PRESENTATION BY:RAJESH JAIN MDS 1ST YEAR DEPARTMENT OF CONSERVATIVE AND ENDODONTICS ITS DENTAL COLLEGE HOSPITAL AND

RESEARCH CENTER GREATER NOIDA PRESENTED ON :21ST MAY 2012

MODERATOR: Dr.Rohit Kochhar

INDEX
INTRODUCTION REVIEW OF LITERATURE PHYSICAL PROPERTIES OF ENAMEL CHEMICAL PROPERTIES OF ENAMEL STRUCTURE OF ENAMEL DEVELOPMENT OF ENAMEL CLINICAL IMPLICATION AGE CHANGES CONCLUSION REFRENCES

Introduction
It is hard protective substance that covers the crown of a tooth It is highly brittle resistance to withstand fracture Define as Acellular hard mineralized tissue that forms the protective covering of variable thickness over the entire surface of the crown

REVIEW OF LITERATURE

Dr.Stack and Dr.Fernhead(1965) stated that enamel is a secretory product of cells derived from the stratified epithelium of the oral cavity and is the most densely calcified tissue in the human body .
Dr.Mortimer,(1970) has confirmed enamel consists of innumerable microscopic crystals of the mineral hydroxyapatite arranged in larger structural units, known as prisms or rods. In the permanent teeth, the rods are approximately 4-7 m in width Meckel (1965)stated that enamel rod is not one continuous homogenous rod since during its formation, it exhibits a circadian rhythm.

Boyde(1997) has found in longitudinal sections of human permanent teeth, the striae are seen as series of dark bands reflecting the successive enamel formation fronts.

Boyde (1997) has confirmed in longitudinal ground sections examined either in reflected light or transmitted they are seen as broad curved light and dark bands passing through the inner two-thirds of the enamel. Boyde (1997) has stated that the enamel tufts project from the DEJ for a short distance into the enamel.Tufts are of no clinical significance and do not appear to be sites of increased vulnerability to caries attack.

Physical properties
Its Permeability like a semipermeable membrane. Colour- yellowish white to greyish white Colour depends on transluscency KHN is approximately 343. Specific gravity 2.8

Chemical properties
Enamel

96% inorganic mat.

4% organic mat. and water

Inorganic substance comprises of hydroxyappitite, magnesium carbonate, calcium carbonate, strontium. organic substances in enamel- sulfhydryl groups, keratin, proteins (serine, glutamic acid, glycine), acid mucopolysaccharides
Tissue Enamel Dentin Cementum Inorganic Content 96% 70% 45-50% Organic Content + Water 4% 30% 50-55%

Structure of Enamel

Enamel Rods : 5-12 million per tooth Run from dentino-enamel junction towards surface of tooth Accompanied by apatite crystals Its shape is hexagonal.

Transverse section
(1)

Cross striations
Cross striations are periodic bands that appear along the full length of enamel rod . Enamel rod appears like a ladder with cross striations being the rungs of the ladder Enamel deposition approximately 4m per day)

Cross Striations

DIRECTION OF RODS
The rods are oriented at right angles to the dentin surface.
In the cervical & central parts of the crown of a permanent teeth, they are approximately horizontal. Near the incisal edge or tip of cusps they change gradually to an increasingly oblique direction until they are almost vertical in the region of the edge or tip of the cusps.

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Hunter-Schreger band

Hunter-Schreger bands are an optical phenomena and are seen in reflected light They can be seen in ground longitudinal sections as alternating dark and light bands

GNARLED ENAMEL

If the discs are cut in an oblique plane, the bundles of rods seem to interwine more irregularly. Its optical appearance of enamel is called gnarled enamel.

Gnarled enamel

Striae of Retzuis
Striae of Retzuis also represent incremental growth It appear like concentric growth rings similar to those found in trees in ground section

A Striae of Retzius is located between the two arrows.

Striae of Retzuis often extend from the DEJ to the outer surface of the enamel, where they end in shallow furrows know as perikymata (or imbrication lines)

Striae of Retzuis

ENAMEL TUFTS
It originate from the DEJ, run a short distance in the enamel or sometimes to one half of the thickness. It formed during the formative stages of enamel.

Enamel lamellae.
It extend from the surface to varying depths of the enamel. It filled with organic material and water. There are three types of lamellae Type A poorly calcified rod segments Type B degenerated epithelial cells Type C organic matter

Enamel Lamella

Dentinoenamel Junction (DEJ)

It is scalloped so that the convexity of the enamel fits into the concavity of dentin. Several structures are evident at the DEJ: enamel spindles, enamel tufts, and enamel lamellae.

