The primitive mouth development

Development of face and anomalies

Development of palate and anomalies

By:
Dr. Sabreen Sami (B.D.S., M.Sc., Ph.D.)

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 First, the oropharyngeal membrane can be realized during the 3rd week of
development between the heart primordium and the brain primordium. As a membrane
composed of ectoderm and endoderm only, lies at the beginning of the digestive tract.
It breaks down during the 4th week in order to form the opening between the future
oral cavity (primitive mouth or stomodeum) and the foregut. At the end of the 4th
week, the center of the face is formed by the stomodeum, surrounded by the first pair
of pharyngeal arches.

The pharyngeal arches not only contribute to formation of the neck, but also play
an important role in formation of the face. The human face begins to form during the
4th week by five facial processes or facial prominences which give rise to the
different parts of the face. These are:

1. Two mandibular processes inferior to the stomodeum, arise from the first
pharyngeal arch.
2. Two maxillary processes lateral to the stomodeum, arise from the first
pharyngeal arches.
3. Single frontonasal process a slightly rounded elevation cranially to the
stomodeum forms the forehead, and has two local ectodermal thickenings on both
sides the nasal placodes. The tissues of the frontonasal process predominantly
of neural crest origin.

The tissues of the maxillary and mandible prominences are of mesenchymal

origin (mixed mesoderm and neural crest), which are the source of connective tissue
components in the facial and oral regions, including (cartilage, bone, ligaments). The
lower jaw and the lower lip are the first parts of the face to form. They result from
merging of right and left mandibular prominences at the midline.

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 During the 5th week, the nasal placodes invaginate to form nasal pits, the tissue
surrounding them enlarges into horseshoe-shaped protrusions:

 on the medial sides called the medial nasal prominences or medial nasal
processes.
 on the lateral sides called the lateral nasal prominences or lateral nasal
processes.

During the 6th week, As the maxillary processes expand toward the midline to form the
maxilla, they compress the medial nasal prominences toward the midline and cause them
to fuse to form:
1. The primordium of the bridge, and septum of the nose.
2. The intermaxillary segment(process) which gives rise to the:
• Median part (philtrum) of the upper lip.

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 • Premaxillary part of the maxilla containing four incisor teeth, and its associated
gingiva (gum).
• Primary palate.

The tips of the maxillary processes grow to meet the intermaxillary process and fuse
with it to complete the formation of the upper lip. The lateral nasal prominences give
rise to the ala of the nose. Both the maxillary processes and the lateral nasal
prominence are fuse together forming the nasolacrimal duct. The cranial end of this
duct expands to form the lacrimal sac.

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 During the 6th week, the nasal pits grow and approach the primitive oral cavity
(stomodeum).
 The tissue in the midline separating the pits becomes the nasal septum.
 In the 7th week, a connection between the nasal cavities and the oral cavity called
is formed called the primitive choanae (openings).
 The ectodermal placode tissue differentiates into the olfactory epithelium, which
is the sensory organ for the smell.
 At the end of the second month, the secondary palate forms to separate the
primitive nasal cavities from the oral cavity.

A facial cleft is an opening or gap in the face, or a malformation of a part of the face
due to the failure of fusion of the facial prominences either completely or partially.
These clefts may occur unilateral or bilateral. All structures like bone, soft tissue, skin,
can be affected. Facial clefts are extremely rare congenital anomalies.
Types of clefts
The oblique facial cleft results from lack of fusion between the maxillary process
and lateral nasal process, exposing the nasolacrimal duct.

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 The lateral facial clefts (macrostomia) come from the corner of the mouth
towards the ear, results from the incomplete lateral merging of maxillary and
mandibular processes.
Median cleft (Frontonasal dysplasia): hyperplasia of inferior frontonasal
prominence, thus preventing fusion of the medial nasal prominences.

Oblique facial cleft Lateral facial cleft Median cleft

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• By the 5th week, the intermaxillary segment extends posteriorly into the oral cavity,
forming the primary palate.

• During the 6th and 8th weeks the medial walls of the maxillary processes produce a
pair of thin medial extensions, called the palatal processes (lateral palatine
processes).

