DENTIN

DENTIN
Introduction
Physical properties
Chemical composition
Dentinogenesis
-Odontoblast Differentiation
-Formation of Dentin Matrix
-Mineralization
-Pattern of Dentin Formation
Structure
-Odontoblast layer
-Odontoblasts
-Odontoblast process
-Dentinal tubules

Types of Dentin
-primary
-secondary
-tertiary
Difference between coronal and root dentin
Histology of dentin
-Peritubular dentin
-Intertubular dentin
-Interglobular dentin
-Tomes granular layer
-Dentino Enamel Junction
-Incremental growth lines
-Contour lines of Owen
-Neonatal lines
-Vonkorffs fibres


Innervation
-Direct innervation theory
-Transduction theory
-Hydrodynamic theory
Age and functional changes
-Dead tracts
-Sclerotic dentin
Effects of operative procedures
Clinical considerations
-Developmental disorders
-Dentin bonding agents
Conclusion
References

INTRODUCTION
Dentin is hard tissue portion of
pulp-dentin complex.
Dentin provides bulk & general
form of tooth.
Hard tissue with tubules
throughout its thickness.
Contain cytoplasmic extensions of
odontoblasts that once formed the
dentin and then maintain it.
The cell bodies of the
odontoblasts are aligned
along inner aspect of dentin,
against a layer of Predentin
where they form the
peripheral boundary of dental
pulp.
New physiologic or reparative
dentin can only be added on
its inner aspect
PHYSICAL PROPERTIES
Light yellowish in color,
becoming darker with age.
Dentin is elastic & subject to
slight deformation.
Harder than bone but softer
than enamel.
More radiolucent than
enamel because of lower
content of mineral salts.

Cont.
Dentin and enamel are
bound firmly at the
dentinoenamel junction that
appears well defined
scalloped border.
In root, dentin is covered by
cementum but the junction
between two is less distinct.
Dentin
CHEMICAL COMPOSITION
Mature dentin (by weight )is
-70% inorganic material
-20% organic material
-10% water
By volume is
-45% inorganic
-33% organic
-22% water

Inorganic Component
Consist of hydroxyapatite crystals
Each crystal is composed of several thousand unit cells
Unit cells have formula of 3Ca
3
(PO
4
)
2
.Ca(OH)
2.
Crystals are plate shaped and much smaller than crystals in
enamel.
It also contains phosphates, carbonates and sulphates.
KHN 68 for dentin



Organic component
About 30% of organic is collagen(mainly type I with small
amount type III and V).
Collagen type I acts as a scaffold that accommodates a large
proportion of the mineral in the holes and pores of fibrils.
Rest of organic portion is lipid and non-collagenous matrix
proteins.
Non collagenous matrix
Consists of proteins and proteoglycans.
The matrix proteins pack the space between collagen fibrils and
accumulate along the periphery of dentinal tubules.
Proteins
-Dentin phosphoprotein (DPP or phosphophoryn)
-dentin sialoprotein(DSP)
-Dentin matrix protein
-Acidic glycoproteins
-Osteonectin
-Osteopontin
Proteoglycans
-Decorin
-Biglycan

DENTINOGENESIS

Dentin formation begins at
the late bell stage of tooth
development. It starts in the
papillary tissue adjacent to
the tip of the folded internal
dental epithelium. This site
although not actually where
the future cusp tip will
reside is where cuspal
development begins.
ODONTOBLAST DIFFERENTIATION
Odontoblast is the cell responsible for the secretion of dentin. It
is derived from undifferentiated mesenchymal cells of dental
papilla. Dentin formation is entirely a connective tissue event.
Before dentinogenesis begins the cells of the internal dental
epithelium are short and columnar.
Then rapid division occurs to accommodate the growth of the
tooth germ.

Odontoblast differentiation. The undifferentiated ectomesenchymal
cell (A) of the dental papilla divides (B), with its mitotic spindle
perpendicular to the basement membrane. A daughter cell (C),
influenced by the epithelial cell(D), differentiates into an
odontoblast (E). Another daughter cell (F), not exposed to this
epithelial influence, persists as a subodontoblast cell(G). This cell
has been exposed to all the determinants necessary for
odontoblast formation except the last.
At this time the dental papillary
cells are separated from
internal dental epithelium by an
acellular zone and are small and
undifferentiated with a central
nucleus and spores cytoplasm
containing only a small number
of fine collagen fibrils.

After completion of cell
division, the shape of the cells
of internal dental epithelium
changes from short cuboidal to
tall coulmnar and their cell
nuclei migrate toward the pole
of the cell away from dental
papilla.

