ENDODONTIC ACCESS AND ANATOMY Endodontic coronal cavity preparation

I. Outline form II. Convenience form III. Removal of caries IV. Toilet of cavity V. Intra-radicular preparation and cleaning Appendix I. Outline form - external outline form evolves from internal anatomy of the pulp as opposed to operative outline form which is based on external anatomy. - size of pulp chamber 1. 2. larger in young teeth smaller in older teeth

- shape of pulp chamber 3. 4. 5. 6. varies with shape of crown age of tooth functional activity history of tooth

- number and curvature of root canals - in Endodontic Access preparation convenience form regulates the ultimate outline form II. Convenience form - objectives of Endodontic Convenience form 1. unobstructed access to the canal orifice 2. direct access to the apical foramen - freedom within coronal cavity to reach apex in unstrained position 3. cavity expansion to accommodate filling techniques 4. complete authority over enlarging instrument - *inadequate convenience form will lead to: 1. perforation of root 2. ledging of root 3. instrument breakage 4. incorrect shape of completed canal 5. improper debridement

III.

Removal of remaining carious dentin - eliminates bacteria from interior of tooth - eliminates discolored tooth structure - eliminates saliva leaking into prepared access cavity - if too much tooth structure is lost which prevents placing of rubber dam and sealing against saliva gingivoplasty or crown lengthening may be necessary.

IV.

Toilet of cavity - all caries, debris and necrotic material must be removed from the pulp chamber before proceeding to root preparation. - flushing the access chamber prevents: 1. obstruction with debris during canal enlargement 2. soft debris from chamber from increasing bacterial population in canal 3. coronal debris from staining crowns especially in anterior teeth

V.

Intra-radicular preparation and cleaning and shaping - will be discussed at another lecture CANAL MORPHOLOGY - see appendix in syllabus

Use of radiographs. An x-ray shows only one two dimensional view of the three dimensional tooth. In preparing outline and convenience form the operator must visualize the total three dimensional morphology of the tooth. Maxillary incisors - relatively straight canals - lateral incisors may have apical curvature to labial or distal or palatal Access: - always on lingual surface of tooth - large triangular funnel shaped coronal preparation - begin with fissure bur at high speed - perpendicular to lingual surface of tooth - penetrate enamel - change direction of bur so it is parallel to long axis of tooth - before pulp chamber is entered, change to round bur at low speed. Mandibular incisors - least likely teeth to need endodontics - some roots have labial or distal curvatures - must explore for second canal by extending adequately into cingulum - triangular shaped access - very similar in coronal appearance Maxillary-mandibular canine

- very stable teeth - usually last ones lost - one large pulp cavity - maxillary canine - one canal - mandibular canine - 43% have 2 roots, 2 canals - access shape - ovoid funnel shaped preparation. Maxillary premolars - first premolars - mostly 2 canals - second premolars - mostly l canal - access-ovoid shaped in bucco-lingual direction - pulp broad bucco-lingually - narrow mesiodistally Buccal Object Rule (Clark's law) - to be used in orienting between two canals on two dimensional x-ray - can be used on any multiple canal tooth - the buccal object rule states that on an angled x-ray, the object (instrument or canal) farthest from the film (most buccal) will appear projected further from the x-ray source compared with a second object closer to the film. - example: the buccal root will always appear distal to the lingual root when an x-ray source is directed from the mesial toward the distal aspect. - to remember - MBD - in Mesial angled x-rays Buccal object is projected to the Distal - DBM - in Distal angled x-ray Buccal object is projected to the Mesial. MANDIBULAR PREMOLARS first premolars - rounded root - narrower mesio-distal than bucco-lingual mostly one canal second premolar - access of first and second premolars is ovoid- shaped extending from cusp tip to cusp tip through occlussal surface MOLARS Maxillary First Molars - three well separated roots - palatal root - longest - mesio buccal root- broad bucco-lingually - mostly 2 canals - distobuccal - smallest root - straightest root - always look for four canals in all first molars

