Tooth development

A process is also known as odontogenesis.

Tooth development is the complex process by which teeth form from embryonic
cells, grow, and erupt into the mouth. It is started at 6th week of gestation.

odontogenesis involves the development of primary (deciduous) and permanent

(secondary) dentition, and overlapping period between the primary and secondary
dentition is referred to as the mixed dentition period.
The process of development for both dentitions is similar, only the time of development
is different.
Two embryonic tissues are responsible for the development of a tooth:
1. Ectomesenchymal tissues( neural crest in origin) which give rise to the dentin
, pulp, periodontal ligament , cementum and part of alveolar bone
2. Oral epithelium (ectoderm) which gives rise to enamel of the tooth.

Nutrition and tooth development

As in other aspects of human growth and development, nutrition has an effect on the
developing tooth. Essential nutrients for a healthy tooth include calcium, phosphorus, and
vitamins A, C, and D. Calcium and phosphorus are needed to properly form the
hydroxyapatite crystals, and their levels in the blood are maintained by Vitamin D.
Vitamin A is necessary for the formation of keratin, as Vitamin C is for collagen. Fluoride,
although not a nutrient, is incorporated into the hydroxyapatite crystal of a developing
tooth and bones.

FORMATION OF PRIMARY DENTITION

Stages of development:

1. INTIATION STAGE:
The first sign of tooth development is appearance of condensation of ectomesenchymal
tissue and capillary network beneath the presumptive dental epithelium. Certain areas
of basal cells of oral ectodermal epithelium proliferate more rapidly than do the cells of
the adjacent areas, to form the primary epithelial band (Figure 16). During initiation
stage there is an interaction between ectodermal epithelium and the ectomesenchymal
underlying tissue

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 Stomodeum

Primary epithelial band

Ectomesenchyme

Figure (16 ) : showing the initiation stage of odontogenesis,notice the two types of tissue
involved in tooth development i.e the oral epithelium and ectomesenchyme.

The dental lamina, which is a band of epithelium, invades the ectomesenchymal cells
along each of horse shoe-shaped future dental arch. At the front of the mouth this
growth is in lingual direction.
The dental lamina of each jaw shows at intervals, down growths, along its length, in a
form of small rounded swellings which involves the whole thickness of the lamina,
from its free edge to its base where the lamina is attached to the mouth epithelium.
These epithelial swellings of the lamina are the enamel organs which represent the
tooth buds of deciduous teeth. The developments of enamel organs of permanent
molars arise directly from a distal backward extension of the dental lamina of the
second molar (Figure 17) .They arise according to the following sequence:
The first permanent molar is initiated at fourth month in utero, the second permanent
molar is initiated at 1st year after birth, and the third permanent molar is initiated at 4 th or
5th years.

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Fig. (17) Showing the development of permanent molars from an extension of
dental lamina growing backward underneath the oral epithelium.

The successors of the deciduous teeth (permanent teeth) develop from the lingual
extension of the free (lingual) end of the dental lamina opposite to enamel organ of
each deciduous tooth.
The lingual extension of dental lamina is named the successional lamina and
developed during the 5th month in utero (permanent central incisor) to 10th month of
baby age (second permanent premolar).

A timetable to remember
Entire primary dentition initiated between 6 and 8 weeks of embryonic
development.
Successional permanent teeth initiated between 20th week in utero
and 10th month after birth
Permanent molars between 20th week in utero (first molar) and 5th year of
life (third molar)

FATE OF DENTAL LAMINA: -

The activity of dental lamina extends over a period of at least 5 years. During these five
years the dental lamina still active in the third molar region after it has disappeared
elsewhere. As the teeth continue to develop they lose their connection with dental
lamina. They later break up by mesenchymal invasion. Remnants of the dental lamina
persist as epithelial pearls of Serres within the jaw and gingiva(figure 18).

