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Essentials of Oral Biology
Essentials of Oral Biology
Oral Biology
Second Edition
Essentials of
Oral Biology
Second Edition
Science and technology are constantly changing fields. New research and
experience broaden the scope of information and knowledge. The authors
have tried their best in giving information available to them while preparing
the material for this book. Although, all efforts have been made to ensure
optimum accuracy of the material, yet it is quite possible some errors might
have been left uncorrected. The publisher, the printer and the authors will not
be held responsible for any inadvertent errors, omissions or inaccuracies.
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Foreword
▪ Dr Heera R
Professor, Department of Oral Pathology
Government Dental College
Thiruvananthapuram
▪ Dr Girish KL
Professor, Department of Oral Pathology
Sri Mookambika Institute of Dental Sciences
Kulasekaram, Kanyakumari
Tamil Nadu
▪ Dr Rajeesh Mohammed PK
Professor, Department of Oral Pathology
KMCT Dental College
Mukkam, Kozhikode
Kerala
▪ Dr Usha Balan
Assistant Professor
College of Dentistry
King Khalid University
Abah, KSA
▪ Dr Ajeesha Feroz
Department of Oral Pathology
Mahe Institute of Dental Sciences
Mahe, UT of Puducherry
Preface to Second Edition
I thank God Almighty for all the blessings He has showered on me in this
venture. The preparation of this textbook was possible only with the help
and cooperation of a number of people.
I would like to express my gratitude to Dr Sripathi Rao, Principal,
Yenepoya Dental College, for his kind words of encouragement and moral
support, received at every stage of the preparation of this book. I also thank
him for writing the Foreword to the book.
I would like to express my heartfelt thanks to Dr Heera R, faculty of Oral
Pathology, Government Dental College, Thiruvananthapuram, my teacher
and friend, for giving me all guidance, moral support, and for sharing her
knowledge at different stages of my work, and also for contribution in the
book.
I gratefully acknowledge the constant support of Dr Rajeesh Mohammed
PK, Dr Girish KL, Dr Usha Balan and Dr Ajeesha Firoz who have also
contributed chapters to this book. I am indebted to Head of the Department
and all my colleagues of Department of Oral Pathology, Yenepoya Dental
College, Mangalore, especially Dr Joshy, Dr Meera and Dr Haziel Diana
Jenifer, for their constructive suggestions and timely support.
The talented staff of CBS Publishers & Distributors deserve praise for their
role in shaping this book.
I owe a great deal of regard and gratitude to my parents, teachers and
beloved students who have played a major role in making me what I am
today. I thank my husband Mr Ajoy S. Joseph, and my children, Joe and Jiya,
who stood by me at all the stages and exhibited patience and affection which
enabled me to carry on with the work smoothly.
We would like to thank Mr S.K. Jain (CMD), Mr. Varun Jain (Director),
Mr. YN Arjuna (Senior Vice President – Publishing and Editorial), and Mr.
Ashish Dixit (Business Head – Digital Publishing, Marketing & Sales) and
his team at CBS Publishers & Distributors Pvt. Ltd. for their skill,
enthusiasm, support, patience and excellent professional approach in
producing and publishing this eBook.
Finally, I thank each and everyone whose contribution, direct or indirect,
has made the preparation of this book a pleasant task.
Maji Jose
Syllabus
I. TOOTH MORPHOLOGY
Oral Embryology
1. General Embryology
2. Development of Orofacial Structures
1
General Embryology
Formation of blastocyst
Germ layers
Neural crest cells
Pharyngeal arches and pouches
Formation of Face
Brain and pericardium forms two prominent bulgings on the ventral aspect of
the embryo after the head fold is formed. These two prominences are
separated by a central depression called stomatodeum which is the
developing oral cavity and is formed by an invagination of ectoderm on the
ventral surface of future head of the embryo. In the deepest part of the
stomatodeum, the lining ectoderm is in contact with endoderm of the foregut.
This combined ectoderm and endoderm constitute the buccopharyrngeal
membrane which separates the developing oral cavity from foregut. The
mesoderm of the forebrain proliferates and forms a bulge that overlaps the
upper part of stomatodeum. This downward bulge is called frontonasal
process. Face develops from the frontonasal process and the 1st pharyngeal
(mandibular) arch of each side.
The ectoderm lining the frontal process forms thickenings on both infero-
lateral borders. These are called nasal or olfactory placodes. These nasal
placodes invaginate to form nasal pit. This nasal pit is surrounded by a
horseshoe shaped ridge which is formed by rapid proliferation of underlying
mesoderm. The medial edge of this ridge is called medial nasal process and
lateral edge is called lateral nasal process and the depressed area between the
two medial nasal processes is called frontonasal process.
At the same time the mandibular arches that form the lateral wall of
stomatodeum gives off a bud-like projection called maxillary process (on
either side). The remaining part of the mandibular arch forms the mandibular
process.
The face is derived from the five prominences that surround the
stomatodeum. These prominences are frontonasal process, pair of maxillary
processes and a pair of mandibular processes (Fig. 2.1).
Lower Lip
Lower lip develops from the mandibular processes which grow medially
towards each other and fuses at midline. This forms the lower margin of
stomatodeum. As the development continues an ectodermal proliferation
occurs which extends into the ectomesenchyme. The structure developed is
called vestibular lamina and it gives rise to a V-shaped sulcus that separates
the lip from the tooth bearing area.
Fig. 2.1: Development of face
Upper Lip
Mandibular arch on either side gives rise to process called maxillary
processes. These processes grow forward and medially towards one another
above the stomatodeum. As they do so, these processes first fuse with lateral
nasal process and later with medial nasal process. The frontonasal process
grows downwards at a faster rate and reaches the same level that of maxillary
process. The inferolateral part of the frontonasal process is now called as
globular process. As the maxillary process grows, the frontonasal process
becomes narrower and the external nares formed by the fusion of medial and
lateral processes come closer. Both maxillary processes form the major part
of lip except for philtrum region. In this region mesoderm is derived from
frontonasal process. The ectoderm of the maxillary process overgrows this
mesoderm to meet that of the opposite side. The upper lip is separated from
the developing jaw in the same manner as that of lower lip.
Cheek
After formation of upper and lower lip the lateral margins of maxillary and
mandibular processes fuses with each other to form cheek.
FORMATION OF PALATE
During the medial growth of maxillary processes, they not only form the
upper lip but also extend backward on either side of stomatodeum. From this
backward extension of maxillary process, two plates like shelves grow
medially. These are called palatal processes (Fig. 2.2). Meanwhile the
primary palate is formed from the frontonasal process. Initially these three
structures are widely separated because of the vertical orientation of palatal
processes (lateral shelves) on either side of the tongue. During 8th week of
intrauterine development after the descent of tongue, the palatine shelves
alter their position from vertical to horizontal direction as a preparation to
their fusion. Two palatal shelves, which grows medially towards each other
and fuse in the midline and with the posterior margin of the primary palate to
form a flat and unarched roof of the mouth, separating nasal cavity from oral
cavity. Palatal shelves also fuse with nasal septum to separate two nasal
cavities. The fusing palatal shelves overlap the primary anterior palate and
the junction of union of these three palatal components is marked by incisive
papilla overlying the incisive canal.
Development of Tongue
The tongue develops in the ventral wall of the primitive oropharynx from the
inner lining of 1st, 2nd, 3rd and 4th pharyngeal arches (Fig. 2.3). The mucous
membrane lining the oropharynx rises into the developing oral cavity as
swellings as a result of invasion by muscle tissue from occipital somites.
DEVELOPMENT OF MANDIBLE
Mandible develops from the mandibular process of first branchial arch. The
cartilage and the bone of the mandibular skeleton are formed from neural
crest cells. 1st branchial arch has its cartilage namely Meckel’s cartilage;
which is a solid rod of hyaline cartilage surrounded by fibrocellular tissue.
Meckel’s cartilage attains its full length after six weeks of intrauterine life
and extends from midline to the developing ear region. Meckel’s cartilage of
each arch shows an upward curve at the ventral end and is separated at the
midline by mesenchyme. A great portion of Meckel’s cartilage disappears
without contributing to formation of mandible. A small part of the ventral end
(near mental foramen) forms the accessory endochondral ossicles that are
incorporated in the mandible. The part of the cartilage extending from the
mental foramen to the lingula is not incorporated into ossification of
mandible. A part of Meckel’s cartilage transforms into sphenomandibular and
malleolar ligament. The dorsal end of Meckel’s cartilage ossifies to form
incus and malleus, two of the auditory ossicles.
The mandibular branch of trigeminal nerve is found in close association
with Meckel’s cartilage. This nerve divides into two branches: Lingual nerve
and inferior alveolar nerve. The lingual nerve travels along the medial aspect
of the cartilage and inferior alveolar nerve along the lateral aspect. More
anteriorly the inferior alveolar nerve again divide giving rise to mental and
incisive branches.
First sign of mandibular development is seen as a condensation of
ectomesenchyme in the fibrocellular tissue in the region of division of
inferior alveolar nerve to mental and incisive branches. An osteogenic
membrane is formed from this condensed ectomesenchyme that is located
lateral to cartilage where the ossification of the mandible begins. A single
ossification center for each half of the mandible arises in the 6th week of
intrauterine life. The ossification spreads from this primary center below and
around the inferior alveolar nerve and incisive branch and upwards to form
outer and inner plates with a trough between them for the nerve. The spread
of intramembranous ossification ventrally and dorsally forms the body and
ramus of mandible. As the ossification proceeds, the trough is converted into
a canal containing the nerves. As a result of formation of buccal and lingual
bony plates above the level of roof of alveolar canal the developing teeth are
found in a bony troughs which is subsequently partitioned by transverse bony
septae to form individual bony crypts. Ossification stops dorsally near the
point of division of mandibular nerve.
The ramus of the mandible develops by the spread of ossification
posteriorly into the mesenchyme turning away from Meckel’s cartilage.
Between 10th and 14th week of intrauterine life, secondary cartilage
develops, which are not related to Meckel’s cartilage which include the
condylar cartilage, the coronoid and symphyseal secondary cartilage. The
condylar cartilage gives rise to condyle and secondary cartilage of coronoid
process form part of coronoid and the secondary cartilage in mental region
form variable number of mental ossicles that are incorporated into the bone in
symphysis region. The two halves of mandible are united at midline only by
4th-12th month postnatally. The mass of cartilage is converted into bone by
endochondral ossification. A thin layer of cartilage persists in the condylar
head till the 2nd decade of life which helps in development of mandible while
the cartilage component of coronoid disappear before birth.
Alveolar Bone
By 2nd month of intrauterine life when the mandible and maxilla is being
formed the ossification extend to form a trough-like structure; to protect the
developing tooth buds. As the bone formation continues, the part of trough
occupying the tooth buds are separated from the nerve by a horizontal plate
of bone. Bony septa develop in the trough separating each tooth germ. As the
growth continues part of the alveolar bone gets incorporated into the basal
bone, adding to its height and thickness. The development of the alveolus
depends on the teeth. Alveolar process fails to develop when teeth are absent
and undergoes resorption when teeth are lost.
Maxilla
Maxilla develops from the mesenchyme of maxillary process of the 1st
branchial arch. A primary intramembranous ossification center appears for
each maxilla in the 7th week at the termination of infraorbital nerve just
above the dental lamina of developing canine. From this center, the
ossification proceeds in all directions to form different processes of maxilla.
Ossification also spreads posteriorly to the palate, forming hard palate. A
medial alveolar plate develop from the junction of body of maxilla and
palatal process which together with the lateral alveolar plate forms a trough
around the developing tooth. By the formation of bony septa these troughs
are converted into separate bony crypts occupying the developing tooth
germs.
Temporomandibular Joint
The temporomandibular joint develops from temporal and condylar blastema;
which are widely separated initially. Temporal blastema develops from the
otic capsule, a component of basicranium that forms the petrous part of the
temporal bone. The condylar blastema arises from the secondary condylar
cartilage of the mandible. Initially the temporal articular fossa is convex
which later turns to concave shape. Temporal and condylar blastema are
widely separated by mesenchyme which gradually become closer by the
growth of condyle. By 10th week of intrauterine life two clefts develop in the
interposed fibrovascular connective tissue resulting in formation of two
distinct joint cavities. The remaining strip of connective tissue becomes
articular disc. Condensation of mesenchyme around the developing joint
forms the analage of joint capsule, progressively isolating the joint with its
synovial membrane from surrounding connective tissue. Immediately after
birth, the temporomandibular joint is a lax structure with the mandibular
fossa and articular eminence forming the flat surfaces. The joint attains the
adult form by the 12th year of life.
Salivary Glands
The development of salivary gland begins with proliferation of epithelium to
form a bud under the influence of underlying ectomesenchyme. The epithelial
bud undergoes further proliferation and turns into a solid chord of cells.
Multiplication of cells at the end of these chord leads to formation of bulbs,
which undergo extensive branching to form numerous bulbs. As the
development progresses canalization of the chords occurs forming a central
tube or duct. The terminal secretary acini and intercalated ducts differentiate
from the terminal ends of the branches. The connective tissue below the
epithelial chord differentiates into a capsule which surrounds the entire
glandular structure.
Parotid buds are the first to appear at 6th week of intrauterine life on the
inner cheek, near the angle of the mouth and then grow back towards the ear.
As the maxillary and mandibular processes fuse the opening of the duct is
pushed backwards.
The submandibular gland bud appears later by 6th to 8th weeks of
intrauterine life on either side of the midline in the linguo-gingival groove of
the floor of the mouth at the site of future papillae.
Sublingual gland arises in the 8th week just lateral to the submandibular
gland bud. Minor salivary glands also develop nearly at the same time.
Section 2
Oral Histology
3. Development of Tooth
4. Enamel and Amelogenesis
5. Dentin and Dentinogenesis
6. Pulp
7. Cementum
8. Periodontal Ligament
9. Alveolar Bone
10. Oral Mucosa
11. Salivary Glands
12. Temporomandibular Joint
13. Maxillary Sinus
3
Development of Tooth
Introduction
Dental lamina
Stages in development of tooth
– Physiological stages
– Morphological stages
Root formation
Clinical considerations
DENTAL LAMINA
Dental lamina is the lingual subdivision that forms from the primary
epithelial band and is intimately concerned with tooth formation. The dental
lamina proliferates into the underlying ectomesenchyme and forms a U-
shaped band along the future dental arches in each jaw (Fig. 3.2). This
structure that forms in the 7th teeth (Fig. 3.1c) Localized/differential week of
intrauterine life, acts as the primor-proliferative activity at 10 specific regions
of dium for the enamel organ of the deciduous dental lamina of upper and
lower dental arches, between 6th and 8th weeks of intrauterine life, results in
formation of round or ovoid structures that protrude into the
ectomesenchyme. These dental placodes form along the dental lamina further
develop into tooth buds that gives rise to enamel organ of 10 deciduous teeth
in each arch. Later in prenatal life, permanent successors develop from the
lingual extensions that proliferate from the developing deciduous tooth
germs. These lingual extensions are called successional lamina. Successional
lamina of central incisor develops at 5th month in utero and second premolar
at 10th month of age. The permanent molars develop from the distal/posterior
extension of dental lamina, referred to as accessional lamina or parent
dental lamina or lamina of permanent molars. Permanent first molar buds
develop at 4th month of intrauterine life and second molar at 1st year and
third molar at 4th or 5th year of life.
Fig. 3.1a: Formation of primary epithelial band
Fig. 3.1c: Formation of tooth bud from dental lamina and vestibule from vestibular
lamina
Fig. 3.2: U-shaped dental lamina
The activity of dental lamina starts at the midline of each arch and
progresses posteriorly. As the tooth development proceeds through various
stages, the dental lamina related to those particular tooth breaks up by
mesenchymal invasion and eventually degenerates, while it is still active in
the region of posterior teeth. Average period of activity of dental lamina is 5
years. A few remnant cells may persist even after the degeneration of dental
lamina. These remnants may be seen in connective tissue of gingiva or in the
jaw bones and are named as cell rests of Serres. These cell rests may
proliferate under certain conditions giving rise to odontogenic cysts or
tumors.
Morphological Stages
Bud stage
Cap stage
• Early cap stage
• Late cap stage
Bell stage
• Early bell stage
• Advanced bell stage
Physiological Phases
Initiation
Proliferation
Morphodifferentiation
Histodifferentiation
Apposition
Stellate Reticulum
Stellate reticulum is layers of star-shaped cells present at the center of enamel
organ of cap and bell stage of tooth development. In cap stage, the central
cells proliferate and increase number. When this happens, the central cells
move away from its source of nutrition. So, these cells start secreting
glycosaminoglycans into the intercellular spaces. Since glycosaminoglycans
are hydrophilic, water is attracted to the intercellular spaces, leading to
widening of the intercellular compartment. Hence, the cells are forced apart
while retaining their intercellular junctions which results in the change of
polyhedral cells into starshaped cells. This gives the appearance of a network
of star-shaped cells at the center portion of the enamel organ referred to as
stellate reticulum. Stellate reticulum is also called enamel pulp. This stellate
reticulum cells undergo degeneration and collapses during bell stage.
Dental Papilla
The dental papilla cells undergo further proliferation and condensation during
cap stage. As the enamel organ invaginates, the dental papilla becomes partly
enclosed in the invaginated portion. Dental papilla also shows active
proliferation of blood vessels. At this stage of tooth development, dental
papilla is the main source of nutrition to the inner enamel epithelium.
Dental Follicle
The marginal condensation of the ectomesenchymal cells enclosing the dental
papilla and enamel organ becomes more conspicuous at this stage. This layer
becomes denser and fibrous, forming a well-formed structure that encloses
the enamel organ and dental papilla. This layer gives rise to cementum,
periodontal ligament and a part of alveolar socket.
BELL STAGE
This structure is called successional lamina and these forms the primordia
of permanent successors which go through various morphological stages and
physiological processes as the primary tooth bud, to give rise to permanent
successors.
Dental papilla In bell stage, the dental papilla becomes completely enclosed
in the invagination of enamel organ. The ectomesenchymal cells are closely
packed and interspersed with fine collagen fibers and capillaries. Dental
papilla is separated from enamel organ by basement membrane and the
basement membrane at this stage is referred to as membrana preformativa,
the blue print of crown.
During bell stage, the inner enamel epithelial cells exert an organizing
influence on the dental papilla cells adjacent to them so that a peripheral layer
of cells undergo histodifferentiation into odontoblasts, the synthetic cells of
dentin. Initially the peripheral cells arrange themselves to a distinct layer.
Later they change their shape to cuboidal and then become columnar. As a
preparation to dentin deposition, these cells develop rich cytoplasmic
synthetic organelles and nucleus shifts away from the secretory end of cells.
The remaining portion of dental papilla becomes the pulp of the formed
tooth.
Dental Sac/Follicle
The dental follicle becomes more distinct at this stage of tooth development;
with more dense fibrous component. Three distinct layers, i.e. the inner
vascular fibrocellular condensation of two to four cell layer thick, middle
loose connective tissue and outer vascular mesenchymal layer can be
appreciated in the dental follicle. The dental follicle gives rise to three
important entities: Cementoblasts forming the cementum of a tooth;
fibroblasts of developing periodontal ligament which connect teeth to the
alveolar bone and osteoblasts forming the alveolar socket.
ROOT FORMATION
Root formation (Fig. 3.7) begins in advanced bell stage after the enamel and
dentin formation reaches the cervical region at future cemento-enamel
junction. At this stage, the enamel organ at the cervical loop proliferates
giving rise to a structure called Hertwig’s epithelial root sheath (HERS).
This Hertwig’s epithelial root sheath determines the number, size and shape
of the root. As it is developing from a bilayered cervical loop, the Hertwig’s
epithelial root sheath has only two layers; inner layer of columnar cells
derived from inner enamel epithelium and outer layer of cuboidal cells
derived from outer enamel epithelium. The Hertwig’s epithelial root sheath is
supported by a basement membrane which separates this structure from the
dental papilla present at inner aspect and dental follicle present at the outer
aspect. As it proliferates, Hertwig’s epithelial root sheath bends to attain a
horizontal position to form a structure termed epithelial diaphragm. This
structure extends between dental papilla and dental sac separating both,
except for a small portion at the center. This part is the future apical foramen.
Once the epithelial diaphragm is formed, further proliferation of HERS
occurs at the proximal end adjacent to the cervical part of the tooth. This
proliferation results in the downward shift of epithelial diaphragm which
maintains the same horizontal plane. As the HERS proliferates, the cells of
dental papilla also proliferate to fill the gap created by the apical shift of
epithelial diaphragm. Meanwhile, the inner enamel epithelial cells lining the
inner aspect of HERS exert an organizing influence on adjacent dental papilla
cells to differentiate into odontoblasts. These odontoblasts begin to secrete
dentin and once a layer of radicular dentin is formed, in that region HERS
loose continuity due to invasion by proliferating dental follicle cells. At this
stage HERS appears as network of cells which eventually undergoes
degeneration to leave only few remnants. Degeneration of HERS allows the
dental follicle cells to come in contact with newly formed dentin. These
dental follicle cells that come in contact with newly formed dentin
differentiate into cementoblasts and begin to deposit cementum on the outer
surface of dentin. Radicular dentin formation continues apically and inward
while cementum formation continues apically and outward till the entire
length of the root is formed. As the cementum formation proceeds the
collagen fibers of the dental follicle get inserted into the cementum which
becomes a part of periodontal ligament. Formation of HERS and deposition
of dentin and cementum are step-by-step processes. So the entire length of
HERS cannot be appreciated in a histological section of root formation. Once
the desired length of root is formed, the lengthening of HERS stops. After
this, the inner cells of epithelial diaphragm causes differentiation of
odontoblasts adjacent to them. These odontoblasts deposit dentin along the
inner aspect of epithelial diaphragm narrowing the opening of the apical
foramen.
Clinical Considerations
The development of tooth is a complex process controlled by various
factors. Therefore this process may be disturbed by defect in genetic
control, nutritional or hormonal imbalances, infections or disturbances in
local environment where the tooth development occurs, resulting in
various anomalies. Developmental anomalies of teeth may be grouped into
those affecting number, size, shape, structure, location, etc.
1. Supernumerary teeth or hyperdontia refers to a condition where
extra teeth than normal are present in dental arch. This may develop
from an additional initiation of dental lamina near the permanent tooth
bud or by splitting of the permanent tooth bud itself. The most common
supernumerary tooth is ‘mesiodens’ occur as an extra small conical
tooth located between the two maxillary central incisors. Other
supernumerary teeth include: Distomolar situated distal to the third
molar and paramolars located either buccal or palatal to the molars.
Multiple supernumerary teeth are present in disease conditions such as
‘Gardner’s syndrome’ and ‘cleidocranial dysplasia’.
2. Anodontia or hypodontia refers to absence of all teeth, i.e. total
anodontia or some teeth, i.e. partial anodontia. True anodontia is
congenital absence of teeth which occur due to lack of initiation. The
absence of third molars is very common, followed by the second
premolar and lateral incisor. Anodontia or hypodontia is usually a
feature of a condition termed as hereditary ectodermal dysplasia.
3. Microdontia is a condition wherein the teeth are smaller and
Macrodontia is larger teeth than normal. Pituitary dwarfism causes
generalized microdontia and pituitary gigantism causes generalized
macrodontia. Peg shaped lateral incisor is the most common single
tooth that appear as microdont. The term Rhizomicry is used when the
roots are smaller than normal and Rhizomegaly refers to abnormally
larger roots. Tooth may have extra root or cusps than normally
expected referred to as supernumerary cusps or roots.
4. Disturbances affecting the shape of the teeth: Talon cusp is an
anomalous cusp-like structure projecting from the lingual aspect, in the
region of cingulum of maxillary and mandibular incisors and
Taurodontism characterized by rectangular shaped tooth resembling
that of a Bull’s tooth. Gemination is a condition that occur when a
single tooth germ divide, by an invagination resulting in incomplete
formation of two teeth. If complete division occurs giving rise to two
smaller teeth, identical in appearance, it is referred to as twinning.
Similarly, two normally separated tooth germs may fuse (join) together
to form a single large tooth. When fusion of two teeth occurs by the
deposition of cementum, it is called concrescence. Dens evaginatus is
a developmental anomaly characterized by the presence of a globule of
enamel or an extra cusp on the occlusal aspect between the buccal and
lingual cusps of premolars. Dens invaginatus (dens in dente) is a
developmental anomaly affecting the shape of the tooth which occur
due to invagination of enamel organ into the dental papilla during
odontogenesis giving rise to a tooth within a tooth appearance. Trauma
to a developing tooth germ may cause a bend or curve in the crown or
root and is referred to as dilaceration. Congenital syphilis is a bacterial
infection that may result in gross anomalies of incisors and first molars
and collectively these defects are called Hutchinson’s teeth. Central
incisors may assume a screwdriver shape and molars, a characteristic
mulberry-like appearance.
5. Amelogenesis imperfecta, dentinogenesis imperfecta, dentin
dysplasia and regional odontodysplasia are a few of the
developmental structural defects. Various environmental factors such
as fluorosis, nutritional deficiencies, infections, etc. may also disturb
odontogenesis.
6. During root formation, some of the remnants of Hertwig’s epithelial
root sheath remain attached to the root surface and may attain a
capacity to form enamel and deposit a globule enamel on surface of
root near cemento-enamel junction or close to furcation area, referred
to as enamel pearl. Similarly, degeneration of Hertwig’s epithelial root
sheath before radicular dentin formation may result in accessory root
canals.
4
Enamel and Amelogenesis
Introduction
Physical properties and chemical composition
Amelogenesis
Structure of enamel
Clinical considerations
E namel is the hardest calcified tissue of the body covering the anatomic
crown of tooth. Enamel is a unique calcified tissue which is different
from other calcified tissues of the body.
Physical Properties
Color: Ranges from grayish white to yellowish white. Yellowish white color
is appreciated where enamel is thin as it is translucent and allows the yellow
color of dentin visible through it. Translucency of enamel is related to the
high mineral content and homogeneity of enamel.
Hardness: Enamel is the hardest biologic tissue of human body and the
hardness is compared to mild steel. Hardness of enamel is 343 KHN (Knoop
Hardness Number). The high mineral content and complex crystalline
arrangement makes it very hard, suitable to resist heavy masticatory stress.
Hardness varies in different parts of same tooth with maximum at the cusp tip
and incisal edge and less in the cervical region. Similarly, surface enamel is
more harder than in deeper portion.
Brittleness: Enamel is highly brittle and tend to fracture because of less
tensile strength. Therefore resilient dentin support is very essential for the
integrity of enamel. Loss of dentin due to caries or improper cavity cutting
leads to fracture of unsupported enamel.
Thickness: Enamel thickness vary considerably over different parts of crown.
Maximum thickness (2.5 mm) is observed at the cusp tip or incisal edge and
thinnest at cervix where it ends at a feather edge. As a functional adaptation,
thickness of enamel is reported to be more in lingual aspect of maxillary
molars and buccal aspect of maxillary teeth, in relation to functional cusps.
Permeability: Enamel is semi-permeable and allows the passage of certain
molecules. Distribution of pores between and around the enamel rods is
responsible for this property of enamel. These pores permit entry of some
bacteria and bacterial products, may result in caries initiation.
Density: Enamel density varies in different parts. Density decreases from
surface to dentino-enamel junction and from incisal to cervical region.
Refractive index: Enamel is birefringent and its refractive index is 1.62.
Solubility: Enamel is soluble in acids. Solubility depends on the presence of
certain ions like fluoride. Surface enamel is less soluble.
Specific gravity: Specific gravity of enamel is 2.8.
Chemical Composition
Enamel is a highly mineralized tissue with 96% of inorganic components, in
the form of hydroxyapatite crystals; 4% of organic components, forming a
lace-like network between the crystals; and water, filling the pores between
crystals and at rod boundaries.
Inorganic Components
Calcium and phosphate in the form of hydroxyapatite crystals.
Traces of strontium, magnesium, lead and fluoride.
Organic Components
Amelogenin (90%)
Non-amelogenins (10%)
Tyrosine rich amelogenin polypeptide (TRAP) and non-amelogenin
proteins make up the major organic components.
AMELOGENESIS
Morphogenic Stage
The function of ameloblasts during this stage is determination of shape of the
tooth. The inner enamel epithelium interacts with underlying connective
tissue and through differential growth helps to establish the dentino-enamel
junction and thereby determine the shape of the tooth to be formed.
The ameloblasts at this stage are low columnar in shape with centrally
placed nucleus. Cytoplasmic organelles are not abundant, the centrioles and
Golgi complex are located at the apical part of cytoplasm and mitochondria is
evenly distributed throughout the cytoplasm.
Maturative Stage
During this stage, ameloblasts helps in the mineralization and maturation of
enamel.
Ameloblasts enter into the maturative phase only after the desired
thickness of enamel matrix is laid down. In this stage, ameloblasts have to
introduce the inorganic material necessary for maturation and also reabsorb
proteins and water to provide space for the minerals. Ameloblasts performing
these dual functions shows morphological alterations. Ameloblasts are ruffle
ended when they are performing the function of introducing inorganic
components and smooth ended when they are reabsorbing proteins and water.
The series of repetitive morphological changes that occur in ameloblasts of
maturative stage, from ruffled ended to smooth ended is referred to as
ameloblast modulation. During this process, tight junctions and deep
membrane infoldings periodically appear (ruffle-ended), then disappear for
short intervals (smooth-ended), from the apical ends of the cells.
Ameloblasts in maturative phase shows slight reduction in height, decrease
in volume and organelle content. Excess synthetic organelles are removed
and the remaining organelles are shifted to the distal end of the cells. The
basal plasma membrane of the ruffle-ended ameloblasts shows a brush border
with many foldings, while that of the smooth ended ameloblasts is smooth.
The cytoplasm of ameloblasts also has vacuoles which contain material
resembling enamel matrix indicating the absorptive function of these cells.
Protective Stage
In this stage, ameloblasts along with other layers of enamel organ has to
perform a protective function. After the enamel formation is completed the
basal plasma membrane of ameloblasts looses the brush border and become
smooth. They secrete protein similar to basal lamina onto the surface of
newly formed enamel. Ameloblasts develop hemidesmosomal attachments to
these basal lamina structure which help in holding these firmly to the tooth
surface. After this, the columnar ameloblasts shorten to cuboidal and along
with other collapsed layers of enamel organs form a 2–3 layered stratified
epithelium which is termed as reduced enamel epithelium (REE). This
reduced enamel epithelium covers the newly formed enamel and protects it,
till the tooth erupts into oral cavity. This also has an important role in
establishing the dentogingival junction.
If not protected, enamel may be resorbed or cementum deposition may
occur on enamel surface.
Desmolytic Stage
In this stage the REE secretes collagenase enzyme which destroy the
connective tissue between oral mucosa and erupting tooth. This facilitates the
eruption process. During this stage the reduced enamel epithelium
proliferates and fuses with the oral epithelium to form a solid plug of
epithelial cells. The central cells of this degenerate to form a canal through
which the tooth erupts.
Amelogenesis, the process of formation of enamel involves two steps:
Matrix deposition and mineralization.
STRUCTURE OF ENAMEL
1. Enamel Rods
Enamel rods are the fundamental structural unit of enamel; each rod is
extending from its site of origin at the dentino-enamel junction (DEJ) to the
outer surface of enamel. The enamel rods are separated by varying amounts
of inter-rod materials. The number of enamel rods varies in different teeth.
The rods are roughly cylindrical in the longitudinal section (Fig. 4.3) with an
average diameter of around 3 to 4 microns near dentino-enamel junction,
which increases gradually to the surface at a ratio of 1:2, to cover the larger
surface area of outer surface compared to DEJ.
In transverse section, the enamel rods have a keyhole shape (Fig. 4.4) with
a head formed by the rod and a tail formed by inter-rod enamel immediately
cervical to it. The rounded heads are commonly directed towards the incisal
or occlusal aspect while the tails are directed towards the cervical region of
the teeth. In enamel, the enamel rods and inter-rod enamel are arranged in
such a way that the heads abuts against the tail of adjacent rods. The width of
body of the enamel rod is approximately 5 microns in head region and 1
micron in tail, and the total length (head + tail) is approximately 9 microns.
Sub-microscopic/Electron Microscopic
Structure/Ultrastructure of Enamel Rods
Enamel rods and inter-rod enamel are composed of millions of tightly packed
hydroxyapatite crystals. Apatite crystals are flattened hexagonal structures
with length ranging from 600 to 1000 Å, width of 400 Å and thickness of 250
Å. These crystals are 30 times larger than that of dentin. The direction of the
crystals is different in rods and inter-rod substance.
In the rods the apatite crystals are arranged parallel to the long axis of the
rod, especially close to the center. But as it goes to periphery the crystals
show lateral flaring (Fig. 4.5).
In the cervical 1/3rd portion of the rod, the lateral flaring goes to the extent
that the crystals become confluent with that of the inter-rod enamel located
immediately cervical to it. Thus, making the boundary between indistinct,
and inter-rod enamel appear like a tail attached to rod. In the remaining
2/3rds portion of the rod, there is marked difference in crystal orientation
between rod and adjacent inter-rod region. The inter crystalline space created
by this abrupt change in direction of apatite crystals gets filled with organic
components. The thin structure formed by the accumulation of organic
material delineating the coronal 2/3rds boundary of enamel rod is called rod
sheath. Thus, enamel rods with distinct rod sheath covering coronal 2/3rds
portion and confluent inter-rod at cervical 1/3rd portion, present keyhole
pattern in the cross section.
Fig. 4.5: Enamel rod with crystals parallel to long axis of rods and inter-rod substance
with different crystal arrangement
In the innermost portion of enamel, close to the DEJ (5 microns thickness),
enamel does not have rod structure. Similarly, in the outermost 30 microns
thick enamel, the rod structure is absent or irregular. In these regions, the
crystals are arranged uniformly with their long axis perpendicular to the
surface. This is due to the absence of Tomes’ process during the formation of
innermost and outermost enamel.
2. Structural Lines
Cross striations: In longitudinal ground sections, the enamel rods appear to
be divided into uniform segments which are separated by fine dark lines.
These periodic lines are called cross striations. Cross striations are arranged
perpendicular to the enamel rods, at a regular distance of 4 μm giving them a
striated appearance. Thus, each segment is of 4 microns length, representing
the daily deposition of enamel.
Cross striations are better appreciated, in less calcified enamel or after
application of mild acids. There are various views about this cross striations.
It reflects the daily rhythmic deposition of enamel; or created due to relation
between enamel rods and inter-rod substance; or particular orientation of
crystals within the rod. Scanning electron microscopy has revealed periodic
constrictions along the length of a rod which is responsible for cross striation.
Another view regarding these striations is these could be representing an area
of higher organic content and less inorganic content,
Incremental lines of Retzius or striae of Retzius: These are the incremental
growth lines in enamel representing the rhythmic deposition of enamel. In
longitudinal sections of enamel, striae of Retzius (Fig. 4.8) appear as series of
brownish dark lines which extend from the DEJ to the outer enamel surface.
These lines run obliquely across the enamel rods and show an occlusal
deviation as they travel to the surface. Striae of Retzius appear as concentric
circles in transverse sections of enamel, comparable to growth rings of a tree.
Each striae is separated by varying distance ranging from 20–40 microns
separating weekly increments of enamel deposition and appears to be the
result of cyclic disturbance in the rod formation occurring at every 7 to 8
days. The striae are closer and numerous in the cervical region.
3. Gnarled enamel
This is the term used to describe an optical appearance that is seen in the
longitudinal section of the enamel at the incisal or cuspal regions. Enamel
rods follow a wavy, tortuous course (Fig. 4.10) as it travels from the
dentinoenamel junction to the outer surface. Enamel rods undulate back and
forth in a vertical direction and right and left in a horizontal direction. In
addition, the enamel rods of adjacent region may intertwine with each other
in the inner 2/3rds of enamel. This irregular twisting and intertwining is more
prominent and complex at the incisal or cuspal regions, creating this optical
appearance. The irregular twisting and intertwining may be associated with
increased strength of enamel enabling it to withstand the strong masticatory
forces.
Fig. 4.9: Neonatal line in enamel
4. Hunter-Schreger Bands
This term is used to describe alternate dark and light bands found to be
extending from DEJ towards the enamel surface. These lines are curved with
the convexities facing the cervical region. Hunter-Schreger bands (Fig. 4.11)
are considered as optical phenomenon and are observed when longitudinal
section of enamel is examined under reflected light or polarized light.
6. Enamel Spindles
These are the spindle shaped structures, extending from the DEJ into the
enamel to a distance 10 microns. These structures are the odontoblastic
processes that are entrapped in enamel matrix. This occurs because some of
the odontoblastic processes penetrate between ameloblast cells before enamel
formation and subsequently get entrapped in the enamel matrix.
In longitudinal sections of teeth, the enamel spindles (Fig. 4.13) are seen as
dark spindle shaped structures, because the organic matrix is lost while
sectioning and is replaced by air. They are found mainly in the incisal or
cuspal region. Enamel spindles are arranged perpendicular to the dentinal
surface and may not follow the direction of enamel rods.
The enamel spindles are responsible for increased sensitivity at DEJ. These
structures are found more in incisal or cuspal region and thought to be
improving the attachment between enamel and dentin.
7. Enamel Tufts
Developmental faulting occurs in enamel prior to full maturation, probably to
release the built in strain resulting from an internal swelling pressure created
by ongoing crystal growth. Enamel tufts develop where enamel matrix
proteins migrate to fill in the faulting voids, which therefore contain reduced
minerals and enhanced organic matrix concentration. Early faulting leads to
formation of enamel tufts while late faulting produces enamel lamellae.
Enamel tufts are hypocalcified structures extending from the DEJ to the
enamel, to a distance of about 1/5th or 1/3rd of enamel thickness. These
structures are better appreciated in transverse sections of enamel. In ground
sections they appear as tuft of grass, therefore the name enamel tuft is given.
Enamel tufts (Fig. 4.14) are ribbon shaped structures with free ends
undulating to the sides. In a thick ground section, these structures originating
at different planes and curving in different directions are projected to one
plane giving the appearance of tuft of grass. Enamel tufts are seen in the
region where the prism sheath is prominent and these structures contain more
of organic contents which is similar to enamelin.
8. Enamel Lamellae
These are hypocalcified structures that extend from the enamel surface
towards the dentin to varying distance (Fig. 4.14). These structures can be
well identified as leaf like structures in transverse sections of enamel and are
seen more in the cervical half of the tooth than coronal half.
Fig. 4.13: Enamel spindles
The enamel lamellae can be grouped based on time of development into
pre-eruptive or post-eruptive lamellae. Pre-eruptive lamellae are formed due
to stress or tension that is created during formation of enamel. When enamel
rod crosses regions of stress or tension, a small segment of the rod in that
region may remain hypocalcified or uncalcified depending on the degree of
stress. The regions remaining uncalcified manifest as a crack like defect in
formed enamel and get filled with surrounding cells.
The post-eruptive lamellae are formed due to physical or thermal insult to
which the tooth is exposed to. This leads to formation of crack like defect in
formed enamel and gets filled by organic material from saliva.
Based on the nature or content present in the defect, enamel lamellae can
be categorized into three types. They are type A, B and C.
Type A: These are composed of hypocalcified enamel rods and are restricted
to enamel.
Type B: These are crack-like defects formed due to early developmental
faulting caused by the internal swelling pressure that occur due to ongoing
crystal growth. Since these defects are formed before the eruption of tooth
they get filled with cells from surroundings. The cells in the deeper portion
degenerate, while superficial cells form cornfield cuticle or cementum like
material (depending on of the cells entering; either from enamel organ or
connective tissue), which is found in these defects. Type B lamellae may
cross DEJ and reach dentin.
Type C: These are also crack-like defects formed due to late developmental
faulting or due to various physical or thermal insult. In contrast to type B, in
this type the crack-like defects are filled with organic materials probably
derived from saliva. Type C lamellae also may reach dentin.
Enamel lamellae may be mistaken for cracks formed while making ground
sections. To differentiate both, decalcification of the ground section can be
done. The structure that remains after decalcification can be considered as
true enamel lamella.
Clinical Considerations
Enamel hypoplasia: Ameloblasts are very sensitive type of cells and
therefore the function may be affected by a number of environmental as
well as hereditary conditions resulting in defective enamel formation,
which is collectively referred to as enamel hypoplasia.
a. Amelogenesis imperfecta is a hereditary type of enamel hypoplasia
which may be, 1. Hypoplastic type caused due to defective matrix
deposition resulting in teeth with thin layer of normal enamel, 2.
Hypocalcification type with defective calcification resulting in soft
enamel that can be scrapped with blunt instrument or 3.
Hypomaturation type with defective maturation resulting in enamel
that can be scrapped with sharp instrument.
b. Environmental enamel hypoplasia: A number of environmental
conditions including nutritional deficiency, infections, endocrine
disturbances, birth injury, etc. may cause defective enamel formation.
Turner’s hypoplasia is one of the most common forms of enamel
hypoplasia occurs in permanent successor tooth due to trauma or
infection to deciduous predecessor tooth. In patients affected by
congenital syphilis, enamel deposition may be defective resulting in
characteristic Mulberry molar Ingestion of excess amounts of fluoride
can result in enamel defect known as dental fluorosis/mottled enamel.
c. Direction of enamel rods must be kept in mind during cavity
preparation for restoration, to ensure that unsupported enamel is not
left behind. Enamel rods which are not supported by dentin may break
and leads to failure of restoration. For example, as the enamel rods at
cervical part of permanent teeth are inclined cervically, a bevel has to
be prepared at gingival seat to remove unsupported enamel.
d. Enamel lamellae can act as pathway for entry of caries causing bacteria
and act as a point of caries initiation.
5
Dentin and Dentinogenesis
Introduction
Physical properties and chemical composition
Dentinogenesis
Microscopic structure of dentin
Age changes in dentin
Dentin sensitivity
Clinical considerations
DENTINOGENESIS
The process of formation of dentin is called dentinogenesis. The cells that
form dentin are odontoblasts, which are derived from dental papilla, which in
turn, is an ectomesenchymal component of tooth germ.
