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Sturdevant’s
Art and Science of
Operative Dentistry
Sturdevant’s
Art and Science of
Operative Dentistry
Second South Asia Edition
André V. Ritter, DDS, MS, MBA

Thomas P. Hinman Distinguished Professor
Department of Operative Dentistry
The University of North Carolina at Chapel Hill School of Dentistry
Chapel Hill, North Carolina, United States of America
Lee W. Boushell, DMD, MS

Associate Professor
Ricardo Walter, DDS, MS

Clinical Associate Professor
Adaptation Editor
V. Gopikrishna, BDS, MDS, PhD
Founder Director
Root Canal Foundation
Chennai, India
Professor
Department of Conservative Dentistry and Endodontics
Saveetha University at Saveetha Dental College
Chennai, India
ELSEVIER
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Sturdevant’s Art and Science of Operative Dentistry, 7e, André V. Ritter, Lee W. Boushell, Ricardo Walter
Copyright © 2019 by Elsevier Inc.
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Sturdevant’s Art and Science of Operative Dentistry: Second South Asia Edition, V. Gopikrishna
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This book is dedicated to
My Parents
Sulochana… for being my beloved Amma (mother) and my Alpha (beginning of life)…
Ambuja… for being the Annapoorni (nurturer) of our lives…
M Velayutham… for teaching me integrity and humility in life…
VG Sivasubramanian… for showing me the path of caring and sharing…
My Teachers
Dr E Munirathnam Naidu… for showing me the attributes of discipline, hard work and perseverance…
Professors A Parameswaran and B Suresh Chandra… for instilling in me the drive to learn, teach and research…
Dr K Sridhar… for making me aware that water always finds its level…
Dr Vijailakshmi Acharya… for inspiring me to be passionate about perfection…
My Family
And above all to… Grace… for being the wind beneath my wings…
—V. Gopikrishna
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Foreword
Dr Clifford Sturdevant had a brass plaque on his desk that reads ‘If it’s almost right
it’s wrong!’ This commitment to excellence also was the mantra upon which his clas-
sic textbook, The Art and Science of Operative Dentistry, was first written and published
in 1968. This textbook has been the basis for training dental students in the fine art
and clinical science of operative dentistry for 50 years. In light of this significant land-
mark, which coincides with the publication of this new seventh edition, we believe
it is important to present the evolution of the various editions of the textbook from
a historical perspective.
The first edition (Sturdevant, Barton, Brauer, 1968) was meant ‘to present the sig-
nificant aspects of operative dentistry and the research findings in the basic and clini-
cal sciences that have immediate application’ in the field of operative dentistry. It is
important to note that Dean Brauer pointed out in his preface that beyond having
the knowledge and skills needed to perform a procedure, the practitioner must also
have high moral and ethical standards, essential and priceless ingredients. Since the
first edition, this textbook series has always attempted to present artistic and scientific
elements of operative dentistry in the context of ethical standards for patient care.
It is also worth noting that the first edition was printed and bound in ‘landscape’
format so that it could more easily be used as a manual in the preclinical laboratory
and would always remain open to the desired page. The handmade 5X models used
to illustrate the various steps in cavity preparation were created by two dental stu-
dents enrolled at Chapel Hill School of Dentistry, the University of North Carolina,
during the writing of the first edition. Illustrations of these models have continued to
be used in later editions, and the models themselves have served as important teach-
ing materials for decades.
Although the techniques, materials, armamentarium, and treatment options con-
tinue to evolve, many of the principles of operative dentistry described in the first
edition are still pertinent today. An understanding of these principles and the ability
to meticulously apply them are critical to provide the outstanding dental treatment
expected by our patients.
The second edition (Sturdevant, Barton, Sockwell, Strickland, 1985) expanded on
many techniques (e.g. acid etching) using experience and published research that
had occurred since publication of the first edition. The basics of occlusion were em-
phasized and presented in a way that would be helpful to the dental student and
practitioner. A chapter on treatment planning and sequencing of procedures, as well
as a chapter providing a thorough treatise on the use of pins, was included. Informa-
tion on silicate cement, self-curing acrylic resin and the baked porcelain inlay was
eliminated for obvious reasons. The chapters on endodontic therapy and the ‘dental
assistant’ were no longer included. Chapters on (1) tooth-coloured restorations and
(2) additional conservative and esthetic treatments explained the changes and im-
provements that occurred in the areas of esthetic options available to patients. In the
chapter on gold inlay/onlay restorations, increased emphasis was given to the gold
onlay restorations for Class II cavity preparations.
The third edition (Sturdevant, Roberson, Heymann, J. Sturdevant, 1995) placed
a new emphasis on cariology and the ‘medical model of disease’ with regard to risk
assessment and managing the high-risk caries patient. This important concept laid
vii
Foreword
the foundation for what is still taught today with regard to identifying risk factors
and defining a treatment plan based on caries risk assessment. The third edition also
included new expanded chapters on infection control, diagnosis and treatment plan-
ning and dental materials. In light of the growing interest in the area of esthetic den-
tistry, a variety of conservative esthetic treatments were introduced including vital
bleaching, micro- and macro-abrasion, etched porcelain veneers and the novel all-
porcelain bonded pontic. Additionally, an entirely new section on tooth-coloured
inlays and onlays was included that chronicled both lab-processed resin and ceramic
restorations of this type and those fabricated chairside with CAD/CAM systems.
With the fourth edition of this text (Roberson, Heymann, Swift, 2002), Dr Clifford
Sturdevant’s name was added to the book title to honour his contributions to the
textbook series and the discipline of operative dentistry. In this edition, a particular
emphasis was placed on bonded esthetic restorations. Consequently, an entirely new
chapter was included on fundamental concepts of enamel and dentin adhesion. This
chapter was intended to provide foundational information critical to the long-term
success of all types of bonded restorations.
The fifth edition (Roberson, Heymann, Swift, 2006) continued with the renewed
emphasis on the importance of adhesively bonded restorations and focused on sci-
entific considerations for attaining optimal success, particularly with posterior com-
posites. Concepts such as the ‘C Factor’ and keys to reducing polymerization effects
were emphasized along with factors involved in reducing micro-leakage and recur-
rent decay.
The sixth edition (Heymann, Swift, Ritter, 2013) represented a transition from a
large printed edition, as in the past, to a smaller, streamlined printed version that fo-
cused on concepts and techniques immediately essential for learning contemporary
operative dentistry. The same amount of information was included, but many chap-
ters such as those addressing biomaterials, infection control, pain control, bonded
splints and bridges, direct gold restorations and instruments and equipment were
available for the first time in a supplemental online format.
The seventh edition (Ritter, Boushell, Walter 2018) continues the legacy of main-
taining and enriching the fundamental concepts and principles of contemporary
operative dentistry. Diagnosis, classification and management of dental caries have
been significantly updated in light of the latest clinical and epidemiological research.
Similarly, content on adhesive dentistry and composite resins has been updated as a
result of the evolving science in these fields.
An entirely new chapter on light curing and its important role in the clinical suc-
cess of resin composite restorations has been added. Moreover, a new scientifically
based chapter details the important elements of colour and shade matching and sys-
tematically reviews how the dental clinician is better able to understand the many
covariables involved in colour assessment. It also reviews how best to improve shade
matching of esthetic restorations to tooth structure.
In an attempt to better optimize restorative treatment outcomes involving peri-
odontal challenges, a new chapter has been included that addresses these principles.
Periodontology applied to operative dentistry chronicles the various clinical consid-
erations involving conditions such as inadequate crown length, lack of root coverage
and other vexing problems requiring interdisciplinary treatment to optimize success.
Finally, this text addresses the ever-evolving area of digital dentistry with a new
chapter, Digital Dentistry in Operative Dentistry. This chapter reviews the various
technologies involved in scanning and image capture for both treatment planning
and restorative applications. Additionally, the authors review various types of digital
restorative systems for both chairside and modem-linked laboratory-based fabrica-
tion of restorations. In recognition of the rapid movement to digital dentistry, this
chapter is a vital addition to a textbook whose tradition has been always to reflect the
latest technologies and research findings in contemporary operative dentistry.
Since its inception 50 years ago, the Sturdevant text has been a dynamic docu-
ment, with content that has included innovative information on the latest materials
and techniques. Over this time period, numerous internationally recognized experts
viii
Foreword
have addressed many specific topics as authors and coauthors of various chapters. It
also should be pointed out that with all editions of the textbook, the authors of the
various chapters are themselves actively involved in teaching students preclinical and
clinical operative dentistry. Moreover, they are ‘wet-fingered dentists’ who also prac-
tice operative dentistry for their individual patients.
In summary, for 50 years Sturdevant’s Art and Science of Operative Dentistry has
been a major resource guiding educators in the teaching of contemporary operative
dentistry. Each edition of this text has striven to incorporate the latest technologies
and science based on the available literature and supporting research. This edition is
a superb addition to this tradition, which will most assuredly uphold the standard
of publication excellence that has been the hallmark of the Sturdevant textbooks for
half a century.
Harald O. Heymann, DDS, MEd
Kenneth N. May, Jr., DDS
ix
Contributors
Sumitha N. Ahmed, BDS, MS Dennis J. Fasbinder, DDS Thiago Morelli, DDS, MS

