FDI World Dental Federation notation

The FDI World Dental Federation notation, also known as the ISO 3950 system, is a standardized two-digit numbering method for designating teeth and areas of the oral cavity in dentistry, facilitating clear communication among dental professionals worldwide.^[1] Developed by the Fédération Dentaire Internationale (FDI) and adopted as an International Organization for Standardization (ISO) standard, it uses the first digit to indicate the quadrant or sextant and the second digit to specify the tooth position or area, promoting precision in clinical records, research, and education.^[2] The system originated from efforts by the FDI to create a universal tooth identification method, with its foundational two-digit approach first proposed in the mid-20th century and formally acknowledged at the organization's 58th annual meeting in Romania in 1970.^[2] It was first published as ISO 3950 in 1977, with updates in 2009 and 2016 to enhance compatibility with digital systems and address ambiguities, such as distinguishing it from the Universal Numbering System used primarily in the United States.^[1]^[3] For permanent dentition, quadrants are numbered 1 (upper right) to 4 (lower right), with teeth 1 through 8 progressing from central incisor to third molar; deciduous teeth use quadrants 5 through 8 similarly, with positions 1 to 5 for incisors to second molars.^[4] Widely adopted outside North America—in Europe, Asia, Africa, and many other regions—the FDI notation supports accurate diagnosis, treatment planning, and international collaboration by minimizing errors in tooth identification, though recent proposals suggest modifications like adding a dot separator (e.g., 1.6) to further reduce confusion with other systems.^[4] Its endorsement by the World Health Organization and integration into global dental informatics underscore its role as the predominant international standard for oral health documentation.^[1]

Introduction

Definition and Purpose

The FDI World Dental Federation notation, also known as ISO 3950, is the most widely adopted international system for numbering teeth in dentistry, recognized and standardized by the International Organization for Standardization (ISO).^[5] Developed originally by the FDI World Dental Federation and approved by the World Health Organization (WHO), it serves as a global benchmark for precise tooth identification across clinical, educational, and research contexts.^[1] The primary purpose of the FDI notation is to enable a simple, unambiguous, and communicable method for linking clinical information—such as diagnoses, treatments, and procedural notes—to specific teeth, thereby minimizing errors in documentation and communication, particularly in diverse linguistic and cultural environments.^[6] This standardization supports accurate patient records, treatment planning, and interdisciplinary collaboration, enhancing overall precision in dental practice worldwide except in regions favoring alternative systems like the Universal Numbering System.^[7] At its core, the system employs a two-digit code: the first digit designates the quadrant of the oral cavity, while the second indicates the specific tooth position within that quadrant, allowing for straightforward association of data without reliance on descriptive language.^[5] Its quadrant-based logic promotes ease of use and logical organization, making it particularly suitable for both permanent and primary dentition in international settings, where regional variations can otherwise lead to confusion.^[7]

