On the structure-property relationship of sound and hypomineralized enamel

Multi-scale characterization of Developmental Defects of Enamel and their clinical significance for diagnosis and treatment

Developmental Defects of Enamel (DDE) such as Dental Fluorosis (DF) and Molar Incisor Hypomineralization (MIH) are a major public health problem. Their clinical aspects are extremely variable, challenging their early and specific diagnosis and hindering progresses in restorative treatments. Here, a combination of macro-, micro- and nano-scale structural and chemical methods, including, among others, Atom Probe Tomography recently applied on tooth enamel, were used to study and compare MIH, DF and healthy teeth from 89 patients. Globally, we show that DF is characterized by an homogenous loss of mineral content and crystallinity mainly disrupting outside layer of enamel, whereas MIH is associated with localized defects in the depth of enamel where crystalline mineral particles are embedded in an organic phase. Only minor differences in elemental composition of the mineral phase could be detected at the nanoscale such as increased F and Fe content in both severe DDE. We demonstrate that an improved digital color measurement of clinical relevance can discriminate between DF and MIH lesions, both in mild and severe forms. Such discriminating ability was discussed in the light of enamel composition and structure, especially its microstructure, organics presence and metal content (Fe, Zn). Our results offer additional insights on DDE characterization and pathogenesis, highlight the potentiality of colorimetric measurements in their clinical diagnosis and provide leads to improve the performance of minimally invasive restorative strategies. STATEMENT OF SIGNIFICANCE: Developmental Defects of Enamel (DDE) are associated to caries and tooth loose affecting billions of people worldwide. Their precise characterization for adapted minimally invasive care with optimized materials is highly expected. Here In this study, first we propose the use of color parameters measured by a spectrophotometer as a means of differential clinical diagnosis. Second, we have used state-of-the-art techniques to systematically characterize the structure, chemical composition and mechanical optical properties of dental enamel teeth affected by two major DDE, Dental Fluorosis (DF) or Molar Incisor Hypomineralization (MIH). We evidence specific enamel structural and optical features for DF and MIH while chemical modifications of the mineral nanocrystals were mostly correlated with lesion severity. Our results pave the way of the concept of personalized dentistry. In the light of our results, we propose a new means of clinical diagnosis for an adapted and improved restoration protocol for these patients.

Enamel Structure Defects in Kdf1 Missense Mutation Knock-in Mice

The Keratinocyte differentiation factor 1 (KDF1) is reported to take part in tooth formation in humans, but the dental phenotype of Kdf1 mutant mice has not been understood. Additionally, the role of the KDF1 gene in dental hard tissue development is rarely known. In this study, we constructed a Kdf1 missense mutation knock-in mouse model through CRISPR/Cas9 gene-editing technology. Enamel samples from wildtypes (WT) and Kdf1 homozygous mutants (HO) were examined using micro-computed tomography (micro-CT), scanning electron microscopy (SEM), an atomic force microscope (AFM) and Raman microspectroscopy. The results showed that a novel Kdf1 missense mutation (c. 908G>C, p.R303P) knock-in mice model was constructed successfully. The enamel of HO mice incisors appeared chalky and defective, exposing the rough interior of the inner enamel and dentin. Micro-CT showed that HO mice had lower volume and mineral density in their tooth enamel. In addition, declined thickness was found in the unerupted enamel layer of incisors in the HO mice. Using SEM and AFM, it was found that enamel prisms in HO mice enamel were abnormally and variously shaped with loose decussating crystal arrangement, meanwhile the enamel rods were partially fused and collapsed, accompanied by large gaps. Furthermore, misshapen nanofibrous apatites were disorderly combined with each other. Raman microspectroscopy revealed a compromised degree of order within the crystals in the enamel after the Kdf1 mutation. To conclude, we identified enamel structure defects in the Kdf1 missense mutation knock-in mice, which displayed fragmentary appearance, abnormally shaped prism structure, decreased mineral density, altered crystal ordering degree and chemical composition of the enamel layer. This may support the potential role of the KDF1 gene in the natural development of enamel.

Special architecture and anti-wear strategies for giant panda tooth enamel: Based on wear simulation findings

Giant pandas are the flagship species in world conservation. Due to bamboo being the primary food source for giant pandas, dental wear is common owing to the extreme toughness of the bamboo fiber. Even though research on tooth enamel wear in humans and domestic animals is well-established, research on tooth enamel wear in giant pandas is scarce. The purpose of this study is to evaluate tooth enamel wear resistance in giant pandas to provide a basis for a better understanding of their evolutionary process. From microscopic and macroscopic perspectives, the abrasion resistance of dental enamel in giant pandas is compared with that of herbivorous cattle and carnivorous dogs in this study. This involves the use of micro-scratch and frictional wear tests. The results show that the boundary between the enamel prism and the enamel prism stroma is well-defined in panda and canine teeth, while bovine tooth enamel appears denser. Under constant load, the tribological properties of giant panda enamel are similar to those of canines and significantly different from those of bovines. Test results show that the depth of micro scratches in giant panda and canine enamel was greater than in cattle, with greater elastic recovery occurring in dogs. Scratch morphology indicates that the enamel substantive damage critical value is greater in pandas than in both dogs and cattle. The analysis suggests that giant panda enamel consists of a neatly arranged special structure that may disperse extrusion stress and absorb impact energy through a series of inelastic deformation mechanisms to cope with the wear caused by eating bamboo. In this study, the excellent wear resistance of giant panda's tooth enamel is verified by wear tests. A possible theoretical explanation of how the special structure of giant panda tooth enamel may improve its wear resistance is provided. This provides a direction for subsequent theoretical and experimental studies on giant panda tooth enamel and its biomaterials.

