On the Mechanics of Fatigue and Fracture in Teeth

Characterizing the microstructures of mammalian enamel by synchrotron phase contrast microCT

The enamel of mammalian teeth is a highly mineralized tissue that must endure a lifetime of cyclic contact and is inspiring the development of next-generation engineering materials. Attempts to implement enamel-inspired structures in synthetic materials have had limited success, largely due to the absence of a detailed understanding of its microstructure. The present work used synchrotron phase-contrast microCT imaging to evaluate the three-dimensional microstructure of enamel from four mammals including Lion, Gray Wolf, Snow Leopard, and Black Bear. Quantitative results of image analysis revealed that the decussation pattern of enamel consists of discrete diazone (D) and parazone (P) bands of rods organized with stacking arrangement of D+/P/D-/P in all mammals evaluated; the D+ and D- refer to distinct diazone bands with juxtaposed rod orientations from the reference plane. Furthermore, the rod orientations in the bands can be described in terms of two principal angles, defined here as the pitch and yaw. While the pitch angle increases from the outer enamel to a maximum (up to ≈ 40°) near the dentin enamel junction, minimal spatial variations are observed in yaw across the enamel thickness. There are clear differences in the decussation parameters of enamel across species that are interpreted here with respect to the structural demands placed on their teeth. The rod pitch and band width of enamel are identified as important design parameters and appear to be correlated with the bite force quotient of the four mammals evaluated. STATEMENT OF SIGNIFICANCE: The multi-functionality of tooth enamel requires both hardness and resistance to fracture, properties that are generally mutually exclusive. Ubiquitous to all mammalian teeth, the enamel is expected to have undergone adaptations in microstructure to accommodate the differences in diet, body size and bite force across animals. For the first time, we compare the complex three-dimensional microstructure of enamel from teeth of multiple mammalian species using synchrotron micro-computed tomography. The findings provide new understanding of the "design" of mammalian enamel microstructures, as well as how specific parameters associated with the decussation of rods appear to be engineered to modulate its fracture resistance.

A New Landscape of Human Dental Aging: Causes, Consequences, and Intervention Avenues

Aging is accompanied by physical dysfunction and physiologic degeneration that occurs over an individual's lifetime. Human teeth, like many other organs, inevitably undergo chronological aging and age-related changes throughout the lifespan, resulting in a substantial need for preventive, restorative as well as periodontal dental care. This is particularly the case for seniors at 65 years of age and those older but economically disadvantaged. Dental aging not only interferes with normal chewing and digestion, but also affects daily appearance and interpersonal communications. Further dental aging can incur the case of multiple disorders such as oral cancer, encephalitis, and other systemic diseases. In the next decades or even hundreds of years, the proportion of the elderly in the global population will continue to rise, a tendency that attracts increasing attention across multiple scientific and medical disciplines. Dental aging will bring a variety of problems to the elderly themselves and poses serious challenges to the medical profession and social system. A reduced, but functional dentition comprising 20 teeth in occlusion has been proposed as a measurement index of successful dental aging. Healthy dental aging is critical to healthy aging, from both medical and social perspectives. To date, biomedical research on the causes, processes and regulatory mechanisms of dental aging is still in its infancy. In this article, updated insights into typical manifestations, associated pathologies, preventive strategies and molecular changes of dental aging are provided, with future research directions largely projected.

Exploring the influence of placing bi-directional E-glass fibers as protective layer under a CAD-CAM resin composite on the fracture pattern

OBJECTIVES

To investigate the influence of the presence and position of bidirectional E-glass fibers under a CAD-CAM resin composite on the fracture pattern evaluated both after quasi-static mechanical loading and after fatigue.

METHODS

Rectangular specimens (10 mm-long, 5 mm-large and 4.2 mm-thick) were prepared and divided into four groups (n = 30/group). The control group (C-Group) consisted of a 4.2 mm-thick layer of monolithic CAD/CAM resin composite resin (Cerasmart, GC). In the 3 other groups including the placement of a fiber layer (F-Groups), the CAD/CAM resin composite layer was reduced to 3-, 2- and 1-mm thickness (F3-, F2- and F1-Groups, respectively). Two bonded layers of bidirectional E-glass FRC (Dentapreg, ADM A.S.) were bonded underneath and a light-curable resin composite base (Gaenial Posterior, GC) was then added to reach a total thickness of 4.2 mm for all samples. In each group, half of the specimens (n = 15) were submitted to quasi-static mechanical loading to failure in a universal testing machine. The other half (n = 15) was subjected to cyclic isometric stepwise loading until failure or completion of 105000 cycles (5000 cycles at 500 N, followed by five stages of 20000 cycles at 750 N, 1000 N, 1250 N, 1500 N, and 1750 N). The data were analyzed by Weibull statistics for quasi-static loading, and by the Kaplan-Meier product limit estimation procedure after fatigue. All fractured specimens were studied using light and electron microscopy techniques, and the types of fracture were determined.

RESULTS

For quasi-static mechanical loading, significant differences were observed for Weibull modulus and characteristic strength between groups, with values ranging from 10.8 to 22.4 for the former and from 2336.6 to 2974.7 for the latter. Also, survival after stepwise fatigue revealed statistically significant differences between groups (p < 0.05), the lowest values of cycles before failure being observed for F1-Group - Median = 61223 (50415; 65446) - as compared to the other groups - C-Group: Median = 89005 (86189; 98195); F3-Group: Median = 85198 (77279; 87860); F2-Group: Median = 89306 (87454; 97024). Both in quasi-static loading and after fatigue, the observation of fracture modes revealed major differences. While all fractures were vertical (split) in C-Group, the majority of the specimens in F-Groups presented some degree of horizontal deflection of the crack. In all deviated fractures, fractographic analysis confirmed a toughening effect of the fiber layer.

