NATIONAL DENTAL COLLEGE AND HOSPITAL GULABGARH, DERA BASSI

DEPARTMENT OF PEDODONTICS AND PREVENTIVE DENTISTRY

SEMINAR

ON

ENAMEL

SUBMITTED BY
Dr. PARVEEN BATHLA PG STUDENT

CONTENTS

INTRODUCTION PHYSICAL PROPERTIES CHEMICAL PROPERTIES MICROSCOPIC STRUCTURE OF ENAMEL SURFACE STRUCTURES DEVELOPMENT OF ENAMEL MOLECULAR ELEMENTS OF TOOTH DEVELOPMENT PROTEINASES ENAMEL DEFECTS AGE CHANGES IN ENAMEL CLINICAL CONSIDERATION ENAMEL PRODUCTION IN VITRO
REFERENCES

ENAMEL

INTRODUCTION:The literal meaning of Enamel is a vitreous, glass like coating fused on to a metallic base similarly the tooth enamel form an outer covering of tooth and protect the inner structure. Enamel is hardest calcified tissue of the human body and is ecto-dermal in origin. Enamel is defined as Acellular hard mineralized tissue that forms the protective covering of variable thickness over the entire surface of the crown. Enamel, along with dentin, cementum, and dental pulp is one of the four major tissues that make up the tooth .

Physical properties of Enamel: Hardest calcified tissue. Ranks 5 on mohs scale with young`s modulus of 83 GPA & 343 KHN Thickness 2-2.5 mm (cusps) to feather edge (cervical line). Brittle in nature. Act as a Semipermeable membrane. Specific gravity 2.8. Compressibilty (elastic modulus) 19 X 10^ 6 psi, tensile strength 1100 psi. Translucent & Color ranges from yellowish white to grayish white. Incisal areas may have a bluish tinge where the thin edge consists only of a double layer of enamel. Enamel is avascular and has no nerve supply within it and is not renewed, however, it is not a static tissue as it can undergo mineralization changes.

Chemical properties of Enamel:

Enamel

inorganic mat. organic mat.& water 96% (by wt) 4%

Inorganic Content Enamel Dentin Cementum 96% 70% 45-50%

Organic Content + Water 4% 30% 50-55%

Inorganic substances in enamel - comprises of crystalline ca phosphate i.e hydroxyapatite. Various ions- strontium, magnesium, lead , fluoride get incorporated if present during enamel formation.

Hydroxyapatite crystal

Apatite crystals of enamel are largest & best developed of all the crystals of mineralized tissue (dentin &bone). Initially crystallites appear as long plates/ribbon of 15 A which grows rapidly in width & slowly in thickness. 1600 A in length, 680 A in width &260 A in thickness. Enamel crystallites are organized into basic structural units called as prisms.

Composition of hydroxyapatite crystal: 10Ca++6PO4 & 2OH By wt. 37% Ca, 52% phosphate, & 3% hydroxyl

Organic substances in Enamel Enamel protein polysacch.protein complex & acid mucopolysaccharides.

ENAMEL PROTEIN Two types (TERMINE et al 1979): 1. Amelogenin (90%)(LMW Protein) 2. Non amelogenin (10%)(HMW Protein) a) Ameloblastin b) Enamelin c) Tuftelin

STRUCTURES OF ENAMEL Enamel Rods Striations Hunter schreger bands Incremental lines of Retzius DEJ Enamel tuft Odontoblastic process & enamel spindles Enamel lamellae Enamel cuticle

ENAMEL RODS cylindrical in shape.

Extend from DEJ to outer enamel surface. 5 million in lower lateral incisor to 12 million in upper first molars. Head is broadest part(5 m wide), elongated thinner portion or tail is (1 wide). The bodies of the rods are nearer occlusally or incisally whereas the tails point cervically. the tooth diameter becomes double while at enamel surface the rod structure is irregular or absent (tome`s processes are lost as amelogenesis comes to an end.). length of rod 9 m. length greater than the thickness of the enamel because of the oblique direction and tortuous/wavy course of the rods. Each rod formed by 4 ameloblasts. One ameloblasts forms the rod head, a part of two ameloblast forms neck & tail by fourth ameloblast

the diameter of the rods increases as they transverses the Enamel, towards the surface of

Rods are surrounded by rod sheath & separated by inter rod substance. Rod sheath: the boundary where crystals of the rod meet those of the interod regions at sharp angles. rod sheath contain more enamel protein than other regions. The inter rod regions is an area surrounding each rod is which crystals are oriented in a different directions from those making up the rod. The consistent arrangement of rod sheaths,with their greater protein content accounts for fish scale appearance in etched ground sections. The rod sheath can also be visualized in undemineralised light microscope sections because of differences between refractive indices of sheath, rod, & interred regions.

A more common pattern in a keyhole pattern or paddle shaped prism in human enamel Keyhole shape results mainly due to lateral flaring of the rod crystals which continue uninterrupted into cervically located inter rod region till they are perpendicular to the rod .Inter rod region which is cervical to the rod is not separated by the rod sheath.