This change in the position of nucleus reverses the polarity of the
cell. It also causes some changes in the adjacent papilla.

The ectomesenchymal cells adjoining the acellular zone rapidly
enlarge to become first preodontoblast and then odontoblast as
their cytoplasm increases in volume to contain increasing amount
of golgi complex and rough endoplasmic reticulum.

Because of these changes the acellular zone is eliminated. And
the newly formed cell has high vascularity and characterized by
being highly polarized as its nuclei positioned away from internal
dental epithelium.

The epithelial cells of the internal dental epithelium are inductive
and have been shown to express and secret several growth
factors which bind to the heparin sulfate formed in the basal
lamina thereby transferring inductive ability to this structure.

After a set number of division the ectomesenchymal receptors
able to capture the growth factors localized to the basal lamina.

As a result of final division two population of cells can be
distinguish i.e. Odontoblasts and sub odontoblast.

The sub odontoblast cells will be removed from the sphere of
influence of the internal dental epithelium so that the
differentiated odontoblasts only will enter into the lifecycle
related to the formation of dentin.


FORMATION OF DENTIN MATRIX

The first formed organic matrix consists type I collagen and
associated ground substances. These material aggregate in the
structureless ground substance immediately below the basal
lamina.

The organic matrix of dentin consists ground substances of dental
papilla and collagen produced by the odontoblast and a periodic
fibers which are aligned at right angle to the basal lamina.

As odontoblast secret these large diameter collagen fibers they
continue to increase in size until the extracellular compartment
between them is obliterated.
At the same time the plasma membrane of the odontoblast
adjacent to the internal dental epithelium push out short,
stubby processes. It also buds off a number of small
membrane bound vesicles which come to lie between the
large diameter collagen fibrils.

The odontoblast then begins to move toward the center of
the pulp, as it does one of its short stubby process get
accentuated and is left behind to form the principal extension
of the cell, the odontoblast process.


MINERALIZATION

It commences within the initial increment of mandible dentin.
Ca
3
(Po
4
)
2
crystals begin to accumulate in matrix vesicles within
the predentin presumably these vesicles bud off from the
odontoblast process and these vesicles are most numerous near
the basal lamina.
Because of rapid growth of crystals the vesicles rupture and
released crystals are mixed up with other crystals from adjoining
vesicles, which forms the advancing front that merge to form
globule.
As the globule expands they fuse with adjacent globule until the
matrix is completely mineralized. These matrix vesicles are
involved only in the initial stage of the reminerilization then the
advancing front projects along the collagen fibrils of the matrix
and appear on the surface and into the fibrils and continue to
grow as mineralization progress.

PATTERN OF DENTIN FORMATION
From here it spreads down the cuspal slopes as far as the
cervical loop of the dental organs and the dentin thickness
until all the coronal dentin is formed.
Then the root dentin form at slightly later stage of
development and requires the proliferation of Hertwigs
epithelial root sheath from the cervical loop of the dental
organ.

Root Formation Cervical loop forms the epithelial
root sheath (of Hertwig)
Copyright 2007, Thomas G. Hollinger, Gainesville, Fl
Cervical loop
Dental papilla
STRUCTURE OF DENTIN

ODONTOBLASTIC LAYER

The outermost stratum of cells of the healthy pulp is
odontoblast layer. This layer is located immediately subjacent
to the predentin.

This layer consists principally the cell bodies of odontoblast,
capillaries and nerve fibers may be found.

The odontoblasts vary in height and their nuclei are not at the
same level and are aligned in staggered array. This often
produces the appearance of 3 to 5 cells thickened layer.
Predentin
Odontoblasts
Cell-free zone
Cell-rich zone
Cell bodies
Odontoblastic
process
ODONTOBLASTS
It is the cell responsible for the formation of dentin. It is
placed at the periphery of the pulp and has a process
extending into the dentin.

NUMBER
The number of
odontoblasts corresponds
to the number of dentinal
tubules and it varies with
tooth type and location
within the pulp space. The
number of odontoblasts is
approximately 59,000 to
76,0000 per sq.mm in
coronal dentin and lesser in
radicular dentin.