SIGNIFICANCE

The present in vitro work tends to show that the fracture pattern of CAD-CAM resin composites is favorably affected by the presence and position of an underlying bidirectional E-glass fiber layer. The placement of E-glass fibers under a CAD-CAM resin composite may therefore represent an interesting strategy to reduce the risk of catastrophic restoration failure, which could be integrated in the development of the new generation of indirect materials, possibly in 3D-printing approaches.

Effect of Tooth Bleach on Dentin Fatigue Resistance in Situ

BACKGROUND

Negative effects of bleaching on dentin have previously been reported in vitro.

OBJECTIVE

The purpose of this study was to determine the effect of carbamide peroxide bleaching on dentin fatigue resistance using a clinically relevant in situ model.

METHODS AND MATERIALS

Following research ethics board approval, 60 human teeth requiring extraction were collected. Sterilized human dentin specimens were cut (1.2x1.2x10 mm) and secured into customized bleaching trays to be used by study participants. Participants were randomly assigned to either bleach (10% carbamide peroxide, n=23) or control (gel without bleach, n=26) treatment groups. Treatment was applied to the bleaching trays and worn overnight by participants for 14 days. After treatment completion, dentin specimens were removed from the bleaching trays and subjected to fatigue testing (10 N, 3 mm/s, 2x105 cycles) while submerged in artificial saliva. Kaplan-Meier survival analysis was conducted to compare the number of cycles to failure during fatigue testing in both groups. A log rank test was run to determine if there were differences in the survival distribution between the two groups (α<0.05).

RESULTS

The median number of cycles to failure was 352 ± 202 and 760 ± 644 for the bleach and control groups, respectively. The survival distributions for the two groups were significantly different (p=0.020). Dentin fatigue resistance was significantly lower in the bleach group compared to the control.

CONCLUSIONS

Direct bleaching of human dentin using an at-home tray bleaching protocol in situ reduced dentin fatigue resistance. This has implications for tooth fracture risk and longevity.

Phase transformation and mechanical properties of new bioactive glass-ceramics derived from CaO-P2O5-Na2O-B2O3-SiO2 glass system

This work investigates the role of sintering temperature on bioactive glass-ceramics derived from the new composition CaO-P2O5-Na2O-B2O3-SiO2 glass system. The sintering behaviour of the samples' physical, structural, and mechanical properties is highlighted in this study. The experimental results indicated that the sintering process improved the crystallization and hardness of the final product. Results from XRD and FTIR showed the existence of carbonate apatite, pseudo-wollastonite, and wollastonite phases. From the results, the bioglass-ceramics sintered at 700 °C obtained the highest densification and optimum mechanical results. It had the value of 5.34 ± 0.21 GPa regarding microhardness and 2.99 ± 0.24 MPa m1/2 concerning fracture toughness, which falls in the range of the human enamel. Also, the sintered samples maintained their bioactivity and biodegradability after being tested in the PBS medium. The bioactivity does not affect but slows down the apatite formation rate. Overall results promoted the novel bioglass-ceramics as a candidate material for dental application.

In silico fatigue performance of molars restored with full crowns under alternating cyclic loadings

OBJECTIVE

In this study, a preclinical approach was used to analyze and directly compare the fatigue performance (fatigue life and damage percentage) and maximum principal stresses (Max. Ps) of prepared models treated with different materials and geometric parameters.

METHODS

Four groups of preparative parameters (crown width, crown length, degree of polymerization and material) were selected, each with five variables. An alternating cyclic occlusal load with an amplitude of 300 N was applied to the ball part along the longitudinal axis. The fatigue properties of the preparations and Max.Ps were analyzed.

RESULTS

A shoulder width of 0.8 mm, a shoulder height offset of 0.2 mm, a degree of polymerization of 5°, and a crown material of ZC resulted in the smallest percentage of damage. In contrast, the effect of different modulus of elasticity (MOE) on Max.Ps was not significant (p = 0.609).

CONCLUSION

The results suggest that the selection of larger modulus of elasticity MOE and larger Poisson's ratio material's, preparation of larger shoulder widths within safety, reasonable increase in crown length, and selection of larger degree of polymerization are favorable methods to protect the preparation.

Biomechanical perspectives on dentine cracks and fractures: Implications in their clinical management

OBJECTIVES

The present review discussed the biomechanical properties of cracks and fractures in crown and root dentine and attempted to explain why cracked teeth and vertical root fractures are so frequent despite the existence of multiple crack toughening mechanisms in dentine. The implications of this knowledge were used to justify how these defects are managed clinically.

DATA, SOURCES AND STUDY SELECTION

Literature search was conducted on PubMed, Web of Science, and Scopus for a narrative review on fracture mechanics of crown and root dentine as well as the clinical management of cracked teeth and teeth with vertical root fracture.

CONCLUSIONS

Although dentine is tougher and less brittle than enamel, it's facture toughness is considerably lower than most ductile metals. Because the initiation toughness of dentine is very low, cracks initiate from incipient damage under low stress While crack toughening mechanisms exist that enable dentine to resist crack extension, these mechanisms are often inadequate for protecting dentine from crack propagation that ultimately leads to catastrophic failure. Additional factors such as ageing also reduces the resistance of dentine to crack growth. Because dentine cracks are eventually filled with bacteria biofilms upon exposure to oral fluids, they enable rapid bacteria ingress into the dental pulp via open dentinal tubules. To date, treatment options for cracked teeth are limited. While most teeth with vertical root fracture are recommended for extraction, new strategies have been reported that appeared to achieve short-term success in preserving these teeth.

CLINICAL SIGNIFICANCE

Current strategies for the management for dentine cracks and fractures are limited and their long-term effectiveness remain uncertain. Understanding the characteristics, toughening mechanism and weakening factors of tooth cracks is helpful in designing better treatment.