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 Epithelial
pearls of
Serres

Figure (18): Epithelial pearls of Serres as one of the fate of dental lamina

2) BUD STAGE: -
It occurs at 8 week. The epithelium of the dental lamina is separated from the
underlying ectomesenchymal cells by a basement membrane (figure 16). It is named
so, because there is an extensive proliferation or in growth of the dental lamina into
buds or ovoid swelling (masses) penetrating into the ectomesenchymal. This
penetration is occurring at 10 different locations involving the primary (deciduous)
dentition of maxillary arch and 10 sites for mandibular arch. The underlying
ectomesenchyme also undergo proliferation.
These buds are representing the primordial of the enamel organs of primary dentition
(figure 19).

3) CAP STAGE: -
By the eleventh week, the tooth bud continues to proliferate. There is unequal growth in
different parts of the tooth bud leading to formation of cap shape structure attached to
the dental lamina, which is characterized by a shallow invagination on the deep surface
of the bud (Figure 20).The epithelial cells now become the enamel organ and remain
attached to the dental lamina. Due to the invagination of the deep surface of the bud the
following layers could be outlined in the enamel organ:
a. outer and inner enamel epithelium

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 b Stellate reticulum: the polygonal shaped cells located in the center of the
enamel organ between the inner and outer enamel epithelium begin to separate as
more intercellular fluid is attracted to this area because the cells of the stellate
reticulum produce hydrophilic extra cellular matrix rich in glycosaminoglycan. The
cells of this region assume a stare shape, hence the name Stellate reticulum. The
volume of extracellular space starts to increase and reached its maximum size
during the next stage i.e. the bell stage.
The ectomesenchymal cells form the dental papilla . The dental papilla is the
formative organ of the dentin and the pulp. The tissue surrounding these two structures
is the dental follicle.
The dental follicle: Is a marginal condensation of the ectomesenchyme surrounding the
enamel organ and dental papilla. It has a dense fibrous and vascular content. The cells
of the dental sac are important for the formation of cementum, periodontal ligament
(PDL) and part of alveolar bone. After further growth of the papilla and the enamel
organ ,the tooth reaches the bell stage.

Dental (enamel) organ

Dental papilla

Dental follicle

Figure 20: Is showing the cap stage of tooth development. The three parts of
tooth germ is represented by enamel organ; dental papilla; and dental follicle.

4) BELL STAGE: -

The bell stage is known for the histodifferentiation and morphodifferentiation that taken
place. The enamel organ is bell-shaped during this stage, and the majority of its cells

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are called stellate reticulum because of their star-shaped appearance. Cells on the
periphery of the enamel organ separate into three important layers. Cuboidal cells on
the periphery of the enamel organ are known as outer enamel epithelium. The
columnar cells of the enamel organ adjacent to the dental papilla are known as inner
enamel epithelium. The cells between the inner enamel epithelium and the stellate
reticulum form a layer known as the stratum intermedium. The rim of the dental organ
where the outer and inner enamel epithelium joins is called the cervical loop. It has two
sub stages early bell and late bell stage. The enamel organ has deep epithelial
invagination and its margin continue to grow.

Early bell stage:

It occurs between twelve to fourteenth week. Four types of epithelial layers could be
seen in the enamel organ at this stage (Table 2 and figures 21 and 22):
i. Inner enamel epithelium: Consists of a single layer of cells that differentiate prior
to amelogenesis into tall columnar cells called ameloblasts. These cells attached to
each other by junctional complex and the cells of stratum intermedium by desmosomes.
The cells of inner enamel epithelium exert an organizing influence on the underlying
ectomesenchymal cells in the dental papilla which later differentiates into odontoblasts
which produce dentin in the crown and root. The function of the inner enamel epithelium
includes;
1- Determine the form and size of the crown.
2- By its effect on dental papilla they initiate the differentiation of dentine forming
cells (odontoblasts) by a process called epithelio-ectomesenchymal interaction.
3- Differentiate into ameloblasts, which lay down enamel.

ii. Stratum intermedium: consists of 3-5 squamous cell layers between the
inner enamel epithelium and stellate reticulum. These cells are attached by
desmosomes and gap junctions. This layer is essential for the enamel
formation because its cells contain alkaline phosphatase. It is absent in the
part of the tooth germ that outlines the root portions of the tooth germ.
iii. Stellate reticulum: expands in this stage further due to an increase in the
amount of intercellular fluid. The cells are star-shaped with long processes that
attach with each other by desmosomes and gap junctions. Its function includes:
Protection of stratum intermedium and inner enamel epithelium,
iv. Outer enamel epithelium: become low cuboidal cells, their outer surface is
indented by capillaries which provide nutrition for the different cells of the enamel
organ.