Clinical Assistant Professor Clinical Professor Clinical Assistant Professor
Department of Operative Dentistry Cariology, Restorative Sciences, and Department of Periodontology
Chapel Hill School of Dentistry Endodontics Chapel Hill School of Dentistry
The University of North Carolina School of Dentistry The University of North Carolina
Chapel Hill, NC, United States University of Michigan Chapel Hill, NC, United States
Chapter 19: Clinical Technique for Direct Ann Arbor, MI, United States Chapter 10: Periodontology Applied to
Composite Resin and Glass Ionomer Chapter 22: Digital Dentistry in Operative Operative Dentistry
Restorations Dentistry
Chapter 13: Clinical Technique for Amalgam Gisele F. Neiva, DDS, MS
Restorations Andréa G. Ferreira Zandoná, DDS, Clinical Associate Professor
MSD, PhD Cariology, Restorative Sciences, and
Lee W. Boushell, DMD, MS Associate Professor Endodontics
Associate Professor Department of Operative Dentistry School of Dentistry
Department of Operative Dentistry Chapel Hill School of Dentistry The University of Michigan
Chapel Hill School of Dentistry The University of North Carolina Ann Arbor, MI, United States
The University of North Carolina Chapel Hill, NC, United States Chapter 22: Digital Dentistry in Operative Dentistry
Chapel Hill, NC, United States Chapter 2: Dental Caries: Etiology, Clinical
Chapter 1: Clinical Significance of Dental Characteristics, Risk Assessment and Gustavo M.S. Oliveira, DDS, MS
Anatomy, Histology, Physiology and Occlusion Management Clinical Assistant Professor
Chapter 3: Patient Assessment, Examination, Department of Operative Dentistry
Diagnosis and Treatment Planning V. Gopikrishna, BDS, MDS, PhD Chapel Hill School of Dentistry
Chapter 7: Instruments and Equipment for Founder Director The University of North Carolina
Tooth Preparation Root Canal Foundation Chapel Hill, NC, United States
Chapter 8: Preliminary Considerations for Chennai, India Chapter 6: Dental Biomaterials
Operative Dentistry Professor Chapter 16: Introduction to Composite
Chapter 11: Fundamentals of Tooth Preparation Department of Conservative Dentistry & Restorations
and Pulp Protection Endodontics Chapter 12: Introduction to Amalgam
Chapter 13: Clinical Technique for Amalgam Saveetha University at Saveetha Dental College Restorations
Restorations Chennai, India
Chapter 14: Complex Amalgam Restorations Chapter 20: Non-Carious Lesions and Their Joe C. Ontiveros, DDS, MS
Chapter 19: Clinical Technique for Direct Management Professor and Head, Esthetic Dentistry
Composite Resin and Glass Ionomer Chapter 9: Dentin Hypersensitivity Restorative Dentistry and Prosthodontics
Restorations School of Dentistry
Chapter 26: Class III and V Amalgam Harald O. Heymann, DDS, MEd University of Texas
Restorations Professor Houston, TX, United States
Department of Operative Dentistry Chapter 17: Colour and Shade Matching in
Terrence E. Donovan, DDS Chapel Hill School of Dentistry Restorative Dentistry
Professor The University of North Carolina
Department of Operative Dentistry Chapel Hill, NC, United States Rade D. Paravina, DDS, MS, PhD
Chapel Hill School of Dentistry Professor
Chapter 21: Additional Conservative Aesthetic
The University of North Carolina Department of Restorative Dentistry and
Procedures
Chapel Hill, NC, United States Prosthodontics
Chapter 25: Resin Bonded Splints and Bridges
Chapter 6: Dental Biomaterials Director, Houston Center for Biomaterials and
Chapter 7: Instruments and Equipment for Patricia A. Miguez, DDS, MS, PhD Biomimetics
Tooth Preparation Assistant Professor (HCBB)
Chapter 16: Introduction to Composite Department of Operative Dentistry Ralph C. Cooley DDS Distinguished Professor in
Restorations Chapel Hill School of Dentistry Biomaterials
Chapter 12: Introduction to Amalgam The University of North Carolina School of Dentistry
Restorations Chapel Hill, NC, United States University of Texas
Chapter 27: Additional Information on Houston, TX, United States
Chapter 15: Fundamental Concepts of Enamel
Instruments and Equipment for Tooth Chapter 17: Colour and Shade Matching in
and Dentin Adhesion
Preparation Restorative Dentistry
Chapter 10: Periodontology Applied to
Operative Dentistry
xi
Contributors
Jorge Perdigão, DMD, MS, PhD John R. Sturdevant, DDS Contributors to Past Editions
Professor Associate Professor
Department of Restorative Sciences Department of Operative Dentistry Stephen C. Bayne, MS, PhD
Division of Operative Dentistry Chapel Hill School of Dentistry Professor and Chair
School of Dentistry The University of North Carolina Department of Cariology, Restorative Sciences,
University of Minnesota Chapel Hill, NC, United States and Endodontics
Minneapolis, MN, United States Chapter 1: Clinical Significance of Dental School of Dentistry
Chapter 15: Fundamental Concepts of Enamel Anatomy, Histology, Physiology and Occlusion University of Michigan
and Dentin Adhesion Chapter 23: Class II Cast Metal Restorations Ann Arbor, MI, United States
Chapter 6: Dental Biomaterials
Richard B. Price, BDS, DDS, MS, PhD, Taiseer A. Sulaiman, BDS (Hons), PhD Chapter 16: Introduction to Composite
FRCD(C), FDS, RCS (Edin) Assistant Professor Restorations
Professor and Head Division of Fixed Department of Operative Dentistry Chapter 20: Non-Carious Lesions and Their
Prosthodontics Chapel Hill School of Dentistry Management
Dental Clinical Services The University of North Carolina Chapter 12: Introduction to Amalgam
Dalhousie University Chapel Hill, NC, United States Restorations
Halifax, NS, Canada Chapter 6: Dental Biomaterials
Chapter 18: Light curing of restorative materials Chapter 16: Introduction to Composite James J. Crawford, MA, PhD
Restorations Professor Emeritus
André V. Ritter, DDS, MS, MBA Chapter 12: Introduction to Amalgam School of Dentistry and Medicine
Thomas P. Hinman Distinguished Professor Restorations The University of North Carolina
Department of Operative Dentistry Chapel Hill, NC, United States
Chapel Hill School of Dentistry Edward J. Swift, Jr, DMD, MS Chapter 4: Infection Control
The University of North Carolina Associate Dean for Education
Chapel Hill, NC, United States Professor R. Scott Eidson, DDS
Chapter 2: Dental Caries: Etiology, Clinical Department of Operative Dentistry Clinical Associate Professor
Characteristics, Risk Assessment and Chapel Hill School of Dentistry Department of Operative Dentistry
Management The University of North Carolina Chapel Hill School of Dentistry
Chapel Hill, NC, United States The University of North Carolina
Chapter 16: Introduction to Composite
Chapter 15: Fundamental Concepts of Enamel Chapel Hill, NC, United States
Restorations
Chapter 19: Clinical Technique for Direct and Dentin Adhesion Chapter 2: Dental Caries: Etiology, Clinical
Composite Resin and Glass Ionomer Characteristics, Risk Assessment and
Ricardo Walter, DDS, MS Management
Restorations
Clinical Associate Professor Chapter 3: Patient Assessment, Examination,
Chapter 21: Additional Conservative Aesthetic
Department of Operative Dentistry Diagnosis and Treatment Planning
Procedures
Chapel Hill School of Dentistry Chapter 7: Instruments and Equipment for
Chapter 20: Non-Carious Lesions and Their
The University of North Carolina Tooth Preparation
Management
Chapel Hill, NC, United States Chapter 27: Additional Information on
Chapter 25: Resin Bonded Splints and Bridges
Chapter 8: Preliminary Considerations for Instruments and Equipment for Tooth Preparation
Frederick A. Rueggeberg, DDS, MS Operative Dentistry
Professor and Section Director, Dental Materials Chapter 11: Fundamentals of Tooth Preparation Ralph H. Leonard, Jr, DDS, MPH
Restorative Sciences and Pulp Protection Director
Dental College of Georgia Chapter 15: Fundamental Concepts of Enamel Dental Faculty Practice
Augusta University and Dentin Adhesion Clinical Professor
Augusta, GA, United States Chapter 19: Clinical Technique for Direct Department of Diagnostic Sciences and General
Composite Resin and Glass Ionomer Dentistry
Chapter 18: Light Curing of Restorative
Restorations School of Dentistry
Materials
Chapter 20: Non-Carious Lesions and Their The University of North Carolina
Management Chapel Hill, NC, United States
Daniel A. Shugars, DDS, PhD, MPH
Research Professor Chapter 4: Infection Control
Department of Operative Dentistry Aldridge D. Wilder, Jr, BS, DDS
School of Dentistry Professor Jeffrey Y. Thompson, PhD
The University of North Carolina Department of Operative Dentistry Professor
Chapel Hill, NC, United States Chapel Hill School of Dentistry Section of Prosthodontics
The University of North Carolina Director
Chapter 3: Patient Assessment, Examination, Chapel Hill, NC, United States Biosciences Research Center
Diagnosis and Treatment Planning
Chapter 5: Pain Control for Operative Dentistry College of Dental Medicine
Chapter 8: Preliminary Considerations for Nova Southeastern University
Gregory E. Smith, DDS, MSD
Operative Dentistry Ft. Lauderdale, FL, United States
Professor Emeritus
Department of Restorative Sciences Chapter 13: Clinical Technique for Amalgam Chapter 16: Introduction to Composite
College of Dentistry Restorations Restorations
University of Florida Chapter 14: Complex Amalgam Restorations Chapter 20: Non-Carious Lesions and their
Gainesville, FL, United States Chapter 26: Class III and V Amalgam Management
Restorations Chapter 12: Introduction to Amalgam
Chapter 24: Direct Gold Restorations
Restorations
Chapter 6: Dental Biomaterials
xii
Preface
to the Second South Asia Edition
“If you would not be forgotten as soon as

you are dead…
Either write something worth reading

or do something worth writing…”
—Benjamin Franklin
The first edition of Sturdevant’s Art

and Science of Operative Dentistry was
published in 1968 and in these past
fifty years it has always been consid-
Dr Clifford Sturdevant
ered to be the Bible of Operative Den-
tistry as it is the most comprehensive
operative dentistry textbook. Drawing from both theory and practice and supported
by extensive clinical and laboratory research, it presents a clearly detailed, heavily il-
lustrated step-by-step approach to conservative, restorative and preventive dentistry.
The first South Asian Adaptation Edition of this iconic textbook was brought out
in 2013 and this current second edition of the same is an endeavour to carry on
the legacy.
Based upon the principle that dental caries is a disease, the book provides both a
thorough understanding of caries and an authoritative approach to its treatment and
prevention. Throughout the book, emphasis is placed on the importance of treating
the underlying causes of the patient problem(s), not just restoring the damage that
has occurred. It is organized in a sequential format; the early chapters present the
necessary general information while the later chapters are specifically related to the
practice of operative dentistry, including conservative esthetic procedures.
This Second South Asia edition of Sturdevant’s Art and Science of Operative Dentistry
has been significantly revised in order to streamline the text and improve readability.
The order and content of chapters have been reorganized keeping in mind the needs
of both undergraduate and postgraduate students.
Five new chapters, namely ‘Periodontology Applied to Operative Dentistry’, ‘Colour
and Shade Matching in Operative Dentistry’, ‘Light Curing in Operative Dentistry’,
‘Digital Dentistry in Operative Dentistry’ and ‘Resin-Bonded Splints and Bridges‘ have
been included in this edition. In addition, the book is now in full colour. The line art
for the book has been completely redrawn in full colour to better show techniques
and details, and new, full colour photos have been added where appropriate, and
highlighted important concepts and clinical tips for the benefit of the student and
clinician. To publish this edition on the year we commemorate the 50th anniversary
of the publication of the First Edition is a milestone for Operative Dentistry. I am
honored to have had the opportunity to work on and present the Second South Asia
Edition.
V. Gopikrishna
xiii
Acknowledgements
It has been an absolute honour and privilege to have worked on this Second South
Asia Edition of Sturdevant’s Art and Science of Operative Dentistry. I would like to ex-
press my sense of gratitude for the faith and confidence reposed on me by Professor
Andre’ V. Ritter, Dr Lee W. Boushell and Dr Ricardo Walter in adapting this classic
textbook to the needs of the South Asian operative dentistry students and clinicians.
I would also like to acknowledge the following coworkers for reviewing the first
South Asia edition of this textbook and giving critical inputs and reviews that helped
me in the genesis of this edition:
REVIEWERS
Dr A.R. Pradeep Kumar, MDS Dr Usha Sathyanarayanan, MDS, PGDHPE
Professor, Thai Moogambigai Dental Adjunct Professor, Saveetha Dental
College, Chennai, Tamil Nadu, India College, Chennai, Tamil Nadu, India
Dr Naganath Meena, MDS Dr S. Balagopal, MDS

Professor, VS Dental College, Professor, Tagore Dental College, Chennai,
Bangalore, Karnataka, India Tamil Nadu, India
Dr B. Sajeev, MDS Dr Vivek Aggarwal, MDS

Professor, Mar Baselios Dental Assistant Professor, Jamia Milia
College, Kochi, Kerala, India Islamia University, New Delhi, India
Dr Mahima Tilakchand, MDS Dr Ruchika Roongta Nawal, MDS

Professor, SDM Dental College, Assistant Professor, Maulana Azad Dental
Dharwad, Karnataka, India College, New Delhi, India
I would also like to thank the entire publishing team at Elsevier including Mr
Anand K Jha, Content Project Manager and Ms Nimisha Goswami, Manager, Content
Strategy, for all their efforts.
I thank my entire team at Root Canal Foundation (www.rootcanalfoundation.com)
for their unwavering support. I thank my family for giving me the moral support and
critical time needed to complete this edition.
V. Gopikrishna
xv
Brief Contents
Foreword vii 14. Complex Amalgam Restorations....................................375

��
Contributors xi 15. Fundamental Concepts of Enamel and Dentin
��
Preface to the Second South Asia Edition xiii Adhesion............................................................................401
��
Acknowledgements xv
16. Introduction to Composite Resins.................................435
��
17 Colour and Shade Matching in Restorative
1. Clinical Significance of Dental Anatomy,
Dentistry.............................................................................445
Histology, Physiology and Occlusion................................ 1
18. Light Curing of Restorative Materials.............................465
2. Dental Caries: Etiology, Clinical Characteristics,
Risk Assessment and Management...................................25 19. Clinical Technique for Direct Composite Resin
and Glass Ionomer Restorations.....................................495
3. Patient Assessment, Examination, Diagnosis,
and Treatment Planning....................................................83 20. Non-carious Lesions and Their Management...............547
4. Infection Control...............................................................111 21. Additional Conservative Esthetic Procedures................559
5. Pain Control for Operative Dentistry.............................125 22. Digital Dentistry in Operative Dentistry.........................611
6. Dental Biomaterials.......................................................... 131 23. Class II Cast Metal Restorations......................................633
7. Instruments and Equipment for Tooth 24. Direct Gold Restorations.................................................. 671
Preparation.........................................................................179 25. Resin-bonded Splints and Bridges..................................679
8. Preliminary Considerations for Operative
Dentistry.............................................................................207
Index...................................................................................... 695
9. Dentin Hypersensitivity...................................................239
10. Periodontology Applied to Operative Dentistry...........245
Supplemental Online Chapters
11. Fundamentals of Tooth Preparation and Pulp
26. Class III and V Amalgam Restorations ............................ e1
Protection...........................................................................263
27. Additional Information on Instruments
12. Introduction to Silver Amalgam.....................................285
and Equipment for Tooth Preparation ..........................e21
13. Clinical Technique for Amalgam Restorations............. 301
xvii
Chapter |1|
Clinical Significance of Dental Anatomy, Histology,

Physiology and Occlusion
“Success in life is founded upon attention to the smallest of things… rather than to the largest of things…”
—Booker T. Washington
A thorough understanding of the histology, physiology consists of animal and plant foods, the human dentition
and occlusal interactions of the dentition and supporting is called omnivorous.
tissues is essential for the restorative dentist. Knowledge
of the structures of teeth (enamel, dentin, cementum and Incisors
pulp) and their relationships to each other and to the sup-
The incisors are located near the entrance of the oral c avity
porting structures is necessary, especially when treating
and function as cutting or shearing instruments for food
dental caries. Proper tooth form contributes to healthy
(Fig. 1.1). From a proximal view, the crowns of these teeth
supporting tissues. The relationships of form to function
have a relatively triangular shape, with a narrow incisal
are especially noteworthy when considering the shape of
surface and a broad cervical base. During mastication,
the dental arch, proximal contacts, occlusal contacts and
incisors are used to shear (cut through) food.
mandibular movement.
Clinical Notes
Teeth and Supporting Tissues Incisors are essential for the proper esthetics of the
smile, facial soft tissue contours (e.g. lip support) and
speech (phonetics).
Dentitions
Humans have primary and permanent dentitions. The pri- Canines
mary dentition consists of 10 maxillary and 10 mandibu-
lar teeth. Primary teeth exfoliate and are replaced by the Canines possess the longest roots of all teeth and are lo-
permanent dentition, which consists of 16 maxillary and cated at the corners of the dental arch. They function in
16 mandibular teeth. the seizing, piercing, tearing and cutting of food. From a
proximal view, the crown also has a triangular shape, with
a thick incisal ridge. The anatomic form of the crown and
Classes of Human Teeth: the length of the root make these teeth strong, stable abut-
ment teeth for a fixed or removable prosthesis.
Form and Function
Human teeth are divided into classes on the basis of Clinical Notes
form and function. The primary and permanent denti- Canines not only serve as important guides in occlu-
tions include the incisor, canine and molar classes. The sion because of their anchorage and position in the
fourth class, the premolar, is found only in the permanent dental arches but also play a crucial role (along with
dentition (Fig. 1.1). Tooth form predicts the function of the incisors) in the esthetics of smile and lip support
teeth; class traits are the characteristics that place teeth (Fig. 1.1).
into functional categories. Because the diet of humans
1
Sturdevant's Art and Science of Operative Dentistry
Figure 1.1 Maxillary and mandibular teeth in maximum inter-cus-