- second mesial canal usually located in line with the groove between the mesiobuccal and palatal canals. Access: - Blunted triangular outline - base of triangle toward buccal - apex of triangle toward palatal - orifice positioned at each angle of the triangle - access cavity is entirely within mesial half of the tooth - triangular access can be extended to blunted triangle to insure locating second mesial canals if present - entire roof of chamber should be removed to insure proper cleaning Maxillary Second Molar - root formation may be different from first molar - usually three canals - access similar to maxillary second molar (blunted triangular - outline) - always look for four canals - more variability of anatomy in second and third molars compared to first molar. Mandibular first molar - has two well formed roots - mesial root - has two canals (buccal and lingual) - distal root - has one or two canals - always look for four canals in all first molars - access - rhomboid/quadralateral shape of access to allow for exploration of second distal canal - access cavity within mesial half of tooth but extended as far distally as necessary to allow for ease of positioning of instruments and filling materials Mandibular second molars - two roots - usually three canals - always look for four canals (rhomboid/quadralateral access outline) - more variability of anatomy in second and third molars as compared with first molar Difficulties caused by poor access preparation 1. Inadequate Opening - compromised cleaning and shaping of canals - compromised instrumentation - coronal discoloration - prevents good fillings - inadequate extension -leaves orifice only partially exposed (mouse-hole effect) - instrument breakage in canal - perforation - ledging

2. Mutilation of coronal tooth due to removal of too much tooth structure - coronal fracture - mutilation of root - ledging, perforation 3. Inadequate caries removal - carious destruction of tooth - discoloration 4. Labial perforation 5. Furcal perforation - difficult to repair - can cause periodontal destruction - weakens tooth structure - can lead to fracture 6. Misinterpretation of angulation of tooth - common with full crown restorations - can lead to root perforations which can cause periodontal problems 7. Entering the wrong tooth - common problem in teeth that are identical coronally, i.e., mandibular anteriors - caused by placing the rubber dam clamp on the wrong tooth 8. Allowing debris to clog orifices - dentinal debris - amalgam fillings IMPORTANT NOTE: The morphology described represents ideal situations. Many teeth that need root canal treatment will no longer have this ideal morphology due to loss of tooth structure, large restorations or crown restorations. By remembering to view the pulp chamber as a three dimensional object, proper access can still be obtained.

Appendix
In order to carry out endodontic treatment, it is (among other things) necessary to know the interior anatomy of the teeth. This outline gives schematic pictures of the anatomy of the fully developed permanent teeth. Also, typical access preparations of the various teeth are described. The shape of the pulp chamber is usually a diminution of the crown. The pulp horns extend towards the cusps in premolars and molars, and towards the incisal edge in incisors and canines. In the following drawings (and in most radiographs) root canals

seem to be straight and the walls seem to be smooth. As a matter of fact, in each tooth there are ramifications, lateral canals and other divergencies from this seemingly straight course. The lateral canals contain periodontal tissues and they can appear everywhere in the root. They are especially prevalent in the most apical part of the root where they form apical deltas.

Permanent dentin production makes the pulp cavity more and more narrow as the patient grows older. Moreover, denticles and hard tissue formation adjacent to cavities also contribute to a narrowing of pulp chamber and root canals.

The apical foramen is usually not situated at the "tip" of the root, but 0.5 - 1.5 mm from the apex. Thus, when a radiograph shows that the tip of a root canal instrument is at the apex, the tip of the instrument is usually beyond the apical foramen (fig). When treating a tooth it is usually not possible to determine the site of the apical foramen and therefore it is recommended to instrument and fill the canal "short of the apex" to decrease the risk of over instrumentation and over filling.

Good visibility and accessibility are necessary to carry out an endodontic treatment satisfactorily. To achieve this, the access preparation must be made so that it is possible to inspect the coronal part of the pulp cavity visually and with instruments after completion of the opening of the pulp chamber. In many instances (probably most) when patients have been referred to an endodontist because a started endodontic treatment has "gone wrong", the cause is poor access preparation.

Underextended access preparations may cause canals to be overlooked, anatomical divergences will not be detected, and infected material will be left in the root canal and that necrotic tissue remaining in the pulp chamber will cause discoloration of the crown. Furthermore, a narrow access preparation may direct a bur or root canal instrument and increase the risk of perforation. It is more important to have good

access than to save a cusp, because a good root filling is necessary to keep an endodontically involved tooth.

Procedure
Remove all caries and fillings that stand in the way of view or that can cause leakage. Undermined enamel shall also be removed together with parts of the crown that make accessability to the canal(s) difficult e.g., mesiobuccal cusps of molars. If there is a pulp exposure, it should be widened, in order to properly determine the extention of the pulp chamber. In this way a proper access preparation can be made. When there is no exposure, access should be made by drilling towards a large pulp horn or the largest area of the pulp chamber. During the access preparation the bur should be used with a pull stroke from the pulp chamber and out. Using this technique of access preparation, it is possible to avoid perforating the floor of the pulp chamber and to get smooth walls without ledges. The access preparation is done with round burs. Long shank round burs are occasionally necessary. The use of fissure burs very often creates ledges in the floor and walls of the cavity access preparation. Such ledges make the canal instrumentation more difficult. Moreover, ledges in the dentin can diminish the tensile strength of the tooth. When completed, the access preparation should be shaped without overhanging edges. In the following schematic drawings the access preparations are drawn with dotted lines.

