Embryology and Anatomy of the Jaw and

Dentition
Vahe M. Zohrabian, MD, Colin S. Poon, MD, PhD, and James J. Abrahams, MD

Radiologists should possess working knowledge of the embryological development and

anatomy of the jaw and dentition in order to aid in the diagnosis of both simple and complex
disorders that affect them. Here, we review the elaborate process of odontogenesis, as well as
describe in detail the anatomy of a tooth and its surrounding structures.
Semin Ultrasound CT MRI ]:]]]-]]] C 2015 Elsevier Inc. All rights reserved.

W ith the ever-increasing sophistication of cross-sectional

imaging techniques in the evaluation of head and neck
pathology, including multidetector computed tomography
processes develop on either side of the frontonasal process. The
medial nasal processes fuse to form the upper lip. The
mandibular processes enlarge and fuse at midline to form the
(CT) and cone-beam CT with improved contrast and spatial mandible, the lower part of the face, and the tongue. The
resolution, as well as dental CT software programs,1,2 radiol- skeleton of the mandible is derived from the cartilaginous
ogists are charged with the accurate identification of abnor- derivative of the first branchial arch called Meckel’s cartilage.
malities of the teeth and jaw. A working knowledge of the The mandibular mentum marks the site where the 2 man-
development and anatomy of teeth is critical in understanding dibular processes merge in the midline. By the sixth week, the
and describing the disease processes that affect them. bilateral maxillary and mandibular processes are completely
fused, forming the primitive maxilla and the mandible. When
the maxillary and mandibular processes fuse laterally, they
Embryology form the corners of the lips, or commissures. Any interruption
or alteration of the development of the face and the jaw can
The structures of the head and neck are derived from the result in congenital anomalies. For example, failure of proper
cephalic portion of the neural tube, which gives rise to the 5 closure at the midline can result in cleft lip, cleft chin, or cleft
pairs of branchial arches. Each arch consists of 3 layers: an palate. Interruption of lateral fusion of the maxillary and
outer ectoderm, a middle layer composed of mesenchyme- mandibular processes can result in cleft corners of the mouth
containing neural crest cells, and an inner layer of endoderm. or macrostomia (large mouth).
The development of the face starts at the fourth week of Ectomesenchyme, a derivative of neural crest cells, forms
embryonic age with the stomodeum, a ventral depression the bony structures of the head and face. The muscles of
located just caudal to the developing brain, which develops mastication are formed from the mesenchymal cells of the first
into the mouth. Surrounding the stomodeum are 5 primordia. branchial arch. The stomodeum, which forms the primitive
These include the single frontonasal process (prominence) oral cavity, is lined by stratified squamous epithelium called
located at midline and cranial to the stomodeum, followed oral ectoderm. At approximately the sixth week, the oral
caudally by the paired maxillary and mandibular processesly- ectoderm proliferates into a thick band of epithelium called the
ing on each side of the stomodeum. The frontonasal process primary epithelial band. This horseshoe-shaped structure
originates from the forebrain. The maxillary and mandibular develops into the alveolar processes of the upper and the
processes are derived from the first branchial arch (also referred lower jaws. The primary epithelial band develops into the
to as the mandibular arch) and form the lateral wall and base of vestibular lamina and the dental lamina. The vestibular lamina
the stomodeum. By the fifth week, medial and lateral nasal develops into the vestibule between the cheek and the alveolar
process. The dental lamina, a thickening of the oral epithelium
Division of Neuroradiology, Department of Diagnostic Radiology, Yale overlying the jaws, forms the basis of development of dentition.
University School of Medicine, New Haven, CT. The process by which the teeth form is called odontogenesis
Address reprint requests to Vahe M. Zohrabian, MD, Yale University School of
(Fig. 1). Humans have 2 sets of teeth, the temporary baby, or
Medicine 333 Cedar St (Room CB-30), P.O. Box 208042, New Haven, CT
06520-8042 . E-mail: vahe.zohrabian@yale.edu deciduous, teeth and the permanent adult, or succedaneous,

http://dx.doi.org/10.1053/j.sult.2015.08.002 1
0887-2171/& 2015 Elsevier Inc. All rights reserved.
2 V.M. Zohrabian et al.