ODONTOBLASTS
SIZE
It is approximately 50 m in height and 7 m in diameter. But
the process narrow to about half the size of the odontoblast
as it enter the tubule.
SHAPE
In the crown of the fully developed teeth, it is columnar but
they are more cuboidal in shape at the mid portion of pulp. It
reflects their functional activity ranges from active synthetic
phase to a quiescent phase.
LIFE SPAN
The lifespan of odontoblast is generally believed to equal to
that of the viable tooth but odontoblasts are end cells which
means that once differentiation.
ODONTOBLAST PROCESS

It is the cytoplasmic extension of
the odontoblast.
SIZE
The processes are largest in
diameter near the pulp (3 to 4mm)
and taper to approximately 1mm
further into the dentin.
CONTENT
The odontoblast process is
composed of microtubules of
20nm in diameter and small
filaments 5 to 7.5nm in diameter.
Occasionally mitochondria, dense
bodies resembling lysosomes,
micro vesicles and coated vesicles
that may open to the extra cellular
space also seen.
Cont.
BRANCHES
Periodically along the course of the process side branches
appear that extend laterally into the adjacent tubules. The
odontoblast process divide near the DEJ and may indeed
extend into enamel as enamel spindles.

LENGTH OF PROCESS
Some controversy exists about the extension of process into
the tubules whether the odontoblast process extends the full
length of the tubule.
with scanning electron microscope and it was claimed that
the odontoblast process extended only 0.7mm into dentin
with the remainder of dentinal tubule empty.


DENTINAL TUBULES

COURSE
It follows a gentle curve in
the crown and less so in the
root.
Where it resembles s
shape starting at right
angles from the pulpal
surface the first convexity of
this doubly curved course is
directed toward the apex of
tooth.

DENTINAL TUBULES

These tubules end
perpendicular to the DEJ&
DCJ.
Near the root tip, cervical
third of crown, incisal edge
and cuspal tip the tubules are
almost straight.
Configuration of these
tubules indicate the course
taken by the odontoblast
during the dentinogenesis.

Clinical significance
The increase in number and
size of the dentinal tubules as
the pulp chamber is
approached is important for
several reactions.
First, when cutting into dentin,
deeper cuts expose more
tubules and damage more
odontoblasts and their
processes than shallower cuts.
Cont.
Secondly, the application of
potentially harmful
substances to the dentin can
damage the pulp.
Both proximity and increased
diameter of tubules make
diffusion of harmful materials
such as bacteria and their
products and clinically applied
liners, bases or even pulpal
obtundents.
Types of Dentin
Dentin
Primary physiologic
dentin
Secondary physiologic
dentin
Tertiary dentin or
reparative dentin or
reactionary dentin or
irregular secondary dentin
Mantle
dentin
Circumpulpal
dentin
Peritubular
dentin
Intertubular
dentin
Primary
Physiological dentin
Secondary
Physiological Dentin
Tertiary dentin
Dead tracts
Types of dentin

TYPES OF DENTIN

PRIMARY DENTIN
Mantle dentin: it is first
formed dentin in the crown
underlying the DEJ. It is thus
the outer most peripheral
part of primary dentin and
is about 20m thick. The
fibrils formed in this zone
are perpendicular to the
D.E.J.

PREDENTIN

It is located adjacent to the
pulp and is about 2 to 6m
wide depending on the
activity of the odontoblast.

During the dentinogenesis
this dentin formed first and
remains unmineralized for a
certain period.
As the collagen matrix
undergoes mineralization of
the predentin area, it
becomes mineralized then a
new layer of predentin is
formed circumpulpally.

Circum Pulpal Dentin:
It forms the remaining primary dentin. It represents the dentin
formed prior to the root completion.
The collagen fibrils are very smaller in diameter and are more
closely packed together. It contains more minerals than the
mantle dentin.

ORTHODENTIN
Or true dentin is a calcified tissue that lacks cells, contains
tubules, and is organized by odontoblasts.

SECONDARY DENTIN
Unlike the enamel, the dentin can repair itself by producing
secondary dentin after any injury to the odontoblast or dentin.

But the undifferentiated mesenchymal cells resting in the
pulpal tissue acts as good source for replacement of
degenerated odontoblasts. This differentiated cells become a
new odontoblast and secret the dentin which is known as
secondary dentin.

Clinical significance
Increased secondary dentinal deposition results in changes of the
pulp chamber shapes as well as changes in size and location of
the apical foramina.
During endodontic therapy the increased secondary dentinal
deposition observed in older teeth makes it more difficult to
access pulp chamber and locate coronal orifices of the root canals
due to constriction.
Increased secondary dentinal deposition decreases the amount of
instrumentation needed during root canal therapy.

Tertiary dentin
Unlike secondary dentin
which is formed as a result
of normal physiologic
stimuli, tertiary dentin is
formed as a result of
pathologic process such as
caries.