Fatigue and wear of human tooth enamel: A review

Human tooth enamel must withstand the cyclic contact forces, wear, and corrosion processes involved with typical oral functions. Furthermore, unlike other human tissues, dental enamel does not have a significant capacity for healing or self-repair and thus the longevity of natural teeth in the oral environment depends to a large degree on the fatigue and wear properties of enamel. The purpose of this review is to provide an overview of our understanding of the fatigue and wear mechanisms of human enamel and how they relate to in vivo observations of tooth damage in the complex oral environment. A key finding of this review is that fatigue and wear processes are closely related. For example, the presence of abrasive wear particles significantly lowers the forces needed to initiate contact fatigue cracking while subsurface fatigue crack propagation drives key delamination wear mechanisms during attrition or attrition-corrosion of enamel. Furthermore, this review seeks to bring a materials science and mechanical engineering perspective to fatigue and wear phenomena. In this regard, we see developing a mechanistic description of fatigue and wear, and understanding the interconnectivity of the processes, as essential for successfully modelling enamel fatigue and wear damage and developing strategies and treatments to improve the longevity of our natural teeth. Furthermore, we anticipate that this review will stimulate ideas for extending the lifetime of the natural tooth structure and will help highlight where our understanding is too limited and where additional research into fatigue and wear of human tooth enamel is warranted.

Biomechanical Modelling for Tooth Survival Studies: Mechanical Properties, Loads and Boundary Conditions-A Narrative Review

Recent biomechanical studies have focused on studying the response of teeth before and after different treatments under functional and parafunctional loads. These studies often involve experimental and/or finite element analysis (FEA). Current loading and boundary conditions may not entirely represent the real condition of the tooth in clinical situations. The importance of homogenizing both sample characterization and boundary conditions definition for future dental biomechanical studies is highlighted. The mechanical properties of dental structural tissues are presented, along with the effect of functional and parafunctional loads and other environmental and biological parameters that may influence tooth survival. A range of values for Young's modulus, Poisson ratio, compressive strength, threshold stress intensity factor and fracture toughness are provided for enamel and dentin; as well as Young's modulus and Poisson ratio for the PDL, trabecular and cortical bone. Angles, loading magnitude and frequency are provided for functional and parafunctional loads. The environmental and physiological conditions (age, gender, tooth, humidity, etc.), that may influence tooth survival are also discussed. Oversimplifications of biomechanical models could end up in results that divert from the natural behavior of teeth. Experimental validation models with close-to-reality boundary conditions should be developed to compare the validity of simplified models.

Interlocking design, programmable laser manufacturing and testing for architectured ceramics

Tough and impact-resistant ceramic systems offer a wide range of remarkable opportunities beyond those offered by the conventional brittle ceramics. However, despite their promise, the availability of traditional manufacturing technique for fabricating such advanced ceramic structures in a highly controllable and scalable manner poses a significant manufacturing bottleneck. In this study, a precise and programmable laser manufacturing system was used to manufacture topologically interlocking ceramics. This manufacturing strategy offers feasible mechanisms for a precise material architecture and quantitative process control, particularly when scalability is considered. An optimized material removal method that approaches near-net shaping was employed to fabricate topologically interlocking ceramic systems (load-carrying assemblies of building blocks interacting by contact and friction) with different architectures (i.e., interlocking angles and building block sizes) subjected to low-velocity impact conditions. These impacts were evaluated using 3D digital image correlation. The optimal interlocked ceramics exhibited a higher deformation (up to 310%) than the other interlocked ones advantageous for flexible protections. Their performance was tuned by controlling the interlocking angle and block size, adjusting the frictional sliding, and minimizing damage to the building blocks. In addition, the developed subtractive manufacturing technique leads to the fabrication of tough, impact-resistant, damage-tolerant ceramic systems with excellent versatility and scalability.

Black Drum Fish Teeth: Built for Crushing Mollusk Shells

With an exclusive diet of hard-shelled mollusks, the black drum fish (Pogonias cromis) exhibits one of the highest bite forces among extant animals. Here we present a systematic microstructural, chemical, crystallographic, and mechanical analysis of the black drum teeth to understand the structural basis for achieving the molluscivorous requirements. At the material level, the outermost enameloid shows higher modulus (E_r = 126.9 ± 16.3 GPa, H = 5.0 ± 1.4 GPa) than other reported fish teeth, which is attributed to the stiffening effect of Zn and F doping in apatite crystals and the preferential co-alignment of crystallographic c-axes and enameloid rods along the biting direction. The high fracture toughness (K_c = 1.12 MPa⋅m^1/2) of the outer enameloid also promotes local yielding instead of fracture during crushing contact with mollusk shells. At the individual-tooth scale, the molar-like teeth, high density of dentin tubules, enlarged pulp chamber, and specialized dentin-bone connection, all contribute to the functional requirements, including confinement of contact compressive stress in the stiff enameloid, enhanced energy absorption in the compliant dentin, and controlled failure of tooth-bone composite under excessive loads. These results show that the multi-scale structures of black drum teeth are adapted to feed on hard-shelled mollusks. STATEMENT OF SIGNIFICANCE: The black drum fish feeds on hard-shelled mollusks, which requires strong, tough, and wear-resistant teeth. This study presents a comprehensive multiscale material and mechanical analysis of the black drum teeth in achieving such remarkable biological function. At microscale, the fluoride- and zinc-doped apatite crystallites in the outer enameloid region are aligned perpendicular to the chewing surface, representing one of the stiffest biomineralized materials found in nature. In the inner enameloid region, the apatite crystals are arranged into intertwisted rods with crystallographic misorientation for increased crack resistance and toughness. At the macroscale, the molariform geometry, the two-layer design based on the outer enameloid and inner dentin, enlarged pulp chamber and the underlying strong bony toothplate work synergistically to contribute to the teeth's crushing resistance.

