
163

*** Remember: The three-cusp type shows the Y-shaped groove pattern and the two-cusp type
shows either the U- or H-shaped groove pattern.
Mandibular Right Second Premolar
.----=--,
SAADDES Occlusal
Crown: three-cusp type occurs most often (one buccal and two lingual cusps). From the buccal, it is
shorter and wider than the first premolar. From the occlusal, it has a square outline. It resembles
other premolars from the buccal aspect only.
Root: one; apex approximates the mental foramen. It is thicker and longer than the root of the
mandibular first premolar.
Cusp: buccal cusp is shorter, not as sharp, and the cusp slopes are less steep than the mandibular first
premolar. Mesiolingual cusp is always larger than the Dl cusp which may be absent. lingual inclines
of the buccal cusps are functional. From a distal view, it is usually possible to see the outline of all
three cusps.
Pits and grooves: central developmental groove is sometimes "U"- shaped or looks like acres-
cent It end s in the mesial and distal fossae, where it often joins a MB and a DB supplemental groove.
Occlusal pattern:larger occlusal surface than first premolar. General shape is more nearly square, es-
pecially three-cusp type, than the first premolar. Most frequently has a single central pit. There is no
mesiolingual groove or transverse ridge (both are common on first premolar).

permanent teeth
The outline of the crown of a maxillary second molar is narrower mesiodist-
ally than that of a maxillary first molar but is about the same width bucco-
lingually.
Two crown outline types are possible on the maxillary second molar when
viewed from the occlusal: rhomboidal and heart-shaped.
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164

Maxillary Right Second Molar

.-------;:=------,
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Buccal Lingual Mesial
Crown: second molar is smaller than first molar, particularly in its width on the lingual side,
which has a smaller or nonexistent DL cusp (tooth may only have t hree cusps} and is also
smaller mesiodistally. When viewed from the occlusal, t he mesiobuccal line ang le is the most
acute. Buccal is broader than lingual due to absence of the fifth cusp (Carabelli}.lt is more an-
gular than the first molar.
Roots: t hree; they are as long as first molar but are less spread apart mesiodistally and faci-
olingually. They bend more to the di stal and have a longer root trunk (as compared to the
first molar}.
Cusps: cusp of Carabelli is absent. The ML cusp is t he largest, DL cusp is the smallest (same as
maxillary first molar}. The primary cusp triangle is formed by the ML, MB, and DB cusps (same
for all maxillary molars}. Note: The DL cusp is not a part of this triangle.
Occlusal pattern: smaller oblique ridge and a more varied pit and groove pattern compared
to first molar. The transverse groove of the oblique ridge connects the central and d istal pits
(same for all maxillary molars}.
Note: The lingual groove is shorter and does not have a pit (compared to first molar}. DL cusp
may also be absent on maxillary third molars.

permanent teeth
You buy a batch of pre-fabricated temporary crown restorations for your of-
fice for the first time. Your assistant drops the entire box on the ground and
they all get mixed up. The hardest tooth to distinguish left from right will be
the:
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165

mandibular second m olar (it is the most symmetri cal molar)
Mandibular Right Second Molar

.--------, r-------, .------.,...,...---, ,....,..,.-------,
Buccal
SAADDES Lingual Occlusal Mesial Distal
Crown: resembles the mandibular first molar except, it has no fifth cusp and it is smaller.
Occl usal outline can be rhombo idal (most common) or heart-shaped. The greatest faci-
olingual diameter is located in the mesial third of the crown.
Root: two; they are closer together and straighter than the first molar roots and are in-
clined more distally. Mesial root is not as broad faciolingually compared to first molar. It
has a longer root t runk.
Cusps: four (two buccal and two lingual). Th is contributes to symmetry.
Occlusal pattern: looks like plu s sign (+). Facial and lingual grooves form right angles with
the central groove. Central groove is straight. Has more secondary develop mental
grooves (three of them) than the first molar. Has two transverse ridges and three fossae
w ith p its.
Distingui shing features: has on ly one buccal groove and one buccal pit.

permanent teeth
The mandibular central incisors are the smallest and simplest teeth of the
permanent dentition.
The mandibular central has a simple root, which is very narrow labiolingually
and wide mesiodistally.
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166

Mandibular Right Centrallnc.isor
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Labial Lingual Incisal Mesial Distal
*** The mandibular central incisor is the least variable tooth in the mouth. It is also the smallest tooth
in the dentition. lt is smaller than the mandibular lateral which is not the case in the maxillary arch.
Crown:very smooth; lacks anatomical features. The incisal outline is straight and perpendicular to the
long axis. The mesial and distal incisal angles are almost 90.
Root:one; tapers evenly to a sharp apex. Very narrow mesiodistally, wide labiolingually, and con-
cave on both the mesial and distal surfaces.
Surfaces: lingual surface (concave) and lingual fossa are very smooth.The cingulum, MMR, DMR, and
incisal ridge come together, forming a shallow lingual fossa.The cing ulum is centered. The labial sur-
face is convex.
Pits and grooves: few if any developmental lines and grooves.
Occlusion: in the intercuspal position, each one occludes with only one tooth, the opposing maxil-
lary central incisor. Only tooth in the dentition that occludes wi th a single tooth (all others occlude
with two).
Important: In an ideal intercuspal position, the distoincisal aspect of the mandibular central inci-
sor opposes the lingual fossa of the maxillary central incisor.

permanent teeth
A permanent maxillary central incisor usually has how many mamelons and
developmental lobes?
two mamelons and two developmental lobes
two mamelons and th ree developmental lobes
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three mamelons and two developmental lobes
three mamelons and fou r developmental lobes
167

three mamelons and four developmental lobes
The permanent maxillary central incisor is generally considered to have 3 mamelons and 4
developmental lobes. Each of the 3 mamelons develops from a separate center of calcifi-
cation. The cingulum is thought to arise from the fourth developmental lobe.
Tooth development begins with increased cell activity in growth centers in the tooth
germ. A growth center (lobe) is an area of the tooth germ where the cell s are particularly
active. These lobes are primary centers of calcification and are primary sections of
formation in the development of the crown of a tooth. They are represented by a cusp on
posterior teeth and mamelons and cingula on anterior teeth. They are always separated
by developmental grooves, which are very prominent in the posterior teeth and form
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specific patterns. With anterior teeth, their presence is much less noticeable and these
lobes are separated by what are known as developmental depression s.
Summary of number of lobes:

All anterior t eeth: three labial and one lingual (cingulum)
Premolars: three buccal and one lingual
Exception: The mandibular second premolar has three buccal and two lingual
lobes.
First molars: maxillary- four lobes (or five if Carabelli); mandibular- five lobes
Second molars (maxillary and mandibular): four lobes, one for each cusp
Third molars: at least four lobes, one for each cus p. Variations are seen.
Important: The minimum number of lobes fro m wh ich any tooth may develop is four.
Remember: The presence of mamelons in a 14-year-old usually indicates a malocclusion.

Generally, mamelons wear off w ithin a few years of eruption through normal excursive
movements of the dentition.

pictures of teeth
Which permanent tooth is shown below?
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D M
168

the permanent maxillary right first molar
Remember:
It is the largest permanent tooth in the maxillary arch (mesiodistal d iameter of crown
= 10.0 mm; buccolingual diameter of crown = 11.0}
Although the crown is relatively short (7.5 mm}, it is broad both mesiodista lly and
buccolingually
Cusp of Carabelli is found lingual to the ML cusp
The total number of pits on t he occlusal surface of the maxillary first molar is the same
as found on the occlusal surface of the mandibular second premolar (three-cusp type}
From a buccal view, the buccal roots present a "plier handle" appearance with the large
lingual root centered between them
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Occlusally, the tooth outline is somewhat rhomboidal, with four distinct cusps. The cusp
order according to size is: mesiolingual, mesiobuccal, distobuccal, and distolingual
Buccal Lingual Mesial Distal

pictures of teeth
The picture below is:
the mesial view of a maxillary ri ght first molar
the distal view of a maxillary right first molar
the mesial view of a maxillary ri ght second molar
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the d istal view of a maxillary right th ird molar
169

the mesial view of a maxillary right first molar
***The key to the photo is t hat the only t wo cusps of the maxillary first molar that are seen from
the mesial are the mesiobuccal cusp and the mesiolingual cusp. A mesial marginal groove usually
notches the mesial marginal ridge about midway along its length. From a distal view, the mesial
cusp tips are seen projecting beyond the outl ine of the distobuccal cusp and distolingual cusp.
Note: The distal facial root is the shortest; therefore w hen viewed from the distal, the mesiofacial
root is sometimes visible. The mesial facial root is flattened mesiod istally and has root depressions
on both mesial and distal surfaces.