• These processes grow predominantly vertically downward and parallel to the

lateral surfaces of the tongue.

• By the beginning of the 8th week, the tongue begins to contract, flattened, and
displaced anteriorly, and the mandible grows and expands makes the tongue moves
down, allowing the palatine processes to grow toward the midline where they meet
and fuse with each other and anteriorly with the primary palate.

• The fused palatal processed form the secondary palate, together with the primary
palate they form the definitive palate, and the incisive foramen is a landmark
between them.

• The nasal septum grows inferiorly toward the secondary palate, and fusion with it
anterodorsally, in the midline to form separate right and left nasal chambers.

• The oral and the nasal cavities connect to each other posteriorly by definitive
conchae.

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«« Complete fusion of the primary and secondary palate is a complex process
involving growth of the component tissues, epithelial to mesenchymal transformation,
cell migration and programed cell death at fusion sites. Disruption of any part of this
process can result in cleft palate. Cleft palate is accompanied by cleft lip.

It is a conic projection from the back edge of the middle of the soft palate, composed
of connective tissue, and some muscular fibers. It also contains many serous glands,
which produce thin saliva. During swallowing, the soft palate and the uvula move
together to close off the nasopharynx and prevent food from entering the nasal cavity.

1. The cleft lip may occur with or without cleft palate, and the cleft palate my also
occurs with or without cleft lip.
2. It is due to the failure of fusion of the maxillary process and medial nasal
prominence due to the underdevelopment of their mesenchyme.
3. Cleft lip is formed in the top of the lip as either a small gap or notch in the lip
(partial or incomplete cleft), or it continues into the nose (complete cleft).
4. Lip cleft can occur as a one-sided (unilateral)
5. The two-sided (bilateral cleft lip) due to lack of fusion between the maxillary
process and median nasal process.
6. The median cleft lip (harelip; lack of fusion between the two medial nasal
processes)

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1. Results from failure of the two palatal processes to fuse along the midline.
2. Palate cleft can occur as complete (soft and hard palate) or incomplete (as a
cleft soft palate).
3. If the cleft lies posterior to the incisive foramen then includes secondary palate
and uvula , the uvula is usually split.

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 Teeth development:
Development stages of teeth
Developmental disturbances of teeth

By:
Dr. Sabreen Sami (B.D.S., M.Sc., Ph.D.)

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Teeth are ectodermal appendages, their development is initiated and organized by a
series of reciprocal inductive signaling between the:
1. Primitive oral epithelium cells (ectoderm): which is a stratified squamous
epithelium lining the surface of the primitive oral cavity (stomodeum).
2. The underlying connective tissue cells (ectomesenchymal cells): These cells
are inducing the overlying ectoderm to start tooth development, which begins in
the anterior portion of what will be the future maxilla and mandible and
proceeds posteriorly.
In the human, there are 20 primary and 32 permanent teeth. Each developing tooth
grows as an anatomically distinct unit, but the basic developmental process is similar
for all teeth.

Initiation of Teeth Development

when the embryo is about 6 weeks old, the epithelium lining of the oral cavity at the
area of the presumptive maxilla and mandibular jaws, begins a rapid proliferation into
the adjacent ectomesenchyme, forms a continuous horseshoe-shaped band of
thickened epithelium around the mouth called primary epithelial band, which at 7th
week gives rise to two subdivisions:
1. An inner (lingual) process called dental lamina which forms first.
2. An outer (buccal) process called vestibular lamina which forms afterward.

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Dental Lamina
An epithelial swelling or out growths called dental placodes proliferate deep into
the ectomesenchymal tissue, at the corresponding area of deciduous teeth. Serve as
the primordium of the enamel organ of the deciduous teeth.
The basement membrane separates the epithelium of dental lamina from the
ectomesenchyme.
The permanent molars arise directly from a distal extension of the dental lamina.
The permanent incisors, canine and premolars which succeed the primary teeth,
developed from the lingual extension of the dental lamina, called the successional
lamina.

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Fate of dental lamina
1. The total activity of the dental lamina extends over a period of at least 5 years.
However, it may still be active in the third molar region after it has disappeared
elsewhere.
2. Remnants of the dental lamina persist as epithelial pearls or islands within the jaw
as well as in the gingiva. These are referred to as cell rest of Serres
(serres’pearls).

Vestibular Lamina
Develops independently, at labial and buccal sides to the dental lamina, in the
maxillary and mandibular dental arches, also called the lip furrow band.
Its cells rapidly enlarged and then degenerate to form a cleft that become the oral
vestibule between the alveolar portion of the jaws and the lips and cheeks

A - mandibular dental organ. B - mesenchymal cells

C - mandibular vestibular lamina. D - alveolar process.
E - maxillary dental organ. F - maxillary vestibular
lamina .

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Physiological phases in teeth development
Teeth development can be divided into the following overlapping phases, which are:
1-Initiation: During this phase, the sites of the future teeth are established with the
appearance of tooth germs along the dental lamina.
2-Prolifertion: During this phase, Proliferative growth causes regular changes in the
size and proportions of the growing tooth germ
3-Histodifferentiation: During this phase, differentiation of cells proceeds to give rise
to the fully formed dental tissues, both mineralized (such as enamel, dentin and
cementum) and unmineralized (such as pulp and periodontal ligament).
4- Morphodifferentiation: The morphologic pattern and relative size of the future
tooth, is established in this phase.
5-Apposition: is the deposition of the matrix of the hard dental structures like dentin,
enamel and cementum.

Morphological stages of tooth development

A series of easily distinguishable stages, categorized according to the morphology of
the developing enamel organ these stages are:
1. Bud stage - Initiation
2. Cap stage - Proliferation
3. Bell stage - Histodifferentiation and Morpho-differentiation.

1-Bud Stage (Initiation)

 The dental placodes continue to growth into the ectomesenchyme tissue and form
small round or ovoid teeth buds, these buds represent the future enamel organ.
 The ectomesenchyme cells proliferating and packed closely beneath and around
the teeth buds, separated from buds by the basement membrane.
 The epithelium of tooth buds shows little if any change in shape or function.

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The enamel organ of bud stage contains two types of cells:
Polygonal cells, which are centrally
situated.
Low columnar cells, which are peripherally
situated.

Both the tooth bud and the surrounded

ectomesenchyme constitute the tooth germ.

2- Cap Stage (Proliferation)

As the tooth bud continues to proliferates into the ectomesenchyme, the more the
adjacent ectomesenchyme cells proliferate and condense, result with an
invagination on the inner surface of tooth bud, which gives a cap form to the tooth
bud.

The enamel organ remains attached to the lamina.

Cap stage is characterized by the following three layers

1. Outer enamel epithelium layer (O.E.E): Covers the convexity of the cap and
consists of a single layer of cuboidal cells.
2. Inner enamel epithelium layer (I.E.E): Covers the concavity of the cap and
consist of tall, columnar cells.
3. Stellate reticulum layer: At the center of the enamel organ consists of star-
shaped cells with long processes and fluids. This layer has a cushion like
consistency to act as a shock absorber to support and protect the delicate enamel
forming cells.

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Dental Papilla and Dental Follicle or Dental Sac:
The centrally situated ectomesenchyme cells under the inner enamel epithelium.
They are rapidly proliferating and condense, form the dental papilla (which
becomes dentin and pulp).

The ectomesenchyme cells surrounds the enamel organ and dental papilla form
capsular structure consisting of circular arrangement of fibers, called dental follicle
or sac (which forms cementum and periodontal ligament).

Still the basement membrane separates the inner enamel epithelium from the dental
papilla and outer enamel epithelium from the dental sac.

The tooth bud connects with the oral epithelium by the dental lamina.

3- Bell Stage (Histodifferentiation and Morphodifferentiation)

The characteristic features of bell stage:
This stage is divided into the early bell stage and the late bell stage.
The bell stage, so called because the enamel organ comes to resemble a bell due to
continued growth of the tooth germ.
During this stage, the cells that will be making the hard tissues of the crown
(ameloblasts and odontoblasts) acquire their distinctive phenotype
(histodifferentiation).

