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Enamel
Enamel
CONTENTS
INTRODUCTION
DEVELOPMENT
LIFECYCLE OF AN AMELOBLAST
AMELOGENESIS
SURFACE FEATURES
DEJ
CEJ
AGE CHANGES
CLINICAL CONSIDERATIONS
ENAMEL DEFECTS
CONCLUSION
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INTRODUCTION
DEVELOPMENT
The enamel organ or the tooth bud originates from the stratified epithelium of
the primitive oral cavity.
Just before enamel and dentin formation, the enamel organ consists of 4
distinct layers
Stellate reticulum
Stratum intermedium
The borderline between the IEE and the connective tissue of the dental papilla
is the subsequent Dentino-Enamel junction (DEJ).
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Capillaries are present in the adjacent connective tissue, which
proliferate and protrude towards it and may even indent the stellate reticulum.
These ensure that there is plentiful supply of nutrients during enamel formation
once dentin formation cuts off the supply from the papilla to the IEE.
IEE: Consists of a single layer of short columnar cells, which differentiate into
tall columnar cells termed ''ameloblasts'' once enamel matrix production begins.
They define the shape of the future crown and also interact with the adjacent
dental papilla to produce dentin-forming odontoblasts.
These cells contain a high amount of glycogen which nourishes the ameloblast
once dentin is laid down.
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LIFE CYCLE OF AN AMELOBLAST
1. Morphogenic
2. Organizing / Differentiation
3. Formative / Secretory
4. Maturative
5. Protective and
6. Desmolytic stages
MORPHOGENIC STAGE:
The shape of the future DEJ is determined by the interaction between the IEE
and the adjacent mesenchymal cells. The cells are short, columnar with large
oval nuclei filling almost the entire cell body.
The cell organelles are located proximally (i.e., towards the stratum
intermedium) while the mitochondria are dispersed throughout the cell. The
adjacent pulpal layer is a cell free zone
The IEE cells became longer (the distal end becoming as long as the nucleus
containing proximal end) and there is a reversal of functional polarity with the
organelles moving distally. Because of the increase in length of the cells
towards the papilla, the now differentiated ameloblasts interact with the
connective tissue ceils directly (the cell free zone disappears) and the latter
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differentiate into odontoblasts Dentin formation begins which cuts off the
nutritional supply via the papilla and the ameloblasts start relying on the
surrounding capillaries for their nutrition. This result in proliferation of
capillaries and the gradual reduction and disappearance of stellate reticulum,
which brings the OEE closer to the stratum intermedium IEE.
Blunt cell processes develop on the distal end of ameloblast, which penetrate
the pre-dentin. The presence of dentin is necessary for the formation of enamel
matrix. Thus reciprocal induction / mutual induction is the phenomenon behind
enamel formation.
which stimulate
MATURATIVE STAGE:
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PROTECTIVE STAGE:
The ameloblastic layers lose their well-defined structure, and together with the
OEE and stratum intermedium form a stratified epithelial covering_of the
enamel termed Reduced Enamel Epithelium(REE).
The REE helps to protect the mature enamel from contacting the connective
tissue until the tooth erupts. If contact does occur, then anomalies may occur
such as resorption/ cemental deposition.
DESMOLYTIC STAGE:
The REE cells produce enzymes that destroy connective tissue fibers_by
desmolysis resulting in separation of the connective tissue oral epithelium and
a fusion between the REE and the oral epithelium.
AMELOGENESIS
Once a small amount of dentin has been laid down, ameloblasts lose the
projections into the pre-dentin. The synthesis of the matrix proteins occurs is
the rough endoplasmic reticulum which are transported to the golgi bodies,
which in turn package them into secretory granules and deposit them along the
pre-dentin The first thin layer of enamel formed is termed dentino-ename!
membrane and this gets partially mineralized immediately. This mineralization
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is supposed to occur via nucleation from the apatite crystals located within the
dentin. This first enamel layer is structureless.
Another site is one surface / side of tomes process which fills the pit
formed by the insertion of the process and later goes onto form enamel
rod / head
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A difference between these 2 occur only in the orientation of the crystallites
The prism sheath is the last area of withdraws by the tomes process. The
organic content is higher and the crystals, which eventually grow originate
from adjacent prisms and are. therefore, differently oriented and are less closely
packed.
Ameloblasts covering the maturing enamel are considerably shorter and have a
ruffled border / vilii on the enamel side. They are packed with mitochondria
indicating an absorptive function of transporting organic components from the
matrix back into themselves. Over 90% of the initially secreted protein is lost
and that which remains is in the prism sheath area.
It is a 2-stage process:
Mineralization starts even before the matrix has reached its full thickness
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COMPOSITION
Enamel is the most highly mineralized tissue known making it also the hardest
calcified tissue in the human body.
Ca10 (PO4)6 (OH)2. The rest consists of trace elements and other minerals
Minor ion substitutions and slight deficiency in calcium make these crystals
different from those present in other mineralized tissues
Width: 65nm
Thickness = 30nm
These crystals are almost 10 times larger than those present in bone or dentin.
The space between these crystals in mature enamel is less than 2nm
These crystals are arranged parallel to the long axis of the rod in the center of
the rod and flare laterally towards the periphery.
ORGANIC: The organic matrix surrounds each crystal as a fine lacy network.
Of the 1% matrix, 58% is protein, 42% liquid and trace amounts of lactate
sugars and citrate. There are 2 types of enamel proteins depending on which
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stage the enamel development has reached, Amelogenin is present in the
developing enamel while enamelin is present in mature enamel.
PHYSICAL CHARACTERISTICS:
THICKNESS: The thickness of enamel varies with the shape of the tooth and
its location on the crown. For example:
-The thickest enamel is always found at the crest of cusps or incisal edges
averaging about 2-2.5mm (molars 3mm)
Clinical significance:
The variable thickness influences the color as underlying yellow dentin is seen
through the thinner regions.
Caries progress is faster within the fissures / near cervical 1/3 with faster
chances of pulpal involvement.
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Clinical significance:
Unsupported enamel will chip off if underlying dentin is lost due to caries or
improper cavity preparation.
Differences in translucency
Thickness of enamel
The cervical areas show a yellowish tinge due to reflection of dentin through
the thin enamel. Incisal edges have a bluish tinge due to double layer of enamel
and no dentin.
Clinical significance:
The shade of the tooth must be determined before isolation for tooth
preparation for a tooth colored restoration as it tends to look whiter when
isolated due to temporary loss of loosely bound water (< 1 % by weight)
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ENAMEL STRUCTURE:
The study of enamel structure is difficult due to its high mineral content as
conventional sections will reveal only empty spaces. Thus, sections of
developing enamel are used as it contains more organic content. The planes of
sections used in studying enamel are:
LIGHT MICROSCOPE
Under this, the rods appear as hexagonal, round or oval interlocking rows
surrounded by a sheath giving a tvpical "fish-scale" appearance.
ELECTRON MICROSCOPE:
The sub microscopic structure of the rod observed in cross section reveals
various types of rod patterns.
Stacked arches = the rods are arranged one over the other with definite
inter rod substance present continuously.
Staggered arches = the rods are not exactly one over the other
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Keyhole / Paddle shape = the rod with its arch shaped head and tail
interpose between subjacent rod heads
The inter rod region or the tail is an area surrounding each rod having crystals
arranged differently than those making up the rods. In longitudinal sections, it
is seen more clearly because the section passes through the heads of one row
and the tails of the adjacent row giving the appearance of some definite inter
rod material.
The rod sheath is the boundary where crystals of rod head meets that of the
inter rod region at sharp angles. It is high inorganic matrix and thus more
resistant to acid dissolution.
The Number of enamel rods ranges from 5 million in lower lateral incisor to
12 million in upper first, molar.
The Length of most rods is greater than the thickness of enamel due to the
oblique direction and wavy course of the rods. The length of the rods in the
cuspal area is greater than those at the cervical area
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The Diameter of the rod average's 4;i. It apparently increases from the DEJ to
the surface at a ratio of 1:2 This could be due to the fact that outer surface of
enamel is greater than the dentinai surfaces where they originate.
The occlusal or incisal rods become gradually oblique and become almost
vertical at the cusp tip/ incisal edges.This angulation displays an orientation
more directly opposed to the forces of mastication. The course of the rods is
not straight but rather wavy or undulating. They bend right and left in the
transverse plane and up and down in the vertical plane. Cervically, they have a
straighter course. Rods in successive rows also shown a change in direction of
about 2°.
Structural Features
Enamel possesses features that characterize the tissue as more complex than the
schematic view of enamel rods presented so far.
Cross Striations:
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width, which appear as alternating bulges and constrictions. Sometimes,
oblique sectioning of the enamel reveals the inter rod substance giving an
illusion of a band.
Seen both in longitudinal and transverse sections, the striae of Retzius represent
incremental growth lines, which occur every 7 or 8 days. Rods crossing these
lines are deficient in mineral content and a shift in the rod direction has also
been observed. In L/S, they are seen as a series of brown lines of varying
widths and color intensity. They form concentric arcs at cusps and incisal
edges. The incomplete arcs emerge on the surface in a stepwise fashion
creating shallow grooves or troughs called Imbrication lines of Pickerell. In
C/S, the striae appear as concentric rings much like the growth rings of a tree
Significance: if broad and prominent striae are present it shows that same bind
of metabolic disturbance caused prolonged rest periods
Neonatal Line:
Enamel Lamellae:
They are thin leaf-like structures extending from the surface towards the DEJ
Lamella basically consists of linear longitudinal defects filled with organic
material. 2 major categories of lamellae are - pre- eruptive and post eruptive.
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To former appear to be caused due to aberrations in the developmental process.
These can be of two types:
The post-eruptive lamellae (Type C) result from various physical and thermal
forces to which teeth are subjected. These contain salivary organic matter.
Enamel Tufts:
Seen in transverse sections resembling tufts of grass, enamel tufts are actually
ribbons of organic material arising from the DEJ and extending 1/5th to 1/3rd
of enamel thickness. The base of each tuft is in a straight line along the DEJ
while its free end undulates right to left in synchrony with the rod paths. They
are believed to occur due to abrupt changes in direction of rods that arise from
different regions of the scalloped DEJ.
Enamel Spindles:
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3)Structures observed due to shift in the rod orientation.
Gnarled Enamel:
SURFACE STRUCTURES
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CLINICAL SIGNIFICANCE: The layer of prismless enamel in primary teeth
poses difficulties in etching. A longer etching time is needed.
Enamel rod ends: are concave depressions of variable depth and shape.
They are shallowest in the cervical region and deepest near occlusal / incisal
edges.
Cracks: are fissure-like outer edges of lamellae. They extend for varying
distances along the surface perpendicular to the DEJ. The length varies
from a few mm to the entire length of the crown
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cellular debris and food remains. If remained uncleaned, caries and gingival
problems can occur.
Pits and Fissures: are defects in the enamel surface usualh associated with
the lines of fusion between cusps and other major divisions of the crown.
Enamel formation in multi-cuspal teeth proceeds from the growth centers
corresponding to the cusps tips and proceeds over the inclines towards the
center of the tooth. When inclines are steep " strangulation" of ameloblast
occurs at the center of the tooth due to collision of ameloblasts from
adjacent cusps colliding as they retreat from the DEJ. The secretary activity
of these cells ceases in there compressed cells leading to a fissural defects in
enamel. Pits are similar manifestations found at the ends of developmental
grooves or at the intersection of 2 / more grooves.
Pits and fissures are present in multicuspid teeth but are also IrequentK seen on
the palatal surface of upper incisors.
The irregular surface that separates the enamel from the dentin is clinically
reffered to as the DEJ. The surface of the DEJ is pitted into which rounded
projections of enamel fit in ensuring a firm hold of the enamel cap on the
dentin. In sections, DEJ is seen as a scalloped line with convexities towards
dentin. The pitted DEJ is preformed even before development of hand tissues.
The DEJ provides a zone in which irritating agents / fluids are able to permeate
through enamel lamellae defects and gain rapid access to pulp via dentinal
tubules.
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Cemento Enamel Junction / CEJ
The enamel and cementum may bear any one of the 3 relationships:
Sometimes all 3 may exist on the same tooth because the CEJ is irregular
AGE CHANGES
With age teeth get progressively altered or worn out occlusaly & proximally as
a result of masticatory forces. Wear facets are pronounced in older
people.There is a loss of vertical dimension & flattening of proximal contours.
Teeth also lend to discolor or darken due to either addition of organic matter
from the environment or due to reflection of the underlying yellow dentin
through the thinned translucent enamel.
Teeth absorb fluoride ions from the environment making teeth less prone to
caries.
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CLINICAL CONSIDERATIONS
Although enamel is the hardest tissue the human body, it comprises one of the
weakest points in a preparation wall, especially when it loses its dentinal
support. Whenever enamel is stressed, it tends to split along the length of
the/rod. Splitting is easier when rods are parallel to each other rather than
twisted together. Fortunately, enamel rods are twisted upon each other in the
inner 1/2 - 2/3 of their thickness while the remaining outer portion is parallel.
According to Noy, the ideal enamel wall has the following structural
requirements:
1. Enamel wall must rest upon sound dentin or else undermined enamel will
fracture
2. Enamel rods, which form the cavosurface angle, must have their inner ends
resting on sound dentin
3. The rods forming the cavosurface angle must have their outer ends covered
by restorative material: This can be produced only via:
4. The cavosurface angle must be trimmed / beveled so that the margins will
not be exposed to injury while condensing the restorative material against it.
Not all material can perform well when placed in cavities with such walls. The
rules should be applied whenever feasible.
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A knowledge of the direction of enamel tods is very important during cavity
preparation. For example :
Enamel walls should be smooth and junction between enamel walls should be
rounded.
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gets interlocked with the enamel surface. The formation of resin microtags
within the enamel surface is the fundamental mechanism of adhesion between
resin and enamel. The effects of acid etching are:
Etching should done perpendicular to the rod heads to attain etch patterns The
latter is of 3 types:
ENAMEL DEFECTS:
1) Carious defects
Smooth surfaces
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2) Non-carious defects
Developmental:
o Amelogenesis Imperfecta
o Enamel pearl
Regressive :
o Attrition
o Abrasion
o Erosion
o Abfraction
3) Others:
Fractures
ENAMEL CARIES:
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Accentuation of incremental lines of Retzius
Pit and fissure caries leads to greater and earlier dentinal involvement and thus
more undermining and larger cavitations. The lesion is triangular in shape with
base at DEJ.
DEVELOPMENTAL
AMELOGENESIS IMPERFECTA:
1. Hypo plastic: (formative stage); The defects are in the matrix formation
C/F = enamel does not form to its full thickness.
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ENAMEL HYPOPLASIA
C) Congenial Syphilis
■ Mulberry molars= First molars have globular masses instead of cusps and
narrow occlusal surfaces.
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C/F: Turners teeth occur due to periapical infection/ trauma to deciduous tooth,
disturbing the underlying ameloblastic layer of permanent tooth bud.
ENAMEL PEARL:
Enamel Pearl/ Enamel Drop/ Enameloma are small masses of enamel found
apically to CEJ.
REGRESSIVE
C/F
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- Initial change = Small polished facet on cusp tip or flattering of ridge or
incisal edge
- Advanced attrition: enamel gets completely worn away with complete loss
of cuspal interdigitations, there is exposure of dentinal tubules resulting in
secondary dentin formation, and at times pulp horns are exposed. Certain habits
like tobacco chewing and bruxism can aggravate attrition
o Improper brushing
C/F=
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C/F=
• Occurs mostly on facial surfaces. Proximal and lingual erosion is also seen
in same conditions
Causes of erosion:
1. Extrinsic
o Lifestyle
2. Intrinsic
-Gastric reflux
o Sphincter incompetence
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-Vomiting;
o psychosomatic-anorexia nervosa,bulimia
o G.I.T disorders
o Drugs
-Regurgitation
-Rumination
OTHERS
Trauma
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Remnants of Nasmyths membrane
Existing restorations
Gingival bleeding
Food colors
Chromatic bacteria
Tobacco stains
Plaque / calculus
Caries
Hereditary Disorders
Fluoride
Age changes
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CONCLUSION:
It is said "Do not judge a book by its cover" but in the case of enamel it does
not hold good. Certain conditions of the tooth can certainly be judged by the
state of the outer enamel. A sound knowledge of the basic units of the tooth is
important for a clinician to understand and diagnose tooth related problems for
a better comprehensive treatment plan for his/ her patient.
BIBLIOGRAPHY
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