Pulp cavity
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Distal view of maxillary Mesiodistal Buccollnguol
cross-section cross-sectio n
right first molar
C&rvical M idroot
cross-section cross-sectio n

pictures of teeth
M D
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170

the permanent maxillary right second molar
Remember: This tooth resembles t he maxillary first molar except:
It is smaller; mesiodistal diameter of crown = 9.0, buccoling ual diameter of crown = 11.0
The buccal is broader than the lingual due to the absence of the fifth cusp (of Carabelli)
It is more angular
DL cusp may be absent. When this occurs, the occlusal outline takes on a "heart sha pe as
opposed to the more common rhomboidal occlusa l outl ine (t rue for all maxillary molars)
Maxillary Right Second Molar
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~~
~G
Maxillary
Mesiodlstol l~colinguol
Right Second
Molar
Pulp Cavity
@ Cervical
G
Midroot
CI OU. 1oeCfloft CIOU 5Kii0ft crosssecHon c ross-section

pictures of teeth
M D
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171

the permanent mandibular right second molar
Remember:
It is the most symmetrical molar (two buccal and two lingual cusps)
Occlusal pattern looks like a plus sign (+)
Cervico-occlusal length of crown = 7.0; mesiodistal diameter of crown = 10.5 mm;
buccolingual diameter of crown = 10.0 mm
The buccolingual dimension is broader at the mesial than at the d istal
The lingual height of contour is located in the middle third
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Mandibular Right Second Molar

pictures of teeth
the buccal view of a permanent

mandibular right second molar
the lingual view of a permanent

mandibular right second molar
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the buccal view of a permanent
mandibular right fi rst molar
the lingual view of a permanent

mandibular right fi rst molar
172

the buccal view of a permanent mandibular right second molar
***Keys to distingu ish between the buccal aspect and lingual aspect:
On the buccal, there is a slight cervical dip of the CEJ; there is no dip at all on the lingual
The buccal developmental groove extends almost halfway down the buccal surface
and ends in a pit; on the lingual, the groove only extends slightly onto the lingual surface
, /Buccal developmental
'(/ ' \ groove
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Mandibular Right
Second Molar
Buccal Lingual
~
Mandibular
Right Second
Molar
CJ
Pulp Cavity
Cervical Midrool
crosssection cross-section
Mesiodistal Buccolinguol
cross-section cross-secHon

pictures of teeth
The picture below is a facial view of what permanent mandibular tooth?
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173

the permanent mandibular right canine
To distinguish a right mandibular canine from a left mandibular canine; remember:
The distal cusp ridge is longer than the mesial cusp ridge
The mesial surface of the crown is almost parallel to the long axis of the tooth
Occlusion: the cusp tip opposes the incisal embrasure between the maxillary canine and the
lateral incisor, while the facial surface opposes their marginal ridges. Important: In a Class II
relationship, during a protrusive movement they contact the maxillary canines and lateral
incisors.
~ 1. The cingulum of a canine is similar to the lingual cusp of a mandibu lar first pre-
~ molar.
...., 2. When viewed from either proximal surface, the facial outline from cusp tip to root
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apex is made up of one continuous arc (from the facial, the proximal surfaces from
the contact to apex look like a straight line).
3. One variation of this tooth is that on occasion, the root is bifurcated (facial and
lingual roots) near its tip. The double root may, or may not be accompa nied by deep
depressions in the root.
0
Mandibular Right
Canine
Incisal
Lingual Mesial Distal

pictures of teeth
D M
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174

the permanent maxillary right first premolar
***The key to determi ning right from left is the mesial marginal groove. It extends onto
the mesial surface, but first it crosses the mes ial marginal rid ge.
Remember:
This tooth has a pronounced cervical concavity on the mesial surface of its crown
Thi s tooth is t he premolar that has a mesial buccal cusp ridge (MBCR) that is longer
than its di stal buccal cusp rid ge (DBCR)
When viewed from the li ngual, the lingual cusp is inclined mesia lly
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Maxillary Right First Premolar Maxillary Right Firs t Premolar
Cervical
c ross-sec:tion
Mesiodistal 8uccolingual
c ross-section croJssection
Buccal Lingual Mesial Pulp cavity

pictures of teeth
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175

the permanent mandibular right first premolar
Remember:
This tooth has a mesio-lingual developmental groove
This tooth has a large buccal cusp that occupies almost two-thirds of the occlusal surface
This tooth has a very prominent transverse ridge w ith no central groove, but may have mesial
and distal pits
It is the only posterior tooth in w hich the occlusa l plane is tilted lingually in relation to the
horizontal plane
Distinguishing features: Has an extreme lingual taper for a posterior tooth. It has the greatest
lingual inclination of the crown from its root of all mandibular teeth. Has a mesiolingual develop-
mental groove. The mesial margina l ridge is shorter in length and less prominent in height than
the d istal marginal ridge.
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Occlusion: the buccal cusp contacts the mesial margi nal ridge area (specifically the mesial t riang-
ular fossa) of the maxillary first premolar and the distal marginal ridge of the canine.
Note: The attached gingiva is very narrow on the facial (compared to any other ma ndibu lar tooth).
Mandibular Right First Premolar Mandibular Right First Premolar
Pulp cavity
Cervical
cross-section
Mesiodislol 8uccolingual
crou-s.eclion cross-section
Buccal Lingual Mesial

pictures of teeth
M D
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176

the permanent mandibular right first molar
***This tooth presents a pentagonal "home plate" occlusal outline t hat is distinctive for this
tooth. There are five cusps. Of them, the mesiobuccal cusp is the largest, the d istal cusp is the
smallest.
Remember:
This tooth is the largest of the mandibular teeth; cervico-occlusal length of crown is 7.5
mm
The mesial-distal dimension (11.0 mm) is slightly greater than the faciolingual dimension
(10.5 mm) of the crown
It is the first permanent tooth to erupt (6-7 years)
It has five cusps (three buccal, two lingual}
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Note: When a protrusive mandibular movement is achieved, the mandibular first molar has
t he potential to contact the maxillary second premolar and t he first molar.
Mandibular Right First Molar Mandibular Right First Molar
Pulp Cavity
tijW
Mesiocl dol
crou-secflon
e.uoecotlnguOI
aonsection
cemeot Midfool
cron~cliOn c ron.uteflon
Mesial Distal

pictures of teeth
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177

the permanent mandibular right second premolar (three cusp type)
Remember:
This tooth most frequently has a single central pit
Resembles other premolars from the buccal aspect only
From the occlusal aspect, the three-cusp type appears square, the two-cusp type appears round
To determine the right from the left for this tooth, the occlu sal view will show a slight mesial
concavity
1. The lingual surface is much wider mesiodistally than the lingual surface of the first
premolar.
2. The interdental papilla between the mandibular second premolar and the first molar
is shorter (cervico-occlusally) than any other in the mouth.
SAADDES Mandibular Right Second Premolar

Pulp Cavity
Mesiolpit
U-Shaped H-Shaped
Groove Groove Cervical
cronsection
Occlusal view of the two-cusp type of permanent mandibu- M esiodistal 8uccollngual

lar right second premolar, showing the U- and H-shaped CfOSSSeC:tion cross-section
groove patterns.

pictures of teeth
the mesial view of a permanent mandibular ri ght first molar
the distal view of a permanent mandibular right first molar
the mesial view of a permanent mandibular left second molar
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the distal view of a permanent mandibular left second molar
178

the distal view of a permanent mandibular right first molar
***The key to the sketch is the distobuccal developmental groove on the facial.
*** You need to know this tooth from every view (mesial, distal, facial, and lingual).
Mandibular Right First Molar
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Distal Mesial
Occlusal
Buccal Lingual

pictures of teeth
D M
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179

the permanent maxillary right second premolar
Remember:
The crown is smaller than the first premolar. From the occlusal, it is much more symmetrical and
Jess angular (more ovoid) than the first premolar. The crown is wider buccolingually (9.0 mm) than
mesiodistally (7.0 mm).
The buccal and lingual cusp are almost equal in height. There is mesial inc.Jination of the lingual
cusp (same as first premolar). The distobuccal cusp ridge (DBCR) is longer than the mesiobuccal
cusp ridge (MBCR) the opposite of the maxillary first premolar.
Maxillary Right Second Premolar
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Maxillary Right Second