Fatigue analysis of restored teeth longitudinally cracked under cyclic loading

OBJECTIVE

To investigate the fatigue behavior of restored teeth, in particular the mechanisms of longitudinal dentinal cracking under cyclic mechanical loading, using finite element analysis (FEA) and the stress-life (S-N) approach.

METHODS

Ten root-filled premolars restored with resin composites were subjected to step-stress cyclic loading to produce longitudinal cracks. Fracture loads and number of cycles completed at each load level were recorded. FEA was used to predict the stress amplitude of each component under the global cyclic load. Both intact and debonded conditions were considered for the dentin-composite interface in the FEA. The predicted stress concentrations were compared with the fracture patterns to help elucidate the failure mechanisms. The S-N approach was further used to predict the lifetimes of the different components in the restored teeth. Cumulative fatigue damage was represented by the sum of the fractions of life spent under the different stress amplitudes.

RESULTS

Longitudinal cracks were seen in ~50% of the samples with a mean fracture load of 770 ± 45 N and a mean number of cycles to failure of 32,297 ± 12,624. The longitudinal dentinal cracks seemed to start near the line angle of the cavity, and propagated longitudinally towards the root. The sum of fractions of life spent for the dentin-composite interface exceeded 1 after ~7000 cycles when that for dentin was much lower than 1, indicating that interfacial debonding would occur prior to dentin fracture. This was supported by micro-CT images showing widened interfacial space in the cracked samples. In the debonded tooth, FEA showed dentinal stress concentrations at the gingival wall of the cavity, which coincided with the longitudinal cracks found in the cyclic loading test. The sum of fractions of life spent for dentin was close to 1 at ~30,000 cycles, similar to the experimental value.

SIGNIFICANCE

Debonding of the dentin-composite interface may occur prior to longitudinal cracking of dentin in root-filled teeth under cyclic loading. The approximate time of occurrence for these events could be estimated using fatigue analysis with stresses provided by FEA. This methodology can therefore be used to evaluate the longevity of restoration designs for root-filled teeth.

Mechanical failure of posterior teeth due to caries and occlusal wear- A modelling study

OBJECTIVES

The purpose of the present work is to explore the effect of occlusal wear and different types and degrees of caries on the mechanical performance and structural integrity of posterior teeth.

METHODS

Three-dimensional (3D) computational models with different combinations of caries parameters (caries location, caries size and caries induced pulp shrinkage) and occlusal wear factors (enamel thickness, marginal ridge height and cuspal slope) were developed and analyzed using the extended finite element method (XFEM) to identify the stress distribution, crack initiation load and ultimate fracture load values. The effect of a non-drilling conservative treatment using resin infiltration on the recovery of mechanical properties of carious molar teeth was also investigated.

RESULTS

Presence of fissural caries, worn proximal marginal ridge and decreased enamel thickness due to occlusal wear, imparted a significant negative effect on the crack initiation load value of the lower molar models. Accordingly, models with intact and strong proximal marginal ridge, generally exhibited higher crack initiation loading, regardless of caries size and location. Presence of fissure caries drastically decreased (55%-70%) the crack initiation load compared to sound teeth. The depth of the fissural lesion and the presence of proximal caries did not have a major effect on crack initiation load values. However, increasing the caries size resulted in lower final fracture load values in most of the cases. Accordingly, the groups with combined and connected large fissural and proximal lesions experienced the largest drop in the fracture load values compared to sound tooth models. The worst condition consisted of two connected large proximal and fissural caries with no proximal marginal ridge, in which the fracture load dramatically decreased to only 25% of that for sound teeth with intact marginal ridge. On the other hand, decreased cuspal slope due to occlusal wear and shrinkage of the pulp due to caries appeared to have a protective role and a direct relation with the fracture resistance of the tooth. Following the application of resin infiltration on the carious models, the crack initiation load and the fracture load could recover up to 75% and 90% of the values for the corresponding sound tooth models, respectively.

SIGNIFICANCE

Presence of fissural caries, if not treated (either with remineralization, resin infiltration or restoration), can be a major risk factor in the initiation of tooth fracture. When combined with decreased enamel thickness and loss of proximal marginal ridge due to mechanical or chemical wear, the weakening effect of the caries will be amplified specially in teeth with steep cuspal slopes. The application of a conservative treatment with resin infiltration can be an effective approach in prevention of further mechanical failure of demineralized enamel. The findings of this study emphasize the importance of early interventions in the management of caries for the prevention of future cuspal or tooth fracture especially in subjects with higher risk factors for tooth fracture such as caries, wear and bruxism.

A scoping review of four decades of outcomes in non-surgical root canal treatment, non-surgical retreatment and apexification studies. Part 1: process and general results

BACKGROUND

Despite initiatives to standardize reports, variance in study design, outcomes assessed, and tools used are persistent in literature. This review scoped existing literature on endodontic outcome studies for future development of core outcome sets.

DESIGN

Comprehensive literature search of randomized controlled trials, cohort, case-control studies, or case series (≥10 patients), published after 1980, patients aged ≥10 years, and any preoperative pulpal and periapical diagnosis in permanent teeth requiring non-surgical root canal treatment (NS-RCT), retreatment (NS-ReTx), or apexification was performed. Abstracted data were reported through descriptive statistics.

RESULTS

Of 9,957 studies screened, 354 were included. An increase in the quantity of endodontic outcome publications and levels of evidence in their study design was noted over the past four decades. Although 41% of studies included participants aged 26-50, literature including participants aged >50 has increased since 2000. Apexification and NS-ReTx were mostly provided by specialists and postgraduate students. The most common follow-up period was 2-5 years (35%), and most randomized controlled trials (58%) reported follow-up times <1 year. Multiple visit treatment was most common in apexification studies (85%). Deficiency, inconsistency and ambiguity were observed across many reports.

