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INTRODUCTION
DEVELOPMENT
LIFECYCLE OF AN AMELOBLAST
AMELOGENESIS
ORGANIC MATRIX FORMATION
MINERALISATION AND MATURATION
COMPOSITION
PHYSICAL CHARACTERISTICS
ENAMELSTRUCTURE
A SINGLE ROD UNIT
STRUCTURAL FEATURES
SURFACE FEATURES
DEJ
CEJ
AGE CHANGES
CLINICAL CONSIDERATIONS
ENAMEL DEFECTS
CONCLUSION
INTRODUCTION
Imagine walking out into a cold, wintry morning without wearing a sweater. Imagine
crashing head-on into a wall without wearing a helmet. Imagine holding a live wire
without its insulation. Now, imagine the tooth without enamel. The importance of
enamel will strike you surely.
Enamel can be defined as a highly mineralized, acellular, inert, hard tissue of
ectodermal origin covering the anatomic crown of the tooth, which once destroyed
cannot be physiologically regenerated or replaced.
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).
The IEE reflects onto the OEE at the cervical loop.
OEE: it is made up of a single layer of cuboidal cells separated from the surrounding
dental sac by a basement membrane.
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.
During enamel formation, these cells undergo structural changes like villi formation,
vesicle inclusion, increase in mitochondria etc, to aid in the active transport of
nutrients.
Stellate Reticulum = It is made up of loosely arranged star-shaped cells having
desmosomal connections with each other and the adjacent OEE and stratum
intermedium.
They basically function as a shock absorber and help the tooth germ to resist any force
that may distort the configuration of the developing DEJ. They also aid in transporting
nutrients from the dental follicle to the IEE.
Stratum intermedium: This layer consists of 2-3 layer of polyhedral cells, which
become spindle shaped once enamel formation reaches its maturative stage. They
exhibit a high activity of enzyme alkaline phosphatase, which helps to increase the
mineral content of enamel.
IEE: Consists of a single layer of short coloumnar cells, which differentiate into tall
coloumnar 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.
Morphogenic
Organizing / Differentiation
Formative / Secretory
Maturative
Protective and
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
ORGANIZING STAGE: OR DIFFERENTIATION STAGE:
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 cells
directly (the cell free zone disappears) and the latter differentiate into odontoblasts.
Dentin formation begins which cuts off the nutritional supply via the papilla and the
ameloblasts start relying or 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.
FORMATIVE STAGE or SECRETORY STAGE,
Blunt cell processes develop on the distal end of ameloblast, which penetrate the predentin. The presence of dentin is necessary for the formation of enamel matrix. Thus,
reciprocal induction / mutual induction is the phenomenon behind enamel formation.
IEE
into odontoblasts
differentiate
which stimulate
Formation of enamel matrix and partial mineralization occurs.
MATURATIVE STAGE:
Full mineralization or maturation occurs as matrix is formed occlusally /incisally and
is getting laid down in the cervical portions. Cells changes include shortening of
ameloblasts development of micro villi and cytoplasmic vacuoles distally indicating
absorptive functions. The stratum intermedium cells became spindle shaped.
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.
DESMOLITIC 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
The development of enamel can be divided into 2 processes:
1) Organic matrix formation
2) Mineralization and maturation
FORMATION OF ENAMEL MATRIX:
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-enamel membrane and this gets
partially mineralized immediately. This mineralization is supposed to occur via
nucleation via nucletion from the apatite crystals located within the dentin. This first
enamel layer is structureless.
DEVELOPMENT OF TOMES PROCESS:
As the first increment of enamel is formed, the ameloblasts begin to move away from
the dentin surface, and as they do each cell forms a conical projection. These
projections called tomes processes jut into the newly forming enamel, giving the
junction between the enamel and the ameloblast a picket fence or saw-toothed
appearance. Tomes process primarily contains secretary granules.
At least 2 ameloblasts are involved in the synthesis of each enamel rod. According to
another interpretation, the head of each rod is formed by one ameloblast while 3
others contribute to the tail part. Thus, each rod is made from 4 ameloblasts.
