Fundamentals of Operative Dentistry Enamel: Forms the shape of the tooth Hard and durable Protective cap for

for vital dentine. Contributes to the aesthetics of the tooth Aims of operative dentistry for enamel: Maintain patients own enamel restore with materials that closely resemble enamel in terms of function, aesthetics, form Enamel is vunerable to acid demin, wear and fracture. Constituents: 96% inorganic HYDROXYAPATITE (wt) 86% if by vol. Small amount of organic matrix 4-12% water inthe intercrystalline spaces. i.e. in the micropores that form dynamic connection between tubules in dentine and pulp This structure is what makes enamel semipermeable --> making the effects of demineralization, reprecipitation or remineralization, fluoride uptake or bleaching a 3D process. Visually, if enamel is blow-dried, spaces in the micropores cause surface to look white and if rewetted, the enamel becomes translucent (REFRACTIVE INDEX) VISUAL: yellowing of teeth due to: thinning or increased translucency of enamel OR accumulation of elements in enamel micropores, increased thickness of dentine as a physiological process of ageing. Fluoride enhances remineralization repair of enamel by PLAQUE ACIDS increase ratio of conversion of hydrocyapatite to fluoroapatite or fluorohydroxyapatite. Clinical appearance of defects (Key diagnostic signs): Colour changes with demineralization cavitation excessive wear morphological faults or fissures cracks Colour: Colour is a function of thickness and color of underlying dentine. Enamel depth is 2.5mm at cusp tips (thickest), 2.0mm at incisal edges. Thinnest at occlusal fissures and pits and at the CEJ where it TAPERS. Can be affected by develpment, mineralization, staining, antibiotic therapy (chlorohexidine), excessive fluoride.

Pathologic discolouration is by acid from bacteria e.g. mutans streptococci in plaque - this results in subsurface enamel porosity that shows as a milky white opacity called white spot lesion. Very difficult to detect early enamel fissure lesions on radiographs. systematic visual ranking correlates to the depth of demineralization: Once demineralization extends to DEJ, white spot poacity is evident when tooth is wet or dried. Takes 4-5 years for demin to press through enamel. Once it hits dentine, it can be seen by a bluish gray tint at lesion. Invasive techniques (unlike preventive) should be used only if dentine involvement can be confirmed by radiographic evidence, deep discolouration, cavitation to dentine. Cavitation acid protons follow DIRECTION OF WIDENED INTERCRYSTALILNE SPACES of affected rods to DEJ. smooth-surface enamel lesions: triangular in two dimensions, base of triangle at enamel surface and it is an inverted cong where apex is at DEJ. Fissure lesions are more comlex shaped as it occures at confluence of 2+ cuspal lobes with divergent rod directions. Divergened rodes form broad base parallel to DEJ. PREVENTION method: topical fluoride to limit/reverse demineralisation and home applications of amorphous and reactive calcium phosphate complexes and synthetic hydroxyapatitde in acid paste to repair defects and replaces crystals in minutes (FIIND OUT) if demine continues, the dentine structis is comprimised and the enamel is undermind which breaks away without support to create a cavity. If untreated, cavity expands and compromise strength of crown and microorganisms can proliferate which implicates the vitality of the pulp. Root caries (caries that extend to root) can be difficult to resture due to isolation, access and gingival tissue and fluid complicating things. Wear Knoop Hardness Number: 343 unlike Dentine: 68. due to attrition or frictional contact against oppositing enamel or restorative materials. normal physiological wear rate: 29micrometres per year. Restorative materials should have compatible hardness, weat rates, smoothness and strength. Factors contributing to wear: bruxism, parafunctional habits, maloocclusion, age, diet. DESIGN OF TOOTH: cavity outline form designd that margins of restorative materials avoid critical high-stress areas of contact, Faults, Fissures Factors of plaque retention: perikymata, pitting defects (termination of enamel rods), esp in cervical area.