In the early bell stage the cells of dental papilla adjacent to inner enamel
epithelium align to form a distinct layer. Initially these cells become cuboidal
and later turn to columnar cells utilizing the acellular space between inner
enamel epithelium and dental papilla. These cells develop rich cytoplasmic
organelles for protein synthesis and the nucleus shift from the center to the
basal region. These cells form odontoblast layer that deposit dentin later. The
differentiation of odontoblasts occurs under the organizing influence of inner
enamel epithelium.
Matrix Deposition
Mantle dentin: During the initial stage of dentin deposition, odontoblasts are
not grown to its full size and have space in between, containing ground
substance of dental papilla (Fig. 5.1a). To this pre-existing ground substance
of dental papilla, odontoblasts deposit collagen which together form the
organic matrix of the first formed dentin. The first formed dentin is referred
to as mantle dentin. The collagen fibers deposited are large diameter (0.1–0.2
pm), discrete and arranged perpendicular to the basement membrane. After
the deposition of collagen odontoblasts leave out many matrix vesicles which
help in initiation of mineralization. As the deposition of dentin matrix
proceeds the odontoblasts move inwards pulpally, leaving behind its
cytoplasmic process, referred to as Tomes’ fibers. These cytoplasmic
extensions can be seen in mineralized dentin as odontoblast processes in
dentinal tubules.
Good to Know
The term ‘Von Korff fibers’ is used to describe silver-staining ‘fiber
bundles’, presumed to be collagenous, seen with the light microscope,
which seem to arise from the sub-odontoblast zone of the dental papilla,
pass between the odontoblasts, and fan out to form the fibrous matrix of
the first formed, or mantle dentin, von Korff inl905 demonstrated these
argyrophilic fibers and therefore the term Von Korff fibers’. These fibers
were considered to be aligned parallel to the dentinal tubules in mantle
dentin, whereas in the collagen fibers of circumpulpal dentin lie at right
angles to the tubules.
Later, Ten Cate et al. (1970) concluded that von Korff fiber is an artefact
of light microscopy, created by the deposition of silver in the extracellular
compartment. The reducing sugars in an extensive extracellular
compartment between widely separated pre-odontoblasts, take up the silver
stain, giving a false appearance of black argyrophilic fibers. On this basis,
with continued hypertrophy of the odontoblasts, and the exclusion ofthis
extracellular compartment, the well-recognized reduction in the number of
the so-called von Korff fibers during circumpulpal dentinogenesis was
justifiable. From his research findings, he concluded that classical
collagenous von Korff fibers do not exist and are artefacts. However,
mantle dentin has large diameter collagen fibrils, lying parallel to the
dentinal tubules. Whether it is worth retaining the term von Korff fibers for
these large diameter fibers in dentin is a matter of discussion, as recent
evidence suggests that all dentinal collagen is the product of odontoblastic
activity.
(Ten Cate AR. A fine structural study of coronal and root dentinogenesis in
the mouse: observations on the so-called Von Korff fibers’ and their
contribution to mantle dentin. J. Anat. 1978; 125(1): 183–97)
Fig. 5.1a: Mantle dentin formation
(Note: The large diameter collagen, perpendicular to dentino-enamel junction)
Circumpulpal dentin: After deposition of mantle dentin the odontoblasts
enlarge and get fully differentiated, obliterating the space between them. This
makes it essential for the odontoblasts to secrete both collagen and ground
substance to form organic matrix (Fig. 5.1b). These collagen fibers deposited
are small diameter (50–200 nm), arranged in closely packed bundles which
are parallel to the basement membrane. Odontoblasts do not release matrix
vesicles rather secrete further components such as lipids, phosphoproteins,
etc. to the matrix which may have role in mineralization. The dentin
formation proceeds in the same manner throughout life of the tooth. The rate
of dentin formation is around 4 microns/day till the crown completion which
slows down to 1 micron/day till crown completion. Afterwards it becomes a
slow process which continues throughout life.
Fig. 5.1b: Formation of circumpulpal dentin
(Note: The difference in the type and arrangement of collagen in mantle dentin and
circumpulpal dentin)
Mineralization
For proper mineralization of dentin, three components are necessary, namely
(i) collagen which forms a scaffold, (ii) non-collagenous proteins that bind to
the collagen template and function as a mineral nucleator, and (iii) crystalline
calcium phosphate deposited in an ordered manner. Non-collagenous dentin
matrix proteins 1 and 2 and dentin sialoprotein are important during
mineralized tissue formation. These highly phosphorylated dentin
phosphoproteins (phosphophoryn) are capable of inducing the formation of
hydroxyapatite and can also inhibit mineral growth and regulate crystal size.
Different patterns of mineralization observed in dentin are linear pattern,
globular pattern, and a combination of the two. Linear calcification
primarily found in the mantle dentin, where the deposition of crystals occurs
along an uninterrupted front. Globular, or calcospheric calcification refers to
the deposition of crystals in several areas of the matrix at same time. Crystal
growth takes place in the form of globular or calcopheric mass. These
globular mass enlarges by addition of more crystals and eventually fuses
together to form a homogenous mineralized dentin; failure of which leads to
formation of interglobular dentin. This type of mineralization is seen
principally in the circumpulpal dentin formed just below mantle dentin. The
size of globular mass depends on rate of deposition. As the rate of dentin
formation decreases the size of globules progressively reduces so that
mineralizing front gets a linear pattern giving a relatively smooth surface.
Thus, in the rest of the circumpulpal dentin, a combined pattern of
calcification occurs with a globular phase alternating with a linear phase.
TYPES OF DENTIN
Primary Dentin
The physiological dentin that is formed till the root formation is completed is
referred to as primary dentin. This primary dentin forms the major part of
dentin, both in crown and root. Primary dentin consists of two different types.
Mantle dentin: This is the portion of primary dentin found at the outermost
portions adjacent to dentino-enamel junction and dentino-cemental junction.
This is the first formed dentin and is roughly of 20 microns thickness. This
layer extends from DEJ up to the zone of interglobular dentin. This layer is
different from rest of primary dentin in that, it contains collagen fibers which
are of large diameter, loosely packed and arranged perpendicular to dentino-
enamel junction. The large diameter collagen bundles observed in early
mantle dentin formation, which are extending from the region between
odontoblasts and fanning out to end near the basal region of ameloblasts is
referred to as von Korff’s fibers. The ground substance is derived from dental
papilla which lacks phosphophoryn. The mantle dentin has high organic
component and is slightly less mineralized than rest of dentin (around 4%).
Mantle dentin is better formed with fewer defects.
Circumpulpal dentin: Circumpulpal dentin forms the remaining part of
primary dentin which makes up the bulk of dentin. Circumpulpal dentin is
composed of organic matrix and closely packed, smaller (50–200 nm)
diameter collagen fibers which are arranged parallel to dentino-enamel
junction. The ground substance is also secreted by odontoblasts which
contain phosphophoryn. Circumpulpal dentin is 4% more mineralized than
mantle dentin and may show mineralization defects referred to as
interglobular dentin. Circumpulpal dentin also include the physiological
secondary dentin.
Secondary Dentin
Although at a slower rate, dentin deposition continues throughout the life of
the tooth. The physiological dentin that is formed after root completion as a
part of continuous, lifelong deposition of dentin is referred to as secondary
dentin. This designation is specifically used for part of physiological dentin
that is formed after root formation and is located internally to primary dentin
in crown and root. Although the number of tubules is lesser than in primary
dentin, secondary dentin has regular tubular structure; therefore the term
regular secondary dentin is also used to designate this type of dentin. The
continuous formation of secondary dentin reduces the size of the pulp
chamber gradually. The rate of deposition of secondary dentin is more at the
roof and floor of the pulp chamber causing reduction in the size of the pulp
chamber and decrease in height of pulp horn.
Tertiary Dentin
This is also referred to as irregular secondary dentin, reactive or reparative
dentin which is formed in response to stimuli such as attrition, abrasion,
erosion, cavity preparation, etc. Tertiary dentin in contrast to physiological
secondary dentin is deposited on the pulpal surface of dentin only in the
affected area.
STRUCTURE OF DENTIN
1. Dentinal Tubules
Dentinal tubules are basic structural and functional units of dentin. It is
tubular or canallike branched structures extending from pulpal end to the
dentino-enamel/dentino-cemental junction. Dentin is composed of numerous
dentinal tubules housing protoplasmic processes of odontoblasts.
Odontoblast Processes
In vital teeth, the odontoblasts are arranged as a continuous layer along the
periphery of pulp adjacent to pulpal surface of dentin. Each cell has a
protoplasmic process that extends for varying distance into the dentinal
tubule. These extensions are referred to as odontoblast processes and are the
major content of dentinal tubules. These processes are of 3–4 microns in
diameter at pulpal end and taper to 1 μ near the periphery. Each process has
many fine branches along its entire length and lie in the corresponding lateral
branches of the tubules.
Fig. 5.3: S-shaped dentinal tubules
The odontoblasts processes contain a fine network of microfilaments (5–
7.5 μm) and microtubules (20 μm) running longitudinally. Cytoplasmic
organelles such as ribosomes, endoplasmic reticulum, mitochondria, ly
sosomes and micro vesicles are also seen in odontoblast processes especially
in the portion closer to cell body. Presence of vesicles indicates a secretory
function of odontoblast processes and is responsible for formation of
peritubular dentin.
The question of the length of the process remains unanswered. Formerly, it
was assumed that the processes reach the dentinoenamel junctions. It is,
however, possible that the processes withdraw, but some nonfunctional
remnants of the process may remain, adhering to the tubule wall.
The distance to which the odontoblast processes extend into dentin is
subjected to much research. Recent electron microscopic studies have
confirmed their presence up to the outer surface of dentin till the
dentinoenamel junction. But they do not follow a regular pattern. In certain
region of the tooth these processes may extend beyond the dentinoenamel
junction and remain in calcified enamel and are referred to as enamel
spindles.
Fig. 5.4: Cross-section of dentinal tubules with peritubular and intertubular dentin
The width of peritubular dentin is highest near dentino-enamel junction
(0.75 μm) and progressively decreases in a pulpward direction (0.4 μm). In
pre-dentin the zone of peritubular dentin is absent. Because it is
hypermineralized, in ground sections of teeth, the zone of peritubular dentin
appear lighter when compared to somewhat darker intertubular dentin and is
seen as a clear transparent ring around each tubule lumen. In decalcified
section peritubular dentin is lost and is represented by a space because of
which the dentinal tubules appear larger.
3. Intertubular Dentin
The major bulk of dentin present between the dentinal tubules, i.e. between
the zones of peritubular dentin is called intertubular dentin (Table 5.2). This
dentin is less mineralized than peritubular dentin. The thickness of
intertubular dentin is highest in the region of dentino-enamel junction where
the dentinal tubules are widely separated.
Intertubular dentin is formed by cell body of odontoblasts and is composed
of organic components and apatite crystals, and is arranged in bundles almost
perpendicular to the dentin tubules and the apatite crystals are deposited
along the fibers with long axis of crystals parallel to the long axis of fibers.
Although highly mineralized, intertubular dentin is retained after
decalcification.
4. Interglobular Dentin
The mineralization of dentin begin as calcospheric or globular masses. These
globular masses enlarge by peripheral addition of new crystallites and
eventually fuses together to form a homogeneous calcified mass, i.e. the
mineralized dentin. Sometimes, few of the globular masses remain discrete
and fail to fuse with each other retaining areas of uncalcified or hypocalcified
dentin matrix between them. The term interglobular dentin is used to describe
these uncalcified or hypocalcified zone that exists in mineralized dentin
matrix. Generally the interglobular dentin has a star shape or they have the
curved outlines of globular masses (Fig. 5.5a).
This type of mineralization defects are seen in the coronal circumpulpal
dentin immediately beneath the mantle dentin and this follows an incremental
pattern. It is not unusual for the interglobular dentin to extend to radicular
dentin, to some extent especially in the cervical portion. In the region of
interglobular dentin, the dentinal tubules traverse uninterruptedly (Fig. 5.5b)
indicating that this is purely a mineralization defect and not a defect in matrix
deposition. The dentinal tubules passing this zone do not show peritubular
dentin covering that portion of its course.
While preparing the sections, the organic matrix in the interglobular dentin
is lost and these areas get filled with air. Therefore in ground sections, the
interglobular dentin appear dark under transmitted light and bright under
reflected light.
Fig. 5.5a: Interglobular dentin
6. Structural Lines
Incremental lines: Dentin formation is a rhythmic process with alternating
periods of activity and rest. This cyclic process is registered as incremental
lines which are perpendicular to the dentinal tubules. These incremental lines
in dentin are called imbrication lines/incremental lines of von Ebner. The
dentin matrix is deposited in daily increments of approximately 4
microns/day. The incremental lines correspond to the rest period and separate
each increment of dentin that is formed. Since the rate of deposition vary in
different teeth and in different regions of the same tooth, the distance
between the incremental lines also vary. These lines are closer in the
radicular region than coronal region.
During dentinogenesis, the matrix that is deposited for four or more days
enter into calcifying period at the same time. The incremental lines separating
these adjacent bands of matrix calcifying at different times are more
prominent and are termed as contour lines of Owen (Fig. 5.7). These contour
lines of Owen are hypomineralized areas and some people believe that these
are incremental lines that are accentuated due to disturbance in
mineralization.
Neonatal line: In all deciduous teeth and in permanent first molars, part of
dentin is formed before and part is formed after birth. The prenatal and
postnatal dentin is separated by a distinct incremental line called neonatal
line. This is formed due to disturbance in mineralization as a result of change
in environment at the time of birth.
Good to Know
The exact nature of Tomes’ granular layer is not known. Previously it
was considered as hypomineralized area of radicular dentin, composed of
many minute interglobular dentin. Later these granules were thought to
represent true spaces created by extensive looping and coalescing terminal
portions of dentinal tubules at cemento-dentinal junction. A recent study
by Kagayama et al., using confocal microscopy, demonstrated fluorescent
fibers running parallel to the surface of dentin in the longitudinal sections
in the granules of Tomes’ layer. From these results the researchers
concluded that Tomes’ granular layer may be the collagen fiber bundles
that remained uncalcified or hypocalcified within the radicular dentin.
[Kagayama M, Sasano Y, Tsuchiya M, Watanabe M, Mizoguchi I,
Kamakura S, Motegi K. Confocal microscopy of Tomes’ granular layer in
dog premolar teeth. Anat Embryol (Berl) 2000 Feb; 201(2):131–7.]
7. Pre-dentin
The pulpal surface of dentin is lined by a layer of non-mineralized dentin
matrix. This layer is comparable to osteoid of bone and is termed as pre-
dentin. The pre-dentin layer varies in thickness between 2 and 6 microns or
even up to 20 microns depending on odontoblastic activity; thick during
active dentinogenesis and decreases with age. This is the mineralizing front
of dentin and is always present throughout the life of a vital tooth. This layer
always exists because the mineralization process lags behind matrix
deposition.
This unmineralized pre-dentin layer acts as a protective layer separating
odontoblasts from mineralized dentin. Presence of this layer also has a
functional significance because it covers the mineralized dentin and protects
it from being resorbed.
In a decalcified section, predentin layer appears pale in color, compared to
dark pink colored mineralized dentin.
8. Dentino-enamel Junction
The junction between the dentin and enamel is called dentino-enamel
junction (see Fig. 4.12). The union of dentin with enamel is intimate without
any dividing plane between the two. The matrix of enamel intermeshes into
the surface of dentin. In microscopic section of tooth, due to change in
orientation and difference in size of crystals the DEJ appear distinct.
The dentino-enamel junction is scalloped with convexity facing the dentin.
The domeshaped elevations on the dentinal surface of enamel fits into
depressions on the surface of dentin. The scalloped pattern is occasionally
indistinct or even absent and is best appreciated in regions where the stresses
on tooth structure are the greatest. This scalloped junction increases the
surface area of contact between enamel and dentin and therefore strengthens
the adhesion and union between them. The scalloped dentino-enamel junction
also serves to reduce the chance of development of cracks along the junction,
because of the numerous changes in direction of DEJ.
9. Cemento-dentinal Junction
This is the junction between dentin and cementum and is relatively straight,
in contrast to scalloped DEJ. The cemento-dentinal junction may be scalloped
in deciduous teeth. The junction between dentin and cementum is not very
distinct in acellular cementum while is somewhat distinct in cellular
cementum.
In decalcified sections, cemento-dentinal junction can be identified easily
because cementum stains more intensely than dentin. Collagen fibers of
dentin are dispersed randomly, whereas those of cementum are more orderly
arranged and aggregated into discrete bundles. At the cemento-dentinal
junction, the fibers of dentin and cementum are found to be intertwining.
Sometimes dentin and cementum are separated by a layer of 10 microns
thickness and is termed as Hyaline layer of Hopewell Smith.
Clinical Considerations
Developmental defects: Mutations of genes (DSPP and DMP-1) involved
in dentin formation lead to different forms of developmental disturbances,
namely dentinogenesis imperfecta or dentin dysplasia. Similarly
environmental conditions affecting mineralization such as calcium
deficiency or vitamin D deficiency also cause defective dentin formation.
Dentin sensitivity: Normally dentin is protected from external
environment by enamel in crown and cementum in root. When the dentin
is exposed, patients experiences severe sensitivity, due to patent dentinal
tubules. Exposed dentin becomes less permeable with time. Partial tubule
occlusion occur due to the growth of intratubular crystals from salivary or
dentinal fluid mineral, adsorption of plasma proteins to the inner surfaces
of dentinal tubules, or formation of a smear layer on the exposed dentin
surface. If the patients continue to have sensitive dentin therapeutic
intervention is needed, i.e. use dentin desensitizing agents.
Smear layer: Whenever dentin is cut using hand or rotary instruments, the
mineralized tissue is shattered to produce considerable quantities of debris,
comprising of very small particles of mineralized collagen matrix, and is
spread over the surface to form what is called the smear layer. This layer
extend a few micrometers into the dentinal tubules and may also contain
bacteria and their by-products. This layer may partly block the tubules and
help to reduce sensitivity. However, it need to be removed before placing
restorations.
Protection from injuries: The odontoblast processes in the dentinal
tubules and pulpal tissue has to be protected from chemical, thermal or
galvanic injury. Chemicals from the restorative materials can seep through
patent tubules in to pulp. To prevent these injuries insulating bases need to
be placed under deep restorations.
6
Pulp
Dr Rajeesh Mohammed PK and Dr Girish KL
Introduction
Morphological characteristics of pulp
Zones of pulp
Structure of pulp
Functions of pulp
Age changes
Clinical considerations
DEVELOPMENT
Coronal Pulp
Coronal pulp is located centrally in the crown of the teeth (Fig. 6.1). In young
teeth, the shape of the pulp chamber resembles outer surface of dentin. The
coronal pulp has pulp horns (cornua), which are protrusions that extend into
the cusps of the tooth. The number of pulp horns in most cases equals the
number of cusps. The pulp horns can be inadvertently exposed during cavity
preparation and is more common in case of deciduous dentition. The coronal
pulp has six surfaces, namely the occlusal, mesial, distal, buccal, lingual and
the floor.
At the cervical region, the pulp organ constricts and at this zone coronal
pulp joins the radicular pulp. The pulp chamber is large at the time of
eruption, but decreases in size with advancing age due to continuous
deposition of secondary dentin.
Radicular Pulp
Radicular pulp (Fig. 6.1) extends from the cervical region of crown to the
root apex. Depending on the tooth, they vary in size, shape and number. It
may be seen as a single extension of the coronal pulp in case of anterior tooth
which single root and as multiple extensions in case of multi-rooted teeth. It
may be straight or curved depending on the shape of the root canal. The
radicular pulp is continuous with periapical tissues through apical foramen or
accessory foramen. The radicular pulp is initially tubular in shape, which
later becomes narrower as it goes to apical region. The radicular pulp is
continuous with periapical tissues through apical foramen.
Apical Foramen
Apical foramen (Fig. 6.1) is the opening seen at the root apex, through which
the radicular pulp communicates with the peri-radicular area. It is through
this opening, that the blood vessels and nerves enter the tooth. They vary in
location, size, shape and number. The average size is 0.4 mm in maxillary
tooth and 0.3 mm in mandibular tooth. The apical foramen is wide in young
tooth and becomes narrower with age. The location and shape undergoes
changes as a result of functional influences on the teeth. In case of mesial
migration of tooth, the apex tilts to the opposite direction leading to
relocation of the foramen. Occasionally the opening is found on lateral side
of the root apex. Sometimes there may be two or more foramen, separated by
dentin and cementum or cementum only.
1. Odontoblastic Zone
This zone is found at the periphery of the pulp and consists of the cell bodies
of odontoblasts which lie in a continuous row near the dentinal end of the
pulp. Many nerve fibers enter this zone and terminate between the
odontoblasts. The odontoblastic layer and the subodontoblastic nerve network
combine to form a sensory complex (peripheral sensory unit) that completely
envelop or encapsulate the central pulp core.
Fig. 6.2: Histological zones of pulp
Odontoblasts
Odontoblasts are dentin forming cells which are of ectomesenchymal origin
and are the most distinctive and the second most prominent cells in the pulp.
They have a constant location adjacent to the dentin, with their cell bodies in
the pulp and the cell processes in the dentinal tubules, i.e. the odontoblastic
zone of the pulp. The number of odontoblasts equals the number of dentinal
tubules and the average number is about 59,000–76,000 per square millimeter
in coronal dentin. They are numerous and larger in the coronal pulp than the
radicular pulp. Morphologic variations of odontoblasts range from the tall
columnar cells in the crown of the tooth to a low columnar type in the middle
of the root and are flattened near the apex of the tooth.
Structure
Odontoblasts have a cell body residing in pulp and cytoplasmic process
extending to the dentinal tubules. The cells are approximately 5–7 μm in
diameter and 25–40 μm in length. The odontoblastic cells lie very close to
each other and are connected to adjacent cells by junctional complexes. The
shape of the cell may be influenced by the degree of activity. More active
cells are taller and contain rich synthetic organelles in cytoplasm such as
rough endoplasmic reticulum, Golgi apparatus, mitochondria, vesicles,
granules, etc. The apical part of the cytoplasm, that is near the pulpal—pre-
dentin junction is devoid of cytoplasmic organelles. The cell body contains
an oval nucleus situated at the pulpal end. The cytoplasmic processes begin at
the apical end of the cell just above the apical junctional complex, where the
cell gradually begins to narrow (3–4 μ) as it enters the pre-dentin. The
odontoblastic process is devoid of major cell organelles but microtubules,
filaments and vesicles are present in abundance.
The size, shape and structure of odontoblasts in the pulp are variable
according to the functional activity of the cells. Accordingly, odontoblasts in
three different stages can be identified in pulp which includes synthetic or
active odontoblasts, intermediate or transitional odontoblasts and resting or
aged odontoblasts.
Fibroblasts
Fibroblasts are the most numerous cell types in the pulp, especially abundant
in the coronal pulp. The shape of fibroblasts vary from fusiform with long
slender protoplasmic processes to stellate (star shaped) with shorter numerous
branches. The fibroblasts are numerous in young teeth and decreases with
age. They help in synthesis, maintenance and degradation of pulp matrix.
Immunocompetent Cells
The immune-competent cells are predominated by macrophages, dendritic
cells and lymphocytes. Apart from these, mast cells, plasma cells,
neutrophils, lymphocytes, monocytes, etc. are also seen.
Macrophages
Macrophages are distributed in the central part of pulp. They are large oval or
spindle shaped irregular cells with a clear cytoplasm containing
mitochondria, rough endoplasmic reticulum and free ribosomes and have a
small round dark staining nucleus. They function as scavenger cells, helping
in elimination of dead cells.
Dendritic Cells
Dendritic cells are antigen expressing or antigen presenting cells and are
found in and around the odontoblast layer with dendritic processes extending
between the odontoblasts. They have a close relationship to vascular and
neural elements. They are non phagocytic cells and participate in
immunosurviellance of pulp by capturing and presenting the foreign antigen
to T cells. The number of dendritic cells increases in carious teeth.
EXTRACELLULAR COMPONENTS
Fibers
Fibers present in the pulp are predominantly collagen type I and III in the
ratio of 55:45. The collagen fibers are distributed throughout the pulp and
forms a delicate network. Collagen fibers in pulp, exhibit typical cross
striations at 64 nm. In young pulp the fibrils are of smaller diameter ranging
from 10 to 12 nm and in older pulp the fibrils aggregate into fibers of greater
dimension. The number of collagen fibers increases with age. They may
appear scattered throughout the pulp or may appear in bundles; and
accordingly termed diffuse or bundle collagen. In addition to collagen, the
pulp also contains a few reticulin fibers and elastic fibers.
Ground Substance
The ground substance is particularly abundant in young pulp and is composed
of acid mucopolysaccharides and protein polysaccharide complex
(glycosaminoglycans and proteoglycans). Ground substance provides a
medium for distribution of cells and extracellular fibers and gives support to
cells of the pulp. It serves as a means of transport of nutrients from the
vessels to cells, as well as for transport of catabolites from cells to blood
vessels. The amount of ground substance decreases with age.
Blood Vessels
The pulp organ is well vascularized and is supplied by superior and inferior
alveolar arteries. The blood vessels enter and exit the dental pulp through
apical and accessory foramina. The arterioles entering the apical foramen
follow a straight course up to the coronal pulp. In the coronal pulp the vessels
undergo extensive branching and some travel to the periphery of the pulp to
form a subodontoblastic capillary network (Fig. 6.2). During dentinogenesis
some of the capillaries even loop around the odontoblasts. The arterioles in
the pulp vary in diameter; greatest of 50 to 100 microns to 10 to 15 microns
for terminal arterioles. The arterioles divide to give rise to meta-arterioles,
precapillaries and capillaries. Capillaries of pulp vary in diameter from 7 to
10 microns and shows pores or fenestrations to facilitate exchange of
materials between vessels and its environment. Veins draining the pulp
follow the same course as the arterioles. Arteriovenous anastomoses is also
seen in coronal pulp.
Lymphatic Channels
The lymph vessels that drain the pulp are thin walled having an irregular
lumen composed of endothelial cells surrounded by an incomplete layer of
smooth muscle cells. The anterior teeth drains into the submental lymph
nodes and the posterior teeth drains into the submandibular and the deep
cervical lymph nodes.
Nerves
Nerve supply to pulp is abundant. Nerve bundles enter pulp through apical
foramen. Pulp receives sensory supply from trigeminal nerve and superior
cervical ganglion. The nerves in the pulp are non-myelinated—A δ and A β
fibers which transmits sharp pain or nonmyelinated or “c” fibers which
transmits dull pain. The non-myelinated fibers are sympathetic and are
mainly controlling the luminal diameter of the vessels. The myelinated fibers
entering the foramen follow a course similar to the arterioles. In the coronal
pulp they undergo extensive branching and advance towards the cell rich
zone, again branch and form a network of nerves in the cell free zone below
the odontoblastic zone. This network of nerves are known as plexus of
Raschkow (Fig. 6.2).
2. Sensory
The pulp has both myelinated and non-myelinated nerve fibers. Sensory
nerve fibers present in the pulp respond to stimuli such as changes in
temperature, pressure, vibration and chemical agents that affect the dentin
and pulp.
3. Inductive
The dental papilla, the primordium of dental pulp performs an important
function in determining the crown pattern and differentiation of ameloblasts
through its inductive influence.
4. Formative
The pulp performs the formative function because of the presence of
odontoblasts which are the formative cells of dentin. These cells are involved
in the support, maintenance and continued formation of dentin.
1. Size
With age there is progressive reduction in pulp size due to continuous
secondary dentin deposition. As a result the pulp horns become less
prominent or even obliterated.
5. Pulpal Calcifications
Calcification may occur in pulp tissue as a result of aging or external stimuli.
These may be nodular, calcified masses referred to as pulp stones or diffuse
calcifications.
Pulp stones or denticles are nodular calcified masses present in coronal or
radicular pulp. They are seen in functional as well as embedded or unerupted
teeth. Incidence increases with age: 66% between the age group of 10–30
years, 80% between 30 and 50 years and 90% above 50 years.
Various other etiological factors such as infection, trauma due to operative
procedures, vascular injury resulting in thrombosis and systemic diseases
(atherosclerosis) also have been considered (Flowchart 6.1).
Diffuse Calcification
Diffuse calcification is composed of small calcified particles with a few
larger masses. The calcified structures are arranged as linear strands parallel
to the long axis of pulp. They are found to be closely associated with blood
vessels with an orientation parallel to the vessels and nerves. It is usually
seen only in radicular pulp.
Clinical Significance
Affected tooth is vital, and usually symptomatic but sometimes manifest mild
neurologic pain. Pulpal calcifications may cause difficulty in extripating the
pulp during RCT.
Clinical Considerations
• In young teeth pulp chambers are large with high pulp horns. Therefore
care should be taken while cavity preparation to avoid inadvertent
pulpal exposure.
• Presence of multiple accessory canals in some teeth may cause failure
of endodontic treatment. Similarly, presence of pulp stones also may
cause difficulty in endodontic treatment.
• Pulpal tissue is highly sensitive to various types of trauma which may
be thermal, chemical or mechanical. Mechanical or thermal trauma
during cavity preparation prior to restoration of teeth may permanently
damage the pulp. Similarly, chemicals leached out from restorative
materials or heat transmitted due to inadequate thermal insulation while
restoring the tooth also may have adverse effect on pulp. Therefore
precautions need to be taken while cavity preparation and restoration.
Permanent damage to the pulp causes death of pulp and therefore loss
of vitality of the tooth.
• Vital teeth respond to thermal and electric stimuli and vitality testing is
a basic procedure carried out in dental clinic to diagnose pulpal
diseases. Routinely used pulp testing strategies may involve sensitivity
tests such as thermal or electric pulp testing, which assess whether
there is response to a stimulus.
• Pulp is connective tissue and any type of insult resulting from dental
caries or trauma can cause the inflammation as in case of any other
tissues of the body. Inflammation of dental pulp is called pulpitis.
Pulpitis may be reversible or irreversible. Irreversible pulpitis results in
permanent damage to the pulp and if not treated, progresses further to
infection of periapical tissue. Chronic mild infection of pulp may
induce a proliferative reaction of pulp which is referred to as pulp
polyp. A pulp polyp will present as a pink globular soft tissue mass
filling a large carious cavity. Once the pulpal tissue is involved in
disease process, the tooth needs root canal treatment.
• As pulpal tissue is located in a closed chamber, surrounded by rigid
dentin, pressure built up in pulp due to inflammation result in intense
pain.
• Dental pulp stem cells found within the cell rich zone of dental pulp
has gained significant importance as a potential resource of stem cells
which may be used for regeneration and repair of a multitude of
diseased and injured organs and tissues. These cells exhibit
multipotency due to their embryonic origin, from neural crests. These
mesenchymal stem cells are capable of extensive proliferation and
differentiation, which makes them important. Because of their ability to
produce and secrete neurotrophic factors, these cells may also be
beneficial for the treatment of neurodegenerative diseases and the
repair of motoneurons following the injury.
7
Cementum and
Cementogenesis
Introduction
Physical properties and chemical composition
Cementogenesis
Types of cementum
Structure
Functions
Clinical considerations
Composition of Cementum
Cementum is composed of 45–55% inorganic components and 50–55%
organic material and water.
Inorganic components are mainly calcium and phosphate in the form of
hydroxyapatite crystals which are of the same size as that of bone. In
addition, cementum also contains some trace elements such as copper, iron,
magnesium, potassium, silica, sodium, zinc and fluoride. Cementum has
highest fluoride content of all mineralized structures of the body.
Organic components include collagenous and non-collagenous matrix.
Collagenous matrix primarily comprises type I collagen fibers (90%) and
some type III fibers in extrinsic fibers.
Collagen fibers of cementum are intrinsic and extrinsic fibers based on
their origin (source). Intrinsic fibers are secreted by cementoblasts, the
synthetic cells of cementum while extrinsic fibers are from outside the
cementum, i.e. from periodontal ligament (Sharpey’s fibers) which get
inserted to the cementum. Intrinsic fibers are smaller, of 1–2 μ diameter and
are arranged parallel to the root surface. Extrinsic fibers are of 5–7 μ
diameter, arranges perpendicular to the root surface.
Noncollagenous matix of cementum contains various proteins, of which
major ones are bone sialoprotein and osteopontin, generally accumulate in
cement lines and in the spaces among the mineralized collagen fibrils. In
addition, cementum derived attachment protein, osteocalcin, osteonectin,
tenascin, fibronectin, alkaline phosphatase, proteoglycans such as chondroitin
sulfate, heparin sulfate, hyaluronate as well as several growth factors have
been identified in cementum.
The noncollagenous matrix has a significant role in initiation and
regulation of mineralization process. The amount of non-collagenous
proteins, depends on cementum types and with speed of formation of the
tissue and packing density of collagen fibrils.
Cementogenesis
Cementogenesis is the formation of cementum and is a rhythmic process.
Cells responsible are cementoblasts that are derived from dental follicle of
the tooth germ.
The formation of cementum can be subdivided into a pre-functional and
functional developmental stage. Pre-functional stage refers to formation of
main cementum varieties that occur during root development. On the other
hand, the functional development of cementum commences when the tooth is
about to reach the occlusal level and continues throughout life. Biological
responsiveness of cementum, i.e. adaptive and reparative functions of
cementum is possible because of functional development, which in turn,
influences the alterations in the distribution and appearance of the cementum
varieties on the root surface with time.
Matrix deposition
After the deposition of radicular dentin, Hertwig’s epithelial root sheath
degenerates and loses continuity, exposing the newly formed dentin. This
allows the cells from the inner part of dental follicle to come in contact with
newly formed dentin. These infiltrating dental follicle cells differentiate into
cementoblasts under the inductive influence of dentin or Hertwig’s epithelial
root sheath. These cells develop rich cytoplasmic synthetic organelles and
increased hydrolytic and oxidative enzymes. They deposit cementum matrix
(cementoid) which include both collagen fibers and ground substance.
Cementoblasts deposit collagen onto the dentin matrix which is in the
process of mineralization, permitting intermingling of fibers of these two
tissues at the future dentino-cemental junction. Noncollagenous matrix
proteins are deposited into the spaces between the fibers.
Once the inner part of the cementum is formed, the periodontal ligament
that get inserted into cementum matrix forms the collagen matrix and further,
cementocytes deposit only noncollagenous matrix proteins.
Mineralization
Mineralization of cementum begins after some amount of organic matrix has
been laid down, by deposition of hydroxyapatite crystals in the form of plates
and spicules. Noncollagenous matrix proteins play a significant role in
mineralization. A calcium binding amino acid, known as Gla protein and
osteocalcin and osteonectin act as nucleating substances to initiate
mineralization, bone sialoprotein promote mineralization and osteopondin
regulate crystal growth.
Possible role of cementoblasts released matrix vesicles, in mineralization
of the initial cementum has been suggested by Yamamoto et al. Based on
experimental findings these researchers suggest that during the initial
cementogenesis, cementoblasts release matrix vesicles which result in
formation of calciferous spherules, that trigger the mineralization. After
insertion of principal fibers, mineralization advances along collagen fibrils
without matrix vesicles (Yamamoto et al. Mineralization process during
acellular cementogenesis in rat molars: A histochemical and
immunohistochemical study using fresh-frozen sections. Histochem Cell Biol
2007 Mar; 127(3):303–11).
Cementoblasts that form cementum recedes outward as the formation
proceeds. So the outer surface of cementum will always have cementoblasts
lining the periphery. Since the mineralization process lags behind matrix
formation, a layer of cementoid is seen lining the mineralized cementum at
the inner aspect of cementoblast layer. The cemetoid layer is less distinct or
even absent in relation to acellular cementum. Sometimes a few
cementoblasts get entrapped in cementum matrix which remains in
mineralized cementum in spaces called lacunae. This happens when the rate
of formation of cementum is faster and the formed cementum is referred to as
cellular cementum. As the cementogenesis proceeds fibers from developing
periodontal ligament get inserted into cementum and the portion of principal
fibers embedded in cementum is called Sharpey’s fibers.
Classification of Cementum
Depending on time of formation
• Primary cementum
• Secondary cementum
Based on presence or absence of cells
• Acellular cementum
• Cellular cementum
Good to Know
Origin of cementoblasts
It was generally accepted that cementoblasts originate by differentiation of
the mesenchymal cells of the dental follicle. Recently, a different
hypothesis for the origin of cementoblasts has been proposed, i.e. epithelial
- mesenchymal transformation of Hertwig’s epithelial root sheath cells
result in formation of cementoblasts.
Accordingly, two types of cementoblasts have been identified 1. Cells
derived from Hertwig’s epithelial root sheath that are involved in
formation of acellular cementum; 2. Cells derived from dental follicle, that
form cellular cementum. These cells were reported to be different in
receptors expressed on cell surface as well as in their reaction to signaling
molecules, e.g. receptor for PTH is expressed by cementoblasts derived
from dental follicle, while those derived from Hertwig’s epithelial root
sheath do not express. The former cells express extracellular protein
osteopondin and osteocalcin, thus phenotypically similar to osteoblasts
while latter express only osteopondin and partial osteoblastic phenotype.
However, investigations carried out by Yamamoto et al., suggested that
there is no intermediate phenotype transforming epithelial to mesenchymal
cells, and that epithelial sheath cells do not generate mineralized tissue.
They concluded that the epithelial-mesenchymal transformation does not
occur in Hertwig’s epithelial root sheath in acellular or cellular
cementogenesis and that the dental follicle is the origin of cementoblasts,
as has been proposed in the original hypothesis. (Yamamoto T, Takahashi
S. Hertwig’s epithelial root sheath cells do not transform into
cementoblasts in rat molar cementogenesis. Ann Anat 2009 Dec;191(6):
547–55.) (Yamamoto T, Yamamoto T, Yamada T, et. al. Hertwig’s
epithelial root sheath cell behavior during initial acellular cementogenesis
in rat molars. Histochem Cell Biol 2014 Nov;142(5): 489–96.)
STRUCTURE OF CEMENTUM
Good to Know
The cellular cementum, generally consists of more of intrinsic fibers
exhibiting alternate intensely and weakly stained lamellae (each about 2.5
microns thick). It has been suggested that this pattern results from periodic
changes of arrangement of the intrinsic fibers. According to Yamamoto et
al., the alternate lamellar pattern conforms to the twisted plywood model,
in which collagen fibrils rotate regularly in the same direction to form two
alternating types of lamellae; one type consists of transversely and almost
transversely cut fibrils and the other consists of longitudinally and almost
longitudinally cut fibrils. The development of the intrinsic fiber
arrangement may be controlled by cementoblasts; the cementoblasts move
finger-like processes synchronously and periodically to create alternate
changes in the intrinsic fiber arrangement, and this dynamic sequence
results in the alternate lamellar pattern. (Yamamoto et al., histological
review of the human cellular cementum with special reference to an
alternating lamellar pattern. Odontology 2010 Jul; 98(2): 102–9.)
Intermediate Cementum
The term intermediate cementum is used to describe a type of secondary
cementum found near root tip region of molars and premolars, which shows
some entrapped cellular debris derived from Hertwig’s epithelial root sheath
or odontoblasts layer. This type of cementum is not generally observed in
deciduous teeth and anterior teeth.
Mixed Stratified Cementum
Generally the acellular cementum is distributed in cervical 2/3rds and cellular
cementum at apical third. At times in the apical region or in furcation areas of
multi-rooted teeth, these two types of cementum show an alternate layered
arrangement where the cellular cementum is covered by a layer of acellular
cementum to which in turn, may be added another layer of cellular
cementum. This type of layered arrangement of cementum is referred to as
mixed stratified cementum. This may represent cementum deposited at
different rates in response to adaptive needs.
Cemento-enamel Junction
This is the junction between cementum and enamel at the cervical region of
tooth (Figs 7.4 and 7.5). The relationship between cementum and enamel at
cervical part of the tooth can be of three types (Fig. 7.4). More than one
relationship may occur at different sites around the neck of a given tooth.
Sharp junction or Butt joint or end-to-end approximating CEJ, where enamel
and cementum meet at a sharp line. This type is reported in around 30%
teeth.
Overlap junction: In this type cementum overlaps the cervical region of
enamel. This occurs due to degeneration of cervical region of reduced enamel
epithelium allowing the dental follicle cells to come in contact with newly
formed enamel. The follicle cells differentiate into cementoblasts and deposit
cementum. This type of junction is seen in 60% of teeth. The type of
cementum that is overlapping enamel is acellular, afibrillar type without any
entrapped cells but containing fibrillar component that does not bear
characteristic collagen periodicity.
Cemento-dentinal Junction
This is the junction between dentin and cementum and is relatively straight in
contrast to scalloped DEJ. The cemento-dentinal junction may be scalloped in
deciduous teeth. The junction between dentin and cementum is not very
distinct in acellular cementum while is somewhat distinct in cellular
cementum.
In decalcified sections cemento-dentinal junction can be identified easily
because cementum stains more intensely than dentin. Collagen fibers of
dentin are dispersed randomly whereas those of cementum are more orderly
arranged and aggregated into discrete bundles. At the cemento-dentinal
junction the fibers of dentin and cementum are found to be intertwining,
which is more pronounced in cellular cementum. This intertwining fibers
along with proteoglycans present between, contribute to attachment between
cementum and dentin. It was thought that dentin and cementum are separated
by 10 microns thickness layer termed as hyaline layer of Hopewell Smith.
FUNCTIONS OF CEMENTUM
Clinical Considerations
▪ Hypercementosis is the deposition of excessive amount of secondary
cementum on the root surface. This may involve single tooth or
multiple teeth. Excessive cementum deposition may be only at the apex
or nearly over the entire root area. Hypercementosis may or may not be
increasing the functional efficiency. If hypercementosis is associated
with improved functional quality, it is called cementum hypertrophy
and if it is not related to function as in a nonfunctional tooth, it is called
cementum hyperplasia. Hypercementosis can occur due to local factors
such as abnormal occlusal trauma, chronic periapical inflammation or
unopposed teeth. As a functional adaptation to compensate for the
occlusal wear there can be excessive cementum deposition in some
teeth. Generalized hypercementosis involving multiple teeth is a
finding in Paget’s disease of bone. Teeth affected do not show any
clinical symptoms. Radiographs reveal thickening of root with a round
apex. Hypercementosis may cause problems while extracting, therefore
care should be taken.
▪ Avascular nature of cementum makes it more resistant to resorption
than bone and this nature permits the orthodontic tooth movement
without causing damage to tooth. However, excessive orthodontic
force may result in resorption of cementum.