CONCLUSIONS

NS-ReTx and NS-RCT/NS-ReTx studies have increased over the past two decades, particularly those focusing on molars and patients >50 years old. Despite the progress in endodontic research, heterogeneity in reporting styles yield considerable limitations, particularly data standardization challenges and inconsistencies in methods and results reporting. This scoping review highlighted the state of available research and supported the development of standardized guidelines for future investigations.

The effect of dental restoration geometry and material properties on biomechanical behaviour of a treated molar tooth: A 3D finite element analysis

OBJECTIVES

To test the hypothesis that restoration of class II mesio-occlusal-distal (MOD) cavities can be strengthened through judicious choice of restoration geometry and material properties.

METHODS

An intact extracted human maxillary molar tooth was digitized, segmented, reconstructed, and four 3D restored tooth models were developed with four different restoration geometries: one straight, one single-curved, and two double-curved. Stress analysis was conducted for representative loading using finite element analysis, and maximum principal stresses were determined at the dentine-enamel and restoration-enamel junctions. A range of restorative material elastic moduli (5-80 GPa) and Poisson's ratios (0.25-0.35) were studied. Vertical loads of 400 N were applied on occlusal points, while the roots of the molar teeth, below the crevices, were supported in all directions. All the materials were modelled as homogeneous, isotropic, and elastic.

RESULTS

The maximum principal stresses at the restoration-enamel junctions were strongly dependent on the MOD restoration geometries. Peak stresses occurred along the palatal surface of the restoration rather than the opposite buccal surface. Double-curved restorations showed the lowest peak stress at restoration-enamel junctions. Choice of the mechanical properties of restorative material in the range of 5-35 GPa further reduced stress concentrations on the enamel.

SIGNIFICANCE

Class II MOD restorations may be stronger if designed with double-curved marginal geometries that can reduce stress concentrations. Designs with convex and concave geometries were particularly effective because they reduced stress concentrations dramatically. Results suggest that relatively minor changes to the geometry of a restoration can have a substantial effect on stress at the restoration-enamel junction and motivate future experimental analysis.

A machine learning approach to investigate the materials science of enamel aging

Understanding aging of tooth tissues is critical to the development of patient-centric oral healthcare. Yet, the traditional methods for analyzing the composition-structure-property relationships of hard tissues have limitations when considering aging and other factors.

OBJECTIVE

To apply unsupervised machine learning tools to pursue an understanding of relationships between the composition and mechanical behavior of aging enamel.

METHODS

Molar teeth were collected from primary (age ≤ 8), young adult (24 ≤ age ≤ 46) and old adult (55 ≤ age) donors. The hardness and elastic modulus were quantified using nanoindentation as a function of distance from the Dentin Enamel Junction (DEJ) within the cervical, cuspal and inter-cuspal regions of the enamel crown. Similarly, a co-located analysis of the chemical composition and structure was performed using Raman spectroscopy. A Self-Organizing Maps (SOMs) algorithm was implemented to identify multi-dimensional composition-property relationships.

RESULTS

The hardness and elastic modulus are positively correlated to crystallinity and negatively correlated with carbonate substitution. Furthermore, the effects from fluoridation on the age-dependent properties of enamel is non-linear and depends on its location. The contributions of fluoridation to the enamel properties are different in the cervical and non-cervical regions and appear to be unique within primary and senior adult teeth.

SIGNIFICANCE

Based on the findings, unsupervised learning methods can reveal complicated non-linear structure-property relationships in tooth tissues and help to understand the materials science of aging and its consequences.

Fracture Resistance of Titanium and Fiber Dental Posts: A Systematic Review and Meta-Analysis

PURPOSE

The fracture resistance of dental post systems is influenced by the material of the post. The purpose of this systematic review and meta-analysis was to assess if there is a difference in fracture resistance between prefabricated dental titanium posts and fiber posts.

METHODS

An online electronic search was performed using the PubMed, Scopus, and Web of Science databases for in vitro studies published from 2010 to 2020 in English. The retrieved eligible studies that compared the fracture resistance of titanium and fiber posts on human teeth were selected. The pooled standardized mean difference (SMD) with a 95% confidence interval was calculated. In addition, the trial sequential analysis (TSA) was performed to test if the available studies are sufficient to make conclusive evidence.

RESULTS

Of the 1165 retrieved studies, 17 studies were included in the qualitative analysis, while 16 studies were included in the quantitative analysis. Because of the high heterogeneity among studies, data from 10 studies were pooled and submitted to TSA. A total of 852 teeth were evaluated for fracture of the posts in 27 independent comparison groups. The pooled effect of the residual studies revealed no significant difference between titanium and fiber posts (SMD = -0.12; 95% CI = -0.30, 0.06; p = 0.20). Results of the TSA revealed no conclusive evidence.

CONCLUSIONS

The results of the current evidence revealed no significant difference between fiber and titanium posts. The evidence is insufficient, and more standardized in vitro studies are required.

The influence of customization of glass fiber posts on fracture strength and failure pattern: A systematic review and meta-analysis of preclinical ex-vivo studies

OBJECTIVE

To perform a systematic review of the literature focused to evaluate in vitro function of prefabricated fiber posts with and without customization by additional auxillary fiber posts and composite resin on the fracture strength of wide or enlarged canals and the failure pattern.

METHODS

Six databases were used as primary search sources (PubMed, Scopus, LILACS, SciELO, Science Direct, and Web of Science) and three databases (Open Grey, Open Thesis, and OATD) were used to partially capture the "grey literature". The research included laboratory studies that used human upper anterior teeth aiming to assess the fracture strength and failure pattern of different glass fiber post customizations by additional auxiliary fiber posts or composite resin. The search had no restriction of year, language, and publication status. The risk of bias of the studies was assessed from the criteria established in systematic reviews of laboratory studies. Standardized mean differences were calculated by comparing the mean fracture strengths of customized and non-customized posts. Pooled estimates were calculated by Glass' delta method using the random-effects model. Subtotal estimates were presented according to each type of relining procedure and an overall estimate was described considering all studies combined.