Reparative dentin is
characterized as having
fewer and more twisted
tubules than normal
dentin.

Sub classified as reactionary or reparative dentin, the former
deposited by preexisting odontoblasts and the latter by newly
differentiated odontoblast-like cells.

OSTEODENTIN
During the formation of reparative dentin the dentin forming cells
are often included in the rapidly produced intercellular
substances. In other instances a combination of osteodentin and
tubular dentin are seen.

FACTORS INDUCING REPARATIVE DENTIN
Abrasion, erosion, attrition
Caries and operative procedures
Chemical substances, thermal injury.


DIFFERENCE BETWEEN CORONAL DENTIN AND ROOT DENTIN

Degree of mineralization is less in root dentin
phosphoryn content is less in root dentin
The rate of deposition is slower in root dentin
Interglobular dentin is more in root dentin
Permeability is less in root dentin
The surface area of dentinal tubule is less in root dentin
Canaliculi are abundant in the root dentin
The dentinal tubule is less carried in root dentin whereas it is
S shaped in coronal dentin

Dentinal Tubules
Coronal dentin
Root dentin
HISTOLOGY OF DENTIN
PERITUBULAR DENTIN

The highly mineralized dentin that immediately surrounds the
odontoblastic process within the dentinal tubule is known as
intratubular or peritubular dentin.
SIZE
It is roughly 44nm wide near the pulp and 750 nm near the DEJ.
CHARACTERISITCS
It is more mineralized (40% more than intertubular dentin). By
electron microscopy, electron microprobe analysis and soft x-ray
radiograph, It will be seem to be an empty space in the
decalcified section.

Dentinal tubules
Peritubular dentin
Intertubular dentin

INTERTUBULAR DENTIN

The main body of dentin is
composed of intertubular
dentin. It is located in
between the dentinal
tubules or more specifically,
between the zones of intra
tubular dentin. Although it
is highly mineralized, this
matrix is retained after
decalcification.

CONTENTS
tightly inter woven
network of collagen (type
I) measuring from 50 to
200 nm in diameter
apatite crystals. Its
orientation is parallel to the
fibrils
ground substances

TUBULE CONTENT
Recent studies with
scanning probe microscopy
has shown that this complex
matrix exists in the form of
a hydrogel with a relatively
dense network and with
little hydraulic conductivity.

Intertubular
dentin
Dentinal
tubules
Intratubular
or peritubular
dentin

INTERGLOBULAR DENTIN

It is an area of unmineralized or hypomineralized dentin where
globular zones of mineralized have failed to fuse into a
homogenous mass with in mature dentin.

It is more obvious in persons having vit- D deficiency and high
exposure to fluoride content of water during dentinogenesis. It
is seen most frequency in the circumpulpal dentin just below
the mantle dentin.

The dentinal tubules pass unintermittently in the interglobular
dentin thus showing the defect in mineralization not in matrix
formation.

Interglobular Dentin
Inter-
globular
dentin
Dentinal
Tubules
Dentino-
Enamel
Junction
Inter-
globular
dentin

TOMES GRANULAR LAYER

When dry sections of root dentin visualized in transmitted light
there is a zone adjacent to the cementum that appears granular.
This zone increases slightly in amount from the cervix to root
apex. Branching and coalescing of adjacent process of dentinal
tubules near the dentinocemental junction causes this zone.
The dark coloration results when light retracts by the
microscopic lens.
Dentin
Cementum
Granular layer
of Tomes
Hyaline layer
Clinical significance
More recent interpretation relates this layer to a special
arrangement of collagen and noncollagenous matrix proteins
at the interface between dentin and cementum.

DENTINO ENAMEL JUNCTION

In ground sections, this
junction can be seen as a
series of scalpers. This
scalloped nature of junction
can be clearly seen in a
demineralized section.

The surface of the dentin at
the DEJ is pitted. Into the
shallow depression of dentin
fit the rounded projection of
enamel. This relation assures
the firm hold of the enamel
cap on the dentin.

Dentin
Cont.
The scanning electron
microscope reveals the junction
to be adherence between
dentin rather than spikes,
which arrangement probably
increases the adherence
between dentin and enamel.
The ridging is most pronounced
in coronal dentin, where
occlusal stresses are the
greatest.
Clinical Significance

The proteins found at the DEJ are believed to provide
nucleation centers for mineralization and possibly serve as a
cementing substance for dentin & enamel.