View preparation for the following teeth:

Central Maxillary Incisor Lateral Maxillary Incisor Maxillary Canine First Maxillary Premolar Second Maxillary Premolar First and Second Maxillary Molars Mandibular Incisors Mandibular Canine First and Second Mandibular Premolars First and Second Mandibular Molars Frequency of Root Canals Average Tooth Length Average Age at the Completion of Root Development

Central Maxillary Incisor

Average Length: 22.5 mm Number of canals: 1 Root development completed at 10 years of age.

The preparation is begun from the palatal surface. The access cavity must be extended in an incisal direction. Too narrow an access cavity (according to wrong in the figure) can leave tissue remnants in the pulp horns which can cause discoloration of the crown. Back to List of Teeth

Lateral Maxillary Incisor

Average Length: 22 mm Number of canals: 1 Root development completed at 10 years of age.

The access preparation of the lateral incisor is also begun from the palatal surface. The root canal is wide in proportion to the root and also there is usually a distopalatal curve in the apical third of the canal. Therefore, the canal must be instrumented carefully to avoid perforation. Back to List of Teeth

Maxillary Canine

Average Length: 26.5 mm Number of canals: 1 Root development completed at 14 years of age.

The access preparation is begun from the palatal surface. The root is often curved apically. This is the longest tooth and therefore considerable widening of the the root canal is needed in order to do a proper root filling. Back to List of Teeth

First Maxillary Premolar

Average Length: 20.6 mm Number of canals: 1 - 19.5% 2 - 79.5% 3 - 1% Root development completed at 13 years of age.

A. When there are two root canals, one is buccal and the other is palatal. B. When there are three root canals, there are two buccal canals and one palatal. The access preparation is begun from the occlusal surface. It is sometimes necessary to cut the cusps to get an adequate view. If the access cavity is not adequately extended buccally and palatally; pulpal remnants will be left undetected.

("wrong" in the figure). Mesially, there is a concavity of the root surface and there is an increased risk of mesio-cervical perforation during access preparation because of this. The roots of the first maxillary premolar are often slender and curved; contours are sometimes difficult to see on the radiograph. Back to List of Teeth

Second Maxillary Premolar

Average Length: 21.5 mm Number of canals: 1 - 56% 2 - 42% 3 - 2% Root development completed at 14 years of age.

The access preparation is again made through the occlusal surface. The root canal in this usually single rooted tooth is band shaped. When there are two canals, one is buccal and one palatal. When there are three canals, two are buccal and one palatal. Back to List of Teeth

First and Second Maxillary Molars

Average Length: first maxillary molar 20.8 mm second maxillary molar 20.0 mm Number of canals: first maxillary molar 3 - 47%, 4 - 53% second maxillary molar 3 - 59%, 4 - 46% Occasionally there are first and second maxillary molars with 1,2, and 5 canals. Root development completed at age: first maxillary molar - 9 second maxillary molar - 15

The access preparation in a maxillary molar is through the occusal surface. Very often it is necessary to reduce the mesiobuccal cusp in order to obtain straight line access to mesiobuccal canal orifice. If there are two canals, they are usually connected, but there are mesiobuccal roots that have two separate canals. Also, there are occasionally two mesiobuccal roots. The palatal and distobuccal roots have one canal each. The mesiobuccal, distobuccal and palatal canal orifices are situated in the "Corners" of the pulp chamber. The location of these orifices represent the vertices of a triangle. The mesiopalatal orifice is mostly situated on a mentally scribed line between the mesiobuccal and palatal canal orifices (A,B). It is not uncommon, especially in the second molar, where the pulp chamber is narrow, for the canal orifices to be more or less in line. (C). Back to List of Teeth

Mandibular Incisors

Average Length: 11.7 mm Number of canals: 1 - 62% 2 - 38% Root development completed at 10 years of age.

Access preparation is done from the lingual surface of the crown. Note that the access cavity has to be extended in a linguo-cervical direction to make it possible to localize a lingual canal. Mostly, the lingual canal joins the buccal canal (see illustration), but separate foramina can occur. Back to List of Teeth

Mandibular Canine

Average Length: 25.6 mm Number of canals: 1 - 57% 2 - 43% Root development completed at 14 years of age. Occasionally there are mandibular canines with two roots.