▪ Cementum resorption or even fracture can occur due to trauma or
excessive forces, but the damage usually is repaired by formation of
new cementum, either acellular or cellular cementum.
▪ Gingival recession or periodontal surgery leads to exposure of cervical
cementum may result in sensitivity particularly in case of gap type of
CEJ.
▪ Absence of cementum or defective cementum formation and therefore
premature loss of deciduous teeth has been reported in conditions like
hypophosphatemia. Congenital absence of cellular cementum in the
deciduous and permanent dentition has been reported in cleidocranial
dysplasia, an autosomal dominant disorder, in which this is related to
the failure in the eruption.
▪ Continuous rhythmic deposition of cementum throughout life is used
for age estimation in forensic odontology.
▪ Cemetum, once exposed to oral environment undergo various changes:
Due to incorporation of minerals from oral environment or adsorption
of microbial toxins from oral microflora, etc.
8
Periodontal Ligament
Dr Rajeesh Mohammed PK and Dr Girish KL
Introduction
Components of periodontium
Structure of periodontal ligament
– Cellular components
– Extracellular component
Functions of periodontal ligament
Clinical considerations
T he tissues which invest and support the tooth in its natural and functional
state are collectively called periodontium. These tissues form the
attachment apparatus of the tooth. The periodontium is comprised of two
mineralized tissues and two fibrous tissues. The alveolar bone and the
cementum form the mineralized components and the periodontal ligament
and the lamina propria of gingiva which contains the gingival group of fibers
forms the fibrous component of the periodontium.
Components of Periodontium
Two mineralized tissues
– Alveolar bone
– Cementum
Two fibrous tissues
– Periodontal ligament
– Lamina propria of gingiva
PERIODONTAL LIGAMENT
Shape
Periodontal ligament resembles the “Hour glass” in shape as it is narrowest in
the middle third of the root and widens both apically and near the alveolar
crest.
Width
The width of periodontal ligament is variable, the average width ranging from
0.15 to 0.38 mm. The width of periodontal ligament decreases with age,
which can be partly attributed to the reduced functional load.
Development
The periodontal ligament develops from the dental follicle, an
ectomesenchymal component of tooth germ. As the root formation
progresses, the dental follicle cells differentiate into cementoblasts to
produces cementum, osteoblasts to produces bone and fibroblasts to produce
the fibers and ground substance of periodontal ligament. As the root
formation proceeds the fibers get embedded in the forming cementum and
alveolar bone.
In the initial stages of formation of periodontal ligament, the ligament
space consists of unorganized short connective tissue fiber bundles which
extend from the cementum and the alveolar bone. As the tooth erupts the
fibers orient themselves in various characteristic planes.
Osteoblasts
Osteoblasts are the bone forming cells derived from the multipotent
mesenchymal cells. They cover the periodontal surface of alveolar bone and
constitute a modified endosteum. The osteoblasts help in the formation of
organic matrix of bone (osteoid) and in the mineralization of the matrix.
Osteoblasts lining the periodontal surface of the alveolar bone may be either
resting or active. Active osteoblasts are plump with abundant synthetic
organelles while resting cells are flattened (for details refer page 95).
Cementoblasts
Cementoblasts are the cementum forming cells which are derived from the
undifferentiated ectomesenchymal cells of the dental follicle and they
resemble osteoblasts and are most often in resting stage. These cells are
distributed along the periodontal surface of cementum. The cementoblasts
help in the formation of cementum which has a functional importance in
maintaining the width of periodontal ligament (for details refer page 79).
Fibroblasts
Fibroblasts are the most numerous and functionally important connective
tissue cells in periodontal ligament. They may be plump, spindle-shaped or
fusiform and are oriented parallel to the collagen fibers. They are large cells
with extensive cytoplasm containing abundant cellular organelles associated
with protein synthesis and secretion such as rough endoplasmic reticulum,
Golgi complex, mitochondria, etc. Unlike other cells, the fibroblasts perform
the dual function of synthesis as well as degradation of collagen fibers,
thereby helping to maintain the turnover of collagen and homeostasis of
periodontal ligament. Fibroblasts produces collagen and ground substance
required for periodontal ligament. They participate in collagen degradation by
secreting collagenase enzyme and by phagocytosing and degrading the
collagen molecules. The fibroblasts in the ligament exist as different
subpopulation, although they look alike at both light and electron
microscopic levels. Fibroblasts in the periodontal ligament are also referred
to as myofibroblasts because of the presence of contractile elements such as
actin and myosin in their cytoplasm, to provide contractile force required for
tooth movement.
Osteoclasts
Osteoclasts are multinucleated giant cells, approximately 20–100 microns in
diameter (refer Figs 9.4a and b). These cells are found in Howship’s lacunae
and have a brush or ruffled border towards the surface to be resorbed. The
osteoclasts help in the resorption of bone (for details refer page 96–97).
Cementoclasts
Cementoclasts resemble osteoclasts structurally and functionally and helps in
the resorption of cementum and other dental hard tissues (for details refer
page 289–290).
Progenitor Cells
Progenitor cells are undifferentiated mesenchymal cells which have the
capacity to undergo mitotic division. Pleuripotent undifferentiated
mesenchymal cells are present in the periodontal ligament which can give
rise to various synthetic cells. They have a perivascular location and are
usually found in a quiescent state having a small close-faced nucleus and a
little cytoplasm. These cells can enter the cell cycle when triggered by stimuli
and undergoes cell division, giving rise two daughter cells, one of which
differentiates into the synthetic cell type while the other remains in the
progenitor compartment.
Macrophages
Macrophages are the scavenger cells with a round or ovoid shape with a
horseshoe or kidney shaped nucleus. The cytoplasm contains numerous
lysosomes. These cells are derived from blood monocytes are usually located
near the blood vessels.
The extracellular components of periodontal ligament
Fibers
– Collagen (type I, III and XII)
– Oxytalan
– Eluanin
Ground substances
– Glycosaminoglycans
– Glycoproteins
Structures present in the connective tissue
– Blood vessels
– Lymphatics
– Nerves
– Cementicles
– —
Collagen Fibers
Collagen is a high molecular weight protein to which small numbers of
sugars are attached. Collagen fibrils have a transverse striation with a
characteristic periodicity of 64 nm. Collagen is secreted mainly by
fibroblasts, and are secreted as tropocollagen which aggregates into
microfibrils which are arranged to form fibrils. These fibrils are packed to
form fibers and the fibers are then packed to form bundles. Periodontal
ligament has predominantly collagen type I, III and XII.
The collagen fibers in the periodontal ligament are found to be gathered
into bundles and organized as functional groups having clear orientation
relative to the periodontal space. These fiber groups are termed as principal
fibers and are assisted in function by a second group of fibers called
accessory fibers.
a. Supportive Function
The periodontal ligament fibers provide attachment of the tooth to the bone.
It helps to transmit masticatory forces to the bone and acts as a shock
absorber against external forces. By providing cushioning effect, the
periodontal ligament protects the vessels and nerves from mechanical injury.
The periodontal ligament also helps to maintain the proper relationship
between gingiva and the tooth.
Tooth support and shock absorption is explained on the basis of three
theories.
Tensional theory: Attributes the major role for the principal fibers of the
periodontal ligament in supporting the tooth and transmitting forces to the
bone.
Viscoelastic system theory: According to this theory displacement of tooth
is largely controlled by fluid movements while fibers have only secondary
role.
Thixotropic theory: Periodontal ligament has rheologic behavior of a
thixotropic gel.
b. Sensory Function
The periodontal ligament through its nerve supply provides efficient
proprioceptive mechanism. This mechanism is so effective that, it is possible
to sense even a grain of sand that is caught between the teeth.
c. Nutritive Function
The periodontal ligament transmits blood vessels which provide anabolites
and remove catabolites from the cells of ligament, cementum, and alveolar
bone. This is of particular importance in case of cementum, as it is avascular
and has to depend entirely on the periodontal ligament for nutrition.
d. Homeostatic Function
Periodontal ligament has synthetic cells and resorptive cells of various
structural components of periodontal ligament. These cells synthesis and
resorb the connective tissue components of periodontal ligament cementum
and alveolar bone. Therefore they help in remodeling of these components
which is very essential for maintaining functional integrity of periodontium.
The activity of these cells are well controlled and balanced, therefore
various components of periodontium are able to maintain their integrity and
relationship to each other. Any disturbance in homeostatic function may
disturb the functional efficiency of attachment apparatus of teeth.
(Age changes, refer page 323)
Clinical Considerations
▪ Periodontal ligament thickness varies in different teeth, is thicker in
functioning teeth than in non-functioning teeth. Abnormal occlusal
forces can damage the periodontal ligament resulting in stretching of
periodontal ligament and expressed as widening of periodontal
ligament space. Abnormal thickening of periodontal ligament,
expressed in a radiograph as uniform widening of periodontal ligament
involving many teeth is a characteristic finding in a disease called
scleroderma.
▪ Ankylosis is a condition in which the tooth roots become fused directly
to the alveolar bone proper and poses difficulty in extraction. Trauma
that damages the periodontal ligament may result in ankylosis.
▪ Tooth which is accidentally knocked out (avulsion) can be reimplanted
only if the periodontal ligament cells are viable.
▪ Untreated gingival inflammation (gingivitis) may progress to involve
the supporting structures. This condition is termed as periodontitis,
which leads to destruction of periodontal ligament and supporting
alveolar bone and mobility of teeth, eventually premature loss of tooth.
▪ Resorption (on the pressure side) and formation (on tension side) of
both bone and PDL forms the basis for orthodontic tooth movement.
9
Alveolar Bone
Dr Heera R
Introduction
Structure of alveolar bone
Development
Chemical composition
Bone histology
Bone remodeling
Clinical considerations
T he alveolar process is that part of the jaw bones in which teeth are found.
It can also be defined as the part of maxilla or mandible that forms and
supports the socket of the teeth in which the teeth are anchored.
Alveolar bone is seen as an extension from the body of maxilla and mandible
without any distinct boundary between them. But an arbitrary boundary can
be drawn at the level of root apices of the teeth which separates the alveolar
process and the basal bone. Like bones in other sites, alveolar bone function
as a mineralized supporting tissue, giving attachment to muscles, providing
frame work for bone marrow and acting as a reservoir of ions, especially
calcium. Alveolar bone is dependent on the presence of teeth for its
development and maintenance.
STRUCTURE
DEVELOPMENT
BONE HISTOLOGY
All bones have a dense outer sheet of compact bone and a central medullary
cavity. The medullary cavity is filled with red or yellow bone marrow. The
marrow is interrupted by a network of bony trabeculae and is known as
trabecular, cancellous or spongy bone.
In adult bone, histologically, both the compact and the trabecular bone
consists of lamellae. Three types of lamellae have been recognized:
circumferential, concentric and interstitial lamellae (Fig. 9.2).
Circumferential lamellae form the outer perimeter of the bone. The bulk of
compact bone is made up of concentric lamellae. The interstitial lamellae fill
the space between adjacent concentric lamellae. The interstitial lamellae are
considered as the fragments of previous concentric lamellae as a result of
remodeling and they contain old remnants of circumferential lamellae as well
as osteonal remnants.
Cells of Bone
Different cell types are responsible for formation, resorption and maintenance
of bone. Two cell lineages are present in bone:
Osteogenic cells derived from mesenchymal (or ectomesenchymal) stem
cells, including osteoprogenitors, preosteoblasts, osteoblasts and osteocytes
which form and maintain the bone.
Osteoclasts, which resorb bone are derived from monocytes and
macrophages and form part of hematopoietic system.
Osteoblasts
Osteoblasts are mononucleated cells of mesenchymal origin and seen as a
layer of cuboidal cells on the surface of bone where bone formation is taking
place. The cells are polarized with a prominent, round nucleus located at the
basal end. The active osteoblasts exhibit basophilic cytoplasm due to the
presence of large amount of RNA content. The cytoplasm contains rich
synthetic organelles such as, rough endoplasmic reticulum, numerous
mitochondria, Golgi complexes and vesicles, etc. The cells contact one
another by means of adherence and gap junction. These cells exhibit high
levels of alkaline phosphatase on the outer surface of their plasma membrane.
Osteoblasts are the synthetic cells of the bone which are involved in
secretion of the organic matrix of bone, i.e. osteoid and also help in
mineralization of uncalcified matrix.
In addition the osteoblasts have a controlling influence in activating
osteoclasts. They contain receptors for parathyroid hormone and regulate
osteoclastic response to this hormone. They also participate in matrix
degradation though the production of hydrolytic enzyme and interleukin-6.
When the bone surfaces are neither in the formative nor resorptive phase,
the layer of osteoblasts lining the bone surface flatten and these cells are
called bone lining cells. These cells cover most surfaces in the adult skeleton
and contain only few cell organelles with little sign of synthetic activity.
They retain their gap junctions with the osteocytes. They are regarded as post
proliferative osteoblasts and protect the bone from resorptive activity of
osteoclasts. They can be reactivated to form osteoblasts.
Osteocytes
During bone formation, some osteoblasts become entrapped with in the
matrix of the bone; these entrapped cells are called osteocytes (Fig. 9.4a).
The number of osteoblasts, that become osteocytes depend, on the rate of
bone formation. The more rapid the formation the more osteocytes are
present per unit volume. So the embryonic (woven) bone and repair bone
have more osteocytes than does lamellar bone. Usually about 15% of
osteoblasts become embedded in the organic matrix as osteocytes.
Approximately 25,000 osteocytes can be seen per cubic mm of bone. The
space in the matrix, occupied by an osteocyte is called the lacuna. Many fine
canals called canaliculae radiate from the lacunae in all directions which
contain cell processes of the osteocytes (Fig. 9.3). Through this canaliculae,
osteocytes maintain contact with adjacent osteocytes, osteoblasts and lining
cells. As a result of this inter connections the osteocytes are regarded as the
main mechanoreceptors of bone. Osteocytes are thought to be capable of
taking part in bone resorption which is referred to as osteocytic osteolysis.
At the ultra structural level, the appearance of osteocytes vary according to
its position in relation to the surface layer. Osteocytes which are newly
incorporated into the bone matrix contain larger amount of organelle like
osteoblasts. With continued bone formation, the osteocytes become more
deeply situated and the number of organelles shows reduction, reflecting
decreased cellular activity.
Osteoclasts
Osteoclasts are multinucleated giant cells responsible for bone resorption;
they are derived from hematopoietic cells of monocyte or macrophage
lineage by fusion of mononuclear precursors. They can be easily
differentiated under light microscope because of their large size and multiple
nuclei. The cells show considerable variation in size and shape. The cell body
is irregularly oval and may show many branching processes. Usually
osteoclasts contain 10–20 nuclei and the size is about 100 microns in
diameter (Fig. 9.4a).
Tissue culture studies indicate that osteoclasts are highly motile and is
evident from the ‘snail tracks’ on the bone surface. The osteoclasts are
recruited only when required since there is no significant reservoir of inactive
osteoclasts. The life span of osteoclasts is thought to be about 10–14 days.
Osteoclasts are characterized cytochemically by possessing tartrate resistant
acid phosphatase within its cytoplasmic vesicles and vacuoles which,
distinguishes it from other multinucleated giant cells.
Typically osteoclasts are found occupying hollowed out depressions on the
resorbing surface known as Howship’s lacunae that they have created.
Scanning electron microscopy shows that the Howship’s lacunae are shallow
troughs with irregular shape which reflect activity and mobility of osteoclasts
during active resorption.
Under electron microscopy, osteoclasts exhibit the following morphologic
characteristics (Fig. 9.4b). The cell membrane of the osteoclast that lies
adjacent to resorbing bone surface is thrown into a number of deep folds that
form the ruffled border. It is composed of many tightly packed microvilli.
This ruffled border provides a large surface area for the resorptive process.
The cytoplasm adjacent to the ruffled border is devoid of cell organelle but
contains numerous contractile actin microfilaments and this zone is referred
to as clear zone. At the periphery of the ruffled border, the plasma membrane
is apposed closely to the bone surface. This sealing zone serve to attach the
cell very closely to the surface of bone and create a microenvironment in
which resorption can take place without diffusion of the hydrolytic enzymes
produced by the cell into adjacent tissue.
Bone Resorption
Once the osteoclast has been activated against the bone surface, bone
resorption occurs in two stages. Initially, the mineral phase is removed and
later the organic matrix. A sealed acidic microenvironment is created in the
resorption lacunae which dissolves the mineral crystals in bone and exposes
the organic matrix. To provide the low pH, the osteoclast secretes protons
across the ruffled border by means of ATP dependent protein pump that
pumps H+ ions to sealed compartment. The H+ ions are generated by the
action of enzyme carbonic anhydrase II on the carbon dioxide and water to
form carbonic acid. The organic matrix is then degraded by the action of
enzymes like collagenase, lysosomal acid proteases (cathepsin B1). The
inorganic and organic bone degradation products are taken inside the
osteoclasts by endocytosis at the ruffled border. These endocytosed products
are translocated in transport vesicles and released extracellularly along the
membrane opposite the ruffled border.
REMODELING OF BONE
The process by which the over all size and shape of bone is established is
referred to as bone remodeling and extends from embryonic bone
development to the preadult period of human growth. During this phase bone
is formed on the periosteal surface. Bone is laid down rhythmically; there are
periods of active deposition and quiescence which result in formation of
regular parallel incremental lines, called resting lines. The resting lines are
formed in periods of relative quiescence (rest period). Simultaneous with
bone deposition bone is resorbed along the endosteal surface at focal points.
During the growing phase of a child, the amount of bone deposition
exceeds that of resorption resulting in increase in bone mass. During adult
phase, the amount of bone deposition is equivalent to that of bone resorption
and bone mass is more or less constant. In old age and in diseases like
osteoporosis bone deposition is generally less when compared to resorption.
Therefore there is an overall decrease in bone mass. The replacement of old
bone, by new bone is called remodeling or bone turn over. In rapidly growing
children bone turn over is about 30–100%. The rate of remodeling decreases
in adults. This bone turn over occurs in discrete focal areas involving groups
of cells called bone remodeling units. The rate of cortical bone turn over is
approximately 5% per year, where as trabecular bone and endosteal surface
of cortical bone is 15% per year.
As the bone deposition continue at the periphery by deposition of
circumferential lamellae, the internal reconstruction of Haversian system take
place to meet the functional and nutritional demands. During this process,
osteoclasts differentiate in the peripheral Haversian canals to cause resorption
of concentric lamellae. The leading edge of resorption is always towards the
periphery and is called cutting cone or resorption tunnel. Initially, the
resorbed area gets filled with loose connective tissue followed by migration
of mononucleated cells onto the area. As these cells differentiate into
osteoblasts, they produce a coating, a thin layer of glycoprotein (mainly bone
sialoprotein and osteopontin) that, acts as a cohesive, mineralized layer
between the old bone and the new bone to be secreted. On top of this
osteoblasts begin to lay down new bone matrix mineralizing it from outside
in. The area of active formation is termed as the filling cone. As bone
formation proceeds some osteoblasts become osteocytes. The old and new
bones are separated by a distinct curved hematoxiphilic line with its
convexity facing the old bone. These lines are called reversal lines and are
indicators of continuous remodeling of bone.
A considerable amount of internal remodeling occurs within the bone by
means of resorption and deposition. The repeated deposition and removal of
bone tissue accommodates the growth of a bone without losing function or its
relationship to neighboring structures during remodeling phase. The
remodeling is enabled by the coordinated action of osteoclasts and
osteoblasts. Bone metabolism is directly under the control of various
hormones (for details refer Chapter 43).
(Age changes, refer Chapter 46)
Clinical Considerations
• Alveolar bone being part of jaw bone bearing teeth, existence of
alveolar bone is significantly dependent on teeth. Alveolar bone may
not be well developed in disease conditions where there is complete or
partial absence of teeth. Similarly alveolar bone undergo resorption
once the teeth are lost.
• Alveolar bone undergoes continuous remodeling to maintain functional
integrity. The response of alveolar bone to applied force and
remodeling capacity forms the basis of orthodontic tooth movement
• Alveolar bone undergoes destruction or resorption in cases of local
conditions such as periodontitis or due to pressure from cysts or
tumours. Alveolar bone loss may eventually results in mobility of
teeth.
• Alveolar bone or the basal bone can be common site of involvement of
various bone disorders such as fibrous dysplasia, Paget’s disease, etc.
• Radiographic examination of status of lamina dura and periapical bone
tissue is a routine procedure carried out in the diagnosis of periapical
diseases.
10
Oral Mucosa
Introduction
Functions of oral mucosa
Classification of oral mucosa
Structure of oral mucosa
Structural variations
Clinical considerations
O ral mucosa is the moist lining of the oral cavity. The mucous lining of
oral cavity shares some features with skin as well as the mucosa lining
the gastrointestinal tract.
Keratinized Epithelium
Light microscopic structure: Four different layers are seen in keratinized
oral epithelium (Figs 10.2a and b).
Stratum basale/basal cell layer: This layer is composed of single layer of
cuboidal or columnar cells that rest on the basement membrane. Basal and
parabasal cells have the capacity to undergo mitotic division. So these cell
layers are also called as proliferative or germinative layer (stratum
germinativum). Basal cells have basophilic cytoplasm and centrally placed
nucleus which is hyper chromatic and relatively larger, occupying 1/3rd of
cytoplasm. The nucleus is arranged perpendicular to basement membrane.
Stratum spinosum/prickle cell layer: It is seen above basal layer and
composed of several rows of polyhedral cells. As the cells pass from basal
layer to prickle cell layer, there is considerable decrease in basophilia,
making the boundary between these layers distinct. Cells are larger than basal
cells and have centrally placed round or ovoid nucleus. The nuclear
cytoplasmic ratio of spinous cells is 1:6. This layer is also called prickle cell
layer because in histological sections, cells have a spiny or prickly
appearance. While tissue processing, cells shrink away from each other
remaining in contact only in the areas of intercellular attachment, resulting in
a prickly appearance. In stratum spinosum as the cell mature and move
superficially they increase in size and become more flattened with flattened
nucleus in a plane parallel to the surface.
Stratum granulosum/granular cell layer: This layer is composed of few
layers of flattened cells seen immediately above stratum spinosum. The
cytoplasm of the cells in this layer is filled with basophilic granules called
keratohyaline granules and hence the name stratum granulosum. The
nucleus of these cells are flattened with long axis parallel to the outer surface
of epithelium.
Figs 10.2a and b: Keratinized mucosa
Stratum corneum/cornified layer: This is the most superficial layer found in
keratinized epithelium and is composed of keratin squames which are larger
and flatter than the cells of stratum granulosum. This layer appears as
eosinophilic amorphous layer in histologic sections. As the cells reach the
cornified layer nucleus undergoes degeneration. If the nucleus is completely
absent in surface layer, the pattern of maturation is called as
orthokeratinization. If pyknotic nucleus is retained in all or some squames it
is called as parakeratinization. Parakeratinized epithelium is mainly seen in
gingiva. In parakeratinized epithelium the keratohyaline granules in stratum
granulosum is less prominent.
Prickle cells
Overall size of the cell and nucleus increases as it passes to spinous cell layer
(Fig. 10.3). Nucleus has evenly distributed chromatin with 2–3 nucleoli.
Cytoplasm is rich in organelles for protein synthesis. The proteins
synthesized by these cells are primarily the fibrilar proteins, known as
cytokeratin and this indicate these cells are in the process of differentiation.
The concentration of the tonofilaments increases and gets arranged to form
bundles. The cells are attached to each other by desmosomes. The number of
desmosomes and width of intercellular space is more in keratinized
epithelium. The size of desmosome is wider in prickle cell layer than basal
cell layer. As the cell passes to upper prickle layers the desmosomes become
smaller.
Fig. 10.3: Ultrastructure of cells of keratinized epithelium
Cells in the upper part of prickle cell layer show new cytoplasmic
organelles called Odland bodies. These are also known as membrane coating
granules, cytoplasmic lamellated body, keratinosomes, microgranules or
cementosomes. (Odland bodies are also present in nonkeratinized epithelium
but are structurally different.)
In keratinized epithelium Odland bodies appear as ovoid membrane bound
organelles of 0.25 microns length, containing a series of parallel internal
lamellae consisting of alternate electron lucent and electron dense bands.
These organelles may be derived from Golgi bodies. The size of the Odland
bodies do not increase but the density increases as the cell passes to more
superficial layer and also these structures move closer of superficial cell
membrane.
Granular layer cells: In this layer the size of the cells still increases. The
cells are flatter with long axis parallel to the epithelial surface. Nucleus is
also flattened and shows pyknotic changes. The cells still retain the capacity
for protein synthesis, only to a lesser extent. This is indicated by decrease in
number of cytoplasmic organelles. Although the cells show a decrease in
cytoplasmic components, the amount of tonofilaments is found to be more.
The cell surfaces become more regular and closely approximated with each
other. Odland bodies are also present in these cells where they fuse with the
superficial cell membrane and discharge the contents into the intercellular
spaces. This discharged material provide lipid rich permeability barrier, at the
junction of stratum granulosum and stratum corneum, that limits the
movements of substances through intercellular spaces.
Desmosomes maintain their structure in this layer while the intercellular
contact layer of desmosomes becomes more condensed. Cytoplasm of
stratum granulosum cells also shows keratohyaline granules. In keratinized
epithelium these are variable in size ranging from 0.1–1.5 microns. Their size
and number increases as the cell moves through the granular layer.
Keratohyaline granules are usually angular or irregular and they are usually
associated with ribosomes suggesting they are synthesized by ribosomes.
Keratohyaline granules contain sulphur rich proteins fillagrin and loricrin
which provide an embedding matrix for the tonofilaments and therefore help
in aggregating the tonofilaments. They also contain a protein involucrin
which provide constituents for the cell membrane thickening and makes it
resistant to chemical solvents.
Stratum corneum: Ultrastructurally stratum corneum is composed of cells
resembling hexagonal discs called squames (Fig. 10.3). Large amount of
bundles of keratin tonofilaments are found to be embedded in a matrix that is
contained in a thick envelope. Keratin is a tough insoluble protein which
more or less completely fills the interior of shrunken cells. Cellular organelles
are almost completely lost and these cells do not produce protein. The
nucleus may be completely lost in case of orthokeratinization or remain
pyknotic in parakeratinization. The cell membrane is thickened. Desmosomes
can be still recognized but they become less distinct. As the cell passes to the
superficial layer, desmosomes tend to degenerate resulting in desquamation
of cells.
Desquamation
The physiological process of shedding off of the superficial cells of
epithelium is called as desquamation. Mechanism of desquamation is not
fully understood. The possible mechanisms include:
Release of hydrolytic enzymes from membrane coating granules causing
destruction of desmosomes which leads to desquamation.
Intercellular junctions have a physiological life span after which there will be
rapid breakdown, leading to desquamation.
Nonkeratinized Epithelium
Light microscopically three different layers are seen in nonkeratinized
oral epithelium (Fig. 10.4)
Stratum basale/basal cell layer: This layer is similar to that of basal layer of
keratinized epithelium and is composed of single layer of cuboidal or
columnar cells immediately adjacent to basement membrane. Basal cells have
centrally placed nucleus which is hyper chromatic and relatively larger and
occupies 1/3rd of cytoplasm. The cytoplasm of these cells shows significant
basophilia due to high RNA content.
Stratum intermedium: This layer is composed of several rows of polyhedral
cells located above basal layer. The cytoplasm of these cells takes up
eosinophilic stain and therefore this layer can be easily differentiated from
basal cells exhibiting basophilic cytoplasm. Cells are larger than basal cells
and have centrally placed round nucleus. The nuclear cytoplasmic ratio of
spinous cells is 1:6. In contrast to stratum spinosum of keratinized
epithelium, the cells of this layer are closely apposed to each other and
prickly appearance is not distinct. As in stratum spinosum, these cells
increase in size when they mature and move superficially and also become
more flattened with flattened nucleus in a plane parallel to the outer surface.
Stratum superficiale: This is the most superficial layer found in
nonkeratinized epithelium and is composed of few layers of flattened cells.
The nucleus of these cells are flattened with long axis parallel to the outer
surface of epithelium. These cells ultimately undergo desquamation.
Stratum Intermedium
Overall size of the cell and nucleus increases as it passes to stratum
intermedium (Fig. 10.5). Relative increase in size of the cell and nucleus is
more in nonkeratinized epithelium than in keratinized epithelium. Nucleus
has evenly distributed chromatin with 2–3 nucleoli. Cytoplasm is rich in
organelles for protein synthesis. The concentration of tonofilaments is more
than that in basal cells but in contrast to the cells of stratum spinosum,
tonofilaments are found in unbundled form. The cells are attached to each
other by desmosomes. The number of desmosomes and width of intercellular
space is less in nonkeratinized epithelium. The size of desmosome is wider in
stratum intermedium than basal cell layer but as the cells move more
superficially the number of desmosomes becomes lesser.
Superficial cells of stratum intermedium show cytoplasmic organelles
called Odland bodies which are structurally different from that of the
keratinized epithelium.
In nonkeratinized epithelium Odland bodies appear as spherical membrane
bound organelles of 0.2 microns diameter. These structures have an electron
dense core from which delicate radiating strands are observed. The size of the
Odland bodies do not increase but their density increases as the cell passes to
more superficial layers and also these structures move closer to superficial
cell membrane.
Stratum Superficiale
In this layer, there is further increase in the size of the cells. The cells are
flatter with long axis parallel to the epithelial surface (Fig. 10.5). Nucleus is
also flattened and shows pyknotic changes. The cytoplasmic organelles
decrease in number indicating a lesser capacity to produce protein. Although
the cells show a decrease in cytoplasmic components, the amount of
tonofilaments is found to be more but in unbundled form. The cell surfaces
become more regular and closely approximated with each other.
Desmosomes decrease in size and number and intercellular space becomes
wider and irregular and maintain their structure in this layer while the
intercellular contact layer of desmosomes become more condensed.
Intercellular Junctions
Intercellular junctions are cell junctions that bind the cells to one another and
allow intercellular communication. Three different types of junctions may be
seen between the epithelial cells, which include desmosomes, tight junctions
and gap junctions (Fig. 10.6).
Desmosomes
Desmosomes are the most characteristic and most numerous type of
intercellular junctions seen in epithelial cells. Ultrastructurally desmosomes
(Fig. 10.7) are present as a circular or ovoid area of 0.2–0.5 microns in which
plasma membranes of adjacent cells remain in juxtaposition to each other
with a distance of 25–30 nm. This space between the plasma membrane
contains an electron dense lamina called intercellular contact layer. This layer
is composed of protein particles of 5 nm diameter which are arranged in a
row.
On the cytoplasmic side, plasma membrane of each of the adjoining cells
show a thickening called attachment plaque and this structure contain the
proteins desmoplakin, plakoglobin and plakophilin. The tonofilaments
present in cytoplasm of each cell run into attachment plaque and loop out
again. The tonofilaments are not attached to the plasma membrane. This
arrangement of tonofilaments helps to dissipate physical forces from
attachment site throughout the cell. There are a separate group of smaller
filaments containing protein cadherins (desmogleins and desmocollin)
attaches the tonofilaments to plasma membrane, penetrate the cell membrane.
These filaments are called as traversing filaments and they traverse the
intercellular region to extend into the intercellular contact layer. The
traversing filaments from both cells come and attach to the intercellular
contact layer retaining the attachment between the cells.
Epithelium connective tissue interface is• Rete ridges are short and
very irregular with long and narrow rete irregular
ridges, interdigitating with connective tissue
papillae.
Four distinct layers are seen in epithelium:• Only three layers are seen:
stratum basale, stratum spinosum, stratum Stratum basale, stratum
granulosum, stratum corneum intermedium, stratum
superficiale
Adjacent cell surfaces are less• Adjacent cell surfaces are more
closely applied closely applied
Odland bodies are ovoid with• Odland bodies are round in shape
alternating electron dense and lucent with central electron dense core
areas and radiating lines
Stratum granulosum with distinct No layer called stratum
keratohyaline granules are seen granulosum is found, no
keratohyaline granules.
Superficial layer is composed of Superficial layer is composed of
keratin flakes Superficial cells do not flattened cells Surface cells
have nucleus or cytoplasmic contain nucleus and cytoplasmic
organelles organelles
Tight Junctions
Tight junctions are characterized by fusion between adjacent plasma
membranes without any intervening space and act as diffusion barriers.
Gap Junctions
The junctions that allow cytoplasmic compartments of adjacent cells to
communicate are special adaptation of mucous membrane channels and are
called gap junctions.
In gap junctions, adjacent cell membranes run parallel to each other with a
gap of 2–5 microns. In these areas some channels are present that allow
communication between the cells.
Hemidesmosomes
These are specific type of attachments seen between basal cells and basement
membrane. These attachments are called as hemidesmosomes because the
structure is equivalent to half ot a desmosome. The hemidesmosomes have
one attachment plaque in the basal plasma membrane of basal cells. The
traversing filaments extending from this attachment plaque enter into the
basal lamina to provide attachment between epithelium and connective tissue
(Fig. 10.8).
Fig. 10.8: Ultrastructure of basal lamina
Nonkeratinocytes
In the oral epithelium, both keratinized and nonkeratinized, 90% of the cells
are keratinocytes which have the capability of producing keratin. Another
10% of the cells belong to a group called nonkeratinocytes. They are
melanocytes, Langerhans’ cells, Merkel cells and inflammatory cells. These
cells do not produce keratin and except for Merkel cells do not possess
desmosomal junctions or tonofilaments.
Melanocytes: Melanocytes are dendritic cells scattered among the basal cells
of epithelium and these are the melanin producing cells. The origin of these
cells is from neural crest cells which migrate to ectoderm by 8–11 weeks of
intrauterine life and have the capacity to replicate throughout postnatal life,
though at a much slower rate than keratinocytes. These cells have a cell body
containing the nucleus located at basal region and multiple long processes
extending between the keratinocytes of stratum spinosum. The melanocytes
neither contain tonofilaments nor possess desmosomal attachment. Because
of absence of desmosomal attachment, the cell tend to shrink against the
nucleus during tissue processing creating a clear halo around. Hence, these
cells appear as clear cells in between the basal cells. Since they are located in
basal layer as clear cells, melanocytes are called low level clear cells. The
melanocytes contain characteristic electron dense cytoplasmic organelles
called melano-somes that contain melanin pigments. Production of melanin
depends on melanocyte stimulating hormone. The variation in pigmentation
seen in different individuals depends on the activity of melanocytes and not
on number of melanocytes.
The melanocytes help to impart color to skin and mucosa and also protect
against u-v light.
Melanocytes can be demonstrated using special stains like silver stain and
also by DOPA reaction.
Langerhans’ cells: Langerhans’ cells are dendritic cells present in the
epithelium of skin and mucosa. These cells have a cell body harboring the
nucleus and long processes extending between the prickle cell layers.
Langerhans’ cells do not have desmosomal attachment and tonofilaments.
These cells also appear as clear cells in histological section because of
shrinkage of cells. Because of their location in upper layer of epithelium
compared to melanocytes, Langerhans’ cells are called high level clear cells.
These cells cannot be differentiated by routine H and E stain. They can be
demonstrated by histochemical, immuno-fluorescent or
immunohistochemical techniques which reveal the cell surface antigen or
ATPase reaction.
Election microscopically, Langerhans’ cells show a characteristic racquet
or flask or rod shaped cytoplasmic organelle called Birbeck granules or
Langerhans’ granules.
The origin of Langerhans’ cells is from bone marrow and they are
immuno-competent cells. They trap the antigens entering the mucosa, process
it and present it to the immune system. They are referred to as antigen
presenting cells.
Merkel cells: These are modified keratinocytes located in the basal layer of
oral epithelium. In contrast to other nonkeratinocytes these Merkel cells are
nondendritic cells which form occasional desmosomal attachment with
neighbouring epithelial cells and contain some tonofilaments. Because of
few desmosomal attachments these cells do not appear as clear cells in
histological sections. Electron microscopically these cells show cytoplasmic
granules with dense core resembling neurosecretory granules. Presence of
these granules and the close association of these cells with nerve endings
suggest the possible role of sensory function of Merkel cells. The Merkel
cells are considered as pressure sensitive cells responding to touch and may
be demonstrated using PAS stain.
There is a controversy regarding the origin of Merkel cells. One opinion is
that these cells could be of neural crest origin, while few others consider that
they are formed by the division of keratinocyte like cells.
Inflammatory cells: Inflammatory cells like lymphocytes are also present in
the epithelium. These cells are of bone marrow origin. Since these cells move
from connective tissue to epithelium and also back, they can be seen at
different levels of epithelium. Lymphocytes appear as round cells with
nucleus occupying the major part of the cell with little cytoplasm. They can
also be demonstrated by immuno histochemical techniques that demonstrate
the surface markers (OKT-3) of these cells. Lymphocytes perform defense
function.
Soft Palate
Soft palate is lined by nonkeratinized stratified squamous epithelium.
Epithelium may show presence of few taste buds. Lamina propria is highly
vascular because of which soft palate appears reddish clinically. The
epithelium connective tissue interface is irregular with thick and short rete
ridges and connective tissue papillae. A distinct layer of elastic fibers are
found forming a lamina between lamina propria and submucosa. The
submucosa is composed of diffuse loose connective tissue containing
numerous minor salivary glands.
Gingiva
Gingiva is the part of the oral mucosa that covers the alveolar process and
surrounds the neck of the tooth. The gingiva is relatively tightly bound to the
buccal and lingual plates of alveolar process and extends from the dento-
gingival junction to the alveolar mucosa.
Palate
The palate forms the roof of the oral cavity and is divided into immovable
hard palate anteriorly and the movable soft palate posteriorly. The hard palate
has a hard bony support while soft palate has only fibrous tissue.
The mucosa covering the hard palate differs in microscopic and
macroscopic structure in different regions.
Tongue
Tongue is a muscular organ situated in the floor of the mouth which play
important role in speech, mastication, deglutition, taste sensation, etc.
Macroscopic Features
Dorsum of the tongue is convex in all directions (Fig. 10.13). A V-shaped
sulcus divides the dorsal aspect of the tongue into anterior 2/3rd, body or oral
part and posterior 1/3rd, base or pharyngeal part. A small pit is seen where
the two arms of ‘V’ meet. It is called foramen caecum representing the
opening of thyroglossal duct. Anterior 2/3rds of the tongue is also called
papillary part because the mucosa has numerous papillae which give it a
velvety appearance. The most numerous papillae are fine pointed, cone-
shaped filiform papillae that are widely distributed on the dorsal surface.
These papillae make the surface of the tongue rough and help in crushing the
food particles while pressing against hard palate. Numerous fungiform
papillae are also seen distributed between the filiform papillae on the dorsal
aspect mainly on the tip and lateral margins. Fungiform papillae are seen as
red round, projections. Anterior to sulcus terminalis, 8–12 large papillae
called circumvallate papillae are seen. Circumvallate papillae are partly
submerged and do not project above the surface of tongue and are surrounded
by a V-shaped sulcus. Margins of the papillae may project above the surface.
In the posterior region of anterior 2/3rds of tongue, on the lateral margin
foliate papillae are seen which consists of series of folds forming clefts.
These foliate papillae are rudimentary in humans.
Taste Buds
Taste buds are specialized sense organs that can perceive the taste sensation.
They are mainly located in papillae of tongue, i.e. superficial surface of
fungiform papillae, lateral walls of circumvallate papillae and in the cleft
walls of foliate papillae. In addition, taste buds are also seen in posterior part
of palate, uvula, epiglottis, pharyngeal region, etc.
Taste buds (Figs 10.15a and b) are barrelshaped structures composed of
30–50 spindle-shaped, modified epithelial cells that extend from basement
membrane to epithelial surface. The taste buds measure around 50–80
microns in height and 30–50 microns in diameter. At the epithelial surface
the tapered end of all cells end in a small opening of 2–5 microns called taste
pore through with the cells communicate to exterior.
Based on the morphological features 4 different types of cells can be seen
in taste buds.
Type I cells (dark cells): They are long narrow cells which make up the
major population (60%) of cells. The base of the cells rests on basement
membrane and apex end as a long finger like microvilli in the taste pore.
These cells have dark nucleus, rich cytoplasmic organelles and large dense
cored vesicles in apical cytoplasm.
Fig. 10.14c: Circumvallate papilla
Dentogingival Junction
The junction between the tooth and gingiva called dentogingival junction.
The junctional epithelium has an important role in this. The epithelium, i.e.
the junctional epithelium that is attached to the tooth to form a dentogingival
junction is called attachment epithelium and the mode by which this
epithelium is attached to the tooth is called epithelial attachment (for details
refer page 117).
Formation of dentogingival junction: Once the enamel formation is
completed the ameloblasts secrete proteinaceous material on to the surface of
newly formed enamel which is structurally similar to basal lamina. This
structure is called primary enamel cuticle. Once the enamel organ transforms
into reduced enamel epithelium (REE) it gets attached to the surface of
enamel with the help of this basal lamina through hemidesmosomes.
During the process of eruption, the connective tissue between the REE and
oral epithelium degenerate, followed by proliferation of oral epithelium and
REE. These layers ultimately fuse together to form a solid plug of epithelium
(Fig. 10.16). The central cells of this plug degenerate forming a canal through
which the tooth emerges into the oral cavity. As the tooth move to the
occlusal plane, the epithelium covering the enamel surface shortens. Even
after the tooth reaches the occlusal plane 1/3rd of the tooth is still covered by
epithelium. Once the tip of the cusp emerges into the oral cavity the part of
reduced enamel epithelium attached to the tooth is called primary attachment
epithelium and is in continuation with oral epithelium. The reduced enamel
epithelium gradually shortens to expose the crown of the tooth completely
and is slowly replaced by the oral epithelium. The attachment epithelium
derived from oral epithelium is referred to as secondary attachment
epithelium. The actual movement of the tooth to occlusal plane is called
active eruption and the exposure of the crown by the apical migration of the
covering epithelium without actual movement of the tooth is called passive
eruption.
Clinical Considerations
1. Clinical conditions resulting in alteration in structure of oral mucosa
– Oral cavity is the mirror of general health of a person. Various
local and systemic disease conditions such as nutritional
deficiency, metabolic disturbances, anemia, endocrine
disturbances, present with oral mucosal changes.