pal position. The classes of teeth are incisors, canines, premolars
and molars. Cusps of mandibular teeth are one-half cusp anterior
of corresponding cusps of teeth in the maxillary arch.
(From Logan BM, Reynolds P, Hutchings RT: McMinn’s color atlas of head
and neck anatomy, ed 4, Edinburgh, 2010, Mosby.)
Premolars Figure 1.2 Cross-section of the maxillary molar and its support-
ing structures. 1, Enamel; 1a, gnarled enamel; 2, dentin; 3a, pulp
Premolars serve a dual role: chamber; 3b, pulp horn; 3c, pulp canal; 4, apical foramen; 5, ce-
I. They are similar to canines in the tearing of food. mentum; 6, periodontal fibres in periodontal ligament; 7, alveolar
bone; 8, maxillary sinus; 9, mucosa; 10, submucosa; 11, blood ves-
II.They are similar to molars in the grinding of food.
sels; 12, gingival and 13, striae of Retzius.
The occlusal surfaces of the premolars present a series
of curves in the form of concavities and convexities that
should be maintained throughout life for correct occlusal
contacts and function. Structures of Teeth
Teeth are composed of enamel, the pulp–dentin complex
Clinical Notes and cementum (Fig. 1.2). Each of these structures is dis-
cussed individually.
Although less visible than incisors and canines, pre-
molars still can play an important role in esthetics.
Enamel
Enamel formation, amelogenesis, is accomplished by cells
called ameloblasts. These cells originate from the embry-
Molars onic germ layer known as ectoderm. Enamel covers the
Molars are large, multi-cusped, strongly anchored teeth anatomic crown of the tooth and varies in thickness in
located nearest to the temporomandibular joint (TMJ), different areas (Fig. 1.2). It is thicker at the incisal and
which serves as the fulcrum during function. These teeth occlusal areas of a tooth and becomes progressively thin-
have a major role in the crushing, grinding and chew- ner until it terminates at the cementoenamel junction
ing of food to the smallest dimensions suitable for swal- (CEJ). The thickness also varies from one class of tooth
lowing. They are well suited for this task because they to another:
have broad occlusal surfaces and multi-rooted anchorage • Averaging 2 mm at the incisal ridges of incisors.
(Fig. 1.2). • 2.3–2.5 mm at the cusps of premolars.
• 2.5–3 mm at the cusps of molars.
The cusps of posterior teeth begin as separate ossifica-
Clinical Notes
tion centres, which form lobes that coalesce. Enamel usu-
Premolars and molars are important in maintaining the ally decreases in thickness towards the junction of these
vertical dimension of the face (Fig. 1.1). developmental features and can approach zero where the
junction is fissured (non-coalesced).
2
Clinical Significance of Dental Anatomy, Histology, Physiology and Occlusion Chapter |1|
Chemical composition
Enamel is a highly mineralized crystalline structure.
• Hydroxyapatite, in the form of a crystalline lattice, is the
largest mineral constituent (90%–92% by volume).
• Organic matrix proteins (1%–2% by volume).
• Water (4%–12% by volume).
Structure of enamel
Enamel is composed of millions of enamel rods or prisms,
which are the largest structural components, rod sheaths
and a cementing inter-rod substance in some areas.
Human enamel is composed of rods that, in transverse
section, have a rounded head or body section and a tail sec-
tion, forming a repetitive series of interlocking prisms. The
rounded head portion of each prism (5 µm wide) lies be-
tween the narrow tail portions (5 µm long) of two adjacent
prisms (Fig. 1.3). Generally, the rounded head portion is
oriented in the incisal or occlusal direction; the tail section
is oriented cervically.
The rods vary in number from approximately 5 million
for a mandibular incisor to about 12 million for a maxil-
lary molar. The rods are densely packed and intertwined in
a wavy course, and each extends from the dentinoenamel
junction (DEJ) to the external surface of the tooth. Enamel
rod diameter near the dentinal borders is about 4 µm and
about 8 µm near the surface. This difference accommo-
dates the larger outer surface of the enamel crown com-
pared with the dentinal surface at the DEJ.
Clinical Notes Figure 1.3 Electron micrograph of cross-section of rods in mature

human enamel. Crystal orientation is different in ‘bodies’ (B) than
• Enamel is the hardest substance of the human body. in ‘tails’ (T). Approximate level of magnification 5000×.
• Enamel rods that lack dentin support because of car- (From Meckel AH, Griebstein WJ, Neal RJ: Structure of mature human
ies or improper preparation design are easily frac- dental enamel as observed by electron microscopy, Arch Oral Biol
tured away from neighbouring rods. For optimal 10(5):775–783, 1965.)
strength in tooth preparation, all enamel rods should
be supported by dentin (Fig. 1.4).
Apatite crystallites
The structural components of the enamel prism are mil-
lions of small, elongated apatite crystallites that vary in size
and shape. The crystallites are tightly packed in a distinct
pattern of orientation that gives strength and structural
identity to the enamel prisms. The crystallites are irregular
in shape, with an average length of 160 nm and an average
width of 20–40 nm. Each apatite crystallite is composed of Figure 1.4 (A) Enamel rods unsupported by dentin are fractured
thousands of unit cells that have a highly ordered arrange- away readily by pressure from hand instrument. (B) Cervical prepa-
ment of atoms. A crystallite may be 300 unit cells long, 40 ration showing enamel rods supported by dentin.
cells wide and 20 cells thick in a hexagonal configuration.
An organic matrix or prism sheath also surrounds individ- as they change direction in progressing from the dentin
ual crystals and appears to be an organically rich interspace to the enamel surface, where they end a few micrometres
rather than a structural entity. short of the tooth surface. They initially follow a curving
path through one-third of the enamel next to the DEJ. Af-
Gnarled enamel ter that, the rods usually follow a more direct path through
Enamel rods follow a wavy, spiralling course, producing the remaining two-thirds of the enamel to the enamel sur-
an alternating arrangement for each group or layer of rods face. Groups of enamel rods may entwine with adjacent
3
Figure 1.5 Gnarled enamel.

(From Berkovitz BKB, Holland GR, Moxham BJ: Oral anatomy, histology
and embryology, ed 4, Edinburgh, 2009, Mosby.)
groups of rods, and they follow a curving irregular path

towards the tooth surface. These constitute gnarled enamel,
Figure 1.6 Photomicrograph of enamel photographed by reflect-
which occurs near the cervical regions and the incisal and
ed light of Hunter–Schreger bands.
occlusal areas (Fig. 1.5). Gnarled enamel is not subject to (From Avery JK, Chiego DJ: Essentials of oral histology and embryology: a
fracture as much as a regular enamel. This type of enamel clinical approach, ed 3, St Louis, MO, 2006, Mosby.)
formation does not yield readily to the pressure of bladed,
hand-cutting instruments in tooth preparation.
Clinical Notes
The orientation of the enamel rod heads and tails and
the gnarling of enamel rods provide strength by resist-
ing, distributing and dissipating impact forces.
Hunter–Schreger bands
The changes in the direction of enamel prisms that mini-
mize fracture in the axial direction produce an optical ap-
pearance called Hunter–Schreger bands (Fig. 1.6). These Figure 1.7 Microscopic view through lamella that goes from
bands appear to be composed of alternate light and dark enamel surface into dentin. Note the enamel tufts (arrow).
zones of varying widths that have slightly different perme- (From Bath Balogh M, Fehrenbach MJ: Illustrated dental embryology, his-
ability and organic content. These bands are found in dif- tology, and anatomy, ed 3, St Louis, MO, 2011, Saunders. Courtesy: James
McIntosh, PhD, Assistant Professor Emeritus, Department of Biomedical
ferent areas of each class of teeth. Because the enamel rod
Sciences, Baylor College of Dentistry, Dallas, TX.)
orientation varies in each tooth, Hunter–Schreger bands
also have a variation in the number present in each tooth.
In anterior teeth, they are located near the incisal surfaces. Enamel lamellae
In molars, the bands occur from near the cervical region to Enamel lamellae are thin, leaf-like faults between enamel
the cusp tips. rod groups that extend from the enamel surface to the DEJ,
sometimes extending into dentin (Fig. 1.7). They contain
Enamel tufts mostly organic material, which is a weak area predisposing
Enamel tufts are hypomineralized structures of the enamel a tooth to the entry of bacteria and dental caries.
rods and the inter-rod substance that project between adja-
cent groups of enamel rods from the DEJ (Fig. 1.7). These Striae of Retzius
projections arise in dentin, extend into enamel in the di- Enamel rods are formed linearly by successive apposition
rection of the long axis of the crown and may play a role in of enamel in discrete increments. The resulting variations
the spread of dental caries. in structure and mineralization are called incremental
4
striae of Retzius and can be considered growth rings

(Fig. 1.2). In horizontal sections of a tooth, the striae of
Retzius appear as concentric circles. In vertical sections,
the lines traverse the cuspal and incisal areas in a sym-
metric arc pattern, descending obliquely to the cervical
region and terminating at the DEJ. When these circles are
incomplete at the enamel surface, a series of alternating
grooves, called imbrication lines of Pickerill, are formed. The
elevations between the grooves are called perikymata; these
are continuous around a tooth and usually lie parallel to
the CEJ and each other.
Nasmyth’s membrane or primary enamel cuticle
Once damaged, enamel is incapable of repairing itself be-
cause the ameloblast cell degenerates after the formation of Figure 1.8 Microscopic view of scalloped dentoenamel junction
(DEJ) (arrow). E, Enamel; D, dentin.
the enamel rod. The final act of the ameloblast is secretion
(From Bath Balogh M, Fehrenbach MJ: Illustrated dental embryology,
of a membrane covering the end of the enamel rod. This histology, and anatomy, ed 3, St. Louis, MO, 2011, Saunders. Courtesy:
layer is referred to as Nasmyth’s membrane or primary enamel James McIntosh, PhD, Assistant Professor Emeritus, Department of Bio-
cuticle. This membrane covers the newly erupted tooth and medical Sciences, Baylor College of Dentistry, Dallas, TX.)
is worn away by mastication and cleaning. This membrane
is replaced by an organic deposit called the pellicle, which depends on a stable attachment to the dentin by means
is a precipitate of salivary proteins. Microorganisms may of the DEJ. Dentin is a more flexible substance that is
attach to the pellicle to form bacterial plaque, which, if strong and resilient (low elastic modulus, high compres-
acidogenic in nature, can be a potential precursor to dental sive strength and high tensile strength), which essentially
disease. increases the fracture toughness of the more superficial
enamel.
Prismless enamel
The DEJ is approximately 2 µm wide and comprises a
A structureless outer layer of enamel about 30 µm thick is mineralized complex of interwoven dentin and enamel
found most commonly towards the cervical area and less matrix proteins. In addition to the physical, scalloped re-
often on cusp tips. No prism outlines are visible, and all lationship between the enamel and dentin, an interphase
of the apatite crystals are parallel to one another and matrix layer (made primarily of a fibrillary collagen net-
perpendicular to the striae of Retzius. This layer, referred work) extends 100–400 µm from the DEJ to the enamel.
to as prismless enamel, may be more heavily mineralized. This matrix-modified interphase layer is considered to
Microscopically, the enamel surface initially has circular provide fracture propagation limiting properties to the in-
depressions indicating where the enamel rods end. These terface between the enamel and the DEJ and thus overall
concavities vary in depth and shape, and they may con- structural stability of the enamel attachment to dentin.
tribute to the adherence of plaque material, with a re-
sultant caries attack, especially in young individuals. The Pit and fissure
dimpled surface anatomy of the enamel, however, gradu- The occlusal surfaces of premolars and molars have grooves
ally wears smooth with age. and fossae that form at the junction of the developmental
lobes of enamel. Failure of the enamel of the developmen-
Dentinoenamel junction tal lobes to coalesce results in a deep invagination of the
The interface of enamel and dentin is known as dentinoe- enamel surface and is termed fissure. Non-coalesced enam-
namel junction or DEJ. It is scalloped or wavy in outline, el at the deepest point of a fossa is termed as pit. These pit
with the crest of the waves penetrating towards enamel and fissures act as food and bacterial traps that predispose
(Fig. 1.8). The rounded projections of enamel fit into the the tooth to dental caries (Fig. 1.9).
shallow depressions of dentin. This interdigitation may
contribute to the firm attachment between dentin and Enamel maturation
enamel. Although enamel is a hard, dense structure, it is perme-
Enamel is the hardest substance of the human body. able to certain ions and molecules. The route of passage
Hardness may vary over the external tooth surface ac- may be through structural units that are hypomineralized
cording to the location; also, it decreases inward, with and rich in organic content, such as rod sheaths, enamel
hardness lowest at the DEJ. The density of enamel also cracks and other defects. Water plays an important role
decreases from the surface to the DEJ. Enamel is a rigid as a transporting medium through small inter-crystalline
structure that is both strong and brittle (high elastic mod- spaces. Enamel permeability decreases with age because
ulus, high compressive strength and low tensile strength). of changes in the enamel matrix, a decrease referred to as
The ability of the enamel to withstand masticatory forces enamel maturation.
5
Pulp–Dentin Complex
Dentin and pulp tissues are specialized connective tissues
of mesodermal origin, formed from the dental papilla of the
tooth bud. Many investigators consider these two tissues as
a single tissue, which form the pulp–dentin complex, with
mineralized dentin constituting the mature end product of
cell differentiation and maturation.
Pulp
The pulp is circumscribed by the dentin and is lined pe-
ripherally by a cellular layer of odontoblasts adjacent
Figure 1.9 Fissure (f) at junction of lobes allows accumulation to dentin. Anatomically, the pulp is divided into the
of food and bacteria predisposing the tooth to dental caries (c); following:
enamel (e); dentin (d); enamel caries lesion (ec); dentin caries le-
I. Coronal pulp located in the pulp chamber in the crown
sion (dc); transparent dentin (td); early enamel demineralization
(arrow). portion of the tooth, including the pulp horns that are
directed towards the incisal ridges and cusp tips.
II. Radicular pulp located in the pulp canals in the root
portion of the tooth. The radicular pulp is continuous
Clinical Notes with the periapical tissues by connecting through the
Effect of fluoride on enamel: Enamel is soluble when apical foramen or foramina of the root. Accessory ca-
exposed to acidic conditions, but the dissolution is not nals may extend from the pulp canals laterally through
uniform. Solubility of enamel increases from the enam- the root dentin to the periodontal tissues. The shape
el surface to the DEJ. When fluoride ions are present of each pulp conforms generally to the shape of each
during enamel formation or are topically applied to tooth (Fig. 1.2).
the enamel surface, the solubility of surface enamel is
The pulp contains nerves, arterioles, venules, capillaries,
decreased. Fluoride can affect the chemical and physi-
cal properties of the apatite mineral and influence the
lymph channels, connective tissue cells, intercellular sub-
hardness, chemical reactivity and stability of enamel stance, odontoblasts, fibroblasts, macrophages, collagen
while preserving the apatite structures. Trace amounts and fine fibres. The pulp is circumscribed peripherally by
of fluoride stabilize enamel by a specialized odontogenic area composed of the odonto-
• lowering acid solubility; blasts, the cell-free zone and the cell-rich zone.
• decreasing the rate of demineralization and
• enhancing the rate of remineralization. Functions of pulp
The dental pulp occupies the pulp cavity in the tooth and
is a unique, specialized organ of the human body that
Translucency of enamel serves four functions:
Because enamel is semitranslucent, the colour of a tooth I. Formative or developmental. The formative function is
depends on the production of primary and secondary dentin by od-
• colour of the underlying dentin; ontoblasts.
• thickness of the enamel and II. Nutritive. The nutritive function supplies nutrients and
• amount of stain in the enamel. moisture to dentin through the blood vascular supply
to the odontoblasts and their processes.
The amount of translucency of enamel is related to vari-
III. Sensory or protective. The sensory function provides
ations in the degree of calcification and homogeneity. Ab-
nerve fibres within the pulp to mediate the sensation
normal conditions of enamel usually result in aberrant
of pain. Dentin receptors are unique because various
colour. Enamel becomes temporarily whiter within min-
stimuli elicit only pain as a response. The pulp usually
utes when a tooth is isolated from the moist oral environ-
does not differentiate between heat, touch, pressure
ment by a rubber dam or cotton rolls. This change in col-
and chemicals. Motor fibres initiate reflexes in the mus-
our is explained by the temporary loss of loosely bound
cles of the blood vessel walls for the control of circula-
(or exchangeable) water (<1% by weight).
tion in the pulp.
IV. Defensive or reparative. The defensive function of the
Clinical Notes
pulp is related primarily to its response to irritation by
The shade of a tooth must be determined before iso- mechanical, thermal, chemical or bacterial stimuli. The
lation and preparation of a tooth for a tooth-coloured deposition of reparative dentin acts as a protective bar-
restoration. rier against caries and various other irritating factors.
In cases of severe irritation, the pulp responds by an
6
Figure 1.10 Pulp cavity size. (A) Premolar radiograph of young person. (B) Premolar radiograph of older person. Note the difference in
the size of the pulp cavity (arrows).
inflammatory reaction similar to that for any other soft