Access preparation is done lingually. The access cavity has to be extended in a linguo-cervical direction to make a localization and instrumentation of a lingual canal possible. The lingual canal can be situated in a lingual root (A) or join the buccal canal in a common foramen (B) or have a separate foramen within the same root as the buccal canal. Back to List of Teeth

First and Second Mandibular Premolars

Average Length: first mandibular premolar 21.6 mm second mandibular premolar 22.3 mm Number of canals: first mandibular premolar 1 - 98%, 2 - 8% (According to "clinical experience", first mandibular premolars with two root canals are more common than the frequency found by Hess in 1917.) second mandibular premolar 1 - 92%, 2 - 8% Occasionally there are mandibular premolars with three or more canals Root development completed at age: first mandibular premolar 13 second mandibular premolar 14

Access preparation is done occlusally. Very often the occlusal surface is pointing lingually and to make instrumentation of the canal(s) possible, the access cavity must be extended facially (according to the most facial dotted line on Fig A.) and in some cases it is necessary to reduce the facial cusp. If this is not done properly there is a risk for perforation because of interference by the facial cusp during access preparation and canal instrumentation. (C) Where there are two canals, one is buccal and the other, lingual and the division is two canals from the main canal mostly takes place in the apical third of the root (B). Back to List of Teeth

First and Second Mandibular Molars

Average Length: first mandibular molar 21.0 mm second mandibular molar 19.8 mm Number of canals: 1 - 0.5% 2 - 18.0% 3 - 79.5% 4 - 2.0% Root development completed at age: first mandibular molar 10 second mandibular premolar 15

Access preparation is done occlusally. In most instances it is necessary to cut the mesiobuccal cusp to obtain proper accessibility. When there is only one canal, this canal is wide, straight and centrally located. Mandibular molars with two canals have one distal and one mesial canal usually situated in distal and mesial roots. When there are three canals there are two mesial and one distal. Teeth with four canals have two mesial and two distal canals. The canal(s) of the mesial root often have many ramifications that can make their instrumentation and cleaning difficult. Back to List of Teeth FREQUENCY OF ROOT CANALS Number of root canals (%) 1 2 3 Maxillary teeth Central incisors 100 Lateral incisors 100 Canines 100 First premolars 19.9 Second 56 premolars First molars 47 Second molars 54

79.5 42 53 46

1 2

Mandibular teeth Central incisors 62 Lateral incisors 62 Canines 57 First premolars 98 Second 92 premolars First molars 0.5 Second molars 0.5

38 38 43 2 8 18 18 79.5 79.5 2 2

Reference Hess, W. The Anatomy of the Root Canals of the Teeth of the Permanent Dentition. 1925.

Back to List of Teeth AVERAGE TOOTH LENGTH(millimeters) Maxilla Mandible Central incisors Lateral incisors Canines First premolars Second premolars First molars Second molars 22.5 22.0 26.5 20.6 21.5 20.8 20.0 20.7 21.1 25.6 21.6 22.3 21.0 19.8

Reference Black, G.V. Descriptive Anatomy of the Human Teeth, 4th Ed., Philadelphia, 1902. Please note that these are average measures and that there is a great variation in tooth length between various teeth.

Back to List of Teeth AVERAGE AGE AT THE COMPLETION OF ROOT DEVELOPMENT Years Central incisors Lateral incisors Canines First premolars Second premolars First molars Second molars . 10 10 14 13 14 10 15

Back to List of Teeth

Tooth development
Main article: Tooth development

Radiograph of lower right (from left to right) third, second, and first molars in different stages of development.

Panoramic x-ray radiography of the teeth of a 64 year-old male. Dental work performed mostly in UK/Europe in last half of 20th Century

Tooth development is the complex process by which teeth form from embryonic cells, grow, and erupt into the mouth. Although many diverse species have teeth, non-human tooth development is largely the same as in humans. For human teeth to have a healthy oral environment, enamel, dentin, cementum, and the periodontium must all develop during appropriate stages of fetal development. Primary (baby) teeth start to form between the sixth and eighth weeks in utero, and permanent teeth begin to form in the twentieth week in utero.[1] If teeth do not start to develop at or near these times, they will not develop at all. A significant amount of research has focused on determining the processes that initiate tooth development. It is widely accepted that there is a factor within the tissues of the first branchial arch that is necessary for the development of teeth.[2] The tooth bud (sometimes called the tooth germ) is an aggregation of cells that eventually forms a tooth and is organized into three parts: the enamel organ, the dental papilla and the dental follicle.[3] The enamel organ is composed of the outer enamel epithelium, inner enamel epithelium, stellate reticulum and stratum intermedium.[3] These cells give rise to ameloblasts, which produce enamel and the reduced enamel epithelium. The growth of cervical loop cells into the deeper tissues forms Hertwig's Epithelial Root Sheath, which determines the root shape of the tooth. The dental papilla contains cells that develop into odontoblasts, which are dentin-forming cells.[3] Additionally, the junction between the dental papilla and inner enamel epithelium determines the crown shape of a tooth.[2] The dental follicle gives rise to three important entities: cementoblasts, osteoblasts, and fibroblasts. Cementoblasts form the cementum of a tooth. Osteoblasts give rise to the alveolar bone around the roots of teeth. Fibroblasts develop the periodontal ligaments which connect teeth to the alveolar bone through cementum.[4] Tooth development is commonly divided into the following stages: the bud stage, the