Dental papilla: at this stage the peripheral cells of the ectomesenchyme under the
influence of the inner enamel epithelium differentiate into odontoblasts.
Dental sac (follicle): shows increase in amount of collagen fibers, which form a circular
arrangement around the enamel organ. With the development of the root these fibers
differentiate into PDL fibers. The functions of the dental sac include:
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1- Tthe nutrition of the enamel organ.
2- Maintain the relationship of enamel organ with the oral mucosa during growth.
3- Controls the form and size of the bony cavity in which the developing tooth germ
lies.
4- Finally the cells (ectomesenchyme) of the dental follicle will form the cementum,
PDL and part of alveolar bone.

Stellate
reticulum

Successional
Lamina of permanent
tooth
OEE
IEE
Cervical loop

Figure 21: Early bell stage of tooth development, which exhibits differentiation
of the tooth germ. Note the enamel organ and the dental papilla. The enamel
organ has differentiated into various layers in preparation for the formation of
enamel:outer enamel epithelium(OEE);inner enamel epithethelium(IEE) both
layers meet at cervical loop.The successional lamina for secondary tooth
appear at this stage.

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 Outer dental epithelium
Stellate reticulum
Inner dental epithelium
Stratum intermedium
Dental papilla •

Figure 22: Various layers of the enamel organ are demonstrated.

b. Late bell stage

The late bell stage is associated with the formation of dental hard tissue
commencing at about the 18th week of gestation (figures 23 and 24).
In late bell stage:
a. The boundary between inner enamel epithelium and odontoblasts outline the
future dentin-enamel junction.
b. The cervical loop of enamel organ gives rise to the epithelium root sheath of
Hertwig.
c. The first laid dentin occurs also in this stage and that is an indication of the
transition of the tooth germ from early to late bell stage.
d. The stellate reticulum starts to reduce in size at the site of hard tissue
formation which starts at the occlusal surfaces. This will reduce the distance
for the passing of nutrition to the preameloblast and latter the ameloblasts.
The dental hard tissue formation is having occluso-cervical direction.
The formation of dentin marks the onset of the crown stage of tooth development.

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 Successional
Lamina of permanent
tooth

Figure 23: Late bell stage with various layer of the enamel organ:OEE=outer
enamel epithelium;IEE=inner enamel epithelium;SI=stratum
intermedium;SR=stratum intermedium;D=recently formed dentin;OD=odontoblast
;PA=preameloblast;DL=dental lamina.

Outer dental epithelium

Stellate reticulum
Inner dental epithelium
Stratum intermedium
Dental papilla •

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Figure 24 : Higher magnification for the late bell stage demonstrating the different
layers of enamel organ.

5) APPOSITION (CROWN) STAGE: -

Hard tissues, including enamel and dentin, develop during this stage. The enamel and
dentin are secreted in successive layers in occluso- cervical direction (figure 25).

Cervical loop

Dental papilla

©Copyright 2007, Thomas G. Hollinger, Gainesville, Fl

Figure 25: Demonstrates the occuluso-cervical direction of hard tissue formation

6) MATURATION STAGE: -
During which the dental hard tissues are fully mineralized.

N.B:- The time period for the last two stages varies according to the tooth
involved.

Epithelio-ectomesenchymal interaction during tooth development:

The development of the tooth germ involves many reciprocal interactions between the
epithelium of the enamel organ and the ectomesenchymal cells of dental sac and dental
papilla. These interactions are termed epithelio-ectomesenchymal interaction during
tooth development. A chemical substance is produced by one cell layer and diffuses the
narrow intervening space to be taken up and cause induction in the other cell layer.