A B

C D

E F

Figure 1 The development of a deciduous tooth. (A) A parasagittal section through the lower jaw of a 14-week-old human
embryo showing the relative location of the tooth primordium. (B) Tooth primordium in a 9-week-old embryo. (C) Tooth
primordium at the cap stage in an 11-week-old embryo, showing the enamel organ. (D) Central incisor primordium at the
bell stage in a 14-week-old embryo before deposition of enamel or dentin. (E) Unerupted incisor tooth in a term fetus.
(F) Partially erupted incisor tooth showing the primordium of a permanent tooth near one of its roots. (Adapted with
permission from Carlson.5) (Color version of figure is available online.)

teeth. There are 20 deciduous teeth (10 maxillary and 10 ectodermal cells constitute the tooth germs. During embryo-
mandibular) and 32 succedaneous teeth. Deciduous teeth logic development, the deciduous teeth are formed starting
begin development at the sixth- to eighth-week of gestation, from the anterior aspect of the maxilla and the mandible and
and permanent teeth begin development at the twentieth proceeding posteriorly. Each tooth develops and erupts at a
week. Each tooth develops from the ectoderm (enamel) and different time, although the pattern of odontogenesis is the
the ectomesenchyme (dentin, cementum, periodontal liga- same5 (Table). The tooth buds of the permanent teeth are
ment, and pulp contents). Ectomesenchyme represents migra- arranged in a horseshoe-shaped arch, lingual to the deciduous
tion of neural crest cells into the developing arches of the teeth. All tooth buds, except for the second and third
mandible and the maxilla. Tooth development begins with the permanent molars, are present and start developing before
localized proliferation of the primary dental lamina invaginat- birth. The major activity of the dental lamina extends over a
ing into the ectomesenchyme, forming focal thickenings of the period of approximately 5 years. However, the dental lamina
oral epithelium called placodes in 10 places in each of the near the third molar continues to be active until approximately
mandibular and the maxillary arches.3-7 These placodes 15 years of age.
develop into tooth buds, which later develop into individual As the tooth bud grows, it assumes a cap shape by
teeth. The tooth buds and surrounding aggregation of invagination of the mesenchyme. The ectodermal component
Embryology and anatomy of jaw and dentition 3