Historical Development

The FDI World Dental Federation notation emerged in response to the need for a unified international system amid the proliferation of national and regional tooth numbering methods in the 19th and early 20th centuries. Early systems, such as the Zsigmondy notation introduced by Austrian dentist Adolf Zsigmondy in 1861, utilized a quadrant-based approach with numbers arranged in a cross pattern to denote tooth positions, starting from the central incisors and progressing posteriorly.^[2] This method, later modified by American dentist Corydon Palmer in the 1870s to simplify symbols for quadrants (using lines or plus signs), gained popularity in Europe and North America but suffered from inconsistencies in quadrant identification and lack of global standardization, complicating cross-border communication in dentistry.^[2] The two-digit system was proposed by German dentist Joachim Viohl in 1968 and adopted by the Fédération Dentaire Internationale (FDI) in 1970 at its 58th annual session in Bucharest, Romania, on October 1, to address these fragmentation issues and facilitate precise, unambiguous recording of dental conditions for clinical, educational, and research purposes.^[2]^[8] The system built on quadrant principles from predecessors like Zsigmondy and Palmer but introduced a fixed numerical scheme—the first digit for the quadrant and the second for the tooth position—ensuring compatibility with emerging computer-based dental records. This development marked a pivotal shift toward internationalization, as the FDI aimed to create a notation that could be easily taught, remembered, and applied worldwide without reliance on symbols that varied by language or region. A key milestone was the publication of the system as an ISO standard in 1977 (ISO 3950:1977), with subsequent revisions in 1984, 1995, 2009, and 2016, establishing it as a technical standard for dentistry and promoting its use in international epidemiological studies and patient documentation.^[3] Subsequent revisions refined the notation for greater precision; notably, the 2016 edition (ISO 3950:2016) enhanced clarity in designating anomalies in oral cavity areas using the digit 9 (replacing 0), with dedicated provisions for supernumerary teeth in ISO 3950-2:2020 using alphanumeric codes, while improving overall quadrant designations and adaptability to digital charting systems.^[1]^[9] The World Health Organization (WHO) endorsed the system alongside ISO, integrating it into global oral health guidelines to support epidemiological surveillance and clinical uniformity, which accelerated its adoption beyond Europe to regions in Asia, Africa, and the Americas.^[1]

The Notation System

Quadrants

In the FDI World Dental Federation notation, the oral cavity is divided into four quadrants to systematically locate teeth within the mouth. This division segments the dentition into upper right, upper left, lower left, and lower right sections, providing a structured framework for dental charting and communication. The quadrants are defined relative to the patient's anatomy, with numbering oriented clockwise starting from the upper right quadrant.^[1] For permanent dentition, the quadrants are numbered as follows: 1 for the upper right, 2 for the upper left, 3 for the lower left, and 4 for the lower right. This sequential assignment begins at the upper right and proceeds clockwise around the dental arches, aligning with the anatomical planes of the sagittal midline and occlusal surface.^[10]^[1] In primary (deciduous) dentition, the quadrants follow a similar clockwise orientation but use distinct numbers to differentiate from permanent teeth: 5 for the upper right, 6 for the upper left, 7 for the lower left, and 8 for the lower right. The first digit of the two-digit FDI code thus indicates both the quadrant and the type of dentition, enhancing clarity in clinical records.^[10]^[1] This clockwise numbering system promotes simplicity and international consistency in dental notation, supporting effective communication among professionals and compatibility with digital systems.^[1]

Tooth Numbering and Code Construction

In the FDI notation system, teeth within each quadrant are numbered sequentially from 1 to 8 for permanent dentition and from 1 to 5 for primary dentition, beginning at the midline with the central incisor designated as 1 and progressing posteriorly to the third molar (8) in permanent teeth or the second molar (5) in primary teeth.^[1] This anterior-to-posterior sequence ensures a logical organization that mirrors the anatomical layout of the dental arch.^[1] The complete FDI code is constructed using a two-digit format, where the first digit indicates the quadrant (1 for upper right permanent, 2 for upper left permanent, 3 for lower left permanent, 4 for lower right permanent, and 5-8 for the corresponding primary quadrants) and the second digit specifies the tooth position within that quadrant (1-8 for permanent or 1-5 for primary).^[1] For example, the code 11 designates the upper right central incisor in permanent dentition, combining quadrant 1 with tooth position 1.^[10] This combination allows for precise identification of any tooth across both dentitions.^[1] The system's design follows a clockwise progression starting from the upper right quadrant, with numbering advancing distally within each quadrant to facilitate efficient charting and communication in clinical settings.^[1] This orientation promotes consistency and reduces errors in international dental records.^[4] The ISO 3950 standard also provides codes for areas of the oral cavity using digits including zero (0), such as 00 for the entire oral cavity or 04 for the upper anterior sextant. Replacement of a zero (0) by a nine (9) identifies the presence of an anomaly in that specific area, for example, 94 for an anomaly in the upper anterior sextant.^[1] Missing teeth are not assigned a specific code in the system and are typically indicated by omission in charting. In practice, supernumerary teeth may be noted using a 9 in the tooth position (e.g., 19 for an extra tooth in upper right first position), though this is not formally specified in the ISO standard.