The use of transillumination in mapping demarcated enamel opacities in anterior teeth: A cross-sectional study

BACKGROUND

Despite intensive efforts for categorizing demarcated enamel opacities, often related to molar incisor hypomineralization (MIH), there is a lack of descriptive criteria aiming to describe them physically outside the scope of color and size. This is most likely due to the indices focusing on molar, not anterior, teeth.

AIM

To map and classify demarcated lesions on permanent anterior teeth using reflected and transilluminated light. The association between classification and related lesion characteristics was also examined.

DESIGN

Permanent anterior teeth with demarcated opacities related to MIH were selected. For each tooth, standardized photographs were taken using transmitted and reflected light. Each lesion was mapped and classified according to its color, lesion size, surface integrity, and type. The data were analyzed using the chi-square and Fisher's exact tests. A logistic regression analysis was performed to identify the risk of PEB.

RESULTS

There were significant relationships between lesion size, color, and type with surface integrity. Lesion type and size were more important than lesion color for assessing the risk of PEB. There was also a significant relationship between lesion size and lesion color.

CONCLUSIONS

Lesion size and type are significant clinical parameters for assessing the risk of PEB on enamel opacities related to MIH.

100 Years of Chalky Teeth Research: From Pioneering Histopathology to Social Good

One hundred years ago, histopathology pioneer Bernhard Gottlieb described developmentally disrupted teeth as having “chalky enamel” and “chalky spots” that “crumble” easily. He also asked pivotal questions about the pathogenesis of “enamel hypoplasia” that remained enigmatic for almost a century. Today, breakthrough pathomechanistic investigations of chalky enamel are revealing surprising answers, and an allied translational initiative—The D3 Group for developmental dental defects (“D3s”) —is converting such scientific knowledge into social good surrounding prevention of tooth decay. Molar hypomineralisation (MH) affects 1-in-5 children worldwide and is well-evidenced, but poorly recognised, as a principal risk factor for childhood tooth decay. Given MH is causally linked to infantile illness, an exciting corollary is that medical prevention would lead to substantial reductions in decay. Here we reflect on the past century of chalky teeth research and retrace the path leading to recognition of MH as a global health concern. Five research eras, today's four major D3s, and diverse experimental attacks are outlined alongside translational wins that have benefitted global health. Addressing hopes for medical prevention of MH, this centennial year's pathomechanistic discovery is contextualised against past accomplishments and new opportunities. Finally, we note the translational value of accessible infographics for guiding future work, and forecast exciting prospects for the next century.

Minimally invasive judgement calls: managing compromised first permanent molars in children

This paper aims to update the reader on how minimally invasive (MI) techniques may be used to improve the longevity of carious or defective/compromised first permanent molars (cFPMs) in young children. Clinical and radiographic diagnosis and the prognostic factors will be discussed in view of recent studies showing that these teeth can be kept in function and have an improved prognosis as the child gets older. Clinical protocols for their care, based on the latest evidence and techniques for MI restorations, together with longevity information of possible restorative options, are described. This paper also explores the rationale behind enforced extractions and related morbidity, in order to help oral healthcare practitioners to determine the optimal management of these key elements in the dentition for the benefit of the patients.

Simplified occlusal replica adapted technique with glass ionomer cement for molar-incisor hypomineralization-affected molars: An 18-month follow-up

BACKGROUND AND OVERVIEW

Molar-incisor hypomineralization (MIH) is a qualitative developmental defect of enamel, which has been a daily concern in clinical practice owing to its difficult treatment.

CASE DESCRIPTION

An 11-year-old girl was admitted to the pediatric dental clinic with a symptom of severe hypersensitivity in the permanent molars owing to MIH. The treatment consisted of a simplified occlusal replica adapted technique with conventional glass ionomer cement in the MIH-affected molars, which involved laboratory and clinical stages. The patient was reexamined every 3 months, and after 18 months there was no additional tooth structure loss, restoration failure, or pain. This technique may be considered a feasible alternative to restore hypomineralized teeth owing to its reduced procedure time and good performance in the follow-up period of 18 months.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

The technique successfully restored the function and shape of the affected teeth, decreasing the sensitivity by means of covering the demarcated MIH opacities.

The effect of amoxicillin on dental enamel development in vivo

The exposure to amoxicillin has been associated with molar incisor hypomineralization. This study aimed to determine if amoxicillin disturbs the enamel mineralization in in vivo experiments. Fifteen pregnant rats were randomly assigned into three groups to received daily phosphatase-buffered saline or amoxicillin as either 100 or 500 mg/kg. Mice received treatment from day 13 of pregnancy to day 40 postnatal. After birth, the offsprings from each litter continued to receive the same treatment according to their respective group. Calcium (Ca) and phosphorus (P) content in the dental hard tissues were analyzed from 60 upper first molars and 60 upper incisors by the complexometric titration method and colorimetric analysis using a spectrophotometer at 680 nm, respectively. Lower incisors were analyzed by X-ray microtomography, it was measured the electron density of lingual and buccal enamel, and the enamel and dentin thickness. Differences in Ca and P content and electron density among the groups were analyzed by one-way ANOVA. There was no significant difference on enamel electron density and thickness among the groups (p > 0.05). However, in incisors, the higher dose of amoxicillin decreased markedly the electron density in some rats. There were no statistically significant differences in Ca (p = 0.180) or P content (p = 0.054), although the higher dose of amoxicillin could affect the enamel in some animals. The amoxicillin did not significantly alter the enamel mineralization and thickness in rats.