cap, the bell, and finally maturation. The staging of tooth development is an attempt to categorize changes that take place along a continuum; frequently it is difficult to decide what stage should be assigned to a particular developing tooth.[5] This determination is further complicated by the varying appearance of different histologic sections of the same developing tooth, which can appear to be different stages.

[edit] Identification

[edit] Nomenclature
Teeth are named by their set, arch, class, type, and side. Teeth can belong to one of two sets of teeth: primary ("baby") teeth or permanent teeth. Often, "deciduous" may be used in place of "primary", and "adult" may be used for "permanent". "Succedaneous" refers to those teeth of the permanent dentition that replace primary teeth (incisors, canines, and premolars of the permanent dentition). Succedaneous dentition would refer to these teeth as a group. Further, the name depends upon which arch the tooth is found in. The term, "maxillary", is given to teeth in the upper jaw and "mandibular" to those in the lower jaw. There are four classes of teeth: incisors, canines, premolars, and molars. Premolars are found only in permanent teeth; there are no premolars in deciduous teeth. Within each class, teeth may be classified into different traits. Incisors are divided further into central and lateral incisors. Among premolars and molars, there are 1st and 2nd premolars, and 1st, 2nd, and 3rd molars. The side of the mouth in which a tooth is found may also be included in the name. For example, a specific name for a tooth may be "primary maxillary left lateral incisor."

[edit] Numbering systems

Main article: Dental notation

There are several different dental notation systems for associating information to a specific tooth. The three most commons systems are the FDI World Dental Federation notation, Universal numbering system (dental), and Palmer notation method. The FDI system is used worldwide, and the universal is used widely in the USA. Although the Palmer notation was supposedly superseded by the FDI World Dental Federation notation, it overwhelmingly continues to be the preferred method used by dental students and practitioners in the United Kingdom.[6] It was originally termed the "Zsigmondy system" after the Austrian dentist Adolf Zsigmondy who developed the idea in 1861, using a Zsigmondy cross to record quadrants of tooth positions. [7]. The Palmer notation consists of a symbol ( ) designating in which quadrant the tooth is found and a number indicating the position from the midline. Permanent teeth are numbered 1 to 8, and primary teeth are indicated by a letter A to E. The universal numbering system uses a unique letter or number for each tooth. The uppercase letters A through T are used for primary teeth and the numbers 1 - 32 are used for permanent teeth. The tooth designated "1" is the right maxillary third molar and the count continues along the upper teeth to the left side. Then the count begins at the left mandibular third molar, designated number 17, and continues along the

bottom teeth to the right side. The FDI system uses a two-digit numbering system in which the first number represents a tooth's quadrant and the second number represents the number of the tooth from the midline of the face. For permanent teeth, the upper right teeth begin with the number, "1". The upper left teeth begin with the number, "2". The lower left teeth begin with the number, "3". The lower right teeth begin with the number, "4". For primary teeth, the sequence of numbers goes 5, 6, 7, and 8 for the teeth in the upper right, upper left, lower left, and lower right respectively. As a result, any given tooth has three different ways to identify it, depending on which notation system is used. The permanent right maxillary central incisor is identified by the number "8" in the universal system. In the FDI system, the same tooth is identified by the number "11". The palmer system uses the number and symbol, 1, to identify the tooth. Further confusion may result if a number is given on a tooth without assuming (or specifying) a common notation method. Since the number, "12", may signify the permanent left maxillary first premolar in the universal system or the permanent right maxillary lateral incisor in the FDI system, the notation being used must be clear to prevent confusion. Victor Haderup of Denmark in 1891 devised a variant of eight tooth quadrant system in which plus(+) and minus(-) were used to differentiate between upper and lower quadrants, and betweenright and left quadrants(e.g.,+1=upper right central incisor;1=lower left central incisor.).Primary teeth were numbered as upper right(05+ to 01+),lower left(-01 to -05).This system is stil taught in Denmark.<reference/>DR. HARSH SHAH

[edit] Anatomic landmarks

[edit] Crown and root

The tooth is attached to the surrounding gingival tissue and alveolar bone (C) by fibrous attachments. The gingival fibers (H) run from the cementum (B) into the gingiva immediately apical to the junctional epithelial attachment and the periodontal ligament fibers (I), (J) and (K) run from the cementum into the adjacent cortex of the alveolar bone.