– Pale pink colour of oral mucosa may be altered in different
clinical conditions. Mucosa may appear reddish in case of
inflammatory conditions, pale in anemias and oral submucous
fibrosis. Patchy areas of brownish pigmentations may be noted in
conditions involving melanocytes.
– Mucosa which is soft in texture and stretchable normally becomes
stiff and non-stretchable in oral submucous fibrosis and
scleroderma due to excessive fibrosis of connective tissue.
– A number of dermatological disorders manifest oral mucosal
lesions such as fluid filled vesicles, ulcers, erosions, red patches,
etc. Examples are: Oral lichen planus, pemphigus, pemphigoid,
etc.
– Loss of papillae of tongue resulting in bald appearance is a
characteristic feature in anemias.
– Use of tobacco may cause oral mucosal cancer or potentially
malignant disorders, which may present as white patches or
plaques, ulcers, ulceroproliferative growth, involving various parts
of oral mucosa.
– Histological alterations noted in different layers of epithelium in
various disease conditions. Identification of these features helps in
diagnosing the lesions accurately and providing appropriate
treatment. Following are some of the important changes:
1. Hyperkeratosis—increase in thickness of keratin layer
2. Acanthosis and atrophy—acanthosis refers to abnormal
thickening of spinous cell layer while atrophy is thinning of
epithelium.
3. Acantholysis—destruction of desmosomal junctions resulting
in loss of intercellular adhesion and is a characteristic feature
in blistering diseases such as Pemphigus and viral infections.
4. Basillar hyperplasia—increased cell proliferation in the basal
cell layer resulting in multiple layers of basal cells
5. Basal cell degeneration-destruction of basal cells and is a
characteristic feature in lichen planus
6. Loss of stratification—refers to loss of arrangement of
epithelial cells in different layers with progressive level of
differentiation and this can be a feature of epithelial dysplasia
7. Potentially malignant disorders and oral mucosal cancer
present with a number of cellular and architectural changes in
epithelium which is collectively referred to as features of
epithelial dysplasia.
2. Clinical considerations related to structural variations
The volume and texture of submucosa in different part of the mucosa
has particular clinical significance. In masticatory mucosa, where there
is no or little submucosa, the mucosa is not stretchable and is firmly
attached to the underlying bone. Therefore injections in these regions
will be painful as the solution cannot be dispersed easily. Any wound
in these region do not gape open. Wounds in these region do not
require suturing and the wound healing in these regions is by secondary
intention. In contrast injections in lining mucosa is less painful.
Wounds in the lining mucosa gape open, requires suturing and wound
healing is by primary intention.
11
Salivary Glands
Introduction
Classification of salivary glands
Gross morphology
Microscopic structure
Clinical considerations
S alivary glands are exocrine glands that synthesize and secrete saliva that
reaches the oral cavity through a ductal system.
Irrespective of the size and location, all the salivary glands are composed of
parenchymal components which includes the secretory units and the ductal
systems.
All the major glands also show a second structural component, i.e.
connective tissue that forms a capsule around the salivary gland, which also
extend between parenchymal components, dividing the gland into lobes and
lobules. In contrast, minor salivary glands do not have a distinct connective
tissue component.
Cytoplasmic Components
Cytoplasm of a secretory cell shows abundant cytoplasmic organelles
required for synthesis and storage of proteinaceous materials. Large number
of rough endoplasmic reticulum (RER) arranged parallelly is found in the
cytoplasm basal and lateral to the nucleus. A prominent Golgi apparatus
consisting of several stacks are seen lateral and apical to the nucleus. The
Golgi apparatus are functionally connected to RER through a series of
budding vesicles at the end of RER. Mitochondria, the energy source of
various synthetic and transportation activities, are also abundant and are
dispersed in the basal and lateral region.
Synthesis of Saliva
The organic component of the saliva is synthe-sized by the secretory cells
utilizing the substrate provided by the nutrients that reach the cell. Water and
electrolytes required for the saliva reaches the cell from circulation and from
tissue fluid.
Fig. 11.2a: Light microscopic structure of serous acinus
Cytoplasmic Components
Cytoplasm of a secretory cell shows cytoplasmic organelles required for
synthesis and storage of proteinaceous materials. Organelles are not so
abundant as in serous cells. All the synthetic cytoplasmic organelles are
mainly located in the peri-nuclear area and are relatively less in number and
are chiefly restricted to the basal region of cells. Rough endoplasmic
reticulum and mitochondria are dispersed in the basal and lateral region of
nucleus. But mitochondria are few in number and rough endoplasmic
reticulum is less extensive. A prominent Golgi apparatus consisting of several
stacks (10–12 sacules) are seen lateral and apical to the nucleus, compressed
between RER and secretory droplets. One of the major differences observed
from that of serous cell is, considerably greater Golgi apparatus which
indicates a greater carbohydrate metabolism. In the Golgi complex
carbohydrate component is added to protein to synthesize glycoprotein of
mucin. Golgi complex is also involved in proteolytic processing steps and
trimming of oligosaccharides. The diluted protein received from rough
endoplasmic reticulum is concentrated in the Golgi complex, which is a
required step for efficient intracellular storage.
Fig. 11.3a: Light microscopic structure of mucous acinus
Mixed Acinus
In mixed salivary glands both serous and mucous acini are seen, which vary
in proportion based on the type of gland, i.e. predominantly serous or
predominantly mucous. Along with these, there are few mixed acini (Fig.
11.4). The basic secretory unit of a mixed acinus is a tubular mucous acinus.
At the blind end this acinus serous cells are arranged to form a crescent
shaped structure called demilune of Gianuzzi (demilune-half moon). The
secretions of the serous cells reaches the lumen through the intercellular
canaliculi present between the mucous cells.
Myoepithelial Cells
Myoepithelial cells are contractile cells found to be embracing/enveloping the
secretory end piece and the first portion of the ductal system, the intercalated
ducts. These cells are epithelial in origin, but exhibit contractile function like
muscles, hence the name myoepithelial cells. The myoepithelial cells are
ectodermal in origin. But it is not clear whether it is from intercalated duct
reserve cells or from neural crest cells.
Myoepithelial cells are situated between the basal plasma membrane of
parenchymal cells and basement membrane supporting the secretory unit or
duct. Shape varies depending on location. Cells associated with acini are
dentritic cells with a cell body containing the nucleus and 4–8 cytoplasmic
processes extending from the cell body, each with two or more secondary
branches. Therefore these cells are compared to an ‘Octopus sitting on a
rock’. The cell body is located in a region where basal region of 2–3
secretory cells come together. The cells processes run parallel to the long axis
of acinus and cradle it like a basket. Therefore, these cells were called as
‘basket cells’.
Fig. 11.4: Light microscopic structure of mixed acinus
Good to Know
Demilunes in mixed ocini-Fixation Artifacts?
Yamashina et al published a scientific article “The serous demilune of rat
sublingual gland is an artificial structure produced by conventional
fixation” (HistolCytol 62: 347–354) claiming that demilunes are ‘created’
due to fixation artefacts. These researchers proposed this concept based on
their findings in a study conducted using rapid freezing of the salivary
gland tissue in liquid nitrogen, followed by rapid freeze substitution with
osmium tetroxide in cold acetone. They demonstrated that both mucous
and serous cells, aligned in the same row to surround the lumen of the
secretory acinus. Sections from the same specimen fixed using
conventional methods showed swollen mucous cells with enlarged
secretory granules and typical serous demilunes at the periphery with
slender cytoplasmic processes interposed between the mucous cells. The
process of demilune formation was explained, to be caused by expansion
of mucinogen of secretory granules, during routine fixation. This
expansion increases the volume of the mucous cells and displaces the
serous cells from their original position, thus creating the ‘demilune
effect’. However Tandler raised many queries about this concept and
claimed that demilunes are real, basic units of salivary gland structure
[Tandler B (2014) Are Demilunes in Mixed Salivary Glands Real or
Fixation Artifacts? A Critique. J CytolHistol 5: 218.]
Ductal System
The ductal system of salivary gland is composed of network of ducts where
the smaller ducts join to form larger caliber ducts. The intralobular ducts, i.e.
the intercalated and striated ducts join together to form interlobular ducts.
The interlobular ducts join together to form a lobar duct which drain a lobe of
the gland. The lobar ducts join to form interlobar duct which runs in the
connective tissue between the lobes and is continued as terminal excretory
duct. In the ductal system, microscopically three structurally different
sequential segments can be identified: Intercalated duct and striated duct
which are intralobular and excretory duct which is interlobular and inter lobar
in location (Fig. 11.5).
Intercalated ducts: These are the smallest diameter duct at the first portion
of ductal system which is seen as a continuation of lumen of secretory acini.
The intercalated ducts carry the saliva from the lumen to the striated duct.
These ducts are inconspicuous and vary in length in different glands: Being
least prominent in mucus-secreting salivary glands (sublingual glands) and
particularly long and prominent in serous glands (parotid gland).
The intercalated ducts are intralobular ducts found among the secretory
acini. Light microscopically these ducts are seen as small diameter structures
lined by a single layer of cuboidal cells with faintly eosinophilic cytoplasm
and centrally located nucleus. Ultrastructurally the lining cells of the
intercalated duct show some resemblance to secretory cells. The cytoplasm
contains basally located rough endoplasmic reticulum, mitochondria, Golgi
complex, few secretory granules, etc. The intercalated ducts are supported by
basement membrane and adjacent cells are attached to each other by
intercellular junctions. Myoepithelial cells are found between basal plasma
membrane of lining cells and supporting basement membrane. A few
undifferentiated mesenchymal cells are also present.
The intercalated ducts not only act as a conduit for saliva, but also
contribute some materials to it.
Striated duct: The intercalated ducts are continuous with the striated ducts
which carry the saliva to the excretory duct. They have a comparatively
larger lumen lined by a single layer of columnar cells, well supported by
connective tissue. These cells have a centrally placed round nucleus and
abundant eosinophilic cytoplasm. The basal portion of the cells present a
striated appearance, thereby the name striated duct. Electron microscopically
the lining cells of striated ducts show some similarity to cells involved in
water electrolyte balance (Fig. 11.6). These cells show numerous infoldings
at the basal part of plasma membrane which helps to increase the surface area
of basal plasma membrane. Many large mitochondria are seen in the
cytoplasm which are arranged within these infolding with long axis parallel
to the infoldings and to each other. These basal infoldings along with
mitochondria is responsible for the striated appearance under light
microscope.
Nerve Supply
Salivary secretion is mediated by innervating nerves. The salivary glands are
supplied by parasympathetic and sympathetic arms of the autonomic nervous
system, which travel to the glands by separate routes. Parasympathetic
innervation to the salivary glands is carried via cranial nerves; parotid gland
from the glossopharyngeal nerve (CNIX) via the otic ganglion from which
the auriculotemporal nerve carries parasympathetic fibres; the submandibular
and sublingual glands from the facial nerve (CN VII) via the submandibular
ganglion. Direct sympathetic innervation of the salivary glands takes place
via preganglionic nerves in the thoracic segments T1–T3 which synapse in
the superior cervical ganglion. Fibres from this ganglion travel along the
external carotid artery to reach the glands.
Once in the glands, the nerves follow the course of blood vessels and
undergo extensive branching reach up to the adjacent region of acini. The
axons from each type of nerve intermingle and travel together in association
with Schwann cells, forming Schwann-axon bundles. The nerve endings,
maintain two types of neuro-effector relationships with salivary parenchymal
and myoepithelial cells:
Hypolemmal or intraepithelial type (within the parenchymal basement
membrane): In this type myelinated axons that split off from the nerve bundle
penetrate the basement membrane of the acinus to reach very close to
secretory cells. The distance between the secretory cell and nerve ending is
only 10–20 nm. The axons show varicosities which are considered as
neuroeffector site. These varicosities contain chemical neurotransmitters such
as nor epinephrine and acetyl choline stored in small vesicles. Afferent nerves
are found to form a hypolemmal association with the epithelial cells of main
salivary ducts.
Epilemmal or subepithelial or interstitial type (outside the parenchymal
basement membrane): In this, the axons remain in the connective tissue and
do not penetrate the basal lamina. Here the distance between the secretory
cell and axon is more and is around 100–200 nm. The neuro-transmitters
from the varicosities of nerve axons have to diffuses through the basal lamina
to reach the secretory cells. Salivary blood vessels receive epilemmal
innervations by both sympathetic and parasympathetic axons.
The relative frequencies of either type of nerve differ greatly between
glands and species. The classical transmitters for parasympathetic axons is
acetylcholine and substance P while in sympathetic axon is noradrenaline. At
least four types of influence can be exerted on salivary parenchymal cells by
the nerves: hydrokinetic (water mobilizing), proteokinetic (protein secreting),
synthetic (inducing synthesis), and trophic (maintaining normal functional
size and state).
Both parasympathetic and sympathetic stimuli result in an increase in
salivary gland secretions. However, increased activity of the sympathetic
nervous system can also inhibits saliva secretion, via vasoconstriction,
thereby decreasing the volume of fluid in salivary secretions, producing an
enzyme rich mucous saliva. To sum up, parasympathetic stimulation results
in secretion of large amount of watery saliva with low organic components
while sympathetic stimulation produces relatively less quantity of thick,
enzyme rich saliva. (Age changes—refer page 324, functions of saliva—
refer page 292)
Clinical Considerations
A number of disease conditions can involve salivary glands which include
a. Developmental defects like aplasia (lack of development) hypoplasia
(under development)
b. Infections that may be caused by virus or bacteria referred to as
sialadenitis; causing pain and swelling of salivary gland. Mumps is a
common viral sialadenitis primarily affecting parotid gland.
c. Sialolithiasis is a condition characterized by intermittent swelling and
pain particularly while eating, caused by blocking of salivary flow by
sialolith (stone in the salivary duct).
d. Sjogren’s syndrome is an autoimmune disorder affecting the salivary
gland resulting in marked reduction in salivary secretion resulting in
xerostomia or dry mouth.
e. Cysts of salivary gland—mucocele is an example for cysts involving
saliary gland, frequently, the minor salivary glands of the lower lip.
f. Benign or malignant tumors—a number of benign and malignant
tumors develop in the salivary gland tissue with abnormal proliferation
of ductal, acinar or myoepithelial cells, each one causing swelling and
other manifestations, e.g. of benign tumours are pleomorphic adenoma
and monomorphic adenoma. Malignant tumours are adenoid cystic
carcinoma, muco-epidermoid carcinoma, acinic cell carcinoma, etc.
12
Temporomandibular Joint
Introduction
Anatomy and histology of TMJ
Ligaments of TMJ
Movements of TMJ
Clinical considerations
TMJ comprises of two bony structures and interposed fibrous disc, enclosed
in a fibrous capsule (Fig. 12.1).
Condyle
Condyle is a large solid oblong structure which is wider medio-laterally (20
mm) than anteroposteriorly (10 mm). It is noticeably convex capsule when
viewed from the side, but only slightly convex when viewed from the front.
The long axis of each condyle inclines slightly backward and medially.
Articulating surface is convex and is located on the superior and anterior
surface of the head of the condyle. The anterior border of the articulating
surface is distinctly marked. A triangular depression beneath this border
marks the insertion of the lower fibers of lateral pterygoid muscle. The
medial and lateral poles of the condyle are also distinct.
2. Articular Capsule
Articular capsule is a dense collagenous sheet of tissue or a sac that encloses
the joint space. The articular capsule is circumferentially attached to the rim
of glenoid fossa and articular eminence above and to the neck of the condyle
below. The anterior portion of the capsule is attached above to the ascending
slope of the articular eminence and below to the anterior margin of condyle.
The posterior portion is attached above to the squamotympanic fissure and
below to the posterior margin of ramus of mandible, adjacent to neck of
mandible. Anterolateral aspect of the capsule may be thickened to form
temporomandibular ligament. Posterior fibers of the capsule blend with
articular disc as they traverse from temporal bone to mandible.
3. Articular Disc
Articular disc or the meniscus is a tough biconcave pad of dense fibrous
connective tissue, located between the condyle and articular surface of
temporal bone, i.e. the glenoid fossa and articular eminence. The disc is
thinnest at the center (about 1 mm) and thicker towards the periphery (2–3
mm). Varying thickness of the disc has lead to the description of four distinct
regions namely anterior band, intermediate zone, posterior band and
bilaminar region.
The shape confirms to the articular surfaces to which it is opposed. The
upper contour of the disc is concave in the anterior region to fit under
articular eminence and convex posteriorly and loosely rest against articular
fossa. The lower surface of the disc is concave in both directions thus
adapting to the upper surface of mandibular condyle.
The medial and lateral margins of the disc blend with the capsule. In the
anterior region disc is divided into two lamellae, the upper one running
forward to fuse with capsule and periosteum in the anterior slope of articular
eminence while the lower one runs down to attach to the front of neck of the
condyle. The region of disc between upper and lower lamellae merges with
the capsule or with lateral pterygoid muscle.
Posteriorly also the disc is divided into two lamellae, upper lamellae
consisting of fibrous and elastic tissue fusing with capsule and inserting into
the squamotympanic fissure. The lower lamella is nonelastic as it is
composed of only collagen and turns down to blend with periosteum of neck
of condyle. Between the lamellae, loose highly vascular connective tissue is
found which is called bilaminar zone.
The articular disc divides the joint space into upper compartment called
temporo-discal which is between disc and temporal fossa and a lower
compartment called condylo-discal situated between disc and condyle. Lower
joint allows the rotational movement of head of the condyle which is also
called hinge movement. Upper joint space allows a translatory movement
anteriorly along the slopes of the articular eminence to produce an anterior
and inferior movement of the jaw.
Histolosy of Articular Disc
Articular disc is composed of dense fibrous tissue with tightly packed
interlacing collagen fibers. The fibroblasts are elongated with long processes.
A few elastic fibers may be present. As an age change, in older persons
articular disc may show cartilage cells. These cartilage cells may be
increasing the resilience and resistance of fibrous tissue. The center portion of
the disc is devoid of blood vessels and nerves while periphery is highly
vascular.
Periphery of articular disc is attached to the fibrous capsule. Anterior part
of the disc fuses with the capsule while posteriorly it is loosely attached.
Being loosely attached posteriorly the disc moves with head of the condyle
but only about half as far.
1. Capsular Ligament
Capsular ligament or articular capsule is a fibrous sac that encloses the joint
cavity. It is attached to the articular margins of the temporal bone superiorly
and to the neck of condyle inferiorly. An articular disc intervenes between the
two articular surfaces and is attached peripherally to the inner surface of the
capsule. The capsule is thin and loose between the temporal bone and
articular disc, but between the disc and mandible it is thicker and stronger. It
is lined by synovial membrane. Anteriorly the tendon of lateral pterygoid
muscle is inserted into it.
2. Temporomandibular Ligament
Temporomandibular ligament or lateral ligament is a strong fan-shaped
ligament functioning to reinforce the lateral wall of the articular capsule and
thus act to limit the lateral and posterior movements of the joint. It is attached
superiorly to the articular tubercle and a segment of the zygomatic process
and runs posteroinferiorly to attach to the condyle and posterolateral aspect of
the neck of mandible.
3. Accessory Ligaments
There are two accessory ligaments which do not contribute to support of the
temporomandibular joint, but facilitate and limit the movements. Accessory
ligaments include:
Sphenomandibular ligament extends from the spine of the sphenoid to the
lingula and lower margin of the mandibular foramen. It represents the
unossified intermediate part of the sheath of the Meckel’s cartilage of the first
pharyngeal arch. Over movement of the mandible is limited by this ligament.
Stylomandibular ligament extends from the lateral border of the styloid
process to the posterior border of the ramus of the mandible above its angle.
It is the thickened part of the investing layer of the deep fascia of the neck. It
separates the parotid gland from the submandibular salivary gland. This
ligament participates in limiting the protrusive movement.
These ligaments are thought to play a significant role during protrusion and
depression of the jaw.
MOVEMENTS OF TMJ
Clinical Considerations
1. TMJ ankylosis: It is the stiffening (immobility) or fixation (fusion) of
the joint which leads to chronic, painless limitation of the movements
of the joint. This can be a true bony fusion or due to enlargement of the
coronoid process, depressed fracture of the zygomatic arch, scarring
from surgery, irradiation, infection, etc. Ankylosis of TMJ may result
in restricted jaw movements, inadequate masticatory (chewing)
function, restricted mouth opening, inhibited facial and physical
growth, impaired speech, etc.
2. Luxation and subluxation: Luxation refers to complete dislocation of
TMJ with head of the condyle moves anteriorly over the articular
eminence into such a position that it cannot be returned voluntarily to
its normal position. Luxation can be caused due to traumatic injury or
is a result of yawning or opening mouth too wide for dental procedures,
etc. Subluxation refers to partial or incomplete dislocation of TMJ,
where the condyle may lie well anterior to the articular eminence. Such
anterior positioning is normal for many people
3. TMJ pain dysfunction syndrome/Myofacial pain dysfunction syndrome:
It is a psycho-physiologic disorder that involves the masticatory
muscles and is characterized by dull, aching and radiating pain that is
exacerbated by mandibular function, tenderness on muscle palpation
and limited movement of joint. This condition may be caused due to
bilateral loss of posterior teeth, excessive alveolar bone resorption in
patients with complete dentures, malocclusion, improperly occluding
restorations, stress, etc. Patients may experience pain, muscle
tenderness, limitation of mouth opening, clicking or popping sound
while opening the mouth.
4. Degenerative disease: As other joints of the body, TMJ is prone to
degenerative joint disease (arthritis and arthrosis). Arthritis is
characterized by inflammation while arthrosis, by the presence of low
and no inflammation. Osteoarthritis of TMJ results from wear and
degeneration caused by normal use or parafunctional use of the joint.
Rheumatoid arthritis, an autoimmune joint disease, can also affect the
TMJs. Degenerative joint diseases may lead to defects in the shape of
the tissues of the joint, limitation of jaw movements, and joint pain.
13
Maxillary Sinus
Dr Usha Balan
Introduction
Anatomy and maxillary sinus
Microscopic features of maxillary sinus
Clinical considerations
Anatomy
Maxillary sinus is the largest of the paranasal sinuses and is pyramidal in
shape. It has a volume of approximately 15 ml (34 × 33 × 23 mm).
Maxillary sinus has four sides and a base. The base faces medially towards
the nasal wall and apex points laterally towards the body of the zygomatic
bone. Anterior side is towards the facial surface of the body of maxilla, while
the posterior side is towards the infratemporal surface of maxilla. Inferior
side is bordered by the alveolar and zygomatic processes of maxilla and the
superior side is bordered by orbital surface of maxilla. The base of the sinus
is thinnest of all the walls. The floor may extend between the roots of
maxillary teeth.
Microscopic Features
Maxillary sinus is lined by respiratory epithelium composed of
pseudostratified ciliated columnar epithelium (Fig. 13.2). Epithelial lining is
made up of columnar cells of varying sizes arranged in a single layer on a
basement membiane. The nuclei of the cells are placed at different levels
giving the erroneous appearance of stratification. The cells on the superficial
aspect have got cilia which help in the movement of the mucous secretions.
Along with these ciliated columnar cells, nonciliated columnar cells, basal
cells and goblet cells are also present. Goblet cells (Fig. 13.3) are unicellular
secretory organs which are goblet shaped with a basally placed nucleus and
apical cytoplasm filled with secretory products. Various cellular organelles
like smooth and rough endoplasmic reticulum, and Golgi bodies are also
located in the basal region. The secretions are rich in mucopolysaccharides
and are finally secreted by exocytosis on the surface of epithelium. Since the
secretory material is mucopolysaccharides, in a hematoxylin and eosin
stained section, the goblet cells appear empty.
The epithelium is separated from subepithelial connective tissue by a basal
lamina. Subepithelial connective tissue layer has collagen fibers and
fibroblasts, protective cells such as lymphocytes, plasma cells and
eosinophils. Minor salivary glands including both serous and mucous glands
are distributed in the connective tissue. This layer is attached to the
periosteum lining the bony wall of the maxillary sinus.
Clinical Considerations
1. Oro-antrai communication/fistula is the connection that is established
between oral cavity and maxillary sinus. This condition commonly
arises as a result of complication of extraction of maxillary first and
second molar especially when the bony wall separating sinus from root
is very thin. Palatal root of maxillary first molar is found in very close
proximity to sinus and therefore any surgical manipulation or chronic
periapical inflammation related to this tooth can erode the bone,
establishing a communication between oral cavity and maxillary sinus.
The communication might get epithelialized and establishes permanent
connection between maxillary sinus and the oral cavity.
2. Developmental defects: such as agenesis (absence), hypoplasia (small
sinus), supernumerary (extra) sinus may involve maxillary sinus.
3. Infection/Inflammation: Maxillary sinus is prone to infection and
inflammation due to various causes and this condition is referred to as
maxillary sinusitis.
4. Sinusitis and toothache: Infection from maxillary teeth may spread to
the sinus and may be one of the possi ble cause for sinusitis. Likewise
sinusitis may lead to toothache. Swelling and the concentration of
mucus fluids resulting from sinusitis can build-up of pressure inside the
sinus cavity and over the upper jaw bones. The nerves innervating the
roots of the maxillary molar teeth which are in close proximity to the
sinus may be affected by this pressure and the patient experiences a
pain much similar to toothache. This is called a sinus toothache. The
intensity of pain depends on the extend of sinus infection and swelling
along with the proximity of the root endings to the infected sinus.
Section 3
Human dentition
Tooth and supporting structures
Types of dentition and teeth
Chronology and sequence of eruption
Tooth numbering systems
Terminologies used in dental morphology
FUNCTIONS OF TEETH
Mastication
• Teeth helps to tear, grind, and chew food in the first step of
digestion, enabling salivary enzymes in the mouth to further break
down food.
Appearance
• Teeth plays an important role in a person’s appearance. They support
the tissues around the mouth and provide an appealing look to the
face.
Speech
• Teeth along with the lips and tongue, plays an important role in
forming a clear and understandable speech. The role of teeth is of
paramount importance, as speech plays a huge part in development
of one’s personality and social acceptance.
Growth of jaws
• Teeth play a role in the growth of the jaws in some periods of life.
Self protection and attack
• Primarily in animals.
PARTS OF A TOOTH
Root
The portion of the tooth which is covered by cementum is called root and is
embedded within the alveolar bone; may be single or multiple (double or
tripleroots).
Three-rooted teeth
Maxillary molars (two buccal [1 mesiobuccal, 1 disto-buccal], and one
palatal).
Single-rooted Deciduous Teeth
All the anterior teeth
Three-rooted teeth
Maxillary molars (two buccal [1 mesiobuccal, 1 disto-buccal], and one
palatal).
Variations frequently occur. In single-rooted teeth, roots generally present a
conical shape, narrow down towards the tip. The tip of the root is referred to
as root apex. In multi-rooted teeth the root begins at the cervix as undivided
portion and then divides at various levels.
Clinical root is the portion of the root that is embedded in the jaw bone and
covered by the gingival (gum) tissue and not exposed to the oral cavity.
Anatomical root is the entire portion of the root covered by cementum.
Cervix or Neck
The constricted portion of the tooth, where the anatomic crown and the root
meets, i.e. junction between the enamel and cementum is referred to as cervix
of the tooth.
The tooth is made up of three hard tissue components and one soft tissue
component (Fig. 14.2).
Hard tissue components are enamel, dentin and cementum.
Soft tissue component is pulp.
Enamel
The enamel is the outermost layer and covers the anatomic crown. It is the
hardest and most highly mineralized tissue of the body. Enamel is translucent
in nature and the color varies from light yellow to grayish white. Enamel is a
nonliving tissue and is incapable of remodeling and repair. Specialized cells
called ameloblasts forms enamel and the process of enamel formation is
called amelogenesis.
Dentin
Dentin is a hard, connective tissue which makes up the bulk of the tooth. It is
covered by enamel on the crown portion and cementum on the root portion. It
is located between enamel or cementum and the pulp chamber. Dentin is
yellowish in color. Unlike enamel, dentin is a living tissue and responds to
stimulus and the exposed dentin is often sensitive to cold, hot, air and touch.
The hardness of dentin is lesser than enamel. The process of dentin formation
is called dentinogenesis and odontoblasts are the specialized cells that form
dentin.
Cementum
The cementum covers the root portion of the tooth. It overlies the radicular
dentin and joins the enamel at the cemento-enamel junction (CEJ).
Cementum is yellowish in color and is softer in consistency than enamel.
Formation of cementum takes place by the specialized cells called
cementoblasts. Primary function of cementum is to anchor the tooth to the
bony socket by providing a media for attachment of the periodontal ligament
fibers.
Pulp
Pulp is the only soft tissue component of tooth and occupies the central
portion of the tooth. Pulp is a mesenchymal connective tissue that supports
the dentin and is surrounded by dentin on all sides except at the apical
foramen and accessory pulp canal openings, where it is in communication
with periodontal soft tissue. The pulp consists of connective tissue, nerves
and blood vessels, which enter the pulp through a small opening at the apex
called apical foramen. It consists of cells (odontoblast, fibroblast,
undifferentiated mesenchymal cells, macrophages, immunocompetent cells),
fibers and intercellular substance.
The teeth are arranged in the jaw bones which follow a U-shaped arch form.
The upper jaw is the maxilla and lower jaw is mandible. Therefore, the teeth
in the maxillary arch are referred to as maxillary or upper teeth, while those
in the mandibular arch are referred to as mandibular or lower teeth.
The maxillary and mandibular arches can be divided along the mid sagittal
plane into right and left halves. Accordingly, in humans, teeth are arranged in
four quadrants, namely right maxillary, left maxillary, right mandibular, and
left mandibular.
Canine b. Canine
• First premolar
• Second premolar
Molars c. Molars
DENTITION
The term dentition is used to collectively consider upper and lower teeth. In
human dentition two sets of teeth can be identified: Deciduous or primary
dentition and permanent dentition.
Deciduous Dentition
It is also known as the primary, baby, milk or lacteal dentition. There are 20
deciduous teeth in total of which 10 are present in the upper and 10 in the
lower jaw. The deciduous dentition consists of 2 incisors, 1 canine (0
premolar) and 2 molars in one quadrant, i.e. 5 in one quadrant, 10 on one side
and 20 in total (Fig. 14.3). There are no premolars in deciduous dentition.
The first deciduous tooth erupts into oral cavity by the age of six months and
the last one by two and a half to three years. The child has only deciduous
teeth till the age of six years until the first permanent tooth erupts.
Dental formula of a human deciduous dentition on left/right side
Permanent Dentition
Permanent teeth are the second set of teeth formed in humans that replace the
deciduous teeth in normal conditions. They are also called secondary
dentition. There are 32 permanent teeth in total, 16 on either arch and 8 in
each quadrant. The deciduous anteriors are replaced by the corresponding
permanent anterior tooth and the deciduous molars are replaced by the
premolars. The permanent teeth that replace the deciduous predecessors are
called as successor or succedaneous teeth. The permanent molars erupt
distal to the space occupied by the deciduous dentition. The permanent
molars are called non-successor teeth ornon-succedaneous teeth as they do
not have deciduous predecessors. The first permanent tooth usually erupts in
the mouth at around six years of age and the last one usually erupts at around
18 years of age, but this can vary greatly between individuals.
The permanent dentition consists of 2 incisors, 1 canine, 2 premolars and 3
molars in one quadrant, i.e. 8 in one quadrant, 16 on one arch and 32 in total
(Fig. 14.4).
Fig. 14.3: Deciduous dentition
Fig. 14.4: Permanent dentition
Dental formula of a human permanent dentition on left/right side
The dentition will be in a transition period with both deciduous teeth and
permanent teeth from the age of 6 years to 12 years, until the last deciduous
tooth is exfoliated and replaced by permanent tooth. The period where there
is presence of both deciduous and permanent dentition is called mixed
dentition period and does not constitute a third stage of dentition.
Anterior Teeth
The term anterior teeth is used to describe those teeth which are closer to the
midline; consists of 12 teeth in the front, facing the lips, 6 in each arch and
includes 4 incisors and 2 canines (Figs 14.3 and 14.4).
Posterior Teeth
These are teeth, which are further away from the midline. In permanent
dentition, the posterior teeth consist of 10 teeth behind the anterior teeth,
facing the cheek, which includes 2 premolars and 3 molars in one quadrant;
10 teeth on one side and 20 posterior teeth in total. In deciduous dentition, the
posterior teeth consist of 8 teeth behind the anterior teeth, facing the cheek
and include 2 molars in one quadrant; 4 teeth in one side and 8 in total (Figs
14.3 and 14.4).
Labial Surface
The surface of the tooth that is facing the lip. This term is used while
describing anterior teeth.
Buccal Surface
The surface of the tooth that is facing the inner cheek. This term is used while
describing posterior teeth.
Palatal Surface
The surface of the tooth that is closest to the palate.
Although the term lingual is used generally to describe the inner surface of
both maxillary and mandibular teeth facing the oral cavity proper, the term
palatal is more appropriate in case of maxillary teeth because it is closer to
the palate. The use of the term lingual may be restricted to the mandibular
teeth.
Proximal Surface
This term is used to describe sides of the tooth or the surfaces that lie next to
an adjacent tooth. All teeth have two proximal surfaces, the mesial and the
distal.
Mesial Surface
Mesial surface is the surface of the tooth that is oriented toward or closer to
the midline of the dental arch.
Distal Surface
Distal surface is the surface of the tooth that is oriented away from the
midline of the dental arch.
Occlusal Surface
Occlusal surface is the broad chewing surface of posterior teeth.
Incisal Surface
Incisal surface is the narrow cutting surface of anterior teeth. Since the incisal
or cutting surface of a newly erupted anterior tooth is narrow and resemble a
ridge the term incisal ridge is preferred. As the teeth undergo physiological
wearing, the ridge becomes flat and form a sharp angle with the labial surface
and is then referred to as incisal edge.
Dental notations are the name given for the systems that are used to identify a
tooth in relation to one another, to the midline and to the arches and helps in
the documentation of these data. Tooth numbering provides the dentists with
an essential shortcut in clinical record-keeping. Different dental notation
systems are used by dentists worldwide for associating information to a
specific tooth. Since tooth numbering systems are used like shortcuts, they
are easier and save time. It allows everyone in the oral health team to
efficiently share information amongst them and further provides those outside
the team with clear and precise information about their work. The three most
common systems are the FDI World Dental Federation notation, Universal
numbering system, and Zsigmondy Palmer notation. Each of these systems
has their own merits and demerits and no single system is superior to the
other. Orientation of the chart in all the systems is traditionally “patient’s
view”, i.e. patient’s right corresponds to notation-chart right. The
designations “left” and “right” on the chart correspond to the patient’s left
and right, respectively.
Requirements of ideal tooth numbering system
Simple to understand and teach
Easy to pronounce in conversation and dictation
Readily communicable in print
Easy to translate into computer input
Easily adaptable to standard charts used in general practice
TRAIT CATEGORIES
The human dentition is peculiar in that, it shows features which are similar or
dissimilar to the adjacent and opposing tooth. Features that help to
differentiate the dentition and teeth into different groups are called trait
categories, which include:
Set Trait
Teeth in primary and permanent dentition show some common characteristics
so that they can be categorized as deciduous or permanent teeth. These
features which help in differentiating permanent teeth from deciduous teeth
are referred to as set trait.
Example: Deciduous teeth are much smaller compared to permanent
teeth(with few exceptions).
Arch Trait
Common features observed in teeth of maxillary or mandibular arch that help
in differentiating the maxillary (upper) teeth from the mandibular (lower)
teeth are referred to as arch trait.
Example: From the proximal aspect, crowns of all mandibular teeth show a
lingual inclination.
Class Trait
Features which help to categorize the teeth, depending on the prominent
features into various classes like incisors, canines, premolars and molars.
Example: Incisors have crowns compressed labiolingually for efficient
cutting; canines have single pointed cusps for piercing food; premolars have
two or three cusps for shearing and grinding; molars have 3–5 somewhat
flattened cusps for grinding.
Type Trait
Features that helps in differentiating different teeth within one class (incisors,
canines, premolars and molars) into central and lateral incisors, first and
second premolar, first, second and third molars.
Example: Maxillary central incisor has a straight incisal edge while lateral
incisor has a curved incisal edge.
The term permanent maxillary central incisor denotes all the four trait
categories, i.e. Permanent: Set trait Maxillary: Arch trait Incisor: Class trait
Central: Type trait
Line angle is the junction between two surfaces that meet each other. The
name of the line angle is based on the two surfaces which meet to form that
line angle. Accordingly, posterior teeth have eight line angles, namely mesio-
buccal, disto-buccal, mesio-lingual, disto-lingual, mesio-occlusal, disto-
occlusal, bucco-occlusal and linguo-occlusal. Mesioincisal and distoincisal
line angles are not considered in anterior teeth and therefore anterior teeth
have only six line angles; namely mesio-labial, disto-labial, mesio-lingual,
disto-lingual, labio-incisal and linguo-incisal.
Point angles are the point where three surfaces meet and are named by
joining the name of those three surfaces which meet. Both anterior and
posterior teeth have four point angles each. The point angles of anterior teeth
are mesio-labio-incisal, mesio-linguo-incisal, disto-labio-incisal and disto-
linguo-incisal. The point angles of posterior teeth are mesio-bucco-occlusal,
mesio-linguo-occlusal, disto-bucco-occlusal and disto-linguo-occlusal.
Fossa
Fossa is an irregular depression or concavity found on the lingual surface of
anterior teeth or occlusal surface of posterior tooth.
Fossae can be lingual fossa, central fossa, distal fossa and triangular
fossa.
A lingual fossa is found on the lingual surface of anterior teeth, bounded by
marginal ridges, cingulum and linguoincisal ridge. The lingual fossa in
canines are divided into two by lingual ridge.
A central fossa is a major fossa found on the occlusal surface of molars
which are formed by the converging ridges, terminating at a central point in
the bottom of a depression, where there is a junction of grooves.
Distal fossa is another major fossa seen on the occlusal aspect of maxillary
molars which is located distal to the oblique ridge
Triangular fossae are found in molars and premolars on the occlusal surfaces
just inside the marginal ridges. There are two triangular fossae including
mesial triangular fossa which is seen adjacent to mesial marginal ridge and
distal triangular fossa which is seen adjacent to distal marginal ridge.
A sulcus is a broad linear depression or valley on the surface of a posterior
teeth. Sulcus is the area between ridges and cusps, the inclines of which meet
at an angle to form a groove called developmental groove.
A groove is a linear depression or a line present at the deepest part of the
sulcus. The grooves can be developmental grooves or supplemental grooves.
Developmental grooves are sharply defined, narrow and linear depression
seen, separating the major portions of a tooth developing from different
lobes. All posterior teeth have a distinct central developmental groove which
divides the occlusal aspect into two parts. Additional developmental grooves
are found extending in buccal or lingual direction separating the cusps from
adjacent ones which may extend onto the buccal and lingual surfaces as
buccal and lingual grooves.
A supplemental groove is a small irregularly placed shallow groove which is
less distinct than the developmental groove. Supplemental grooves are
supplemental to a developmental groove and are not found between
developmental portions of a tooth.
Pits are small pinpoint depressions located at the junction of developmental
grooves or at terminals of the grooves. Pits are usually found at the deepest
part of fossae, and depending on the location they are named as central pit,
mesial or distal pit, lingual or palatal pit and buccal pit. Pits can be a site for
initiation of caries.
Fissure is a cleft or ditch formed at the bottom of a developmental groove.
This also can be a site for initiation of caries.
A lobe is one of the primary sections of formation in the development of the
crown. Cusps and mamelons are representative of lobes.
All the deciduous incisors develop from one lobe while the second
deciduous molars develop from five lobes.
All the permanent anterior teeth develop from four lobes: Three labially
(mesial, labial and distal lobes) and one lingually (lingual lobe). The lingual
lobe is represented by cingulum. Mamelons are the three rounded
protuberances found on the incisal ridges of newly erupted incisor teeth (Fig.
14.8) representing the three lobes from which the labial portion of the tooth
develop.
Premolars also develop from four lobes, namely mesial, buccal, distal and
lingual lobe. Mandibular second premolar which is three cusp type develop
from five lobes: Three for buccal portion and two for lingual portion. In this
tooth, the lobes are named as mesial, buccal, distal, mesio-lingual and disto-
lingual lobes.
FUNCTIONAL OR FUNDAMENTAL
CURVATURES OF TEETH
All the teeth show a form that is directly related to the function it has to
perform. The fundamental curvatures of teeth are proximal contours creating
contact points and interproximal spaces, facial and lingual contours and
curvature of cervical line.
Functions
Buccal and lingual contours can deflect the food material away from gingival
margin during mastication and therefore helps in maintenance of health of
periodontal tissues. Cervical contours also serve to decrease the tooth bulk
from its gingival third to incisal third.
Height of contour or crest of curvature is the greatest bulge of the curved
outlines of a tooth (Fig. 14.11). As a general rule, height of contour of facial
and lingual surfaces of both anterior and posterior teeth are in the cervical
third, except lingual crest of curvature of posterior teeth which is near the
middle third. The crest of curvature of proximal surfaces represent the contact
areas.
Interproximal Spaces
Triangular or V-shaped spaces seen between adjacent teeth, cervical to their
contact is called interproximal spaces. The sides of the triangle are formed by
the proximal surfaces of adjacent teeth, the base is formed by the alveolar
bone and the contact area of the two teeth forms the apex of the triangle.
These spaces are normally filled with gingival tissues called papillary gingiva
or interdental papilla. When gingival recession occurs between the teeth, the
interdental papilla and bone no longer fill the entire interproximal space, and
creates a void which exists cervical to the contact and is called a cervical
embrasure or gingival embrasure.
Embrasures
Embrasures (spillways) are triangular or V-shaped spaces seen on facial,
lingual or occlusal to the contact areas (Figs 14.10b and c). They allow the
passage of food around the teeth, so that food is not forced into the contact
area between the teeth. These embrasures or spillways are named for their
locations in relation to the contact area and are facial (buccal or labial),
lingual, incisal or occlusal. The gingival or cervical embrasure is generally
termed as interproximal space. The term gingival embrasure is used if the
interdental gingiva is not filling the space as in case of gingival recession.
Functions of Embrasures
Makes a spillway and allow food to be forced away from contact areas and
thus prevent food from being packed between them.