tissue injury. The inflammation may become irreversi-
ble, however, and can result in the death of the pulp be-
cause the confined, rigid structure of the dentin limits
the inflammatory response and the ability of the pulp
to recover.
Clinical Notes
Knowledge of the contour and size of the pulp cavity is
essential during tooth preparation. In general, the pulp
cavity is a miniature contour of the external surface of
the tooth. Pulp cavity size varies with tooth size among
individuals and even within a single person. With ad-
vancing age, the pulp cavity usually decreases in size.
Radiographs are an invaluable aid in determining the
size of the pulp cavity and any existing pathologic con-
dition (Fig. 1.10). A primary objective during operative
procedures must be the preservation of the health of
the pulp.
Figure 1.11 Pattern of formation of primary dentin. This figure
also shows enamel (e) covering the anatomic crown of the tooth
and cementum (c) covering the anatomic root.
Dentin
Dentin forms the largest portion of the tooth structure,
extending almost the full length of the tooth. Externally,
dentin is covered by enamel on the anatomic crown and
cementum on the anatomic root. Internally, dentin forms
the walls of the pulp cavity (pulp chamber and pulp ca-
nals) (Fig. 1.11).
Dentinogenesis
Dentin formation or dentinogenesis is accomplished by
cells called odontoblasts. Odontoblasts are considered as a
part of pulp and dentin tissues because their cell bodies are
in the pulp cavity, but their long, slender cytoplasmic cell
processes (Tomes’ fibres) extend well (100–200 µm) into
the tubules in the mineralized dentin (Fig. 1.12). Because
of these odontoblastic cell processes, dentin is considered
a living tissue, with the capability of reacting to physiologic
and pathologic stimuli. Dentin formation begins at areas
subjacent to the cusp tip or incisal ridge and gradually
spreads to the apex of the root (Fig. 1.11). In contrast to Figure 1.12 Odontoblasts (o) have cell processes (Tomes’ fibres
enamel formation, dentin formation continues after tooth [tf]) that extend through the predentin (pd) into dentin (d). mf,
eruption and throughout the life of the pulp. Mineralization front.
7
Predentin
Dentin formation begins immediately before enamel for-
mation. The most recently formed layer of dentin is always
on the pulpal surface. This unmineralized zone of dentin
is immediately next to the cell bodies of odontoblasts and
is called predentin.
Enamel spindles
Odontoblastic processes occasionally cross the DEJ into
enamel; these are termed enamel spindles when their ends
are thickened (Fig. 1.13). They may serve as pain receptors,
explaining the enamel sensitivity experienced by some pa-
tients during tooth preparation.
Dentinal tubules
The dentinal tubules are small canals that extend through
the entire width of dentin, from the pulp to the DEJ
(Fig. 1.14). Each tubule contains the cytoplasmic cell pro- Figure 1.13 Longitudinal section of enamel. Odontoblastic
cess (Tomes’ fibre) of an odontoblast and is lined with a processes extend into enamel as enamel spindles (A).
layer of peritubular dentin, which is much more mineralized (From Berkovitz BKB, Holland GR, Moxham BJ: Oral anatomy, histology
than the surrounding intertubular dentin (Fig. 1.14). and embryology, ed 4, Edinburgh, 2009, Mosby. Courtesy: Dr. R Sprinz.)
The course of the dentinal tubules is a slight ‘S’-curve in
the tooth crown, but the tubules are straighter in the in-
cisal ridges, cusps and root areas (Fig. 1.15). Near the DEJ,
the tubules divide into several terminal branches, form-
ing an intercommunicating and anastomosing network
(Fig. 1.16).
Clinical Notes
• The surface area of dentin is much larger at the DEJ
or dentinocemental junction than it is on the pulp
cavity side. Because odontoblasts form dentin while
progressing inward towards the pulp, the tubules
are forced closer together. The number of tubules
increase from 15,000 to 20,000/mm2 at the DEJ to
45,000 to 65,000/mm2 at the pulp.1
• The lumen of the tubules also varies from the DEJ
to the pulp surface. In coronal dentin, the average
diameter of tubules at the DEJ is 0.5–0.9 µm, but this
increases to 2–3 µm near the pulp (Fig. 1.17).
Figure 1.14 Dentinal tubules in cross-section, 1.2 mm from

Secondary dentin pulp. Peritubular dentin (P) is more mineralized than intertubular
After the primary dentin is formed, dentin deposition dentin (I).
continues at a reduced rate even without obvious external (From Brännström M: Dentin and pulp in restorative dentistry, London,
1982, Wolfe Medical.)
stimuli, although the rate and amount of this physiologic
secondary dentin vary considerably among individuals.
In the secondary dentin, the tubules take a slightly dif- and dentin repair/formation. Deep dentin formation
ferent directional pattern in contrast to primary dentin processes occur simultaneously with the pulpal inflam-
(Fig. 1.18). Secondary dentin forms on all internal aspects matory response and result in the generation of tertiary
of the pulp cavity, but in the pulp chamber, in multi-root- dentin at the pulp–dentin interface. The net effect of
ed teeth, it tends to be thicker on the roof and floor than these processes is to increase the thickness/effectiveness
on the side walls.2 of the dentin as a protective barrier for the pulp tissue.
Two types of tertiary dentin form in response to lesion
Tertiary dentin formation.
The pulp–dentin complex responds to tooth pathology I. Reactionary tertiary dentin. In the case of mild injury
through pulpal immune-inflammation defence systems (e.g. a shallow caries lesion), primary odontoblasts
8
Figure 1.16 Ground section showing dentinal tubules and their

lateral branching close to the dentinoenamel junction (DEJ).
(From Berkovitz BKB, Holland GR, and Moxham BJ: Oral anatomy, histol-
ogy, and embryology, ed 4, Edinburgh, 2010, Mosby.)
Figure 1.17 Tubules in superficial dentin close to the dentinoe-

namel junction (DEJ) (A) are smaller and more sparsely distributed
compared with deep dentin (B). The tubules in superficial root
dentin (C) and deep root dentin (D) are smaller and less numerous
than those in comparable depths of coronal dentin.
Figure 1.15 Ground section of human incisor. Course of dentinal

tubules is in a slight S-curve in the crown, but straight at the incisal
tip and in the root.
(From Young B, Lowe JS, Stevens A, Heath JW: Wheater’s function-
al histology: a text and colour atlas, ed 5, Edinburgh, 2006, Churchill
Livingstone.)
initiate increased formation of dentin along the in-

ternal aspect of the dentin beneath the affected area
through secretion of reactionary tertiary dentin (or re-
actionary dentin). Reactionary dentin is tubular in Figure 1.18 Ground section of dentin with pulpal surface at
right. Dentinal tubules curve sharply (arrows) as they move from
nature and is continuous with primary and secondary primary to secondary dentin. Dentinal tubules are more irregular
dentin. in shape in secondary dentin.
II. Reparative tertiary dentin. More severe injury (e.g. a (From Nanci A: Ten Cate’s oral histology: development, structure, and
deep caries lesion) causes the death of the primary function, ed 7, St Louis, MO, 2008, Mosby.)
9
Dentinal crystallites are smaller than enamel crystal-

lites, having a length of 20–100 nm and a width of about
3 nm, which is similar to the size seen in bone and cemen-
tum.2
Physical properties
I. The hardness of dentin averages one-fifth that of
enamel, and its hardness near the DEJ is about 3 times
greater than near the pulp.
II. Dentin becomes harder with age, primarily as a result
of increase in mineral content.
III. Dentin is a hard, mineralized tissue; it is flexible, with
a modulus of elasticity of approximately 18 GPa.3 This
flexibility helps in supporting the more brittle, non-
Figure 1.19 Reparative dentin in response to a carious lesion.
(From Trowbridge HO: Pulp biology: progress during the past 25 years,
resilient enamel.
Aust Endo J 29(1):5–12, 2003.) IV. The ultimate tensile strength of dentin is approximately
98 MPa, whereas the ultimate tensile strength of enam-
el is approximately 10 MPa.
V. The compressive strength of dentin and enamel are ap-
odontoblasts. When therapeutic steps successfully re- proximately 297 and 384 MPa, respectively.3
solve the injury, replacement cells (variously referred
to as secondary odontoblasts, odontoblast-like cells or od- Dentin versus enamel
ontoblastoid cells) differentiate from pulpal mesenchy- During tooth preparation, dentin usually is distinguished
mal cells. The secondary odontoblasts subsequently from enamel by
generate reparative tertiary dentin (or reparative den- I. Colour and opacity. Dentin is normally yellow-
tin) as a part of the ongoing host defence. Reparative white and slightly darker than enamel. In older pa-
dentin usually appears as a localized dentin deposit tients, dentin is darker, and it can become brown
on the wall of the pulp cavity immediately subjacent or black when it has been exposed to oral fluids,
to the area on the tooth that had received the injury old restorative materials or slowly advancing
(Fig. 1.19). caries.
II. Reflectance. Dentin surfaces are more opaque and dull,
Sclerotic dentin
being less reflective to light than similar enamel sur-
Sclerotic dentin results from aging or mild irritation (e.g. faces, which appear shiny.
slowly advancing caries) and causes a change in the com- III. Hardness. Dentin is softer than enamel and provides
position of the primary dentin. The peritubular dentin greater yield to the pressure of a sharp explorer tine,
becomes wider, gradually filling the tubules with calcified which tends to catch and hold in dentin.
material, progressing pulpally from the DEJ. These areas IV. Sound. Enamel would yield a scratchy sound on prob-
are harder, denser, less sensitive and more protective of the ing with a sharp explorer tine, which is not apparent in
pulp against subsequent irritations. dentin.
I. Sclerosis resulting from aging is called physiologic dentin
sclerosis. Hydrodynamic theory of dentinal sensitivity
II. Sclerosis resulting from a mild irritation is called re- Sensitivity is encountered whenever odontoblasts and
active dentin sclerosis. Reactive dentin sclerosis often their processes are stimulated during operative procedures,
can be seen radiographically in the form of a more even though the pain receptor mechanism appears to be
radiopaque (lighter) area in the ‘S’-shape of the tu- within the dentinal tubules near the pulp. Physical, ther-
bules. mal, chemical, bacterial and traumatic stimuli are trans-
mitted through the dentinal tubules.
Chemical composition of dentin The most accepted theory of pain transmission is the
Dentin is less mineralized than enamel but more mineral- hydrodynamic theory, which accounts for pain transmission
ized than cementum or bone. Human dentin is composed through rapid movements of fluid within the dentinal
of approximately (by weight) tubules.4 Dentinal tubules are filled with dentinal fluid, a
• 70% inorganic material. Hydroxyapatite crystallites are transudate of plasma. When enamel or cementum is re-
arranged in a less systematic manner than enamel crys- moved during tooth preparation, the external seal of den-
tallites. tin is lost, allowing tubular fluid to move towards the cut
• 20% organic material. Approximately 90% type I col- surface (Fig. 1.20). Pulpal fluid has a slight positive pres-
lagen and 10% non-collagenous proteins. sure that forces fluid outward towards any breach in the
• 10% water. external seal.
10
Figure 1.20 Stimuli that induce fluid movements in dentinal tu-

