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V .

HARISH MADHAV

1ST MDS 2011 BATCH

COMPOSITION PHYSICAL CHARACTERISTICS DEVELOPMENT STRUCTURE AGE CHANGES

CLINICAL CONSIDERATIONS

Consists of 96 % mineral and 4 % organic material and water Inorganic content is hydroxyapatitie which is found in bone , cartilage etc .

Various ions such as strontium , lead , magnesium and fluoride may be incorporated or adsorbed by hydroxyapatite crystals . Bulk of organic material is formed tyrosine rich amelogenin polypeptide(TRAP).

On cusps of human molars it attains a thickness of 2 _ 2.5 mm


THINS DOWN TO A KNIFE EDGE ON CERVICAL PORTION OF THE TOOTH Enamel is translucent and color varies from light yellow to gray white Specific gravity of enamel is 2.8 Compressive stregnth is 350 mpa Tensile stregnth is 10 mpa . Shear stregnth is 90 mpa .

Modulus of elasticity is 130 gpa.


Hardness is 350 500 khn . Solubility decreases in presence of fluorides and increases in presence of carbonates .

Dental laminae serve as primordium for ectodermal portion of deciduous teeth Later during development of jaws the permanent molars arise from distal extension of dental lamina .

The epithelium of dental laminae is separated from underlying ecto mesenchyme by a basement membrane . The tooth buds initiate the primordia of enamel organs .

Outer enamel epithelium and inner enamel epithelium. Stellate reticulum (enamel pulp ) Dental papilla Dental sac

The basement membrane that separates enamel organ and dental papilla is membrana preformativa.

Cervical portion of enamel organ gives rise to hertwigs epithelial root sheath . Inner enamel epithelium and odontoblasts boundary outlines future dentinoenamel junction.

It moulds the shape of roots and initiates radicular dentin formation Consists of outer and inner enamel epithelium only .

The inner enamel epithelium interacts with the adjacent connective tissue cells which differentiate into Odontoblasts .
The ameloblasts enter their formative stage after first layer of dentin has been formed . The presence of dentin seems to be necessary for beginning of enamel matrix formation and vice a versa . This phenomenon is Reciprocal induction .

At the border of the wide basal openiong of the enamel organ , the inner enamel epithelium reflects into the outer enamel epithelium . This is CERVICAL LOOP . The different layers of epithelial cells of enamel organ are named according to morphology , function and location . Stellate reticulum derives its name from morphology of cells . The inner enamel epithelium is so named because of its function and also called ameloblastic layer .

Single layer of cuboidal cells separated from sorrounding connective tissue of dental sac by a delicate basement membrane . During enamel formation , cells of outer enamel epithelium develop villi and cytoplasmic vescicles and large numbers of mitochondria , all indicating cell spciealisation for active transport . Capillaries show areas with very thin walls , a structural modification commonly found in areas of active transport .

They are star shaped with long processes reaching in all directions from a central body. They are connected with each other and with cells of outer enamel epithelium and stratum intermedium by desmosomes . The structure of stellate reticulum is rendering it resistant and elastic .

The cells of stratum intermedium situated between the stellate reticulum and inner enamel epithelium . They are flat to cuboidal in shape and are arranged in one to three layers . The cells of stratum intermedium show mitotic division even after cells of inner enamel epithelium cease to divide . Have high alkaline phosphatase activity .

The cells of inner enamel epithelium are derived from basal cell layer of oral epithelium.
Before enamel formation begins , these cells assume a columnar form and differentiate into ameloblasts that produce the enamel matrix . It should be mentioned that differentiation occurs in the region of incisal edge or cusps than in the area of cervical loop.

At the free border of enamel organ the outer and inner enamel epithelial layers are continuous and reflected into one another as CERVICAL LOOP . When crown has been formed the cells of this portion give rise to hertwigs epithelial root sheath .

MORPHOGENIC Cells are short and columnar with large oval nuclei . Inner enamel epithelium is separated from dental papilla by a delicate basal lamina

ORGANISING During its terminal stage dentin formation begins Reversal of polarity takes place Cell free zone between inner enamel epithelium and dental papilla disappears . FORMATIVE Presence of dentin is necessary for enamel formation Earliest abrupt change is development of blunt cell processes.

Maturative Ameloblasts are reduced in length and closely attached to enamel matrix .

Protective Reduced enamel epithelium is formed from ameloblasts . It protects the mature enamel by separating it from connective tissues.

Desmolytic Reduced enamel epithelium proliferates and elaborates enzymes that cause desmolysis and fusion of two epihtelia occur .

FORMATION OF ENAMEL MATRIX


DEVELOPMENT OF TOMES PROCESSES DISTAL TERMINAL BARS AMELOBLASTS COVERING MATURING ENAMEL MINERALISATION AND MATURATION OF ENAMEL MATRIX

Ameloblasts are derived from inner enamel epithelium


Ameloblasts begin their matrix secretion when small amount of dentin is laid down .(Reciprocal induction )

As enamel formation proceeds a thin layer of enamel is formed along dentin this is Dentino enamel membrane .

The projections of ameloblasts into enamel matrix have been termed Tomes processes Rods are at an angle to ameloblasts and tomes processes.

The ameloblasts covering mature enamel are considerably shorter than ameloblasts over incompletely formed enamel . Over 90 % of initially secreted protein is lost.

Mineralisation of enamel matrix takes place in two stages time interval between two appears very small . Initial stage there is 25 30 % of mineralisation .
Second stage or maturation complete mineralisation . Maturation starts from height of crown and progresses cervically , from depth to surface of crown .

Rods or prisms Rod sheaths & Inter-prismatic substance 5 million lower lateral incisors 12 million in first molars
DEJ to tooth surface ratio of 1:2 . Cuspal rods longer than cervical portion .
Diameter Number

Enamel

In cervical and central parts of crown of deciduous tooth they are approximately horizontal and near incisal edge or tip of cusp they change gradually to an increasingly oblique direction until they are almost vertical in region of cusp tips .
In permanent tooth in cervical region rods deviate in a apical direction . Rods follow a wavy course from dentin to enamel surface .

*Common pattern is KEY HOLE or PADDLE SHAPED PRISIM in human enamel .

When cut longitudanally sections pass through of heads or bodies of one row of rods and tails of adjacent row . HA crystals 5 microns in breadth and 9 microns in length, hexagonal. Apatite crystals are arranged parallel to long axis of prisms , although deviations of upto 40 degrees have been reported . If discs are cut in an oblique plane in region of cusps and incisal edges bundles of rods seem to intertwine more irregularly , this optical appearance is GNARLED ENAMEL .

Change in direction of Rods may be responsible for functional adaptation and minimise the risk of cleavage in axial direction
This change in direction is responsible for apppearance of Hunter Schreger bands .

This are alternating dark and light strips ,of varying widths that can be seen in longitudanal ground section under oblique reflected light .

They appear as brownish bands in ground sections of enamel . They show the successive pattern of enamel during formation of crown . In longitudanal sections surround the tip of dentin . In cervical parts of crown they run obliquely. In transverse section they can be compared to growth rings of a tree . They show periodic bending of enamel rods to variations in basic organic structure or to a physiological calcification rhythm .

PERIKYMATA ,

ROD ENDS , CRACKS

A relatively structureless layer of enamel approximately 30 microns thick has been found in 70 % of permanent teeth and all deciduous teeth .
Found least often on cusp tips and most on towards the cervical areas . It is more mineralised than enamel beneath it .

Transverse wave like grooves beleived to be external manifestations of striae of retzius. They are about 30 perikymata per millimetre in the region of of cementoenamel junction and concentration gradually deceases to 10 in the region of occlusal or incisal edge . ENAMEL ROD ENDS are concave and vary in depth and shape , they are shallow in cervical regions and deep in incisal or occlusal edges . CRACKS are narrow fissure like structures seen on almost all surfaces. They are beleived to be the outer edges of lamellae .They extend for varying distances from dentino enamel junction. Enamel of deciduous teeth is formed partly before birth and partly after birth and the boundary between two portions is marked by an accentuated line of retzius called NEONATAL LINE OR NEONATAL RING It is because of change in environment of enamel formed before birth and after birth due to nutrients difference .

Each enamel rod is built up of segments separated by dark lines that give it a striated appearance . The striations are more pronounced on enamel that is insufficiently calcified.
The rods are segmented because the enamel matrix is formed in a rythmic manner . in humans these segments are seem to have a uniform legnth of 4 micron.

A delicate membrane called Nasmyths membrane , or the primary ENAMEL CUTICLE covers the entire crown of newly erupted tooth but is soon removed by mastication .

This cuticle is apparently secreted after epithelial enamel organ retracts from cervical region during tooth development.

The pellicle forms within hours after enamel surface is mechanically cleaned and becomes colonised by microorganisms to form a bacterial plaque .

ENAMEL LAMELLAE This are thin leaf like structures that extend from surface towards dentino enamel junction . They may extend to and sometimes penetrate into dentin , they consist of organic material with little mineral content . Three types of lamellae can thus be differentiated :Type A Lamellae composed of poorly calcified rod segments Type B Lamellae consisting of degenerated cells Type C Lamellae arising in erupted teeth where the cracks are filled with organic matter Type A Lamellae are restricted to enamel Type B and Type C are reaching into the dentin .

Lamellae extend in longitudanal and radial direction of tooth from tip of crown towards cervical region.
Enamel lamellae may be a site of weakness in a tooth and may form a road of entry for bacteria that initiate caries .

They arise at the dentino enamel junction and reach enamel to about one fifth to one third of thickness of enamel . They were so termed as they resemble tufts of grass .They consist of hypocalcified enamel rods and interprismatic substance .

DENTINO ENAMEL JUNCTION In sections this structure appears not straight but scalloped line and convexities are directed towards dentin .

Into shallow depressions of dentin fit rounded projections of enamel .