Rod is filled with crystals which are approx. parallel to long axis of rods in head region & deviates 65 degree in tail. In first 5 m ,next to dentin there is no rod structure because tome`s processes not yet formed when this enamel is laid down.

Directions of rods Enamel rods are arranged circumferentially in rows around the long axis of the tooth . Rods are oriented at right angles to dentine surface.

Near the cusp tip, they have a small radius and run vertically. In cervical and central part of crown of Deciduous tooth they are approximately horizontal. Near the incisal edge cusp tip they change gradually to an increasingly oblique direction until they are they are almost vertical. The permanent teeth is similar in the overall two thirds of the crown. In the cervical region the rods deviate from the horizontal in an apical direction superimposed on this row arrangements are two other patterns. S shaped course in horizontal plane and change in direction of about 2 b/w successive rows.

CROSS STRIATIONS: Each enamel rod is built up of segments separated by dark line/ band. These periodic bands or cross striations occur at 4 m intervals across the rods. Striated appearance because of alternating constrictions and expansions of the rods. Indicates a daily (circadian) variation in the secretory activity of ameloblasts.

GNARLED ENAMEL Optical appearance found at the cusps and incisal edges of teeth. The twisted appearance results from the orientation of enamel rods and the rows in which they lie. The rods undulates back & forth within the rows. This undulation vertically directed rods ( i.e at cusp tip) around a ring of small circumference give this appearance.

HUNTER SCHREGER BANDS Named after scientist who first noted band microscopically. Optical phenomena seen due to Change in directions of rods & provides enamel with strength for mastication and biting. Alternate dark and light bands seen in longitudinal sections and oblique reflected light These zones can be reversed by altering direction of illumination. Originate at DEJ & found in inner four fifth of enamel. The repeating pattern from cervical to incisal/occlusal areas seen along long axis of the tooth. Variations in calcification of the enamel coincide with the distribution of the bands of Hunter schreger.. Diazone and parazone: purely an artifact of sectioning in HSB, not a true structure. In sections vertical to HSB,decussating prisms are intersected at different angles. Layers in which prisms are truncated were called DIAZONES by PREISWERK(1894, 1896). While layers in which prisms are intersected at low angles or longitudinally were called PARAZONES .

INCREMENTAL LINES Dr. retzius first noted growth lines in Enamel & termed them the striae of retzius These are growth lines which are result of rhythmic recurrent deposition of Enamel Appear as dark bands in longitudinal sections of the enamel, reflecting successive Enamel forming fronts. In longitudinal sections surround tip of dentin and run obliquely in cervical parts. In transverse section concentric circles.when these circle not complete, a series of groove called line of pickerill are formed. Decrease in number of crystals in striae & bending of the enamel rod occur as they cross striae. Formed as a result of temporary constriction of tomes process associated with corresponding increase in the secretory face forming interrod Enamel. Accentuated incremental lines are produced by systemic disturbances. Prominent in permanent teeth less prominent in postnatal deciduous teeth and rare in prenatal teeth.

NEONATAL LINE/ NEONATAL RING The Enamel of the deciduous teeth develops partly before and partly after birth, the boundary between the two portions of enamel in deciduous teeth in marked by an accentuated incremental line of Retzius. Result of abrupt change in the environment and nutrition at the time of birth. Microscopically the Enamel internal to this line is of different consistency from external to it because internal was formed before birth and external after birth.

DENTINOENAMEL JUNCTION Scalloped profile in cross section at junction of Dentin & Enamel. Junction is like series of ridges that increase surface area and adhesion b/w dentin and Enamel.

The surface of dentine is pitted at DEJ.

ENAMEL TUFTS Project from DEJ into Enamel one fifth to one third of its thickness. Branched like tufts of grass and contain greater concentration of protein than rest of Enamel. Occur because of abrupt changes in direction of group of rods that arise from DEJ considrered as adaptation to spatial conditions.

ODONTOBLAST PROCESS AND ENAMEL SPINDLES Odontoblast processes push b/w adjoining ameloblasts and when enamel formation begins, get trapped forming a tubule. These small tubules may contain living process of odontoblast ,contributing to the vitality of DEJ. The direction of the odontoblast process and spindles in the enamel corresponds to the original directions of ameloblast i.e. at right angles to the surface of the dentine. Rods and spindle directions are divergent.

ENAMEL LAMELLAE: Leaf like structures that extends from the Enamel surface towards DEJ and penetrate dentin. Consist of organic material but little mineral content. Lamellae may develope in planes of tension, where rods cross such plane, a short segment of rods may not calcify, if it distribution in more severe a crack may develope. 3 types of lamellae Type A Type B Lamellae composed of poorly calcified rod segments. it is restricted to enamel may

- consist of degradation cells & may reach dentin

Type C

- in erupted teeth, where cracks are filled with organic matter & reach dentin - More common

Spaces b/w group of rods are another eg. of lamellae & may be caused by stress cracks that occur because of impact or temp. changes Enamel lamellae may be a site of crack in a tooth and form a road of entry for bacteria that initate caries.