bules distort odontoblasts and afferent nerves, leading to a sensa- Figure 1.22 Principal fibres of periodontal ligament continue to
tion of pain. Many operative procedures such as cutting or air- course into surface layer of cementum as Sharpey’s fibres.
drying induce such fluid movement (arrow). (From Avery JK, Chiego DJ: Essentials of oral histology and embryology: a
clinical approach, ed 3, St Louis, MO, 2006, Mosby.)
Dentinal permeability
The permeability of dentin is not uniform throughout the
Cementum
tooth.
I. Coronal dentin is much more permeable than root Cementum is a thin layer of hard dental tissue covering
dentin. There are also differences within coronal dentin the anatomic roots of teeth and is formed by cells known
(Fig. 1.21).5 as cementoblasts, which develop from undifferentiated mes-
II. Dentin permeability primarily depends on the remain- enchymal cells in the connective tissue of the dental folli-
ing dentin thickness (i.e. length of the tubules) and the cle. Cementum is light yellow and slightly lighter in colour
diameter of the tubules. than dentin. Sharpey’s fibres are portions of the principal
As the tubules are shorter, more numerous and larger in collagenous fibres of the periodontal ligament embedded
diameter closer to the pulp, deep dentin is a less effective in cementum and alveolar bone to attach the tooth to the
pulpal barrier than superficial dentin (Fig. 1.21). alveolus (Fig. 1.22).
Chemical composition
Cementum is slightly softer than dentin. It consists of the
following:
• About 45%–50% inorganic material (hydroxyapatite)
by weight.
• About 50%–55% organic matter and water by weight.
The organic portion is composed primarily of collagen
and protein polysaccharides.
Types of cementum
Cementum is avascular and is formed continuously
throughout life because as the superficial layer of cemen-
tum ages, a new layer of cementum is deposited to keep
the attachment intact. Two kinds of cementum are formed:
• Acellular cementum. The acellular layer of cementum
Figure 1.21 Ground section of MOD (mesio-occluso-distal) tooth does not incorporate cells into its structure and usually
preparation on the third molar. Dark blue dye was placed in the predominates on the coronal half of the root.
pulp chamber under pressure after tooth preparation. Dark ar-
eas of dye penetration (D) show that the dentinal tubules of axial • Cellular cementum. Cellular cementum incorporates
walls are much more permeable than those of the pulpal floor of cells into its structure and occurs more frequently on
preparation. the apical half of the root.
11
Clinical Notes
• Cementum thickness can increase on the root end to
compensate for attritional wear of the occlusal or in-
cisal surface and passive eruption of the tooth.
• Cementum joins enamel to form the CEJ, which is
referred to as the cervical line. In about 10% of teeth, Figure 1.23 Contours. Arrows show pathways of food passing
enamel and cementum do not meet, and this can re- over facial surface of mandibular molar during mastication. (A)
sult in a sensitive area as the openings of the dentinal Overcontour deflects food from gingiva and results in understimu-
tubules are not covered. lation of supporting tissues. (B) Undercontour of tooth may result
• Abrasion, erosion, caries, scaling and restoration fin- in irritation of soft tissue. (C) Correct contour permits adequate
ishing and polishing procedures can denude dentin stimulation and protection of supporting tissue.
of its cementum covering, which can cause the den-
tin to be sensitive to various stimuli (e.g. heat, cold, or lingual convexities may result in iatrogenic injury, as il-
sweet substances, sour substances). lustrated in Fig. 1.23, in which the proper facial contour
is disregarded in the design of the cervical area of a man-
dibular molar restoration. Overcontouring is the worst of-
fender, usually resulting in increased plaque retention that
Physiology of Tooth Form leads to a chronic inflammatory state of the gingiva.
Proper form of the proximal surfaces of teeth is just as
Function important to the maintenance of periodontal tissue health
as is the proper form of facial and lingual surfaces. The
Teeth serve four main functions: proximal height of contour serves to provide
I. Mastication. Normal tooth form and proper alignment I. contacts with the proximal surfaces of adjacent teeth,
ensure efficiency in the incising and reduction of food thus preventing food impaction;
with the various tooth classes—incisors, canines, pre- II. adequate embrasure space (immediately apical to the
molars and molars—performing specific functions in contacts) for gingival tissue, supporting bone, blood
the masticatory process and in the coordination of the vessels and nerves that serve the supporting structures
various muscles of mastication. (Fig. 1.24).
II. Esthetics. The form and alignment of the anterior teeth
are important to a person’s physical appearance. Proximal Contact Area
III. Speech. The form and alignment of anterior and pos-
terior teeth assist in the articulation of certain sounds When teeth initially erupt to make proximal contact with
that can have a significant effect on speech. previously erupted teeth, a contact point is present. The con-
IV. Protection of supporting tissues. The form and align- tact point increases in size to become a proximal contact
ment of the teeth assist in sustaining them in the dental area as the two adjacent tooth surfaces abrade each other
arches by assisting in the development and protection during physiologic tooth movement (Figs. 1.25 and 1.26).
of gingival tissue and alveolar bone that support them.
Contours
Facial and lingual surfaces possess a degree of convexity that
affords protection and stimulation of supporting tissues
during mastication. The convexity generally is located at
I. the cervical third of the crown on the facial surfaces of
all teeth and
II. the lingual surfaces of incisors and canines.
Lingual surfaces of posterior teeth usually have their
height of contour in the middle third of the crown. Normal
tooth contours act in deflecting food only to the extent that
the passing food stimulates (by gentle massage) and does
not irritate (abrade) supporting soft tissues. If these curva-
tures are too great, tissues usually receive inadequate stim-
ulation by the passage of food. Too little contour may re-
sult in trauma to the attachment apparatus. Normal tooth Figure 1.24 Portion of the skull, showing triangular spaces be-
contours must be recreated in the performance of operative neath proximal contact areas. These spaces are occupied by soft
dental procedures. Improper location and degree of facial tissue and bone for the support of teeth.
12
Figure 1.25 Proximal contact areas. Black lines show positions of contact faciolingually. (A) Maxillary teeth. (B) Mandibular teeth. Facial
and lingual embrasures are indicated.
Figure 1.26 Proximal contact areas. Black lines show positions of contact incisogingivally and occlusogingivally. Incisal, occlusal and
gingival embrasures are indicated. (A) Maxillary teeth. (B) Mandibular teeth.
The physiologic significance of properly formed and lo- I. Incisal third of the approximating surfaces of maxillary
cated proximal contacts cannot be overemphasized; they and mandibular central incisors (Fig. 1.26). It is posi-
promote normal healthy interdental papillae filling the in- tioned slightly facial to the centre of the proximal sur-
terproximal spaces. Improper contacts may result in food face faciolingually (Fig. 1.25).
impaction between teeth, potentially increasing the risk of II. Proceeding posteriorly from the incisor region through
periodontal disease, caries and tooth movement. In addi- all the remaining teeth, the contact area is located near
tion, retention of food is objectionable because of its physi- the junction of the incisal (or occlusal) and middle thirds or
cal presence and the halitosis that results from food decom- in the middle third.
position. Proximal contacts and interdigitation of maxillary III. Proximal contact areas typically are larger in the molar
and mandibular teeth, through occlusal contact areas, sta- region, which helps prevent gingival food impaction
bilize and maintain the integrity of the dental arches. during mastication. Adjacent surfaces near the proxi-
The proximal contact area is located in the following re- mal contacts (embrasures) usually have remarkable
gions: symmetry.
13
Figure 1.27 Relationship of ideal interdental papilla to molar con-

tact area.
Embrasures
Embrasures are V-shaped spaces that originate at the proxi-
mal contact areas between adjacent teeth and are named
Figure 1.28 Embrasure form. w, improper embrasure form caused
for the direction towards which they radiate. These embra-
by overcontouring of restoration resulting in unhealthy gingiva from
sures are lack of stimulation; x, good embrasure form; y, frictional wear of
I. facial, contact area has resulted in decrease of embrasure dimension; z,
II. lingual, when the embrasure form is good, supporting tissues receive ad-
III. incisal or occlusal and equate stimulation from foods during mastication.
IV. gingival (Figs. 1.25 and 1.26).
Initially, the interdental papilla fills the gingival embra-
sure. When the form and function of teeth are ideal and
optimal oral health is maintained, the interdental papilla
may continue in this position throughout life. When the
gingival embrasure is filled by the papilla, trapping of food
in this region is prevented. In a faciolingual vertical sec-
tion, the papilla is seen to have a triangular shape between
Figure 1.29 Embrasure form. x, Portion of tooth that offers pro-
anterior teeth, whereas in posterior teeth, the papilla may tection to underlying supporting tissue during mastication; y, res-
be shaped like a mountain range, with facial and lingual toration fails to establish adequate contour for good embrasure
peaks and the col (valley) lying beneath the contact area form.
(Fig. 1.27).
This col, a central faciolingual concave area beneath the cause an increase in the problems associated with inad-
contact, is more vulnerable to periodontal disease from in- equate proximal contacts and faulty embrasure forms.
correct contact and embrasure form because it is covered Preservation of the curvatures of opposing cusps and
by non-keratinized epithelium. surfaces in function maintains masticatory efficiency
The correct relationships of embrasures, cusps to sulci, throughout life. Correct anatomic form renders teeth more
marginal ridges and grooves of adjacent and opposing self-cleansing because of the smoothly rounded contours
teeth provide for the escape of food from the occlusal sur- that are more exposed to the cleansing action of foods
faces during mastication. When an embrasure is decreased and fluids and the frictional movement of the tongue, lips
in size or absent, additional stress is created on teeth and and cheeks. Failure to understand and adhere to correct
the supporting structures during mastication. Embrasures anatomic form may contribute to the breakdown of the
that are too large provide little protection to the supporting restored system (Fig. 1.30).
structures as food is forced into the interproximal space by
an opposing cusp (Fig. 1.28). A prime example is the fail-
ure to restore the distal cusp of a mandibular first molar Periodontium
when placing a restoration (Fig. 1.29). Lingual embrasures
are usually larger than facial embrasures; and this allows The periodontium consists of the oral hard and soft tissues
more food to be displaced lingually because the tongue that invest and support teeth. It can be divided into the
can return the food to the occlusal surface more easily than following:
if the food is displaced facially into the buccal vestibule I. The gingival unit, consisting of
(Fig. 1.25). The marginal ridges of adjacent posterior teeth i. free gingiva,
should be at the same height to have proper contact and ii. attached gingiva and
embrasure forms. When this relationship is absent, it may iii. alveolar mucosa.
14
Figure 1.31 Vertical section of a maxillary incisor illustrating sup-

porting structures: 1, Enamel; 2, dentin; 3, pulp; 4, gingival sulcus;
5, free gingival margin; 6, free gingiva; 7, free gingival groove; 8,
lamina propria of gingiva; 9, attached gingiva; 10, mucogingival
junction; 11, periodontal ligament; 12, alveolar bone; 13, cemen-
Figure 1.30 Poor anatomic restorative form. (A) Radiograph of tum and 14, alveolar mucosa.
flat contact/amalgam gingival excess and resultant vertical os-
seous loss. (B) Radiograph of restoration with amalgam gingival
excess and absence of contact resulting in osseous loss, adjacent Attached gingiva
root caries. (C) Poor embrasure form and restoration margins. The attached gingiva, a dense connective tissue with kerati-
nized, stratified, squamous epithelium, extends from the
depth of the gingival sulcus to the mucogingival junction.
A dense network of collagenous fibres connects the at-
II. The attachment apparatus, consisting of tached gingiva firmly to cementum and the periosteum of
i.cementum, the alveolar process (bone).
periodontal ligament and
ii.
Alveolar mucosa
alveolar process (Fig. 1.31).
iii.
The alveolar mucosa is a thin, soft tissue that is loosely at-
tached to the underlying alveolar bone (Fig. 1.31, labels 12
Gingival Unit and 14). It is covered by a thin, non-keratinized epithelial
layer. The alveolar mucosa is delineated from the attached
Free gingiva gingiva by the mucogingival junction and continues api-
I. The free gingiva is the gingiva from the marginal crest cally to the vestibular fornix and the inside of the cheek.
to the level of the base of the gingival sulcus (Fig. 1.31,
labels 4 and 6). Clinical Notes
II. The gingival sulcus is the space between the tooth and
The level of the gingival attachment and gingival sul-
the free gingiva. cus is an important factor in restorative dentistry. The
III. The outer aspect of the free gingiva in each gingival em- margin of a tooth preparation should not be positioned
brasure is called gingival or interdental papilla. subgingivally (at levels between the marginal crest of
IV. The free gingival groove is a shallow groove that runs par- the free gingiva and the base of the sulcus) unless dic-
allel to the marginal crest of the free gingiva and usu- tated by caries, previous restoration, esthetics or other
ally indicates the level of the base of the gingival sulcus preparation requirements.
(Fig. 1.31, label 7).
15
conclusion that in the final analysis, optimal function and