DISTAL TERMINAL BARS: Are localized cytoplasmic condensations, which
separate the tomes process from the rest of the cell.
When tomes process is established enamel protein secretion becomes staggered and
gets confined at 2 sites:
-One site is adjacent to the proximal part of process which results in matrix wall
formation and subsequent inter-rod substance / tail.
-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.
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 / villi 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.
MINERALIZING AND MATURATION OF ENAMEL MATRIX.
It is a 2-stage process:
1st stage: immediate partial mineralization contributing to 25-30% of total mineral
content occurs.
2nd stage: Is characterized by completion of mineralization from height of crown
towards cervical region.
Maturation, which begins from the DEJ, is characterized by growth of the ribbonshaped crystals. Each rod matures from the depth to the surface and from height of
crown to the cervical area.
Mineralization starts even before the matrix has reached its full thickness
COMPOSITION
Enamel is the most highly mineralized tissue known making it also the hardest
calcified tissue in the human body.
Enamel is basically composed of 96% inorganic material and 1% organic material and
3% water.
INORGANIC: Out of the 96% inorganic matter, 90-92% is composed of
hydroxyapatite
which
is
slightly
different
from
the
basic
formula
of
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
The crystals are hexagonal is cross section with dimensions:
Width:
65nm
Length:
0.05- 1(160-1000nm)
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 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)
- It thins down to a knife-edge; sometimes less than 100m at the cervix or within the
fissures and pits of multi cusped teeth.
Clinical signification:
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.
HARDNESS: Since enamel is highly mineralized, it is extremely hard with hardness
comparative to mild steel. Thin enables it to withstand mechanical forces. Enamel has
a high modulus of elasticity and low tensile strength categorizing it as a rigid, brittle
material. This is compensated by the cushioning effect of underlying dentin which
enables enamel to
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)
PERMEABILITY: Enamel acts like a semi permeable membrane permitting
complete or partial passage of certain molecules like iodine, etc
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:
Longitudanal / sagittal sections
Horizontal / transverse sections
Tangential /longitudinal facial
Structurally, enamel is composed of millions of the repetitive basic unit enamel rod.
The enamel rod is the largest structural component. The other component is the rod
sheath and a cementing inter- rod substance in some areas.
LIGHT MICROSCOPE:
Under this, the rods appear as hexagonal, round or oval interlocking rows surrounded
by a sheath giving a typical fish-scale appearance.
ELECTRON MICROSCOPE:
The sub microscopic structure of the rod observed in cross section reveals various
types of rod patterns:
Irregular / structure less pattern = observed near the DEJ.
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
Keyhole / Paddle shape = the rod with its arch shaped head and tail interpose
between subjacent rod heads.
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 in organic 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.
The Diameter of the rod averages 4. 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 dentinal surfaces where they originate.
Rod direction: In general, rods are arranged perpendicular to the dentin surface and
the external surface. In the cervical region, where the crown contours become
constricted, the perpendicular orientation results in a gingival inclination of the rods.
In primary teeth, the central and cervical rods are almost horizontal.
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 20
Structural Features:
Enamel possesses features that characterize the tissue as more complex than the
schematic view of enamel rods presented so far.
The features are presented in 3 groups:
1) Structures related to incremental growth patterns.
Cross Striations:
Seen in longitudinal sections running perpendicular to enamel rods, cross
striations mark the daily growth increments of enamel. Human enamel is known to
form at a rate of 4 / day. This produces periodic variation in rod 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.
Incremental lines of Retzius:
Seen both in longitudinal and transverse sections, the stria 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 Pickerill 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:
It is an accentuated line of Retzius in primary teeth demarcating enamel
before birth and after birth. It is wider due to disturbance, which occurs during several
days of enamel formation.
2) Structures with organic content higher than the enamel tissue as a whole.