Table The Usual Times of Eruption and Shedding of Deciduous and endocrine conditions that can affect the development of
and Permanent Teeth dental lamina and tooth buds. Absence of teeth (anodontia) is a
Teeth Eruption Shedding rare condition that can be associated with hereditary ectoder-
Deciduous mal dysplasia. Teeth can also be fused or abnormally located
Central incisors 6-8 mo 6-7 y (ectopia). Faulty development of dentin and enamel results in
Lateral incisors 7-10 mo 7-8 y conditions of amelogenesis and dentinogenesis imperfecta,
Canines 14-18 mo 10-12 y rendering the teeth prone to dental caries and fracture. Other
First molars 12-16 mo 9-11 y abnormalities include tooth impaction because of impedance
Second molars 20-24 mo 10-12 y of tooth eruption by bone or an adjacent tooth, ankylosis with
Permanent
absence of periodontal ligament and direct attachment of tooth
Central incisors 7-8 y to bone, as well as abnormal timing of tooth eruption.
Lateral incisors 8-9 y Furthermore, when epithelial cells from dental lamina fail to
Canines 12-13 y regress, epithelial rests may persist and develop into cysts
First premolars 10-11 y (odontogenic cysts). They may also result in the formation of
Second premolars 11-12 y odontomas, or benign tumors or hamartomas of odontogenic
First molars 6-7 y origin.
Second molars 12-13 y
Third molars 15-25 y
Adapted with permission from Carlson.5
Anatomy of Dentition
of the tooth bud forms the enamel organ, composed of the The human adult jaw contains 32 teeth: 16 teeth in the maxilla
outer enamel epithelium, the stellate reticulum, and the inner and 16 in the mandible.8 From the midline and extending
enamel epithelium (Fig. 1C). The stratum intermedium, distally, the teeth are named as follows: central incisor, lateral
arising from the stellate reticulum, is a layer of condensed cells incisor, canine (cuspid), first premolar (first bicuspid), second
along the inner enamel epithelium. Other ectodermal cells premolar (second bicuspid), first molar, second molar, and
surround the enamel organ and the dental papilla, forming the third molar (wisdom tooth). Alternatively, the teeth may be
dental, or a fibrous sac that invests the tooth germ and numbered using either of 2 major numbering systems: the
separates it from the adjacent bone. The dental follicle gives Universal/National System and the International Standards
rise to the supporting structures of teeth, including the Organization System.9 According to the Universal/National
cementum and the periodontal ligament. The enamel organ, System used in the United States, permanent adult teeth are
dental papilla, and dental follicle together constitute the tooth numbered 1 through 16 from right to left in the maxilla and 17
germ. Ameloblasts are derived from the inner enamel epithe- through 32 from left to right in the mandible (Fig. 2A).
lium, which forms the enamel of the tooth.4,5 During the bell Children possess 20 instead of 32 teeth (10 each in the maxilla
stage, a concavity along the inner surface of the enamel organ and mandible), lacking premolars and third molars. Pediatric
transforms the tooth bud into the shape of a bell (Fig. 1D). The teeth are labeled using sequential letters (A through T), starting
ectomesenchymal cells within the concavity form the dental with tooth letter A in the posterior right maxilla, letter J in the
papilla, and its peripheral-most cells take on a columnar shape posterior left maxilla, letter K in the posterior left mandible,
and are known as odontoblasts. Odontoblasts form the dentin and letter T in the posterior right mandible (Fig. 2B).
of the tooth and later the dental pulp, or soft tissue core– The teeth are individually embedded in bony sockets in an
containing nerves, blood vessels, and connective tissues osseous ridge called the alveolar process and are anchored in
(Fig. 1E). Enamel formation is induced by the production of place by the periodontal ligament, allowing for slight motion of
dentin, which begins at the cusp or top of a tooth and the teeth.10 The alveolar process divides the oral cavity into
progresses toward the tooth apex or root. As an increasing central and peripheral portions, with the central oral cavity
amount of dentin is produced, the dental pulp cavity is filled proper containing the tongue and the peripheral oral vestibule
and narrowed to form the root canal. Enamel formation occurs containing the lips and cheeks (Fig. 3). The mucosa lining the
only in a preeruptive tooth, whereas dentin deposition occurs oral vestibule reflects onto the alveolar process to create a
throughout life. Dental lamina starts to disintegrate at the furrow called the fornix vestibuli, allowing for mobility of the
various stages of tooth eruption (Fig. 1F). cheeks and lips. The mucosa covering the alveolar process is
A number of anomalies can occur during tooth develop- divided into alveolar mucosa and gingiva below and above the
ment. Development of excess dental lamina can lead to an fornix, respectively. The gingiva covers the free border of the
increased number of tooth buds, resulting in too many teeth alveolar process adjacent to the teeth. The upper and lower
(supernumerary). Deficient dental lamina can result in a labial frenula are vertically oriented mucosal folds that connect
decreased number of teeth (hypodontia), with the third molar the lips to the alveolar processes, and the lingual frenulum
being most commonly absent, followed by second premolar anchors the tongue to the floor of the oral cavity (Figs. 3 and 4).
and the lateral incisor. Hypodontia is often associated with The tooth anatomy, which follows, is best depicted in
small teeth (microdontia). Hypodontia and microdontia Figures 4 and 5. A tooth is divided into an enamel-covered
can also be further influenced by environmental factors anatomical crown projecting into the oral cavity and a root that
such as trauma, infection, chemotherapeutic medications, is embedded into the alveolar process and surrounded by
4 V.M. Zohrabian et al.

A B

Figure 2 Universal System for tooth numbering in adults (A) and children (B). Approximate age of eruption for primary and
permanent teeth and age of shedding of primary teeth are given. (Adapted with permission from Nunez et al.9) (Color
version of figure is available online.)