ENAMEL CUTICLE A delicate membrane called Nasmyths membrane, or primary enamel cuticle covers the entire crown of the newly erupted tooth but a probably soon removed by masticaton. This membrane is a typical basal lamina secreted by ameloblast when enamel formation is completed & is composed of keratin.

Enamel surface: structureless Enamel layer Salivary pellicle Perikymata Cracks (lamellae)

Structureless Enamel layer: Rodless enamel occurs in outermost 30 um of all primary teeth & 70% of permanent at gingival third. Crystals in these regions are perpendicular to tooth surface. In erupted teeth both these layer are rapidly lost by abrasion attrition & erosion.

Salivary pellicle: Organic deposit on surface of tooth always reappear shortly after teeth mechanically polished.

Perikymata/imbrications lines: Transverse, wave like grooves across the face of crown. External manifestation of the striae of Retzius. Usually lie parallel to each other and CEJ. More prominent on facial surface and cervical areas 30/mm at CEJ to 10/mm near occlusal or incisal edge. Course is irregular in cervical region.

Cracks: Narrow fissure like structures. The outer edges of lamellae and at right angles to DEJ. Mostly < 1mm but sometime may be longer.

Difference in Enamel of primary and permanent teeth Primary teeth Permanent teeth

Thin enamel .5- 1 mm More opaque & white Inorganic 92% More permeable Enamel rod direction in cervical region - Horizontal

2.5 mm Yellowish white inorganic 96% Less Apical

DEVELOPMENT OF ENAMEL Enamel organ Life cycle of Ameloblasts Amelogenesis

ENAMEL ORGAN

Oral epithelium 6th week IU Dental lamina proliferates Enamel Organ Enamel formation is part of the overall process of tooth development. The stages of tooth development are the bud stage, cap stage, bell stage, and crown, or calcification, stage. Enamel formation is first seen in early crown stage & involves the differentiation of cells of internal dental epithelium into Ameloblasts

FOUR LAYERS Outer Enamel Epithelium Stellate reticulum Stratum intermedium Inner Enamel Epithelium

Outer Enamel Epithelium It consists of single layer of cuboidal cells which get laid down into folds. B/w these folds mesenchyme of dental sac forms papillae that contains capillary loops which provide nutritional supply to enamel organ. Inner Enamel Epithelium Present at concavity of enamel organ & are tall columnar cells these cell differentiate into ameloblast. The cells of IEE have an organizing influence on underlying mesenchymal cells of dental papilla to differentiate into odontoblast and their product dentin becomes the initiator for further differentiation of inner dental epithelium cells( reciprocal induction)into ameloblasts.

Stellate reticulum (enamel pulp) Cells are star shaped & located in centre of enamel organ & assumes a branched reticular form. The spaces in this reticular network are filled with mucoid fluid rich in albumin which gives this layer cushion like consistency before Enamel formation starts this collapses , reducing distance b/w Ameloblasts and capillaries near outer Enamel epithelium. Temporary structures enamel knot & cord present in centre of enamel organ they disappear before enamel formation begins . they act as reservoir of dividing cells for growing enamel organ. . Stratum intemedium It Consists of flat cuboidal cells & are present b/w IEE & stellate reticulum. These cells have high alkaline phosphatase activitiy & glycogen deposits. It play a role in enamel formation either through control of fluid diffusion into and out of Ameloblasts.

LIFE CYCLE OF AMELOBLAST Morphologic stage Differentiation stage Secretory stage Maturation stage Protective stage

Morphologic stage IEE cells are short columnar with large centrally located nuclei . Golgi elements & centriole present in proximal portion. Mitochondria scattered throughout.

Differentiation stage

Cells elongates & their nuclei shift proximally toward stratum intermedium. Golgi complex increases into volume and migrates from its proximal position to centre. RER increases & most of mitochondria cluster in proximal region. Adajacent ameloblasts are closely aligned to each other & maintained by junctional complexes. (imp. of junc.complexes: selective passage between ameloblasts)

Secretory stage
Synthesis of enamel protein occur s in RER ,packed & condensed into granules in golgi bodies , and their contents released against newly formed mantle dentin. Ameloblast control over passage of inorganic ions from capillaries of dental follicle to Enamel surface. After this first structureless enamel layer is formed the ameloblasts migrate away from the dentin surface & permit formation of conical processes -Tome`s process. Tome`s processes jut into newly formed enamel giving junction b/w enamel and ameloblast a picket fence or saw toothed appearance . Secretory granules are present in Tome`s process . Tome`s process persists until final new enamel increments are formed.

Maturation stage
Ameloblasts reduced in length and closely attached to enamel matrix. Cells of stratum intermedium loose regular arrangement and assume spindle shape. Cells become striated/ ruffled border. Ameloblasts display microvilli at their distal extremities. Reduction in height and decrease in volume and excess organelles digested by lysosomse enzymes. Water & organic material are selectively removed from enamel while additional inorganic material is introduced by alternate bursts of activity. Ruffle ended Ameloblast associated with introduction of inorganic material & smooth ended cells with removal of protein and water.

Protective stage
Ameloblast protect enamel surface from follicular connective tissue Cell layers form stratified epithelial covering of enamel called REDUCED ENAMEL EPITHELIUM. Ameloblast secrete material morphologically similar to basal lamina. The distal cell membrane no longer folded & has developed Hemidesmosomes which provide a firm attatchment for the Ameloblasts to the enamel surface that is utilized to form primary Epithelial attatchment b/w gingival & newly erupted tooth.

MOLECULAR ELEMENTS OF AMELOBLAST DIFFERENTIATION

Amelogenesis is under the control of expression of various molecules

Gene transcription factors

a) MSX-2 gene ( homebox gene) Expressed during bud stage in epithelium localized to enamel knot region Regulates morphogenesis

b) Egr-1 Expressed in the polarized ameloblasts before any matrix is produced.

Membrane receptors
a. b. c. Receptor molecules on the cell surface recognize & bind signaling molecule B5 FgF EGF

INTRACELLULAR RECEPTORS
a. CRABP-1 Transmit signal of retinoic acid. Expressed by secretory but not maturation stage ameloblasts b. Growth hormone receptor Appear only on differentiating ameloblasts vitamin D receptor identified during differentiation.

Amelogenesis: Organic matrix formation Mineralization

Formation of the enamel matrix Ameloblasts begin their secretory activity when a small amount of dentine has been laid down. Ameloblast lose the projection which had penetrated the basal lamina. A thin layer of enamel forms along the dentin. This has been termed the Dentinenamel membrane. The presence of membrane shows that the distal ends of enamel rods are not in direct contact with dentin. Head of rod formed by one and tail by three Ameloblast thus each rod is formed by four Ameloblast. Bulk of developing enamel matrix is protein Amelogenin produced by Ameloblast.

AMELOGENINS amelogenin nanospheres appear as beaded rows of electro luscent structures aligned with and separated ,the enamel mineral crystallites (FINCHAM et al 1995) Dr. Alan fincham is the father of Amelogenin. Gene specific protein. Latest studies have indicated that Amelogenin exists in the form of nanospheres. Molecular wt. 25 KDa derived from gene located on x chromosome. Hydrophobic protein rich in Proline,Glutamine. Undergoes long term & short term extracellular processing. Accumulates during secretory stage. support & locate framework for developing enamel. Regulate growth of crystal in thickness & width. May also nucleate crystals. During mineralization process 90% of amelogenin in enamel matrix get removed by proteolytic enzyme into TRAP & LRAP.

NON AMELOGENINS Ameloblastin Undergo rapid degradation. Promotes mineral formation and crystal elongation. Determination of prismatic pattern.

Enamelin Protein in developing Enamel that is tightly bound to crystals and similar in composition as that of mature Enamel matrix. Contains Glycine, Glutamic acid, Aspartic acid & serine phosphate. Organically bound phosphate or serine phosphate play a key role in nucleation of Hydroxyapatite thus initiating calcification. Tuftelin Participates in establishment of DEJ. Its gene is located on autosome 1. Cell signaling. Nucleator for first Enamel crystal.

Mineralization and Maturation of enamel matrix Two steps Immediate partial mineralization. Maturation

Immediate partial mineralization Immediate partial mineralization occur in the matrix segment and inter prismatic substance as they are laid down( 25% to 30% of total mineral content).

Maturation The gradual completion of mineralization& conversion of first formed enamel which is soft or moderately hard into hardest of hard tissue. Maturation process starts from the height of the crown and progress cervically. The incisal and occlusal regions reach maturity ahead of the cervical regions. Crystal increase in thickness more rapidly than width. Organic matrix gradually become thinned and widely spaced to make room for the growing crystals. Over 90% of initially secreted protein is lost during enamel maturation. Human enamel forms at a rate of around 4 m per day. Ameloblast undergo programmed cell death.

Studies involving microradiography of thin ground section indicates mineralization in 4 stages: First stage primary mineralization 30% mineralization achieved. Second stage

Starts at surface of enamel & sweeps rapidly into deeper layers until it reaches innermost 8 m layer.

Third stage Tertiary increase in mineral rebounding from innermost layer out toward the enamel surface. Fourth stage(quaternary mineralization) outer layer mineralizes rapidly & heavily & becomes the most mineralized part of enamel.

PROTEINASES AND TOOTH DEVELOPMENT serve two important functions: a. processing b. degrade enamel proteins. Enamelysin (MMP-20) is the foremost enamel matrix-processing enzyme cleavage products reside in mature and deeper layers Full length protein reside on surface enamel. They activate the parent proteins MMP20) or enamlysin reside in recently formed tooth enamel. Enamlysin cleave amelogenin , important in early tooth development. a decrease in enamel protein content degrade the organic matrix

Enamel matrix serine proteinases 1(EMSP 1) was cloned from the enamel organ epithelia. EMSP 1 involved in the degradation of enamel prior to its removal Accor. To USC led team of dental researchers, a gene critical for tooth formation expresses a protein that is cleaved into two proteins with opposite functions viz.DSP (dentin sialophosphate) and DPP (dentin phosphoprotein)

 DSP : imp. in the development of enamel and dentin.DSP protects the tooth against caries but over expression can lead to inc hardness of enamel. DPP : asso.with early stages of mineralization .Over expression leads to softer enamel. Thus, a fine balance of DSP and DPP results in delicacy of the DEJ. ENAMEL DEFECT Carious defect Non-carious defects Developmental defects: Enamel hypoplasia Amelogenesis imperfect Enamel Pearl Odontodysplasia Dens evaginatus Regressive defects: Attrition Abrasion Erosion Abfraction Fractures Discolorations

CARIES First sign- white spot due to loss of translucency which sometime get remineralized and becomes brown. When lesion is invaded two third of enamel it becomes visible radiographically. In fissures start at adjoining lateral wall. The high mineral content of enamel, which makes this tissue the hardest in the human body, also makes it susceptible to a demineralization process which often occurs as dental caries. Ca10(PO4)6(OH)2(s) + 8H+(aq) 10Ca2+(aq) + 6HPO42-(aq) + 2H2O(l) As enamel continues to become less mineralized and is unable to prevent the encroachment of bacteria, the underlying dentin becomes affected as well. When dentin, which normally supports enamel, is destroyed by a physiologic condition or by decay, enamel is unable to compensate for its brittleness and breaks away from the tooth easily.

Zones of caries in Enamel

Zone 1 Translucent zone deepest zone, pore volume 1%. Zone 2 Dark zone does not transmit light, pore volume 2-4% Remineralization increases dark zone. Zone 3 Body pore volume 5- 25% demineralized ,well marked striae of retzius. bacteria present. Zone 4 Surface zone unaffected by caries, low pore volume. Hypermineralised & high fluoride. HYPOPLASIA Defined as incomplete or defective formation of organic matrix of enamel. Two types:Hereditary: Environmental: Causes are: [systemic/local] Nutritional deficiencies (Vit. A, D, C). Local infection /trauma. Congenital syphilis (mulberry molars and screw driver shaped incisor). Hypocalcaemia (pitting is seen). Birth injury (neonatal line), pre-maturity. Chemical intoxication.

HYPOPLASIA DUE TO NUTRITIONAL DEFICIENCY & EXANTHEMATOUS FEVERS Vitamin A, C, D Deficiency. Rickets most common cause. Chickenpox, measles & scarlet fever. Pitted variety.

HYPOPLASIA DUE TO LOCAL INFECTION/ TRAUMA - Turners hyoplasia. - Single tooth involved most common is maxillary incisor or maxillary/mandibular premolar. - Infection from carious deciduous teeth in periapical tissue may disturb the ameloblastic layer of permanent tooth. - Trauma to deciduous tooth injures permanent tooth bud.

Hypoplasia due to congenital synthesis. Hutchisons teeth in anteriors. Screw driver shaped maxillary central incisors. Mulberry molars.

Enamel hypoplasia due to Hypocalcemia In tetany (ca -6-8 mg/100 ml). molar pitting variety of hypoplasia.

Hypoplasia due to birth injuries traumatic birth. premature born children. children who suffer hemolytic disease at birth.

Hypoplasia due to fluoride Mottled enamel Fluoride conc. > 1ppm in drinking water. There can be white flecking/ spotting on enamel, white opaque areas, pitting and brownish staining or corroded appearance. They wear and even fracture easily

AMELOGENESIS IMPERFECTA (Hereditary brown enamel, Heriditary Enamel Dysplasia)

Heterogeneous group of enamel defects having genetic basis. Autosomal dominant. MUTATION IN AMELX,ENAM,MMP20,KLK-4 GENES

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 .

Classification (Witkop and Sauk) 1. Hypoplastic a. Pitted, autosomal dominant b. Local, autosomal dominant c. Smooth, autosomal dominant d. Rough, autosomal dominant e. Rough, autosomal recessive f. Smooth, X-linked dominant 2. Hypocalcified a. Autosomal dominant b. Autosomal recessive 3. Hypomaturation a. Hypomaturation- hypoplastic with taurodontism, autosomal dominant b. X- linked recessive c. Pigmented, autosomal dominant

d. Snow capped teeth

1) Hypoplastic type - defective formation of matrix. 2) Hypocalcification type- defective mineralization of the formed matrix. 3) Hypomaturation type crystallite remain immature.

Hypoplastic amelogenesis imperfecta Yellow brown color. Enamel pitted ,rough or smooth & glossy. Defective Ameloblast. Reduced Enamel thickness-undersized teeth so lack of contact b/w adjacent teeth.

Hypocalcification amelogenesis imperfecta Colour clear to cloudy white , yellow brown. Enamel is soft, may crack down. Enamel thickness normal but mottled appearance. Rarely snow capped with opaque enamel.

Hypomaturation amelogenesis imperfecta Poorly mineralized enamel start to fracture shortly after in function. Increased permeability, stained & dark. Under pressure explorer penetrate soft enamel.

Radiographic findings: In hypo plastic type-square shaped crown, thin opaque enamel, low or absent cusp Pitted enamel appears as sharply localized areas of mottled density In hypocalcified type-enamel density even less than dentine

With abrasion-oblitration of pulp chambers

ENAMEL RENAL SYNDROME Enamel-renal syndrome (ERS) is characterized by hypoplastic amelogenesis imperfecta (AI) and nephrocalcinosis (NC). It is listed as a "rare disease" by the office of rare diseases (ORD) of the National Institutes of Health (NIH). This means ERS affects less than 200,000 people in the US population. The common features of this syndrome are the presence of thin or no enamel, delayed tooth eruption, intrapulpal calcifications, bilateral nephrocalcinosis, and normal plasma calcium.

Enamel pearl Enamel pearl: Also called Enameloma or Enamel Drop. Enamel pearl is condition where enamel is found on locations where it is not supposed to be. Usually present in furcation area of molars. Thickness of enamel layer varied between 0.3-0.5 mm in different pearls and increased pearl diameter. Pearl enamel is loosely textured than crown enamel which is due to porosities due to loosely packed crystals.

Odontodysplasia Developmental disturbance enamel & dentine thin, irregular & fail to mineralize adequately. Central incisors & canine most affected. Teeth small, mottled brown. Caries susceptible, brittle so fracture easily. Delayed or no eruption. Radiographically enamel thin so not evident, pulp chamber & root canal are large & wide.

Dens Evaginatus/Leong`premolar Outfolding of enamel organ resulting in tubercle of enamel on occlusal of premolar

Tubercle has dentin core & very slender pulp horn

REGRESSIVE DEFECT Attrition: Physiologic wearing away of tooth structure as a result of tooth to tooth contact occlusally and proximally. Commonly seen in old age Permanent teeth > deciduous teeth Small polished facet on cusp tip & flattening of incisal edge

Abrasion 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 exposed dentin is polished. Sharpe angle at the depth of the lesion and at enamel Secondary dentin formation occurs.

Erosion Loss of tooth structure resulting from chemo-mechanical acts in the absence of specific micro-organisms. Seen mostly on facial surfaces Manifested as shallow, broad, smooth, highly polished scooped out depression.

causes Diet soft drinks, lemon, citrus fruit juices Salivary citrates Local acidosis in the periodontal tissue Gastric reflux Vomiting

Abfraction

Flexure of tooth under heavy lateral load which may lead to displacement or # of rods at the CEJ. Wedge shaped lesion seen commonly on buccal surface of mandibular teeth Produce micro fractures in the thinnest region of enamel at CEJ which predisposes to loss when subjected to tooth brush abrasion.

Fractures Due toTrauma Dentinal caries leading to undermining of enamel which fracture under occlusal load. Discoloration 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. Tetracycline Discoloration of either deciduous or permanent teeth. Formation of complex with calcium ions i.e tetracycline orthophosphate. Oxytetracycline or doxycycline diminish tooth discoloration.

Yellowish brownish gray. Dentin is more heavily stained than enamel.

Erythropoetic prophyria Genetic disease resulting in the deposition of porphyrins through throughout the body. These deposits also occur in enamel and leave an appearance described as red in color and fluorescent.

Age Changes in Enamel Attrition of occlusal surface and proximal contact point as a result of mastication. Wear facets are common. Crystal increase in size and pores diminishes. Water content of enamel decreases. Generalised loss of rod ends and flattening of perikymata. Localized increase of elements such as nitrogen and fluoride in superficial enamel layers of older teeth. Darker with age(due to addition of organic material from the environment or deepening of dentin color seen through thinning layer of translucent enamel. Reduced permeability to fluids.

Clinical Considerations Cemento-enamel junction-Exhibits 3 types of relationships. In about 60% of teeth, cementum overlaps enamel. In about 30% of teeth, enamel and cementum meet edge to edge.

In about 10% of teeth cementum and enamel do not meet and dentin in this area is not covered by cementum.

Cavity cutting Unsupported enamel rods are not left at the margins, they would break and produce leakage.

Brittleness of Enamel Enamel is brittle and does not withstand forces in thin layers or in areas where there is no underlying dentine.

Deep enamel fissures Although these are not considered pathological, food lodgement and difficult clearance area may lead to dental caries, caries penetrate the floor of fissure rapidly because the enamel in these areas is very thin. As the destructive process reaches the dentin, it spread along to DEJ under rising to enamel. Dental lamellae may also be predisposing locations for caries because they contain much organic materials. Bruxism, also known as clenching of or grinding on teeth, destroys enamel very quickly. The wear rate of enamel, called attrition, is 8 micrometers a year from normal factors. The truly destructive forces are the parafunctional movements, as found in bruxism, which can cause irreversible damage to the enamel.

Fluoride If incorporated into the hydroxyapatite crystals becomes more resistant to acids. Lead to precipitation of calcium phosphate . Shifts equilibrium of Ca and phosphate ions towards the solid phase. Remineralization reaction is enhanced . Interference in enzymatic action of bacteria.

Direct antibactericidal action. Formation of large appatite crystals. Lowers solubility of enamel. Recommended dosage in drinking water is 0.7-1.2 mg/L. Excessive ingestion may damage the tooth-forming cells, leading to fluorosis. Discoloration ranging from white spots to brown and black stains. Skeletal fluorosis -- bone disease caused by excessive consumption of fluoride. Causes pain and damage to bones and joints.

Fluoride catalyzes the diffusion of calcium and phosphate into the tooth surface, which in turn remineralizes the crystalline structures in a dental cavity. The remineralized tooth surfaces contain fluoridated hydroxyapatite and fluorapatite, which resist acid attack much better than the original tooth did..The acute toxic dose of fluoride is ~5 mg/kg of body weight

Effect of dental procedures Dental restorations involve the removal of enamel. the purpose of removal is to gain access to the underlying decay in the dentin or inflammation in the pulp. Enamel can sometimes be removed before there is any decay present. The most popular example is the dental sealant. Sealants are unique in that they are preventative restorations for protection from future decay and have shown to reduce the risk of decay by 55% over 7 years. Aesthetics is another reason for the removal of enamel. Removing enamel is necessary when placing crowns and veneers to enhance the appearance of teeth. In both of these instances, it is important to keep in mind the orientation of enamel rods because it is possible to leave enamel unsupported by underlying dentin, leaving that portion of the prepared teeth more vulnerable to fracture.

Enamel etching Invented in 1955,(BUNOCORE) By dissolving minerals in enamel, etchants remove the outer 10 micrometers on the enamel surface and make a porous layer 550 micrometers deep. This roughens the enamel microscopically and results in a greater surface area on which to bond. Remove the smear layer

increase retention of resin sealant promote mechanical retention. phosphoric acid is a common wet etching agent

There are three patterns formed by enamel etching : - Type 1 the enamel rods are dissolved. - Type 2 area around the enamel rods are dissolved. - Type 3 no evidence left of any enamel rods. type 1 - most favourable pattern type 3 - the least The explanation for these different patterns is not known for certain but is most commonly due to different crystal orientation in the enamel. Tooth whitening Effects on enamel 1. Surface textureMost SEM studies show no change( Haywood et al, 1991) One study testing 16% and 35% carbamide peroxide solution showed loss of aprismatic layer,exposure and demineralization of enamel and pitting (Bitter, 1995).

2. Surface hardness and wear resistance. - Surface hardness is unaffected(Zalkind et al, 1996) OTHER study- decrease in hardness and wear resistance ( Seghi and Denry,1992)

3. Chemical structure - Loss of organic componenets i.e. carbon, hydrocarbon and tertiary amine replaced by oxygen Loss of average 1.06g/mm2 of calcium after 6 hours with carbamide peroxide(Haywood et al, 1991) Tooth bleaching procedures attempt to lighten a tooths colour in either mechanical or chemical actions. A bleaching agent is used to carry out an oxidation reaction in the enamel or dentin. Agents most commonly used to change the color intrinsically are hydrogen peroxide and carbamide peroxide. Effects on enamel can be adverse apart from tooth whitening. It can result in low pH,decrease in fracture toughness and no significant change in surface hardness. These changes are due to change in organic matrix.

Tooth whiteners in T/P work mainly through mechanical action. They have mild abrasives which aid in removal of stains on enamel. Oxygen radicals from the peroxide in the whitening agents contact the stains in the interprismatic spaces within the enamel layer. When this occurs, stains will be bleached and the teeth now appear lighter in color. Teeth not only appear whiter but also reflect light in increased amounts, which makes the teeth appear brighter as well. Studies show that whitening does not produce any ultrastructural or microhardness changes in the dental tissues. However, a tooth whitening product with an overall low pH can put enamel at risk for decay or destruction by demineralization. Consequently, care should be taken and risk evaluated when choosing a product which is very acidic.

Enamel & Microabrasion This technique involves the rotary application of a mixture of weak hydrochloric acid and silicon carbide particles in a water-soluble paste. An acid is used first to weaken the outer 2227 micrometers of enamel in order to weaken it enough for the subsequent abrasive force Enamel loss is lower than acid etching Bond strength is higher for acid etching Remove superficial stains of enamel

EDTA treated Enamel - Dissolution mainly started on the peripheral borders of the prisms Reaching laterally and then cervical portion. complete delineation of rod cores with a decrease in interprismatic zone. removal of calcium ions occur more in hypo mineralized sections.

 Shade Enamel becomes temporarily whiter when isolated. Thus shade must be selected before isolation and preparation of tooth. This is due to temporary loss of loosely bound water.

Growth tracks in enamel : Enamel consists of tightly packed crystals organized by differential orientation of prisms and inter prisms. Crystal orientation is influenced by both cellular and physico chemical factors. structure of enamel testifies the events that take place during enamel formation. prisms are the fossilised tracks traced out by ameloblasts. The tangential diameter of ameloblasts and the central distance of the prisms increase from the DEJ to the enamel surface. The prisms cross striations are the light microscopic variations of the prism varicosities or compositional variations and these are due to rhythm in enamel formation and the variation is diurnal. In human Enamel, the rate of enamel formation is 3.5 4um and the enamel formation increases from the inner incisal to outer enamel epithelium and decreases from incisal area to the cusp region. The evenly spaced striae of retzius are the incremental lines that represent 6-11 day rhythm in enamel formation while other lines represent the stress levels. The geometry of the enamel growth tracks and their chronological significance are valuable tools in chronological mapping of dental development and for understanding temporal and spatial patterns in tooth morphogenesis. The taxonomic significance of prism packing patterns, prism decussation and enamel thickness should be clarified through further systematic descriptive research.

Regrowth of enamel from cultured cell Can` t regenerate itself due to loss of cells so vulnerable to wear and tear. The idea of culturing technique originates from 1975 when Dr. J.G.Rheinwald and Dr.H.Green of harvard medical school reported the use of feeder layers for culturing epithelial cells from skin. The 3T3-J2 cells used in the culturing were gifted by Dr.H.Green. Cell scaffold approach (based on tissue engineering technology) was used to produce artificial enamel.

Considering the crown engineering,three main parameters have been considered : a) the relationship between crown morphology and tooth function b)The growth of the organ which is hardly compatible with the organ scaffolds c)Easily availiable non dental competent cell sources. The in vitro synthesis involves : BMDC (BONE MARROW DERIVED CELLS) DENTAL TISSUES. The PEK(primary enamel knot) is involved in signalling crown morphogenesis and formation and fate is recognised by re association between : a) embryonic day 14 (ED14) incisor and molar enamel organs and mesenchyme. b) ED14 and molar enamel organs and BMDC. The mesenchyme controls the fate of EK cells using apoptosis as criteria and function to determine whether tooth is uni/multicusped.

 Epithelial cells extracted from developing teeth of 6 month old pigs continued to proliferate when cultured on special feeder layer of cells(3T3-J2 cells) This study was reported at the 85th general session of the international association for dental research by a team of researchers from the institute of medical science,university of tokyo(japan) Now a days researcher`s are seeding cultured dental epithelial cells onto collagen sponge scaffolds along with cells from the middle of tooth. These scaffolds were then transferred into the abdominal cavities of rats where conditions were favourable for cells to intearct and develop. When removed after 4 weeks,the remnants of scaffolds were found to contain enamel like tissue. The key finding of this study was that even after multiple divisions that occurred during the propagation of cells in culture,the dental epithelial cells retained the ability to produce enamel as long as they were provided with an appropriate environment.

Calcium mediated differentiation of cell in vitro: Primary human ameloblast were isolated from human fetal tooth buds. Cells were treated with calcium cell morphology studied by phase contrast microscopy

Proliferation of cells measured by BrdU immunoassay. The effect of calcium on mRNA expression of amelogenin ,type 1 collagen ,DSPP,amelotin and KLK 4 was compared by PCR analysis. Von kossa staining done to measure mineral formation Calcium induced cell organization and clustering at 0.1-0.3 mM concentration The addition of 0.1 mM calcium to the cultures up regulation of expression of amelogenin,type 1 collagen and amelotin. After pre t/t with 0.3 mM calcium,mineralised matrix could form.

REFERENCES ORBANS- TEXTBOOK OF ORAL HISTOLOGY TEN CATE ORAL HISTOLOGY DEVELOPMENT STRUCTURE & FUNCTION SIXTH EDITION SHAFERS STURDEVENT AFM STUDY OF DENTAL ENAMEL STRUCTURE AND SYNTHESIS COMPOSITION AND STRUCTURE OF DENTAL ENAMEL- JADA 1975; 91(3);594601 SOBEN PETER BERKOWITZ et al : oral anatomy & histology third edition James k. avery : oral development & histology Phillips` science of dental material High Levels of Hydrogen Peroxide in Overnight Tooth-Whitening Formulas: Effects on Enamel and Pulp Journal of Esthetic and Restorative Dentistry; Volume 17 Issue 1 Page 40 - January 2005 10% or 16% carbamide peroxide did not effect the structure of enamel, whereas 35% carbamide did affect the structure Journal of Oral Rehabilitation Volume 27 Issue 4 Page 332 - April 2000 Ectopic Tooth Enamel. An SEM Study of the Structure of Enamel in Enamel Pearls by S.Risnes The Emergence of "Nanospheres" as Basic Structural Components Adopted by Amelogenin by Janet Moradian. Enamel Matrix: Structural Proteins by termine,torchia and conn SEM study of EDTA treated enamel by Hoffman et al

 A study on effect of bleaching agent on enamel by R.R.Seghi Functions of KLK4 and MMP-20 in dental enamel formation by Yuhe Lu, Department of Biologic and Materials Sciences, University of Michigan School of Dentistry, 1011 North University, Ann Arbor A study on General Histology and Cytology of Structural characteristics of staircase-type retzius lines in human dental enamel analyzed by scanning electron microscopy by S. Risnes in the Department of Anatomy, Dental Faculty, University of Oslo, Blindern, 0316 Oslo 3, Norway Kala Vani SV, Varsha M, Sankar YU. Enamel renal syndrome: A rare case report. J Indian Soc Pedod Prev Dent 2012;30:169-72 A study on enamel regeneration after restorative therapy by dr.kazue yamagishi