RESULTS

The search provided 2291 results, from which six met the eligibility criteria and were included in the qualitative assessment of the review. Only three studies presented a moderate risk of bias. The meta-analysis results showed that the use of auxiliary posts produced higher mean fracture strengths than non-customized posts (SMD = 2.21; 95%CI: 0.74; 3.68), and it was more effective than the use of composite resin to reline the posts.

CONCLUSION

Based on laboratories studies, even though has not been observed any difference to a statistically significant level on fracture strength and failure pattern of the customized and non-customized post, future studies should follow a standardized approach to implementation and reporting of data.

Fracture toughness of the stomatopod dactyl club is enhanced by plastic dissipation: A fracture micromechanics study

The dactyl club of stomatopods is a biological hammer used to strike on hard-shell preys. To serve its function, the club must be imparted with a high tolerance against both contact stresses and fracture. While the contact mechanics of the club has been established, fracture toughness characterization has so far remained more elusive and semi-quantitative using nanoindentation fracture methods. Here, we used microcantilever fracture specimens with a chevron-notched crack geometry to quantitatively evaluate the fracture response of the impact region of dactyl clubs. The chevron-notched geometry was selected as it minimizes surface-related artefacts due to ion milling, and further allows to carry out fracture tests on samples free of pre-cracks with stable crack propagation even for brittle materials. Both linear elastic as well as elastic-plastic fracture mechanics methods, together with finite element modelling, were employed to analyse the fracture data. We find that crack-tip plastic dissipation is the main mechanism contributing to the fracture properties of the dactyl club material. Our study also suggests that the chevron-notched crack geometry is a suitable method to quantitatively assess the fracture toughness of hard biological materials. STATEMENT OF SIGNIFICANCE: Characterizing the fracture resistance of biomineralized structures is essential to draw their structure-properties relationships. Yet measuring the fracture properties of such materials is often hampered by their small size and irregular shape. Indentation fracture is used to circumvent these issues but does not discriminate between the elastic and elastic-plastic contributions to the fracture resistance. The dactyl club "hammer" of mantis shrimps is a biological material whose fracture properties are central to its function. A microfracture study was conducted using microcantilever specimens with chevron-notched crack geometry to assess the fracture toughness. Adopting linear elastic and elastic-plastic fracture mechanics protocols, we find that plastic dissipation is the major contribution to the fracture response of the hypermineralized impact region of the dactyl club.

Stiff, strong and tough laminated glasses with bio-inspired designs

Glass is an attractive material with outstanding transparency, hardness, durability and chemical stability. However, the inherent brittleness and low toughness of glass limit its applications. Overcoming the brittleness of glass will help satisfy the rapidly increasing demands of glass in building materials, optical devices, electronics and photovoltaic systems, but it has been a challenge to create glass that is stiff, strong and tough while maintaining its transparency. In this study we explore how the basic design of laminated glass can be enriched with bio-inspired architectures generated with laser engraving. We assess the performance of designs based on continuous plies (90° cross plies, Bouligand), finite glass blocks (segmented Bouligand, nacre-like brick-and-mortar) and hybrid designs. It shows that simultaneous improvements of stiffness, strength and energy absorption upon continuous ply designs can be achieved by promoting delocalized shearing of the polymeric interlayer over brittle fracture of the glass building blocks, and by only placing enriched architectures under tensile deformation so that interlayer shearing can be realized. This principle can be realized simply by adjusting size and arrangement of the building blocks, and by combining continuous plain layers with architectured layers.

Effect of Alternative Palatal Root Access Technique on Fracture Resistance of Root Canal Treated Maxillary Fourth Premolar Teeth in Dogs

A biomechanical study was performed to identify the effect of different treatment methods for difficult to instrument palatal roots on the fracture resistance of root canal treated maxillary fourth premolar teeth in dogs. Forty maxillary fourth premolar teeth with surrounding alveolar bone were harvested from beagle cadavers. Inclusion criteria included maxillary fourth premolars with no evidence of disease and similar distal root canal volumes on radiographic evaluation. The teeth were randomly divided into a control group and three treatment groups based on the endodontic treatment technique for the palatal root. The control group had a single 2 mm transcoronal access on the mesiobuccal aspect of the tooth to allow instrumentation of both the mesiobuccal and palatal root through a single small access. Alternative treatment modalities that are described for difficult to instrument palatal roots investigated in this study included enlarging the transcoronal mesiobuccal access to 4 mm, making an additional access directly over the palatal root (2 mm), and hemisection with extraction of the palatal root. All teeth had the same distal root access size (2 mm) and relative location. After access, all teeth were filed, shaped, obturated, and restored in the same fashion. Axial compression testing was performed at an angle of 60 degrees to the long axis of the tooth using a universal materials testing machine. The maximum force prior to fracture was determined for each tooth based on a force vs. deflection curve. The mean maximum force prior to fracture for all teeth was 831 N. No significant difference in mean fracture resistance was identified between the control group and treatment groups or between the different treatment groups themselves. Thus, when faced with a difficult to instrument palatal root, the treatment method chosen should be based on operator preference and experience.