Tables of Codes

Permanent Dentition

The FDI notation system for permanent dentition utilizes a two-digit coding method to designate the 32 adult teeth, divided equally among four quadrants, with each quadrant encompassing eight teeth numbered sequentially from the midline outward.^[1] The first digit specifies the quadrant—1 for the upper right, 2 for the upper left, 3 for the lower left, and 4 for the lower right—while the second digit indicates the tooth's position within that quadrant, starting with 1 for the central incisor and progressing to 8 for the third molar.^[1] This numbering reflects anatomical symmetry across the dental arches, where corresponding teeth in opposing quadrants share the same positional digit; for instance, tooth 11 (upper right central incisor) mirrors tooth 41 (lower right central incisor), and tooth 18 (upper right third molar) aligns with tooth 48 (lower right third molar).^[1] The eight third molars, denoted as positions 8 in each quadrant, exhibit variability in presence due to agenesis or impaction, with a global pooled prevalence of impaction at approximately 36.9% per individual.^[11] The following table outlines the FDI codes for permanent teeth by quadrant and type:

Quadrant	Central Incisor	Lateral Incisor	Canine	First Premolar	Second Premolar	First Molar	Second Molar	Third Molar
1 (Upper Right)	11	12	13	14	15	16	17	18
2 (Upper Left)	21	22	23	24	25	26	27	28
3 (Lower Left)	31	32	33	34	35	36	37	38
4 (Lower Right)	41	42	43	44	45	46	47	48

^[1]

Primary Dentition

The FDI notation for primary dentition, also known as deciduous teeth, employs a two-digit system to identify the 20 temporary teeth that erupt in children, using quadrants numbered 5 to 8 to distinguish them from the permanent dentition. This design ensures no overlap in coding, allowing dental professionals to document both primary and permanent teeth concurrently during the mixed dentition phase.^[1] Each of the four quadrants in primary dentition contains five teeth: two incisors, one canine, and two molars, reflecting the absence of premolars in this set. The first digit of the code indicates the quadrant—5 for the upper right, 6 for the upper left, 7 for the lower left, and 8 for the lower right—while the second digit specifies the tooth position from the midline, numbered 1 through 5. Specifically, 1 denotes the central incisor, 2 the lateral incisor, 3 the canine, 4 the first molar, and 5 the second molar.^[10]^[12] Key examples include 51 for the upper right central incisor, 55 for the upper right second molar, and 85 for the lower right second molar. The following table summarizes the codes by quadrant and tooth type:

Quadrant	Central Incisor	Lateral Incisor	Canine	First Molar	Second Molar
5 (Upper right)	51	52	53	54	55
6 (Upper left)	61	62	63	64	65
7 (Lower left)	71	72	73	74	75
8 (Lower right)	81	82	83	84	85

Unlike permanent dentition, which includes eight teeth per quadrant with premolars assigned codes 4 and 5, primary dentition limits each quadrant to five teeth, with codes 4 and 5 exclusively for the first and second molars. The shifted quadrant numbers (5-8) prevent confusion with permanent teeth codes (1-4), supporting precise clinical communication.^[10]^[1] Primary teeth typically exfoliate and are replaced by permanent successors as children grow, yet the FDI system's separate quadrant designations facilitate ongoing tracking of both dentitions without ambiguity in records.^[1]^[12]

