ENAMEL

CONTENTS
INTRODUCTION
DEVELOPMENT
LIFECYCLE OF AN AMELOBLAST
AMELOGENESIS
ORGANIC MATRIX FORMATION
MINERALISATION AND MATURATION
PHYSICAL CHARACTERISTICS

COMPOSITION

ENAMEL STRUCTURE 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
Outer enamel epithelium (OEE)
Stellate reticulum
Stratum intermedium
Inner enamel epithelium (IEE) / Ameloblastic layer
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 developjng 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 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.

LIFE CYCLE OF AN AMELOBLAST

Functionally, the life cycle of the IEE is divided into 6 stages:
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
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 ceils 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 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.
FORMATIVE STAGE or SECRETORY STAGE,
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.
IEE -- differentiate into amelobiasts interacts with C/T --differentiate
into odontoblasts Lays down dentin

to lay down enamel.

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.
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
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-ename!
membrane and this gets partially mineralized immediately. This mineralization

is supposed to occur via nucleation 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" fit into the newly
forming enamel, giving the junction between the enamel and the ameloblast a
pjcket 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 / 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.
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
ribbon-shaped 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% 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

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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)
- It thins down to a knife-edge; sometimes less man 100m at the cervix or
within the fissures and pits of multi cusped teeth.
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.
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 withstand the
crushing and grinding forces of mastication. The hardness of enamel decreases
from the surface towards the DEJ.

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Clinical significance:
Unsupported enamel will chip off if underlying dentin is lost due to caries or
improper cavity preparation.
COLOUR: It ranges from yellowish white to grayish white. It has been
suggested that colour is determined by

Differences in translucency

Color of underlying dentin

Thickness of enamel

Amount of stain in 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.
TRANSLUCENCY: Translucency of enamel is related to the variation in the
degree of calcification and homogenecity.
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

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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:
Longitudinal / 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 tvpical "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

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 Keyhole / Paddle shape = the rod with its arch shaped head and tail
interpose between subjacent rod heads

A SINGLE ROD UNIT

It is shaped somewhat like a cylinder. In transverse section it possesses a
rounded "head/ body and a "tail". The head measures 5 in width and 9 in
length while the tail is 5 in length. The head is oriented incisally / occlusally
while the tail is cervically oriented. Apatite crystals, present centrally within
the rod head are arranged almost parallel to the long axis of the rods, The
crystals deviate at a 65 angle from this axis as they fan out into the tail region.
The orientation of the crystals is a property of the ameloblast and their tomes
processes.
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.
Rod direction: In genera!, rods are arranged perpendicular to the denim
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 2.

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

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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.
Incremental lines of Retzius:
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:
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.

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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 contain salivary organic matter.
CLINICAL SIGNIFICANCE - These can serve as avenues for caries
invasion.
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:
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.

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3)Structures observed due to shift in the rod orientation.

Hunter schreger Bands:
When longitudinal sections are viewed by reflected light, enamel displays
alternating light and dark bands coursing from the DEJ towards the surface and
disappearing in the outer 1/3 of the enamel. These zones are an optical
phenomenon resulting from the orientation of rod groups relative to the plane
of sectioning. Due to the undulating course of the rods, there is differential
reflection of light creating dark 'diazones' and light 'parazones'.
Gnarled Enamel:
It is so called because of its complex, twisted, irregular rod arrangement. It is
found throughout the entire thickness of the pulp and represents very hard
enamel which is difficult or impossible to cleave by hard instruments or carbide
burs.

SURFACE STRUCTURES
Aprismatic / structureless enamel: Many teeth exhibit a superficial layer
of enamel that is devoid of typical rod structure. It is found in the outer 30
of all primary teeth and in the cervical region of many (around 70%)
permanent teeth. It is believed to be caused by the cessation of the secretary
activity by the ameloblast and the retraction of the Tomes process, thus
hailing (he characteristic shift in crystal orientation. No prism outline in
visible and all appatite crystals are parallel to one another perpendicular to
the striae of retzius. This enamel is also present near the DEJ.

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CLINICAL SIGNIFICANCE: The layer of prismless enamel in primary teeth

poses difficulties in etching. A longer etching time is needed.
Perikymata: are transverse wave-like grooves believed to be external
manifestation of striae of Retzius. They appear as corrugations and are seen
clearly in teeth not exposed to abrasive forces These ridges alternate with
the troughs called imbrication lines of pickerell. Perikymata are continous
around the tooth lying 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
Enamel cuticle/Nasmyths membrane : is a delicate organic membrane
covering the entire crown of the newly erupted tooth but is soon removed
by mastication. This membrane may represent the final organic matrix
secreted by the ameloblast or it could be the degenerated remains of the
REE. It represents a typical basal lamina
Pellicle: Within hours after eruption, a secondary deposit derived from
salivary proteins forms on all the exposed surfaces of the tooth. Unlike the
cuticle, the pellicle can be constantly replenished within 1-2 days. The
pellicle gets colonized to form microbial plaque consisting of oral flora,

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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.
CLINICAL SIGNIFICANCE: Susceptibility to caries

Dentino Enamel Junction / (DEJ)

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:
1. Cementum may overlap Enamel (65%)
2. Edges of Cementum and Enamel may simply abut (30%) or
3. They may not contact at all.
Sometimes all 3 may exist on the same tooth because the CEJ is irregular
CLINICAL SIGNIFICANCE: Dentinal Sensitivity occurs when Cementum and
Enamel do not contact each other.

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 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.
Enamel

permeability decreases because the pores between the crystals

diminish in size as the crystal acquires more ions and increasing 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.

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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:
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.

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A knowledge of the direction of enamel tods is very important during cavity

preparation. For example :
o In a class II SAF, the gingival seal is beveled at an angle of 20 or 6
centigrade with a GMT to ensure full length enamel rods forming the
gingival margins because the rods bend apically in this area.
o

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 Buonocore 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 capillarv action. The monomer polymerizes and the material

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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:
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 25-40m 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 lo 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:
1) Carious defects
Smooth surfaces

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 Pit and fissures

2) Non-carious defects
Developmental:
o Amelogenesis Imperfecta
o Enamel hypoplasia: Hereditary and Environment
o Enamel pearl
Regressive :
o Attrition
o Abrasion
o Erosion
o Abfraction
3) Others:
Discoloration: Extrinsic and intrinsic
Fractures
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
loss of inter rod substance

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 presence transverse striations perpendicular to enamel rods

Accentuation of incremental lines of Retzius
It is a cone shaped lesion with apex at the DEJ
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:
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 hand instrument.
3. Hypo Maturation (Maturation stage): Enamel crvstals remain immature
C/F - enamel can be pierced with an explorer tip.
Others features common to all of them are
o May/may not be discolored
o Presence of parallel vertical grooves at times

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o Abrasion and open contacts

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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 hvpoplastic 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 measeles ,chicken pox

C/F = Pitted, stained, unsightly teeth
Incisors, cuspids & 1st molars are usually affected
c) Congenial Syphilis

C/F Hutchinsons teeth=Permanent incisors are Screw driver shaped and

notched
Mulberry molars= First molars have globular masses instead of cusps and
narrow occlusal surfaces.
d) Hypocalcaemia: Pitting of enamel occurs when serum Ca+2 is very low
e) Birth Injuries: The Neonatal line is indicative of trauma at time of birth at
times, enamel formation totally ceases
f) Local infection and Injury =

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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.
o Can manifest abstain severe pitting
o Single tooth involvement
o Upper incisors and maxillary mandibular premolars are
commonly affected.
g)Fluoride: Ingestion of fluoride containing drinking water (> lppm)
during the time of tooth formation 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.

REGRESSIVE
ATTRITION: is the physiologic wearing away of the tooth as a result of tooth
to tooth to contact occlusally,incisally and proximally
C/F

Permanent dentitions affected more than deciduous.

Males > Females

Older > Younger

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- Initial change = Small polished facet on cusp tip or flattering of ridge or

incisal edge
- Gradually = reduction of CUSP height and flattening of occlusal inclined
Planes, there is shortening of dental arch length (due to proximal wear)
-

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
ABRASION: is the wearing away of tooth substance through abnormal
mechanical process. Causes o Improper brushing
o Habits (hair pin opening causes incisal notching)
o Occupational - tailors, shoemakers
o 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.

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C/F=

Occurs mostly on facial surfaces. Proximal and lingual erosion is also seen

in same conditions

Enamel, dentin and cementum get affected

3 types of erosive lesions are seen

Dish / Saucer shaped, shallow concavities -gingival 1/3 of incisors
Wedge / notch shaped V-shaped (PM, M)
Irregular random location
Causes of erosion:

1. Extrinsic
o Diet - soft drinks, foods
o Environment - wine tasters, swimmers
o Drugs - Vit. C, mouth wash
o Lifestyle
2. Intrinsic
-Gastric reflux
o Sphincter incompetence
o increased gastric pressure

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o increased gastric volume

-Vomiting;
o psychosomatic-anorexia nervosa,bulimia
o G.I.T disorders
o Drugs
-Regurgitation
-Rumination

IDIOPATHIC EROSION OR ABFRACTION =some cervical wedge shaped

defects are caused due to heavy eccentric occlusal forces resulting in
microfractures or abfractures the cervical areas flex under such loads and lead
to microfractures

OTHERS
FRACTURES: can occur due to:
Trauma
Dentinal caries leading t undermining of enamel
Defective weak enamel
Excessive occlusal load
DISCOLOURATION: This can be either extrinsic or intrinsic

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Causes of extrinsic discoloration

Remnants of Nasmyths membrane
Poor oral hygiene
Existing restorations
Gingival bleeding
Food colors
Chromatic bacteria
Tobacco stains
Plaque / calculus
Esthetic staining (racial)
Causes of intrinsic discoloration
Caries
Hereditary Disorders
Tetracycline and other drugs
Fluoride
Age changes
Non vital teeth / endodontically treated teeth
Internal resorption / Pink spot of mummery

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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
o Orbans- Oral histology and embryology
o Oral histology- inheritance and development -Vincent Proverza
o Oral histology -A.R. Ten Cate.
o Oral development and histology- James K Avery
o Art and Science of operative dentistry - Sturdvent
o G.J. Mount and Hume

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