Embrasures help to dissipate and reduce occlusal forces.
They permit a slight amount of stimulation to the gingiva by fractional
massage of food while at the same time protecting the gingiva from undue
trauma.
Introduction
Importance of deciduous teeth
Description of morphology of maxillary central incisor, lateral incisor and
canine
P rimary dentition is seen in children up to the age of six years. The first
primary tooth appears in the oral cavity at the age of six months and the
dentition is completed by two and a half years. These teeth are called
deciduous teeth because they fall off to give space for permanent successors.
The term deciduous is derived from a Latin word which means ‘falls off’.
Other names used to describe these teeth are ‘milk teeth’, ‘temporary teeth’
or ‘baby teeth’.
The deciduous teeth are twenty in number which include two incisors, one
canine and two molars in each quadrant. There are no premolars in primary
dentition. The primary molars are replaced by premolars of permanent
dentition.
The deciduous maxillary central incisors are two in number, one on each side
of the midline.
Crown
Crown is mesio-distally wider than cervico-incisally, i.e. width of crown is
more than the length. The opposite holds true for the corresponding
permanent tooth. Mesial outline is relatively straight while distal outline is
convex. Incisal edge is straight with sharp mesio-incisal angle and rounded
disto-incisal angle. Cervical line is curved towards the root. Labial surface is
slightly convex and smooth without any developemental grooves. Cervical
third of labial surface shows a prominent cervical ridge running in a mesio-
distal direction.
From the lingual aspect, a significant lingual convergence of the crown can
be appreciated. Cingulum and marginal ridges are well developed, making
lingual fossa more distinct. Cingulum may extend beyond the cervical one-
third towards the incisal region resulting in partial division of lingual fossa.
Mesial and distal aspects of deciduous maxillary central incisors show
marked convexity. Cervical one-third of crown is wider bucco-lingually
because of well developed cingulum and a prominent cervical ridge on buccal
aspect. Curvature of cervical line is greater on the mesial aspect than distal.
A wider mesio-distal dimension of crown than bucco-lingual can be well
appreciated from incisal aspect. Incisal edge is straight and is centered over
the bulk of crown.
Root
Root is cone shaped with evenly tapered sides till the blunt apex. Root is
longer in proportion to the crown length. Because of lingual tapering, in
cross-section root is triangular in shape with base at the labial aspect and tip
at the lingual aspect. A prominent developmental groove may be present on
the mesial surface of root.
Maxillary lateral incisor is located distal to the central incisor, one on each
side of the maxillary arch.
Morphology of maxillary lateral incisor is similar to that of central incisor.
The differences are:
Crown is wider cervico-incisally than mesio-distally, i.e. crown length is
more than its width.
Crown is smaller in all dimensions and less symmetrical.
Disto-incisal angle is more rounded
Root is much longer in proportion to the crown length.
It is the third tooth from the midline in the maxillary arch. It is located distal
to the lateral incisor on either side. It is also called cuspid.
Crown
Primary maxillary canine is larger than central and lateral incisors. Crown
length is almost equal to the width and is constricted at the cervix. Mesial and
distal outlines are convex with both mesial and distal contact areas located
nearly at the same level, i.e. at middle of middle one-third. Primary maxillary
canine has a well developed sharp cusp. The mesial cusp slope is longer
than the distal cusp slope. Labial surface shows a labial ridge extending
vertically from the cervical region to the cusp tip.
Lingual aspect of this tooth shows a bulky cingulum and prominent
marginal ridges and lingual fossa. A distinct lingual ridge is also present
which divides lingual fossa into mesio-lingual and disto-lingual fossae.
From the proximal aspect a greater labio-lingual measurement especially at
cervical one-third can be appreciated which is due to prominent labial
cervical ridge.
Cervical line curves incisally to a greater degree on mesial aspect than on
the distal.
When observed from incisal aspect, crown is wider mesio-distally than
labio-lingually. Cingulum is centered over the crown.
Root
Root is long, slender and tapering. Length of root is twice as that of crown.
The deciduous mandibular central incisors are two in number, one on each
side of the midline of mandible.
Crown
Deciduous mandibular central incisors have considerable morphological
resemblance to permanent counterparts but are significantly smaller in size.
These teeth are the smallest incisors in the mouth.
From labial aspect this tooth is smooth and relatively flat except for the
cervical 1/3rd. The mesial and distal surfaces tapers evenly to a narrow cervix
and contact areas mesially and distally are located at incisal 1/3rd. The incisal
edge is straight and is at right angles to the long axis of tooth. Both mesio-
incisal and disto-incisal angles are sharp.
Crown is narrower lingually and cingulum, marginal ridges and lingual
fossae are less prominent. When a deciduous mandibular central incisor is
examined from proximal aspect, cervical convexity of labial and lingual
outlines appears to be prominent. Incisal edge is centered over the crown,
from the proximal aspect. Distally the curvature of cervical line is lesser
when compared to mesial side.
Root
Root is twice as long as crown and it tapers to a sharp tip. There may be
developmental depression on the distal aspect of root.
Mandibular lateral incisors are two in number and are located distal to the
central incisors, one on each side of the mandibular arch. In general this tooth
resembles a deciduous mandibular central incisor. Differences are:
Larger than centrals in all dimensions except labio-lingual dimension which
is same in central and lateral incisors.
Incisal edge is slopping distally with distal contact area located at a lower
level.
Mesio-incisal angle is sharp while disto-incisal angle is rounded.
Cingulum, marginal ridges and lingual fossa are more prominent.
It is the third tooth from the midline in the mandibular arch. It is located
distal to the lateral incisor on either side. It is also called cuspid. The
mandibular primary canine has the same general form as the maxillary
canine. Differences observed are:
Crown is longer and narrower mesio-distally but thicker labio-lingually, but
to a lesser extent when compared to maxillary canine.
Cusp tip is pointed with a longer distal cusp slope than mesial slope.
Labial ridge is less prominent.
Labio-lingual measurement is not as great as maxillary canine because of less
prominent cervical ridge and cingulum.
On lingual aspect the cingulum, marginal ridges, lingual ridge and lingual
fossae are less prominent.
Root
Root is shorter and tapers to a pointed tip.
The deciduous maxillary molars are four in number, two on either side of the
arch, which includes the first and second molars.
BUCCAL ASPECT
Crown
Shape of Buccal Aspect
Crown appears wider mesio-distally than cervico-incisally, i.e. width of
crown is more than the length. Mesial half of the tooth is longer than distal
half.
The crown tapers considerably towards the cervix with the cervical
measurement 2 mm less than that at contact area. This gives a narrower
appearance to the cervical portion of crown and root.
Buccal Surface
Buccal surface is smooth with a little evidence of developmental grooves. A
poorly developed buccal developmental groove extending onto buccal
surface is located distal to the center, separating the larger mesio-buccal cusp
from disto-buccal cusp. A prominent buccal ridge is present, running from
the tip of mesio-buccal cusp to a cervical direction. The cervical ridge is
distinct on the buccal surface running in a mesio-distal direction and is
significantly prominent on the mesial half.
Root
Deciduous maxillary first molar has three roots: Two buccal and one palatal,
namely mesio-buccal, disto-buccal and palatal. All three roots can be seen
from this aspect and are long, slender and widely separated. The furcation is
close to the cervical line. So the root trunk is very small.
PALATAL ASPECT
The form of the palatal aspect is similar to that of buccal aspect. Features
observed are:
Crown is narrower palatally
Palatal surface is slightly convex cervico-occlusally and markedly convex
mesio-distally
Mesio-palatal cusp is the most prominent cusp of this tooth and is largest and
sharpest.
Disto-palatal cusp may or may not be present. If present is small, rounded
and poorly defined. The disto-palatal cusp is separated from mesio-palatal
cusp by a less defined palatal groove. When disto-palatal cusp is absent it is
called three cusp type and in such types die palatal cusp occupies the entire
palatal portion of occlusal aspect.
Because of the small disto-palatal cusp, a portion of the disto-buccal cusp
which is more developed can be seen from palatal aspect.
Root
All three roots can be seen from this aspect, palatal being the longest.
MESIAL ASPECT
Crown
Shape of Mesial Aspect
Cervical 1/3rd of crown is much wider bucco-palatally than the occlusal
1/3rd making the occlusal table narrow.
Mesial Surface
Mesial surface is relatively flat except for the region of contact area.
Root
From the mesial aspect, only two roots are visible; mesio-buccal and palatal
root. Lingual root is thin and long, with a sharp curve buccally above middle
1/3rd. The disto-buccal root is not visible because mesio-buccal root is broad
enough to hide die disto-buccal root. Since the furcation is close to the
cervical line, the root trunk is very small.
DISTAL ASPECT
Crown tapers markedly towards the distal aspect and therefore is narrower
distally than medially. Crown length is lesser on distal aspect than mesial.
Disto-buccal cusp is more prominent than disto-palatal which is smaller and
may be even absent.
Cervical ridge on the buccal surface is not as prominent as on mesial aspect
Cervical line is curved occlusally to a lesser extend than mesial
Distal marginal ridge is more cervically oriented.
All three roots can be seen from the distal aspect: Mesio-buccal, disto-buccal
and palatal. Because the disto-buccal root is shorter and narrower than mesio-
lingual root, a portion of that root is also seen.
Root
Root trunk is very small with the level of bifurcation closer to the cervical
line.
OCCLUSAL ASPECT
Shape
Occlusal aspect is nearly rectangular with shorter sides represented by
marginal ridges.
Because of palatal convergence crown is wider buccally than lingually in a
mesio-distal direction. Since the crown has a distal convergence, it is wider
mesially than distally in a bucco-lingual direction. The occlusal table is
narrow in this tooth because of occlusal convergence from the proximal
aspects.
Occlusal Surface
Occlusal surface shows anatomic landmarks such as cusps, ridges, fossae,
pits, grooves, etc.
Cusps
Occlusal surface of primary maxillary first molar shows four cusps, namely
mesio-lingual, mesio-buccal, disto-lingual and disto-buccal. Mesio-lingual
cusp is largest and sharpest of all cusps, followed by mesio-buccal and disto-
buccal. Disto-lingual cusp is very small or may be even absent.
Ridges
Triangular ridges of all cusps are found extending from cusp tip towards the
center of occlusal surface.
Oblique ridge: Sometimes a well-developed oblique ridge may be seen
extending between mesio-palatal and disto-buccal cusps.
Transverse ridge may be formed between mesio-lingual and mesio-buccal
cusps.
Mesial marginal ridge forms the mesial boundary of occlusal aspect and is
well developed and is occlusally located than distal marginal ridge. The
palatal half of the mesial marginal ridge shows a distal inclination making the
palatal surface narrow.
Distal marginal ridge is straight in bucco-palatal direction and is smaller, less
developed and cervically located than mesial marginal ridge.
Fossae
Central fossa is the major fossa located at the center of occlusal aspect.
Mesial triangular fossa is a minor fossa located just inside the mesial
marginal ridge and is large and deep when compared to distal triangular
fossa.
Distal triangular fossa is located just inside the distal marginal ridge and is
less distinct.
Grooves
Occlusal surface shows both developmental and supplementary grooves.
These grooves show an ‘H’ pattern.
Developmental grooves
Central groove: Extends from the central fossa in a mesial direction to end in
the mesial triangular fossa.
Distal extension of central groove: This groove is seen in teeth in which the
oblique ridge is less prominent and this extends from central pit to the disto-
lingual developmental groove.
Buccal groove: Starts from the central pit and traverse in a buccal direction
separating the two buccal cusps and may extend onto buccal surface.
Distal developmental groove: It is present distal to the oblique ridge outlining
the disto-palatal cusp.
Lingual developmental groove: This groove is present only in four cusp types
where a disto-palatal cusp is present and this is seen as a lingual extension of
distal developmental groove between two lingual cusps.
Supplementary grooves
Supplementary grooves are found radiating from mesial pit, one in a buccal
direction, one in a lingual direction and a third one towards the marginal
ridge which may cross the marginal ridge and extend onto the mesial side.
Pits
Central, mesial and distal pits are seen at the deeper part of respective fossae.
Sometimes distal pit is absent.
BUCCAL ASPECT
Crown
Crown of deciduous second molar is considerably larger than that of first
deciduous molar with a narrow cervix. Buccal view shows two well
developed cusps: mesio-buccal and disto-buccal cusps which are separated by
a buccal developmental groove. Mesio-buccal cusp is larger than distobuccal
cusp. Buccal surface shows a prominent cervical ridge but not as prominent
as in first molar.
Root
Deciduous maxillary second molar has three roots, namely mesio-buccal,
distobuccal and palatal. All three roots can be seen from this aspect and are
long, slender and widely separated. The trifurcation is close to the cervical
line. So the root trunk is very small.
PALATAL ASPECT
Crown
From lingual aspect there are two major cusps visible: Mesio-lingual and
disto-lingual cusps. The lingual cusps are separated by lingual groove which
extends onto lingual aspect which is gradually obliterated as it reaches the
cervical 1/3rd. Mesio-lingual cusp is larger and well developed. A fifth cusp,
‘cusp or tubercle of Carabelli’ is found lingual to mesio-lingual cusp which
is separated from the mesio-lingual cusp by a developmental groove. In some
teeth, fifth cusp may be absent or is represented by traces of developmental
groove.
Root
All three roots are visible from the palatal aspect. Palatal root is thicker and
larger and same length as mesio-buccal.
MESIAL ASPECT
Crown
From mesial aspect, deciduous maxillary second molar is similar to
permanent maxillary first molar. Features observed are:
Root
Only two roots are seen from this aspect: Mesio-buccal and palatal.
Bifurcation is around 2 or 3 mm above cervical line.
DISTAL ASPECT
Root
Root trunk is very small with the level of bifurcation at an apical level than
other sides.
OCCLUSAL ASPECT
Shape
Shape is rhomboidal. The crown is wider mesially than distally in a bucco-
palatal direction because of distal convergence. The occlusal table is narrow
in this tooth because of occlusal convergence from the proximal aspects.
Occlusal Surface
Occlusal surface shows various anatomic landmarks such as cusps, ridges,
fossae, pits and grooves.
Cusps
Occlusal surface of primary maxillary second molar shows four well
developed cusps, namely mesio-palatal, mesio-buccal, disto-palatal and disto-
buccal. Mesio-palatal cusp is largest and sharpest of all cusps and this cusp
occupies a greater portion of occluso-palatal area. Second largest cusp is
mesio-buccal followed by disto-buccal. Disto-palatal cusp is smallest of the
four major cusps. A fifth cusp, ‘tubercle of Carabelli’ is found palatal to
mesio-palatal cusp which is separated from the mesio-palatal cusp by a
developmental groove.
Ridges
Triangular ridges of all cusps are found extending from cusp tip towards the
center of occlusal surface.
Oblique ridge: A well developed oblique ridge is seen extending between
mesio-palatal and disto-buccal cusps.
Transverse ridge may be formed between mesio-palatal, mesio-buccal cusps.
Mesial marginal ridge forms the mesial boundary of occlusal aspect and is
well developed.
Distal marginal ridge forms the distal boundary of occlusal aspect and is
equally well developed as mesial marginal ridge.
Fossae
Central fossa is the major fossa, located mesial to the oblique ridge.
Distal fossa is less prominent and is located distal to the oblique ridge.
Mesial triangular fossa is well defined and is situated distal to mesial
marginal ridge.
Distal triangular fossa is less distinct and found just inside the distal marginal
ridge.
Pits
Pinpoint depressions can be seen at deepest part of the fossae where the
grooves converge. Mainly three pits are seen in deciduous maxillary second
molar: Central pit, mesial pit and distal pit.
Grooves
Both developmental and supplementary grooves are present:
Developmental grooves
Central groove extends from central pit in a mesial direction to the mesial pit.
Buccal developmental groove also begins from central pit and traverse
buccally separating the two buccal cusps.
Distal developmental groove extends from central fossa in a distal direction
across the oblique ridge to join the distal pit.
Disto-lingual developmental groove is found in the distal fossa with a mesial
inclination separating the two lingual cusps.
Lingual developmental groove is seen as an extension of disto-lingual
developmental groove which extends onto the palatal side between palatal
cusps.
Supplementary grooves
Supplementary grooves are present in mesial and distal triangular fossae.
The primary mandibular molars are four in number, two on either side of the
arch, which includes the first and second molars.
This tooth is morphologically unique and does not resemble any other
deciduous or permanent tooth. Its outline and form differs considerably from
that of all other primary and permanent teeth. Differentiating feature is its
overdeveloped mesial marginal ridge which somewhat resembles a cusp.
BUCCAL ASPECT
Crown
Shape of Buccal Aspect
From the buccal aspect crown appears wider mesio-distally than cervico-
occlusally. Distal part of crown is shorter than mesial part. Considerable
degree of cervical convergence is observed which is more from the distal
aspect than mesial.
Buccal Surface
Buccal surface is convex in mesio-distal direction but slopes abruptly
towards the occlusal surface. In the cervical region of buccal surface, a
prominent cervical ridge is seen extending in a mesio-distal direction. This
cervical ridge is more prominent at mesial half and referred to as ‘tubercle of
Zuckercandl’. On the buccal surface, two buccal cusps are separated by a
depression which may at times harbor a buccal developmental groove.
Root
Mandibular first primary molar has two roots: Mesial and distal. Furcation is
close to cervical line and the root trunk is short. Mesial root is wider and
longer than distal root. Roots are slender widely separated and the apical third
spread beyond the crown outlines.
UNGUAL ASPECT
Crown
Crown and root converges lingually on the mesial side, making mesial
surface visible from this aspect. Since there is no convergence from distal
aspect, distal surface cannot be seen. Crown length is almost equal in both
mesial and distal portions in contrast to the buccal aspect.
Two lingual cusps are seen from this aspect: Mesio-lingual and disto-lingual
cusps. Mesio-lingual cusp is larger, longer and sharper, while disto-lingual
cusp is small and rounded. The mesio-lingual cusp in some teeth is so
prominent and is almost centered over mesial root. Mesial marginal ridge is
so well developed that it resembles a cusp from lingual aspect. Along with
the lingual cusps part of two buccal cusps also may be seen from lingual side.
Cervical line is nearly straight
Lingual surface is convex mesio-distally and cervico-occlusally and the
surface is traversed by a lingual groove which separates both lingual cusps.
Root
Both mesial and distal roots can be seen from this aspect. Since the
bifurcation is slightly more apical, the root trunk may be longer lingually.
MESIAL ASPECT
Crown
Shape of Mesial Aspect
Crown appears to incline lingually as in case of permanent mandibular teeth.
Crown length is more on the mesio-buccal part than mesio-lingual part.
Cervical portion of the crown is much wider than occlusal, making the
occlusal table narrow.
Mesial Surface
Mesial surface is relatively flatter.
Root
Only one root is visible from this aspect, i.e. mesial root. The mesial root is
flat and square with broad apex. Deep developmental depression is present,
running the entire length of root.
DISTAL ASPECT
Root
Distal root is rounded, thinner and less broad than mesial root.
OCCLUSAL ASPECT
Shape
Shape of occlusal aspect is roughly rhomboidal with an obtuse disto-buccal
angle and acute mesio-buccal angle, because of prominent buccal cervical
ridge. The occlusal surface is wider mesio-distally than bucco-lingually.
Generally the occlusal table is narrow with relatively shallow surface. The
distal half of the occlusal table is wider than the mesial half. Occlusal aspect
also shows a lingual convergence.
Occlusal Surface
Occlusal surface shows various anatomic landmarks such as cusps, ridges,
pits, fossae and grooves, etc.
Cusps
Deciduous mandibular first molar has four cusps: Mesio-lingual, mesio-
buccal, disto-buccal and disto-lingual cusps. Both mesio-lingual and mesio-
buccal cusps are larger and well developed while distal cusps are smaller.
The mesio-lingual cusp is the largest and the disto-lingual cusp is the smallest
of all cusps.
Ridges
Triangular ridges of all cusps are found extending from cusp tip towards the
center of occlusal surface.
Transverse ridge may be found between mesio-lingual, mesio-buccal cusps.
Mesial marginal ridge forms the mesial boundary of occlusal aspect and is
very prominent, long and occlusally placed.
Distal marginal ridge forms the distal boundary of occlusal aspect. It is not
well developed and is cervically placed when compared to mesial marginal
ridge.
Fossae and Pits
Central fossa is the major fossa located at the center of occlusal aspect.
Mesial triangular fossa is located just inside the mesial marginal ridge.
Distal triangular fossa is shallow and it lies inside the distal marginal ridge
Pits may be seen as pinpoint depression at deepest part of fossae where
grooves join.
Grooves
Both developmental and supplementary grooves are seen:
Developmental grooves
Central groove runs from mesial pit to central pit, separating the mesio-
buccal and mesio-lingual cusps.
Buccal developmental groove begins from central pit, traverse buccally
between the mesiobuccal and disto-buccal cusps. This groove usually does
not extend onto the buccal surface.
Lingual groove extends between two lingual cusps which also may not
extend onto lingual surface.
Supplementary grooves
Supplementary grooves are present in both mesial and distal triangular
fossae.
BUCCAL ASPECT
Mesiodistal dimension of the crown at the cervix is much less when
compared to that at contact area making the cervix narrow. Crown appears to
be tilted distally on its root base.
Three cusps are visible from buccal aspect: mesio-buccal, disto-buccal and
distal cusp. All the buccal cusps are nearly of the same size in contrast to the
permanent mandibular first molar.
Buccal surface shows two grooves: A mesio-buccal groove which separates
mesio-buccal and disto-buccal cusp and a disto-buccal groove which
separates disto-buccal cusp from distal cusp.
A well-developed cervical ridge is present on the buccal surface immediately
below the cervix extending mesio-distally.
Root
Mandibular second primary molar has two roots: Mesial and distal.
Bifurcation is very close to the cervical line and the root trunk is short. Roots
are slender widely separated and the apical third spread beyond the crown
outlines.
LINGUAL ASPECT
Root
From lingual aspect, both mesial and distal roots are seen. Bifurcation is very
close to the cervical line and the root trunk is short. Roots are slender, widely
separated and the apical third of the root may extend beyond the crown
outlines.
MESIAL ASPECT
Mesial Surface
Mesial surface is convex except for cervical region which is flat.
Root
Only one root is visible from this aspect i.e. mesial root. Mesial root is broad
and flat with blunt apex.
DISTAL ASPECT
Root
Only one root is visible from this aspect, i.e. distal root. Distal root is flat and
almost as broad as mesial root but tapers at the apical 1/3rd.
OCCLUSAL ASPECT
Shape
Shape of occlusal aspect is rectangular with a lingual and distal convergence.
Because of lingual convergence crown is wider buccally than lingually.
Mesial half is wider in bucco-lingual direction than distal half due to the
distal convergence.
Occlusal Surface
Occlusal surface shows various anatomic landmarks such as cusps, ridges,
pits, fossae, grooves, etc.
Cusps
Deciduous mandibular second molar has five cusps: Three buccal cusps and
two lingual cusps. The buccal cusps are mesio-buccal, disto-buccal and distal
cusps. All the three buccal cusps are nearly of same size. Lingually there are
two cusps: The mesio-lingual and disto-lingual cusps which are also nearly of
same size. Mesio-lingual cusp is the most prominent cusp of this tooth.
Ridges
Triangular ridges are seen extending from the tips of all five cusps towards
the central part of occlusal surface. Triangular ridges of lingual cusps are
longer than that of buccal cusps.
Mesial marginal ridge: Forms the mesial boundary of the occlusal aspect and
is better developed, more pronounced and located more occlusally than the
distal marginal ridge.
Distal marginal ridge: It is located at distal margin of occlusal aspect. It is
shorter, less developed and more cervically placed.
Cusp ridges: Forms the buccal and the lingual boundaries of the occlusal
aspect
Fossae
Three fossae can be seen; one major (central fossa) and two minor (mesial
and distal triangular fossae).
The central fossa is the largest fossa located at the center of the occlusal
aspect.
Mesial triangular fossa is a triangular shaped depression located distal to the
mesial marginal ridge.
Distal triangular fossa is less distinct and is located mesial to distal marginal
ridge.
Pits
Pits are present as small pinpoint depression at the deepest part of all fossae,
where the developmental grooves converge. The pits are named according to
the fossa in which they are located: Central pit, mesial pit and distal pit.
Grooves
Both developmental and supplementary grooves are seen:
Developmental grooves
Central groove: It is the major groove seen on the occlusal aspect and is
centrally located dividing occlusal surface into buccal and lingual halves. It
starts from the mesial pit and runs in a mesial direction to end in the distal pit.
Mesio-buccal groove starting from central groove extends between two
mesio-buccal and disto-buccal cusp and extends on to buccal side.
Disto-buccal groove: Between disto-buccal and distal cusp and extends on to
buccal surface.
Lingual groove-separates two lingual cusps and extend onto the lingual
surface.
Supplementary grooves
Supplemental grooves are seen in the mesial and distal triangular fossae,
sometimes crossing over the marginal ridges.
Roots are thin and longer Roots are thick and smaller relative to
compared to crown length and are crown length and are not flared
flared
Type of teeth
16. Cervical ridge Prominent cervical ridge is seen Cervical ridge is seen
in all deciduous teeth mainly in even in permanent
molars, on the buccal aspect molars but is less
especially in the mesio-buccal pronounced
portion
18. Surfaces The labial and lingual surfaces The labial and lingual
are flat above the cervical ridge. surfaces are relatively
Both these surfaces converges convex. There is no
occlusally, so that the bucco- such convergence
lingual measurement near
occlusal portion is much lesser
than that of cervical region
21. Root crown Root of deciduous teeth are Root is not so longer
ratio longer when relative to their when relative to
crown length crown length
22. Root flare Roots flare out beyond crown Do not flare out and
boundary are well within the
confines of crown
boundary
25. Root trunk The root trunk is very small and The root trunk is
not distinct longer and distinct
28. Pulp horns Pulp horns are at a higher level Pulp horns are not as
high as in deciduous
teeth
29. Pulp canal Pulp canal is wider relative to the Pulp canal is
size of root. Less curved and narrower relative to
apically less constricted the size of root. More
tortuous and apically
more constricted
Introduction to incisors
Chronology of maxillary central incisors
Measurement table
Morphology of maxillary central incisors
Developmental variations and clinical considerations
P ermanent incisors are eight in number; four in the maxilla and four in
mandible, which include two central incisors and two lateral incisors in
maxilla and mandible each. Central incisors are located on either side of
the midline with their mesial surfaces in contact. Lateral incisors are situated
distal to the central incisors on each side of the arch. As the name indicate the
incisors function in incising or cutting food. These teeth are also important in
articulation of speech and esthetics. The maxillary and mandibular incisors
guide the jaw during closure.
Maxillary central incisors are two in number and occupy either side of the
midline. They are the most prominent teeth in the oral cavity with a great
esthetic value and are larger in all dimensions than the lateral incisors. The
morphologic characteristics of this tooth can be described from five aspects,
namely labial, lingual, mesial, distal and incisal.
LABIAL ASPECT
Labial aspect is the surface of the tooth facing the lip. The description of
features is categorized as features of crown and of root.
Crown
Shape
Shape of maxillary central incisor is squarish or rectangular with a slight
cervical convergence (narrower at the cervical region than incisal).
Cervicoincisal length is 2 mm more than the mesiodistal width.
Labial Surface
Labial surface of maxillary central incisor is smooth with convexity at the
cervical third. Surface becomes relatively flat as the incisal edge is
approached. Two shallow vertical depressions may be appreciated dividing
the labial surface into three portions, each representing parts developed from
three different lobes.
MLATAL/LINGUAL ASPECT
Crown
The lingual outline of maxillary central incisor is reverse of the labial outline.
The crown and the root show convergence towards the lingual side which
makes the mesial and the distal surfaces visible from this aspect.
In contrast to the smooth labial surface, the lingual surface shows
concavities and convexities.
Convexities
There is a convex area called cingulum located at the cervical third which is
placed slightly to the distal in a mesio-distal direction. Either side of the
lingual aspect is bordered by linear elevations called marginal ridges. The
ridge on the mesial side is called mesial marginal ridge and on the distal side
is called distal marginal ridge. Mesial marginal ridge is slightly longer than
the distal marginal ridge as a result of distal location of the cingulum. The
lingual surface also shows the presence of linguo-incisal ridge, which forms
the incisal boundary of the lingual surface.
Concavity
The major portion of the lingual aspect of the central incisor is occupied by a
concavity called lingual fossa. The lingual fossa is M-shaped and is bounded
superiorly by the cingulum, inferiorly by the linguo-incisal ridge and on
either side by the mesial and distal marginal ridges. A deep developmental
groove may be present on the lingual surface extending onto the cingulum.
Cervical outline is semicircular with curvature towards the root.
Root
Root is lingually converged and conical in shape with blunt and rounded
apex. Cross section of the root is triangular in shape with rounded angles.
MESIAL ASPECT
Mesial aspect is one of the proximal aspects that is closer to the midline of
the face. Morphological characteristics of crown and roots are separately
mentioned.
Crown
Shape of mesial aspect: From the mesial aspect the crown appears triangular
or wedge shaped with the base at the cervix and apex at the incisal edge.
Root
Root is cone shaped and tapered with a rounded apex. The root surface on the
mesial aspect is relatively flat and may show longitudinal developmental
depression.
DISTAL ASPECT
Distal aspect is the proximal aspect that is away from the midline of the face.
Distal aspect is similar to that of mesial aspect with slight differences.
The crown appears to be broader from this aspect than the mesial aspect.
Extent of curvature of cervical line is less on the distal aspect
The root is tapered towards the rounded apex.
INCISAL ASPECT
Incisal aspect is the cutting/biting surface of the tooth. The features described
may be appreciated when the tooth is held in such a way that incisal edge is
towards the observer, in a horizontal direction with labial aspect upwards.
When the tooth is observed in this manner, root will be visible as it
superimposed over the crown.
The shape of the maxillary central incisor is triangular from this aspect
with the base on the labial surface and the apex towards the cingulum. The
mesio-distal dimension is greater than the labio-lingual dimension. The labial
aspect shows a semicircular arch form and the lingual aspect is tapered and
more convex at the cingulum. Slight disto-lingual twist of the incisal edge
may be appreciated from this aspect because of lingual positioning of the
disto-incisal angle compared to that of mesio-lingual angle. As the incisal
edge is located at the center, equal extent of the labial and lingual halves can
be seen. The lingual fossa, marginal ridges and distally placed cingulum can
be appreciated on the lingual aspect. Root cannot be appreciated from this
aspect because it is superimposed on the crown.
‘Shovel shaped’ central incisors: The term shovel shaped is used to describe
an incisor that has prominent mesial and distal marginal ridges and deep
lingual fossa.
Deep lingual pit: As a developmental variation, central incisors may show a
deep lingual pit at the incisal border of cingulum. Such teeth may be prone to
develop dental caries.
Accessory lingual ridge: Rarely maxillary central incisors may show vertical
ridges extending from cingulum to incisal edge.
Talon cusp: At times in incisors, the cingulum may become very prominent
to such an extent, it resembles eagle’s talon, which is referred to as talon
cusp. In such cases chances of dental caries is considerably more. In addition,
very prominent cingulum may interfere with occlusion and may cause trauma
to tongue.
Screw driver shaped central incisor: In patients affected by congenital
syphilis which is a bacterial infection, central incisors may assume a screw
driver shape. In this condition, due to the absence of middle lobe, mesial and
distal outlines of central incisors converge incisally making incisal 1/3rd
narrower than cervical 1/3rd. In addition these teeth may also show a
notching of incisal edge.
FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Labial Aspect
Straight incisal edge with sharp mesio incisal angle and rounded disto-incisal
angle.
Relatively straight mesial outline and slightly curved distal outline.
Mesial contact area is more incisally placed (incisal 1/3rd, closer to mesio-
incisal angle) than distal (at junction of incisal and middle 1/3rd).
Distal tilt of root.
Lingual Aspect
Distal placement of cingulum.
Longer mesial marginal ridge than distal marginal ridge.
Proximal Aspect
Cervical line more curved on mesial aspect than distal.
Incisal Aspect
Disto-lingual twist of incisal edge.
Permanent maxillary right central incisor
21
Permanent Maxillary Lateral
Incisors
Introduction to incisors
Chronology and measurement table
Morphology of maxillary lateral incisor
Differences between maxillary central and lateral incisors
L ateral incisors are the second teeth from the midline located on either side
of the dental arch, distal to the central incisors. Lateral incisors bear close
resemblance to central incisors and support them in functions. When
compared to central incisors, these teeth are smaller and appears relatively
long and narrow. The morphologic characteristics can be described from five
aspects, namely labial, lingual, mesial, distal, and incisal aspects. Further,
features on each aspect (except incisal) is described under two subheadings,
i.e. crown and root.
LABIAL ASPECT
Crown
Shape of Labial Aspect
Shape of maxillary lateral incisor is rectangular with a slight cervical
convergence. Crown is smaller in all dimensions and is less symmetrical than
that of central incisors.
Outlines of the Labial Aspect
Mesial outline is slightly convex with contact area located at the junction of
middle and incisal 1/3rd.
Distal outline is more convex from cervix to disto-incisal angle with contact
area at the middle of middle 1/3rd.
Incisal outline is represented by incisal edge which is rounded or slightly
curved with rounded incisal angles. Mesio-incisal angle is rounded in contrast
to that of central incisors. Disto-incisal angle of maxillary lateral incisor is
more rounded compared to mesio-incisal angle. More rounded disto-incisal
angle along with convex outline gives a semicircular shape to the distal
outline of the tooth.
Cervical line is semicircular, curved towards the root.
Labial Surface
Labial surface is smooth similar to that of central incisors, but is more convex
with less prominent labial depressions.
Root
Root tapers evenly from cervix to apex; apex is distally curved. Like crown,
root is 2 mm narrower than central incisor but with same length giving a long
and narrow appearance.
Crown
The lingual outline of maxillary lateral incisor is reverse of the labial outline.
The crown and the root are narrower on the lingual side because of lingual
convergence. Therefore, the mesial and the distal surfaces are visible from
this aspect.
In contrast to the smooth labial surface, the lingual surface shows
concavities and convexities.
Concavities
The lingual aspect of the lateral incisor shows a concavity called lingual fossa
which is more pronounced than that of central incisors. The lingual fossa is
inverted ‘V’ shaped and is bounded superiorly by the cingulum, interiorly by
the linguo-incisal ridge and on either side by the mesial and distal marginal
ridges. A deep developmental groove may be present on the lingual surface
extending onto the cingulum.
Cervical outline is semicircular with curvature towards the root.
Convexities
Cingulum is seen as a convexity at the cervical third. Unlike the central
incisors, the cingulum is narrower and is located at the center in a mesiodistal
direction. Mesial and distal sides of the lingual aspect are bordered by linear
elevations called marginal ridges. In most of the lateral incisors, mesial and
distal marginal ridges are more prominent than in central incisors. Incisally
the lingual surface is bounded by a prominent linguo-incisal ridge.
Root
Root is narrower lingually, conical in shape with blunt and distally tilted
apex.
MESIAL ASPECT
The mesial aspect of lateral incisor closely resembles the central incisors but
is smaller in all dimensions, than central incisors.
Crown
Shape of mesial aspect: From the mesial aspect the crown appears triangular
or wedge shaped with the base at the cervical portion and apex at the incisal
edge.
Root
Root is cone shaped and tapering to a blunt apex.
DISTAL ASPECT
Distal aspect of maxillary lateral incisor resembles the mesial aspect. The
differences observed are:
The width of crown appears thicker on distal side.
Curvature of cervical line is less.
Root may show a developmental groove.
INCISAL ASPECT
Incisal aspect generally resembles that of central incisor except for its smaller
size. Labial and lingual outlines are more rounded or convex, giving ovoid or
round shape to the incisal aspect in contrast to the triangular shape of the
central incisor. The cingulum is more prominent and is centered in a mesio-
distal direction.
Contact areas are more incisally Contact areas are more cervically
placed with mesial contact area at placed with mesial contact area at
incisal third close to incisal angle junction between incisal and
and distal contact area at the junction middle third and distal contact area
between incisal and middle third at the middle of middle 1/3rd
Permanent maxillary lateral incisors are less symmetrical, and may often
show variations in the form and size.
Peg shaped laterals: This is a common developmental variation observed in
which maxillary laterals present with a characteristic conical shape. Peg
shaped lateral may also be observed as a developmental malformation caused
due to congenital syphilis.
Missing laterals: This is one of the commonest tooth that may be
congenitally absent.
‘Shovel shaped’ lateral incisors: The term shovel shaped is used to describe a
lateral incisor that has prominent mesial and distal marginal ridges and deep
lingual fossa.
Deep lingual pit: As central incisors, even lateral incisors may show a deep
lingual pit at the incisal border of cingulum. Such teeth may be prone to
develop dental caries.
Accessory lingual ridge: Rarely maxillary lateral incisors may show vertical
ridges extending from cingulum to incisal edge.
Talon cusp: At times in lateral incisors, the cingulum may become very
prominent to such an extent, it resembles eagle’s talon, which is referred to as
talon cusp. In such cases chances of dental caries is considerable more, In
addition, very prominent cingulum may interfere with occlusion and may
cause trauma to tongue.
Palatal gingival groove: Lateral incisors may show a deep groove extending
from cingulum to the root surface.
FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Labial Aspect
Curved incisal edge with relatively less rounded mesio-incisal angle and
more rounded disto-incisal angle.
Relatively more curved distal outline than mesial outline.
Mesial contact area is more incisally placed (at junction of incisal and middle
1/3rd) than distal (middle of middle 1/3rd).
Distal tilt of root.
Proximal Aspect
Cervical line more curved on mesial aspect than distal.
Permanent maxillary right lateral incisor
22
Permanent Mandibular
Central Incisors
Introduction to incisors
Chronology and mandibular central incisor
Measurement table
Morphology of mandibular central incisor
Differences between maxillary and mandibular incisors
M andibular incisors are four in number; two central incisors and two
lateral incisors. Both mandibular central and lateral incisors have
similar morphology.
These teeth assist maxillary incisors in functions like cutting food,
esthetics, speech and also in guiding the mandible while closing.
Mandibular central incisors are two in number located on either side of the
midline of mandibular arch, with their mesial surfaces in contact. They are
the smallest teeth in permanent dentition. The morphologic characteristics of
this tooth may be described from five aspects, namely labial, lingual, mesial,
distal and incisal. Further, features on each aspect (except incisal) is
described under two subheadings, i.e. crown and root.
Chronology of permanent mandibular central Incisor
LABIAL ASPECT
Crown
Shape of Labial Aspect
Mandibular central incisors have a narrow long appearance from the labial
aspect. The crown is nearly bilaterally symmetrical.
Labial Surface
Labial surface is smooth without any developmental lines. Surface is flat at
incisal 1/3rd, but slightly convex at cervical and middle 1/3rd.
Root
Root is conical and it tapers to apex which may show a distal tilt.
LINGUAL ASPECT
Crown
Mandibular central incisor shows a lingual taper and therefore part of mesial
and distal surfaces are visible from this aspect. At cervical 1/3rd, cingulum is
present as a convexity, which is centered on the lingual aspect. Confluent
with cingulum on either side, marginal ridges are seen. Between the marginal
ridges, the lingual fossa is present as a slight concavity. In this tooth
cingulum, marginal ridges and lingual fossa are not distinct.
Root
Root is narrower lingually and conical in shape.
MESIAL ASPECT
Crown
Shape of Mesial Aspect
Mandibular central incisor is wedge-shaped from proximal aspect with the
base located at the cervix and apex at incisal edge.
Mesial Surface
Mesial surface is smooth and flat except for slight convexity at incisal 1/3rd,
where contact area is located.
Root
Root outlines are straight up to middle 1/3rd, from where tapering start. Root
tip is located in the midline. Development depression may be seen on the
surface of the root.
Central and lateral incisors vary in Both central and lateral incisors are
size and in morphology nearly of same size and have
somewhat similar morphology
Mesial and distal sides are not as Mesial and distal sides are relatively
flat as in mandibular incisors, flat with contact areas located nearly
rather is convex with contact areas at the same level, closer to the incisal
located at different levels edge
Since the difference between the The crown length is much more
crown length and width is only a relative to the mesio-distal
little the crown of maxillary measurement giving the crown of
incisors has a squarish shape mandibular incisors a thin long
appearance
Since the upper incisors have a Since the lower incisors have a
labial position in normal lingual position in normal occlusion,
occlusion, attrition leads to lingual attrition leads to labial inclination of
inclination of incisal edge incisal edge
DISTAL ASPECT
INCISAL ASPECT
From this aspect labial and lingual surfaces of the tooth are visible. Since the
incisal edge is located lingual to midline, more of labial surface can be
appreciated. The incisal edge is straight and perpendicular to the labio-lingual
root axis plane. Bilateral symmetry of mandibular central incisor can be
better appreciated from this aspect.
Crown shows a greater labio-lingual measurement than mesio-distal. The
labial surface is broader and shows a considerable lingual inclination.
Although the cervical 1/3rd of labial surface is convex, and relatively flatter
middle and incisal 1/3rd as incisal edge is approached. The lingual surface
shows a convexity at the cingulum which is centered in a mesio-distal
direction. Middle and incisal 1/3rd are concave because of the lingual fossa.
FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Introduction
Chronology and mandibular lateral incisor
Measurement table
Morphology of mandibular lateral incisor
Differences between mandibular central and lateral incisors
M andibular lateral incisors are two in number, located distal to the central
incisors. They are larger and less symmetrical than central incisors. The
morphologic characteristics of this tooth may be described from five
aspects, namely labial, lingual, mesial, distal and incisal. Further, features on
each aspect (except incisal) is described under two subheadings, i.e. crown
and root.
LABIAL ASPECT
Crown
Shape of Labial Aspect
Mandibular lateral incisors have a narrow long appearance from the labial
aspect similar to that of central incisors. In contrast to central incisor, the
crown is larger and not bilaterally symmetrical and is tilted distally.
Chronology of permanent mandibular lateral incisor
Labial Surface
Labial surface is smooth without any developmental lines. Surface is flat at
incisal 1/3rd, but slightly convex at cervical and middle 1/3rd.
Root
Root is conical and it tapers to apex which may show a distal tilt.