Comparisons with Other Systems

Universal Numbering System

The Universal Numbering System (UNS), also known as the American National Standards Institute/American Dental Association (ANSI/ADA) system, is a sequential alphanumeric notation primarily utilized in the United States for identifying teeth in clinical records and procedures. For permanent dentition, it assigns numbers 1 through 32 to the 32 adult teeth, beginning with the upper right third molar as tooth 1 and proceeding counterclockwise around the mouth from the dentist's perspective: across the upper arch to the upper left third molar (16), then continuing to the lower left third molar (17) and ending at the lower right third molar (32). Primary dentition employs letters A through T for the 20 deciduous teeth, starting with the upper right second primary molar as A, moving counterclockwise similarly to the upper left second primary molar (J), then from the lower left second primary molar (K) to the lower right second primary molar (T). This system was officially recognized by the American Dental Association in 1968 and remains the standard for dental claims and documentation in the U.S.^[13] Unlike the FDI notation, which divides the mouth into explicit quadrants (1–4 for permanent teeth, 5–8 for primary), the UNS omits quadrant designations, relying instead on a continuous sequence that circles the arches without separating upper and lower. This results in non-intuitive numbering, such as lower teeth receiving higher numbers (17–32) than their upper counterparts, potentially complicating quick quadrant-based analysis in international contexts or research. For instance, the lower anterior teeth (e.g., central incisors as 24 and 25) are numbered after the upper arch, diverging from the logical anterior-to-posterior progression within each quadrant found in FDI.^[14]^[15] Direct mappings between UNS and FDI facilitate interoperability in global dental practice. Key equivalences for permanent teeth include UNS 1 corresponding to FDI 18 (upper right third molar) and UNS 32 to FDI 48 (lower right third molar). For primary teeth, UNS A aligns with FDI 55 (upper right second primary molar). These correspondences allow practitioners to translate records efficiently, though the sequential nature of UNS can make bilateral or arch-specific comparisons less straightforward than FDI's structured two-digit codes.^[16]^[15] Relative to FDI, the UNS offers simplicity for routine U.S.-based charting and electronic health records, as its linear progression avoids the need to specify quadrants explicitly, reducing errors in domestic documentation. However, it is less intuitive for international collaboration or quadrant-oriented diagnostics, where FDI's explicit localization provides clearer anatomical context without requiring full-mouth recall of the sequence.^[13]^[15]

Palmer Notation

The Palmer notation, also known as the Zsigmondy-Palmer system, is a symbol-based dental identification method that divides the oral cavity into four quadrants and assigns positions to teeth using numeric or alphabetic codes combined with orientation symbols. Developed by Hungarian dentist Adolf Zsigmondy in 1861 and later modified by American dentist Corydon Palmer in the 1890s, it relies on visual symbols to indicate quadrant location rather than numeric prefixes, making it particularly suited for diagrammatic charting in clinical settings.^[17] In this system, permanent teeth are numbered from 1 to 8 in each quadrant, starting from the central incisor (1) and progressing distally to the third molar (8). Quadrants are denoted by specific symbols: the upper right uses a right-facing L-shape (often represented in text as + or ┘), the upper left a left-facing L-shape (| or └), the lower left an upside-down L-shape (⌒ or ┐), and the lower right a mirrored L-shape (- or ┌). For primary dentition, teeth are identified with letters A through E (A for central incisor to E for second molar), paired with the same quadrant symbols, or sometimes simplified using horizontal lines above or below the numbers for quick notation. This orientation-based approach allows for a more intuitive, patient-facing representation, as the symbols mimic the dental arch layout without imposing a sequential order on quadrants.^[17] A key structural difference from the FDI World Dental Federation notation lies in quadrant identification: while FDI employs the first digit (1-4 for permanent dentition, with 1 and 2 maxillary and 3 and 4 mandibular; 5-8 for primary dentition, with 5 and 6 maxillary and 7 and 8 mandibular) to specify location, Palmer uses symbol orientation, rendering it less reliant on memorized numeric sequences but more diagrammatic and context-dependent for written communication. Tooth position numbering (1–8) aligns directly with FDI's second digit, facilitating straightforward conversions; for instance, the upper right canine (Palmer 3 with + or ┘ symbol, often textually 3+) corresponds to FDI 13, and the lower right second permanent molar (Palmer 7 with - or ┌ symbol, textually 7-) maps to FDI 47. This similarity in positional coding stems from shared foundational principles, yet Palmer's symbol-heavy design can pose challenges in digital or international documentation.^[17] As a historical predecessor to the FDI system, Palmer notation influenced the development of standardized international notations in the mid-20th century but remains less uniformly adopted globally due to its dependence on precise symbol rendering, which can vary in transcription across languages and media.^[17]