Attachment Apparatus the absence of disease is the principal characteristic of a good
occlusion.6
Periodontal ligament
The tooth root is attached to the alveolus (bony socket)
by the periodontal ligament (Fig. 1.31, label 11), which is Tooth Alignment and Dental Arches
a complex connective tissue containing numerous cells,
blood vessels, nerves and an extracellular substance con- Central Groove (Fig. 1.32A)
sisting of fibres and ground substance. Most of the fibres The cusps in the posterior teeth are separated by distinct
are collagen, and the ground substance is composed of a developmental grooves and sometimes have additional
variety of proteins and polysaccharides. supplemental grooves on the cusp inclines. The facial cusps
The periodontal ligament serves the following functions: are separated from the lingual cusps by a deep groove,
I. Attachment and support. Bundles of collagen fibres, termed central groove.
known as principal fibres of the ligament, serve to attach
cementum to alveolar bone and act as a cushion to sus-
Fossae
pend and support the tooth.
II. Sensory. Bundles of collagen fibres, known as principal If a tooth has multiple facial cusps or multiple lingual
fibres of the ligament, serve to attach cementum to alveo- cusps, the cusps are separated by facial or lingual devel-
lar bone and act as a cushion to suspend and support opmental grooves. The depressions between the cusps are
the tooth. termed fossae (singular, is fossa).
III. Nutritive. Blood vessels supply the attachment appara-
tus with nutritive substances. Facial Occlusal Line
IV. Homeostatic. Specialized cells of the ligament function
to resorb and replace cementum, the periodontal liga- The maxillary arch is larger than the mandibular arch,
ment and alveolar bone. which results in the maxillary cusps overlapping the man-
dibular cusps when the arches are in maximal occlusal con-
Alveolar process tact (Fig. 1.32B). In Fig. 1.32A, two curved lines have been
The alveolar process—a part of the maxilla and the mandi- drawn over the teeth to aid in the visualization of the arch
ble—forms, supports and lines the sockets into which the form. These curved lines identify the alignment of similarly
roots of teeth fit. The alveolar process comprises thin, com- functioning cusps or fossae. On the left side of the arches, an
pact bone with many small openings through which blood imaginary arc connecting the row of facial cusps in the man-
vessels, lymphatics and nerves pass. It consists of two parts: dibular arch have been drawn and labelled facial occlusal line.
I. Alveolar bone proper. This is the inner wall of the bony
socket which consists of the thin lamella of bone that Central Fossa Occlusal Line
surrounds the root of the tooth. An imaginary line connecting the maxillary central fossae
II. Supporting alveolar bone. This is the part of the alveolar
is labelled central fossa occlusal line. The mandibular facial oc-
process which surrounds the alveolar bone proper and clusal line and the maxillary central fossa occlusal line coincide
supports the socket. Supporting bone is composed of exactly when the mandibular arch is fully closed into the maxil-
two parts: lary arch. On the right side of the dental arches, the maxil-
i. Cortical plate. This consists of compact bone and
lary lingual occlusal line and mandibular central fossa oc-
forms the inner (lingual) and outer (facial) plates of clusal line have been drawn and labelled. These lines also
the alveolar process. coincide when the mandible is fully closed.
ii. Spongy base. This fills the area between the plates
and the alveolar bone proper.
Maximum Inter-cuspation
This refers to the position of the mandible when teeth are
Occlusion brought into full interdigitation with the maximal number
of teeth contacting. Synonyms for maximum inter-cuspa-
Occlusion literally means closing; in dentistry, the term tion (MI) include inter-cuspal contact, maximum closure and
means the contact of teeth in opposing dental arches when maximum habitual inter-cuspation (MHI).
the jaws are closed (static occlusal relationships) and dur- I. Functional cusps. Cusps that contact opposing teeth along
ing various jaw movements (dynamic occlusal relation- the central fossa occlusal line are termed functional cusps
ships). (supporting, centric, holding or stamp cusps).
A wide variety of occlusal schemes can be found in II. Nonfunctional cusps. Cusps that overlap opposing teeth
healthy individuals. Failing to find a single adequate are termed nonfunctional cusps (nonsupporting, non-
definition of an ideal occlusal scheme has resulted in the centric or non-holding cusps).
16
Figure 1.32 Dental arch relationships. (A) Dental arch cusp and fossa alignment; (B) maximum inter-cuspation; (C) molar view; (D) inci-
sor view; (E) facial view of anteroposterior variations; (F) molar classes I, II and III relationships and (G) skeletal classes I, II and III relation-
ships.
17
The mandibular facial occlusal line identifies the man- lar deficiency or excessive eruption of posterior teeth, and
dibular functional cusps, whereas the maxillary facial crossbite as a result of mandibular growth excess (Fig. 1.33,
cusps are nonfunctional cusps. These terms are usually ap- A-3). These variations have significant clinical effects on
plied only to posterior teeth to distinguish the functions of the contacting relationships of posterior teeth during vari-
the two rows of cusps. ous jaw movements because anterior teeth do not provide
gliding contact. The various variations in premolar and
Anteroposterior Interarch molar relationships are illustrated in Figs. 1.33B and C.
Relationships
Posterior Cusp Characteristics
The cusp interdigitation pattern of the first molar teeth is
used to classify anteroposterior arch relationships using Four cusp ridges can be identified as common features of
a system developed by Angle.7 The location of the mesi- all the cusps:
ofacial cusp of the maxillary first molar in relation to the
mandibular first molar is used as an indicator in Angle’s Outer Incline Ridge
classification. Three interdigitated relationships of the first
molars are commonly observed (Fig. 1.32E and F). The outer incline of a cusp faces the facial (or the lingual)
surface of the tooth and is named for its respective sur-
• Angle class I. The most common molar relationship
finds the maxillary mesiofacial cusp located in the me- face. In the example using a mandibular second premolar
siofacial developmental groove of the mandibular first (Fig. 1.34A), the facial cusp ridge of the facial cusp is indi-
molar. This relationship is termed Angle class I. cated by the line that points to the outer incline of the cusp.
• Angle class II. Slight posterior positioning of the man-
dibular first molar results in the mesiofacial cusp of the Inner Incline Ridge
maxillary molar settling into the facial embrasure be-
tween the mandibular first molar and the mandibular The inner inclines of the posterior cusps face the central
second premolar. This is termed Angle class II. fossa or the central groove of the tooth. The inner incline
• Angle class III. Anterior positioning of the mandibular cusp ridges are widest at the base and become narrower as
first molar relative to the maxillary first molar is termed they approach the cusp tip. For this reason, they are also
as Angle class III and is the least common. In class III termed as triangular ridges. Triangular ridges are usually
relationships, the mesiofacial cusp of the maxillary first set off from the other cusp ridges by one or more sup-
molar fits into the distofacial groove of the mandibular plemental grooves. In Fig. 1.34, B-1 and C-1, the outer
first molar. inclines of the facial cusps of the mandibular and maxil-
lary first molars are highlighted. In Fig. 1.34, B-2 and C-2,
Although Angle’s classification is based on the relation-
the triangular ridges of the facial and lingual cusps are
ship of the cusps. Fig. 1.24G illustrates that the location of
highlighted.
tooth roots in alveolar bone determines the relative posi-
tions of the crowns and cusps of teeth:
• Class I molar relationship. When the mandible is pro-
Mesial Cusp Ridges and Distal Cusp
portionally similar in size to the maxilla, a class I molar Ridges
relationship is formed. The mesial and distal cusp ridges extend from the cusp tip
• Class II molar relationship. When the mandible is pro- mesially and distally and are named for their directions.
portionally smaller than the maxilla, a class II molar rela- The mesial and distal cusp ridges extend downward from
tionship is formed. the cusp tips, forming the characteristic facial and lingual
• Class III molar relationship. When the mandible is profiles of the cusps as viewed from the facial or lingual
relatively greater than the maxilla, a class III molar rela- aspect. At the base of the cusp, the mesial or distal cusp
tionship is formed. ridge abuts to another cusp ridge, forming a developmen-
tal groove, or the cusp ridge turns towards the centre line of
Interarch Tooth Relationships the tooth and fuses with the marginal ridge.
Marginal ridges are elevated; the rounded ridges being lo-
Fig. 1.33 illustrates the occlusal contact relationships of cated on the mesial and distal edges of the tooth’s occlusal
individual teeth in more detail. In Fig. 1.33, A-2, incisor surface (Fig. 1.34A).
overlap is illustrated. The overlap is characterized in two
dimensions:
Functional Cusps
I. Horizontal overlap (overjet)
II. Vertical overlap (overbite) In Fig. 1.35, the lingual occlusal line of maxillary teeth and
Differences in the sizes of the mandible and the max- the facial occlusal line of mandibular teeth mark the loca-
illa can result in clinically significant variations in incisor tions of the functional cusps. These cusps contact opposing
relationships, including open bite as a result of mandibu- teeth in their corresponding faciolingual centre on a marginal
18
Figure 1.33 Tooth relationships.
19
Figure 1.34 Common features of all posterior teeth.
20
Figure 1.35 Functional cusps.
21
Figure 1.36 Nonfunctional cusps.
22
ridge or a fossa. Functional cusp–central fossa contact has Nonfunctional Cusps

been compared to a mortar and pestle because the support-
ing cusp cuts, crushes and grinds fibrous food against the The nonfunctional cusps overlap the opposing tooth
ridges forming the concavity of the fossa (Fig. 1.34D). Func- without contacting the tooth. Fig. 1.36 illustrates that the
tional cusps also serve to prevent drifting and passive erup- nonfunctional cusps form a lingual occlusal line in the
tion of teeth, hence the term holding cusps. Functional cusps mandibular arch (Fig. 1.36D) and a facial occlusal line in
(Fig. 1.35) can be identified by five characteristic features8: the maxillary arch (Fig. 1.36B). The nonfunctional cusps
are located in the anteroposterior plane in facial (lingual)
I. They contact the opposing tooth in MI.
embrasures or in the developmental groove of opposing
II. They support the vertical dimension of the face.
teeth, creating an alternating arrangement when teeth are
III. They are nearer the faciolingual centre of the tooth than
in MI.
nonsupporting cusps.
IV. Their outer incline has the potential for contact.
V. They have broader, more rounded cusp ridges than
Summary
nonsupporting cusps.
An intimate knowledge of the anatomy and physiol-
Clinical Notes
ogy of the dental tissues is important for a clinician
• As the maxillary arch is larger than the mandibular to be able to use various dental materials optimally.
arch, the maxillary functional cusps are located on A thorough understanding of the tooth anatomy and
the maxillary lingual occlusal line (Fig. 1.35D). their occlusal relationships is crucial for a restorative
• The mandibular functional cusps are located on the dentist in being able to perform adequate restorative
mandibular facial occlusal line (Fig. 1.35A and B). rehabilitation.
• The lingual tilt of posterior teeth increases the rela-
tive height of the functional cusps with respect to
the nonfunctional cusps (Fig. 1.35C), and the central
fossa contacts of the functional cusps are obscured
by the overlapping nonfunctional cusps.
References
1. Garberoglio R, Brännström M: Scanning 5. Sturdevant JR, Pashley DH: Regional 8. Kraus BS, Jorden E, Abrams L: Dental
electron microscopic investigation of dentin permeability of class I and II cavity anatomy and occlusion, ed 1, Baltimore, MD,
human dentinal tubules, Arch Oral Biol preparations (abstract no. 173), J Dent Res 1969, Williams & Wilkins.
21:355–362, 1976. 68:203, 1989. 9. Digka A, Lyroudia K, Jirasek T, et al:
2. Scott JH, Symons NBB: Introduction to dental 6. Mohl ND, Zarb GA, Carlsson GE, et al: Visualisation of human dental pulp
anatomy, ed 9, Philadelphia, PA, 1982, The dentition. In Mohl ND, Zarb GA, vasculature by immunohistochemical and
Churchill Livingstone. Carisson GE, et al, editors: A textbook of immunofluorescent detection of CD34: a
3. Craig RG, Powers JM: Restorative dental occlusion, Chicago, IL, 1988, Quintessence. comparative study, Aust Endod J 32:101–106,
materials, ed 12, St Louis, MO, 2006, Mosby. 7. Angle EH: Classification of malocclusion, 2006.
4. Brännström M: Dentin and pulp in restorative Dent Cosmos 41, 1899, 248–264,
dentistry, London, 1982, Wolfe Medical. 350–357.
23
Chapter |2|
Dental Caries: Etiology, Clinical Characteristics,