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. To former appear to
be caused due to aberrations in the developmental process. These can be of two types:
Type A: Which contains poorly calcified rod segments
Type B: Which contains degenerated cells.
The post-eruptive lamellae (Type C) result from various physical and thermal forces
to which teeth are subjected. These contains salivary organic matter.
CLINICAL SIGNIFICANCE These
Enamel Tufts:
Seen in transverse sections resembling tufts of grass, enamel tufts are actually
ribbons of organic material arising from the DEJ and extending 1/5 to 1/3 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:
Seen in longitudinal sections, spindles are bulbous club-shaped irregular blind
canals filled with air or debris. They once housed the ends of odontoblastic processes.
They do not follow the path of the enamel rods. At times it is seen that the enamel
spindles is continuous with the dentinal tubule [it could be the reason behind increase
in sensitivity once tooth preparation approaches the DEJ]
SURFACE STRUCTURES
the tooth lieing parallel to each other and the CEJ. Their number varies from
30/mm near the CEJ gradually decreasing to 10/mm occlusally. Over the cusps
they are absent as the lines of Retzius do not reach the surface. With age, these
ridges are worn away.
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
Pits and Fissures: are defects in the enamel surface usually 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 frequently seen
on the palatal surface of upper incisors.
CLINICAL SIGNIFICANCE:
Susceptibility to caries
AGE CHANGES
Enamel is a non-vital tissue incapable of regeneration physiologically.
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 tend 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.
Enamel permeability decreases because the pores between the crystals
diminish in size as the crystal acquires more ions and increase in size. Water
content also decreases. This can account for lower caries rate as well.
Teeth absorb fluoride ions from the environment making teeth less prone to
caries.
CLINICAL CONSIDERATIONS:
Although enamel is the hardest tissue in 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:
a bevel (applicable when restorative material is stronger than the tooth
structure [such as direct gold/ cast metal / ceramic])
Plane of enamel wall is parallel to length of rods [Applicable when
restorative material is weaker than the tooth structure such as in amalgam]
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.
A knowledge of the direction of enamel rods is very important during cavity
preparation. For example :
In a class II SAF, the gingival seat is beveled at an angle of 20 0 or 6 centigrade
with a GMT to ensure full length enamel rods forming the gingival margins
because the rods bend apically in this area.
When preparation margins came to an area of abrupt directional changes of
enamel rods or an area where no rules for enamel rod direction exist (mesio
incisal angle of incisor / cuspal area), this area should be included in the
preparation and margins placed in areas of a more predictable rod pattern.
Enamel walls should be smooth and junction between enamel walls should be
rounded.
Thickness of enamel at different locations should be kept in mind to avoid injudicious
cutting of dentin
Enamel structures:
1. Lamellae, cracks, pits and fissures are predisposed to caries
2. Gnarled enamel is difficult to cleave with hand instruments
3. DEJ: Sensitivity is high because of spindles and dentinal anastamosis
4. Striae of Retzius gets accentuated due to caries
5. CEJ: if no contact exists then sensitivity or caries can occur.
ACID ETCHING: Discovered by Bounocore in 1955, acid etching transforms the
smooth enamel into a very irregular surface and also increases its surface free energy.
When fluid resin material is applied, the resin penetrates into the surface aided by
capillary action. The monomer polymerizes and the material 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:
1. Preferential dissolution of inter- prismatic enamel first followed by cores (or
vice versa). Least dissoluble are the sides (rod sheath area)
2. Increase in surface area up to 2000 times than that of unetched area
3. Etching depth of 25 m is reached in enamel
4. Exposes proteinacious organic matrix
5. Removal of smear layer to help increase wettability of enamel( thus ensuring
that this fully reacted surface enamel, possessing minimal surface energy to
able to react to an adhesive, is removed)
Etching should done perpendicular to the rod heads to attain etch patterns. The latter
is of 3 types:
Type 1 Preferential removal of rod cores (Prismatic)
Type 2 Preferential removal periphery with intact core (inter-prismatic)
Type 3 Irregular and indiscriminate
ENAMEL DEFECTS:
These can be broadly classified as:
Smooth surfaces
1. Carious defects
Pit and fissures
2. Non-carious defects
Developmental:
Amelogenesis Imperfecta
Enamel hypoplasia Hereditary and Environment
Enamel pearl
Regressive :
Attrition
Abrasion
Erosion
Abfraction
3. Others:
ENAMEL CARIES:
It is preceded by dental plaque. The smooth surface incipient lesion is seen as a
smooth chalky white area (white spot). On drying the tooth surface certain histologic
changes seen are
-
DEVELOPMENTAL
AMOLOGENESIS IMPERFECTA :
It represents a group of hereditary defects of enamel unassociated with any other
generalized defects. These defects can occur in any of the stages of amelogenesis.