Adoption and Standards

International Usage

The FDI World Dental Federation notation has achieved widespread international adoption, with approximately 200 national dental associations and specialist groups in over 130 countries recognizing it as the standard tooth numbering system.^[18] This prevalence extends across Europe, Asia, Africa, and Latin America, where it serves as the primary method for dental communication outside North America. The system is also endorsed by the World Health Organization (WHO) for oral health surveys and reporting, enabling consistent data collection and global comparisons of dental conditions.^[19] In clinical settings, the FDI notation facilitates precise tooth identification in various applications, including patient records, treatment planning, radiographic interpretations such as X-rays, insurance documentation, and digital tools like electronic health records. Its two-digit format ensures unambiguous referencing during treatments, diagnostics, and interdisciplinary consultations, reducing errors in multinational environments. For instance, dental software systems integrated with international standards often default to FDI codes to support seamless data exchange across borders.^[4] Educationally, the FDI notation is commonly taught as the primary system in dental curricula outside the United States, for example in Saudi Arabia where it is used by 80% of colleges for patient records.^[20] This emphasis promotes uniformity in global dental training and prepares graduates for international practice. Despite its dominance, challenges arise in multinational practices where dual notation may be necessary to accommodate diverse professional backgrounds, though the FDI system's inherent simplicity—relying on a logical quadrant and sequential numbering—enhances interoperability and minimizes confusion in collaborative care.^[4]

ISO Standardization and Recent Developments

The FDI World Dental Federation notation was formalized as the International Standard ISO 3950, first published in 1977 by the International Organization for Standardization (ISO) under Technical Committee ISO/TC 106 for Dentistry, providing a two-digit system for designating teeth and oral cavity areas.^[21] This standard originated from the FDI's earlier work to promote global uniformity in dental communication.^[1] Subsequent revisions have maintained the core two-digit format while ensuring compatibility with emerging dental practices. The 2016 edition (fourth edition) represents a technical update to the 2009 version, refining the designation principles for permanent and deciduous dentition, including the use of digit 9 to indicate anomalies in areas of the oral cavity.^[5] For supernumerary teeth, ISO 10394:2023 provides a complementary designation system using a two-character alphanumeric code (e.g., A5 for a supernumerary tooth in the upper right second premolar position) that is compatible with existing records and software based on ISO 3950.^[9] Notations for dental implants and orthodontic appliances are addressed through broader ISO/TC 106 standards on materials and procedures, rather than modifications to the core tooth numbering.^[22] Recent developments include a 2024 proposal to revise the FDI two-digit system by inserting a dot between the quadrant and tooth position digits (e.g., 1.6 instead of 16), aimed at improving precision in digital records and reducing errors in mixed dentition tracking where primary and permanent teeth coexist; as of 2025, this proposal has not been formally adopted.^[4] This revision seeks to enhance digital compatibility for electronic health records and software applications, minimizing misinterpretation between FDI and other systems like the Universal Numbering System, while preserving the existing numeric structure for backward compatibility.^[23] The standard's maintenance is overseen by ISO/TC 106 in collaboration with the FDI World Dental Federation, which provides expertise to align the notation with advancing dental technologies, including 3D imaging for automated tooth identification and forensic applications.^[24] This ongoing collaboration ensures the system's relevance in clinical, educational, and digital contexts without disrupting established practices.^[22]