ENAMEL SPINDLES

Occasionally odontoblast
processes pass across the DEJ
into the enamel. Since many
are thickened at their end
they have been termed as
enamel spindles.
This extension of the
odontoblast process into the
enamel occur before hard
substances were formed.


ENAMEL SPINDLES

DIRECTION OF SPINDLES
It corresponds to the
ameloblast direction and at
right angle to the dentin.
In ground sections of dried
teeth the organic content of
spindles disintegrates and is
filled with air and appear dark
in transmitted light.

Enamel spindles are extensions of
primary dentinal tubule into the
initial enamel matrix.
Clinical Significance
More numerous in incisal enamel or cusps of teeth than in the
cervical enamel.

Not sites for initiation of dental decay , however once the
lesion approaches the DEJ, decay may proceed more rapidly in
these areas due to higher porosity.


DENTINOCEMENTAL JUNCTION

Peripheral to the granular
layer of terms and separating
it from the cementum is a
thin, structuring layer.
Cementum is a thin layer.
It is smooth in permanent
teeth and scalloped in
deciduous teeth.
A. Cementodentinal junction
B. Tomes' granular layer
C. Homogeneous dentin
D. Approximate boundary between
mantle and circumpulpal dentin
Cont.
In decalcified sections, cementum is more electron dense
than dentin and fibers of cemental and dentin intertwine at
their interface in a very complex fashion.
And it is not possible to precisely determine which fibrils are
of dentinal and which are of cemental origin.


INCREMENTAL LINES

It can be called as imbrication
lines or von Ebner lines. These
lines appear as fine lines in the
dentin or striatum in the
dentin.
It can be best seen in
longitudinal ground sections of
tooth.
It runs at right angle to the
dentinal tubules and generally
mark the normal rhythmic
linear pattern of dentin
deposition in an inward and
rootward direction.
Incremental lines of von Ebner
The distance between lines vary
from 4 to 8 m in the crown to
much less in the root. Daily
increment decreases as the
tooth reaches its functional
occlusion.

CONTOUR LINES OF OWEN



It is caused by an
accentuated deficiencies in
mineralization.


Dentin
Enamel
Lines of
Owen
Dentino-enamel Junction
Clinical Significance
These lines are readily demonstrated in ground sectional and
analysis with soft x-ray has shown that these lines to
represent hypo calcified brands.
Periods of illness or inadequate nutrition also are marked by
accentuated contour lines within the dentin.

NEONATAL LINES

In the deciduous teeth and first permanent molars, where dentin
is seen to be separated by an accentuated contour line as
prenatal and post natal dentin. This is termed the neonatal line
and it is seen in both enamel and dentin.
This line reflects the abrupt change in environment that occurs at
birth. The dentin matrix formed prior to birth is usually of better
quality.
Clinical Significance
This neonatal line may be a zone of hypo calcification.
NEONATAL LINES

VONKORFFS FIBERS

In the mandible dentin, large
collagen fiber arises from the
activity of the subodotoblast in the
subodontoblastic layer. This fiber
passes spirally between the
odontoblast to fan out against the
surface of the basal lamina in the
component of the mandible
dentin.
Cont.
Because of argyrophilic
reaction it was long believed
that bundles of collagen
formed among the
odontoblasts. Recently ultra
structured studies revealed
that the staining is of the
ground substances among the
cell and not collagen.


INNERVATION

Dentinal tubules contains
numerous nerve endings in
the predentin and inner
dentin no further than 100
to 150m from the pulp.
The nerves and their
terminals are found in close
association with the
odontoblast process within
the tubule.

Theories of pain transmission through
dentin
There are three major accepted theories
-Direct innervation theory
-Transduction theory
-Hydrodynamic theory
Direct innervation theory
This is the oldest theory of dentinal innervation and is based
on the belief that dentinal nerve terminals extend to the DEJ.
When the dentin is penetrated the nerve terminal is
deformed directly by mechanical perturbation and initiates an
action potential.

Presently, the evidence suggests that nerve terminals extend
between 200 and 300m into the predentin-dentin, which is
too close to the pulp to support theory.
Transduction theory
The transduction theory is based on several experimental criteria
suggesting that the odontoblast can transduce a mechanical
stimulus and transfer that signal to a closely opposed nerve
terminal.

This theory is supported by reports showing odontoblasts to be
derived from neural crest cells, to be closely associated with
nerve terminals, and to contain gap junctions that electronically
couple adjacent odontoblasts.