Susceptibility of Dental Enamel of Different Ages to Caries-Like Lesion Development

This study investigated the impact of estimated age, anatomical location, and the presence of wear facets on the susceptibility of enamel to develop caries-like lesions. Extracted human premolars (n = 261) had their age estimated between 10 and 93 years old, using established forensic methods. Specimens of enamel (4 × 4 mm) were prepared from the middle of the buccal surfaces, preserving the outer surface layer. The central area of the block (4 × 1 mm) was protected with nail polish and used as an internal control. The specimens were demineralized for 8 days (with 0.1 M acetic acid, 1.28 mM Ca, 0.74 mM Pi, and 0.03 µg F/mL, pH 5.0), to simulate caries-like lesion development. They were then scanned individually using microtomography, and digital 2D images were used to calculate the outcomes of integrated mineral concentration loss (ΔZ in µm/g/cm3) and lesion depth (LD in µm) at 3 locations, i.e., the cervical, middle, and occlusal thirds. The presence of natural surface wear facets was considered in the analysis. Data were evaluated using a linear mixed-effects models (α = 0.05). ΔZ increased significantly as a function of estimated tooth age at all 3 locations, and this increase was greater after the age of 30 years (p < 0.001), when a higher ΔZ was found in the occlusal third than in the middle and cervical thirds (p < 0.001). LD increased only in the occlusal third before the age of 30 years (p = 0.039) and this increase was significantly greater after 30 years at all 3 locations (p < 0.01), with no differences among them (p > 0.15). The presence of wear facets significantly increased ΔZ and LD (p < 0.001 for both). Overall, we concluded that the susceptibility of enamel to developing caries-like lesions increased with estimated dental age. This effect was more pronounced after the estimated age of 30 years and in the presence of natural tooth wear facets.

Influence of Dentine Pre-Treatment by Sandblasting with Aluminum Oxide in Adhesive Restorations. An In Vitro Study

Dentine pretreatment through sandblasting procedures has been widely studied but no curve test results are currently available. Thus, the aim herein was to in vitro compare the adhesive strength in sandblasted or not samples using a universal testing machine. Thirty -two bovine teeth were divided into two groups, namely test (n = 16 bars), sandblasting with aluminum oxide particles (50 µm) was performed before the adhesion procedures), and control (n = 16 bars), where no sandblasting procedure was performed. A bi-material curve test was used to evaluate the characteristics of the dentine pretreatment in terms of tensile stress and fracture strength. A scanning electron microscope (SEM) was used to analyze the fracture topography in the composite, bonding, dentin, and at the relative interfaces. The results demonstrated a statistically significant difference between the two groups in terms of tensile stress at maximum load showing values of 84.300 ± 51.342 MPa and 35.071 ± 16.609 MPa, respectively for test and control groups (p = 0.033). Moreover, a fracture strength test showed values of 18.543 ± 8.145 MPa for test and 8.186 ± 2.833 MPa for control group (p = 0.008). In conclusion, the sandblasting treatment of the dentine significantly influenced the mechanical resistance of the adhesion in this in vitro study.

Chemical gradients in human enamel crystallites

Dental enamel is a principal component of teeth1, and has evolved to bear large chewing forces, resist mechanical fatigue and withstand wear over decades2. Functional impairment and loss of dental enamel, caused by developmental defects or tooth decay (caries), affect health and quality of life, with associated costs to society3. Although the past decade has seen progress in our understanding of enamel formation (amelogenesis) and the functional properties of mature enamel, attempts to repair lesions in this material or to synthesize it in vitro have had limited success4-6. This is partly due to the highly hierarchical structure of enamel and additional complexities arising from chemical gradients7-9. Here we show, using atomic-scale quantitative imaging and correlative spectroscopies, that the nanoscale crystallites of hydroxylapatite (Ca5(PO4)3(OH)), which are the fundamental building blocks of enamel, comprise two nanometric layers enriched in magnesium flanking a core rich in sodium, fluoride and carbonate ions; this sandwich core is surrounded by a shell with lower concentration of substitutional defects. A mechanical model based on density functional theory calculations and X-ray diffraction data predicts that residual stresses arise because of the chemical gradients, in agreement with preferential dissolution of the crystallite core in acidic media. Furthermore, stresses may affect the mechanical resilience of enamel. The two additional layers of hierarchy suggest a possible new model for biological control over crystal growth during amelogenesis, and hint at implications for the preservation of biomarkers during tooth development.

Nature's design solutions in dental enamel: Uniting high strength and extreme damage resistance

The most important demand of today's high-performance materials is to unite high strength with extreme fracture toughness. The combination of withstanding large forces (strength) and resistance to fracture (toughness), especially preventing catastrophic material failure by cracking, is of utmost importance when it comes to structural applications of these materials. However, these two properties are commonly found to be mutually exclusive: strong materials are brittle and tough materials are soft. In dental enamel, nature has combined both properties with outstanding success - despite a limited number of available constituents. Made up of brittle mineral crystals arranged in a sophisticated hierarchical microstructure, enamel exhibits high stiffness and excellent toughness. Different species exhibit a variety of structural adaptations on varying scales in their dental enamel which optimise not only fracture toughness, but also hardness and abrasion behaviour. Nature's materials still outperform their synthetic counterparts due to these complex structure-property relationships that are not yet fully understood. By analysing structure variations and the underlying mechanical mechanisms systematically, design principles which are the key for the development of advanced synthetic materials uniting high strength and toughness can be formulated. STATEMENT OF SIGNIFICANCE: Dental enamel is a hard protective tissue that combines high strength with an exceptional resistance to catastrophic fracture, properties that in classical materials are commonly found to be mutually exclusive. The biological material is able to outperform its synthetic counterparts due to a sophisticated hierarchical microstructure. Between different species, microstructural adaptations can vary significantly. In this contribution, the different types of dental enamel present in different species are reviewed and connections between microstructure and (mechanical) properties are drawn. By consolidating available information for various species and reviewing it from a materials science point of view, design principles for the development of advanced biomimetic materials uniting high strength and toughness can be formulated.