A-enamel tuft B- enamel spindle C-enamel lamella D-dentine E-enamel

Dentinoenamel junction

Enamel spindles

It originate from the DEJ Before enamel forms, some developing odontoblasts process extend into the ameloblast layer, and when enamel formation begins become trapped to form enamel spindles.

Enamel Spindles

DEVELOPMENT Enamel organ Life cycle of Ameloblasts Amelogenesis

ENAMEL ORGAN

Oral epithelium 6th week IU Dental lamina Enamel Organ

LAYERS OF DEVELOPMENT OF ENAMEL

Outer enamel epithelium Stellate reticulum Stratum intermedium Inner enamel epithelium

Outer enamal epithelium

Stellate reticulum Inner enamal epithelium Stratum Intermedium

Outer Enamel Epithelium

It Consists of single layer of cuboidal cells.

Stellate Reticulum

Cells are star shaped the cells of adjacent layer by desmosomes. It prevents injury to the DEJ.

Stratum Intermedium
It Consists of flat cuboidal cells. It play a role in enamel formation either through control of fluid diffusion into and out of ameloblasts

Inner Enamel Epithelium

Cells are columnar and differentiates into ameloblasts during enamel formation. Cell differentiation occurs earlier at the region of incisal edge or cusp tips.

Inner Enamel Epithelium

Cells are columnar and differentiates into ameloblasts during enamel formation.
Cell differentiation occurs earlier at the region of incisal edge or cusp tips.

LIFE CYCLE OF AMELOBLASTS

1. 2. 3. 4. 5. 6.

Morphogenic stage. Organizing stage. Formative stage Maturitive stage Protective stage. Desmolytic stage.

Morphogenic Stage
Cells are short columnar with large nuclei that almost fill the cell body.

Organizing stage
It is characterized by change in the appearance of the cell. Its cell become tall columnar. Cell free zone between inner enamel epithelium and dental papilla disappears.

Formative stage
Ameloblasts retain approximately same length. Blunt processes appear at the distal end of ameloblasts

Maturative stage
Ameloblasts reduced in length and closely attached to enamel matrix. Cells of stratum intermedium loose their cuboidal shape and regular arrangement and assume spindle shape.

Protective stage
It is arrange in a well defined layer Cell layers together form stratified epithelial covering of the enamel called REDUCED ENAMEL EPITHELIUM.

Desmolytic stage.
It proliferates and induce the atrophy of the connective tissue fibers by desmolysis.

Premature degeneration of reduced enamel epithelium may prevent the eruption of tooth.

CLINICAL IMPLICATION
ENAMEL DEFECT

1. Carious defect
SMOOTH SURFACE CARIES PIT AND FISSURE CARIES

2. Non-carious defects
Developmental defects: - Amelogenesis imperfecta - Enamel hypoplasia - Enamel Pearl Regressive defects: - Attrition - Abrasion - Erosion - Abfraction Fractures Discolorations

Enamel Caries:
Smooth surface caries: Initial smooth surface lesion is seen as a smooth chalky white area (white spot) on drying the tooth surface.

Pit and fissure caries:

It result in early dentinal involvement. Its cone shaped with its apex at the surface,base towards the DEJ resulting in undermining of enamel.

DEVELOPMENTAL DEFECT Amelogenesis Imperfecta:

It is a group of hereditary defects of enamel associated with any other generalized defect. Three types: 1. Hypoplastic type 2. Hypomineralization type 3. Hypomaturation type clinical features: Color ranging from yellow to dark brown. Affects all teeth of both dentition. Open contacts. Abrasion of occlusal/incisal surfaces. Smooth or may have // vertical grooves. Cheesy in consistency or may be hard.

Enamel Hypoplasia:
Defined as incomplete or defective formation of organic matrix of enamel. Two types:1. Hereditary: 2. Environmental: - Causes are: [systemic/local]
Nutritional deficiencies (Vit. A, D, C) Endocrinopathies. Chemical intoxication. Congenital syphilis (mulberry molars and screw driver shaped incisor) Hypocalcaemia (pitting is seen) Birth injury (neonatal line), pre-maturity. Rh incompatibility (grayish brown stain) Febrile diseases (result in Chronological hypoplasia)

Enamel pearl:
Also called Enameloma or Enamel Drop. small masses of enamel seen apically to CEJ, occurring frequently at bifurcation of molars.