Cont.
Arguments are that there have been no reports of synaptic
specializations between odontoblasts and nerve terminals,
and therefore no means of chemical transmission, and that
odontoblasts are not excitable cells, and therefore are unable
to produce an electrical response.

Hydrodynamic theory
The movement of the fluid contained in the dentinal tubules,
in response to iatrogenic or environmental trauma, is the
basis of the hydrodynamic theory.

When the fluid in the dentinal tubules, a derivative of the
blood plasma, is perturbed, the nerve terminals within the
dentinal tubules and the odontoblast layer are deformed and
initiate an action potential.

Numerous studies have demonstrated that rapid movement
of the dentinal fluid will cause pain whether the stimulus is
osmotic, chemical, temperature-related, or mechanical.
AGE AND FUNCTIONAL CHANGES
Pulp atrophy the size of the pulp chamber will be decreased
as secondary dentin deposited over the pulp chamber with
age advances.
Deposition of peritubular dentin constricts the lumen of the
dentinal tubule.
Because of deposition of sclerotic dentin the tubular fluid
volume will be decreased.
Dentin becomes darker with age.
The odontoblast seem to atrophy and may disappear
completely under areas of sclerotic dentin.



DEAD TRACTS

In dried ground sections of
normal dentin the
odontoblast processes
disintegrate and the empty
tubules are filled with air.
They appear black in
transmitted light and white in
reflected light. It appears
mostly in the area of narrow
pulpal horns and it elicits
repairative dentin deposition
from the pulpal end
Areas of dentin characterized by degenerated odontoblast
process give rise to dead tracts. These areas demonstrated
decreased sensitivity and appear to a great extent in older
teeth.



SCLEROTIC DENTIN

In addition to the reparative
response, dentin can also
elicit protective response. It
result in scaling of dentinal
tubules by depositing the
apatite crystals into the
dentinal matrix which formed
after the application of
stimuli.
Then gradually the tubule
lumen is obliterated and the
dentin becomes less
permeable.

Sclerotic dentin
It appears transparent in transmitted light and dark in
reflected light. It occurs almost in the elder people.

Clinical Significance
Because sclerosis reduces the permeability of dentin, it may
help to prolong pulp vitality.
It is more resistant to acid etching than normal dentin.
Consequently, the penetration of a dentin adhesive is limited.


EFFECTS OF OPERATIVE PROCEDURES ON DENTIN

During the crown preparation, 30,000 to 45,000 dentinal tubules
will be opened by cutting every square mm of dentin. It results
in irritation of many thousands of odontoblasts.

Following things should be considered whenever the
cavity/crown preparation is going to be done.

1. Mechanical injury
-During cavity preparation

2. Type of cutting instrument
-Hand Cutting Instruments
-Rotary Cutting Instruments
3. Heat production and coolant
- 6000 TO 1,00,000 rpm Heat production will be
more and it gives some detrimental effect on dentin
pulp complex.

4. Desiccation
-drying of dentinal tubules

5. Remaining dentin thickness and pulpal proximity
-RDT 1/permeability

6. Smear layer
Hydroxyapatite crystals
Denatured collagen fibers
Other debris of tooth structure
Contaminated particles.

7. Vibration
- use of run out burs
- abraded diamond burs

8. Chemical injury
- Effect of acid etching and dentin bonding agent
- liners and bases
- varnishes

9. Postoperative sensitivity
-Effective measures to prevent post operative sensitivity:
Suitable liners
Varnish to prevent micro leakage
DBA to seal the dentinal tubules
Minimum depth of preparation.



Dentinogenesis Imperfecta

It is a developmental disturbances in structure of teeth.

Shields and his co-workers have suggested the classification:
-Type I
-Type II
- type III

Revised classification
-Dentinogenesis imperfecta 1
-Dentinogenesis imperfecta 2

Type I
Type I : DI that always occurs in families with osteogenesis
imperfecta, although the latter may occur without DI.

Type I DI segregates as an autosomal dominant trait with
variable expressivity but can be recessive.
Dentinogenesis imperfecta 1 (Type II)
Also known as opalescent
dentin.
DI that never occurs in
association with osteogenesis
imperfecta unless by chance.
This type is the one most
frequently referred to as
hereditary opalescent dentin.
It is caused by mutation in the
DSPP(dentin
sialophosphoprotein) gene
(gene map locus 4q21.3),
encoding dentin
phosphoprotein and dentin
sialoprotein.
Cont.
The teeth are blue-gray or
amber brown and
opalescent.
Enamel may split readily
from the dentin when
subjected to occlusal stress.
A deficiency of dentin
sialophosphoprotein had
been suggested as a
causative factor in
dentinogenesis imperfecta.
On dental radiographs, the
teeth have bulbous
crowns, roots that are
narrower than normal, and
pulp chambers and root
canals that are smaller
than normal or completely
obliterated.

Cont.
Dentinogenesis imperfecta 2 (Type III)
(Brandywine type)
This is a racial isolate in
Maryland with this unusual
form of DI characterized by
the same clinical appearance
of the teeth as types I and II
but also by multiple pulp
exposures in deciduous teeth,
a characteristic not seen in
types I or II.
Type III is an autosomal
dominant trait.
Radiographs of the deciduous
dentition show very large
pulp chambers and root
canals, at least during the first
few years, although they may
become reduced in size with
age.

Radiographs of permanent
teeth have pulpal spaces that
are either smaller than
normal or completely
obliterated.

Histological features
Histologic appearance of
the teeth in Dentinogenesis
imperfecta 1 emphasizes
the fact that this is purely a
mesodermal disturbance.
The appearance of the
enamel is essentially normal
except for its peculiar
shade, which is actually a
manifestation of the
dentinal disturbance.

Histological features
The dentin, on the other
hand, is composed of
irregular tubules, often with
large areas of uncalcified
matrix. The tubules tend to
be larger in diameter and
thus less numerous than
normal in a given volume of
dentin. In some areas there
may be complete absence
of tubules.

Histological features
The pulp chamber is usually almost obliterated by the
continued deposition of dentin. The odontoblasts have only
limited ability to form well-organized dentinal matrix, and
they appear to degenerate readily, becoming entrapped in
this matrix.

The histopathology of the in type III has not been adequately
documented.

Chemical and physical features
Chemical analysis explains many of the abnormal features of the
of dentinogenesis imperfecta 1. Their water content is greatly
increased, as much as 60% above normal, while the inorganic
content is less than that of normal dentin.

The density, x-ray absorption and hardness of the dentin are low
thus there will be rapid attrition of affected teeth.

There is no significant information available on teeth in type III.
Treatment
It is directed primarily toward preventing the loss of enamel
and subsequent loss of dentin through attrition.

Cast metal crowns on posterior teeth and jacket crowns on
anterior teeth have been used with considerable success.

Caution must be exercised in the use of partial appliances
which exert stress on teeth, because roots are easily fractured.

Experience has further shown that fillings are not usually
permanent because of softness of dentin
Dentin Dysplasia
Is a rare disturbance of dentin formation characterized by
normal enamel but atypical dentin formation with abnormal
pulpal morphology.

Because of spontaneous exfoliation of multiple teeth, this
phenomenon known as rootless teeth.

Shields and his associates classified it into
-Type I or radicular dentin dysplasia
-Type II or coronal dentin dysplasia

Type I dentin dysplasia is by more common.

Etiology
Both type I and II, appears to be a hereditary disease,
transmitted as an autosomal dominant characteristic.
Clinical features
Type I (radicular):
Both dentitions are
affected, although the teeth
appear clinically normal in
morphologic appearance
and color or slight amber
translucency.
The teeth characteristically
exhibit extreme mobility
and are commonly
exfoliated prematurely or
after only minor trauma as
a result of their abnormally
short roots.

Clinical features
Type II (coronal):

Both dentitions are also affected in this form of dentin dysplasia,
although the involvement of each dentition is different clinically,
radiographically and histologically.

The deciduous teeth have the same yellow, brown or bluish-grey
opalescent appearance as seen in dentinogenesis imperfecta.

The clinical appearance of the permanent dentition is normal.

Roentgenographic features of
dentin dysplasia
Type I (radicular).
In both dentitions, the roots
are short, blunt, conical, or
similarly malformed.

In deciduous teeth, the pulp
chambers and root canals
are usually completely
obliterated, while in the
permanent dentition, a
crescent shaped pulpal
remnant may still be seen in
pulp chamber.

Roentgenographic features of
dentin dysplasia
Type II (coronal):
The permanent teeth,
however, exhibit an
abnormally large pulp
chamber in coronal portion
of tooth, often described as
thistle-tube in shape and
within such areas
radiopaque foci resembling
pulp stones may be found.

The pulp chambers of the
deciduous teeth become
obliterated as in type I and
in dentinogenesis
imperfecta.

Periapical radiolucencies do
not occur unless for an
obvious reason.


Histologic features of dentin dysplasia
Type I (radicular) .