Functionally graded biomimetic biomaterials in dentistry: an evidence-based update

Design and development of novel therapeutic strategies to regenerate lost tissue structure and function is a serious clinical hurdle for researchers. Traditionally, much of the research is dedicated in optimising properties of scaffolds. Current synthetic biomaterials remain rudimentary in comparison to their natural counterparts. The ability to incorporate biologically inspired elements into the design of synthetic materials has advanced with time. Recent reports suggest that functionally graded material mimicking the natural tissue morphology can have a more exaggerated response on the targeted tissue. The aim of this review is to deliver an overview of the functionally graded concept with respect to applications in clinical dentistry. A comprehensive understanding of spatiotemporal arrangement in fields of restorative, prosthodontics, periodontics, orthodontics and oral surgery is presented. Different processing techniques have been adapted to achieve such gradients ranging from additive manufacturing (three dimensional printing/rapid prototyping) to conventional techniques of freeze gelation, freeze drying, electrospinning and particulate leaching. The scope of employing additive manufacturing technique as a reliable and predictable tool for the design and accurate reproduction of biomimetic templates is vast by any measure. Further research in the materials used and refinement of the synthesis techniques will continue to expand the frontiers of functionally graded membrane based biomaterials application in the clinical domain.

Breaking crown dentine in whole teeth: 3D observations of prevalent fracture patterns following overload

Teeth with intact crowns rarely split or fracture, despite decades of cyclic loading and occasional unexpected overload. This is largely attributed to the presence of dentine, since cracking and fracture of enamel have been frequently reported. Dentine is similar to bone, comprising mineralised collagen fibres as a main constituent. Unlike cortical bone, however, where microcracking and damage arrest are essential for re/modelling and healing, dentine can neither remodel nor regenerate. This raises questions regarding the evolutionary benefits of toughening, leading to uncertainty whether cracks actually appear in dentine in situ. Here we study the notion that circumpulpal dentine is usually protected against, rather than damaged by severe overloads, even though it is not much more massive or stronger than it needs to be. To address this, we examined hydrated teeth still within whole jawbones of freshly-slaughtered skeletally mature pigs, mechanically loaded until fracture. Force displacement curves, optical and electron microscopy combined with 3D microstructural analysis by conventional micro-computed tomography (μCT) revealed mostly brittle fracture paths in circumpulpal crown dentine. Once overload cracks reach this mass of dentine they propagate rapidly along straight paths often parallel to the enamel flanks of the oblong shovel shaped premolars. We find infrequent signs of active toughening mechanisms with minimal crack diversion, ligament bridging and microcracking. When such toughening is seen, it mainly appears in softer dentine in the root, or near the dentine-enamel-junction (DEJ) in mantle dentine. We observed shear bands in overloaded circumpulpal dentine, due to mutual gliding of upper and lower segments. These shear bands are formed as periodic arrays of rotated dentine fragments. The 3D data consistently demonstrate the importance of the layered tooth structure, containing a stiff outer enamel shell, a soft sub-DEJ interlayer and a stiff circumpulpal dentine bulk, for deflecting cracks from splitting the tooth.

Structure-behaviour correlations between two genetically closely related snail species

Species, through their structure and composition, have evolved to respond to environmental constraints. Predator-prey interactions are among environmental pressures that can lead to speciation, but it remains unclear how this pressure can be related to the material structure and performance. Recently, two land snails, Karaftohelix editha and Karaftohelix gainesi, were found to exhibit divergent phenotypes and responses to predation despite sharing the same habitat and most of their genome. Indeed, under attack from a beetle, K. editha snails retract into their shell whereas K. gainesi snails swing their shell. In this paper, we looked at the microstructure, composition, morphology and mechanics of the shells of those two species and discuss potential relationships between material structure and the snail defence behaviour. The results of this study provide additional arguments for the role of predator-prey interactions on speciation, as well as an unusual approach for the design of biomimetic structures adapted to a particular function.

Discrete element models of tooth enamel, a complex three-dimensional biological composite

Enamel, the hard surface layer of teeth, is a three-dimensional biological composite made of crisscrossing mineral rods bonded by softer proteins. Structure-property relationships in this complex material have been difficult to capture and usually require computationally expensive models. Here we present more efficient discrete element models (DEM) of tooth enamel that can capture the effects of rod decussation and rod-to-interface stiffness contrast on modulus, hardness, and fracture resistance. Enamel-like microstructures were generated using an idealized biological growth model that captures rod decussation. The orthotropic elastic moduli were modeled with a unit cell, and surface hardness was captured with virtual indentation test. Macroscopic crack growth was also modeled directly through rupture of interfaces and rods in a virtual fracture specimen with an initial notch. We show that the resistance curves increase indefinitely when rod fracture is avoided, with the inelastic region, crack branching, and 3D tortuosity being the main sources of toughness. Increasing the decussation angle simultaneously increases the size of the inelastic region and the crack resistance while decreasing the enamel axial modulus, hardness, and rod stress. In addition, larger contrasts of stiffness between the rods and their interfaces promote high overall stiffness, hardness, and crack resistance. These insights provide better guidelines for reconstructive dental materials, and for development of bioinspired hard materials with unique combinations of mechanical properties. STATEMENT OF SIGNIFICANCE: Enamel is the hardest, most mineralized material in the human body with a complex 3D micro-architecture consisting of crisscrossing mineral rods bonded by softer proteins. Like many hard biological composites, enamel displays an attractive combination of toughness, hardness, and stiffness, owing to its unique microstructure. However few numerical models explore the enamel structure-property relations, as modeling large volumes of this complex microstructure presents computational bottlenecks. In this study, we present a computationally efficient Discrete-element method (DEM) based approach that captures the effect of rod crisscrossing and stiffness mismatch on the enamel hardness, stiffness, and toughness. The models offer new insight into the micromechanics of enamel that could improve design guidelines for reconstructive dental materials and bioinspired composites.

Root canal treatment in elderly patients: A review and clinical considerations

Life expectancy has increased as a result of advancements in health care services; thus, maintaining healthy dentition is an important factor in overall health. Furthermore, the growing desire of elderly patients to maintain their teeth has led to an increased need for the performance of complex dental treatment in elderly patients. