CHAPTER 4.

LOCAL EFFECT: ENAMEL DISCOLORATION

A. INTRODUCTION

Aesthetics is an integral part of orthodontics, and color is an important aspect

of aesthetics. Hue, value, and chroma are the three objective variables used
to describe color. The tooth color exhibits a large variation influenced by the
structure of enamel and dentin. The other factors such as sunlight in the
environment, light scattered from adjacent gingival and perioral tissues, and
lip and gum color influence the appearance of the teeth. Tooth color is altered
in the oral environment by intrinsic, extrinsic, and internalized discoloration 9.

Orthodontic treatment can lead to adverse effects on enamel surfaces. These

are manifested as enamel loss caused by etching, enamel surface alterations
leading to decalcification, and microcracks and scratches induced during
debonding and clean-up procedures. Besides structural defects, the
aforementioned changes can adversely affect color and esthetics of enamel.
Therefore, there have been needs to improve the bonding properties in which
clinically sufficient bond strength is obtained, while minimizing enamel defect
and discoloration6.

Recent research has shown that the strongest association with orthodontic
treatment is improved esthetics of teeth followed by improvement in overall
esthetics. As one of the main points of orthodontic treatment is perfection of
esthetics, the effects of orthodontic etching and debonding techniques on
tooth structure and appearance should be understood clearly. An adverse
effect on tooth structure such as demineralization, enamel tear–outs, micro–
cracks,or a clinically detectable color change would lead to esthetically
unpleasing results. Aside from the formation of white spot lesions due to
decalcification, tooth discoloration could occur under orthodontic attachments
because of the irreversible penetration of resin tags into the enamel structure.
It was reported that this resin impregnation into the enamel structure could not
be reversed by debonding and cleaning procedures. The length and amount
of the resin tags differed between enamel treated with phosphoric acid then
bonding (conventional etching) and self–etching primer. Although the resin
tags were between 10 to 20 μm after conventional etching, fewer and shorter
tags of 5 to 10 μm occurred after treating with self–etching primer. As resin
tags are thought to be responsible for tooth color change, all other factors
being equal, self–etching systems may produce less iatrogenic color change
in enamel following orthodontic treatment. In addition to the effects of etching,
it was pointed out that the roughness of the bonding area might be affected by
grinding the enamel during adhesive removal and this could lead to color
changes at the bonding site3.

B. CAUSES

1.Formation of white spots and

2.Irreversible penetration of resin tags into enamel structures. Resin tags

could absorb colorants and corrosion products of the orthodontic applianc 6.

3. The discoloration of the adhesive resins may result from endogenous

changes such as the formation of oxidation by‑products and decomposition of
initiators and exogenous changes by the formation of stains. Resins with
reduced particle size and hardness, low water sorption, higher filler‑resin ratio,
and optimal filler matrix resin system increase the color stability of
composites. Re‑deposition of calcium fluoride that is formed during the
reaction with enamel results in discoloration following bonding with
resin‑modified glass ionomer cement (RMGIC). The colored corrosion
products and the crevice corrosion of the stainless steel result in enamel stains
in the presence of voids and poor oral hygiene 9.

C. DIAGNOSIS

There are 2 methods to determine tooth color:

1. Visual determination
Visual determination is highly subjective but remains the most frequently
applied method for color determination. However, several factors such as
external light conditions, fatigue of the human eye, experience, and age and
the inherent limitations of the contemporary shade guides can influence visual
color selection.

2. Instrumental measurement.
The need for objective color matching and scientific advancements has led
to the development of instrumental measurement devices. Various
commercial systems, including
a. Tri-stimulus colorimeters
b. Spectroradiometers
c. Spectrophotometers( figure 1,2, 3 & 4)
d. Digital color analyzers,
are used currently and quantify color using the Munsell system9.

Spectrophotometers:

Figure 1: Teeth cleaned and pumiced before bonding procedure and mounted
on thermocol sheet
Figure 2: Use of X-Rite i1Pro reflectance spectrophotometer for color
evaluation (hand-held spectrophotometer)8

Figure 3: Spectrophotometric analysis of tooth surface 5.

Figure 4: reflection spectrophotometer (V-670, JASCO, Japan)7

Digital color analyzers: Vita Easyshade (VITA Zahnfabrik GmbH, Bad

S¨ackingen, Germany) (Figure 5) was used to assess color alterations of
natural teeth that occurred after bonding and adhesive clean–up procedures.

Figure 5: Vita Easyshade device used for color assessment

Surface analysed: The upper anterior teeth (from canine to canine) were
isolated and the color measurements were taken from the middle third of the
teeth.

All color measurements were done by one author (H.G.C.) three times to
minimize the error. The average of the three measurements was calculated at
pretreatment (T0), after resin removal with high–speed tungsten carbide burs
(T1), and after polishing with Sof–Lex XT discs (3M ESPE, St Paul,
Minnesota) (T2).

When the total color difference between any two measurements exceeded the
threshold of one unit, a fourth measurement was performed, and the closest
three measurements were used to calculate the average.

Color evaluation was done in accordance with the CIE (Commission

Internationale de l’Eclairage) L*a*b* color system (1931) that uses three
parameters to define color:
a. L* coordinate corresponds to a degree of lightness and darkness and
ranges from 0 (black) to 100 (white), b.
b. a* coordinate correspond to the Chroma and represent positions on the red
(+) / green (–) axes.
c. b* coordinate correspond to the Chroma and represent positions on the
yellow (+) / blue (–) axes.

The difference between two colors was calculated with the following formula:
∆𝐸 =[(L2 −L1)2 +(a2 -a1)2+(b2 -b1)2 ]1/2

The following ∆E values were calculated according to the formula:

∆E1: The color alteration that occurred between pretreatment and adhesive
remnant removal with tungsten carbide burs.
∆E2: The color alteration that occurred between adhesive remnant removal
with tungsten carbide burs and polishing with Sof–Lex XT discs (3M ESPE, St
Paul, Minnesota).
∆E3: The color alteration that occurred between pretreatment and polishing
with Sof–Lex XT discs (3M ESPE, St Paul, Minnesota) 3.
 D. STUDIES

Authors Sample Bonding Method of color Results

size technique evaluation
(human
premolars)
Joo et al 135 1.CE and Reflection Staining color
2.SEPwith spectrophotometer change was not
different different in CE
adhesive and SEP
following
finishing‑polishin6
Trakyali 75 CE with Colorimeter Color changes
et al different not clinically
adhesives observed
Zaher et 55 1.Conventional Reflectance SEP produces
al and spectrophotometer less esin tag
2.SEP with depth then
transbond XP conventional
adhesive
Boncuk 175 1.Conventional Spectrophotometer Highest color
et al and change in etch
2.SEP with and rinse group
transbond XP and least in
adhesive and RMGIC1
RMGIC
Ye et al 120 1.Light cure, Spectrophotometer Chemical color
2.Chemical show highest
cure 3.RMGIC color change &
RMGIC showed
least color
change11
Jahabin 100 1.Chemical Colorimeter No significant
et al cure with & difference
without primer between groups
2.light cure
with & without
primer
3.no mix
Eliades et 26 1.CE with Colorimeter No significant
al transbont XT difference
adhesive between groups12
2.RMGIC
Table 1: In vitro studies (CE=Conventional etching, SEP=Self‑etching primer,
RMGIC=Resin modified glass ionomer cement) 9

Authors Sample Bonding Method of color Results

technique evaluation
Corekci et Treatment: Grengloo Light Spectrophotomet Composites have
al 22 bond er similar effects of
Control:22 Kurasper enamel
Transbond discoloration
Karamouzo 26 patients Chemical and Reflectance Chemically cured
s et al light cure spectrometer resin showed
greater color
change
Al Maaitah 34 patients Different Reflectance Etching
et al etching spectrometer techniques had
techniques no statistically
without primer significant
and no mix change
Table 2: in vivo studies9
E. TREATMENT

Bishara, Denehy & Goepferd describe a method used to remove or improve

superficial stains in the enamel including mild decalcification present before
and after orthodontic therapy. This procedure is only successful in the
treatment of stains involving the outer enamel surface and is not effective for
treating generalized pigmentation of the enamel and/or dentin. A step-by-step
approach for the removal of the superficial enamel stains is presented.

The technique will not work on dark devitalized teeth, tetracycline stains, or
other intrinsic stains since this procedure is recommended for treating
superficial enamel to a maximum depth of 100 pm. The procedure is also
obviously not necessary if the stains can be removed by routine dental
prophylaxis.

Active ingredient: Fine powdered pumice is mixed with 18% hydro- chloric acid
(HCl) to make a thick slurry mix. The acid is obtained by diluting 38% USP
hydrochloric acid with distilled water.

Steps:

1. Pumice teeth thoroughly to remove any superficial stains.

2. Isolate teeth with rubber dam. The entire labial surfaces of the teeth to be
treated must be exposed (Fig. 6). Extreme care should be exercised when
using the acid to prevent soft-tissue contact and injury to either the patient or
the operator. The operator should wear gloves and both operator and patient
should have protective eye wear.
Figure 6: Teeth to be treated are isolated with rubber dam.

3. Seal rubber dam to the tooth with Copalite” or another appropriate sealant
to prevent seepage of the acid to the gingiva (Fig. 7).

Figure 7: Sealant is applied to the border of the rubber dam to prevent

accidental seepage of the acid-pumice mixture to the gingival tissues.

4. Use a trimmed wooden cotton-tipped applicator to apply the acid-pumice

paste to the area of the tooth requiring treatment (Fig. 8).
Figure 8: Acid-pumice mix applied for 5 seconds to the stained area with a
wooden applicator.

Have sodium bicarbonate (baking soda) available as a thin paste to neutralize

any accidental spill of acid on the soft tissues or teeth.

5. Rub the acid-pumice paste with an erasing motion on the enamel for 5
seconds, then rinse for 5 seconds. Blend the rubbing action on the enamel
adjacent to the stain to get a more uniform appearance.

To prevent enamel pitting, do not leave the acid on the tooth for an extended
time. After several applications, the stains will begin to disappear gradually.
The color change should be evaluated when the tooth is wet (Fig. 9) and not
when the enamel is dry and desiccated (Fig. 10).

Figure 9: Dried teeth. Note difference in colors.

Figure 10: Teeth should be wet for better color evaluation.

6. Repeat up to a maximum of ten applications. Each application is estimated

to cause a total loss of enamel surface of approximately 10 μm

If the stain is still present after a maximum of ten 5-second applications, the
stain is too deep for this procedure and another restorative approach should
be considered.

7. To treat stains in the interproximal embrasures, use a wooden applicator

with a fine tip (Fig. 11) or use the middle third of a fine sandpaper strip, 2 to 3
mm wide, coated with the HCl pumice mixture, and buff against the
interproximal surfaces

Figure 11: Application of the mix interproximally.

At the end of the etching phase, the entire labial surface of the teeth will appear
slightly dull.

8. Apply a solution of 2% sodium fluoride on the treated teeth and allow it to

remain for 3 minutes (Fig. 12).

Figure 12: Two percent sodium fluoride gel is applied for 3 minutes.

9. Polish the enamel with a Vivadent green cup using the fluoride solution as
a lubricant (Fig. 13).

Figure 13: Polishing the enamel surface with a green cup using the fluoride
gel.
A fine prophylaxis paste can also be used to polish the enamel surfaces to
restore the gloss; however, the polishing cups give a better luster clinically.
Polishing the enamel surface at the end of the procedure is very important to
prevent or minimize the formation of new extrinsic stains.

Within a few weeks, the enamel gloss tends to improve through additional
remineralization from the calcium salts in the saliva. There is also a tendency
for the color of the tooth to improve within 6 months of application.

Various clinical illustrations of the results obtained with this procedure are
presented in Figs. 14 through 16.

Figure 14: A and B. Enamel surface before and after the procedure.

Figure 15: A and B. Effects of the procedure on brown enamel stains.

Figure 16: A and B. Decalcification on the buccal surface of the mandibular
first molar before and after treatment.

The procedure may also be used in combination with other restorative

procedures such as resin or veneer coverage to minimize tooth structure
removal and maximize esthetic results by decreasing the stain’s prominence
prior to veneering or composite restoration (fig 17).

Figure 17: A, An enamel defect that involves both the superficial and deep
layers of enamel can be more conservatively treated with the acid-pumice
mixture followed by composite buildup. B, In such a case, the more superficial
(and larger) defect can be treated with the present procedure to reduce the
discolored area while the deeper enamel defect is removed. C, The tooth is
finally restored with composite2.

CONCLUSION

Eslami at el aimed to evaluate etched enamel discoloration following

immediate and delayed exposure to colored agents using 64 premolars which
were divided into four groups. Buccal surface of the teeth were divided into
two halves and baseline color values were measured. One half was covered
and the other half was etched and dried. In first and second groups, the
patients did not eat any colored agents for the next 24 hours. Both halves were
colorimetered after 48 hours and1 month, respectively. In third and fourth
groups, the process was similar, but the patients drank cola and avoid eating
any other colored agents and the teeth were colorimetered after 48 hours and
1 month, respectively. Color change values (Δ𝐸) of each half were calculated
according to CIE lab system. The results showed a significant difference in
groups III and IV regarding comparison of Δ𝐸 of the etched and control
enamel. So it was concluded that within limitations of present study, it was
shown that using colored agents for 24 hours after etching the teeth had
statistically significant unacceptable effect on tooth color, which remained at
least for 1 month. Therefore, it seems reasonable to ask the orthodontic
patients not to use any colored agents for the first 24 hours following bonding
the teeth10.