lineardfects or craze lines are NOT significant. Surface pellicle and dendritic cuticles extend 1-3micrometres into enamel. impt in ion exchange and in adhesion and colonization of plaque on surface. More importantly: fissure systems occlusally and less impt: buccally and lingually. These result from incomplete fusion of the lobes of enamel in developing toth that now provide a reservoir for acidogenic bacteria nad their nutrients to accumulate in. --> PREVENTION METHOD: enamel bonded resin fissure sealant for high caries risk patient and individuals for incipent enael pit and fissure lesions. Cracks: important especially if defect extends through dentine, viewed in cavity prep, or patient complains of pain on biting. --> TREATMENT: occlusal coverage for restorations and adhesive splinting Enamel Rods: mineralized epidermal tissue Formed by ameloblast which secretes organic matrix gel to outline contours of enamel to initiate mineralization. Calcium ions form foci of mineralization/crystallisation that are introduced into the matrix extracellularly or intracellularly. --> seeds of hydroxapatite. Crystals enlarge to replace organic matrix that is now pushed between the growing rods of enamel prisms. Repeating units of hydroxyapatide: Ca10(PO4)6(OH)2 majority of apatite exist as impore form with carbonate substituted in lattice and destabilizes the structure: first to be solubilised in an event of n acid attack substitution of fluoride in prisms and and facilitative role of fluoride in enhancing mineralization help prevent net demin -> more cares resistant enamel Tomes process secretes enamel protein matrix and initiates mineralization and orientation of enamel crystals: divergent directso f crystals from central and peripheral surfaces of it is repeated in symmetrical pattern--> forming enamel rods and the interrod enamel. interrod crystals are almost perpendicular to rod crystals. crystals in mature enamel are closley packed and hexagonal shaped (30x60 nm dimensions) Matrix proteins, enamelins and water form shell around each crystal. Rod andi nterrod enamel continuous throughout thickness of enamel apart from amorphous inner and outer enamel. Crystals in rods are parallel to long axis of rods that is perpendicular to enamel surface. Narrow space filled with organic material called rod sheaths separate two enamel units. narrow spacenot bounded by rod sheath form isthmus of confluent crystals. Rod core and connecting isthmus of interrod enamel described as keyhole shaped. More recent studies show interrod enamel continuous within enamel mass and is formed before rod crystals. cylindrical enamel rods embedded in surrounding interrod enamel

Enamel and Acid etching Orientation of crystals and spacing make enael rod differntially soluble if exposed to WEAK acids. depending on type of acid, contact time, plane of cavity preparation. Effect of acid contact in etching ename: 10micrometres of surace enamel which as no rod structure. at rod and interrod level: differential dissolutino of the enamel causes macroporosities (3D~) and it has high surface energy that resin monomer flows into pores to form retentive resin tages up to 20micromtres deep. Microporosities form within individual crystal cores that contribute MOST to enamel-resin bond. etch penetration increase bondable surface area 10-20 fold and adhesives to enamel through micromech interlocking is very very strong. a perpendicular wall to enamel surface preserves dentinal suport for neamel bute not eptimum bondable enamel substrate as the sides of rods are exposed and not hte top i.e. central core is more suscptible to acid dissolution and resin bond strengs twice as high when adhering to acid etched ends. as compared to sides of rystals. CLINICAL RELEVANCE: tangential cut or bevel of 45deg across 90 deg cavosurface angle of prepared cavity expose ends of rods and crystals. especially for resin composite and maximise integrity of the restoratin ar margins!!!! EXCEPTION is on occlusal surfaces where bevelling will extend resin margins into high stress areas. acid etch if enamel for micromech retention is beter than macromechanical undercuts. strength an resilience: rod sheaths form natural cleavage lines throug which longitudinally may fcture. esp if underlying dentine support is removed. fracture at cavomargin or cavity of dental restorraitiong creates a gap defect that allows leakage or ingress of pacteria and by products that could cause secondary caries. enamel microcracks and crazying a margins during polymerizzation shringake. therefore bevelling acute or riight angles so bond near margins is cross sectioned to rods and not sides of rods that may be lifted away (splint) from each other. planing cavosurface margin with hand instruments or low speed rotary to remove fragile enamel is impt as ifinishing step. ENAMEL IS INCAPABLE OF SELF REPAIR. demin is less than dentin as it is impeded by large apatite crystals (10x larger than dentine ones) an less surace to volume exposure to acids. Tight adaptation of crystals to eachothermakes structure less penetrable by acids. Preventive measure and exogenous or salivary renewal of calium etc etc reverse dynamics of demineralisation. crystals seaprated by organic matricx that provide strain relief to prevent fracture. Enamel thickness and degree of mineralization greatest in occlusal and incisal areas where masticatory contact occurs. enamel rods group and undulate in offset pattern (sigmoidal path?) functionap adaptation of occlusal stress: cusp tips show spiralling weave of rod direction i.e gnarled enamel). If uniformly crstalline, it would shatter. strong latticework of interwoven enamel rods and interrod enamel with an area of continouous enamel. Enamel rods at right angles to each other limir lateral propagation of occlusal stress and transfer stress (dissipating ) it throughout the structure into dentine.