Risk Assessment and Management
“There are no such things as incurables…
There are only things for which man has not yet found a cure…”
—Bernard Baruch
This chapter presents basic definitions, terminologies The balance between demineralization and reminerali-
and information on dental caries, clinical character- zation has been illustrated in Fig. 2.4 in terms of
istics of the caries lesion, caries risk assessment and • Pathologic factors (i.e. those favouring demineraliza-
caries management in the context of clinical operative tion) and
dentistry. • Protective factors (i.e. those favouring remineraliza-
tion).3
Individuals in whom the balance tilts predominantly to-
Definition wards protective factors (remineralization) are much less
likely to develop dental caries than those in whom the
Dental caries is defined as a preventable, chronic and biofilm- balance is tilted towards pathologic factors (demineraliza-
mediated disease modulated by diet. This multifactorial, oral tion). It is essential to understand that caries lesions, or
disease is caused primarily by an imbalance of the oral flora cavitations in teeth, are signs of an underlying condition,
(biofilm) due to the presence of fermentable dietary carbohy- an imbalance between protective and pathologic factors fa-
drates on the tooth surface over time. vouring the latter. In clinical practice, it is very easy to lose
sight of this fact and focus entirely on the restorative treat-
ment of caries lesions, failing to treat the underlying cause
of the disease. Although symptomatic treatment is impor-
Demineralization–Remineralization tant, failure to identify and treat the underlying causative
Balance factors allows the disease to continue and increases the
chance of treatment failure. Caries management efforts
Traditionally, the tooth–biofilm–carbohydrate interac- must be directed not only at the tooth level (traditional or
tion has been illustrated by the classical Keyes–Jordan surgical treatment) but also at the total-patient level (caries
diagram.1 However, dental caries onset and activity are, management by risk assessment).
in fact, much more complex than this three-way interac-
tion, as not all persons with teeth, biofilm and consuming Clinical Notes
carbohydrates will have caries over time. Several modify-
• Understanding the balance between demineraliza-
ing risk and protective factors influence the dental car- tion and remineralization is the key to caries man-
ies process, as will be discussed later in this chapter agement.
(Fig. 2.1). • Restorative treatment does not cure the caries pro-
At the tooth surface and sub-surface level, dental caries cess. Instead, identifying and managing the risk fac-
results from a dynamic process of attack (demineraliza- tors for caries must be the primary focus, in addi-
tion) (Figs. 2.2 and 2.3) and restitution (remineralization to the restorative repair of damage caused by
tion) of the tooth matter. This cycle is summarized in caries.
Box 2.1.
25
Figure 2.1 Modified Keyes–Jordan diagram. As a simplified description, dental caries is a result of the interaction of cariogenic oral flora
(biofilm) with fermentable dietary carbohydrates on the tooth surface (host) over time. However, dental caries onset and activity are,
in fact, much more complex, as not all persons with teeth, biofilm, and who are consuming carbohydrates will have caries over time.
Several modifying risk factors and protective factors influence the dental caries process.
(Modified from Keyes PH, Jordan HV: Factors influencing initiation, transmission and inhibition of dental caries. In Harris RJ, editor: Mechanisms of hard
tissue destruction, New York, 1963, Academic Press.)
Figure 2.3 Extensive active caries in a young adult (same pa-

tient as in Fig. 2.2). (A) Mirror view of teeth nos. 20–22 and (B)
cavitated lesions (a) are surrounded by extensive areas of chalky,
opaque demineralized areas (b). The presence of smooth-surface
Figure 2.2 (A) Young adult with multiple active initial and cavitat- lesions such as these is associated with rampant caries. Occlusal
ed caries lesions involving teeth nos. 8–10 and (B) cavitated areas and interproximal smooth-surface caries usually occur in advance
(a) are surrounded by areas of extensive demineralization that are of facial smooth-surface lesions. The presence of these types of
chalky and opaque (b). Some areas of initial (non-cavitated) caries lesions should alert the dentist to the possibility of a high caries
have superficial stain. risk patient and possibly extensive caries activity elsewhere in the
mouth. The interproximal gingiva is swollen red and would bleed
easily on probing. These gingival changes are the consequence
26 of longstanding irritation from the biofilm adherent to the teeth.
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Listen, as she condoles with a widower, on his recent
bereavement:
Sickness and afflictions is trials sent

By the will of a wise creation,
And always ought to be underwent
With fortitude and resignation.
Then mourn not for your pardner’s death,
But to forgit endevver,
For, sposen she hadn’t a died so soon,
She couldn’t a lived forever.
And when, at last, she secured a widower of her own, the Rev.
Shadrack Sniffles, how jubilant her muse became:
The heart that was scornful and cold as a stun,

Has surrendered at last to the fortinit one.
Farewell to the miseries and griefs I have had!
I’ll never desert thee, O Shadrack, my Shad.
The wonderful puns and repartees of Charles Lamb and Sydney

Smith, prince and king of wits! are open to the same objection as
those alluded to above: they are only too familiar, already. But as
that is equivalent to saying that they have charmed only too many
people; turned too many sorrowful or wearied minds out of their
ordinary channels; excited too much healthful and delightful laughter;
we are, after all, not disposed to complain. Rather let us, Sancho-
Panza-like, invoke a benison, first on Cervantes himself; then on the
English Hood and Hook, and Moore and Sheridan and Lamb, on the
three Smiths, Sydney and James and Horace; on Dickens,
Thackeray and Jerrold, and Edmund Lear; on our own Irving, Derby,
Whicher, Morris, Brown, the Clarkes; our Lowell, Saxe, Holmes,
Strong; our Warner, Cozzens, Dodgson, Gilbert, Locke, Bret Harte;
our Grail Hamilton, and our Phebe Carey; and on all the named and
unnamed, known and unknown writers, through whom have come to
us the exquisite sense of fun, the blessing of irrepressible mirth, and
of hearty, wholesome, innocent, delicious laughter!
And if, despite our struggles, we are accused, as we shall be,
and justly, of having told some more than twice-told tales, of quoting
already hackneyed quotations charity will urge in our behalf (and, let
us trust, not vainly), Burns’ pathetic plea, reminding the critics, that
while
“What’s done they” easily “compute.

They know not what’s resisted.”
“SOUND AND” UNSOUND, “SIGNIFYING

NOTHING.”
A young gentleman of Rochester, suspecting that the poetical
enthusiasm of certain of his young lady acquaintances was not
genuine; that they appreciated the musical jingle of verses, without in
the least regarding the sentiment, laid a wager with one of his
friends, that he could write a set of stanzas, which should not contain
one grain of sense, and yet would be just as warmly applauded by
those young ladies as the most eloquent poetry.
He won the wager. (But this occurred many years ago. There are
no such young ladies in Rochester now).
See! the fragrant twilight whispers

O’er the orient western sky,
While Aurora’s verdant vespers
Tell her evening reign is nigh.
Now a louder ray of darkness,

Carols o’er the effulgent scene,
And the lurid light falls markless
On the horizon’s scattered screen.
Night is near, with all his horrors,

Sweetly swerving in his breast,
And the ear of fancy borrows
Morning mists to lull the west.
Ere he comes in all his splendor,
Hark! the milky way is seen,
Sighing like a maiden tender
In her bower of ruby green.
Such a scene, ah! who can list to,

And not saddened, silent, seek
To unveil the burning vista
Of Diana’s raven cheek?
Thus tremulous, and ever dear,

Robed in repellant rapture;
Our hours shall stay, swift as the year,
Illumed by Cupid’s capture!
And when hyenal joys are ours,

And memory soars above us,
Hope shall retrace for future years
The love of all who love us.
Something of the same character is the subjoined:
EVENING SONG.
Brightly blue the stars shine o’er us,

While the sinking sun ascends
To the wide spread waves before us,
And a pleasing softness lends.
Homeward now the aged plough-boys

Wing their way o’er hill and dale,
And the laughter-loving cow goes
Tripping lightly down the vale.
Gentle zephyrs’ ink-stained fingers

Point the hour-hand of the clock,
There the warbling sheep-fold lingers—
Save it from the cruel hawk!
Thus excoriate the hours,

Till the red volcano’s powers
Kindle on the hearth its fires:
Poets! dissipate your lyres!
In the following musical poem, the letter e does duty so well for
all the other vowels, as to suggest the idea that our ordinary lavish
use of them is a piece of extravagance!
When the September eves were new,

When fresh the western breezes blew,
When meek Selene, gem-besprent,
The dew her crested jewels lent;
We met, Belle, where the beeches grew,
When the September eves were new.
When the September eves were new,

Endless, meseemed, the sweets we knew!
Sweet fell the dew; sweet swept the breeze;
Sweet were the templed beechen trees;
The spell yet sweeter, tenderer grew,
When the September eves were new!
When the September eves were eld,

The templed beechen trees were felled;
Keen-edged the western breezes blew;
Crestless the meek Selene grew;
The fettered dew her jewels held,
When the September eves were eld.
When the September eves were eld,

Fled were the scenes we erst beheld—
Reft were the tender scenes we knew;—
The desert, where the beeches grew!
Yet, Belle, we sweeter secrets held,
Ere the September eves were eld!
The construction of the following verses, from which the letter s is

omitted, shows that our language is not of necessity a succession of
sibilant sounds, as it is generally supposed to be:
Oh! come to-night, for naught can charm
The weary time when thou’rt away.
Oh, come! the gentle moon hath thrown
O’er bower and hall her quivering ray.
The heather bell hath mildly flung
From off her fairy leaf the bright
And diamond dew-drop that had hung
Upon that leaf a gem of light.
Then come, love, come!
To-night the liquid wave hath not,

(Illumined by the moonlit beam
Playing upon the lake beneath,
Like frolic in a fairy dream—)
The liquid wave hath not, to-night,
In all her moonlit pride, a fair
Gift-like to them that, on thy lip,
Do breathe and laugh and home it there.
To-night, to-night, my gentle one,

The flower-bearing Amra tree
Doth long, with fragrant moan, to meet
The love-lip of the honey-bee.
But not the Amra tree can long
To greet the bee, at evening light,
With half the deep, fond love I long
To meet my Nama here to-night.
What a boon would a volume of poems, modeled on the above

principle of architecture, be to perthonth troubled with a lithp; whose
reading at present (through the perverseness of the English
language), sounds thus:
Thweetly murmurth the breethe from the thea,

Thoothing my thoul to thlumberth,
Fond memorieth bearing to me,
Of the patht, in endleth numberth.
I thigh ath I think how yearth have thped,
How joy hath left me to thorrow;
My heart now thleepeth the thleep of the dead;
Will it waken to gladneth to-morrow?
THE NIMBLE BANK-NOTE.

“And he rose with a sigh,
And he said, ‘Can this be?’”
(Motto chosen chiefly for its inappropriateness.)

One evening at the house of a friend of mine, while we were
seated at the table, Mr. Baker, my friend’s husband, absently feeling
in his vest pocket, found a five dollar note which he had no
recollection of putting there.
“Hallo!” he exclaimed, “that is no place for you. I should have put
you in my pocketbook. Here, wife, don’t you want some ready
money?” and he threw the note across the table to her.
“Many thanks,” she replied; “money is always acceptable,
although I have no present need of it.” She folded the note and put it
under the edge of the tea-tray, and then proceeded to pour out the
tea and attend to the wants of her guests.
At her right sat Mrs. Easton, or Aunt Susan, whom we all knew as
an acquaintance who, from time to time, spent a week with Mrs.
Baker. Her visit was just at an end, and she was to return home that
evening.
As Mrs. Baker was pouring her tea, it occurred to her that she
was in her aunt’s debt for certain small matters, and when she had
the opportunity, she pushed the note under her plate, saying:
“Here, auntie, take this five dollars in part payment of my debt.”
“Very well,” she replied, “but the money does not belong to me. I
owe you fifteen dollars, my dear Grace, which you lent me last
Saturday. I had to pay the taxes on my little home, and had not the
ready money, and Grace lent it to me,” explained Aunt Susan.
Grace, an orphan, was a cousin of Mrs. Baker. She and her
brother Frank boarded with her, and made a very pleasant addition
to the family circle. She was studying music, and her brother was a
clerk in a mercantile establishment.
As soon as Aunt Susan received the note, she handed it to
Grace, saying:
“I will give you this now on account, and the rest as soon as I get
it.”
“All right,” answered Grace, laughing, “and since we all seem in
the humor of paying our debts, I will follow suit. Frank, I owe you
something for music you bought me; here is part of it,” and she threw
the bank-note across the table to her brother, who sat opposite.
We were all highly amused to see how the note wandered around
the table.
“This is a wonderful note,” said Mr. Baker; “I only wish somebody
owed me something, and I owed somebody something, so that I
might come into the ring.”
“You can,” said Frank. “I owe Mrs. Baker—or you, it’s all the
same—for my board; I herewith pay you part of it.”
Amid general laughter, Mr. Baker took the note and playfully
threw it to his wife again, saying:
“It’s yours again, Lucy, because what belongs to me belongs to
you. It has completed the round, and we have all had the benefit of
it.”
“And now it must go around again,” replied she gayly. “I like to
see money circulate; it should never lie idle. Aunt Susan you take it.
Now I have paid you ten dollars.”
“Dear Grace, here is another five dollars on my account,” said
Aunt Susan, handing it to Grace.
“And you Frank, have paid ten dollars for the music you bought
me,” said Grace, handing it to her brother.
“And I pay you ten dollars for my board,” he continued, and the
note once more rested in Mr. Baker’s hands.
The exchanges were quick as thought, and we were convulsed
with laughter.
“Was there ever so wonderful an exchange?” exclaimed Grace.
“It’s all nonsense!” exclaimed Mr. Baker.
“Not in the least,” answered his wife. “It’s all quite right.”
“Certainly,” said Frank; “when the money belonged to you, you
could dispose of it as you would; I have the same right; it is a fair
kind of exchange, though very uncommon.”
“It shows the use of money,” said Aunt Susan. “It makes the
circuit of the world and brings its value to every one who touches it.”
“And this note has not finished its work yet, as I will show you, my
dear, if you will give it to me again, said Mrs. Baker to her husband.
“I present you with this five dollar note,” said Mr. Baker.
“And I give it to you, Aunt Susan—I owed you fifteen dollars, and
I have paid my debt.”
“You have, my dear friend, without doubt; and now, my dear
Grace, I pay you my indebtedness, with many thanks for your
assistance.”
“I take it with thanks, Aunt Susan,” replied Grace; “and now the
time has come when this wonder-working, this inexhaustibly rich
bank-note must be divided, because I do not owe Frank five dollars
more. How much have I to pay you?”
“Two dollars and sixty-two cents,” replied Frank.
“Can you change it?”
“Let me see; sixty-two, thirty-eight, yes, there is the change; the
spell is broken, Grace, and you and I divide the spoils.”
“This bank-note beats all I ever saw. How much has it paid? Let
us count up,” said Grace. “Mrs. Baker gave Aunt Susan fifteen
dollars, which Aunt Susan gave me; I gave Frank twelve dollars and
sixty-two cents; Frank gave Mr. Baker ten dollars—altogether fifty-
two dollars and sixty-two cents.”
“It’s all nonsense, I tell you,” cried Mr. Baker, again; “you all owe
each other what you owed before.”
“You are deceived, my dear, by the rapid, unbroken race this little
sum has made; to me it is as clear as daylight,” replied Mrs. Baker.
“If it is all nonsense, how could the note which you gave Mrs.
Baker, if nothing to me or to you, be divided between us two?” asked
Grace.
Mr. Baker did not seem to see it very clearly, but the others did,
and they often relate this little history for the amusement of their
friends.
THE RATIONALISTIC CHICKEN.