LINGUAL ASPECT
Crown
Morphologic features are similar to that of central incisor. Tooth shows a
lingual taper and therefore a part of mesial and distal surfaces are visible
from this aspect. At cervical 1/3rd, cingulum is present as a convexity, which
is slightly distally placed. Confluent with cingulum on either side marginal
ridges are seen. Distal placement of the cingulum makes mesial marginal
ridge longer than that of distal marginal ridge. Between the marginal ridges
lingual fossa is present as a slight concavity. Marginal ridges, cingulum and
lingual fossa may be slightly more prominent than in central incisors but not
as prominent as that of maxillary incisors.
Root
Root is narrower lingually and is conical in shape.
MESIAL ASPECT
Crown
Mesial aspect is similar to that of central incisors. Except for the difference in
size, no morphological difference is appreciated.
Mesial Surface
Mesial surface is smooth and flat except for slight convexity at incisal 1/3rd
where contact area is located.
Root
Root is conical with an apical taper. Root tip is located in the midline.
Developmental depression may be seen on the surface.
DISTAL ASPECT
Morphology resembles that of mesial aspect. While comparing the mesial and
distal aspects of a mandibular lateral incisor following differences can be
observed:
The lingual inclination of the crown appears to be more on distal aspect
because of disto-lingual inclination of the incisal ridge.
Crown is straight without any distal tilt Crown is tipped distally on the
root
Incisal edge is straight, perpendicular Incisal edge is inclined distally
to the long axis of tooth
Contact areas are nearly at the same Contact areas are at different
level, close to incisal edge levels with more cervically
located distal contact
INCISAL ASPECT
FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Labial Aspect
Incisal edge sloping distally.
Crown tipped distally on root.
Contact areas are at different level with more cervically located distal contact.
Sharp mesio-incisal angle and rounded disto-incisal angle.
Lingual Aspect
Distal placement of cingulum.
Longer mesial marginal ridge than distal marginal ridge.
Proximal Aspect
Cervical line more curved on mesial aspect than distal.
Incisal Aspect
Disto-lingual twist of incisal edge.
Permanent mandibular right lateral incisor
24
Peermanent Maxillary
Canines
Introduction
Chronology of maxillary canine
Measurement table
Morphology of maxillary canine
Developmental variations and clinical considerations
Maxillary canines are two in number located on either side of the dental arch,
distal to the lateral incisors. The morphologic characteristics can be described
from five aspects, namely labial, lingual, mesial, distal and incisal. Further,
features on each aspect (except incisal) is described under two subheadings,
i.e. crown and root.
LABIAL ASPECT
Crown
Shape of Labial Aspect
The crown is roughly pentagonal in shape and is narrower by 1 mm than
central incisors.
Labial Surface
Labial surface is convex. The middle labial lobe is well developed forming a
prominent labial ridge running cervico-incisally up to the cusp. On either side
of labial ridge shallow depressions are seen dividing the labial aspect into
mesial, middle and distal lobes.
Root
Maxillary canines have the longest root. Root is slender and conical with
bluntly pointed apex which bends distally.
LINGOAL/PALATAL ASPECT
Crown
The crown outline on the lingual aspect is similar to that of the labial aspect.
Canines show a significant lingual tapering because of which both crown and
root are narrower lingually. As in other anterior teeth, lingual aspect of
canines also shows convexities and concavities.
Convexities
The cingulum is seen as a convexity at cervical 1/3rd and is very prominent
resembling a cusp. In a mesio-distal direction, cingulum is centered over the
tooth. Mesial and distal sides of the lingual aspect are bordered by linear
elevations called marginal ridges. Both the mesial and distal marginal ridges
are prominent: Distal marginal ridge being more elevated than the mesial
marginal ridge. In addition, canines have a distinct lingual ridge running in a
cervico-incisal direction from cingulum to the cusp tip. Cingulum, marginal
ridges and lingual ridge are confluent with each other with a little evidence of
developmental grooves.
Concavities
The lingual aspect of canines shows a concavity called lingual fossa, which is
more pronounced than those of other anterior teeth. The lingual fossa is
divided into mesial and distal lingual fossae by the lingual ridge.
Root
Root is narrower lingually and much of mesial and distal surfaces are seen
from this aspect.
MESIAL ASPECT
Crown
Shape of Mesial Aspect
The crown is wedge shaped with base at cervical 1/3rd and apex at cusp tip.
The entire crown appears bulkier from this aspect because of prominent labial
and lingual ridges. A greater labio-lingual measurement of this tooth can be
appreciated from this aspect.
Mesial Surface
Mesial surface is convex on all aspects except for a shallow concavity
between contact area and cervix.
Root
Root is conical with an apical taper. Mesial surface of root has a deep
developmental depression running cervico-apically.
DISTAL ASPECT
General morphology is similar to that of mesial aspect. Differences observed
are:
Curvature of cervical line is less
Distal marginal ridge is heavier and regular
Developmental depression on distal surface of the root is more pronounced
than on the mesial side.
INCISAL ASPECT
Permanent maxillary canines show wide variation in size from very small to
large.
Root division: Root may be bifurcated into labial and lingual roots.
Talon cusp: At times in canines the cingulum may become very prominent to
such an extent, it resembles eagle’s talon, which is referred to as talon cusp.
In such cases chances of dental caries is considerable more. In addition, very
prominent cingulum may interfere with occlusion and may cause trauma to
tongue.
FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Labial Aspect
Distal slope of the cusp is longer than mesial slope.
Relatively more curved distal outline than mesial outline.
Mesial contact area is more incisally placed (at junction of incisal and middle
1/3rd) than distal (middle of middle 1/3rd).
Distal tilt of root.
Proximal Aspect
Cervical line more curved on mesial aspect than distal.
Distal surface of the crown often shows a concavity below contact area.
Incisal Aspect
The mesial half of the tooth appears more convex and bulkier labio-lingually
than distal half.
The distal half of the crown appears stretched with greater mesiodistal width
than the mesial half.
Permanent maxillary right canine
25
Permanent Mandibular
Canines
Introduction
Chronology of mandibular canines
Measurement table
Morphology of mandibular canine
Differences between maxillary and mandibular canines
Developmental variations and clinical considerations
M andibular canines are the third teeth from the midline situated on either
side of mandibular arch, between lateral incisor and first premolar.
They bear close resemblance to maxillary canines and assist them in
function. The morphologic characteristics are described from five aspects,
namely labial, lingual, mesial, distal, and incisal. Further, features on each
aspect (except incisal) is described under two subheadings, i.e. crown and
root.
LABIAL ASPECT
Crown
Shape of Labial Aspect
The crown of mandibular canine appears narrower and longer when
compared to bulky maxillary canine. The long thin appearance is created by
lesser mesio-distal measurement, incisally located contact areas and nearly
straight mesial and distal outlines. Crown is tilted distally on the root base.
Labial Surface
Shows a distinct ridge extending from cervical 1/3rd to the cusp tip which is
named as labial ridge and is less prominent than in maxillary canine.
Root
Root is conical in shape with an apical taper ending in a blunt apex.
LINGUAL ASPECT
Crown
Both crown and root are narrower on the lingual side because of lingual
convergence. Lingual aspect of mandibular canine resembles that of
maxillary canine and shows convexities and concavities. At cervical 1/3rd,
cingulum is present as a convexity, which is slightly distally placed.
Confluent with cingulum on either side marginal ridges are seen. Distal
placement of cingulum makes the mesial marginal ridge longer but distal
marginal ridge is bulkier. The lingual fossa is divided into mesial and distal
lingual fossae by the lingual ridge that runs from cingulum to cusp tip. In
contrast to the maxillary canine in mandibular canine various anatomic
landmarks such as cingulum, marginal ridges and lingual fossae are less
prominent. Therefore lingual aspect appears flatter and smoother.
Root
Root is conical in shape with an apical taper ending in a blunt apex and is
narrower on lingual aspect throughout its length.
MESIAL ASPECT
Crown
Shape of Mesial Aspect
From the mesial aspect mandibular canine is wedge-shaped with the base
located at the cervix and apex at incisal edge. A greater bulk in labio-lingual
direction at cervical 1/3rd can be well appreciated. But the incisal portion
appears thinner and cusp appears more pointed due to less prominent lingual
ridge.
Outlines of Mesial Aspect
Labial outline is curved although the curvature is lesser than that of maxillary
canine. Crest of curvature of labial outline is more close to the cervix. From
the crest of convexity the labial outline shows a lingual inclination up to the
cusp tip.
Lingual outline is relatively straight at cervical 1/3rd in the region of less
prominent cingulum, and then becomes slightly concave till it joins to the
incisal edge. Lingual outline also shows less curvature than maxillary canine.
Cervical line is curved in an incisal direction and is to a deeper degree than in
maxillary canines.
The cusp tip is located lingual to the root axis line in most of the specimens
and in few it may be even centered over root axis line.
Mesial Surface
Mesial surface is convex on all aspects except for a shallow concavity
between contact area and cervix.
Mesial slope is shorter than Mesial slope is much shorter than distal
distal slope slope
Both the cusp slopes are in Distal cusp slope is lingually placed
straight line
Root
Root outlines are straight up to middle 1/3rd, from where tapering start. Root
tip is more pointed. Deep developmental depression may be seen on root
surface.
DISTAL ASPECT
Incisal Aspect
Greater labio-lingual measurement compared to mesio-distal can be
appreciated from this aspect. When the tooth is viewed from this aspect the
labial and lingual surfaces and cusp can be seen. Labial contour is wider than
lingual contour because of considerable lingual convergence. When viewed
from incisal aspect crest of contour of labial outline is more mesially located.
Distal half of the crown appears more flat compared to convex mesial
portion. Crest of contour of lingual outline is located over cingulum which
may be distally located making mesial marginal ridge longer. Cusp tip is
located more mesially in a mesio-distal direction while lingual to the center in
a labio-lingual direction. The cusp ridges are lingual to the cusp which is
more so in case of distal cusp ridge. The disto-incisal line angle is located
more lingually due to disto-lingual twist of the crown to follow the dental
arch.
Permanent maxillary canines show wide variation in size from very small to
large.
Root division: Root may be bifurcated into labial and lingual roots.
FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Labial Aspect
Crown is tilted distally on the root base.
Distal slope of the cusp is longer than mesial slope.
Mesial contact area is more incisally placed, located close to mesio-incisal
angle than distal (at junction of incisal and middle 1/3rd).
Distal tilt of root.
Lingual Aspect
Cingulum is distally placed.
Mesial marginal ridge is longer than distal marginal ridge.
Proximal Aspect
Cervical line more curved on mesial aspect than distal.
Distal marginal ridge is more prominent.
Developmental depression on distal surface of root is more prominent.
Incisal Aspect
The distal half of the crown appears more flat compared to convex mesial
half.
The disto-incisal line angle is located more lingually due to disto-lingual
twist of the crown to follow the dental arch.
Permanent mandibular right canine
26
Permanent Maxillary First
Premolars
Introduction
Chronology of maxillary first premolar
Measurement table
Morphology of maxillary first premolar
Developmental variations and clinical considerations
Maxillary first premolars belongs to the group of bicuspids and are situated
distal to the maxillary canines on either side. The tooth resembles the canine
from the buccal aspect with a few differences.
The morphologic characteristics of maxillary first premolar can be
described from five aspects, namely buccal, palatal/lingual, mesial, distal, and
occlusal. Further, features on each aspect (except occlusal) is described under
two subheadings, i.e. crown and root.
BUCCAL ASPECT
Crown
Shape of Buccal Aspect
Shape of the crown from the buccal aspect is roughly trapezoidal with the
shorter arm of the uneven side representing the cervical portion. This
appearance is created by the cervical convergence. The mesio-distal
dimension at the cervix is 2 mm less than its width at the points of its greatest
mesio-distal measurement.
Root
Although the maxillary first premolar has two roots, the buccal root
superimposes the palatal root, and therefore only the buccal root is visible
from this aspect. The buccal root is tapered apically with blunt apex.
Crown
The palatal aspect of the crown is the reverse of the outline of the buccal
aspect.
The crown tapers towards the lingual and the tapering is more from the
distal aspect, so that more of the distal surface is seen from this aspect.
The palatal surface is spheroidal or smoothly convex with convex mesial
and distal outline which are in continuation with the mesial and distal cusps
slopes of the palatal cusp.
The palatal cusp is 1 to 1.5 mm shorter than the buccal cusp which makes a
portion of the buccal cusp visible from this aspect. The cusp slopes of lingual
cusp meet at somewhat rounded angle.
The cervical line is convex and regular with the curvature towards the root.
Root
In most of the cases, only the palatal root is visible as it superimposes the
buccal root. A portion of the buccal root may also be visible from this aspect.
MESIAL ASPECT
Crown
Shape of Mesial Aspect
Shape of the crown from the mesial aspect is roughly trapezoidal with the
occlusal outline representing the shorter arm of the uneven side. Bucco-
lingual dimension appears to be greater than the mesio-distal.
Mesial Surface
Mesial surface appears to be convex at all points except for the marked
depression called the mesial developmental depression or canine fossa,
immediately cervical to the contact area which may extend up to the level of
the root bifurcation.
Root
The root begins at the cervix as a single trunk and shows bifurcation giving
rise to a buccal root and a lingual root. The level of bifurcation varies from
the middle half to apical third of root length. Because of the apical location of
the furcation area, furcation involvement of this tooth is least likely to occur
in periodontal diseases. If involved prognosis is poor.
A developmental groove and a depression are present on the root surface
below the furcation area.
DISTAL ASPECT
OCCLUSAL ASPECT
Occlusal Surface
Occlusal surface shows various anatomic landmarks such as cusps, ridges,
fossae and grooves.
Cusps
Premolar has two equally developed cusps, one buccal cusp and one palatal
cusp. Buccal cusp is 1 mm longer and more pointed than palatal cusp.
Ridges
Triangular ridges of buccal and palatal cusps are seen extending from the tip
of cusp to the centre of occlusal aspect. Buccal triangular ridge is more
prominent than palatal triangular ridge.
Transverse ridge: The triangular ridge of the buccal cusp meets the triangular
ridge of the palatal cusp to form a transverse ridge.
Mesial marginal ridge: Forms the mesial boundary of the occlusal aspect and
is located more occlusally than the distal marginal ridge.
Distal marginal ridge: It is located at distal margin of occlusal aspect and is
more cervically placed.
Cusp ridges of buccal and lingual cusp forms the buccal and lingual boundary
of occlusal aspect.
Grooves
Developmental and supplemental grooves are seen.
Developmental grooves
Central developmental groove divides the occlusal surface into equal halves,
extending in a mesio-distal direction from mesial triangular fossa to distal
triangular fossa.
Mesio-buccal and disto-buccal developmental grooves: There are two
collateral developmental grooves extending from mesial and distal pit
respectively in a buccal direction.
Mesial marginal developmental groove: This is a distinguishing feature seen
in maxillary first premolar. This groove starts from the mesial pit as an
extension from the central groove, runs in a mesial direction across the mesial
marginal ridge immediately lingual to the mesial contact area and ends on the
mesial surface.
Supplementary grooves
Supplementary grooves may be seen in addition to the developmental
grooves, and are relatively few in number.
Single root: In maxillary first premolars, root may remain undivided and
present as single root.
Leongs premolar/Dens evaginatus: At times an accessory tubercle may be
seen on occlusal aspect between buccal and lingual cusps. This is referred to
as Leongs premolar/Dens evaginatus. This structure may interfere with
occlusion. At times wearing away of covering enamel and dentin lead to
exposure of pulp, necessitating root canal treatment.
Mesial developmental depression on mesial aspect of crown that extends
even onto the root may increase the possibility of periodontal diseases.
FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Buccal Aspect
Mesial slope of the buccal cusp is longer than distal slope
Buccal surface shows prominent depression mesial to buccal ridge
Distal tilt of root
Palatal Aspect
Lingual cusp tipped to the mesial side.
Proximal Aspect
Cervical line is more curved on mesial aspect than distal.
Distal marginal ridge is more cervically located compared to mesial marginal
ridge.
Presence of mesial marginal developmental groove.
Presence of mesial developmental depression extending from crown to the
mesial surface of root.
Occlusal Aspect
Mesiobuccal cusp slope is longer.
Straight mesial outline.
Angle between mesiobuccal and mesial outline is nearly 90 degree.
Distolingual outline of occlusal aspect is curved with lingual convergence.
Longer and convex distal marginal ridge.
Large and deeper distal triangular fossa.
Permanent Maxillary First Premolars
27
Permanent Maxillary Second
Premolars
Introduction
Chronology of maxillary second premolar
Measurement table
Morphology of maxillary second premolar
Differences between maxillary first and second premolars
Developmental variations and clinical considerations
BUCCAL ASPECT
Crown
Shape of Buccal Aspect
Shape of the crown is squarish and is less angular. Crown shows lesser
degree of cervical convergence.
Outlines
Mesial outline is slightly curved with mesial contact area located near the
junction of middle and occlusal 1/3rd.
Distal outline is more convex than mesial outline and contact area on distal
side is slightly more cervically placed than that of mesial.
Occlusal outline is represented by buccal cusp and cusp slopes. Cusp slopes
meet at an obtuse angle making the buccal cusp tip less pointed. In contrast to
the first premolar, mesial cusp slope is shorter than the distal cusp slope.
Cervical line is only slightly curved towards the root.
Buccal surface: Buccal surface is smooth and convex. The middle buccal
lobe is well developed to form a buccal ridge that extends cervico-occlusally
up to the cusp tip. The buccal ridge is less prominent in second premolar than
in first premolar. Very shallow depression may be present on either side of
ridge.
Root
Maxillary second premolar has only one root. Root is conical in shape with
tapered apex bending distally.
Crown
Palatal aspect is slightly narrower than the buccal due to palatal convergence,
but the degree of convergence is less compared to that of first premolar. The
palatal cusp is sharp and its height is almost same as that of buccal cusp. Tip
of the palatal cusp is slightly mesially located to the center, in a mesiodistal
direction.
Root
From palatal aspect root is smooth with a little convergence.
MESIAL ASPECT
Crown
Shape of Mesial Aspect
Shape of the crown from the mesial aspect is somewhat similar to that of first
premolar and is roughly trapezoidal with the occlusal outline representing the
shorter arm of the uneven side.
Mesial Surface
Mesial surface appears to be convex and the mesial developmental
depression observed in first premolar is not found in second premolar.
Root
Root is conical and shows shallow depression running longitudinally on
mesial surface.
DISTAL ASPECT
OCCLUSAL ASPECT
Shape
Occlusal aspect of maxillary second premolar is less angular and is ovoid in
shape. Greater bucco-lingual dimension of crown than the mesio-distal
dimension can be appreciated from this aspect. Because of less lingual
convergence, the buccal and palatal halves of occlusal surface are almost
equal in width. Tooth is bilaterally more or less symmetrical. When observed
from occlusal aspect contact area on mesial side is at the junction of buccal
and middle 1/3rd and on distal side is slightly lingual to the position of mesial
contact area.
Buccal ridge appears to be less prominent. Lingual crest may be slightly
mesially located.
Occlusal Surface
Occlusal surface shows various anatomic landmarks such as cusps, ridges,
grooves, fossae and pits.
Buccal cusp is longer than palatal Both buccal and palatal cusps are
cusp nearly of same height
Mesial developmental groove is No such groove is seen
present crossing over the marginal
ridge to the mesial surface
Cusps are relatively closer and Cusps are spread apart and occlusal
occlusal table is narrower table is wider
13. First premolar usually has two roots Second premolar usually has only
one root
Cusps
Second premolar has two equally developed cusps: One buccal cusp and one
palatal cusp, Buccal and palatal cusps are nearly of same height. The
intercuspal distance between the buccal and palatal cusp tips is more making
the occlusal table wide.
Ridges
Triangular ridges of buccal cusp and palatal cusp are seen extending from the
tip of cusp to the center of occlusal aspect.
Transverse ridge: A transverse ridge is formed by union of the triangular
ridge of the buccal cusp and the triangular ridge of the palatal cusp.
Mesial marginal ridge: Forms the mesial boundary of the occlusal aspect and
is located more occlusally than the distal marginal ridge.
Distal marginal ridge: It is located at distal margin of occlusal aspect and is
more cervically placed.
Cusp ridges of buccal and palatal cusps forms the buccal and palatal
boundary of occlusal aspect.
Grooves
Central developmental groove is relatively short and it extends in a mesio-
distal direction from mesial triangular fossa to distal triangular fossa, dividing
the occlusal surface into buccal and lingual halves.
Supplementary grooves are many in this tooth making occlusal aspect
irregular or wrinkled in appearance.
FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Buccal Aspect
Mesial slope of the buccal cusp is shorter than distal slope.
Distal tilt of root.
Palatal Aspect
Lingual cusp tipped to the mesial side.
Proximal Aspect
Cervical line is more curved on mesial aspect than distal.
Distal marginal ridge is more cervically located compared to mesial marginal
ridge.
Deeper developmental depression on distal aspect of root.
Occlusal Aspect
Lingual cusp tipped to the mesial side.
Distobuccal cusp slope is longer.
Longer and convex distal marginal ridge.
Large and deeper distal triangular fossa.
Permanent maxillary second premolar
28
Permanent Mandibular First
Premolars
Introduction
Chronology of mandibular first premolar
Measurement table
Morphology of mandibular first premolar
Differences between maxillary and mandibular first premolars
Developmental variations and clinical considerations
M andibular premolars are four in number, two first premolars and two
second premolars located one on each side of the dental arch. They are
successors of mandibular deciduous molars. The functions include
mastication and maintenance of vertical dimension of face. Also assists
canines to shearing the teeth and support the side of mouth and cheeks.
GENERAL CHARACTERISTICS OF
MANDIBULAR PREMOLARS (ARCH TRAITS)
Mandibular first premolar is located between canine and second premolar and
therefore bears resemblance to both, in certain features. The morphologic
characteristics of mandibular first premolar can be described from five
aspects, namely buccal, lingual, mesial, distal, and occlusal. Further, features
on each aspect (except occlusal) is described under two subheadings, i.e.
crown and root.
BUCCAL ASPECT
Crown
Shape of Buccal Aspect
From this aspect the tooth is bilaterally symmetrical and has a trapezoidal
shape with narrow cervix.
Mesial outline is straight or slightly convex from cervix to contact area.
Contact area is located slightly occlusal to midpoint of the tooth.
Distal outline is more convex and the contact area is nearly at the same level
as mesial or slightly more occlusal in its location.
Root
Mandibular first premolar has only one root. Root is conical and tapers to a
nearly pointed apex.
LINGUAL ASPECT
Crown
From this aspect mandibular premolars show many unique characteristics.
Crown and root taper considerably to the lingual side, making a part of
mesial and distal aspect visible from this aspect.
Occlusal aspect slopes lingually in a cervical direction; therefore most of
occlusal aspect can be seen from lingual aspect.
Contact areas and marginal ridges are more prominent because of narrow
cervical region.
Lingual cusp is short and poorly developed but is pointed. This cusp is a non-
occluding cusp.
Both mesial and distal marginal ridges can be seen. Mesial marginal ridge is
sloping and more cervically placed, while distal marginal ridge is relatively
straight and more occlusally placed (more cervical location of the mesial
marginal ridge is seen only in this tooth while in all other posterior teeth
mesial marginal ridge is more occlusally placed than the distal marginal
ridge).
Another characteristic feature observed in this tooth is the mesio-lingual
developmental groove which extends to lingual surface along the mesio-
lingual line angle, demarcating the mesial marginal ridge from mesial slope
of lingual cusp.
Root
Root is conical in shape and is narrow on lingual aspect.
MESIAL ASPECT
Crown
Shape of Mesial Aspect
Crown is rhomboidal in shape with noticeable tilt to the lingual side at the
cervix.
Outlines
The buccal outline is curved from cervical line to the buccal cusp tip. A
distinct inclination to lingual side is observed with the crest of curvature
located at the junction of middle and cervical 1/3rd.
Lingual outline is less curved than buccal and crest of curvature is located
nearly at middle 1/3rd. Because of extreme lingual tilting, lingual outline
extend beyond the boundary of root outline giving an impression that the
lingual side of the tooth is overhanging.
Occlusal outline is represented by buccal and lingual cusps and mesial
marginal ridge. The inclination of the occlusal aspect can be well appreciated
from mesial aspect and the lingual height of the crown is only 2/3rds of
buccal height. Buccal cusp is centered over the root and most of occlusal
portion is occupied by buccal triangular ridge which also shows a cervical
inclination. Lingual cusp is short but sharp and is nonfunctional. Lingual cusp
tip is in line with lingual outline of root. The mesial marginal ridge is at a
lower level compared to distal marginal ridge and it shows an inclination in a
cervical direction. Because of this more of occlusal surface can be seen from
this aspect. The direction of mesial marginal ridge is almost parallel to that of
buccal triangular ridge but located at a lower level.
Cervical line is slightly curved towards the crown.
Mesial surface: Mesial surface is smooth. A prominent mesio-lingual
developmental groove can be visible which demarcate the mesial marginal
ridge from mesial slope of lingual cusp and extending to lingual surface
along the mesio-lingual line angle.
Root
Root is nearly straight at cervical 1/3rd and taper at apical 1/3rd to a blunt
apex. A deep developmental groove may be present on root.
DISTAL ASPECT
OCCLUSAL ASPECT
Shape
The occlusal aspect is roughly diamond shaped. Tooth is not bilaterally
symmetrical. The distal portion appears to be bulkier than mesial.
Considerable degree of lingual convergence of the tooth can be appreciated
from this aspect which is more from mesial aspect. Occlusal aspect is
broadest at the buccal half, in the region of contact; which is located
immediately lingual to buccal line angles. Because of lingual inclination
more of buccal surface is seen which shows a distinct buccal ridge. The crest
of lingual outline is located distal to center of tooth.
Occlusal Surface
Occlusal surface shows anatomic landmarks such as cusps, ridges, fossa,
grooves, and pits, etc.
Cusps
Occlusal surface of mandibular first premolar shows two cusps: One buccal
cusp and a lingual cusp. Buccal cusp and its triangular ridge make up the bulk
of the occlusal surface of the tooth. Buccal cusp tip is near the center of
crown and the cusp slopes are nearly in a straight line.
Mesial slope of buccal cusp is Distal slope of buccal cusp is longer than
longer than distal slope mesial slope
Both buccal and lingual cusps Buccal cusp is well developed but the
are almost equally developed lingual cusp is much smaller and the
crown height lingually is only 2/3rds of
the buccal aspect
Ridges
Triangular ridges of both buccal and lingual cusps can be seen. Buccal
triangular ridge occupies the major portion of occlusal aspect which also
shows a lingual inclination. The triangular ridge of buccal cusp forms a
transverse ridge with the small triangular ridge of lingual cusp.
Marginal ridges are well developed and prominent. The mesial marginal
ridge is at a lower level compared to distal marginal ridge and it shows an
inclination in a cervical direction. Distal marginal ridge is horizontal; nearly
perpendicular to long axis of tooth and is more occlusally placed than that of
mesial marginal ridge.
Grooves
A shallow central groove may be found extending from mesial to distal fossa
across the transverse ridge. The central groove is placed more lingually,
therefore, it divides the occlusal surface into two unequal parts. Mesial and
distal developmental grooves are found in the fossae, which run in a bucco-
lingual direction. Mesial groove is in continuation with mesio-lingual
developmental groove which crosses onto lingual side along the mesio-
lingual line angle, separating mesial marginal ridge and mesial slope of
lingual cusp.
FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Buccal Aspect
Distal slope of the buccal cusp is longer than mesial slope.
Distal tilt of root.
Lingual Aspect
Mesiolingual developmental groove.
Proximal Aspect
Cervical line is more curved on mesial aspect than distal.
Presence of mesio-lingual developmental groove.
Mesial marginal ridge is more cervically located and slopes from buccal to
lin-glial.
Distal marginal ridge is more occlusally placed compared to mesial marginal
ridge and is perpendicular to long axis of tooth.
Deep developmental depression on distal surface of root.
Occlusal Aspect
Distobuccal cusp slope is longer.
Mesiolingual developmental groove.
Permanent mandibular right first premolar
29
Permanent Mandibular
Second Premolars
Introduction
Chronology of mandibular second premolar
Measurement table
Morphology of mandibular second premolar
Differences between mandibular first and second premolars
Developmental variations and clinical considerations
M andibular second premolars are larger than first premolars and are
located between first premolar and first molar. Except for buccal
aspect, second premolar does not resemble first premolar in
morphology. Second premolars are mainly seen in two forms; two cusp types
and three cusp types which differ from each other mainly in occlusal
morphology. The morphologic characteristics of mandibular second premolar
can be described from five aspects, namely buccal, lingual, mesial, distal, and
occlusal. Further, features on each aspect (except occlusal) is described under
two subheadings, i.e. crown and root.
BUCCAL ASPECT
Crown
Shape of Buccal Aspect
Crown appears squarish from buccal aspect. This appearance is created due to
short and less sharp buccal cusp and wider cervical 1/3rd which results from
less cervical convergence.
Buccal Surface
Buccal surface is convex with a buccal ridge which is inconspicuous,
extending from cervical region to the cusp tip. On either side of buccal ridge
shallow depression may be present.
Root
Root is wider and longer; ending in a blunt apex which may be tilted distally.
Crown
From this aspect second premolar exhibits considerable morphological
variations from that of first premolar. Difference can also be observed
between two cusp type and three cusp type second premolars.
The lingual aspect is narrower than buccal aspect but, the degree of
convergence is not as prominent as in mandibular first premolar. In three
cusp type the lingual side shows only minimal convergence.
Lingual cusp is well developed and is only slightly shorter than buccal
cusp making only part of occlusal aspect visible from this aspect.
In two cusp types only one lingual cusp is seen, the cusp ridges of which
merges with marginal ridges.
In three cusp types two lingual cusps are seen separated by a groove that
extends onto lingual surface. Mesio-lingual cusp is longer and broader than
disto-lingual cusp therefore help in side identification. Lingual surface is
smooth and convex.
Root
Root is smooth and convex and taper apically to end in a blunt apex.
MESIAL ASPECT
Crown
Shape of Mesial Aspect
From this aspect crown shows a lingual inclination, but to a lesser extent than
that of first premolar. Crown and root are wider bucco-lingually than first
premolar.
Root
Root is conical and tapers apically to a blunt apex.
DISTAL ASPECT
Morphology is similar to the mesial aspect. More of occlusal aspect is seen
from this aspect due to two reasons.
Distal tilt of the crown on root base
Concave and cervically located distal marginal ridge.
In three cusp types the disto-lingual cusp is smaller; therefore part of
mesio-lingual cusp is also visible from this aspect.
OCCLUSAL ASPECT
Occlusal Surface
Occlusal surface shows anatomic landmarks such as cusps, ridges, fossae and
pits, grooves, etc.
Only one lingual cusp is seen One or two lingual cusps are seen
Lingual cusp is very short, narrow Lingual cusp is well developed and is
and is non-occluding cusps only lightly shorter than buccal cusp
Ridges
All the three cusps have well developed triangular ridges. Mesial and distal
marginal ridges are found forming the mesial and distal boundaries of
occlusal aspect. Distal marginal ridge is slightly concave and cervically
located. Mesial marginal ridge is straight and is occlusally placed.
Grooves
Mesial developmental groove: Starts from central pit runs in a mesial
direction to end in the mesial triangular fossa.
Distal developmental groove: Extends from central pit to distal triangular
fossa.
Lingual groove: Extends from central pit, travel in a lingual direction
between the two lingual cusps and runs to a short distance onto the lingual
surface.
Supplementary grooves are seen radiating from developmental grooves.
All the three developmental grooves converge at the central pit giving a Y-
shaped configuration.
Two Cusps Type
In two cusp type second premolars, the occlusal aspect has a round shape
with more lingual convergence. Mesio-lingual and disto-lingual line angles
are rounded. Marginal ridges form the boundary of occlusal surface. Only
two cusps are seen: One buccal cusp and one lingual cusp, both are well
developed. Lingual cusp is located directly opposite to buccal cusp and
triangular ridges of both cusps form a transverse ridge. Mesial and distal
fossae are seen inner to marginal ridges which are roughly circular. Central
fossa is absent in two cusp types. A central groove extends from mesial to
distal fossa. This groove has a ‘U’ or crescent shape. Supplementary
grooves are also present in the fossae.
FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Buccal Aspect
Distal slope of the buccal cusp is longer than mesial slope.
Distal tilt of root.
Lingual Aspect
Distolingual cusp is smaller than mesiolingual cusp.
Proximal Aspect
Cervical line is more curved on mesial aspect than distal.
Distal marginal ridge is more cervically located.
Mesial marginal ridge is more occlusally placed and almost straight.
Deep developmental depression on distal surface of root.
Occlusal Aspect
Distolingual cusp is smaller than mesiolingual cusp.
Large, deeper distal triangular fossa.
Permanent mandibular right second premolar
30
Permanent Maxillart First
Molars
Introduction
Chronology of maxillary first molar
Measurement table
Morphology of maxillary first molar
Developmental variations and clinical considerations
T here are three types of permanent molars: The first molar, second molar,
and third molar. In the permanent dentition, there are 12 molars, three in
each quadrant and are non-succedaneous teeth. The name molar comes
from the Latin word for “grinding”. Molar teeth have a major role in
mastication of food, giving support to the cheeks and also in maintaining
vertical dimension of face and fullness of cheek.
GENERAL CHARACTERISTICS OF
PERMANENT MAXILLARY MOLARS (ARCH
TRAITS)
There are two maxillary first molars, one on right and another on left side of
the arch located between second premolar and second molar. Permanent
maxillary molars are the largest and strongest of all maxillary teeth. Since
these teeth are the first permanent teeth in the arch to erupt into the oral
cavity, it is often the first one to be decayed. The first molars (maxillary and
mandibular) are usually referred to as sixth year molars because they erupt at
the age of 6 years. The morphologic characteristics of maxillary first molar
can be described from five aspects, namely buccal, palatal/lingual, mesial,
distal, and occlusal aspects. Further, features on each aspect (except occlusal)
is described under two subheadings, i.e. crown and root.
BUCCAL ASPECT
Crown
Shape of Buccal Aspect
Shape is trapezoidal with broader of the dissimilar outline being occlusal and
narrower the cervical outline.
Buccal Surface
On the buccal surface a buccal groove is seen separating the two buccal
cusps. This groove extends to the middle 1/3rd and there may be a pit where
the groove ends.
Root
From the buccal aspect, a distinct root trunk (undivided part of the root) is
visible. At a point about the junction of cervical and middle 1/3rd of the root
(around 4 mm above the cervical line) the root trunk bifurcate giving rise to
two buccal roots a mesio-buccal and a disto-buccal. Both the roots are well-
separated, taper apically and often are curved distally.
LINGUAL/PALATAL ASPECT
Crown
Crown of maxillary first molar is often broader mesio-distally on the palatal
side than on the buccal side, except in the cervical 1/3rd. The outline is
reverse of that of buccal outline.
Two well developed cusps are visible from this aspect, the larger mesio-
lingual cusp and smaller disto-lingual cusp. Mesio-lingual cusp is the longest
cusp of this tooth and the cusp slopes meet at 90 degrees. The disto-lingual
cusp is smallest and is more rounded. The lingual cusps are separated by a
lingual developmental groove that extends from occlusal aspect to the lingual
surface.
Frequently a fifth cusp is found on the lingual surface of mesio-lingual
cusp which is located 2 mm cervical to the tip of the mesio-lingual cusp. This
cusp is separated from mesio-lingual cusp by a fifth cusp groove. The cusp is
named as ‘cusp of Carabelli’ after the person who first described it. The
presence or absence of this cusp is a racial characteristic and when present it
may show variation in size and shape.
Root
Only one root is present on the palatal side which is the longest of all three
roots. The palatal root tapers to a blunt apex. From the palatal aspect along
with the palatal root both mesio-buccal and disto-buccal roots are also
visible.
MESIAL ASPECT
Crown
Shape of Mesial Aspect
Crown appears to be short and broad facio-lingually. A prominent curvature
at cervical 1/3rd buccally and lingually is observed.
Mesial Surface
Mesial surface is generally convex. A shallow concavity may be seen cervical
to the contact area which may continue onto the root surface.
Root
Two roots are visible from this aspect, mesio-buccal root and the lingual root.
The level of bifurcation on the mesial aspect is closer to (less than 4 mm)
the cervical line.
The mesio-buccal root is broad in bucco-lingual direction and the apex is
in-line with tip of mesio-buccal cusp. The palatal root is 1.5 mm longer than
mesio-buccal root but narrower in a bucco-lingual direction. The roots are
well-separated and the boundaries of the roots may extend beyond the crown.
This feature helps to differentiate this tooth from that of 2nd molar.
DISTAL ASPECT
Crown
Tooth shows a convergence distally making the buccal and palatal aspects
visible from the distal aspect.
Mainly two cusps, disto-buccal and disto-lingual cusps are visible from
this aspect. Parts of other cusps including the ‘cusp of Carabelli’ can be
seen. Of the two cusps, disto-buccal cusp is slightly larger than disto-lingual
cusp.
The distal marginal ridge is shorter, more concave and cervically placed
than mesial marginal ridge making a part of occlusal aspect visible from
distal aspect.
Cervical line is less curved on distal aspect. Distal surface is generally
convex except for a shallow concavity at cervical region which may continue
onto the root surface up to the level of bifurcation.
Roots
All the three roots are seen from this aspect. A portion of mesio-buccal root is
seen because the disto-buccal root is shorter and narrow. The level of
bifurcation on the distal side is more apical than on mesial side.
OCCLUSAL ASPECT
Shape
Occlusal outline is rhomboidal or parallelogram in shape. It has two acute
angles and two obtuse angles. Acute angles are mesio-buccal and disto-
lingual and obtuse angles are mesio-lingual and disto-buccal.
Tooth is wider bucco-lingually (1 mm) than mesio-distally. Crown shows a
buccal convergence and a distal convergence. The palatal half of the tooth is
wider mesio-distally than buccal half. Similarly, the mesial half of the tooth is
bucco-lingually wider than distal half.
Occlusal Surface
Occlusal surface shows various anatomic landmarks such as cups, ridges,
fossae, pits, grooves, etc.
Cusps
Four major cusps are seen, i.e. mesio-lingual cusp which is longest and
largest followed by mesio-buccal, disto-buccal and disto-lingual cusp. Of this
four cusps mesio-lingual, mesio-buccal and disto-buccal forms the primary
cusps of first molar. A fifth cusp the ‘cusp of Carabelli’ is also seen lingual to
mesio-lingual cusp which is located 2 mm cervical to the tip of the mesio-
lingual cusp.
Ridges
Triangular ridges of all the four major cusps are seen.
Oblique ridge: The triangular ridge of the mesio-lingual cusp is divided into
two parts by a groove named Stuart groove. The distal extension of the
triangular ridge of the mesio-lingual cusp and the triangular ridge of disto-
buccal cusp meet and form a diagonal ridge called oblique ridge.
A transverse ridge is formed by the triangular ridges of the mesio-buccal
cusp and mesial portion of the triangular ridge of the mesio-lingual cusp.
Mesial and distal marginal ridges form mesial and distal boundary of
occlusal aspect.
Cusp ridges: The buccal and lingual sides of occlusal surface are bounded by
cusp ridges.
Fossae
There are four fossae on the occlusal aspect of a maxillary first molar, two
fossae are major and other two are minor.
Major fossae
Central fossa: This is the largest fossa situated mesial to the oblique ridge,
bounded by oblique, transverse and cusp ridges of buccal cusp.
Distal fossa: This is also a major fossa, relatively smaller than central fossa,
and is located distal to the oblique ridge. It is linear in shape.
Minor fossae
Mesial triangular fossa is a minor fossa, triangular in shape and is located
adjacent (distal to) mesial marginal ridge.
Distal triangular fossa is similar to mesial triangular fossa, but smaller and is
located adjacent to distal marginal ridge.
Pits
Pits are observed at the deepest part of all fossae as pin point depression
where the grooves converge.
Grooves
Both developmental and supplementary grooves are present.
Developmental grooves
Central groove: Extends mesially from the central fossa, over the transverse
ridge and ends in mesial triangular fossa.
Transverse groove of the oblique ridge: This groove extends from the central
fossa in a distal direction across the oblique ridge to the distal triangular
fossa.
Distal oblique groove: Extends from the distal triangular fossa, along the
distal aspect of oblique ridge in a lingual direction between the mesio-lingual
and distolingual cusps.
Buccal groove: Extends from the central fossa, traverse in a buccal direction
between the mesio-buccal and disto-buccal cusps and continues onto the
buccal aspect of the tooth.
Lingual groove: This is seen as a continuation of the distal oblique groove
and extends onto the lingual surface of the tooth between mesio-lingual and
disto-lingual cusps.
Fifth cusp groove: This groove separates the fifth cusp from the mesio-
lingual cusp.
Stuart groove: This is a small groove which extends from central groove to
separate the two portions of triangular ridge of mesio-lingual cusp.
Supplementary grooves
In addition to developmental grooves, supplementary grooves are also
present in triangular fossae extending to a buccal and a lingual direction.
First molars are the teeth most often get decayed and the first tooth in
permanent tooth to be lost, as they may be mistaken as primary teeth and
neglected by parents. The deep pits and grooves present may act as the site of
initiation of caries.
The maxillary first molars may have an additional cusp on the buccal
surface of the mesio-buccal cusp, which is termed as paramolar
tubercle/parastyle.
Taurodontism is a term used for developmental variation of molar teeth
where the crown of the tooth is enlarged at the expense of root. This term is
given as this tooth resembles that of a cud chewing animal. Bifurcation of the
root will be shifted apically. This condition may exist as an isolated trait
(autosomal dominant) or as part of several syndromes. Endodontic treatment
of teeth affected by taurodontism needs special consideration.
Concrescence is the fusion of cementum of adjacent teeth, a good reason
to have radiographs before extraction of a tooth.
Mulberry molar is dental defects specifically involving first molars, in
congenital syphilis and caused by direct invasion of tooth germs by
Treponema pallidum which can pass through the placenta. In mulberry
molars the cusps are replaced by many globular masses of enamel, giving
resemblance to mulberry fruit.
Dens in dente/Dens invaginatus is a condition characterized by deep
invagination in crown portion of tooth resulting in enamel being reflected
into the tooth giving an appearance, tooth within a tooth. In affected teeth,
caries may develop in the invagination and escape detection.