Figure 3 The oral cavity and vestibule. Fingers pulling the lower lip
down expose the vestibule (V), which is separated from the oral cavity Figure 4 The anatomy of the tooth and mucosa. Am, alveolar mucosa;
(Oc) by the alveolar process and teeth. Fornix vestibuli (curved Af, apical foramen; C, cementum; D, dentin; E, enamel; Fv, fornix
arrow), gingiva (black arrow), alveolar mucosa (white arrow), lingual vestibuli; G, gingiva; Ld, lamina dura; L, lip; Pl, periodontal ligament;
frenum (open arrow), and labial frenum (arrowheads). (Adapted with P, pulp; Rc, root canal; T, tongue; and V, vestibule. (Adapted with
permission from Abrahams et al.1 ) permission from Abrahams et al.1)
Embryology and anatomy of jaw and dentition 5

A Enamel B
Crown Dentin

Pulp
Root canal Lamina dura
Lamina
dura PDL
Root canal
Cementum

Root Pulp
PDL

Dentin
Enamel

Apical
Foramen
Figure 5 Radiologic anatomy of the tooth. (A) Intraoral radiograph and (B) axial CT image demonstrate anatomy of a tooth.
It should be note that the periodontal ligament (PDL) appears as a thin, radiolucent line deep to the sclerotic lamina dura.
Cementum, lining the root, is not actually visible on radiographs. The enamel is extremely radiodense, although most of the
tooth is composed of opaque, softer dentin. The pulp chamber and root canals are radiolucent. The root apex is the deepest
portion of the tooth.

Mesial

B
Buccal/Facial

Occlusal

Lingual/Palatal

Distal

Figure 6 Tooth surfaces. (A) Axial CT and (B) sagittal CT images demonstrate that each crown has 5 free surfaces, as denoted
earlier. The same terminology is used to describe directions. Impacted third molar (M).
6 V.M. Zohrabian et al.

anatomical crown. Radiographically, the enamel appears as an

extremely dense, opaque covering over the crown, whereas the
cementum surrounding the root is indistinguishable from the
underlying dentin and is not visualized on radiographs. Dense
cortical bone lining the tooth socket is known as lamina dura,
and on radiographs, appears as a thin rim of sclerotic cortical
Mesiobuccal
bone lining the socket. The periodontal space, containing the
periodontal ligament, appears as a thin, radiolucent line
between the lamina dura and the root. The ligament, attaching
Distobuccal to both the cementum of the root and the lamina dura,
Lingual functions to hold the tooth in the bony socket. The core of the
tooth is composed of dentin, a modification of bone that
appears slightly less dense than the overlying enamel. Deep to
the dentin is a radiolucent central compartment known as
pulp. The pulp is composed of connective tissue, housing
nerves and blood vessels. The neurovascular bundle enters at
the root apex via the apical foramen and travels up the root
through the root canals to enter the more expanded pulp
Figure 7 Named roots of molar tooth. An axial CT image from a dental chamber in the crown of the tooth. The number of roots varies
scan demonstrates the 3 roots of a mandibular molar: mesiobuccal, from teeth to teeth, although molars typically have 3 roots.
distobuccal, and lingual. Each crown has 5 free surfaces10 (Fig. 6A). The surface
facing the lips or cheek is known as the facial surface, also
dense cementum. The cementoenamel junction, or cervical referred to as the labial surface for incisors and canines and
constriction or neck, demarcates the boundary between the buccal surface for premolars and molars. The crown surface on
anatomical crown and the root. With age, as the gingiva the inside facing the tongue is known as the palatal surface in
recesses, exposing the root, the portion of tooth exposed in the the maxilla and lingual surface in the mandible. The surfaces
oral cavity is referred to as the functional crown instead of the abutting adjacent teeth are termed mesial and distal, although

Figure 8 An anatomical specimen demonstrating the inferior (A), lateral (B), and anterior (C) aspects of the maxilla. The
white probe demonstrates the course of the greater palatine nerve; the black probe demonstrates the course of the
nasopalatine nerve. A, alveolar process; As, anterior nasal spine; G, greater palatine foramen; Gg, groove for greater palatine
nerve; If, incisive foramen; L, lesser palatine foramen; Lt, lateral pterygoid plate; Mb, maxillary bone: palatine process; Mp,
median palatine suture; Mt, medial pterygoid; Nc, nasal conchae; Np, nasopalatine canal; Ns, nasal septum; Pb, palatine
bone: horizontal plate; Pt, pterygoid process; Tp, pterygopalatine fossa; Ts, transverse suture. (Adapted with permission
from Gray.2)
Embryology and anatomy of jaw and dentition 7

Figure 9 An anatomical specimen demonstrating the lingual (A and B), buccal (C), and superior (D) aspect of the mandible.
A, alveolar process; B, buccinator muscle insertion; Cd, condyle; Cp, coronoid process; D, digastric fossa; Gt, genial
tubercle; L, lingula; Lf, lingual foramen; Lp, lateral pterygoid muscle insertion; M, mental foramen; Mf, mandibular
foramen; Mg, mylohyoid groove; Ml, mylohyoid line; Mm, masseter muscle insertion; Mp, medial pterygoid insertion; O,
oblique line; Rf, retromolar fossa; Rt, retromolar triangle; S, submandibular fossa; Sf, sublingual fossa; T, temporal crest; and
Tm, temporalis muscle insertion; arrowheads, groove for mylohyoid nerve. (Adapted with permission from Gray.2)

they can also be referred to as medial or lateral for incisors and Anatomy of the Maxilla
canines and anterior or posterior for premolars and molars.
The biting surface is known as the occlusal surface, or that The bony anatomy of the maxilla8,11,12 is shown in Figure 8,
where the maxillary and mandibular teeth oppose each other and neurovascular anatomy13-15 is highlighted in Figure 11. In
(Fig. 6B). Direction can also be described using this terminol- brief, the roof of the oral cavity anteriorly is formed by the
ogy, such that toward the midline is labeled mesial or anterior, bones of the hard palate, the maxilla, and the palatine bones,
and toward the molars is labeled distal or posterior. Moving in which are separated anteroposteriorly by the transverse suture.
the direction of the root apex is moving in an apical direction, The hard palate is also divided into right and left halves by the
and moving toward the crown of the tooth is moving in the median palatine suture, or palatine raphe. More posteriorly,
coronal direction. For example, one can describe the impacted the roof of the oral cavity is formed by the fibromuscular soft
third molar in Figure 6A as follows: the crown of the third palate. The alveolar process forms the anterior and the lateral
molar is oriented in a mesial direction and impacted in the borders of the hard palate, and the pterygoid process of the
distal surface of the second molar, and the root is oriented sphenoid bone, as well as lateral and medial pterygoid plates,
distally. In relation to the crown itself, occlusal is toward the lie posterior to the alveolar process. The greater and lesser
occlusal surface and cervical is toward the cervical constriction. palatine foramina, containing the exiting greater and lesser
The roots of teeth may be labeled using this terminology, such palatine nerves, can be seen on the roof of the hard palate. The
that a mandibular molar has 3 roots: mesiobuccal, distobuccal, hard palate separates the oral cavity from the nasal cavity and
and lingual (Fig. 7). paranasal sinuses superiorly. Most anteriorly, the nasal cavity,
8 V.M. Zohrabian et al.

A B

Figure 10 An axial CT image of the nasopalatine canals and incisive foramen. The more superior image (A) demonstrates the
2 nasopalatine canals (Np); the inferior slice (B) demonstrates their common opening, the incisive foramen (/f). (Adapted
with permission from Gray.2)