The geometrical structure of interfaces in dental enamel: A FIB-STEM investigation

In this study a high resolution structural analysis revealed that enamel prisms are surrounded by an interface that is discontinuous with frequent mineral to mineral contact separated by gaps. This contact manifests either by crystallites bridging the boundary between prismatic and interprismatic enamel or continuous crystallites curving and bridging the interprismatic enamel to the prisms. The geometrical resolution of this TEM investigation of the interfaces is ≤2 nm as a basis for micromechanical models. Within this resolution, contrary to existing structural descriptions of dental enamel structure in materials science literature, here the crystallites themselves are shown to be either in direct contact with each other, sometimes even fusing together, or are separated by gaps. Image analysis revealed that on average only 57 ± 15% of the interface consists of points of no contact between crystallites. This work reveals structural features of dental enamel that contribute important understanding to both the architecture and mechanical properties of this biological material. A new structural model is proposed and the implications for the mechanical properties of dental enamel are discussed. STATEMENT OF SIGNIFICANCE: In this study a high resolution structural analysis, employing focused ion beam and transmission electron microscopy revealed that enamel prisms are surrounded by interfaces that are discontinuous with frequent mineral to mineral contact separated by gaps. Although the interfaces in enamel have been investigated previously, existing studies are lacking in detail considering the geometry and morphology of the interfaces. We think that this result is of great importance when it comes to the understanding of the mechanical properties. In our opinion the concept of soft sheaths is no longer feasible. The resulting observations are included in a new structural model which provides new qualitative insights into the mechanical behavior. Existing analytical models were applied to simulate the new geometrical structure.

Machinability of high-speed enamel cutting with carbide bur

The cutting of tooth enamel using a high-speed air-turbine handpiece and carbide bur is a key procedure in oral surgeries, such as the minimally invasive extraction. However, presently little is known about the cutting mechanics and material removal mechanism related to tooth enamel machinability. In this study, the machinability of high-speed enamel cutting with carbide bur is studied by a computer-aided numerical control system. The dynamic cutting forces of enamel of the occlusal, buccal/lingual, and proximal surfaces were measured by the force measuring system. The force ratio, cutting torque, rotating speed, specific cutting energy, and bur wear were analyzed. The microstructure of enamel and carbide burs was observed by the scanning electron microscope, and the relationship between enamel microstructures and machinability was further analyzed. The results show that during the high-speed enamel cutting with carbide bur, the chip thickness is on the nano-scale, and the plastic deformation of the machined surface is obvious. With increased material removal rate, the cutting force, torque, specific cutting energy, and bur wear increases accordingly, whereas the rotating speed decelerates (p < 0.05). The different angles between the cutting direction and the axial direction of the enamel rods give rise to the large differences in the cutting mechanics and mechanism of the proximal, buccal/lingual, and occlusal surfaces of the teeth. When the cutting direction is parallel, vertical, and oblique 45° to the axial direction of the enamel rods, the force required for material fracture and crack propagation increases, and the cutting force increases as a consequence. Parallel and oblique 45° cutting are the main modes of tooth segmentation in the minimally invasive extraction. In comparison with the parallel cutting mode, the cutting force, torque, and cutting ratio of the oblique 45° cutting mode can be significantly increased, and the tool wear is obviously accelerated. This is the lowest priority in segmentation surgery, hence the problems of overload and temperature rise need to be considered. The cutting mechanics and cutting mechanism obtained in this study will provide scientific process guidance for dental cutting operations with the air-turbine handpiece driving bur.

On the method of revealing enamel structure by acid etching. Aspects of optimization and interpretation

The study aimed at finding an optimal combination of acid concentration and etching time when nitric acid is used as etchant for the study of the finer details of human dental enamel structure. Four hundred 2-3-mm-thick segments of facio-lingually sectioned human third molar crowns were assigned to 20 groups with 20 specimens in each group, each group differing with respect to acid concentration (0.1, 1, 2.5, and 5%) and etching time (15, 30, 45, 90, and 180 s). After etching and preparation, specimens were observed in the scanning electron microscope (SEM). Surface roughness/topography increased with increasing acid concentration and increasing etching time, but not in a linear fashion; generally, prisms tended to go from flat-surfaced to cone-shaped and prism sheaths from fissure-like to wedge-shaped. Intragroup variations and intergroup similarities were considerable. The two major enamel factors determining the etch effect are crystal orientation and prism sheath properties. Other factors, such as distribution of porosities and crystal quality, also contribute probably. Slight to moderate topography is best for observing the finer enamel structure, for example, etching with concentrations in the range 0.1-1% and with etching times in the range 15-90 s, the stronger the acid, the shorter the time. The depth effect of nitric acid is judged to be relatively small. Considerable variations in expression of prism cross-striations were observed. SEM observations of acid-etched enamel in carefully selected planes are a powerful method for the study of enamel structure, bearing in mind the artifactual aspects of the observed surface.

Prevalence of Molar Incisor Hypomineralization among School Children Aged 9 to 12 Years in Virajpet, Karnataka, India

BACKGROUND:

The molar incisor hypomineralization (MIH) is defined as a qualitative defect of the enamel characterised by the progressive and simultaneous hypomineralization of the enamel structure of the first permanent molars which is of systemic origin, which may be associated frequently with incisors. Although the reported prevalence of MIH ranges from 2.4% to 40.2% worldwide, very little data is available from India.

AIM:

To determine the prevalence of molar incisor hypomineralization among school children aged 9 to 12 years in virajpet, Karnataka.

METHODS:

This cross-sectional descriptive study consisted of 1600 school children aged 9-12 years selected by stratified cluster sampling procedure. The European Academy of Pediatric Dentistry criteria were followed for MIH diagnosis. Chi-square test was used to analyse the categorical data. P ≤ 0.05 was considered for statistical significance.

RESULTS:

The prevalence of MIH is 13.12% with no gender predilection. Ten-year-old children showed the highest prevalence (15%) among all the age group. Majority of children with MIH (70.2%) have lesions in both molars and incisors with demarcated opacities and atypical restorations being the most frequent defect type.

CONCLUSION:

Prevalence of MIH was 13.12% in the 9-12-year child population in Virajpet. There is a need for a proper planned preventive and restorative program about the increasing prevalence of MIH.

Effect of a self-etching primer containing 4-META and sodium sulfite after phosphoric acid etching on bonding strength of MMA-TBB resin to human enamel

PURPOSE

The aim of this study was to evaluate the shear bond strength and durability of MMA-TBB resin to human enamel applied a self-etching primer with phosphoric acid etching.

METHODS

A self-etching primer (Teeth primer, TP) containing 4-methacryloyloxyethyl trimellitate anhydride (4-META) and sodium sulfite and two etchants having different phosphoric acid concentrations (K-etchant gel, KE, 35-45%: Red gel, RG, 20-25%) were used as treatment agent, and MMA-TBB resin was used as luting agent. Enamel surfaces were treated with six methods which were as follow: KE, RG, TP, KE+TP, and RG+TP. After enamel specimens were bonded with MMA-TBB resin and stored in distilled water for 24h, the shear bond strength test was done at 0 thermocycling or 20,000 thermocycling. These results were statistically verified with Steel-Dwass multiple comparisons and Man-Whitney U test.

RESULTS

The shear bond strength of TP group, KE+TP group, and RG+TP group were significantly higher than KE group and RG group in pre-thermocycling. KE+TP group and RG+TP group were significantly higher than other groups in post-thermocycling.

CONCLUSIONS

Applying TP with phosphoric acid etching can increased shear bond durability despite difference of phosphoric acid concentrations (35-45% or 20-25%).

Hydration-induced nano- to micro-scale self-recovery of the tooth enamel of the giant panda

The tooth enamel of vertebrates comprises a hyper-mineralized bioceramic, but is distinguished by an exceptional durability to resist impact and wear throughout the lifetime of organisms; however, enamels exhibit a low resistance to the initiation of large-scale cracks comparable to that of geological minerals based on fracture mechanics. Here we reveal that the tooth enamel, specifically from the giant panda, is capable of developing durability through counteracting the early stage of damage by partially recovering its innate geometry and structure at nano- to micro- length-scales autonomously. Such an attribute results essentially from the unique architecture of tooth enamel, specifically the vertical alignment of nano-scale mineral fibers and micro-scale prisms within a water-responsive organic-rich matrix, and can lead to a decrease in the dimension of indent damage in enamel introduced by indentation. Hydration plays an effective role in promoting the recovery process and improving the indentation fracture toughness of enamel (by ∼73%), at a minor cost of micro-hardness (by ∼5%), as compared to the dehydrated state. The nano-scale mechanisms that are responsible for the recovery deformation, specifically the reorientation and rearrangement of mineral fragments and the inter- and intra-prismatic sliding between constituents that are closely related to the viscoelasticity of organic matrix, are examined and analyzed with respect to the structure of tooth enamel. Our study sheds new light on the strategies underlying Nature's design of durable ceramics which could be translated into man-made systems in developing high-performance ceramic materials. STATEMENT OF SIGNIFICANCE: Tooth enamel plays a critical role in the function of teeth by providing a hard surface layer to resist wear/impact throughout the lifetime of organisms; however, such enamel exhibits a remarkably low resistance to the initiation of large-scale cracks, of hundreds of micrometers or more, comparable to that of geological minerals. Here we reveal that tooth enamel, specifically that of the giant panda, is capable of partially recovering its geometry and structure to counteract the early stages of damage at nano- to micro-scale dimensions autonomously. Such an attribute results essentially from the architecture of enamel but is markedly enhanced by hydration. Our work discerns a series of mechanisms that lead to the deformation and recovery of enamel and identifies a unique source of durability in the enamel to accomplish this function. The ingenious design of tooth enamel may inspire the development of new durable ceramic materials in man-made systems.

Perception of Indian Dental Surgeons regarding Molar Incisor Hypomineralization

Aim

To determine the perception of Indian dental professionals about prevalence, severity, and etiological factors of molar incisor hypomineralization (MIH).

Materials and methods

An online survey was mailed to dental professionals encompassing various questions regarding etiology, diagnosis, prevalence, and management of MIH.

Results

More than 90% of the respondents encounter teeth with hypomineralization in their practice, with less than half of them encountering such teeth on a monthly basis. Among these more than one-third find it difficult to manage one or the other aspect of MIH. The etiology was found to be varying as per the respondents.

Conclusion

Molar incisor hypomineralization is a common condition encountered by dental professionals with no apparent consensus regarding the anticipated prevalence, severity, and etiology of this condition. Knowledge of clinicians' level of perception could be an incentive for pediatric dentists to become more acquainted with MIH by conducting research into its different aspects.How to cite this article: Upadhyay S, Kumar G, Dhillon JK, Gill NC. Perception of Indian Dental Surgeons regarding Molar Incisor Hypomineralization. Int J Clin Pediatr Dent 2018;11(2):116-121.

The Association between Molar-Incisor Hypomineralization and Dental Caries with Socioeconomic Status as an Explanatory Variable in a Group of Finnish Children

The aim of this study was to investigate if a developmental enamel defect known as Molar-Incisor Hypomineralization (MIH) is associated with dental caries. Socioeconomic status (SES) was examined as a confounding factor between caries and MIH. In this cross-sectional study, 636 children, aged 8 to 13 years, from three towns (two rural areas and one urban area) in Finland were examined for MIH in line with the criteria of the European Academy of Paediatric Dentistry. Caries status for permanent teeth was recorded as decayed, missing and filled teeth (DMFT). Caries experience (DMFT > 0) in the first permanent molars (FPMs) was set as an outcome. SES was determined using a questionnaire completed by parents. The prevalence of MIH was 18.1%. The mean DMFT in FPMs for children with MIH was higher than for their peers, 1.03 ± 1.25 vs. 0.32 ± 0.80 (p = 0.000, Mann-Whitney U test). In a multivariate analysis using the generalized linear mixed model where locality, SES, age and MIH were taken into account as caries risk indicators, MIH was the strongest risk indicator of caries in FPMs (Odds Ratio: 6.60, 95% Confidence Interval: 3.83–11.39, p = 0.000). According to the study results, children with MIH have a higher risk for dental caries than children without MIH.

An investigation into the effect of a resin infiltrant on the micromechanical properties of hypomineralised enamel

BACKGROUND

Resin infiltration may alter the mechanical properties of enamel hypomineralised lesions (HL); however, variable surface layer (SL) thickness may affect resin penetration.

AIMS

To determine the thickness of the SL of HL and to investigate the effect of resin infiltration on the mechanical properties of HL.

DESIGN

The thickness of the SL over HL was determined using polarised light microscopy. Etching time using 15% HCl gel to remove the SL of 52 samples was determined. Selected HL and control areas of 21 teeth were infiltrated with Icon^® resin infiltrant, and cross-sectional Knoop microhardness (KHN) measurements were recorded before and after resin infiltration.

RESULTS

Ninety-six point five per cent of HL had a detectable SL with mean thickness of 58 ± 29 μm. Application of HCl for 120 s produced a mean MIH erosion depth of 58 ± 12 μm. Eleven of 21 samples had evidence of infiltration using visual examination. The infiltrant penetrated some of the HL leading to an increase in KHN (111 ± 75 KHN) which, when compared to adjacent non-infiltrated HL (96 ± 52 KHN), was not statistically significantly different (P = 0.56).

CONCLUSIONS

There was marked variation in the SL thickness of HL. Resin infiltration of HL did not increase microhardness significantly.

STEM and HRTEM studies of accumulated deposits on human tooth surface

The aim of this study was to clarify the fine structure of accumulated deposits on the surface of teeth that are considered to affect the gloss of teeth. The study was carried out using, as specimens, human incisor teeth having gloss, which were extracted from teenage donors and those incapable of showing gloss even by brushing which were extracted from donors in their 50s. Thin longitudinal sections of tooth enamel with accumulated deposits on the surface were prepared by focused ion beam (FIB) milling, and the fine structure was analyzed using a scanning transmission electron microscope (STEM) and a high resolution transmission electron microscope (HRTEM). By FIB, thin longitudinal sections could be prepared from tooth enamel together with organic and inorganic substances accumulated on the surface without artifacts. The accumulated deposits on the surface of teeth having gloss were composed of organic substances. However, it was first revealed by STEM observation that the accumulated solid deposits on the surface of teeth having no gloss had a complicated structure wherein inorganic and organic substances coexisted. It is suggested that the organic substances contain proteins derived from saliva. The inorganic substances were spherical and needle-like hydroxyapatites (HAs). It is considered that amino acids constituting the proteins affected the nucleus formation and the crystal formation of HA. It is considered that the unevenness of the accumulated deposits existing on the surface of tooth enamel having no gloss causes the decrease in gloss of teeth due to diffuse reflection of light.

Enhanced protective role in materials with gradient structural orientations: Lessons from Nature

Living organisms are adept at resisting contact deformation and damage by assembling protective surfaces with spatially varied mechanical properties, i.e., by creating functionally graded materials. Such gradients, together with multiple length-scale hierarchical structures, represent the two prime characteristics of many biological materials to be translated into engineering design. Here, we examine one design motif from a variety of biological tissues and materials where site-specific mechanical properties are generated for enhanced protection by adopting gradients in structural orientation over multiple length-scales, without manipulation of composition or microstructural dimension. Quantitative correlations are established between the structural orientations and local mechanical properties, such as stiffness, strength and fracture resistance; based on such gradients, the underlying mechanisms for the enhanced protective role of these materials are clarified. Theoretical analysis is presented and corroborated through numerical simulations of the indentation behavior of composites with distinct orientations. The design strategy of such bioinspired gradients is outlined in terms of the geometry of constituents. This study may offer a feasible approach towards generating functionally graded mechanical properties in synthetic materials for improved contact damage resistance.

STATEMENT OF SIGNIFICANCE

Living organisms are adept at resisting contact damage by assembling protective surfaces with spatially varied mechanical properties, i.e., by creating functionally-graded materials. Such gradients, together with multiple length-scale hierarchical structures, represent the prime characteristics of many biological materials. Here, we examine one design motif from a variety of biological tissues where site-specific mechanical properties are generated for enhanced protection by adopting gradients in structural orientation at multiple length-scales, without changes in composition or microstructural dimension. The design strategy of such bioinspired gradients is outlined in terms of the geometry of constituents. This study may offer a feasible approach towards generating functionally-graded mechanical properties in synthetic materials for improved damage resistance.

Effects of coating materials on nanoindentation hardness of enamel and adjacent areas

OBJECTIVES

Materials that can be applied as thin coatings and actively release fluoride or other bioavailable ions for reinforcing dental hard tissue deserve further investigation. In this study we assessed the potential of resin coating materials in protection of underlying and adjacent enamel against demineralization challenge using nanoindentation.

METHODS

Enamel was coated using Giomer (PRG Barrier Coat, PBC), resin-modified glass-ionomer (Clinpro XT Varnish, CXT), two-step self-etch adhesive (Clearfil SE Protect, SEP) or no coating (control). After 5000 thermal cycles and one-week demineralization challenge, Martens hardness of enamel beneath the coating, uncoated area and intermediate areas was measured using a Berkovich tip under 2mN load up to 200μm depth. Integrated hardness and 10-μm surface zone hardness were compared among groups.

RESULTS

Nanoindentation and scanning electron microscopy suggested that all materials effectively prevented demineralization in coated area. Uncoated areas presented different hardness trends; PBC showed a remarkable peak at the surface zone before reaching as low as the control, while CXT showed relatively high hardness values at all depths.

SIGNIFICANCE

Ion-release from coating materials affects different layers of enamel. Coatings with fluoride-releasing glass fillers contributed to reinforcement of adjacent enamel. Surface prereacted glass filler-containing PBC superficially protected neighboring enamel against demineralization, while resin-modified glass-ionomer with calcium (CXT) improved in-depth protection. Cross-sectional hardness mapping of enamel on a wide range of locations revealed minute differences in its structure.

Noninvasive Assessment of Early Dental Lesion Using a Dual-Contrast Photoacoustic Tomography

Dental hard tissue lesions, including caries, cracked-tooth, etc., are the most prevalent diseases of people worldwide. Dental lesions and correlative diseases greatly decrease the life quality of patients throughout their lifetime. It is still hard to noninvasively detect these dental lesions in their early stages. Photoacoustic imaging is an emerging hybrid technology combining the high spatial resolution of ultrasound in deep tissue with the rich optical contrasts. In this study, a dual-contrast photoacoustic tomography is applied to detect the early dental lesions. One contrast, named B-mode, is related to the optical absorption. It is good at providing the sharp image about the morphological and macro-structural features of the teeth. Another contrast, named S-mode, is associated with the micro-structural and mechanical properties of the hard tissue. It is sensitive to the change of tissue properties induced by the early dental lesions. Experiments show that the comprehensive analysis of dual-contrast information can provide reliable information of the early dental lesions. Moreover, the imaging parameter of S-mode is device-independent and it could measure tissue properties quantitatively. We expect that the proposed scheme could be beneficial for improving safety, accuracy and sensitivity of the clinical diagnosis of the dental lesion.

Noninvasive Assessment of Early Dental Lesion Using a Dual-Contrast Photoacoustic Tomography

Dental hard tissue lesions, including caries, cracked-tooth, etc., are the most prevalent diseases of people worldwide. Dental lesions and correlative diseases greatly decrease the life quality of patients throughout their lifetime. It is still hard to noninvasively detect these dental lesions in their early stages. Photoacoustic imaging is an emerging hybrid technology combining the high spatial resolution of ultrasound in deep tissue with the rich optical contrasts. In this study, a dual-contrast photoacoustic tomography is applied to detect the early dental lesions. One contrast, named B-mode, is related to the optical absorption. It is good at providing the sharp image about the morphological and macro-structural features of the teeth. Another contrast, named S-mode, is associated with the micro-structural and mechanical properties of the hard tissue. It is sensitive to the change of tissue properties induced by the early dental lesions. Experiments show that the comprehensive analysis of dual-contrast information can provide reliable information of the early dental lesions. Moreover, the imaging parameter of S-mode is device-independent and it could measure tissue properties quantitatively. We expect that the proposed scheme could be beneficial for improving safety, accuracy and sensitivity of the clinical diagnosis of the dental lesion.

The effect of enamel proteins on erosion

Enamel proteins form a scaffold for growing hydroxyapatite crystals during enamel formation. They are then almost completely degraded during enamel maturation, resulting in a protein content of only 1% (w/v) in mature enamel. Nevertheless, this small amount of remaining proteins has important effects on the mechanical and structural properties of enamel and on the electrostatic properties of its surface. To analyze how enamel proteins affect tooth erosion, human enamel specimens were deproteinated. Surface microhardness (SMH), surface reflection intensity (SRI) and calcium release of both deproteinated and control specimens were monitored while continuously eroding them. The deproteination itself already reduced the initial SMH and SRI of the enamel significantly (p < 0.001 and p < 0.01). During the course of erosion, the progression of all three evaluated parameters differed significantly between the two groups (p < 0.001 for each). The deproteinated enamel lost its SMH and SRI faster, and released more calcium than the control group, but these differences were only significant at later stages of erosion, where not only surface softening but surface loss can be observed. We conclude that enamel proteins have a significant effect on erosion, protecting the enamel and slowing down the progression of erosion when irreversible surface loss starts to occur.

Amelogenin and Enamel Biomimetics

Mature tooth enamel is acellular and does not regenerate itself. Developing technologies that rebuild tooth enamel and preserve tooth structure is therefore of great interest. Considering the importance of amelogenin protein in dental enamel formation, its ability to control apatite mineralization in vitro, and its potential to be applied in fabrication of future bio-inspired dental material this review focuses on two major subjects: amelogenin and enamel biomimetics. We review the most recent findings on amelogenin secondary and tertiary structural properties with a focus on its interactions with different targets including other enamel proteins, apatite mineral, and phospholipids. Following a brief overview of enamel hierarchical structure and its mechanical properties we will present the state-of-the-art strategies in the biomimetic reconstruction of human enamel.

XRMA and ToF-SIMS Analysis of Normal and Hypomineralized Enamel

Molar incisor hypomineralization (MIH) is a developmental disturbance of the enamel. This study presents analyses of hypomineralized and normal enamel in first molar teeth diagnosed with MIH, utilizing time-of-flight secondary ion mass spectrometry area analyses and X-ray microanalysis of area and spot profiles in uncoated samples between gold lines which provide electrical conductivity. Statistical analysis of mean values allows discrimination of normal from MIH enamel, which has higher Mg and lower Na and P. Inductive analysis using complete data sets for profiles from the enamel surface to the enamel-dentin junction found that Mg, Cl and position in the profile provide useful discrimination criteria. Element profiles provide a visual complement to the inductive analysis and several elements also provide insight into the development of both normal and MIH enamel. The higher Mg content and different Cl profiles of hypomineralized enamel compared with normal enamel are probably related to a relatively short period during the development of ameloblasts between birth and the 1st year of life.

Uniaxial compressive behavior of micro-pillars of dental enamel characterized in multiple directions

In this work, the compressive elastic modulus and failure strength values of bovine enamel at the first hierarchical level formed by hydroxyapatite (HA) nanofibers and organic matter are identified in longitudinal, transverse and oblique direction with the uniaxial micro-compression method. The elastic modulus values (∼70 GPa) measured here are within the range of results reported in the literature but these values were found surprisingly uniform in all orientations as opposed to the previous nanoindentation findings revealing anisotropic elastic properties in enamel. Failure strengths were recorded up to ∼1.7 GPa and different failure modes (such as shear, microbuckling, fiber fracture) governed by the orientation of the HA nanofibers were visualized. Structural irregularities leading to mineral contacts between the nanofibers are postulated as the main reason for the high compressive strength and direction-independent elastic behavior on enamels first hierarchical level.

Influence of structural hierarchy on the fracture behaviour of tooth enamel

Tooth enamel has the critical role of enabling the mastication of food and also of protecting the underlying vital dentin and pulp structure. Unlike most vital tissue, enamel has no ability to repair or remodel and as such has had to develop robust damage tolerance to withstand contact fatigue events throughout the lifetime of a species. To achieve such behaviour, enamel has evolved a complex hierarchical structure that varies slightly between different species. The major component of enamel is apatite in the form of crystallite fibres with a nanometre-sized diameter that extend from the dentin-enamel junction to the oral surface. These crystallites are bound together by proteins and peptides into a range of hierarchical structures from micrometre diameter prisms to 50-100 μm diameter bundles of prisms known as Hunter-Schreger bands. As a consequence of such complex structural organization, the damage tolerance of enamel increases through various toughening mechanisms in the hierarchy but at the expense of fracture strength. This review critically evaluates the role of hierarchy on the development of the R-curve and the stress-strain behaviour. It attempts to identify and quantify the multiple mechanisms responsible for this behaviour as well as their impact on damage tolerance.

Amelogenin and enamel biomimetics

Mature tooth enamel is acellular and does not regenerate itself.

Review of research on the mechanical properties of the human tooth

‘Bronze teeth' reflect the mechanical properties of natural teeth to a certain extent. Their mechanical properties resemble those of a tough metal, and the gradient of these properties lies in the direction from outside to inside. These attributes confer human teeth with effective mastication ability. Understanding the various mechanical properties of human teeth and dental materials is the basis for the development of restorative materials. In this study, the elastic properties, dynamic mechanical properties (visco-elasticity) and fracture mechanical properties of enamel and dentin were reviewed to provide a more thorough understanding of the mechanical properties of human teeth.

Finite element analysis of depth effect on measuring elastic modulus of a core-shell structure for application of instrumented indentation in tooth enamel

Tooth enamel is a complex structure, consisting of numerous enamel rods surrounded by a protein-rich sheath. Considering the possible effect of the protein-rich sheath on the indentation deformation of an enamel rod and the limitation of the Oliver-Pharr method in measuring the elastic modulus of the enamel rod, we used a finite element method to analyze the indentation deformation of an elastic-perfectly plastic cylinder surrounded by an elastic-perfectly plastic film. A concept of the threshold indentation depth was proposed, at which the percentage error of the measured modulus of the cylinder is ±10%. For the indentation depth less than the threshold indentation depth, the elastic modulus measured from the indentation test can be approximated as the intrinsic elastic modulus of the cylinder. The normalized threshold indentation depth strongly depends on the modulus ratio of the film to the cylinder and the ratio of the film thickness to the cylinder radius. The results can be used to guide the use of the Oliver-Pharr method in characterizing the mechanical properties of tooth enamel and bio-composites with core-shell structures.

Mechanical Properties of Enamel Nanocomposite

For adult Indian premolar teeth, we report for the first time ever the simultaneous evaluations of nanohardness, Young's modulus, and fracture toughness of the enamel nanocomposite. The nanohardness and Young's moduli were evaluated from near the beginning of the middle enamel region to within ~10 μm of the dentino-enamel junction (DEJ) and in the dentin region using the nanoindentation technique. The fracture toughness from near the middle of the enamel region to near the DEJ zone was measured using the microindentation technique. The deformation was studied using scanning electron microscopy (SEM) and field emission scanning electron microscopy (FESEM). The relative differences in the extents of biomineralization in the enamel and dentin regions were studied by the energy dispersive X-ray (EDS) technique. The variations of the toughness of the enamel as a function of the toughness of the protein matrix phase have been analyzed which showed that the predicted value of the toughness of the protein present in the nanocomposite was comparable to that of other bioproteins reported in the literature. Further, the work of fracture estimated from the measured value of toughness of the enamel nanocomposite agreed well with the experimental data reported in the literature.

Role of crystal arrangement on the mechanical performance of enamel

The superior mechanical properties of enamel, such as excellent penetration and crack resistance, are believed to be related to the unique microscopic structure. In this study, the effects of hydroxyapatite (HAP) crystallite orientation on the mechanical behavior of enamel have been investigated through a series of multiscale numerical simulations. A micromechanical model, which considers the HAP crystal arrangement in enamel prisms, the hierarchical structure of HAP crystals and the inelastic mechanical behavior of protein, has been developed. Numerical simulations revealed that, under compressive loading, plastic deformation progression took place in enamel prisms, which is responsible for the experimentally observed post-yield strain hardening. By comparing the mechanical responses for the uniform and non-uniform arrangement of HAP crystals within enamel prisms, it was found that the stiffness for the two cases was identical, while much greater energy dissipation was observed in the enamel with the non-uniform arrangement. Based on these results, we propose an important mechanism whereby the non-uniform arrangement of crystals in enamel rods enhances energy dissipation while maintaining sufficient stiffness to promote fracture toughness, mitigation of fracture and resistance to penetration deformation. Further simulations indicated that the non-uniform arrangement of the HAP crystals is a key factor responsible for the unique mechanical behavior of enamel, while the change in the nanostructure of nanocomposites could dictate the Young's modulus and yield strength of the biocomposite.

Identification of a protein-containing enamel matrix layer which bridges with the dentine-enamel junction of adult human teeth

OBJECTIVE

To investigate the ultrastructure and chemical composition of the dentine-enamel junction and adjacent enamel of minimally processed third molar tooth sections.

DESIGN

Undecalcified human third molar erupted teeth were sectioned and etched with 4% EDTA or 37% phosphoric acid prior to visualization by scanning electron microscopy. Confocal Raman spectroscopy was carried out at 50 μm and more than 400 μm away from the dentine-enamel junction before and after mild etching.

RESULTS

A novel organic protein-containing enamel matrix layer was identified for the first time using scanning electron microscopy of etched bucco-lingual sections of crowns. This layer resembles a three-dimensional fibrous meshwork that is visually distinct from enamel "tufts". Previous studies have generally used harsher solvent conditions which likely removed this layer and precluded its prior characterization. The shape of the organic enamel layer generally reflected that of sheath regions of enamel rods and extended from the dentine-enamel junction about 100-400 μm into the cuspal enamel. This layer exhibited a Raman CH stretching peak at ∼2931 cm(-1) characteristic of proteins and this signal correlated directly with the presence and location of the matrix layer as identified by scanning electron microscopy.

CONCLUSIONS

The enamel protein layer was most prominent close to the dentine-enamel junction and was largely absent in cuspal enamel >400 μm away from the dentine enamel junction. We hypothesize that this protein containing matrix layer could provide an important biomechanical linkage between the enamel and the dentine-enamel junction and by extension, with the dentine, of the adult tooth (246 words).

The role of property gradients on the mechanical behavior of human enamel

In this study, the mechanical design principles of human enamel were evaluated using a hybrid experimental and computational approach. Nanoindentation was applied to evaluate the load-depth response of human enamel, and Vickers indentations were used to assess the damage behavior. An elastic-plastic numerical model was then developed to analyze the stress and strain distribution about the indentations, and to characterize energy dissipation about indents in three locations including inner, middle and outer enamel. Results confirm that enamel exhibits a gradient in its mechanical behavior. Outer enamel has a limited potential for energy dissipation by inelastic deformation, indicating that the ability of outer enamel to resist fracture is low. While inner enamel, the region close Dentin Enamel Junction (DEJ), possesses less resistance to penetration deformation, it has a much higher capacity to dissipate energy by inelastic deformation than outer enamel. The computational simulations identified that the gradients in mechanical properties of human enamel promote resistance to penetration, energy dissipation and mitigation of fracture, all critical performance requirements of human teeth.

Ceramic-like wear behaviour of human dental enamel

This paper reports a transmission electron microscopy (TEM) analysis of subsurfaces of enamel specimens following in vitro reciprocating wear tests with an enamel cusp sliding on a flat enamel specimen under hydrated conditions. The obtained results show that crack formation occurred in the wear scar subsurface. The path followed by these cracks seems to be dictated either by the histological structure of enamel or by the contact stress field. Moreover, the analysis of a set of enamel wear results obtained from the literature and application of fracture-based models, originally developed for ceramics, correlate well, confirming the similar wear processes taking place in these materials. This analysis also reveals a marked influence of coefficient of friction on the enamel wear rate: for a higher coefficient of friction value, enamel wear can be severe even under forces generated during normal operation of teeth.

Increase in severity of molar-incisor hypomineralization and its relationship with the colour of enamel opacity: a prospective cohort study

BACKGROUND

Predicting risk of posteruptive enamel breakdown (PEB) of molar-incisor hypomineralization (MIH) opacity is a difficult but important clinical task. Therefore, there is a need to evaluate these aspects through longitudinal studies.

OBJECTIVE

The aim of this longitudinal study was to analyse the relationship between colours of MIH opacity of children aged 6-12 (baseline) and other clinical and demographic variables involved in the increase in severity of MIH.

MATERIALS AND METHODS

A blinded prospective 18-month follow-up was conducted with 147 individuals presenting mild MIH. Tooth-based incidence of increase in severity of MIH (PEB or atypical restorations) was used as dependent measurement. Enamel opacities were recorded according to colour shades of white, yellow and brown, allowing assessment of susceptibility to structural loss over time, according to colour of MIH opacity. Poisson regression models were used to adjust the results for demographic and clinical variables.

RESULTS

Brown and yellow MIH opacities were at higher risk for PEB and atypical restorations than those of white ones, even after adjustment for clinical and demographic variables.

CONCLUSION

Teeth presenting mild MIH severity associated with yellow and brown enamel opacities were at high risk for increase in severity of MIH than lighter ones. This result could help clinicians determine a risk-based treatment for children with MIH.