Enameloma or enamel pearl is ectopic formation of enamel appear as
small droplets of enamel on the root surface, mostly close to bifurcation.
FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Buccal Aspect
Mesio-buccal cusp larger than disto-buccal cusp.
Palatal Aspect
Mesio-lingual cusp is largest cusp.
Cusp of Carabelli is present on lingual aspect of mesio-lingual cusp.
Proximal Aspect
Cervical line is more curved on mesial aspect than distal.
Distal marginal ridge is more cervically located.
Mesial marginal ridge is placed at an occlusal level than that of distal
marginal ridge.
Deep developmental depression on distal surface of root.
Occlusal Aspect
Distal and buccal convergence of occlusal aspect.
Mesiolingual cusp is largest cusp and distolingual the smallest.
Oblique ridge running from mesio-lingual to disto-buccal cusp.
Permanent maxillary right first molar
31
Permanent Maxillary Second
Molars
Introduction
Chronology of maxillary second molar
Measurement table
Morphology of maxillary second molar
Differences between maxillary first and second molars
Developmental variations and clinical considerations
M axillary second molars are situated distal to the first molars. Although
they are relatively smaller, they assist first molars in function. These
teeth may show considerable variation in morphology. The
morphologic characteristics of maxillary second molar can be described from
five aspects, namely buccal, palatal/lingual, mesial, distal, and occlusal.
Further, features on each aspect (except occlusal) is described under two
subheadings, i.e. crown and root.
BUCCAL ASPECT
Crown
Crown is shorter and less wider than first molars and is tipped distally on the
root trunk.
Mesial outline is slightly convex with contact area located at the junction
of occlusal and middle 1/3rd.
Distal outline is shorter than the mesial outline. Distal contact area is
located at the middle of middle 1/3rd.
Two cusps can be seen on this aspect, mesio-buccal and disto-buccal.
Mesio-buccal cusp is longer and wider than disto-buccal cusp. Smaller disto-
buccal cusp and distal tilting of the crown allows a part of the disto-lingual
cusp visible from this aspect. Buccal groove present on buccal surface
separates two buccal cusps, which is shorter than that of the buccal groove of
first molar and only rarely end in a pit.
Root
The maxillary second molar has two buccal roots and a palatal root and all
three roots are visible from this aspect. The root trunk is distinct and the level
of bifurcation is more apical when compared to that of the first molar making
the root trunk longer.
Both the buccal roots are nearly parallel, not spread apart and may show a
distal tilt. The mesio-buccal root apex is in-line with buccal groove.
LINGUAL/PALATAL ASPECT
Crown
General outline of palatal aspect is reverse of that of buccal outline.
Two cusps can be seen from this side, the mesio-lingual and disto-lingual
cusps. The mesio-lingual cusp is longer and the disto-lingual cusp may be
very small or even absent in some teeth. Part of the disto-buccal cusp may be
visible. In contrast to maxillary first molars in this tooth a fifth cusp is not
seen. Lingual groove separates both the lingual cusps.
MESIAL ASPECT
From the mesial aspect second molars resemble first molars. The differences
observed are:
Cusp of Carabelli is not present
Roots are less separated
Buccal and palatal roots are of equal length
Buccal and palatal roots generally do not extend beyond the crown boundary.
DISTAL ASPECT
From the distal aspect also the second molar shows similarity to first molar.
The tooth is converging to the distal aspect; therefore buccal and lingual
surfaces are visible. Since the tooth shows a distal tilt and a cervical
placement of the marginal ridge, the tooth appears shorter from this aspect
and also much of occlusal aspect is seen.
All the three roots are seen; palatal, mesio-buccal and disto-buccal. Apex
of the palatal root is often in-line with that of disto-lingual cusps.
OCCLUSAL ASPECT
Second molar shows similar morphological features as 1st molar with a few
differences.
Rhomboidal shape is more prominent with acute angles (mesio-buccal and
disto-lingual) are less and obtuse angles (mesio-lingual and disto-buccal) are
greater. It appears as though the lingual portion is pushed distally. Crown
shows a lingual convergence and a distal convergence which is more
pronounced than in the first molars. Tooth is bucco-lingually wider than
mesio-distally with a difference of around 2 mm.
There are four cusps, i.e. mesio-lingual, mesio-buccal, disto-buccal and
disto-lingual. Greater difference in the cusp size is observed in this tooth.
Mesio-buccal and mesio-lingual cusps are nearly of the same size and are
noticeably larger than disto-buccal and disto-lingual cusps. Disto-lingual cusp
is very small or even may be absent. No fifth cusp is observed. Occlusal
surface shows more pits and grooves and the oblique ridge is less prominent
than in first molar.
10. Relatively longer buccal Short buccal groove, may not end in pit
groove, may end in a pit
12. Roots of maxillary first molars Roots do not spread out and all roots
are spread out show adistal tilt
Maxillary second molar may be prone to dental caries due to deep pits and
fissures. Rarely cusp of Carabelli may be present on lingual aspect of mesio-
lingual cusp. Chances of concrescence with maxillary third molar is
considerably more due to crowding of teeth in maxillary posterior region.
FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Buccal Aspect
Mesio-buccal cusp larger than disto-buccal cusp.
Palatal Aspect
Disto-lingual cusp is the smallest cusp.
Proximal Aspect
Cervical line is more curved on mesial aspect than distal.
Occlusal Aspect
Distal and lingual convergence of occlusal aspect.
Mesio-lingual cusp is the largest and disto-lingual cusp is the smallest.
Oblique ridge running from mesio-lingual to disto-buccal cusp.
Permanent maxillary right second molar
32
Permanent Maxillary Third
Molars
Introduction
Chronology of maxillary third molar
Measurement table
Morphology of maxillary third molar
T hird molars are the last tooth in the arch and erupt by the age of 17 to 21
years or later. These teeth show maximum variation in size and shape.
The third molars are sometimes referred to as the “wisdom” tooth
because they erupt last.
The characteristics of maxillary third molars are:
Smaller than 1st and 2nd molars.
Crown shows significant convergence.
Oblique ridge is less prominent.
Disto-lingual cusp is much smaller or absent.
Occlusal aspect may have many supplementary grooves giving wrinkled
appearance.
Root trunk is longer with point of bifurcation located more apically.
Three roots, i.e. mesio-buccal, disto-buccal and lingual are seen. The roots
are shorter than other maxillary molars and are less separated or often fused.
Chronology of permanent maxillary third molar
Introduction
Chronology of maxillary second molar
Measurement table
Morphology of maxillary second molar
Differences between maxillary first and second molars
Developmental variations and clinical considerations
GENERAL CHARACTERISTICS OF
MANDIBULAR MOLARS (ARCH TRAITS)
The mandibular first molars are the largest and strongest of all the mandibular
teeth and have the widest crown of all teeth in the dentition. The mandibular
first molar is the first permanent tooth to erupt into the oral cavity and is
referred to as the “six-year-molar” as it erupts at 6 years. It normally erupts
slightly before the maxillary first molar and is considered as the key of
occlusion. Normally there are five functioning cusps on the occlusal surface
of this tooth. The morphologic characteristics of mandibular first molar can
be described from five aspects, namely buccal, lingual, mesial, distal, and
occlusal. Further, features on each aspect (except occlusal) is described under
two subheadings, i.e. crown and root.
BUCCAL ASPECT
Crown
Shape of Buccal Aspect
Shape is roughly trapezoidal with the cervical and occlusal outlines
representing the uneven sides. Crown is broader mesio-distally than cervico-
occlusally.
Buccal Surface
Buccal surface of first molars is smooth and convex and shows two
developmental grooves. The groove that separates the mesio-buccal and
disto-buccal cusp is the mesio-buccal groove which extends up to the middle
third and ends in a pit. The disto-buccal groove separates disto-buccal and
distal cusp, which ends at the cervical third without a distinct pit. The
cervical portion of buccal aspect may show a prominent ridge running in a
mesio-distal direction which is referred to as buccal cervical ridge.
Roots
Mandibular first molar has two roots; mesial and distal. The level of
bifurcation is 3 mm below the cervical line. Since the bifurcation is closer to
the cervical line, the root trunk is short. The mesial root is the wider and the
stronger of the two. The mesial and distal roots show a distal tilt. The tip of
mesial root is almost in-line with the mesio-buccal cusps and of the distal
root is often in-line or distal to the distal surface of crown.
LINGUAL ASPECT
Crown
Shape of Lingual Aspect
From the lingual aspect the tooth shows a convergence lingually, making a
part of mesial and distal surfaces visible. The degree of lingual convergence
is more prominent distally. Tooth also tapers to the cervical region.
Lingual Surface
Lingual surface is smooth and convex at the coronal 1/3rd and almost flat at
the cervical region. Lingual developmental groove extends onto a short
distance onto the lingual surface demarcating both the lingual cusps.
Root
From this aspect both the mesial and distal roots are seen which show a
lingual convergence. The root trunk appears to be longer because of the
occlusal placement of cervical line. The level of bifurcation is 4 mm above
the cervical line.
MESIAL ASPECT
Crown
Shape of Mesial Aspect
Shape is rhomboidal with the crown tilted lingually on the root axis (arch
trait). A greater bucco-lingual measurement of the crown and the root can be
appreciated from this aspect.
Mesial Surface
Mesial surface is smooth and relatively convex except for a slight concavity
cervical to the contact area.
Root
Only mesial root is visible from this aspect because the broad mesial root
superimposes the narrower distal root. The outline of mesial root is relatively
straight up to the junction of cervical and middle third and from there it tapers
to a blunt apex. The apex is located directly below the mesio-buccal cusp.
DISTAL ASPECT
Crown
The general morphology of distal aspect is similar to that of mesial aspect.
The crown is shorter distally than mesially. Due to the distal convergence of
the crown, a part of buccal and lingual surface is also seen from this aspect.
The distal convergence of the buccal surface is more pronounced than that of
the lingual surface.
Differences are
The distal marginal ridge is short, curved and is more cervically located than
the mesial marginal ridge.
Because of the distal tilt of the crown and cervical placement of the marginal
ridge most of the occlusal surface and all cusps are seen from this aspect.
Curvature of cervical line is less than on mesial aspect.
Root
The distal root and a part of the mesial root are visible from this aspect. The
distal root is narrower than the mesial root and ends in a pointed apex.
OCCLUSAL ASPECT
Shape
The occlusal aspect is roughly quadrilateral in shape with the mesio-distal
dimension more than bucco-lingual with a difference of 1 mm or more. The
lingual and the distal convergence of the crown can be well appreciated.
Because of the lingual tilt when tooth is viewed from occlusal aspect much of
buccal surface also can be seen. The mesial outline is slightly convex and the
contact area is centered in a bucco-lingual direction. The distal contact area is
located buccal to the center point of distal marginal ridge.
Cusps
Mandibular first molar has five cusps: Three buccal cusps and two lingual
cusps. The buccal cusps are mesio-buccal, disto-buccal and distal. Of the
three buccal cusps, the mesio-buccal cusp is the largest followed by disto-
buccal and the distal cusp. The distal cusp is the smallest and the sharpest and
is located at the disto-lingual line angle. Lingually there are two cusps: The
mesio-lingual and disto-lingual. The mesio-lingual and the disto-lingual
cusps are the longest and tht sharpest of the five cusps. The mesio-lingual
cusp is longer than the disto-lingual cusp and the width may be equal or
slightly more than that of the disto-lingual cusp.
Ridges
Triangular ridges are seen extending from the tips of all five cusps towards
the central part of occlusal surface. Triangular ridges of lingual cusps are
longer than that of buccal cusps.
Transverse ridge: The triangular ridge of the mesio-buccal cusp meets the
triangular ridge of the mesio-lingual cusp to form a transverse ridge.
Similarly, a transverse ridge is also formed by the triangular ridges of both
the disto-buccal and disto-lingual cusps.
Mesial marginal ridge: Forms the mesial boundary of the occlusal aspect and
is located more occlusally than the distal marginal ridge. It is placed 1 mm
below the level of the cusp tips.
Distal marginal ridge: It is located at distal margin of occlusal aspect. It is
shorter, concave and more cervically placed.
Cusp ridges: Forms the buccal and the lingual boundaries of the occlusal
aspect.
Fossae
Three fossae can be seen; one major (central fossa) and two minor (mesial
and distal triangular fossae).
The central fossa is the largest fossa located at the center of the occlusal
aspect. Central fossa is bounded by the distal slope of the mesio-buccal cusp,
mesial and distal slope of the disto-buccal cusps, mesial slope of the distal
cusp, triangular ridges of distal and disto-lingual cusps, mesial slope of disto-
lingual cusp, distal slope of mesio-lingual cusp and the transverse ridge.
Mesial triangular fossa is a triangular shaped depression located inner (distal)
to the mesial marginal ridge.
Distal triangular fossa is less distinct and is located inner (mesial) to distal
marginal ridge.
Pits
Pits are present as small pinpoint depression at the deepest part of all fossae,
where the developmental grooves converge. The pits are named according to
the fossa in which they are located: Central pit, mesial pit and distal pit.
Grooves
Developmental and supplemental grooves are seen.
Developmental grooves
Central groove: It is the major groove seen on the occlusal aspect and is
centrally located dividing occlusal surface into buccal and lingual halves. It
starts from the central pit and runs in a mesial direction between the mesio-
buccal and mesio-lingual cusps to end in the mesial triangular fossa. The
distal extension of the central groove runs between the disto-buccal and disto-
lingual cusps to end in distal triangular fossa. The central groove follows a
zigzag pattern.
Mesio-buccal groove: This groove starts from the central fossa, slightly
mesial to the origin of central groove and traverse in a buccal direction
between the mesio-buccal and disto-buccal cusps and extend onto the buccal
surface.
Disto-buccal groove: It starts from the distal portion of the central groove
and traverse in a buccal direction between the disto-buccal and distal cusps
and extends onto the buccal surface.
Lingual groove: It starts in the central pit, extends lingually between the two
lingual cusps and onto the lingual surface.
Supplementary grooves
In addition to the developmental groove there are supplementary grooves in
triangular fossae extending to a buccal and lingual direction. Supplementary
grooves are less distinct in the distal triangular fossa.
First molars are the teeth most often get decayed and the first tooth in
permanent tooth to be lost, as they may be mistaken as primary teeth and
neglected by parents. The deep pits and grooves present may act as the site of
initiation of caries.
Differences between maxillary first and mandibular first molars (arch
traits)
Maxillary first molar Mandibular first molar
Crown is bucco-lingually broader than Crown is mesio-distally
mesio-distally broader than bucco-
lingually
Have four major cusps: Two buccal and two Have five cusps: three
lingual buccal and two lingual
Lingual cusps are of different size; large Lingual cusps are nearly of
mesio-lingual and a smaller disto-lingual equal size
Occlusal aspect has four fossae: Two major Occlusal aspect has only
and two minor three fossae: One major
and two minor
At times mandibular first molars may have only four cusps as in second
molar with distal cusp missing. Sometimes an additional cusp on the buccal
surface of the mesio-buccal cusp may be present, at the middle third of the
crown which is termed as paramolar tubercle/protostylid. An extra cusp,
when located on distal marginal ridge between distal cusp and disto-lingual
cusp, it is referred to as tuberculum sextum and when present between two
lingual cusp, it is termed as tuberculum intermedium.
Root division: Occasionally mesial root of mandibular molar may be divided
into mesio-lingual and mesio-buccal roots making it three rooted.
Taurodontism is a term used for developmental variation of molar teeth
where the crown of the tooth is enlarged at the expense of root. This term is
given as this tooth resembles that of a cud chewing animal. Bifurcation of the
root will be shifted apically. This condition may exist as an isolated trait
(autosomal dominant) or as part of several syndromes. Endodontic treatment
of teeth affected by taurodontism needs special consideration.
Concrescence is the fusion of cementum of adjacent teeth, a good reason to
have radiographs before extraction of a tooth.
Mulberry molar is dental defects specifically involving first molars, in
congenital syphilis and caused by direct invasion of tooth germs by
Treponema pallidum which can pass through the placenta. In mulberry
molars the cusps are replaced by many globular masses of enamel, giving
resemblance to mulberry fruit.
Dens in dente/Dens invaginatus is a condition characterized by deep
invagination in crown portion of tooth resulting in enamel being reflected
into the tooth giving an appearance, tooth within a tooth. In affected teeth,
caries may develop in the invagination and escape detection.
Enameloma or enamel pearl is ectopic formation of enamel appears as
small droplets of enamel on the root surface, mostly close to bifurcation.
FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Buccal Aspect
Crown tilted distally
Mesio-buccal cusp largest and distal cusp smallest
Distal tilt of root
Lingual Aspect
Disto-lingual cusp is smaller than mesio-lin-gual cusp.
Proximal Aspect
Cervical line is more curved on mesial aspect than distal.
Distal marginal ridge is more cervically located.
Mesial marginal ridge is more occlusally placed and almost straight.
Deep developmental depression on distal surface of root.
Occlusal Aspect
Disto-lingual cusp is smaller than mesio-lin-gual cusp.
Large, deeper distal triangular fossa.
Distal convergence of the crown.
Smallest distal cusp.
Permanent mandibular right first molar
34
Permanent Mandibular
Second Molars
Introduction
Chronology of mandibular second molar
Measurement table
Morphology of mandibular second molar
Differences between mandibular first and second molars
Developmental variations and clinical considerations
M andibular second molars are two in number, one on either side of the
arch, situated distal to the mandibular first molars. They supplement
the first molar in function. Although the second molar resembles the
first molar in its general morphology, a few differences can be observed. The
morphologic characteristics of mandibular second molar can be described
from five aspects, namely buccal, lingual, mesial, distal, and occlusal.
Further, features on each aspect (except occlusal) is described under two
subheadings, i.e. crown and root.
BUCCAL ASPECT
Crown
Shape of Buccal Aspect
Shape is roughly trapezoidal with the cervical and occlusal outlines
representing the uneven sides. Tooth is wider mesio-distally than the crown
length. The degree of cervical convergence is less therefore, the tooth appears
to be wider at the cervix. Crown tilts distally so the distal side appears to be
shorter.
Buccal Surface
Buccal surface is smooth and convex. The buccal groove extends between the
mesio-buccal and disto-buccal cusps, which ends at the middle third of the
surface in a pit. The cervical portion of buccal aspect may show a prominent
ridge running in a mesio-distal direction which is referred to buccal cervical
ridge (sometimes called buccal cingulum).
Root
Two roots are present; mesial and distal. The level of bifurcation is more
apical when compared to that of first molar. Both mesial and distal roots are
usually closer together, nearly parallel and ending in a pointed tip.
Crown
Tooth shows convergence lingually but to a lesser extent than that of first
molar.
Mesial and distal outlines are more convex.
Occlusal outline is represented by the lingual cusps and the cusp slopes. Two
lingual cusps are seen; mesio-lingual cusp and a disto-lingual cusp. The
mesio-lingual cusp is slightly wider and longer of the two.
Cervical line is regular.
Lingual surface is smooth and convex. The lingual groove extends between
the mesio-lingual and disto-lingual cusps, which is shorter than the buccal
groove.
Root
Two roots, mesial and distal roots are seen which end in a pointed apex.
MESIAL ASPECT
Crown
Shape of Mesial Aspect
From this aspect shape of second molar resembles that of first molar except
for the differences in measurement.
Mesial Surface
Mesial surface is smooth and convex.
Root
Only mesial root is visible from this aspect because the mesial root is broad
enough to hide the distal root.
DISTAL ASPECT
OCCLUSAL ASPECT
Shape
The occlusal aspect of mandibular second molar differs considerably from
mandibular first molar.
The tooth when viewed from occlusal aspect has a roughly rectangular
shape which is wider in a mesio-distal direction than the bucco-lingual.
The occlusal outline shows a distal and lingual convergence. The extent of
the lingual convergence is lesser than the first molar.
Mesial outline of the tooth is straight while distal outline is convex.
Because of the lingual tilt when tooth is viewed from occlusal aspect much
of buccal surface also can be seen. The mesio-buccal portion of the buccal
surface shows a prominent bulge, representing the cervical ridge.
Occlusal Surface
The occlusal surface shows various anatomic landmarks such as cusps,
ridges, fossae, pits and grooves.
Cusps
Four cusps are present; the mesio-lingual, disto-lingual, mesio-buccal and
disto-buccal. The mesio-buccal and mesio-lingual cusps are larger than disto-
buccal and disto-lingual cusps. Unlike the mandibular first molars, distal cusp
is absent in second molar.
Ridges
Triangular ridges are seen extending from the tips of all the four cusps
towards the central part of occlusal surface.
Transverse ridges-triangular ridges of mesio-buccal and mesio-lingual cusps
meet to form a transverse ridge. Similarly, a transverse ridge is also formed
by the triangular ridges of both the distal cusps.
Mesial marginal ridge forms the mesial boundary of the occlusal aspect and
is located more occlusally than the distal marginal ridge.
Distal marginal ridge is located at distal margin of occlusal aspect. It is
concave and more cervically placed.
Cusp ridges forms the buccal and the lingual boundaries of the occlusal
aspect.
Fossae
The central fossa is the largest fossa located at the center of the occlusal
aspect.
Mesial triangular fossa is a triangular shaped depression located inner (distal)
to the mesial marginal ridge.
Distal triangular fossa is less distinct and is located inner (mesial) to distal
marginal ridge.
Pits
Pits may be present in any of the fossae where the grooves converge.
Grooves
Occlusal surface shows both developmental and supplemental grooves.
Developmental grooves
Central groove: Begins from central fossa and extends in a mesial and distal
direction to end in the mesial triangular fossa and distal triangular fossa
respectively. The central groove is relatively straight in second molar when
compared to zigzag pattern in first molar.
Buccal groove runs from the central fossa in a buccal direction separating two
buccal cusps which also extends to the buccal surface.
A lingual groove extends from central fossa between the two lingual cusps.
These developmental grooves arising from central fossa give a criss-cross
pattern.
Has five cusps, three buccal Has only four cusps, two buccal cusps and
cusps and two lingual cusps two lingual cusps. Distal cusp is absent
Supplementary grooves
There may be many supplementary grooves radiating from the developmental
grooves making the occlusal surface irregular.
The deep pits and supplementary grooves make the mandibular second molar,
prone to caries.
The mandibular first molars may have an additional cusp on the buccal
aspect similar to distal cusp of first molar.
There is possibility of concrescence with third molar, i.e. the fusion of
cementum.
Enameloma or enamel pearl is ectopic formation of enamel appear as small
droplets of enamel on the root surface, may be seen in this tooth, mostly close
to bifurcation.
FEATURES TO BE CONSIDERED TO
DIFFERENTIATE SIDE
Buccal Aspect
Crown tilted distally.
Occlusal surface appears to be slopping cervically from mesial to distal.
Mesio-buccal cusp wider than a disto-buccal cusp.
Distal tilt of root.
Lingual Aspect
Disto-lingual cusp is smaller than mesiolingual cusp.
Proximal Aspect
Cervical line is more curved on mesial aspect than distal.
Distal marginal ridge is more cervically located.
Mesial marginal ridge is more occlusally placed.
Deep developmental depression on distal surface of root.
Occlusal Aspect
Distal convergence of occlusal surface.
Mesial outline of occlusal aspect nearly straight while distal is more convex.
Disto-lingual cusp is smaller than mesio-lingual cusp.
Permanent mandibular right second molar
35
Permanent Mandibular Third
Molars
Introduction
Chronology of mandibular third molar
Measurement table
Morphology of mandibular third molar
Occlusion
Deciduous dentition
Mixed dentition
Permanent dentition
– Compensating curves
– Occlusal relationship between maxillary and mandibular posterior
teeth
At birth, teeth are not present in the mouth and over a period of time they
erupt into the oral cavity. The maxillary and mandibular alveolar ridges,
before the tooth eruption are called gum pads. The maxillary gum pads are
wider than mandibular gum pads. The first deciduous tooth erupts into the
oral cavity by six months of age and the dentition is completed by the age of
20–30 months. Natural spacing is seen in deciduous dentition and is more
distinct in maxillary arch mesial to canine and in mandibular arch distal to
canines. This space is called primate space, anthropoid space or simian
space. Spacing in deciduous dentition is necessary for the proper alignment
of permanent dentition.
Deciduous teeth are more or less upright in their arrangement in alveolar
bone. The contact relations between the teeth vary in deciduous dentition
with degree of bruxism present in the child. Normally, deep bite may be seen
in deciduous anterior region which is reduced later by gradual attrition of
incisors, forward movement of mandible and by the eruption of molars.
The mesio-distal relationship between distal surfaces of deciduous second
molars may be:
Flush terminal plane (Fig. 36.1a): In this type of relation, the distal surface
of maxillary second molar is in the same plane as that of distal surface of
mandibular second deciduous molar. This type of relation results due to
larger mesio-distal measurement of mandibular second molar when compared
to maxillary second molar. This is considered as ideal relation which favors
the development of proper occlusion of permanent molars.
Mesial step terminal plane (Fig. 36.1b): In this type the distal surface of
mandibular molar is anteriorly (mesially) located compared to distal surface
of maxillary second molar. This causes a step directed mesially.
Distal step terminal plane (Fig. 36.1c): When the maxillary second molar is
in an anterior location than the mandibular second molar, the distal surface of
mandibular second molar is located more distal to that of distal aspect of
maxillary second molar resulting in a distal step.
MIXED DENTITION
The mixed dentition begins with the emergence of the mandibular first molar
at the age of 6 years and last up to 11–12 years, till all the deciduous teeth are
replaced by permanent successors. Initially when the permanent first molars
erupt distal to the deciduous molars they also show a flush terminal plane but
the mesial movement of mandibular first molar results in class I molar
relation. The space for the mesial shift of mandibular first molar is obtained
by growth of mandible and by utilizing primate space and leeway space.
At about the age of 8–9 years, by the eruption of larger anterior teeth
crowding occur for a short period of time. The difference between the space
available and space required to accommodate larger permanent incisors is
called incisor liability. This liability is overcome by increase in width of
dental arch in the intercanine region, by utilizing primate space and also by a
labial inclination of permanent incisors which increase the dental arch
circumference.
Posterior successor teeth have a relatively lesser mesio-distal diameter than
deciduous predecessors. Therefore the total mesio-distal measurements of
deciduous canine and deciduous first and second molars are more than the
total mesio-distal measurements of permanent canine, and two premolars.
The difference between these two measurements is called leeway space of
Nance. This space is around 0.9 mm on either side making up a total of 1.8 in
maxillary arch and 1.7 on either side of mandible with a total of 3.4 mm in
mandibular arch. This space is utilized by the permanent first molars to drift
mesially to develop a class I molar relation.
PERMANENT DENTITION
Compensating Curves
The natural dentition shows compensating curves.
Antero-posterior compensating curve runs in an antero-posterior
direction, which can be appreciated from lateral (buccal) aspect.
Curve of Spee (Fig. 36.2a): It is defined as anatomic curvature of occlusal
alignment of teeth beginning at the tip of lower canine and following buccal
cusp tips of the premolar and molar and continues to the anterior border of
the ramus of mandible. This curve of dental arch was first described by von
Spee. This imaginary curve is concave for mandibular arch and convex for
maxillary arch. When the dental arches are placed into occlusion these
concave and convex lines matches perfectly.
Lateral compensating curve runs in bucco-lingual direction one side of the
arch to other, which can be appreciated from frontal view.
Wilson curve (Fig. 36.2b): When dental arch is observed from the anterior
(front) region with mouth slightly open, a lateral (medio-lateral)
compensatory curves can be appreciated in the maxillary molar region.
Generally the posterior teeth in the maxillary arch have a slight buccal
inclination while mandibular posterior teeth have a slight lingual inclination.
If a line is drawn through the buccal and lingual cusps tips of both the right
and left posterior teeth, a curved plane of occlusion is observed. The
curvature is convex in the maxillary arch and concave in mandibular arch.
When the arches are brought to occlusion both these curvatures match
perfectly. This curvature in occlusal plane observed from frontal view is
called curve of Wilson.
Theories of Occlusion
a. Bonwill Theory of Occlusion
According to this theory of occlusion, the teeth move in relation to each other
as guided by condylar and incisal guidance. The condylar guidance refers to
the path that the trans-cranial rotation axis of the condyles travel during
mandibular opening. The incisal guidance is a measure of amount of
movement and angle at which the lower incisors and mandible must move
from the overlapping position in centric occlusion to an edge to edge
relationship with maxillary incisors.
Oral Physiology
37. Eruption
38. Shedding
39. Saliva
40. Physiology of Taste and Speech
41. Mastication
42. Deglutition
43. Calcium Phosphorus Metabolism
44. Mineralization
45. Hormonal Influence on Orofacial Structures
46. Age Changanses of Oral Tissues
37
Eruption
Introduction
Types of physiological tooth movements
– Pre-eruptive movements
– Eruptive movements
– Post-eruptive movements
Mechanism of tooth movement
Clinical considerations
T eeth undergo complex movements within the jaw bones during its
development, as it moves from jaw bone to the functional position and
also later to compensate for masticatory wear and to maintain their
position in growing jaws. All these movements of teeth together are referred
to as physiological tooth movements. The physiological movements of teeth
are described under three headings.
Pre-eruptive movements: The movements made by the developing tooth
germ within the jaw bone.
Eruptive tooth movements: The movements made by a developed tooth as it
moves from the jaw bone to the functional position in the oral cavity.
Post-eruptive movements: The movements made by a fully erupted tooth to
compensate for occlusal wear and to maintain the occlusal plane as the jaw
bone continues to grow.
5. Pulp Growth
The role of growing pulp in providing eruptive force has been suggested by
Sicher. The supporters of this theory suggest that in the apical end of
developing root there is active mitotic division of cells which bring about
pulp growth and may provide at least a part of eruptive force.
Rate of eruption is found to be decreased after injection of antimitotic
drugs. This observation is insufficient to confirm the role of pulp growth
alone, because the antimitotic drugs can adversely affect proliferation of
other tissues that would be influencing eruption.
Clinical Considerations
There are a number of clinical conditions, where eruption process is
disturbed.
1. Premature eruption: Tooth erupts into oral cavity much earlier than
normal time of eruption. Frequently involved tooth are deciduous
mandibular central incisors. The term ‘natal’ teeth is used when the
deciduous teeth are present at the time of birth. Deciduous teeth which
erupt within first 30 days of life is termed as neonatal teeth. Premature
loss of deciduous teeth causes premature eruption of permanent teeth
which may be related to hormonal disturbances.
2. Delayed eruption: Tooth erupts into oral cavity much later than normal
time of eruption. Both deciduous and permanent dentition may be
affected.
3. Impacted teeth: Teeth which are prevented from eruption into oral
cavity by some physical barrier in eruptive path or nonavailability of
space.
4. Embedded teeth: It refers to those teeth that are unerrupted due to lack
of eruptive forces
5. Ectopia: Remote location of a tooth away from its normal position. For
example: Maxillary canine erupting in nasal cavity/maxillary sinus/at
the inner canthus of eye, or mandibular 3rd molar erupting at angle of
mandible/lower border of mandible/through the skin of cheek.
6. Transposition: Condition wherein 2 teeth exchange position. For
example: Exchange of position between maxillary canine and
premolar.
7. Rotation: Developmental anomaly wherein a tooth turns
partially/completely.
38
Shedding
Introduction
Mechanism of shedding
Histology of shedding
Pattern of shedding
Clinical considerations
Mechanism of Shedding
Shedding of the deciduous teeth occur as a result of resorption of roots of the
teeth and destruction of supporting periodontal ligament. The factors
suggested to be playing role in shedding are:
Pressure from erupting permanent successors: This pressure helps in the
differentiation of odontoclasts that can resorb the dental hard tissues. In case
of congenitally missing permanent successor, the deciduous tooth is retained
for a longer time, supporting the role of pressure from the successor teeth in
exfoliation.
Force of mastication: Although the deciduous tooth is retained for sometime
when permanent successor is missing, ultimately it exfoliates suggesting the
role of other factors on shedding. As individual grows, force of mastication
increases and become greater than what deciduous periodontal ligament can
withstand. This leads to trauma to the periodontal ligament, followed by
destruction, initiating resorption and ultimately shedding.
Combination of these two factors may be deciding the rate and patterns of
resorption. When the root is resorbed, supporting tissue decreases making the
tooth unable to bear the masticating forces. This makes the tooth mobile and
accelerates the process of shedding.
Histology of Shedding
Shedding is brought about by resorption of dental hard tissues and destruction
of supporting periodontal ligament. The cells responsible for resorption of
tooth are odontoclasts.
Odontoclasts are highly specialized cells responsible for resorption of dental
hard tissue including cementum, dentin and enamel. They are structurally and
functionally similar to osteoclasts, the bone resorbing cells. Origin of
odontoclast is from circulatory monocytes that are capable of giving rise to
all different tissue macrophages.
Light microscopically odontoclasts can be readily identified as large,
multinucleated giant cells, occupying the irregular bays on the surface of
resorbing dental hard tissue. They may also be found in the pulp.
Electron microscopically these cells have a ruffled border adjacent to the
resorbing hard tissue. This is formed by folding of cell membrane into a
series of invaginations of 2–3 mm in depth. Mineral crystallites may be seen
in the depth of these invaginations. Cytoplasm has large number of
mitochondria and vacuoles which are seen close to the ruffled border.
Histochemically the cells have increased levels of enzyme acid phosphatase.
The mechanism by which odontoclasts actually resorb the hard tissues of
teeth is not understood. Possibly during the initial stage, the crystallites are
removed exposing the organic matrix. As a second step, organic matrix is
removed by extracellular dissolution into smaller molecules and phagocytosis
by odontoclasts.
Vacuoles in the odontoclasts, rich in acid phosphatase suggest that they are
phagosomes causing break down of ingested materials.
Histological sections show that periodontal ligament degeneration may be
through apoptotic cell death or through a mechanism that interfere with
formative function of fibroblasts.
Clinical Considerations
1. Retained deciduous teeth: Deciduous teeth remaining in the oral cavity
for longer time than the normal exfoliation period are referred to as
retained deciduous teeth.
The causes of retained deciduous teeth may be
• Congenital absence of permanent successor
• Failure of eruption of permanent successor
• Ankylosis of deciduous tooth (fusion of tooth to alveolar bone).
• Eruption of permanent tooth in a lingual or labial position so that
the deciduous tooth escape from the pressure exerted by them.
2. Remnants of roots of deciduous tooth
Remnants of roots of deciduous tooth is commonly seen in maxillary
premolar region. The roots of deciduous molars are so divergent that
the distance between roots is more than the diameter of the developing
permanent tooth. This allows a portion of root to escape from
resorption. These unresorbed root pieces may get resorbed and
replaced by bone. The remnants closer to the surface extrude through
the mucosa and ultimately exfoliate,
3. Submerged tooth
Submerged tooth is the one which remains below the level of normal
occlusal plane of other teeth. This can occur if the tooth is ankylosed
(fused) to the alveolar bone. Ankylosis may be due to trauma resulting
in damage to periodontal ligament. Imbalance between resorption and
repair that occur during the process of exfoliation may also lead to
ankylosis of deciduous teeth. An ankylosed tooth is unable to undergo
physiological tooth movement to compensate for increased height of
alveolar bone. When adjacent teeth continue eruption, the ankylosed
tooth remains submerged with occlusal plane of this tooth at a lower
level. When the deciduous tooth is ankylosed, it fails to exfoliate and
therefore prevent eruption of its successor. A submerged tooth should
be extracted, after a radiographic confirmation of presence of
permanent successor.
39
Saliva
Introduction
Composition
Function
Synthesis
Control of secretion
S aliva is the fluid secreted by the salivary gland that keeps the oral cavity
moist. Saliva is secreted by three pairs of major salivary glands, namely
parotid, submandibular and sublingual glands and numerous minor
salivary glands which are widely distributed in the oral mucosa. The total
volume of saliva secreted varies from 600 to 700 ml per day or even may be
up to 1 to 1.5 liters/day. pH of saliva varies from 6.2 to 7.6. During rapid
secretion the saliva becomes more alkaline because of high bicarbonate
content. Specific gravity of saliva is 1.002 to 1.012.
COMPOSITION OF SALIVA
Saliva Contains
Water-99%
Organic and inorganic components-1%
Organic Components
Mucin or carbohydrate rich glycoproteins
Antibacterial components
– Lactoferrin
– Kallikrein
– Lysozymes
– Peroxidase
– Thiocyanate
Digestive enzymes
– Ptyalin or amylase
– Maltase
– Lipase
Free amino acids, fatty acids, urea, uric acid, free glucose, peptides, blood
clotting factors, blood group substances, epidermal growth factors, etc.
Inorganic Component
Sodium, chloride, potassium, calcium, bicarbonates, phosphates, ammonia,
magnesium, fluoride, iodine, etc.
Dissolved Gases
Carbon dioxide, oxygen, nitrogen, etc.
In addition, the whole saliva obtained from the mouth also contains
desquamated epithelial cells and a few leukocytes from crevicular fluid and
oral micro-organisms.
FUNCTIONS OF SALIVA
Mechanical Function
Lubrication: Because of water and mucin content, saliva helps to keep oral
cavity wet and helps in speech, mastication and deglutition.
Salivary glycoproteins forms a lining of oral tissues and therefore prevent
adhesion of microbes, microbial products and various other materials.
Lavage: Saliva helps to flush out food debris and micro-organisms from the
oral cavity.
Saliva helps to dilute hot and other irritant materials therefore preventing
trauma to mucosa.
Digestive Function
Saliva contains amylase or ptyalin which can act on starch and split it into
disaccharides. Lipase present in the saliva secreted by von Ebner’s gland is
important in lipid digestion in newborn. Saliva also contains some maltase
enzyme.
Taste Sensation
Taste sensation can be perceived only when the substance is dissolved and
therefore the solvent action of saliva is very important in perception of taste.
Saliva also helps in cleaning the taste buds to ready them for the next taste
perception. ‘Gustin’ present in saliva helps in development and maturation of
taste buds.
Water Balance
When the water content in the body is reduced, salivary secretion is
decreased and mouth becomes dry. The nerve endings in the posterior aspect
of tongue are stimulated and a dry mouth reflex is initiated which stimulate
the salivary flow. If the body tissue is short of water, reflex does not occur
leading to drying of mouth. Thus, encourages the individual to drink water
and water balance is maintained.
Endocrine Function
Saliva contains some biologically active materials. For example, parotin
secreted by parotid gland. Parotin is reported to promote mesenchymal tissue
growth, decreases serum calcium level, promoting the mineralization of
dentin, etc. in animals. The status of parotin as a true hormone has not been
identified.
Excretion
Saliva act as a route through which certain substances are excreted such as
mercury, lead, thiocyanate, ethyl alcohol, some drugs, etc. (Excretion of ethyl
alcohol in saliva can be used as a method to determine whether the individual
has consumed alcohol in case of medico legal cases.) Certain viruses like
viruses of rabies, mumps and poliomyelitis are also excreted through saliva.
Tooth Integrity
Saliva contains calcium and phosphate ions. Due to ionic exchange between
saliva and tooth, enamel undergoes maturation. Due to this, enamel becomes
harder, less permeable and more resistant to caries. Ionic exchange can also
lead to remineralization of initial caries lesion preventing further progression.
Temperature Regulation
This function of saliva is significant in animals.
The organic components of the saliva are synthesized by the secretory cells
of salivary gland utilizing the substrate provided by the nutrients that reach
the cell from the blood vessels and stored in secretory granules. When the
secretory unit is stimulated the stored products are expelled out.
Water and electrolyte required for the sava reaches the cell from
circulation and from tissue fluid. When there is nerve stimulation, chloride
ions are actively transported into the cell. This increased electronegativity
induces the influx of sodium ions. This increased sodium and chloride ions in
the cell create an osmotic force resulting in transport of water into the cell
causing cell swelling. The pressure in the cell results in minute rupture of
secretory border of cell, expelling water and electrolytes. Kallikrein presents
in saliva act upon plasma proteins to produce bradykinin. This produces the
vasodilatation resulting in seepage of water into the tissue fluid, during active
secretion of saliva.
Clinical Considerations
• Sialorrhea is the term used to describe a condition where there is an
excessive flow of saliva. This may be associated with various
conditions, such as acute inflammation of the mouth, mental
retardation, mercury toxicity, teething, etc. Sialorrhoea is called
hypersalivation or ptyalism.
• Xerostomia is the term used for dry mouth due to a lack of saliva.
Xerostomia can be caused due to a number of reasons: Psychological
causes like anxiety and depression; dehydration due to diarrhoea,
sweating, vomiting, diabetes mellitus and diabetes insipidus; use of
antihistaminic drugs; diseases affecting salivary glands such as
Sjogren’s syndrome, tumors or salivary gland aplasia. Xerostomia can
cause difficulty in speech and eating. It also leads to halitosis (bad
breath), dramatic increase in dental caries and infections.
40
Physiology of Taste and
Speech
Dr Usha Balan
Physiology of taste
– The sensation of taste
– Mechanism of taste stimulation
Physiology of speech
– Speech process
– Integration of speech
– Perception of speech
PHYSIOLOGY OF TASTE
Speech Process
Speech is often described as “an overlaid process” secondary to vegetative
functions. Phenomenon of speech process includes four mutually dependent
divisions.
Respiration
Phonation
Resonation
Articulation
These process co-ordinate to produce dynamic acoustic modulation of
speech.
Phonation
Second step in speech process is phonation. Breath stream emitted from the
lungs strikes the vocal folds housed in the larynx. Phonation results from
vibratory activity of vocal folds. Exhaled air stream is interrupted by
vibratory pattern of vocal folds, and air puffs emerging from this process
create sound. This sound is referred as source excitation which serves as an
acoustic material from which speech sounds are later developed.
Processes concerned with shaping or modifying source sounds into
identifiable speech sounds are resonance and articulation.
Resonation
Resonation is the third step in speech process. Resonance system gives a
distinguishing quality which is characteristic of each voice. Sounds are
modified by selective alteration of size and shape of vocal tract. Depending
on the configuration of vocal tract, certain frequencies are amplified whereas
others are attenuated.