This pitted DEJ is visible even before development of hard tissues that is enamel and dentin .

Ocasionally odontoblast processes pass into the dentinoenamel junction and terminate as rounded processes and they have been termed ENAMEL SPINDLES. They originate from processes of odontoblasts that extend into enamel before epithelium is formed . The direction of odontoblats processes and spindles in the enamel corresponds to the original direction of the ameloblasts.

Generalised loss of rod ends and much slower flattening of perikymata , finally the perikymata disappear completely.

Loss of vertical dimension


Attrition and wear of proximal contacts. Rate at which structure is lost depend on location of the surface of tooth in the mouth .

Anterior teeth loose their structure more rapidly . Localised increase of certain elements such as fluoride have been reported . Apart from this zinc , copper ,tin , aluminium, lead very slight increase . Teeth become darker and resistance to decay increased .

* Deep enamel fissure predispose teeth to caries, although deep clefts between adjoining cusps cannot be regarded as pathologic they afford areas for retention of caries producing agents.

As the destructive process reaches the dentin it spreads along the dentino enamel junction undermining the enamel . * Careful examination is necessary for discovering cavities because most enamel fissures are more minute then a single tooth brush .

Surface of enamel in cervical region should be kept smooth and well polished by proper home care and by regular cleansing by the dentist .

Infectious microbiological disease results in destruction and dissolution of calcified tissues .


Millers chemico parasitic theory , consists of two stages .

Decalcification of enamel and dentin (preliminary)


Dissolution of softened residue (subsequent ) Caries preferentially attack cores of rods and more permeable striae of retzius. Lateral spread of caries Undermining of enamel

On clean dry tooth the the earliest evidence is appearance of white spot.
For this enamel must be exposed to plaque for 14 days . Chalky white opaque areas Lose their translucency because of extensive sub surface porosity . Disappears (partially or completely) on wetting the enamel unlike developmental hypocalcifications . Surface texture is unaltered . Usually on facial and lingual surfaces of teeth.

Beginning pulpally Zone 1 - Translucent zone

Zone 2 Dark zone

Zone 3 Body of lesion


Zone 4 - Surface zone

PREVENTIVE CARE PIT AND FISSURE SEALANTS


DIET MANAGEMENT

REMINERALISATION ( CPP AND ACP ) AND( FLUORIDE )


ADHESIVE RESTORATIONS GLASS IONOMERS COMPOSITES

Introduced by Buonocore in 1955

One of the recently developed techniques is operative use of composite resins . In this procedure the enamel surface is mechanically bonded directly to enamel surface.

* Use of 37 % phosphoric acid.

Acid etching of enamel produces an uneven dissolution of enamel rods and their sheaths .

SILVERSTONE ET AL Type 1 pattern involves dissolution of prism cores without dissolution of prism peripheries. Type 2 pattern is opposite of type 1 , peripheral enamel is dissolved , but the cores are left intact . Type 3 pattern etching is less distinct than other two patterns , it includes areas that resembles the other patterns and areas whose topography is not related to enamel prism morphology .

AMELOENESIS IMPERFECTA Hypoplastic Hypomaturation Hypocalcified It is a structural defect of tooth enamel . TREATMENT Improvement of cosmetic appearance.

Defined as incomplete or defective formation of organic enamel matrix of tooth. Causes Nutritional deficiency ( vitamins) Congenital syphilis Hypocalcemia Birth injuries Local infection or trauma Fluoride(Mottled Enamel )

Thought to arise from an invagination of surface of tooth crown before calcification has occurred
Permanent lateral incisors are teeth most frequently involved . Treatment Root canal treatment or restorative treatment

Arise from attempt of a single tooth to divide which result in incomplete formation of two teeth .
Structure is usually one with two completely or incompletely separated crowns that have a single root and root canal

Arises through union of two normally separated tooth germs . Depending on stage of fusion it may be complete or incomplete .

Anamolous structure arising lingually from cingulum area of maxillary or mandibular permanent incisor .
Esthetics , caries control and occlusal accommodation .

Developmental condition appears clinically as a accessory cusp on occlusal surface between cusps of a premolar .
It is thought due to proliferation or evagination of inner enamel epithelium .

It is a rare hereditary disturbance of enamel organ in which both appositon and maturation are disturbed.
Moth eaten , poorly calcified enamel . Teeth are non functional so extraction and replacement is necessary.

If the cells of hertwigs root sheath remain adherent to dentin surface then ameloblasts are formed and enamel is produced .
Such droplets of enamel are called enamel pearls, found in furcation area of permanent molars (maxillary).

Is a type of hypoplasia occuring due to disturbance of ameloblasts during formative stage due to deficiency in hypocalcification .

When the concentration of fluoride is above 1 ppm .


Teeth show a corroded appearance , pitting and brownish appearance . Bleaching the affected teeth with an agent such as hydrogen peroxide is effective,veneering .

STURDEVANTS
SHAFERS 5TH EDITION ORBANS 11 TH EDITION