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 The tooth crown assumes its final shape (morpho-differentiation).
The enamel organ in bell stage composed of four layers of epithelial cells:
1. Inner enamel epithelium.
2. Stratum intermedium between the IEE and stellate cells.
3. Stellate reticulum.
4. Outer enamel epithelium.
The rim of the enamel organ where the inner and outer enamel epithelium meet is
known as cervical loop.
The enamel organs of deciduous teeth except the permanent molars in the bell
stage show successional lamina and their permanent successor teeth in the bud
stage.
At the end of this stage the dental lamina disintegrates, leaving the developing teeth
completely separated from the epithelium of the oral cavity.
A- Early bell stage
High degree of histodifferentiation is achieved in the early bell stage. The enamel
organ shows four distinct layers:
1. Inner enamel epithelium (IEE):
It consists of a single layer of cells that differentiate prior to amelogenesis into
columnar cells, the ameloblasts. The IEE are separated from the peripheral cells of
dental papilla by a basement membrane and cell free zone about 1-2 μm wide.
2. Stratum intermedium (SI):
This first appears at the early bell stage, as layers of flattened squamous cells lying
between the IEE and stellate reticulum. It is important in the mineralization of the
enamel during amelogenesis by secreting the alkaline phosphatase enzyme which
stimulates the mineralization process.
3. The stellate reticulum (SR):
There is a continuous expansion in the size of the stellate reticulum because of
increased amount of intercellular fluid. Just prior to the beginning of enamel

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 formation, the stellate reticulum collapses and gets mixed up with the cells of the
stratum intermedium.
4. The outer enamel epithelium (OEE)
This forms the outer layer of cuboidal cells contain large centrally placed nuclei,
which limits the enamel organ and separated from the surrounding dental sac by a
basement membrane (under electron microscope, called basal lamina).

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Dental Papilla
• The organizing influence of the IEE helps the peripheral mesenchymal cells of the
dental papilla to differentiate into specialized cells called odontoblasts which
produce dentin. These cells change their shape from cuboidal to columnar and
produce a thin layer of predentin then dentin.
• Thereafter, the IEE produces enamel.
• The basement membrane disappears when dentin is secreted.

Dental sac
Before formation of dental hard tissue begins, the dental sac shows a circular
arrangement of its fibers and it resemble a capsular structure. With the development of
the root, the fibers of dental sac differentiate into periodontal ligament fibers that
become embedded in the cementum and alveolar bone.

B-The Late Bell Stage

This point is where the cells continue to divide until the tooth crown attains its full
size. After crown formation, gives rise to epithelial component of root formation, there
are two more features of tooth development are also seen:
1. Future dentinoenamel junction - The boundary between the first layer of dentin
and the first layer of the enamel matrix. The laying down of dentin starts before the
inner enamel epithelium lays down the first layer of enamel matrix over the dentin
in the future incisal and cuspule areas.

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2. Hertwig’s epithelial root sheath - The enamel organ forms a double layered called
Hertwig’s epithelial root sheath (Root Sheath of Hertwig). It contains only the
outer and the inner enamel epithelium without the stratum intermedium and stellate
reticulum. The root sheath initiates formation of dental root and determines the
number, shape, length and dimensions of the roots.

Developmental disturbances of teeth:

1. Anodontia: is a complete lack of tooth development. It is rare, most often
occurring in a condition called ectodermal dysplasia.
2. Hypodontia: (congenital missing tooth or teeth). It is one of the most common
developmental abnormalities. The absence of third molars is very common,
followed in prevalence by the second premolar and lateral incisor. Hypodontia is
often associated with the absence of a dental lamina, which may be due to infection
or chemotherapy medications, and is also associated with many syndromes, such as
Down syndrome.
3. Hyperdontia: is the development of supernumerary teeth. It is believed to be
associated with an excess of dental lamina or epithelial rest of Serres.
4. Natal and neonatal teeth: Natal teeth are present at the time of birth. Neonatal
teeth will erupt during the first 30 days after birth. Although both conditions occur

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more frequently in females, natal teeth are three times more common than neonatal
teeth. The most common location being the mandibular region of the central
incisors.

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