Articulation
Articulation is the fourth step in speech producing sequence. Articulators and
articulatory valves are responsible for this act. Vocal organs are the
articulators and the articulatory valves are the place at which airstream is
modified to produce speech sounds. When vocal organs assume a certain
position they produce sound, simultaneously articulatory valves stop,
constrict and narrow the air-stream, thus producing speech sounds.
Articulation thus refers to placement and movement of lips, teeth, tongue,
mandible, soft palate and associated structures during speech to produce
speech sound.
Integration of Speech
Processes of respiration, phonation, resonances and articulation are co-
ordinated and integrated by the nervous system to produce the complex and
dynamic behavior known as speech production.
Perception of Speech
Speech is studied in terms of both production as well as perception of sound.
Properties of each sound is influenced by speech sounds that preceed and
succeed it. Perception of sound depends not only on factors like acoustic
signals but also on adequacy of listeners auditory system, nature of
perceptual environment and linguistic orientation of both speaker and
listener.
41
Mastication
Introduction
Objectives of mastication
Forces of mastication
Masticatory cycle/chewing cycle
Changes in various structures during mastication
Control of masticatory cycle
M astication is the act of chewing food whereby the ingested food is cut
or crushed into small pieces, mixed with saliva and formed into a bolus
in preparation to swallowing.
Objectives of Mastication
Mastication helps in deglutition by
• Breaking the large food particles into smaller particles which
otherwise may cause irritation to gastrointestinal tract.
• Forming a bolus that can easily be swallowed.
Mastication helps digestion by
• Stimulating salivary secretion
• Causing break down of food particles thereby increasing surface area
for enzymatic action.
• Facilitating mixing of food with saliva and initiating digestion by
salivary enzymes.
• Exposing the digestible components present inside in some food
materials.
Mastication also ensures healthy growth and development of oral tissues.
The act of mastication is a complex process that uses masticatory muscles,
teeth, periodontal supportive structures and also the lips, cheeks, tongue,
palate and salivary glands. During mastication well coordinated functioning
of masticatory muscles move the mandible to bring the teeth together. During
this process of contact between teeth considerable force is exerted on the food
particles resulting in reduction in size of food particles.
Forces of Mastication
The maximum biting force that can be applied to the teeth varies from
individual to individual. Males are able to exert more masticatory force than
females. The masticatory force exerted on anterior teeth is 55 pounds (10–15
kg) and on molars is 200 pounds (around 50 kg) approximately. Biting force
can be increased by exercise. Maximum biting force up to 150 kg has been
recorded in traditional Eskimos who have lived on very tough diet requiring
vigorous mastication.
Introduction
Phases of deglutition
Infantile and adult swallow
Preparatory Phase
During this phase, the bolus is prepared and positioned on the tongue as a
preparation to swallowing. The tip of the tongue presses against the maxillary
incisors or anterior part of palate and lateral aspect rises against posterior
teeth and palate so that tongue develops a spoon-like depression. Posteriorly
the pharyngeal part of the tongue arches up to the soft palate. At the same
time, soft palate is depressed to create a glossopalatine seal, which prevent
the bolus from escaping into the pharynx.
Oral Phase
During oral phase, bolus is propelled from the oral cavity to the pharynx. The
tongue muscles and the muscles of floor of the mouth play an important role
in this phase. The oral phase starts after the bolus is positioned on the tongue.
During this phase, the lips are closed and upper and lower teeth come in
contact. This is followed by elevation of the anterior 2/3rds of the tongue,
which presses against anterior part of the hard palate. Mean while the
glossopalatine seal is opened by elevation of the soft palate with depression
of posterior part of tongue. This allows the passage of food to pharynx. The
entry of food into the nasopharynx is prevented by the elevation of the soft
palate. The inward and forward constriction of posterior pharyngeal wall
closes the palatopharyngeal isthmus.
Oral phase of deglutition is under voluntary control and it lasts for 0.5
seconds. During this phase, airway is open and breathing continues normally.
Pharyngeal Phase
In pharyngeal phase, the bolus is transported from the oropharynx into the
esophagus by a peristaltic wave caused by contraction of the pharyngeal
constrictor muscle. The pharyngeal phase begins, when the bolus makes
contact with the posterior part of oral mucosa and mucosa of the pharynx.
These contacts on sensitive areas act as stimuli for a series of reflexes that are
responsible for the bolus being transferred into the esophagus and not into
trachea or nasopharynx.
In the beginning of pharyngeal phase tongue makes a rapid piston-like
movement to propel the bolus through oropharynx to hypopharynx. The
whole pharyngeal tube is elevated by stylopharyngeus and palatopharyngeus
muscles. The entry of bolus to the esophagus is facilitated by the upward
movement of larynx which stretches the opening of esophagus and elevation
of larynx that lifts the glottis away from the food passage. Simultaneous
relaxation of the upper esophageal sphincter occurs followed by a wave of
peristalsis caused by contraction of pharyngeal muscles propels the bolus into
the esophagus.
During this phase, there are possibilities of food entering back into oral
cavity, upward into nasopharynx, forward into larynx and downward into
esophagus. Due to co-ordinated movements of various structures, the entry of
food to other passages is prevented.
Bolus is prevented from moving back to oral cavity by the tongue which
takes a position against the roof of the mouth and also by increased intraoral
pressure created in the oral cavity by the movement of tongue.
Entry of bolus to nasopharynx is prevented by upward movement of soft
palate which becomes triangular in shape and contacts the adjacent
pharyngeal wall.
Several mechanisms operate to prevent aspiration of food to the larynx.
a. Larynx rises and is pulled up under the tongue.
b. Epiglottis folds down from an upright to horizontal position over the
laryngeal opening.
c. The intrinsic muscle of the glottis approximate the vocal cords and
the pyriform sinus create lateral food channels so that the bolus
deviates around the laryngeal opening.
Temporary arrest of breathing occurs during the pharyngeal phase of
swallowing and is referred to as deglutition apnea. The pharyngeal phase of
deglutition takes around 0.7 seconds. The second phase of deglutition ends
when the bolus is transferred from the pharynx into the upper part of
esophagus and then the muscles of the tongue, palate, pharynx and larynx
relax, the mandible is moved into rest position and respiration resumes.
Esophageal Phase
During this phase, the bolus moves down the length of esophagus to the
stomach. This is an involuntary stage. Esophagus helps to move food from
pharynx to the stomach. The peristaltic movements (the alternative
contraction and relaxation of muscle fibers of GIT) help in the movement of
food in esophagus. When the bolus reaches esophagus these peristaltic waves
are initiated which propel the food from pharynx to stomach.
The distal 2–5 mm is the lower esophageal sphincter. When bolus enters
this part of the esophagus, the sphincter relaxes and the contents enter into
the stomach. Later this sphincter contracts to prevent movement of food back
to esophagus. This phase is somewhat longer, liquids take 3 seconds whereas
solids take 9 seconds.
Calcium metabolism
Phosphorus metabolism
Hormonal control of serum calcium level
Other hormones that have role in serum calcium level
Functions of calcium and phosphorus
Clinical considerations
Daily Requirement
200 mg/day for infants
1000–1300 mg/day for children and adolescents
1000 mg/day for adults
1300 mg/day for pregnant and lactating females
Absorption is mainly in jejunum and ileum and only about 1/3rd of the
dietary intake of calcium is absorbed under normal circumstances.
Excretion
Calcium is excreted both in urine and feces. In urine it is excreted as calcium
chloride and calcium phosphate. Renal threshold is 7 mg/dl of serum calcium.
Not only non absorbed calcium, even absorbed calcium is excreted through
feces.
Phosphorus
Normal serum phosphorus level
2–4 mg/dl in adults
3–5 mg/dl in children
Daily Requirement
240 mg for infants
800 mg for adults
1200 mg for pregnant and lactating females.
Absorption of phosphorus takes place in small intestine in the form of soluble
inorganic phosphate. Approximately 70% of dietary phosphate is absorbed in
the form of orthophosphate. By the action of intestinal phosphatases food
bound phosphorus is released during digestion.
An excess of calcium, iron or aluminum may interfere with absorption.
Excretion: Occurs primarily through urine in the form of phosphates of
various cations. Fecal phosphorus is usually excreted as calcium phosphate.
VITAMIN D
CALCITONIN
Actions of Calcitonin
Effect on bone
• Acts directly on the osteoclasts causing an immediate inhibition of
bone resorbing activity.
• Decreases development of new osteoclasts.
• Facilitates bone formation.
Effect on kidney
Acts on kidney and increases excretion of calcium and decreases the
reabsorption.
Effect on intestine
Prevents absorption of calcium.
Functions of Calcium
Hemostasis: Calcium is necessary for activation of clotting factors in plasma.
Calcium plays important role in formation of bone and teeth and in its
maintenance.
Calcium is essential for neurotransmitter release and helps in neuromuscular
excitability.
Calcium is bound to cell surface and has role in stabilization of cell
membrane, normal membrane permeability and adhesion between cells.
Calcium is essential for all secretory processes such as release of hormone by
endocrine cells and release of secretory products of exocrine glands.
Calcium is essential for activation of certain enzymes involved in
inflammation and also acts as secondary messenger of hormonal action.
Functions of Phosphorus
Phosphorus is important for formation of bone and teeth.
Phosphates by their function in phosphorylation, is important in the
metabolism of fat and carbohydrate.
Phosphorus is used in building the more permanent organic phosphates
including some catalyst essential for the structure and functions of cells.
Phosphates are utilized for the formation of phosphoproteins, nerve
phosphatides and nucleoproteins of cells.
They provide energy rich bonds in such compounds as adenosine
triphosphate and is important in muscle contraction.
Phosphate form part of coenzymes as pyridoxal phosphate which is necessary
for decarboxylation and transamination of certain amino acids such as
tyrosine, tryptophan and arginine.
Clinical Considerations
A low concentration of serum calcium which is less than 8 mg% produces
hyperirritability of nerves and neuromuscular junction, leading to
contraction of muscle spontaneously. This condition is called tetany which
is characterized by carpopedal spasm and convulsions.
44
Mineralization
Introduction
Booster theory
Seeding theory
Matrix vesicle theory
Introduction
Effect of thyroid hormone
Effect of parathyroid hormone
Effect of pituitary hormones
Effect of sex hormones
Effect of adrenal hormones
Effect of pancreatic hormone
THYROID HORMONE
PITUITARY HORMONES
Pituitary gland is the master endocrine gland, secretions of which control the
functioning of many other glands and many body functions. Anterior
pituitary produces at least six hormones: The somatotropic, the thyrotropic,
the adrenocorticotropic and the lactogenic hormone. The posterior pituitary
produces antidiuretic hormone. Decreased activity of this hormone results in
excessive production of urine and general dehydration of the body. The main
effect of pituitary hormones on teeth and orofacial structures are mainly
through the effect of growth hormone and partly by thyroid stimulating
hormone.
Hypopituitarism can occur due to congenital defects or due to destructive
diseases. If it occurs before puberty it leads to a condition called dwarfism. In
pituitary dwarf the eruption of teeth is delayed and the shedding time of
deciduous teeth is also delayed, as is the growth of body in general. The size
of the crown and root of the tooth is smaller than normal. The supporting
structures of the teeth also show retardation of development. Because of
incomplete eruption, clinical crown of the teeth may be smaller.
Decreased growth hormone also causes retardation of development of
maxilla and mandible. The dental arch is smaller than normal, therefore
results in crowding of teeth and malocclusion. Pituitary dwarfs are reported
to have a decrease in caries rate.
Hypopituitarism in adults does not show any specific dental changes.
Hyperpituitarism that occurs before the closure of epiphysis of long bones
leads to a condition called gigantism and if it occurs later in life after
epiphyseal closure, leads to acromegaly.
Gigantism is characterized by symmetric overgrowth of the body. As a part
of general overgrowth of bones, both mandible and maxilla are larger than
normal. The teeth, both crown and root are larger and is in proportion to the
size of the jaws. The eruption of both deciduous and permanent teeth is
accelerated with premature shedding of deciduous teeth.
In acromegaly, mandible continues to grow leading to abnormally long
face and mandibular prognathism. Supra-eruption of teeth may occur leading
to overgrowth of alveolar bone. Increase in length of mandibular arch may
lead to malocclusion. The lips become thick and the tongue enlarged with
indentations on the sides of the tongue. The enlarged tongue exerts pressure
on the teeth leading to buccal or labial displacement of teeth and
malocclusion.
SEX HORMONES
ADRENAL HORMONES
Various hormones have been secreted by adrenal cortex and medulla. The
main secretions from adrenal medulla are epinephrine (adrenaline) and
norepinephrine. Adrenaline is very essential for a quick physiological
response to crisis situations. Adrenal cortex is concerned with liberation of
steroids which involve in carbohydrate, mineral, fat and protein metabolisms
and fluid electrolyte balance. Hydrocortisone also has a marked anti-
inflammatory effect.
Chronic insufficiency of adrenal cortex leads to a condition called
Addison’s disease which is characterized by pigmentation of oral mucous
membrane involving buccal mucosa, tongue, gingiva and lip.
Hyperfunctioning of adrenal cortex causes Cushing’s syndrome. The
changes in orofacial region could be related to osteoporosis. Cortisone causes
osteoporosis by suppressing the activity of osteoblasts resulting in defective
matrix deposition.
PANCREATIC HORMONE—INSULIN
T he term age changes refer to all the changes that occur in the body from
birth to death. However, it is usual to consider age changes as those
which are evident in later life. Effects of aging in relation to the oral
tissues can be discussed in the following headings:
Changes in dental tissues
Enamel
Dentin
Cementum
Dental pulp
Changes in supporting structures of teeth
Periodontal ligament
Alveolar bone
Changes in oral mucosa
Changes in salivary glands
ENAMEL
Enamel is the hardest calcified tissue in the human body which forms the
resistant covering of the teeth, rendering them suitable for mastication.
Enamel being a nonliving tissue it is incapable of repair. But its surface can
however be modified at a crystal level by ion exchange or grossly by
attrition, abrasion, erosion or by dental caries.
Age changes observed in enamel are
Attrition: Attrition is the physiological wearing away of the teeth resulting
from masticatory movements of teeth and friction from food particles. It is
the most conspicuous change in the teeth with advancing age and can be
appreciated on both occlusal and proximal surfaces. The amount of wear
differs a great deal, due to variations in the type of occlusion present, habit,
and muscular power, type of food and tooth loss. Attrition causes loss of
vertical dimension of the crown, loss of enamel from the occluding surfaces
of the teeth to produce polished attrition facets and flattening of proximal
contour.
Modification in surface layer: The enamel of newly erupted teeth are
covered with pronounced rod ends and perikymata. With increasing age,
these surface structures disappear. The rates at which they are lost depend on
the location of the surface of the tooth and on the location of tooth in the
mouth. Facial and lingual surfaces lose their structure more rapidly than
proximal surfaces. Anterior teeth lose their structure more rapidly than
posteriors.
Increase of inorganic content: Due to exchange of ions with the oral
environment during aging, superficial enamel surface of older teeth have
increased inorganic content. The thickness of hypermineralized surface zone
increases in older teeth and exhibits more resistance to decay. A steady
increase in nitrogen and fluoride level in enamel with age has also been
reported.
Decrease permeability: Permeability of enamel decreases with age, possibly
as a result of surface consolidation of crystals, formation of fluoroapatite and
a reduction of matrix between individual crystals.
Decrease in water content: The crystals in enamel acquire more ions and the
pores between them decreases. As the major portion of water in enamel lie in
these pores, reduction in the pores in older enamel, results in decrease in their
water content.
Change in color of teeth: Color of the teeth becomes darker with age due to
deepening of the color of the dentin. It is also possible that enamel itself
either becomes darker with age or more translucent contributing to change in
color of tooth.
DENTIN
The dentin provides the bulk and general form of the tooth. Unlike enamel,
dentin is deposited throughout life and is a vital tissue that can react and
respond to various stimuli to which it is exposed.
Age changes of dentin can be
Changes in physical properties: Color of dentin becomes darker with age.
Density and mineralization and hardness of dentin of both crown and root
increases with age.
Vitality of dentin: The vitality of dentin is decreased in advancing age
probably due to decrease in the odontoblastic activity.
Thickness of dentin: Although at a slower rate, dentin is laid down
throughout life, resulting in gradual increase in thickness as age advances.
Dentin tend to be deposited in greater amounts in certain areas of pulp such
as in the floor of the pulp chamber.
Secondary dentin deposition: This is the type of dentin formed after root
completion and in the absence of obvious trauma to the tooth, such as
attrition, abrasion, erosion, etc. Deposition of secondary dentin is a normal
aging process that continues throughout life.
Dead tracts: Dead tracts are empty dentinal tubules that are formed due to
degeneration of odontoblast processes in the dentinal tubules. This usually
occurs due to exposure of dentin following attrition, abrasion or erosion.
These empty dentinal tubules are filled with air; thereby appear dark under
transmitted light. Dead tracts may also develop in unerupted teeth and in
teeth with a little or no visible damage, especially in the region of cusp or
incisal edges due to death of odontoblasts occurring as a result of
overcrowding. Therefore dead tract can also be considered as an age change.
Sclerotic or transparent dentin: Mild stimuli induce protective changes in
the existing dentin. Continued deposition of intratubular dentin occurs in the
tubules and this leads to gradual reduction in tubule diameter or even
complete closure of tubules. The refractive indices of dentin in which the
tubules are occluded are equalized and therefore such areas appear
translucent or transparent in the transmitted light and dark in reflected light.
Sclerotic dentin is frequently found near the root apex in the teeth of
elderly people as an age change. The sclerotic dentin is more brittle and less
permeable.
Reparative dentin: This is the type of response seen due to severe irritation
caused by extensive abrasion, erosion, caries or operative procedures.
Majority of the odontoblasts in this affected area degenerates, but a few may
survive and continue to form dentin at a rapid rate to seal off the exposed
tubules from the pulp. This dentin produced by survived odontoblasts is
called reparative dentin. Dead odontoblasts are replaced by new odontoblasts
differentiated from undifferentiated mesenchymal cells present in the pulp.
The dentin produced by these new odontoblasts is called reactionary dentin.
CEMENTUM
PULP
Pulp is the soft tissue component of the tooth situated in the pulp cavity.
Age changes in the dental pulp are
Size and morphology: With age a progressive reduction in pulp size occurs
due to secondary dentin deposition. The pulp horn becomes less prominent or
may disappear. Similarly, the radicular dentin becomes narrow or even
obliterated.
Cellular and fibrous components: The pulp in older teeth becomes more
fibrous with appreciable amount of mature collagen with proportionate
reduction in the cellular components and ground substances. The collagen
fibers of aged pulp is more resistant to enzymatic degradation. The number of
cells in the pulp including fibroblasts and odontoblasts decreases with age.
The odontoblast layer may show intercellular edema and vacuolation in
sections of pulp, which could be even because of poor fixation.
Changes in blood supply and innervations: Loss and degeneration of
myelinated and unmyelinated axons occur which can be correlated with an
age related reduction in sensitivity. As these progresses, the number of nerves
gets greatly diminished. There is a decrease in the blood supply as the apical
foramen is almost obliterated by secondary dentin and cementum which
initiates most of the other changes in the pulp. Blood vessels decrease in
number may also show decrease in size of lumen, thickening of vessel walls
with fibrosis and calcifications. Arteriosclerotic changes begin to develop
from the age of 40 years.
Reduction in sensitivity and healing potential: As age advances the
sensitivity and healing or reparative capacity of pulp decreases. Decreased
sensitivity can be directly related to nerve degeneration. Overall reduction in
vascular supply and cellular component could be responsible for decreased
reparative capacity of pulp.
Pulpal calcifications: Calcification may occur in pulp tissue as a result of
aging or external stimuli. These may be nodular, calcified masses referred to
as pulp stones or diffuse calcifications.
They are seen in functional as well as embedded, unerupted teeth.
Although pulp calcifications are seen in young individuals, the incidence
increases with age: 66% between the age group of 10 to 30 years, 80%
between 30 to 50 years and 90% above 50 years.
Diffuse Calcification
Diffuse calcification is composed of small calcified particles with a few
larger masses. The calcified structures are arranged as linear strands parallel
to the long axis of pulp. They are found to be closely associated with blood
vessels with an orientation parallel to the vessels and nerves. It is usually
seen only in radicular pulp.
PERIODONTAL LIGAMENT
ALVEOLAR BONE
It is that part of the maxilla and mandible that forms and supports the socket
of the teeth. As age advances alveolar bone facing periodontal ligament
becomes irregular. Bone also shows osteoporotic changes and decreased
metabolic rate, vascularity, healing capacity, etc. Cancellous bone becomes
dense with coarse trabecular pattern. Since the existence of alveolar bone
greatly depends on teeth, when the teeth are lost, it undergoes gradual
atrophy.
ORAL MUCOSA
It is defined as a moist lining of the oral cavity and shows various age
changes such as:
Clinically, the oral mucosa of an elderly person relatively has a smooth and
dry surface than that of a youngster and may be described as atrophic or
friable. Permeability of mucosa to water is reduced in older individuals.
Histologically, the epithelium appears thinner and more or less regular
epithelium-connective tissue interface resulting from the flattening or
shortening of epithelial ridges. In the lamina propria, there is decreased
cellularity with increased amount of collagen, which is reported to become
more highly cross linked. The number of blood vessels decreases resulting in
reduced blood flow to the oral tissues and decreased rates of metabolic
activity. This leads to thinning of the mucosal layer and thus the oral mucosa
is more susceptible to damage and infections as age advances.
Gingiva may show a decrease in degree of keratinization.
Sebaceous glands (Fordyce’s spots) of the lips and cheeks also increase with
age.
A striking and relatively common feature in elderly persons is nodular
varicose veins on the undersurface of the tongue.
The number of taste buds decreases as much as 60% in old age resulting in
decrease or loss of taste perception. Threshold for salt and bitter tastes
increases with age.
The dorsum of the tongue may show a reduction in the number of filiform
papillae. The reduced number of filiform papillae may make the fungiform
papillae more prominent.
SALIVARY GLANDS
The salivary glands show various age changes which include:
Structural changes: The salivary glands become less active with age due to
relative decrease of acinar tissue with increase in fibrous and adipose tissue.
Replacement of parenchyma with fatty tissue is more apparent in parotid
gland. Salivary glands also show a progressive accumulation of lymphocytes.
Quantity and quality of saliva: Since parotid is the major source of watery
saliva, with advancing age the viscosity of saliva increase with a total
reduction in the salivary secretion.
Oncocytes: Altered epithelial cells found in the salivary glands that can be
identified by their marked granularity and acidophilia under light microscope
are thought to represent an age related change. The number of oncocytes
increases with age.
Section 5
Allied Topics
Introduction
Soft tissue processing
Hard tissue processing
– Decalcification
– Ground sectioning
The most commonly used method of preparing soft tissue for the light
microscopic study is by embedding the tissue in paraffin and cutting and
mounting the section on slides and staining. The procedure for soft tissue
processing can be either manual or automatic. In manual method, all the
procedures of soft tissue processing have to be done manually and require
constant vigil. In automatic tissue processing, the tissue specimens are
automatically transferred through all the processing solutions in the automatic
tissue processor in which the time for the tissue to pass from one solution to
the other can be preset.
Solutions used
Methyl and ethyl alcohol
Isopropyl alcohol
Acetone
Clearing
Paraffin and alcohol are not miscible. So impregnation of tissue by paraffin is
not possible unless alcohol is replaced by a fluid that is miscible with both
alcohol and paraffin. This process is called clearing. Xylene is one of the
solutions that is miscible with both paraffin and alcohol. The term “clearing”
comes from the fact that the clearing agents often have the same refractive
index as proteins in the specimen. As a result, when the tissue is completely
infiltrated with the clearing agent, it becomes translucent or clear. The
presence of opaque areas after clearing indicates incomplete dehydration.
Xylene
Xylene is a colorless, clear, oily, liquid aromatic hydrocarbon (sweet-
smelling), used as a solvent and clearing agent in the preparation of tissue
sections for microscopic study. Also called xylol; di-methylbenzene C6H4
(CH3)2 and has a molecular weight of 106. Xylene is obtained from coal tar
and sometimes from petroleum. Xylene is insoluble in water and is soluble in
alcohol.
Xylene is an organic solvent which is miscible with both alcohol and
paraffin and is the most commonly used clearing agent in lab. It is widely
used as a solvent and thinner for paints and varnishes, often in combination
with other organic compounds and as a solvent in glues and printing inks, etc.
Xylene is stable under ordinary conditions of use and storage, but is highly
flammable under adverse conditions and can form explosive mixtures in air.
Xylene is an irritant to the eyes and mucous membranes at low
concentrations, and is narcotic at high concen trations. Although the
carcinogenic effect of xylene is suggested, there is no direct evidence of
carcinogenicity in humans.
Impregnation
Impregnation is the procedure where there is saturation of tissue cavities and
cells by a supporting substance, which is generally, but not always, the
medium in which they are finally embedded. Impregnation procedure
replaces the xylene with paraffin and is achieved by immersion in molten
paraffin wax (60°C).
Factors affecting impregnation
Size and type of tissue
Clearing agent employed
Vacuum embedding
Embedding or blocking
Embedding is the process by which tissues are surrounded by a medium such
as agar, gelatin, or wax, which when solidifies will provide sufficient external
support during section. Impregnated tissue is transferred from wax bath to a
mould filled with molten wax to get a block of wax with the tissue specimen
at the center with the cutting surface facing the base of the block.
Procedure
Embedding is done using Leuckhart’s L-shaped pieces, ice trays, paper boats
or embedding cassette. The L-shaped block or paper boat is arranged to form
a cube on a clean, flat surface. The cube is then filled with molten wax and
the specimen is embedded into this with the help of a warm forceps. Make
sure that there are no air bubbles trapped between the tissue and the molten
wax. Care should be taken while embedding, so that the tissue to be
embedded has proper orientation. The wax-filled mould containing the tissue
is then allowed to cool. The wax blocks are labeled for easier identification.
The hardened wax block is removed from the mould and trimmed using a
sharp knife.
Fig. 47.1: Steps to be followed in tissue processing
Sectioning
To view the specimen under microscope, the embedded tissues are to be cut
into thin sections of 3–5 μ with a microtome. The microtome is a device used
to cut the tissue into thin sections of specified thickness. The preparation of
sections using a microtome also can be manual or automatic. The wax block
is to be fixed onto a wooden or metal block to prevent wax block from
crumbling during sectioning and the metal or wooden block is clamped onto
the microtome for sectioning.
The cut sections are transferred and floated on a warm water bath. The
temperature of the water bath is to be maintained at 10° less than the melting
temperature of wax. The inside of the water bath should be preferably of
black color. This helps in easy visualization of the floated specimens against
a dark background. The water bath helps to remove wrinkles and spread the
specimen. Floated sections are picked up on an adhesive coated glass slide.
Egg albumin with additives is the commonly used section adhesive. Glass
slide should be kept on a slide warmer at 58° temperature for 20 mins to
ensure complete adhesion.
Staining
Staining is the biochemical technique of adding a class-specific dye to a
substrate (DNA, proteins, lipids, carbohydrates) to qualify or quantify the
presence of a specific compound.
Hematoxylin and eosin (H and E) staining is the routinely used method in
histopathology lab.
Other commonly used staining procedures in histopathology tab are
Gram staining
Papanicolaou staining (Pap stain)
Periodic acid-Schiff staining (PAS stain)
H and E stain/hematoxylin and eosin stain Hematoxylin and eosin stain is
the most popular staining method in histology and is the most widely used
stain in medical diagnosis. The staining method involves application of the
basic dye hematoxylin, which colors basophilic structures with blue-purple
hue, and alcohol-based acidic eosin-Y, which colors eosinophilic structures
bright pink. The basophilic structures are usually the ones containing nucleic
acids, such as the ribosomes and the chromatin-rich cell nucleus, and the
cytoplasmic regions rich in RNA. The eosinophilic structures are generally
composed of intracellular or extracellular protein. Most of the cytoplasm is
eosinophilic. Red blood cells are stained intensely red.
Hematoxylin is a natural dye which is extracted from the logwood of the
tree, Haematoxylon campechianum. Oxidation of this extract produces a
colored substance hematein, which itself is a poor dye. This dye when used in
conjunction with a mordant becomes a powerful dye. The color of dye is red
which turns into blue when the tissue section is treated with weak alkali
(blueing) following hematoxylin staining.
Eosin is the second component of the H and E and is the counter stain.
Eosin is a red dye formed by the action of bromine on fluorescein and is both
water and ethanol soluble. Eosin-Y is the commonly used form of eosin.
Eosin is used to stain cytoplasm, collagen and muscle fibers.
Hematoxylin and eosin staining procedure can be carried out manually or
using automated equipment.
Methods of hematoxylin and eosin staining
Remove wax with xylene.
Rehydrate the tissues using descending grades of alcohol
Wash sections in water
Stain with hematoxylin
Differentiate in acid alcohol
Wash in water
Blueing by using tap water or Scott’s tap water substitute
Rinse in water
Stain with eosin
Wash in running water
Dehydrate using ascending grades of alcohol
Removal of alcohol and clearing in xylene
Mounting
The stained section on the slide must be covered with a thin glass coverslip to
protect the tissue from being scratched, to provide better optical quality for
viewing under the microscope, and to preserve the tissue section for years to
come. The mounting medium is used to adhere the coverslip to the slide.
There are two types of mounting media: Water based mounting media and
resinous mounting media. Distrene dibutyl phthalate xylene (DPX) and
Canada balsam are the commonly used mounting media which are resinous
mounting media.
Procedure
Apply drops of mounting medium upon tissue section.
Hold the coverslip at an angle of 45°. Allow the edge of the coverslip to
contact the drop so that the drop spreads along the edge of the coverslip.
Let go off the coverslip and allow the medium to spread slowly.
Allow it to dry and the section is ready for viewing under microscope.
Although paraffin embedded tissue processing is the one carried out
routinely in a histopathology laboratory, another method termed as frozen
section/cryosection procedure is performed, when rapid microscopic
analysis of a specimen is required. In this case tissue to be examined is placed
on a metal tissue disc which is then secured in a chuck and frozen rapidly to
about –20 to –30°C. The entire process is done in a cryostat machine, which
is a microtome inside a freezer, which is then used to cut thin sections. The
sections are taken on to a glass slide and stained with H and E stain. The
preparation of the sample is much more rapid; however, the technical quality
of the sections is much lower than formalin fixed paraffin embedded tissue
processing. It is used most often in oncological surgery to ensure that the
entire tumour and its surrounding borders are removed.
To study the structure of hard tissues of the body, two procedures can be
adopted: Ground sections and decalcified sections.
Decalcified Sections
Decalcification is the process by which calcium in the mineralized tissue is
removed, so that the tissue becomes soft enough to make thin sections. The
structure of all hard tissues of the body except enamel can be studied in
decalcified sections. Enamel cannot be studied by this procedure because it is
highly mineralized (96%) and is lost during decalcification.
Decalcification is usually carried out between the fixation and processing
steps. A variety of agents or techniques have been developed to decalcify
tissues, each with advantages and disadvantages. Immersions in solutions
containing mineral acids, organic acids, or EDTA are the commonly used
methods. Electrolysis has also been tried.
Mineral acids such as nitric acid and hydrochloric acids are used to
decalcify dense cortical bone and teeth because they will remove large
quantities of calcium at a rapid rate. Frequently used acid for decalcification
is 5% nitric acid. Nitric acid may cause yellowing of the tissue, that may
interfere with further staining procedure. To avoid this 0.1% urea is added to
nitric acid. 10 to 15% formic acid is one of the best decalcifying agents. The
use of EDTA is limited by the fact that it penetrates tissue poorly and works
slowly. Electrolysis is slow and is not suited for routine daily use.
Procedure
Hard tissue to be decalcified should be fixed in 10% formalin or formal
saline. To reduce the time for decalcification, tissue can be cut into smaller
pieces. Then, place the tissue in a container with decalcifying solution. The
solution should be changed daily for few days and then the specimen should
be tested for completion of decalcification.
Ground Sections
Ground sections are of particular importance in the study of structure of
dental hard tissues especially enamel. This method can also be used to study
the structure of bone. In this method the hard tissue specimen is made into
thin sections of desirable thickness by grinding, using abrasive stones.
Procedure
The tooth to be examined should be cut into 2–3 sections using dental hand
piece and diamond impregnated or carborundum disc. These sections should
be ground using an Arkansas stone or by simply rubbing on a glass plate
using abrasive slurry. Grinding should be continued till it is approximately
25–50 microns thickness. Fine abrasives should be used for final polishing.
Most suitable abrasive is domestic scouring powders followed by soapy
water. Once the desirable thickness is attained the section should be washed
and dehydrated and mounted on a glass slide using synthetic resin or Canada
balsam as mounting medium and is allowed to dry.
Grinding of the tooth can also be done using a laboratory lathe. Initial
grinding is done by holding the tooth in fingers and pressing it against the
rotating course abrasive wheel of the lathe. When the tooth is thin, it is
difficult to hold with fingers. Therefore a wooden block wrapped with
adhesive plaster with sticky side directed outward can be used. Stick the tooth
onto the plaster and press the wooden block to the rotating wheel of the lathe
so that the tooth becomes thinner. Then change the coarse wheel to fine
wheel and continue grinding till the section is sufficiently thin. To remove the
adhesive plaster the sections can be soaked in water. The section removed
from the plaster is then mounted on a glass slide using a mounting medium.
Precision equipment like hard tissue microtomes are now available for the
preparation of ground section.
48
Microscope
Types of microscopes
Light microscopy
Types of Microscopes
Microscopes are broadly classified as: Simple microscopes and compound
miroscopes.
Simple microscopes
It has a single lens system through which the upturned image of the object is
seen.
Compound microscopes
These are again classified into two types:
Light microscope
Electron microscope
Light microscopes
They are of the following types
Bright field microscope
Dark field microscope
Phase contrast microscope
Fluorescence microscope
Ultraviolet microscope
Interference microscope
Electron microscopes
They are of two types
Transmission electron microscope (TEM)
Scanning electron microscope (SEM)
Light Microscopy
Microscope in which the final magnified image of the object, illuminated by
visible light is seen through glass lenses is called optical or light microscopes
or bright field microscope.
The ordinary microscope is called a bright field microscope because it
forms a dark image against a brighter background.
The bright field microscope used in histopathology lab today is a
compound microscope that uses multiple lens system to magnify the object, it
has a light source, a condenser lens that focuses the light on the specimen and
two sets of lenses—objective and ocular—that contribute to the
magnification of the image.
Through the refraction or bending of light rays by the system of
microscope lenses, an image of the specimen is formed that is larger than the
object itself, permitting the structures of the specimen to be seen.
Magnification
The magnifying capability of a compound microscope is the product of the
individual magnifying powers of the ocular lens and the objective lens.
Resolving Power
Resolving power is the ability to distinguish two points as separate and
distinct. Resolving power of the microscope depends upon the wavelength of
light and the numerical aperture of the lens (light gathering ability of the lens
system).
Muscles of mastication
Muscles of soft palate
Muscles of facial expression
Muscles of pharynx
Suprahyoid muscles
Muscles of tongue
Suprahyoid muscles
Muscles of tongue
50
Vascular and Nerve Supply of
Orofacial Region
Face
The facial artery is the chief artery of the face which is the branch of external
carotid artery. This artery gives off anterior branches and posterior branches.
Anterior branches include: Inferior labial supplying lower lip, superior labial
supplying upper lip and lateral nasal supplying ala and dorsum of the tongue.
The anterior branches anastomose with similar branches of opposite side.
Posterior branches are smaller and anastomose with transverse facial artery
which is a branch of superficial temporal artery.
Other arteries supplying face include transverse facial artery, infra-orbital
and mental branches of maxillary artery and dorsal nasal branch of the
ophthalmic artery.
Facial vein is the main vein draining the face. It begins at the medial corner
of the eye by the confluence of supra-orbital and supratrochlear veins. The
facial vein passes across the face following the course of facial artery. Below
the mandible this vein joins to the retromandibular vein to form the common
facial vein which drains into internal jugular vein.
The lymph from major part of forehead, lateral halves of eyelids, lateral
part of the cheeks and parotid region is drained into pre auricular lymph
nodes. The central part of lower lip and the chin drain into submental lymph
nodes. The remaining region of face which include midportion of forehead,
external nose, upper lip, lateral part of lower lip, medial part of eyelids,
greater part of the lower jaw drain into the submandibular lymph nodes.
The trigeminal nerve is the sensory nerve of the face. The ophthalmic
division supplies the forehead, upper eyelid, and the nose. The upper lip, ala
of the nose, lower eyelid, upper part of the cheek are supplied by maxillary
division of trigeminal nerve. Mandibular division of trigeminal nerve
provides sensory supply to lower lip, chin, lower part of cheek, lower jaw
except for angle, lower margin, etc. Skin over the angle and lower margin of
the lower jaw and parotid region are supplied by cervical plexus.
The motor nerve supply of face is through the five branches of facial
nerve: Temporal, zygomatic, buccal, mandibular, and cervical.
Palate
The palate receives its arterial supplies from greater and lesser palatine
branches of maxillary artery.
The veins of hard palate drain into pterygoid plexus while those of soft
palate drain into pharyngeal plexus. The venous drainage of cheek is to
pterygoid venous plexus via buccal veins. The veins of the lips drain into
facial vein via superior and inferior labial veins.
Lymphatic channels from the major part of palate drain into jugulodigastric
group of nodes. Lymph vessels from posterior part of palate terminate in
retropharyngeal lymph nodes.
The nerve supply to most of the palate is from the maxillary division of
trigeminal nerve. Anterior part of the palate is supplied by the nasopalatine
nerve which emerges through the incisive foramen. The remaining part of the
hard palate is supplied by greater palatine nerve while lesser palatine nerve
supplies the soft palate. All muscles of soft palate except for tensor palati are
supplied by pharyngeal plexus. The tensor palati is supplied by mandibular
nerve.
Tongue
The arterial supply of the tongue is from lingual artery, a branch of the
external carotid artery.
The veins of dorsum and sides of the tongue form the lingual veins which
follow the course of lingual arteries to drain into internal jugular veins. The
deep lingual veins from ventral surface of the tongue join the facial, internal
jugular or lingual veins.
The lymphatic vessels from the tip of the tongue drain into the submental
nodes. The remaining part of anterior two-thirds of the tongue drain
unilaterally into submandibular lymph nodes. The posterior one-third drains
bilaterally into jugulo-omohyoid node.
The sensory innervations of tongue are from three different sources. The
anterior one-third of the tongue is supplied by lingual nerve although the taste
sensation is mediated by chorda tympani. The posterior one-third including
the circumvallate papillae are supplied by glossopharyngeal nerve which
carries taste and general sensations. The posterior most part of the tongue is
innervated by vagus nerve via internal laryngeal branch. Lingual nerve
supplies the mucosa on the ventral aspect of the tongue. The motor supply to
intrinsic and extrinsic muscles of the tongue is hypoglossal nerve except for
palatoglossus which is supplied by cranial part of accessory nerve through the
pharyngeal plexus.
Gingiva
The labial gingiva around the mandibular anterior teeth are supplied by
mental artery and perforating branches of incisive artery. The buccal artery
and perforating branches from inferior alveolar artery supplies the posterior
buccal gingiva. The lingual gingiva is supplied by the lingual artery and
perforating branches from the inferior alveolar artery. The arterial supply to
the buccal gingiva around maxillary posterior teeth is by gingival and
perforating branches from posterior superior alveolar artery and by buccal
artery. The labial gingiva of anterior teeth is supplied by labial branches of
infraorbital artery and by perforating branches of the anterior superior
alveolar artery. The palatal gingiva is primarily supplied by branches of
greater palatine artery.
The venous drainage of gingiva could be via buccal, lingual, greater
palatine and nasopalatine veins which drain into internal jugular vein or to
pterygoid plexus of veins.
The lymphatic drainage from labial and buccal gingivae of both maxillary
and mandibular teeth drain into submandibular lymph node though the
gingiva in the labial region of mandibular incisors drain to the submental
node. The palatal and lingual gingiva drain into jugulodigastric nodes directly
or indirectly through submandibular node.
In the mandibular arch the entire lingual gingiva is innervated by lingual
nerve. The labial and buccal gingiva in relation to the anterior teeth and
premolars are supplied by mental nerve while the gingiva of molar region
receives nerve supply from long buccal nerve. The labial gingiva in relation
to maxillary anterior teeth is innervated by anterior superior alveolar nerve
and infra-orbital nerve. The buccal gingiva of premolars gets the nerve
supply from middle superior alveolar nerve and infraorbital nerve. The
posterior superior alveolar nerve supplies the posterior buccal gingiva in
relation to molars. The major portion of palatal gingiva is innervated by
greater palatine nerve except for the anterior gingiva which is supplied by
nasopalatine nerve.
Chapter 6: Pulp
Essay Questions of 10 or more marks
Discuss in detail histological/microscopic structure of pulp. Add a note on
functions of pulp (Pages 67–71)
Discuss in detail structural components of pulp (Pages 68–70)
Short Answers for 4–5 marks
Pulp stones/pulp calcifications (Pages 72–73)
Age/regressive changes of pulp (Pages 71–73)
Histological zones of pulp (Pages 67–68)
Functions of pulp (Pages 71)
Odontoblasts (Pages 68–69)
Short Notes for 2–3 marks
Morphological characteristics of pulp (Pages 65–66)
Accessory canals (Pages 66–67)
Zone of Weil (Page 68)
Plexus of Rashkow (Page 68)
Undifferentiated mesenchymal cells of pulp (Page 69)
Chapter 7: Cementum
Essay Question of 10 or more marks
Classify cementum and discuss in detail structure of cementum (Pages 76–
81)
Short Answers for 4–5 marks
Physical properties and chemical composition of cementum (Pages 74–75)
Cementogenesis (Pages 75–76)
Structure of acellular cementum (Pages 77–78)
Structure of cellular cementum (Pages 78–79)
Cementoenamel junctions (Page 80)
Differences between acellular and cellular cementum (Page 80)
Hypercementosis (Page 82)
Functions of cementum (Pages 81–82)
Short Notes for 2–3 marks
Classification of cementum (Page 76–77)
Cementocytes (Page 78)
Acellular afibrillar cementum (Page 79)
Intermediate cementum (Page 79)
Cementodentinal junction (Page 81)
Mixed stratified cementum (Page 79)
Age changes of cementum (Page 322)