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The image shows an enamel infraction, that can be seen through a transilluminator with a minimal infection site shown by the green arrow.

Abstract

Enamel infractions are microcracks seen within the dental enamel of a tooth. They are sometimes referred to as a non-cavitated enamel fracture, is a microfracture or superficial break in a tooth's enamel layer that does not penetrate into the dentin underneath. Usually, trauma—like a direct blow to the tooth—or stress from too much pressure—like bruxism—cause these infractions. Enamel infractions, as opposed to cavities, may not entail bacterial decay or tooth structure loss, although they may still result in sensitivity or cosmetic issues. To stop more harm, early detection via clinical examination or dental imaging is essential. They can be seen more clearly when transillumination is used. Enamel infractions are found more often in older teeth, as the accumulated trauma is greatest. Enamel infractions can also be found as a result of iatrogenic damage inadvertently caused by instrumentation during dental treatments and not discriminatory towards any age group.Monitoring the condition is often the first step in treatment, followed by preventative measures like applying fluoride or, in more extreme situations, restorative processes like veneers or dental bonding maintain tooth health and avoid more serious dental problems down the road, it is crucial to comprehend the nature of enamel infractions.

Signs and Symptoms

An up-close look at enamel infractions reveals pits and grooves that show how developmental defects affect tooth structure and make teeth more susceptible to decay.

Enamel infractions are typically asymptomatic, but if they persist for an extended period of time, they may cause problems, such as making the enamel more sensitive to food and temperature. The only visible symptom, if it is able to be seen through the naked eye is minor microcracks. Additionally, because dentin is yellow-orange in contrast to enamel, which is apparent as a white or lighter tint, there may be dental discoloration.

Cause and Mechanism

Enamel Infractions are characterized by the quality and quantity of enamel present throughout childhood. Various factors are involved in the development of infractions, some of these factors are nutritional, environmental, genetic, and systemic factors. Structural abnormalities stem from genetic mutations that alter the normal proteins necessary for enamel formation but due to a lack of essential nutrients like calcium, vitamin D, and vitamin A contribute to these genetic factors. This lack of vitamins hinders the formation and mineralization of enamel during crucial stages of enamel development in early childhood. Environmental factors that also play a role are an excess of fluoride exposure during enamel development (which can cause fluorosis).

The direct mechanical forces exerted during chewing, such as vertical pressure and lateral forces as teeth grind or shear food, are the main cause of enamel wear in the grooves. The enamel in the grooves wears down over time due to abrasion from the constant friction between the food and the tooth surface, especially in places where food is more frequently trapped or where contact is poor. Particularly in areas of the molars that are subjected to high levels of stress during chewing, repeated mastication can cause fatigue damage to the enamel.As individuals age, the enamel on molars may naturally thin, making it more prone to damage during mastication.

Ameloblasts (the cells responsible for the production of enamel) don't function properly due to other systemic factors like infections, trauma, or severe illness that occur similarly in the development of the enamel. All these factors combined in early childhood can reduce ameloblast activity which can result in insufficient enamel matrix protein secretion. As a result, the organic matrix could not be correctly formed or mineralized with hydroxyapatite crystals that leads to poor mineralization of the enamel. This can lead to a weakened enamel surface that is more porous, thinner, prone to pits and grooves which raises the risk of dental caries and sensitivity.

An oral examination is being held and can be observed through the image.

Up above is the dental operating microscope where enamel infractions can be observed.

The transilluminator is the device she is working on used to observe enamel infractions.

Diagnosis

Enamel infractions are diagnosed through a dental examination. A dentist can assess the teeth's condition once the first tooth erupts in the mouth and will continue to do so throughout every appointment. In order for the provider to take preventive action if necessary depending on the health of the teeth or any abnormalities, it is crucial that a child have a dental examination during the early years of tooth development and continue with check ups throughout their life. A dental examination would also be used to identify this if it were discovered later in life. Methylene blue staining, dental operating microscope magnification, and the transilluminator are commonly used methods for crack diagnosis. Even though cracks can be found with these methods, it is very difficult to pinpoint the exact size and depth of a crack.

Treatment

Minor infractions may not require any treatment, however, major infractions may require treatment including smoothing, fluoride treatment, and crown restoration.

Other treatments include restoration, where there is an overlay of material on the tooth to harden and make it a tooth-like structure. Even uncomplicated patients who show no strong effects can be recommended to undergo a crown restoration to be preventive and frequently x-rayed to stay updated on the condition of the tooth. For older patients, it is suggested to only do a crown restoration if there has been an infection which is not common.

Prognosis

Enamel infractions don't usually go beyond the enamel so they don't require any treatment because they don't cause any infections. Any treatment necessary is mostly for patients with concerns of the appearance of the tooth where they then are able to get crowns on their teeth or veneers. Most patients can continue normally with enamel infractions as long as the infraction doesn't get bigger or cause any complications.

Epidemiology

One of the most common dental traumas are enamel infractions. Despite their high frequency, enamel infractions are often underreported, primarily because they are typically asymptomatic and may not be easily noticeable without a detailed clinical or radiographic examination. Demographic evaluations indicate a higher prevalence of trauma in males compared to females, particularly in younger populations. Studies have consistently shown that males are more likely to experience dental trauma, with some studies reporting a male-to-female ratio of up to 2:1 in children and adolescents. This higher prevalence is often attributed to behavioral factors such as greater involvement in contact sports, physical activities, and risk-taking behaviors. Additionally, males tend to engage in more high-risk activities, which increases their exposure to trauma that may result in enamel infractions. However, it is important to note that while enamel infractions are more common in males, they can affect individuals of all ages and genders, especially when there are contributing factors such as bruxism or malocclusion. More than 75% of tooth fractures occur in the upper jaw, with the majority affecting the anterior teeth—particularly the central incisors, followed by the lateral incisors and canines. This trend highlights the vulnerability of these teeth to trauma, often resulting in enamel infractions or more extensive fractures.Despite their frequency, enamel infractions are often underreported, as they are typically asymptomatic and may not be easily noticeable without a detailed clinical or radiographic examination which is why it's important to be preventive.

Research Direction

A promising minimally invasive method for treating superficial enamel cracks that can enhance both appearance and functionality is the application of infiltrant resin. The two case studies illustrate the method's conservative nature and present a viable option for patients with enamel infractions who would prefer not to undergo more invasive procedures. In another article, it emphasizes how the detection of enamel cracks has greatly improved due to recent technological advancements like transillumination, OCT, and AI. Effective treatment and the avoidance of more serious damage depend on an early and precise diagnosis. As these technologies advance, they might provide more accurate, non-invasive, and economical methods of detecting enamel cracks, improving dental care outcomes.

References

Category:Dental enamel Category:Acquired tooth pathology