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Epithelial root sheath of Hertwig:

The development of the roots begins after enamel and dentin formation has reached the
future cemento-enamel junction.
The enamel organ is forming the epithelial root sheath of Hertwig, which molds the
shape of the roots and initiates radicular dentin formation.
The epithelial root sheath of Hertwig is consisting of the outer and inner enamel
epithelium only. It is extending by proliferation from the cervical loop. This area is having
the outer enamel epithelium becomes continuous with the inner enamel epithelium. The
cells of the inner enamel epithelium remain short and normally do not produce enamel,
but the inner enamel epithelium has the potential to induce the differentiation of the cells
of dental papilla to become odontoblast to form the radicular dentin. During its formation
the root sheath grows apically to enclose the dental papilla and separates the papilla
from the dental follicle ectomesenchymal cells.

The root sheath also helps in the formation of the epithelial diaphragm when both ends
bend inward to enclose the dental papilla to form the limit for the primary apical
foramen. The root sheath ultimately undergoes fragmentation, after root formation.
Remnants of the root sheath do persist in close proximity as a cluster of cells knows as
epithelial rest cells of Malassez.
In adult the rest cells found, in PDL. These rest cells may be involved in formation
odental cysts.

Figure 26: The epithelial root sheath of Hertwig is extending from the cervical
loop and is composed of only the inner and outer enamel epithelium.

Epithelial root sheath of Hertwig

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Root formation:

It begins when the enamel and dentin formation has reached to the future cement
enamel junction(CEJ). When a tooth first erupts, only about 2/3 of the length of its root
is completed.
Root development is concomitant with the start of eruptive movement.

Prior to the beginning of root formation the root sheath forms the epithelial diaphragm
(figure 27). The outer and inner enamel epithelium bends at the future cemento-enamel
junction (CEJ) into a horizontal plane, narrowing the wide cervical opening of the tooth
germ.
The proliferation of the cells of the epithelial diaphragm is accompanied by proliferation
of the cells of the dental papilla adjacent to the diaphragm.
The free end of the diaphragm does not grow into connective tissue but the epithelium
proliferate above the epithelial diaphragm, so that the epithelial root sheath proliferate
apically at the same rate at which the developing tooth is erupting.
The inner enamel epithelium of the root sheath induces the peripheral cells of the dental
papilla to differentiate into odontoblasts. When the odontoblasts are differentiated and
begin to deposit dentin the continuity of root sheath is lost.
The breakdown of root sheath at the level of developing root, at which dentin production
has begun, allows the undifferentiated ectomesenchymal cells of the dental sac to move
toward the surface of root dentin(figure 28).
The remnants of root sheath stayed in periodontal ligament as cell rests of Malassez.
The factor which leads to differentiation of the cells of dental sac into cementoblasts
probably is coming from the recently deposited root dentin.
Cementoblasts start to lay down the cementum on the surface of the dentin.
In single rooted teeth, the epithelial root sheath simply grows apically as an epithelial
cylinder.

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 Epithelial diaphragm

Figure 27 :Formation of epithelial diaphragm prior to the formation of the root.

In teeth with two to three roots the single cervical opening must be divided into two or
three opening. This subdivision is done by the horizontal outgrowth of two or three
epithelial flaps across the cervical opening. These flaps meet in the center of cervical
opening where they fuse. Then from the edges of this opening two to three root sheaths
grow apically.

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Figure 28 : Showing stages in root development .(1) The HERS, (2) •
epithelial rest cells of Malassez, (3) Dental follicle, (4) cementoblasts, (5)
periodontal ligament, (6) alveolar cells, (7) bone, (8) odontoblasts.

N.B: -
Cells of root sheath of Hertwig may remain adherence to the dentin surface. They may
differentiate into fully functioning ameloblast and produce enamel called enamel pearls
found in area of furacation of roots of permanent molars.