TREATMENT : Periodontal treatment should be done.

REGRESSIVE DEFECT Attrition:

Physiologic wearing away of tooth structure as a result of tooth to tooth contact occlusally and proximally. C/F: Males > Females Commonly seen in old age Permanent teeth > deciduous teeth

1. 2. 3.

TREATMENT

Correction of developmental abnormality. Correction of parafunctional chewing habit. Protection of tooth by metal or metal ceramic crown where structural defect are present.

Abrasion:
1. 2. 3. 4. Pathologic wearing away of tooth substance through some abnormal mechanical process. Causes: Improper brushing technique. Habits Occupational Improper flossing C/F: - Wedge shaped defect is seen at the DEJ and exposed dentin is sensitive. - Sharpe angle at the depth of the lesion and at enamel edge

TREATMENT

Adaptance of normal brushing habit prevent abrasion. Restorine treatment helps to keep the tooth surface intact and prevent further tooth wear.

Erosion:

1. 2. 3.

Loss of tooth structure resulting from chemomechanical acts in the absence of specific microorganisms. C/F: Seen mostly on facial surfaces Manifested as shallow, broad, smooth, highly polished scooped out depression. Three types of erosive lesions: - dish/saucer shaped - wedge/V shape - irregular

Causes: 1. Extrinsic :
Diet soft drinks, lemon, citrus fruit juices Salivary citrates Local acidosis in the periodontal tissue. Environment acid fumes. Occupational industries manufacturing Dyes, battery . Drugs vitamin C, mouth washes. 2. Intrinsic : Gastric reflux Increase in gastric pressure. Increase in gastric volume. Vomiting.

EROSION

TREATMENT

Treatment of etiology-GERD-Medical therapy Salivary hypofunction -use sugarless gum/mint chewing. Sjogrens syndrome/post therapeutic head and neck radiation -use oral pilocarpine (salagen)

Abfraction:

The term used to describe possible flexure of tooth under heavy lateral load which may lead to displacement or # of rods at the CEJ. Wedge shaped lesion seen commonly in lower premolars. Produce micro fractures in the thinnest region of enamel at CEJ which predisposes to loss when subjected to tooth brush abrasion. Lost enamel will expose dentin and cause sensitivity.

ABFRACTION

Fractures:
Can occur due to 1. Trauma 2. Dentinal caries leading to undermining of enamel which fracture under occlusal load.

Discoloration:
Can occur due to Extrinsic factors: 1. Tobacco/tea stains 2. Poor oral hygiene 3. Food colors 4. Gingival bleeding 5. Existing restorations 6. Chromogenic bacteria

Intrinsic factors:
1. Caries. 2. Fluorosis. 3. Tetracycline and other drugs. 4. Age changes. 5. Non vital teeth 6. Internal resorption. 7. Hereditary disorders.

DISCOLORATION

TREATMENT OF TOOTH DISCOLORATION

Avoidance of the foods and beverages that cause stains Using proper tooth brushing and flossing techniques Professional tooth cleaning: Some extrinsic stains may be removed with ultrasonic cleaning, rotary polishing with an abrasive prophylactic paste, or air-jet polishing with an abrasive powder.
Enamel microabrasion: This technique involves the rotary application of a mixture of weak hydrochloric acid and silicon carbide particles in a water-soluble paste.

Bleaching (tooth whitening):it is a safe, easy, and inexpensive modality that is used to treat many types of tooth discoloration.

Age changes & Clinical considerations

Attrition is seen in aged people. Wear facets are common. Decrease in vertical dimension and flattening of proximal contours. Color changes with age. Permeability decreases. Caries incidence is less in aged people. Surface composition: more amount of fluoride and localized increase in nitrogen.

CONCLUSION
Enamel is an important structural entity of the tooth hence its protection is utmost important.

Its function is to form a resistant covering of the teeth, rendering them suitable for mastication.

REFRENCES

1. Ten cates oral histology -Nanci,Atonio edition 2003, pg:145-190 2.Oral anatomy embrylogy & histology- Berkovitz 3rd edition pg:101-116 3.Essential of oral histology & embryology Avery 3rd edition,pg:97-106 4.Oral histology and embrylogy by Orbans 11th edition pg:49-105 5.Textbook of oral medicine -Anil govindrao ghom 2nd edition pg:128-130,133-136,141-145