The crown of a tooth can be used to describe two situations. The anatomic crown of a tooth is designated by the area above the cementoenamel junction (CEJ) and is consequently covered in enamel. Also, it is possible to describe the clinical crown of a tooth as any parts visible in the mouth, but frequently the anatomic crown is meant when the term is used. The majority of the crown is composed of dentin, with the pulp chamber found in the center. The crown is only found within bone before eruption into the mouth. Afterwards, it is almost always visible. The anatomic root is found below the cementoenamel junction and is covered with cementum, whereas the clinical root is any part of a tooth not visible in the mouth. Similarly, the anatomic root is assumed in most circumstances. Dentin composes most of the root, which normally has pulp canals. The roots of teeth may be single in number (single-rooted teeth) or multiple. Canines and most premolars, except for maxillary first premolars, usually have one root. Maxillary first premolars and mandibular molars usually have two roots. Maxillary molars usually have three roots. The tooth is supported in bone by an attachment apparatus, known as the periodontium, which interacts with the root.

[edit] Surfaces
Surfaces that are nearest the cheeks or lips are referred to as facial, and those nearest the tongue are known as lingual. Facial surfaces can be subdivided into buccal (when found on posterior teeth nearest the cheeks) and labial (when found on anterior teeth nearest the lips). Lingual surfaces can also be described as palatal when found on maxillary teeth beside the hard palate. Surfaces that aid in chewing are known as occlusal on posterior teeth and incisal on anterior teeth. Surfaces nearest the junction of the crown and root are referred to as cervical, and those closest to the apex of the root are referred to as apical. The words mesial and distal are also used as descriptions. "Mesial" signifies a surface closer to the median line of the face, which is located on a vertical axis between the eyes, down the nose, and between the contact of the central incisors. Surfaces further away from the median line are described as distal.

[edit] Cusp
A cusp is an elevation on an occlusal surface of posterior teeth and canines. It contributes to a significant portion of the tooth's surface. Canines have one cusp. Maxillary premolars and the mandibular first premolars usually have two cusps. Mandibular second premolars frequently have three cusps--- one buccal and two lingual. Maxillary molars have two buccal cusps and two lingual cusps. A fifth cusp that may form on the maxillary first molar is known as the cusp of Carabelli. Mandibular molars may have five or four cusps.

[edit] Cingulum
A cingulum is a convexity found on the lingual surface of anterior teeth. It is frequently identifiable as an inverted V-shaped ridge,[8] and its appearance is comparable to a girdle.[9] All anterior teeth are formed from four centers of development, referred to as lobes. Three are located on the facial side of the tooth, and one on the lingual side. The cingulum forms from this lingual lobe of development.[10] The majority of a lingual surface's cervical third is made up of the cingulum.[11] On lower incisors, a cingulum usually is poorly developed or absent. Maxillary canines have a large, well-developed cingulum,[11] where as the cingulum of mandibular canines is smoother and rounded.[12]

[edit] Ridges
Ridges are any linear, flat elevations on teeth,[13] and they are named according to their location. The buccal ridge runs cervico-occlusally in approximately the center of the buccal surface of premolars. The labial ridge is one that runs cervico-incisally in approximately the center of the labial surface of canines. The lingual ridge extends from the cingulum to the cusp tip on the lingual surface of most canines. The cervical ridge runs mesiodistally on the cervical third of the buccal surface of the crown. These are found on all primary teeth but only on the permanent molars. Cusp ridges are ridges that radiate from cusp tips. There are two marginal ridges, mesial and distal, present on all teeth. On anterior teeth, they are located on the mesial and distal borders of the lingual surface; on posterior teeth, they are located on the mesial and distal borders of the occlusal surface. Triangular ridges are those that project from the cusp tips of premolar and molars to the central groove. Transverse ridges are formed by the union of two triangular ridges on posterior teeth. The joining of buccal and lingual triangular ridges is usually named as an example. The oblique ridge is found on the occlusal surfaces of maxillary molars. It is formed by the union of the distal cusp ridge of the mesiolingual cusp and the triangular ridge of the distobuccal cusp. The oblique ridges usually forms the distal boundary of the central fossa.