DEVELOPMENT OF THE SECONDARY DENTITION: -

1- The incisors, canines, and premolars of 2 nd dentition:-

These teeth are developed from tooth buds growing off the dental lamina as
successional lamina at the level of the tooth germs of the primary dentition, which are
at that time, were in the bell stage.
The secondary enamel organs remain temporarily attached to the parent dental lamina
by a successional dental lamina. The secondary tooth germs developed lingual to the
primary tooth germ. The lingual extension of the dental lamina (successional lamina)
develops from the 5th month in utero for permanent Central incisor, to tenth month of
age for second premolar.
2. The molars of the secondary dentition:
They have no primary predecessors. Their enamel organs develop from a blind
backward extension of the dental lamina of the primary dentition. This blind extension
grows backward in the jaw, underneath the oral mucosa, from the dental lamina of the

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second molars of the primary dentition. This extension give rise, in succession, to the
enamel organs of first, second and third molars of secondary dentition.
The development of the first permanent molar is initiated at the fourth month in utero,
the second molar is initiated at about first year after birth, the third molar at the fourth or
fifth years.
Both the primary and secondary teeth are in different stages of development, but they
share a common bony crypt.

THE ROOT FORMATION ANOMALIES:

1- Formation of accessory root canal:

If the continuity of the root sheath were broken before dentin formation, the result could
be missing or defective epithelial cells. The odontoblasts would not differentiate, and
dentin would not form opposite the defect in the root sheath. The result would be a
small lateral canal connecting the PDL with the main root canal. The supplemented
canal called accessory root canal.

2- Exposed root dentin: -

This caused by failure of degeneration of the epithelial root sheath at the proper time,
and remains adherent to the root dentin surface, so ectomesenchymal cells of the
dental follicle will not come in contact with the dentin. Thus ectomesenchymal cells of
the dental follicle will not differentiate into cementoblasts and no formation of
cementum.
The exposed dentin areas could be found in any place of the root surface especially in
cervical zone, and may be the cause of cervical sensitivity late in life when gingival
recession takes place.

3-Formation of enamel pearls:

The epithelial root sheath may also remain adherent to the dentin in the cervical area
near the furacation zone. In this case the inner cells of the epithelial root sheath may
differentiate in functional ameloblast and produce enamel known as enamel pearls. It is
found lodged between the roots of permanent molars.

Agents affecting tooth and bone development:

1- Vitamin A deficiency:
(a) In vitamin A deficiency the ameloblast fail to differentiate properly.
Consequently their organizing influence on the adjacent mesenchymal cells is
disturbed and atypical dentin known as osteodentin is formed.
(b) Metaplasia of enamel organ result in defective enamel and dentin formation.
(c) Bone is laid down in abnormal location.
(d) Enamel hypoplasia.

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2- Vitamin C deficiency:
a) Scurvy the disease results in cease of bone, dentin and cementum deposition,
and the formative cells to atrophy.
b) Gingival bleeding.
c) Loosening of the tooth due to bone resorption.
3- Vitamin D deficiency :
a) Hypoplasia of the enamel.
b) Hypomineralized cementum.

4-Parathyroid hormone:
Both hypo and hyperparathyroidism produce calcium imbalance results in hypo and
hyper calcified bands in the forming dentin.

5-Pituitary gland:
Retarded eruption occurs in persons with hypopitutiarism.

6- Thyroid gland: hypothyroidism results in small clinical crown.

7- Tetracycline and fluorides:

The first formed dentin is showing staining if tetracycline is deposited to the mother from
the 5th month of pregnancy until term i.e. during the period of mineralization .The same
effect is in the child up to 12 years of age because the period is marked by
mineralization of crown extends from 5 months in utero (transplacental crossing) to 12
years of age and include the mineralization of both also include hypoplasia and loss of
the enamel. The staining of teeth with tetracycline(figure 29) is permanent while with the
bone is not due to the process of remodeling of the bone which continuously throughout
life.
8. Fluoride at concentration of 0.5 PPM prevents caries. But higher concentration
(3 ppm) causes mottled enamel.

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 Incorporation of
Tetracycline
during
Dentinogenesis

©Copyright 2007, Thomas G. Hollinger, Gainesville, Fl

Fig.(29) showing permanent lines formed by incorporation of tetracycline in the

dentin .

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