containing the nasal conchae, is separated in the midline by a consists of 2 vertical rami attached to a U-shaped body. The
nasal septum and a bony prominence on the anterior aspect of alveolar process, housing the teeth, is the most superior portion
the maxilla, known as the anterior nasal spine. The nasopala- of the mandibular body, and the lower half is referred to as the
tine nerves run anteroinferiorly on either side of the nasal basilar bone. Given that the alveolar process curves more
septum and enter the hard palate through the nasopalatine sharply than the mandibular body does, it is positioned
canals on either side of the septum. The nasopalatine canals medially relating to the mandibular body. Posterior to the
form a common opening on the inferior aspect of the palate, teeth, the alveolar process tapers into the retromolar triangle
known as the incisive foramen. These structures are excep- and joins the lingual aspect of the ramus to form the temporal
tionally demonstrated on axial CT images (Fig. 10). The crest. Buccal to the alveolar process, the anterior portion of the
maxillary sinuses are located posterior and lateral to the nasal coronoid process joins the body of the mandible to form the
cavity, and the pterygopalatine fossae lie posterior to them. oblique line. The retromolar fossa lies between the temporal
The maxillary division of the trigeminal nerve (V2) exits the crest and the oblique line.
foramen rotundum at the skull base and crosses the pterygo- The mylohyoid ridge is a prominent bony crest on the inner
palatine fossa superiorly to enter the orbit through the inferior or lingual surface of the mandible, representing the point of
orbital fissure as the inferior orbital nerve (Fig. 11). The anterior origin of the mylohyoid muscle. Inferior to the mylohyoid
branch of the superior alveolar nerve, arising from the inferior ridge sits a concavity for the submandibular gland known as
orbital nerve, supplies the canines and the incisors, as well as the submandibular fossa. Above the mylohyoid line sits a small
forms part of the superior dental plexus to supply the anterior concavity for the sublingual gland known as the sublingual
part of the hard palate. The maxillary artery, via the posterior, fossa. In the midline on the lingual aspect of the mandible,
middle, and anterior superior alveolar arteries, supplies the there is a bony protuberance, the genial tubercle, for
teeth of the maxilla. The nasopalatine nerve, a branch of the the insertion of the geniohyoid and genioglossus muscles.
pterygopalatine ganglion, courses through the sphenopalatine The mandibular foramen is situated on the lingual aspect of the
foramen and enters the nasopalatine canal in the hard palate. mandibular ramus centrally approximately 1-2 cm posterior to
The sphenopalatine artery follows the course of the nasopala- the third molar at the levels of the crowns of the teeth. After the
tine nerve. In the pterygopalatine fossa, the maxillary nerve mandibular nerve (V3) exits the foramen ovale in the skull base
gives off 2 ganglionic branches that pass through the pterygo- and branches, the inferior alveolar nerve travels deep to the
palatine ganglion without synapsing and form the lesser and lateral pterygoid muscle to enter the mandibular foramen. Just
greater palatine nerves. The greater palatine nerve supplies the before entering the foramen, a small branch, the mylohyoid
molars and posterior two-thirds of the hard palate. nerve, does not enter the foramen and travels in a groove on
the lingual surface of the mandible to supply the mylohyoid
muscle. After entering the mandibular foramen, the inferior
Anatomy of the Mandible alveolar nerve travels through the mandibular canal (also called
The bony anatomy of the mandible8,11,12 is shown in Figure 9 the inferior alveolar canal) to supply small dental and
and the neurovascular anatomy13-15 in Figure 11. The mandible interdental branches that enter the apical foramina and travels
Embryology and anatomy of jaw and dentition 9

B C

Figure 11 Neurovascular anatomy. (A) View of the mandible illustrating the mandibular foramen, the mental foramen, and
the nutrient canals, which extend from the inferior alveolar canal toward the teeth. (B) Parasagittal view through the
trigeminal nerve and the lateral nasal cavity. The mylohyoid nerve travels on the lingual surface of the mandible and does
not enter the mandibular foramen. The greater palatine nerve arises from the pterygopalatine nerve, a branch of V2.
(C) Midsagittal view through the incisive foramen and the nasal septum. The nasopalatine nerve, a branch of the
superoposterior nasal nerve, travels along the nasal septum and through the incisive foramen. (Adapted with permission
from Gray.2)

between teeth to supply the periodontal ligament. The inferior Conclusions

alveolar artery, a branch of the maxillary artery, accompanies
Advancements in CT technology have provided radiologists
the nerve in the mandibular canal. Between the first and the
the ability to assess pathology and anatomy of the teeth and
second premolars, the main terminal branch of the inferior
jaws with detail that is not possible by conventional panoramic
alveolar nerve exits on the buccal surface of the mandible
and intraoral radiography. Radiologists should possess a basic
through the mental foramen as the mental nerve to supply
understanding of tooth development and anatomy to appro-
sensation to the chin and the lower lip. A small terminal
priately discriminate between normal, benign, and malignant
branch, the incisive nerve, travels anteriorly within the
processes, as well as to refer patients to dental specialists for
mandible toward the midline in the incisive canal to help
further workup when indicated.
innervate the canines and the lateral incisors. At the mental
foramen, the inferior alveolar artery also branches into the
mental and the incisive arteries, with the incisive artery exiting
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