[edit] Developmental groove

The teeth demonstrating the least number of developmental grooves are the mandibular central and lateral incisors.[14] however the canines show the most prominent developmental grooves, because they have strong anchorage to the bone.

[edit] Embrasures
Embrasures are triangularly shaped spaces located between the proximal surfaces of adjacent teeth. The borders of embrasures are formed by the interdental papilla of the gingiva, the adjacent teeth, and the contact point where the two teeth meet. There are four embrasures for every contact area: facial (also called labial or buccal), lingual (or palatal), occlusal or incisal, and cervical or interproximal space. The cervical embrasure usually is filled by the interdental papilla from the gingiva.

Embrasures have three functions. They form spillways between teeth to direct food away from the gingiva. Also, they provide a mechanism for teeth to be more self cleansing. Lastly, they protect the gingiva from undue frictional trauma but also providing the proper degree of stimulation to the tissues.

[edit] Mammelons
Mammelons are usually found as three small bumps on the incisal edges of anterior teeth. They are the remnants of three lobes of formation of these teeth, the fourth lobe represented by the cingulum. Since this surface of the tooth is the first to wear away from attrition, mammelons may not be visible on teeth of older people. Instead, the best chance to see this characteristic is soon after eruption of the tooth into the mouth.

[edit] Distinguishing characteristics of teeth

[edit] Incisor
8 incisors are anterior teeth, 4 in the upper arch and 4 in the lower. Their function is for shearing or cutting food during chewing. There are no cusps on the teeth. Instead, the surface area of the tooth used in eating is called the incisal ridge or incisal edge. Though similar, there are some minor differences between the primary and permanent incisors.
[edit] Maxillary central incisor

Main article: Maxillary central incisor

The maxillary central incisor is usually the most visible tooth, since it is the top center two teeth in the front of a mouth, and it is located mesial to the maxillary lateral incisor.The overall length of the deciduous maxillary central incisor is 16 mm on average, with the crown being 6 mm and the root being 10 mm.[15] In comparison to

the permanent maxillary central incisor, the ratio of the root length to the crown length is greater in the deciduous tooth. The diameter of the crown mesiodistally is greater than the length cervicoincisally, which makes the tooth appear wider rather than taller from a labial viewpoint. The permanent maxillary central incisor is the widest tooth mesiodistally in comparison to any other anterior tooth. It is larger than the neighboring lateral incisor and is usually not as convex on its labial surface. As a result, the central incisor appears to be more rectangular or square in shape. The mesial incisal angle is sharper than the distal incisal angle. When this tooth is newly erupted into the mouth, the incisal edges have three rounded features called mammelons.[16] Mammelons disappear with time as the enamel wears away by friction.
[edit] Maxillary lateral incisor Main article: Maxillary lateral incisor

The maxillary lateral incisor is the tooth located distally from both maxillary central incisors of the mouth and mesially from both maxillary canines.
[edit] Mandibular central incisor Main article: Mandibular central incisor

The mandibular central incisor is the tooth located on the jaw, adjacent to the midline of the face. It is mesial from both mandibular lateral incisors.
[edit] Mandibular lateral incisor Main article: Mandibular lateral incisor

The mandibular lateral incisor is the tooth located distally from both mandibular central incisors of the mouth and mesially from both manibular canines.

[edit] Canine
Both the maxillary and mandibular canines are called the "cornerstone" of the mouth because they are all located three teeth away from the midline, and separate the premolars from the incisors. The location of the canines reflect their dual function as they complement both the premolars and incisors during chewing. Nonetheless, the most common action of the canines is tearing of food. There is a single cusp on canines, and they resemble the prehensile teeth found in carnivorous animals. Though similar, there are some minor differences between the deciduous and permanent canines.
[edit] Maxillary canine Main article: Maxillary canine

The maxillary canine is the tooth located laterally from both maxillary lateral incisors of the mouth but mesially from both maxillary first premolars. It is the longest tooth in total length, from root to the incisal edge, in the mouth.

[edit] Mandibular canine Main article: Mandibular canine

The mandibular canine is the tooth located distally from both mandibular lateral incisors of the mouth but mesially from both mandibular first premolars.

[edit] Premolar
Premolars are found distal to canines and mesial to molars. They are divided into first and second premolars. The functions of premolars vary. There are no deciduous premolars. Instead, the teeth that precede the permanent premolars are the deciduous molars.
[edit] Maxillary first premolar Main article: Maxillary first premolar

The maxillary first premolar is the tooth located laterally from both the maxillary canines of the mouth but mesially from both maxillary second premolars. The function of this premolar is similar to that of canines in regard to tearing being the principal action during chewing. There are two cusps on maxillary first premolars, and the buccal cusp is sharp enough to resemble the prehensile teeth found in carnivorous animals with boners. There is a distinctive concavity on the cervical third of the crown extending onto the root.[17]
[edit] Maxillary second premolar Main article: Maxillary second premolar

The maxillary second premolar is the tooth located laterally from both the maxillary first premolars of the mouth but mesially from both maxillary first molars. The function of this premolar is similar to that of first molars in regard to grinding being the principal action during chewing. There are two cusps on maxillary second premolars, but both of them are less sharp than those of the maxillary first premolars.
[edit] Mandibular first premolar Main article: Mandibular first premolar

The mandibular first premolar is the tooth located laterally from both the mandibular canines of the mouth but mesially from both mandibular second premolars. The function of this premolar is similar to that of canines in regard to tearing being the principal action during mastication. Mandibular first premolars have two cusps. The one large and sharp is located on the buccal side of the tooth. Since the lingual cusp is small and nonfunctional, which means it is not active in chewing, the mandibular first premolar resembles a small canine.
[edit] Mandibular second premolar Main article: Mandibular second premolar

The mandibular second premolar is the tooth located distally from both the mandibular first premolars of the mouth but mesially from both mandibular first molars. The function of this premolar is to assist the mandibular first molar during mastication. Mandibular second premolars have three cusps. There is one large cusp on the buccal side of the tooth. The lingual cusps are well developed and functional, which means the cusps assist during chewing. Therefore, whereas the mandibular first premolar resembles a small canine, the mandibular second premolar is more like the first molar.

[edit] Molar
Molars are the most posterior teeth in the mouth. Their function is to grind food during chewing. The number of cusps, and thus the overall appearance, vary among the different molars and between people. There are great differences between the deciduous molars and those of the permanent molars, even though their functions are similar. Permanent maxillary molars are not considered to have any teeth that precede them. Despite being named "molars", the deciduous molars are followed by permanent premolars. The third molars are commonly called "wisdom teeth."
[edit] Maxillary first molar Main article: Maxillary first molar

The maxillary first molar is the tooth located laterally from both the maxillary second premolars of the mouth but mesially from both maxillary second molars. There are usually four cusps on maxillary molars, two on the buccal and two palatal.
[edit] Maxillary second molar Main article: Maxillary second molar

The maxillary second molar is the tooth located laterally from both the maxillary first molars of the mouth but mesially from both maxillary third molars. This is true only in permanent teeth. In deciduous teeth, the maxillary second molar is the last tooth in the mouth and does not have a third molar behind it. The deciduous maxillary second molar is also the most likely of the deciduous teeth to have an oblique ridge. There are usually four cusps on maxillary molars, two buccal and two palatal.
[edit] Maxillary third molar Main article: Maxillary third molar

The maxillary third molar is the tooth located laterally from both the maxillary second molars of the mouth with no tooth posterior to it in permanent teeth. In deciduous teeth, there is no maxillary third molar. There are usually four cusps on maxillary molars, two buccal and two palatal. Nonetheless, for this tooth, there are great variances among third molars, and a specific description of a third molar will not hold true in all cases.
[edit] Mandibular first molar Main article: Mandibular first molar

The mandibular first molar is the tooth located distally from both the mandibular second premolars of the mouth but mesially from both mandibular second molars. It is located on the mandibular arch of the mouth, and generally opposes the maxillary first molars and the maxillary 2nd premolar. This arrangement is known as Class I occlusion. There are usually five well-developed cusps on mandibular first molars: two on the buccal, two palatal, and one distal.
[edit] Mandibular second molar Main article: Mandibular second molar

The mandibular second molar is the tooth located distally from both the mandibular first molars of the mouth but mesially from both mandibular third molars. This is true only in permanent teeth. In deciduous teeth, the mandibular second molar is the last tooth in the mouth and does not have a third molar behind it. Though there is more variation between individuals to that of the first mandibular molar, there are usually four cusps on mandibular second molars: two buccal and two palatal.
[edit] Mandibular third molar Main article: Mandibular third molar

The mandibular third molar is the tooth located distally from both the mandibular second molars of the mouth with no tooth posterior to it in permanent teeth. In deciduous teeth, there is no mandibular third molar. For this tooth, there are great variances among third molars, and a specific description of a third molar will not hold true in all cases TAXONOMY-DENTAL ANATOMY