Accordingly they are of 3 types
1. Hypo plastic: (formative Stage): The defects are in the matrix formation
C/F = enamel does not form to its full thickness.
2. Hypo calcified:(Calcification Stage): Defects is in mineralization of matrix
C/F = enamel is soft that it can be flaked off with a hand instrument.
3. Hypo Maturation (Maturation Stage): Enamel crystals remain immature
C/F = enamel can be pierced with an explorer tip.
Others features common to all of them are
May /may not be discolored
Presence of parallel vertical grooves at times
Abrasion and open contacts
ENAMEL HYPOPLASIA:
It is an incomplete or defective formation of the organic enamel matrix of teeth.
It is of 2 types:
1. Hereditary = It is similar to hypoplastic enamel hypoplasia, All primary as
well as permanent teeth are affected.
2. Environmental = either of the dentitions or even just a single tooth can be
defective. A number of factors cause this:
a] Nutritional deficiency of vitamins A, C and D
b] Exanthematous fevers such as in measles, chicken pox
C/F = Pitted, stained, unsightly teeth
Incisors, cuspids 1st & molars are usually affected
c] Congenial Syphilis
g] Fluoride: Ingestion of fluoride containing drinking water (> 1ppm) during the
time of tooth formative leads to mottled enamel formation
C/F: Ranges from white specks/ patch to pitting to brownish staining to a totally
corroded appearance
ENAMEL PEARL:
Enamel Pearl/ Enamel Drop/ Enameloma are small masses of enamel found apically
to CEJ occurring
a position of
REGRESSIVE
ATTRITION: is the physiologic wearing away of the tooth as a result of tooth to
tooth contact occlusally, incisally and proximally
C/F
Advanced attrition: enamel gets completely worn away with complete loss of
cuspal interdigitations, there is exposure of dentinal tubules resulting in
secondary dentin formation, at times pulp horns are exposed.
Certain habits like tobacco chewing and bruxism can aggravate attrition
ABRASION: is the wearing away of tooth substance through abnormal mechanical
process. Causes
- Improper brushing
- Habits (hair pin opening causes incisal notching)
- Occupational tailors, shoemakers
- Improper flossing / tooth picking- proximal wear
C/F =
o V wedge shaped ditch on root side of CEJ
o Sharp angle between depth of lesion + enamel edge
o Exposed dentin is highly polished. Sensitivity and pulp exposure may
occur
EROSION: is wear or loss of tooth surface by chemico- mechanical action. It is
common in adults and increases with age. C/F:
Occurs mostly an facial surfaces. Proximal and lingual erosion is also seen in
same conditions
Causes of erosion:
1. Extrinsic
2. Intrinsic
-
Gastric reflux
- Sphincter incompetence
- Increased gastric pressure
- Increased gastric volume
Vomiting:
- Psychosomatic anorexia nervosa, bolemia
- G.I.T disorders
- Drugs
-
Regurgitation
Rumination
OTHERS
FRACTURES:Can occur due to:
-
Trauma
Existing restorations
Gingival bleeding
Food colors
Chromatic bacteria
Tobacco stains
Plaque / calculus
Caries
Hereditary Disorders
Fluoride
Age changes
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:
-