Premolar
Pulp Cavity
Mesiodis-tal 6uecolinguol
c:ron-secfkN\ c rousec.flon

pictures of teeth
The picture below is a facial view of what permanent maxillary tooth?
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180

the permanent maxillary right canine
Remember:
The crown has a prominent labial ridge. The cing ulum is large and centered mesiodis-
tally.lt is wider labiolingually (8.0 mm) than mesiodistally (7.5 mm). From the proximal
view, they appear to be positioned vertically in the arch.
It is the longest root (17.0 mm). The heavy root results in a bony labial ridge called the
canine eminence. Note: Mandibular canine root is 16.0 mm long.
When viewed from the incisal, the cusp tip is located on the mesiofacial of the crown.
The m esial cusp ridge is shorter than the distal cusp ridge.
Cervicoincisal length of crown is 10.0 mm; for the m andibular canine it is 11.0 mm.
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Pulp Cavity
MttlO<IiUOI ~llngt,;Qf
OOU Secflon CI010S SoeCiiOn
Lingual Incisal Mesial Dista l

pictures of teeth
The picture below is a lingual view of what permanent maxillary tooth?
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181

the permanent maxillary right lateral incisor
Remember:
The crown resembles the maxillary central incisor; however, it is smaller in all dimensions
except the root (root lengths are eq ual - 13.0 mm). The mesiod istal measurement (6.5 mm)
is greater than the labiolingual measurement (6.0 mm).
A lingual pit is common (more pronounced than mandibular lateral). The lingual surface is
the most concave of any of the incisors (maxillary and mandibular).
Maxillary Right Lateral Incisor
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Facial Incisal Mesial Distal
Maxillary Right Lateral Incisor

Pulp Cavity

pictures of teeth
The picture below is a facial view of what permanent maxillary tooth?
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182

the permanent maxillary right central incisor
Remember:
The crown is t he longest (1 0.5 mm) and widest (8.5 mm) incisor tooth. It is the most prominent
tooth in the mouth. The crown outline is wider mesiodistally (8.5 mm) than faciolingually (7.0
mm).
The mesial curvature of the cervica l line is larger (3.5 mm) than any other tooth. The cingulum
is well-developed and is located off-center toward the distal.
Maxillary Right Central Incisor
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Lingual Incisal Mesial Distal
Maxillary Right Central Incisor

Pulp Cavity

pictures of teeth
The picture below is a buccal view of what permanent mandibular tooth?
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183

the permanent mandibular right second premolar
Remember:
This tooth resembles other premolars from the buccal aspect only
The apex of the root approximates the mental foramen
Most frequently has a single central pit. There is no mesiolingual groove or trans-
verse ridge (both are common on the first premolar)
Mandibular Right Second Premolar
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Lingual Occlusal Mesial Distal

pictures of teeth
The picture below is a labiolingual section of the pulp cavity of which
permanent mandibular tooth?
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184

the permanent mandibular right canine
Remember:
It may be bifurcated into labial and lingual parts. A developmental depression may
appear on the mesial root surface. In cross-section, the root is ovoid, but wider
mesiodistally at the labial.
Mandibular Right Canine

Pulp Cavity
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Cervical
cross-sec tion
Mesiodistal Labiolingual
c ross-section cross-section

pictures of teeth
The picture below is a facial view of what permanent mandibular tooth?
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185

the permanent mandibular right lateral incisor
Remember:
The crown is not as bilaterally symmetrical as the mandibular central incisor. The crown is tilted
distally on the root. The di stoincisal angle is more rounded than the mesioincisa l angle. It is
broader labiolingually (6.5 mm) than mesiodistally (5.5 mm).
The lingual surface is smooth . The cingulum is slightly off-center to the dista l. The mesial mar-
ginal ridge is slightly longer than the distal marginal ridge.
Mandibular Right Lateral Incisor
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Lingual Incisal Mesial Distal
Mandibular Right
Lateral Incisor
Pulp Cavity

pictures of teeth
The picture below is a lingual view of what permanent mandibular tooth?
.-- --\
! !
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\
~
186

the permanent mandibular right central incisor
Remember:
The mand ibular cent ral incisor is the least variable tooth in t he mouth . It is also t he smallest tooth
in t he dentition. It is smaller than the mandibular lateral, which is not the case in t he maxi llary arch.
The crown is very smooth and lacks anatomical feat ures. The incisal outline is straight and perpendi-
cular to the long axis. The mesial and d istal incisal angles are almost 90.
The 3 smallest incisal embrasures in the mouth in order are: in between the mandibular central in-
cisors, in between the mandibular central and lateral incisors and in between the maxillary central inci-
sors.
The cingulum is centered.
Mandibular Right Central Incisor
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Labial Incisal Mesial Distal
Mandibular Right
Central Incisor
Pulp Cavity

temporomandibular joint
Which ligaments below are considered to be accessory ligaments of the TMJ?
sphenomandibular ligament
temporomandibular ligament
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stylomandibular ligament
lateral d iscal ligament
187

sphenomandibular ligament
stylomandibular ligament
The sphenomandibular and stylomandibular ligaments are considered to be accessory liga-
ments. The former is attached to the lingula of the mandible and the latter at the angle of the
mandible. These ligaments are responsible for limitation of mandibular movements (they limit ex-
cessive opening).
The temporomandibular ligament (also called the lateral ligament) runs from the articular emi-
nence to the mandibular condyle. It provides lateral reinforcement for the capsule. This ligament pre-
vents posterior and inferior displacement of the condyle (it isthe main stabilizing ligament of the
TMJ).
Collateral ligaments (medial and lateral) also referred to as "discal ligaments," are ligaments that
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arise from the periphery of the disc. They are attached to the medial and lateral poles of the condyle
respectively, and stabilize the disc on the top ofthe condyle. These ligaments restrict movement of
the disc away from the condyle during function. Note: They are composed of collagenous connec-
t ive tissue; thus they do not stretc h.
Spine of
sphenoid bone
Sphenomandibular - -t ---.,- Styloid process

llgament of temporal bone
Stylomandibular
ligament
Angle of mandible

A patient comes into your dental office complaining of chewing difficulties.
When you ask him to protrude his mandible, the mandible markedly
deviates to the right. Which muscle, which inserts fibers into the capsule and
articular disc of the TMJ, is most likely damaged?
right medial pterygoid muscle
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left medial pterygo id muscle
right lateral pterygoid muscl e
left lateral pterygoid muscle
188

right lateral pterygoid muscle
***On protrusion, the mandible will deviate to the same direction as the damaged lateral pterygoid
muscle.
The l ateral pterygoid muscle is actually comprised of the superior belly and the inferior belly.
The inferior belly originates from the lateral pterygoid plate and inserts on the neck of the
condyle.
The superior belly originates from the greater wing of the sphenoid and infratemporal crest,
and inserts on the joint capsule, the articular disc, and the neck of the condyle.
Note: Each belly ha sdifferent fu nctions. When the right and left inferior bellies contract simultan-
eously, the mandible is protruded, whereas unilateral contraction result s in a lateral movement of
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the mandible to the opposite side. When the right and left inferior bellies contract along with the
mandibular depressor muscles, the result is mouth opening. The function of the superior belly is to
assist in stabilizing the position of the articular disc during mouth closure.
The \lusclcs of \hstication \\ith \ssociatcd \Jo,cmcnts of th< \landihlc

Muscles of Mastication Movements of the Mandible
Masseter Elevation of the mandible (during jaw c losing)
Temporalis
Elevation of the mandible (during jaw c losing)
Retraction of the mandible (lower jaw backward)
Medial pterygoid Elevation of the mandible (during jaw c losing)
l ateral pterygoid One muscle: lateral deviation of the mandible (to

shift the lower jaw to tl1e opposite s ide)
Both muscles: protrusion ofd1e mandible (pulls
articular disc forward)

A patient with constant, unexplained headaches is referred to a TMJ special-
ist by his physician. In order to check for tenderness, the specialist must pal-
pate the joint. What is the best way to palpate the posterior aspect of the
mandibular condyle?
intraorally
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externally over the posterior surface of the condyle with the mouth open
through the external auditory meatus
any of the above
189

externally over the posterior surface of the condyle with the mouth open
The temporomandibular joint should be evaluated for tenderness and noise. When
checking for joint noises (clicking and crepitus), t he joint is palpated laterally (in front
of the external auditory meatus) wh ile the patient opens and cl oses the mandible.
Tenderness can be assessed by palpating the lateral aspects of t he joints when the
mouth is closed and during opening of the mouth. The joint should also be palpated
for tenderness while the patient opens maximally, and t he fingertip should be
positioned slightly posteri or to the condyle to apply force to determine if t here is
inflammation of t he retrodisca l t issue.
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Note: Placing fingertips in t he patient's external auditory meatus, can produce false
joint sounds during mandibular function because of pressure against the thin ear
canal carti lage.
Remember:
1. The posterior aspect of the condyle is rounded and convex, whereas the
anteroinferior aspect is concave.
2. The condyles are not symmetrical nor identical.
3. Sleep bruxism is characterized by episodes of massive bilateral clenching t hat
lasts up to 5 minutes; it often coincides w ith passage from deeper to lighter sleep,
not lighter to deep sleep; it occurs approximately every 90 minutes.
4. There is no single factor that is responsible for all bruxing. The most common
treatment for bruxing is a nightguard.

A 56-year-old man comes into the ER with his mouth wide open. His wife
explains that he can't close his mouth. The resident on-call quickly diagnoses
this as a bilateral dislocation of the TMJ and treats it promptly with reduct-
ion. Dislocation of the TMJ is almost always:
posteriorly and occurs while sleeping
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anteriorly and occurs w hile laughing or yawning
anteriorly and occurs w hile chewing food
posteriorly and occurs while laughing or yawn ing
190

anteriorly and occurs while laughing or yawning
Dislocation of either or both TMJs can occur when the condyle translat es anterior to the crest
of the articular eminence, and the condyle becomes trapped in front of the eminence,
resulting in the patient's inability to close the mouth. When the mouth is opened to its fullest
extent, such as with laughing or yawning, the condyle will translate to its anterior limit.
Sometimes t he mouth is opened beyond its normal limit, and the mouth locks open because
the condyle becomes trapped in front of the articular eminence.
Dislocation is also called an open lock. Reduction of t he d islocation is done by standing

behind the patient with th e thumbs inside the mouth and the index fingers below the chin.
The thumbs depress the back of the mandible, and t he chin is elevated by the index fingers.
SAADDES
The head of the condyle will then slide into the articular fossa.
Note: The term subluxation refers to hypermobi lity or hypertranslation of the mandible.
When t here is natural laxity or looseness of the ligaments associated with the TMJ, the
mandible is able to open beyond the usual anterior limit and can appear to be a d islocation, as
previously described. However, with a subluxation, the patient can self-reduce, or return, the
mandible to its normal position without the assistance of a dentist.
Closed Position Open Position Anterior Dislocation

Which component of the TMJ has the most vasculature and innervation?
articu lar fossa
anterior band of the articu lar d isc
posterior band of the articular disc
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articu lar eminence
retrodiscal tissue
191

retrodiscal tissue
The articular disc (meniscus) is composed of dense fibrous connective tissue, and it is positioned
in between the condyle and the fossa, thereby dividing the joint into superior and inferior joint
spaces.
The articular disc (meniscus) varies in thickness; the thinner central intermediate zone separates
the thicker portions, which are the anterior and posterior bands. The posterior band of the
art icular disc is the thickest of the two bands, and it is attached with posterior loose connective
tissues called retrodisca l tissues (bilaminar zone; posterior attachment). The less thick anterior
band of the articular disc is contiguous with the capsular ligament, the condyle, and the superior
belly of the lateral pterygoid muscle.
Note: The retrodiscal tissue is highly vascula rized and innervated, whereas the articular disc for
the most part is not. Only the extreme periphery of the articular disc is slightly innervated.
SAADDES
So~ head of th& lateral plerygoid m,
Articulardist
~--5~~~~!1~:::::::::=-
$upet"ior
comportment sur;.e11or1om"o
Jtefrodlscol pod
lnfet"lor Inferior lomino
lnleriOf head of lhe lotetol pterygoid m.

A relatively unsuccessful treatment option for individuals suffering from
osteoarthritis is to inject or implant hyaline cartilage into areas of articular
cartilage degeneration. If osteoarthritis were to involve the TMJ, this treat-
ment modality would definitely be unsuccessful because the articular surf-
aces of the TMJ are covered with:
SAADDES
dense fibrous connective tissue
peri osteum
elastic cartilage
periosteum and elastic cartilage
192

de nse fibrous connecti ve ti ssue
Important: The most superficial layer of the articular surfaces of the TMJ (condyle and
fossa) consists of dense fibrous connective tissue not hyaline cartilage. Underneath this
superficial layer is a layer of fibrocartilaginous tissue that offers resistance against both
compressive and lateral forces. Articular surfaces of most diarthrodial joints are covered
by hyaline cartil age, but the TMJ is an atypical diarthrodial joint in that its articular
surfaces are covered w ith a dense fibrous connective tissue.
The TMJ is the articulation between the condyle of the mandible and the squamous
portion of the temporal bone. The condyle is elliptically shaped w ith its long axis oriented
mediolaterally. The articular surface of the temporal bone is composed of the concave
SAADDES
articular fossa (which is the anterior three-fourths of the larger mandibular or glenoid
fossa) and the convex articular eminence (tubercle).
The disc completely divides the TMJ into two compartments. These two compartments are
synovial cavities, an upper and a lower synovial cavity. The synovial membrane lin ing the
j oint capsu le produces the synovial flu id that fill s these cavities.
The disc is attached to the lateral and medial poles of the mandibular condyle. The disc is
not attached to the temporal bone anteriorly, except indirectly through the capsul e. Pos-
teriorly, the disc is divided into two areas. The upper division ofthe posterior portion of the
disc is attached to the temporal bone's postglenoid process, and the lower division attaches
to the neck of the condyle. The disc blends with the capsule at these points. Note: The pos-
terior area of attachment of the disc to the capsule is one of the places where nerves and
blood vessels enter the joint.
The disc consists of dense fibrous connective tissue. Few cells are present, but
fibroblasts and wh ite blood cell s are among these. The central area of the disc is avascular
and lacks innervation, and the peripheral reg ion has b lood vessels and nerves.

A patient with chronic TMJ inflammation is being treated by a dental TMJ
expert. To supplement his examination, the dentist wants to image the soft
tissues of this patient's TMJ. Which of the following is the best imaging
modality for identifying the position of the articular disc in the temporo-
mandibular joint?
SAADDES
panoramic radiograph
magnetic resonance imaging (MRI)
computerized axial tomography (CAT Scan)
lateral t ranscranial radiograph
193

magnetic resonance imaging (M RI)
Magnetic resonance imaging (MRI) is considered to be the gold standard for providing an image of
the soft tissue of the temporomandibular joint, especially the position of the art icular disc in relation
to the condyle because sagittal cuts can be made at different depths through the condylar head.
Thus the medial pole can be clearly differentiated from the lateral pole, one of the most important ad-
vantages in diagnosis ofintracapsular disorders. The MRI utilizes a magnetic field to alterthe energy
levels of primarily the water molecules of the soft tissue, which results in good visualization of the dif-
ferent soft tissues, including the articular disc.
Note:The major advantage of the MRI technique is that there is no exposure of the patient to x-ray
radiation. Currently, no harmful effects of MRI have been demonstrated. The other imaging modali-
ties (i.e., panoramic radiograph, CAT Scan, lateral transcranial radiograph) are best used for evaluat-
ing the bony structures of the temporomandibular joint.
SAADDES
Magnetic resonance Imaging showing the disc centered over the condyle (A). Note the image is reversed from typ-
ical radiographs. The cortical bone and the disc appear dark. 8, The disc is dearly visible in front of the condyle.
Depending on the depth of the slice, the medial pole can be distinguished from the disc position at the lateral pole.
Reproduced with permission from Dawson, Peter E.; Functional Occlusion From TMJ to Smile Design, St. louis,
2007, Mosby.

Reciprocal clicking is always a sign of damage to the ligaments that fasten
the disc in place.
A disc cannot click if the posterior and collateral ligaments are intact.
SAADDES
194

Reciprocal clicking is always a sign of damage to the ligaments that fasten the d isc
in place. A d isc cannot click if the posterior and collateral ligaments are intact. The
variations in deformation of the ligaments and disc appear unlimited. However, many
cl icking and deformed TMJs have adapted sufficiently so that they can comfortably
accept loading.
Adapted centric posture is the manageably stable relationship of the mandible to

the maxilla that is achieved when deformed TMJs have adapted to a degree that they
can comfortably accept firm loading when completely seated at the most superior po-
SAADDES
sition against the articular eminentiae.
like centri c relation, adapted centric posture is a horizontal axis position of the
condyles. It occurs irrespective of vertica l d imension or tooth contact. It is also a m id-
most position, because even if a d isc is completely displaced, the medial pole of each
condyle adapts to the concavity of the fossae and maintains contact against the me-
dial incline of each fossa wal l.
The mandible is in adapted centric posture if five criteria are fulfil led:
1. The condyles are comfortably seated at the highest point against the articular em-
inentiae.
2. The medial pole of each condyle is braced by bone (the d isc may be partially in-
terposed).
3. The inferi or head of the lateral pterygoid muscles have released contraction and
are passive.
4. The condyle-to-fossa relationship is manageably stable.
5. Load testing produces no sign of tension or tenderness in either TMJ.

A patient with temporomandibular disorder comes to the dental office for
treatment. He has bilateral "clicking" of the condyles upon opening and
tenderness on palpation of the joint. An MRI shows damaged collateral
ligaments. The most common direction in which the articular disc in the TMJ
will be displaced in this patient is:
SAADDES
laterally
medially
posteriorly
anteromedially
195

anteromedially
In a healthy temporomandibular joint (TMJ), the articular disc is seated on the condyle
and is held in place by the collateral ligaments (medial and lateral, also ca lled "discal
ligaments") that are attached to the medial and lateral poles of the condyle. Attached
to the anterior portion of the articular disc are muscle fibers from the lateral pterygoid
muscle.
When the collateral ligaments become elongated or torn, they become loose and this
allows the lateral pterygoid muscle to pull the articular d isc out of place. When this oc-
curs, it is cal led a disc displacement. Because of the anteromedial direction of the lat-
SAADDES
eral pterygoid muscle, the articular d isc is usuall y d isplaced anteromedially.
Note:When the articular d isc is displaced anteromedially to the condyle, a click sound
is usually demonstrated when the mouth is opened and the condyle moves past the
thick posteri or band of the articular d isc. There can also be a clicking sound when the
mandible moves to the opposite side, as the condyle again moves past the th ick pos-
terior band of the articular disc. Often another reciproca l cl ick wil l be demonstrated
when the mouth is subsequently closed and the condyle moves from the thin central
area ofthe disc and then past the thicker posterior band as the articular disc once again
becomes d isplaced. A crepitation sound (also known as crepitus) is usually associated
w ith a degenerative process (osteoarthritis) of the condyle, the dull thud is usually as-
sociated w ith a self-reducing subluxation of the condyle, and tinnitus is descri bed as
ear ring ing.

The TMJ is a(an):
arthrodi al joint
ginglymus joint
ginglymoarthrodial joint
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196

ginglymoarthrodial joint
The TMJ is a ginglymoarthrodial joint (meaning that it glides and rotates), permitting both hinge-
like rotation and sl iding (gliding) movements. Note: Ginglymus means rotat ion, and arthrodial
means freely movable.
Components of the TMJ:
Mandibular condyle (sometimes called the condyloid process of the mandible) - the art iculat ing
surface or functioning part of the condyle is located on the superior and anterior surfaces of the
head of the condyle. This surface is covered with a layer of dense fibrous connective tissue.
Articular fossa -this fossa is the anterior three-fourths of the larger mandibular fossa. It is con-
sidered to be a non-functioning portion of the joint. Remember: The mandibular fossa (glenoid
fossa) is the temporal component of the TMJ; it is bounded in front by the articular eminence, and
behind, by the tympanic part of the temporal bone, which separates it from the ext ernal auditory
meatus.
SAADDES
Articular eminence (also called the articular tubercle) is a rid ge that extends mediolaterally just
in front ofthe mandibular fossa. It is considered to be the functional portion of the joint It is lined
with a thick layer of dense fibrous connective tissue.
Articular disc (also called the meniscus) is a biconcave fibroca rtilaginous disc interposed be-
tween the condyle of the mandible and the mandibular (glenoid) fossa of the temporal bone, which
provides the gliding surface for the mandibular condyle, resulting in smooth joint movement The
central part is avascular and devoid of nerve tissue; only the extreme periphery is slightly inner-
vated.
Upper synovial
cavity
Articular eminence
Joint disc
lower synovial
cavity

All of the following structures make up the articulating parts of each tem-
poromandibular joint EXCEPT one. Which one is the EXCEPTION?
mandibular condyle
articula r fossa and articular eminence
SAADDES
retrodiscal tissue
articular d isc (meniscus)
197

retrodiscal tissue
The articular disc (meniscus) is composed of dense fibrous connective tissue, and it is positioned
in between the condyle and the fossa, thereby dividing the joint into superior and inferior joint
spaces.
The articular disc (meniscus) varies in thickness; the thinner central intermediate zone separates
the thicker portions, which are the anterior and posterior bands. The posterior band of the
art icular disc is the thickest of the two bands, and it is attached with posterior loose connective
tissues called retrodisca l tissues (bilaminar zone; posterior attachment). The less thick anterior
band of the articular disc is contiguous with the capsular ligament, the condyle, and the superior
belly of the lateral pterygoid muscle.
Note: The retrodiscal tissue is highly vascula rized and innervated, whereas the articular disc for
the most part is not. Only the extreme periphery of the articular disc is slightly innervated.
SAADDES
So~ head of th& lateral plerygoid m,
Articulardist
~--5~~~~!1~:::::::::=-
$upet"ior
comportment sur;.e11or1om"o
Jtefrodlscol pod
lnfet"lor Inferior lomino
lnleriOf head of lhe lotetol pterygoid m.

Which of the following structures secretes the fluid which lubricates the TMJ?
retrodiscal tissue
internal synovial layer of the fibrous capsule
outer fibrous layer of the fibrous capsu le
articula r d isc
SAADDES
198

internal synovial layer of the fibrous capsule
The fibrous capsule (joint capsule) is a sheet of fibrous tissue that covers the temporomandibular
joint. Think of it as a bag that contains the joint. It isolates the contents of the joint and allows free
movement of the condyle and articular disc within a small"swimming pool" of synovial fluid. It is fairly
thin except laterally, where it forms the temporomandibular ligament (also called the lateral tem-
poromandibular ligament). Medially and laterally, the capsule is firm, to stabilize the mandible dur-
ing movement. Anteriorly and posteriorly, the capsule is loose to allow mandibular movements.
Usually, only a thin lining of synovial fl uid is present on the articular surfaces. Larger amounts of joint
fluid usually are associated with painful internal derangement. The joint capsule and ligaments restrict
excessive displacement of the mandible.
The fibrous capsule consists of two layers:
l . lnternal synovial layer (synovial membrane)- this thin layer secret es synovial fl uid that lubri-
SAADDES
cates the joint.
2. Outerfibrous layer - a thicker layer of fibrous tissue which is reinforced by accessory ligaments
(stylomandibular and sphenomandibular lig aments).
External ocou.stic;:
me-atus
Joint capsule-

Translatory movements take place in which compartment of the TMJ?
upper (mandibular fossa -articular disc) compartment
lower (condyle- articula r disc) compa rtment
both the upper and lower compartments
SAADDES
199

upper (mandibular fossa- articular disc) compartment
The temporomandibular joints are considered the most complex joints in the human
body because they must provide for rotational movements, sliding movements (trans-
latory motion) and an infinite range of combined movements and functions, unlike
any other joint in the body.
When the mouth opens, two distinct motions occur at the joint. The first motion is ro-
tation around a horizontal axis through the condylar heads. The second motion is
translation. During these movements the condyle and meniscus move together an-
teriorly beneath the articular eminence. In the closed mouth position, the thick pos-
terior band of the meniscus lies immediately above the condyle. As the condyle
SAADDES
translates forwa rd, the thinner intermediate zone of the meniscus becomes the artic-
ulating surface between the condyle and the articular eminence. When the mouth is
fully open, the condyle may lie beneath the anterior band of the meniscus.
In the lower (condyle- articula r disc) compartment, only a hinge-type or rota ry mo-
tion can occur. This rotational or terminal hinge-axis opening of the mandible is pos-
sible only when the mandible is retruded in centric relation w ith the conscious effort
by the patient or by the dentist's control. Note: Duri ng mouth opening, the articula r
disc moves anteriorl y in relation to the articular eminence.
In the upper (mandibular fossa -articu lar disc) compartment, only sliding move-
ments or translatory motion can occur. When the lateral pterygoid muscles contract
simultaneously, the discs and condyles can slide forward, down over the articular em-
inence (protrusion ).
Note: The inferior compartment (lower) allows for rotation of the mandible corre-
sponding to the first 20 mm or so of opening. After 20 mm the articular disc and upper
compartment become active and allow fo r forwa rd t ranslation of the condyle.

primary dentition
All of the following statements are true EXCEPT one. Which one is the
EXCEPTION?
t he crowns of the primary anterior teeth are wider mesiodistally and shorter incisocervically
than their permanent counterparts
the crowns of the primary molars are shorter and more narrow mesiodistally at the cervical
SAADDES
third as compared to the permanent molars
the pulpal horns are lower in primary molars, especially the distal horns, and the pulp chamb-
ers are proportionately smaller
the roots of the primary anterior teeth taper more rapidly than do those of the permanent
anteriors
the roots of t he primary molars are longer and more slender than t hose of the permanent
molars
the enamel ends abruptly at the cervical line on primary teeth, rather t han becoming t hinner,
which occurs on permanent teeth
200

the pulpal horns are lower in primary molars, especially the distal
horns, and the pulp chambers are proportionately smaller
***The pulpal horns are higher in primary molars, especially the mesial horns, and the pulp cham-
bers are proportionately larger.
SAADDES
Comparison of maxillary, primary, and permanent second molars, linguobuccal cross section. A, The
enamel cap of primary molars is thinner and has a more consistent depth. 8, A comparatively greater
thickness of dentin is over the pulpal wall at the occlusal fossa of pri mary molars. C, The pulpal horns
are higher in primary molars, especially the mesial horns, and pulp chambers are proportionately
larger. 0, The cervical ridges are more pronounced, especially on the buccal aspect of the first primary
molars. E, The enamel rods at the cervix slope occlusally instead of gingivally as in the permanent
teeth. F, The primary molars have a markedly constricted neck compared with the permanent molars.
G, The roots of the primary teeth are longer and more slender in comparison with crown size than
those of the permanent teeth. H, The root sof the primary molars flare out nearer the cervix than do
those of t he permanent teeth.

primary dentition
Stainless steel crowns are often used in pediatric dentistry. Also common in
pediatric dentistry are kids throwing temper tantrums. One day a 4-year-old
patient throws a tantrum and knocks over your case of stainless steel
crowns. When picking out the primary mandibular first molars you
remember which of the following statements?
SAADDES
they resemble the permanent mandibular first premolar
they resemble the permanent mandibular first molar
they resemble the permanent maxillary second molar
they resemble the primary mandibular second molar
none of the above; their anatomy is unlike any other tooth in the mouth (pri mary or
permanent)
201

none of the above; their anatomy is unlike any other
tooth in the mouth (primary or permanent)
The general shape of the occlusal surface is oval (wider mesiodistally than buccolingually). It has
four cusps (Note: The primary mandibular second molar has five cusps), with the mesiobuccal the
largest and the mesiolingual next in size. The distobuccal and the distolingual are much smaller. The
buccal surface is longer than that of the lingual and has a very prominent cervical ridg e across the
gingival area, directly above where the tooth const ricts at the cervix. The tooth has t wo roots: a
mesial root, which is much longer and wider, and a distal root. The apex of the mesial root is
flattened or squared off.
looking at it from the occlusal, the mesiobuccal angle is acute and prominent because of the
mesial cervical ridge on the buccal surface. The DB angle is obtuse. The shape of the occlusal table
SAADDES
is that of a rhomboid.
Note: The primary first and second molars first show calcification at five to six months in utero. In
general. the root of a deciduous tooth is completely formed in j ust about one year after eruption of
that tooth into the mouth.
The Primary Mandibular Right First Molar
Buccal L.ingual Occlusal Mesial Distal

primary dentition
A frantic mother calls you on the phone asking what to do about her child's
first tooth. You want to impress her. Before she can say it, you tell her what
tooth it is. It is a:
primary mandibular central incisor

primary mandibular first molar
primary maxillary central incisor
SAADDES
primary maxillary fi rst molar
You got that right, and now you really impress her and tell her how old her
child is. She is about:
4-Y2 months old

6-Y2 months old
1O-Y2 months old
1 year old
202

6-'h months old
This tooth usually erupts at around 6-1/ 2 months of age. The root is fully formed and calcified
by about 18 months of age. Remember: This tooth is usually bilaterally symmetrical when
viewed from the facial and incisal.
The Primary Mandibular Right Central Incisor
SAADDES
Labial Lingual Incisal Mesial Distal
1. The first permanent tooth to erupt is the mandibular first molar ("six year
molars"), followed shortly thereafter by the maxillary first molar.
2. The first permanent tooth to begin calcifying is the mandibular first molar (at
birth).
3.The first succedaneous tooth to erupt is the mandibular central incisor (around
six to seven years old). (Remember: The mandibular first molar and the maxillary first
molar are not succedaneous teeth).
4. The permanent maxillary central incisors erupt at approximately seven to eight
years of age. The permanent maxillary lateral incisors erupt at approximately eight
to nine years of age.

primary dentition
A 10-1/ 2- year-old patient comes into your office. You are not sure whether
his maxillary canines are permanent or primary. Which of the following
statements will help you determine which they are?
the cusp on the primary maxillary canine is much shorter than the cusp on the
permanent maxillary canine
SAADDES
the mesial cusp ri dge on the primary maxillary canine is shorter than the d istal cusp
ri dge; this is the opposite of all other can ines
the cusp on the primary maxillary canine is much longer and sharper than the cusp
on the permanent maxillary can ine
the primary maxillary canine is much narrower and longer than the permanent
maxillary canine
203

the cusp on the primary maxillary canine is much longer and
sharper than the cusp on the permanent maxillary canine
The most significant differences between the primary maxillary can ine and the permanent maxillary
can ine are:
1. The cusp on the primary canine is much longer and sharper
2. The mesial cusp ridge is longer than the distal cusp ridge (thisisthe opposite of all other can ines)
*'**Obviously they differ in other ways, but these two differences are the most sign ificant
Note: The primary maxillary canine also appears especially wide and short.
SAADDES
Primary Maxillary
Right Canine Primary Mandibular
Facial view Right Canine
Facial view
Permanent Maxillary Permanent Mandibular

Right Canine Right Canine
Facial view Facial view

primary dentition
The picture below is the buccal view of which primary molar?
SAADDES
204

the primary mandibular right first molar
A A B
SAADDES
D c c D
Primary ri ght molars, buccal aspect. A, Maxil- Primary right molars, lingual aspect. A, Maxil-
lary first molar. 8, Maxillary second molar. C, lary first molar. 8, Maxillary second molar. C,
Mandibular first molar. 0, Mandibular second Mandibular first molar. 0, Mandibular second
molar. molar.
Occlusal views of the Primary Right Molars
Maxillary first molar Maxillary second molar Mandibular first molar Mandibular second molar

primary dentition
When attempting a MO Class II amalgam preparation and filling on a prim-
ary tooth, you encounter a very large mesial marginal ridge that resembles
a cusp. You also notice a transverse ridge that runs from the mesiolingual
cusp to the mesiobuccal cusp that is rather large. This tooth often proves
difficult to restore, which tooth is it?
SAADDES
mandibular fi rst molar
205

This transverse ridge separates t he mesial portion from the remainder of the occlus-
al surface.
Other characteristics of t he primary mandibular first molar:

It does not resemble any other pri mary or permanent tooth
The mesiobuccal cusp is always t he largest and longest cusp, occupying nearl y
two-thirds of the buccal surface
The mesiolingual cusp is larger, longer, and sharper than the d istolingual cusp
The crown is wider mesiodistally t han high cervico-occlusall y
SAADDES
The mesial marginal ridge is very well developed and resembles a cusp
It has a prominent mesiobuccal cervical ridge
Class II cavity preparations are difficult due to morphology and a high mesial
pulp horn
It has no central fossa
Primary Mandibular Right First Molar

primary dentition
How many lobes develop to form a primary canine tooth?
SAADDES
206

4
All canines (permanent and primary) have four lobes, th ree on the facial (mesiofacial, midfac-
ial, and distofacial) and one on the lingual. The cusp tip is located on the midfacial (central
facial) lobe.
.~ 1.The pulp cavities of canines when viewed in a mesiodistal section normally appear
~1 pointed at the incisal tip.
?I 2. When viewed from the facial, prima ry canines resemble a pentagon (five-sided).
SAADDES
c B A
A B c
0
0
Primary right anterior teeth, facial aspect. A, Max Primary right anterior teeth, lingual aspect. A,
illary central incisor. B, Maxillary lateral incisor. C, Maxillary central incisor. B, Maxillary lateral incisor.
Maxi llary canine. 0, mandibular central incisor. E, C, Maxillary cani ne. 0, mandibular central incisor.
Mandibular lateral incisor. F, Mandibular canine. E, Mandibular lateral incisor. F, Mandibular canine.

primary dentition
A 10-year-old patient comes into your office with his mother. They are
concerned about affording orthodontic treatment for his slightly crowded
anterior teeth. He has not lost his primary molars yet. From thi s information
alone, you tell his mother...
don't worry, the premolar teeth that replace these pri mary molars take up less space
in the arch, so we can expect to see more room in a few years
SAADDES
get a second job, the premolar teeth that replace these primary molars take up more
space in the arch so we can expect to see even less room than there is now
the premolar teeth that replace these primary molars take up the same amount of
space in the arch. Based on th is we cannot tell at this point whether you r son will
need o rthodontic t reatment
207

don't worry, the premolar teeth that replace these primary molars take up Jess
space in the arch, so we can expect to see more room in a few years
Remember: The sum of the mesiodistal widths of the primary molars in any one quadrant is greater
than the permanent teet h that succeed them (premolars). Roughly 2 - 5 mm greater.
Some differences between primary and permanent molars:
Primary molarshave crowns that are shorter and more bulbous, with pronounced buccal and
lingual cervical ridges and a constricted cervical area
Pri mary molars have an occlusal table that is narrower faciolingually
Primary molars have anatomy that is shallow (i.e., the cusps are short, the ridges are not pro-
nounced, and the fossae are not as deep)
Primary molars have a prominent mesial cervical ridge (makes it easy to disti nguish rights from
SAADDES
lefts)
Pri mary molars have roots that are longer and more slender than the roots of the permanent
molars. The roots are extremely narrow mesiodistally and very broad buccolingually.
Primary molars have roots that are very divergent and less curved. There is little or no root
t runk.
Primary right molars, mesial aspect. A, Maxillary first

molar. B, Maxillary second molar. C, Mandibular first
molar. 0, Mandibular second molar.

primary dentition
Although it usually isn't much of a problem, which of the following criteria
would NOT be used to distinguish primary maxillary central incisors from
their permanent counterparts?
they are shorter incisocervica ll y
SAADDES
they are w ider mesiodistally than incisocervically
there are no mamelons present
the incisal edge is straighter
the distal flare of the root is greater
208

the distal flare of th e root is greater
The primary incisors (centrals and laterals) are very similar to the permanent incisors,
but d iffer in one important trait, the newly erupted primary incisors do not show
mamelons. The most characteristic featu re of the primary max illary incisor is the
mesiodistal width of the crown. It is the only primary or permanent incisor with a
mesiodistal d iameter (6.5 mm) greater than its crown height (6.0 mm).
1. The primary maxillary central incisor has a shorter length incisocervica lly
8 (6.0 mm) than the permanent maxillary central incisor (1 0.5 mm).
2. Also, compared to the permanent central incisor, the incisal edge of the
SAADDES
pri mary central incisor is straighter.
3. Labial and lingual cervica l ri dges are promin ent on all primary central and
lateral incisors.
4. Remember: When extracting primary incisors (centrals and laterals) where
the roots have been partially resorbed due to pressure from the developing
permanent teeth, the facial part of the remaining primary root w ill usually be
the longest and the most securely attached to the g ingiva.

primary dentition
The crowns of all 20 primary teeth begin to calcify between:
1 to 2 months in utero
SAADDES
209

Dedduous First E'idenct of Amount of Enamel Enamel CompletW Root Completed
Tetth Calcification Formed at Birth (Months afler Birth) (Years)
Maxillary
Cttlltal incisot 4 months in urero Five-sixths 1.5 1.5
Late-ral incisot 4.5 months in utero Two-lllitds 2.5
Canine 5.5 months in ute-ro One-thitd 3.25
First molar 5 months in urero Ocdus.al completely 2.5
c.akifit.d plus 1/2 to
3/4 crown height
Second 1nolar 6 months in utero Occlusal completely II
SAADDES
cakilied; calcified
tissue covers 1/5 to
1/4 CtOWn heig_ht
Mandibular
Centtal incisor 4.5 motnhs in Ule-ro Three-fifths 2.5 1.5
Lateral incisor 4.5 months in ute-ro Three-fifths 1.5
Canine 5 months in utero One-thitd 3.25
First molar 5 months in utero Occlus.al comple.tely 5.5 2.5
c.akilie.d
Second Molar 6 months in urero Occlusal completely 10
c.akilie.d
1. On average primary teeth take 10 months for completion of calcification.
2. The pri mary teeth begin to form in utero at about six weeks. Hard tissue formation
occurs in all prima ry teeth by the 18th week in utero.
3. The permanent teeth begin to develop at approximately four months of age in utero.
Maxillary and mandibular first molars begin to calcify at birth. They are the first to begin
calcification. The mandibular third molars are generally the last t eeth to begin calcifying.
This happensat about 8-10 years of age.

primary dentition
Sally and Annie, ages six and eight respectively, come into your office and get
their picture put up on the "Cavity-Free Board:' On the back of each picture,
your assistant writes how many baby teeth they have lost and how many adult
teeth they have. Which numbers are correct?
Sally (0, 4); Annie (2, 6)
SAADDES
Sally (2, 6); Annie (4, 10)
Sally (2, 6); Annie (2, 6)
Sally (0, 4); Annie (8, 12)
210

Sally (0, 4); Annie (8, 12)
***Sally w ill have lost no teeth yet and have all her permanent first molars. Ann ie will
have lost her maxillary and mandibular incisors (centrals and laterals) and have all per-
manent first molars and permanent maxillary and mandibular centrals and laterals.
Ordinarily, a 6-year-old child wou ld have t he following teeth clinica lly visible in the
mouth: All (20) primary teeth and four permanent first molars- (" 6 year molars").
Remember:
Mandibular centrals erupt between the age of 6-7 (usually closer to age 7)
Maxillary centrals erupt between the age of 7-8
SAADDES
Ordinarily, a 8-year-old child wou ld have the fol lowing teeth clinica lly visible in the
mouth: 12 primary and 12 permanent teeth.
The 12 permanent teeth include the:
Mandibular first molars (2) - right and left
Maxillary fi rst molars (2)- right and left
Mandibular central incisors (2)- ri ght and left
Maxillary central incisors (2)- right and left
Mandibular lateral incisors (2)- right and left
Maxillary lateral incisors (2)- right and left
The primary teeth incl ude t he maxillary and mandibular can ines along with t he max-
illary and mandibular first and second molars (12 total).
~!if?:~ 1. The largest primary tooth is the mandibular second molar.
~~~1, 2. The mandibular central incisor is the smallest primary tooth.
~~ 3. The largest permanent tooth is t he maxillary first molar.
4. The mandibular central incisor is the smallest permanent tooth.

primary dentition
The mesiolingual cusp is the most prominent cusp on the primary maxillary
first molar.
The mesiolingual cusp is the longest and sharpest cusp on the primary max-
illary first molar.
SAADDES
the first statement is fa lse, t he second is true
211

Characteristics of the primary maxillary first molar:

In all dimensions except labiolingual diameter it is the smallest molar. Note: The
length of the crown is 5.1 mm; the M-D diameter of the crown is 7.3 mm and the labia-
lingual diameter of the crown is 8.5 (the mandibular first molar is smaller at 7.0 mm
labiolingually).
The DL cusp is poorly defined; it is small and rounded when it exists at all
The cervical line is higher mesially than distally
The cervical ridge stands out very distinctly on the mesiobuccal portion of this tooth
The occlusal pit-groove pattern is most frequently H-shaped
SAADDES
The number of roots (three) and the form of the roots closely resembles the perma-
nent maxillary first molar; they are slender and long, spread widely and have a very
small root trunk
On the crown, the mesial surface normally is larger than the distal surface
The Primary Maxillary Right First Molar

primary dentition
A preschool child is shown below with a normal dentition. Note the spaces
between the maxillary lateral incisor and canine and the mandibular canine
and first primary molar. These spaces are termed spaces, and their
presence allows for the space to be filled by permanent teeth as they erupt.
primitive
SAADDES
private
primate
hawley
Copyright 200().2004 Unrversrty o f Washmgton. All r igh ts reserved. Access to the Atlas o f
Pediatric DentiStry 1sgovemed by a license. Unauthon:zed access or reproduction 1s fOJbdden
w ithout the prior w ritten perm~sion o f the Unrversrty ofWashmgton. For .nformat.on. corr
ta.ct! license@u.wash ington.edu
212

primate
Primate spaces appear in the deciduous dentition . The spaces appear between the maxillary lat-
eral incisors and the maxillary canines. They also appear between the mandibular canines and the
mandibular fi rst molars.
***Spacing is normal throughout the anterior part of the primary dentition, but is most noticeable
in these two locations.
These primate spaces are normall y present from the time the teeth erupt. Developmental spaces
bet ween the incisors are often present from the beginning, but become somewhat larger as the
ch ild grows and the alveolar processes expand. Generalized spacing of the primary teeth is a
requ irement for proper alignment of the permanent incisors. This spacing is most frequently
caused by the growth of the dental arches.
SAADDES
,9 ~ '.L
c
B
/
~::.,,7
;U U,V
Primary right anterior teeth, mesial aspect.
Primary right anterior teeth, Incisal aspect. A, Maxillary central A, Maxillary central incisor. 8, Maxillary lat-
incisor. 8, Maxillary lateral incisor. C, Maxillary canine. 0, eral incisor. C, Maxillary canine. 0, Mandibu-
Mandibular central Incisor. E, Mandibular lateral incisor. F, lar central incisor. E, Mandibular lateral
Mandibular canine. incisor. F, Mandibular canine.

primary dentition
A neophyte dental student, only about two weeks into the program, gets
scared when her 10-year-old cousin gets hit in the face and loses a tooth.
She calls you up and says that her cousin lost his permanent mandibular first
molar. Once she tells you more about the root morphology of the tooth, you
realize it is primary and the child simply lost his ...
primary mandibular fi rst molar
SAADDES
primary mandibular second molar
primary maxillary first molar
primary maxillary second molar
213

primary mandibular second molar
..,.*The permanent mandibular first molar has a morphology that closely resembles the primary
mandibular second molar.
The differences include:
Relative size of the distal cusp. The pri mary molar has its mesiobuccal, distobuccal, and distal
cusp almost equal in size. The distal cusp of the permanent molar, however, is smaller than the
other two cusps.
From the buccal aspect, the primary mandibular second molar has a narrow mesiodistal cali-
bration at the cervical port ion of the crown when compared with the calibrat ion mesiodistally of
the crown at the contact level. The mandibular first permanent molar, accordingly, is wid er at the
cervical portion.
Groove patterns are different on the occlusal surface
The primary tooth has more divergent roots to allow for t he eruption of the permanent second
SAADDES
premolar
The primary tooth has a more prominent facial crest of contour
Primary Mandibular Right Second Molar

r.;~- 1. Primary second molars have the greatest faciolingual diameter of all primary teeth.
The maxillary second molar measures 10 mm faciolingually and the mandibular second
molar measures 8.7 mm. The first molars measure 8.5 mm (max.) and 7.0 mm (mand.)
respectively.
2. The primary teeth that present the most noticeable morphologic deviations from
permanent teeth are the first molars.

primary dentition
Morphologically, the primary maxillary second molar strikingly resembles
the:
permanent maxillary th ird molar
permanent maxillary second molar
SAADDES
permanent maxillary first molar
permanent mandibular second molar
214

permanent maxillary first molar (but it is smaller)
In general, the primary second molars are larger than the primary first molars and resemble the form
of the permanent first molars. Note: lsomorphy is the term used to describe this close resemblance.
Other characteristics of the primary maxillary second molar:

The faciolingual measurement (10.0 mm) of the crown is greater than the mesiodistal meas-
urement (8.2 mm)
May have a fifth cusp (of Carabell i)
Has a prominent mesiobuccal cervical ridge
Has an oblique ridge
From the largest to smallest cusp: ML cusp, MB cusp, DB cusp, and DL cusp
The largest and longest pulp horn is the mesiobuccal
SAADDESPrimary Maxillary
Right Second Molar
Permanent Maxillary
Right First Molar
A
~J M
Universal numbering system for primary dentit ion. !, Maxillary arch. II, Mandibular arch

primary dentition
Primary molar relationships are known as:
class relationships
step relationships
primitive relationships
SAADDES
occlusion relationships
215

step relationships
The primary molar relationship shown in the fig-
ure to the left is a mesial-step relationship, as the
d istal surface of the lower second primary molar
is mesial to the d istal surface of t he upper second
primary molar. The mesial-step molar relation-
ship allows for the first permanent molars to
erupt into a normal occlusion immediately on
eruption. Note that the permanent molars are in
a normal Class I occlusion.
This figure to the left demonstrates t he flush-ter-
SAADDES
minal-plane relationship for primary molars. The
distal surfaces of t he maxillary and mand ibular
second primary molars are in an end-to-end re-
lationship.
In t hese cases (the flush-terminal-plane), the first permanent molars do not erupt immediately
into a normal relationship. As you can see, the first permanent molars are in a Class II relation-
ship. The Class II relationship usually is temporary until the second primary molars are lost and
t he permanent molars move into a Class I relationship. This occurs at approximately age ten or
eleven and is called t he late mesial shift. Both the mesial-step and flush-terminal-plane rela-
t ionships usually result in the development of a Class I permanent molar occlusion, although the
flush-terminal-plane relationship can result in a Class II relationship if the late mesial shift does
not occur. Another step relationship involves a situation w here the d istal surface of the
mandibular primary second molar is located to the distal of the distal surface of the maxillary pri-
mary second molar.Thi s is termed a distal-step relationship. In these cases, the permanent mo-
lars erupt into a Class II relationship. Important: The terminal plane relationship of primary
second molars determines the future anteroposterior positions of permanent first molars.

primary dentition
Both the mesial-step and flush-terminal -plane relationships usually result in
the development of a:
class I permanent molar occlusion
cl ass II permanent molar occlusion
SAADDES
cl ass Ill permanent molar occlusion
216

class I permanent molar occlusion
***Although the flush-terminal plane relationship can result in a Class II permanent molar re-
lationship ifthe late mesial shift does not occur.
Another step relationship involves a situation w here the distal surface of the mandibular pri-
mary second molar is located to the distal of the distal surface of the maxillary primary second
molar. This is termed a di stal-step relationship. In these cases, t he permanent molars erupt
into a Class II relationship.
The primary molar relationships are as follows:
A 8 c
A. Flush-terminal-plane relationship
SAADDES
B. Distal-step relationship
C. Mesial-step relationship
The Ang le Classification of permanent molar relationships are as follows:
A. Class I molar relationshi p

B. Class II molar relationship
C. Class Ill molar relationship
A B c
Note: Primary molars should be assigned terminology according to step relationships, and per-
manent molars should be assigned terminology according to the Angle Classification system.

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Summary of Tooth Formation

Saad Alqahtani, Twitter @saaddes

Central cells of the dental papilla

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Bud srage/e.ighth week P-roliferation Growth of dental lamina into bud

Saad Alqahtani, Twitter @saaddes

Apposition stage/ varies

SAADDES Induction. prolifermion De.ntal tissue..; secreted as marix in

Maturation stage/ varies Maturation Dental tissues fully mineralize [ 0

Saad Alqahtani, Twitter @saaddes

maxillary lateral incisor

mandibular central incisor

copyngh t 0 20 132014 Dental Decks