Normal dentinal tubule
formation appears to have
been blocked so that new
dentin forms around
obstacles and takes on
characteristic appearance
described as lava flowing
around boulders. This
pattern is known as
cascades of dentin results
from repetitive attempts to
form root structure.
Type II (coronal) .

The deciduous teeth exhibit amorphous and atubular dentin in
the radicular portion, while coronal dentin is relatively normal.

The permanent teeth also show relatively normal coronal
dentin, but the pulp has multiple pulp stones or denticles.
Treatment and prognosis of dentin dysplasia
There is no treatment for the disease, and its prognosis depends
upon the occurrence of periapical lesions necessitating tooth
extraction as well as upon the exfoliation of teeth due to
increased mobility.
Dentin bonding agents
Adhesion to dentin remains much challenging as compared to
adhesion to enamel.

It is believed that dentin adhesion relies primarily on the
penetration of adhesive monomers into the filigree of
collagen fibers left exposed by acid etching.

Challenges in dentin bonding
Dentin is an intrinsically
hydrated tissue, penetrated
by amaze of 1- to 2.5 m
diameter fluid-filled dentin
tubules.
Adhesion can be affected by
the remaining dentin
thickness after tooth
preparation.



After tooth preparation, with bur or other instrument,
residual organic and inorganic components form a smear layer
of debris on surface and this layer fills the orifices of tubules,
forming smear plugs and decreases dentin permeability 68%.

Composition of SL is basically hydroxyapatite and altered
denatured collagen.
Dentin bonding agents bonding to the inorganic component
of dentin
-Phosphate group
-Amino group


Dentin bonding agents bonding to the organic component of
dentin
-Isocyanate group
-Carboxylic acid group
SMEAR LAYER
When tooth surface is
altered by rotary and
manual instrumentation
during cavity
preparation, cutting
debris is smeared over
enamel and dentin
surfaces, forming smear
layer.

CURRENT STRATEGIES
OF ADHESION
COLLAPSE OF
COLLAGEN NETWORK
RE-EXPANSION OF
COLLAGEN NETWORK
Three-step, Total-Etch Adhesives

Because clinical technique involves simultaneous application
of acid to and dentin, this method is commonly known as
total-etch technique.

Acids demineralize intertubular and peritubular dentin, open
the dentin tubules, and expose dense filigree of collagen
fibers.

The acid-etching step not only alters the mineral content of
dentin substrate, but also changes its surface free energy.

TE BONDING
When primer and bonding resins are applied to etched
dentin, they penetrate the intertubular dentin, forming a
resin-dentin interdiffusion zone, or hybrid layer.
One-bottle, Total-Etch Adhesives
These are called the one-bottle systems because they
combine the primer and bonding agent into a single solution.

And a separate etching step still is required.

First coat applied on etched dentin words as a primer- it
increases the surface-free energy of dentin.

Second coat acts as the bonding agent used in three-step
systems- it fills the spaces between the dense network of
collagen fibers.
Self-Etching Primer Systems
These acidic primers include a phosphonated resin molecule
that performs two functions simultaneously etching and
priming of dentin and enamel.

The bonding mechanism of SEPs is based on the
simultaneous etching and priming of enamel and dentin,
forming a continuum in the substrate and incorporating smear
plugs into the resin tags.

To simplifying the bonding technique, the elimination of
rinsing and drying steps reduces the possibility of overwetting
or overdrying, either of which can affect adhesion adversely.
SE BONDING
Self-Etching Adhesives(All-in-One)
Continuing the trend toward simplification, no-rinse, self-
etching materials that incorporate the classic steps of etching,
priming and bonding into one solution have become
increasingly popular.

Because all-in-one adhesives with etching, priming, and
bonding functions delivered in single solution are now
available, including Adper Prompt L-Pop, iBond, Xeno III etc.
Conclusion

Preserving the vitality of the tooth.

It is mandatory to give the treatment without any iatrogenic
damage to the tooth structure.

It should be borne in mind of all the dental surgeons who are
going to do any restorative procedure for dental patients.


References
1. Text book of Oral histology and embryology- Orbans
2. Text book of Oral histology, development, structure
and function- Ten Cates
3. Oral development and histology James K Avery 3
rd
edi.
4. Text book of Endodontic practice- Grossman 11
th
edition
5. Operative Dentistry - Sturdevants 5
th
edition
6. Fundamentals of operative dentistry- James Summit
3
rd
edition
6. Science of Dental Materials - Phillips 11
th
edition
7. Oral pathology- Shafers 4
th
edition


Thank you