(Inspecting its shell.)
BY J. S. STONE.
Most strange!
Most queer,—although most excellent a change!
Shades of the prison-house, ye disappear!
My fettered thoughts have won a wider range,
And, like my legs, are free;
No longer huddled up so pitiably:
Free now to pry and probe, and peep and peer,
And make these mysteries out.
Shall a free-thinking chicken live in doubt?
For now in doubt undoubtedly I am:
This Problem’s very heavy on my mind,
And I’m not one either to shirk or sham:
I won’t be blinded, and I won’t be blind.
Now, let me see:

First, I would know how did I get in there?
Then, where was I of yore?
Besides, why didn’t I get out before?
Dear me!
Here are three puzzles (out of plenty more)
Enough to give me pip upon the brain!
But let me think again.
How do I know I ever was inside?
Now I reflect, it is, I do maintain,
Less than my reason, and beneath my pride,
To think that I could dwell
In such a paltry miserable cell
As that old shell.
Of course I couldn’t! How could I have lain,
Body and beak and feathers, legs and wings,
And my deep heart’s sublime imaginings,
In there?
I meet the notion with profound disdain;

It’s quite incredible; since I declare
(And I’m a chicken that you can’t deceive)
What I can’t understand I won’t believe.
Where did I come from, then? Ah! where, indeed?
This is a riddle monstrous hard to read.
I have it! Why, of course,
All things are moulded by some plastic force,
Out of some atoms somewhere up in space,
Fortuitously concurrent anyhow;—
There, now!
That’s plain as is the beak upon my face.
What’s that I hear?

My mother cackling at me! Just her way,
So prejudiced and ignorant I say;
So far behind the wisdom of the day.
What’s old I can’t revere.
Hark at her. “You’re a silly chick, my dear,
That’s quite as plain, alack!
As is the piece of shell upon your back!”
How bigoted! upon my back, indeed!
I don’t believe it’s there,
For I can’t see it: and I do declare,
For all her fond deceivin’,
What I can’t see I never will believe in!
A MEDLEY.
I only know she came and went, [Lowell.
Like troutlets in a pool; [Hood.
She was a phantom of delight, [Wordsworth.
And I was like a fool. [Eastman.
One kiss, dear maid, I said, and sighed, [Coleridge.
Out of those lips unshorn! [Longfellow.
She shook her ringlets round her head, [Stoddard.
And laughed in merry scorn. [Tennyson.
Ring out, wild bells, to the wild sky, [Tennyson.
You hear them, Oh, my heart, [Alice Cary.
’Tis twelve at night by the castle clock— [Coleridge.
Beloved, we must part. [Alice Cary.
Come back, come back, she cried in grief, [Campbell.
My eyes are dim with tears; [B. Taylor.
How shall I live through all the days, [Mrs. Osgood.
All through a hundred years? [J. J. Perry.
’Twas in the prime of summer time, [Hood.
She blessed me with her hand; [Hoyt.
We strayed together deeply blest, [Mrs. Edwards.
Into the dreaming land. [Cornwall.
The laughing bridal roses blew, [Patmore.
To deck her dark brown hair, [B. Taylor.
No maiden may with her compare, [Brailsford.
Most beautiful, most rare! [Read.
I clasped it on her sweet cold hand, [Browning.
The precious golden link; [Smith.
I calmed her fears, and she was calm— [Coleridge.
Drink, pretty creature, drink! [Wordsworth.
And so I won my Genevieve, [Coleridge.
And walked in Paradise; [Hervey.
The fairest thing that ever grew [Wordsworth.
Atween me and the skies! [Tennyson.
ANOTHER MEDLEY.
(WHO ARE THE AUTHORS?)
The curfew tolls the knell of parting day,

In every clime, from Lapland to Japan;
To fix one spark of beauty’s heavenly ray,
The proper study of mankind is man.
Tell, for you can, what is it to be wise,

Sweet Auburn, loveliest village of the plain!
“The man of Ross,” each lisping babe replies,
And drags, at each remove a length’ning chain.
Ah, who can tell how hard it is to climb

Far as the solar walk, or milky way?
Procrastination is the thief of time,
Let Hercules himself do what he may.
’Tis education forms the common mind,

The feast of reason and the flow of soul;
I must be cruel only to be kind,
And waft a sigh from Indus to the pole.
Syphax! I joy to meet thee thus alone,

Where’er I roam, whatever lands I see;
A youth to fortune and to fame unknown,
In maiden meditation, fancy free.
Farewell! and wheresoe’er thy voice be tried,

Why to yon mountain turns the gazing eye?
With spectacles on nose, and pouch on side,
That teach the rustic moralist to die.
Pity the sorrows of a poor old man,

Whose beard descending, swept his aged breast;
Laugh where we must, be candid where we can,
Man never is, but always to be blest.
AND ANOTHER MEDLEY.

The moon was shining silver bright,
All bloodless lay the untrodden snow,
When freedom from her mountain height,
Exclaimed, “Now don’t be foolish, Joe!”
An hour passed by; the Turk awoke,

Ten days and nights with sleepless eye,
To hover in the sulphur smoke,
And spread its pall upon the sky.
His echoing axe the settlers swung,

He was a lad of high degree;
And deep the pearly caves among,
Sweet Mary, weep no more for me.
Loud roars the wild, inconstant blast,

And cloudless sets the sun at even;
When twilight dews are falling fast,
And rolls the thunder-drum of heaven.
Oh, ever thus, from childhood’s hour,

By torch and trumpet fast arrayed,
Beneath yon ivy-mantled tower,
They lingered in the forest shade.
My love is like the red, red rose;

He bought a ring with posy true;
Deep terror then my vitals froze;
And, Saxon, I am Rhoderick Dhu!
LIFE.
Why all this toil for triumph of an hour?
[Young.
Life’s a short summer—man is but a flower;
[Dr. Johnson.
By turns we catch the fatal breath and die—
[Pope.
The cradle and the tomb, alas! so nigh.
[Prior.
To be is better far than not to be,
[Sewell.
Though all man’s life may seem a tragedy:
[Spencer.
But light cares speak when mighty griefs are dumb—
[Daniel.
The bottom is but shallow whence they come.
[Sir Walter Raleigh.
Your fate is but the common fate of all;
[Longfellow.
Unmingled joys may here no man befall;
[Southwell.
Nature to each allots his proper sphere,
[Congreve.
Fortune makes folly her peculiar care;
[Churchill.
Custom does often reason overrule,
[Rochester.
And throw a cruel sunshine on a fool.
[Armstrong.
Live well—how long or short permit to heaven;
[Milton.
They who forgive most shall be most forgiven,
[Bailey.
Sin may be clasped so close we cannot see its face—
[French.
Vile intercourse where virtue has no place,
[Sommerville.
Then keep each passion down, however dear.
[Thompson.
Thou pendulum betwixt a smile and tear;
[Byron.
Her sensual snares let faithless Pleasure lay,
[Smollet.
With craft and skill to ruin and betray,
[Crabbe.
Soar not too high to fall, but stoop to rise,
[Massinger.
We masters grow of all that we despise.
[Cowley.
Oh, then, renounce that impious self-esteem;
[Beattie.
Riches have wings; and grandeur is a dream.
[Cowper.
Think not ambition wise because ’tis brave,
[Sir Walter Davenant.
The paths of glory lead but to the grave,
[Gray.
What is ambition? ’Tis a glorious cheat.
[Willis.
Only destructive to the brave and great.
[Addison.
What’s all the gaudy glitter of a crown?
[Dryden.
The way to bliss lies not on beds of down.
[Francis Quarles.
How long we live, not years but actions tell;
[Watkins.
That man lives twice who lives the first life well.
[Herrick.
Make then, while yet you may, your God your friend.
[William Mason.
Whom Christians worship, yet not comprehend.
[Hill.
The trust that’s given guard, and to yourself be just;
[Dana.
For live we how we may, yet die we must.
[Shakespeare.
THE KEY.
ANSWERS TO PUZZLES.
1. Cobweb. M. A. R.
Back to puzzle
2. Thanks.
Back to puzzle
3. Of course I can! (Of Corsican.)

Back to puzzle
4. Maid of Orleans.
Back to puzzle
5. Because they have studded the heavens for centuries.

Back to puzzle
6. The winds blue, and the waves rose.

Back to puzzle
7. In violet.
Back to puzzle
8. They leave out their summer dress.
Back to puzzle
9. Because I am the querist.

Back to puzzle
10. Penmanship. English Paper.

Back to puzzle
11. Heather: weather. Hearth and Home.

Back to puzzle
12. Nothing.
Back to puzzle
13. It contains all the letters of the alphabet.

Back to puzzle
14. A lawsuit.
Back to puzzle
15. His father was Enoch, who did not die.

Back to puzzle
16. Yes: he was the Daughter-of-Pharaoh’s son.

Back to puzzle
17. When Autumn is turning the leaves.

Back to puzzle
18. Bud-dhism.
Back to puzzle
19. Starch. (Star, sac, scar, tar, trash, act, arc, arch, art, ash, rat,
rash, chart, cart, cat, car, chat, cash, cast, crash, hart, hat.)
Back to puzzle
20. Ague. (Hague; league; plague.)

Back to puzzle
21. Lettuce, alone. (Let us alone!)

Back to puzzle
22. The moon.

Back to puzzle
23. A human being. The Sphinx Riddle.

Back to puzzle
24. Noah.
Back to puzzle
25. Macaulay. Rural New Yorker.

Back to puzzle
26. N R G.
Back to puzzle
27. M T.
Back to puzzle
28. O B C T.
Back to puzzle
29. X L N C.
Back to puzzle
30. L E G.
Back to puzzle
31. Dutch S.
Back to puzzle
32. French L.
Back to puzzle
33. K.
Back to puzzle
34. In the days of no A (Noah,) before U and I were born.

Back to puzzle
35. T.
Back to puzzle
36. Q.
Back to puzzle
37. It’s laudin’ ’em.

Back to puzzle
38. No man has three feet; a man has two feet more than no
man: therefore, a man has five feet.
Back to puzzle
39. A branch. M. L. C.
Back to puzzle
40. Love Me Little: Love Me Long.

Back to puzzle
41. Ma mère. E. P.
Back to puzzle
42. Amiable (Am I able?)

Back to puzzle
43. Conundrum.
Back to puzzle
44. Purcell. M. D.
Back to puzzle

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Sturdevant's Art & Science of Operative

Dentistry: Second South Asia Edition -

André V. Ritter, DDS, MS, MBA

Lee W. Boushell, DMD, MS

Ricardo Walter, DDS, MS

Manager, Content Strategy: Nimisha Goswami

Printed and bound at …

Sumitha N. Ahmed, BDS, MS Dennis J. Fasbinder, DDS Thiago Morelli, DDS, MS

“If you would not be forgotten as soon as

Either write something worth reading

The first edition of Sturdevant’s Art

Dr Naganath Meena, MDS Dr S. Balagopal, MDS

Dr B. Sajeev, MDS Dr Vivek Aggarwal, MDS

Dr Mahima Tilakchand, MDS Dr Ruchika Roongta Nawal, MDS

Foreword vii 14. Complex Amalgam Restorations....................................375

Clinical Significance of Dental Anatomy, Histology,

Figure 1.1 Maxillary and mandibular teeth in maximum inter-cus-

Clinical Notes Figure 1.3 Electron micrograph of cross-section of rods in mature

Figure 1.5 Gnarled enamel.

groups of rods, and they follow a curving irregular path

striae of Retzius and can be considered growth rings

inflammatory reaction similar to that for any other soft

Figure 1.14 Dentinal tubules in cross-section, 1.2 mm from

Figure 1.16 Ground section showing dentinal tubules and their

Figure 1.17 Tubules in superficial dentin close to the dentinoe-

Figure 1.15 Ground section of human incisor. Course of dentinal

initiate increased formation of dentin along the in-

Dentinal crystallites are smaller than enamel crystal-

Figure 1.20 Stimuli that induce fluid movements in dentinal tu-

Figure 1.27 Relationship of ideal interdental papilla to molar con-

Figure 1.31 Vertical section of a maxillary incisor illustrating sup-

conclusion that in the final analysis, optimal function and

Figure 1.33 Tooth relationships.

Figure 1.34 Common features of all posterior teeth.

Figure 1.35 Functional cusps.

Figure 1.36 Nonfunctional cusps.

ridge or a fossa. Functional cusp–central fossa contact has Nonfunctional Cusps

Dental Caries: Etiology, Clinical Characteristics,

“There are no such things as incurables…

Figure 2.3 Extensive active caries in a young adult (same pa-

Sickness and afflictions is trials sent

The heart that was scornful and cold as a stun,

The wonderful puns and repartees of Charles Lamb and Sydney

“What’s done they” easily “compute.

“SOUND AND” UNSOUND, “SIGNIFYING

See! the fragrant twilight whispers

Now a louder ray of darkness,

Night is near, with all his horrors,

Such a scene, ah! who can list to,

Thus tremulous, and ever dear,

And when hyenal joys are ours,

Something of the same character is the subjoined:

Brightly blue the stars shine o’er us,

Homeward now the aged plough-boys

Gentle zephyrs’ ink-stained fingers

Thus excoriate the hours,

When the September eves were new,

When the September eves were new,

When the September eves were eld,

When the September eves were eld,

The construction of the following verses, from which the letter s is

To-night the liquid wave hath not,

To-night, to-night, my gentle one,

What a boon would a volume of poems, modeled on the above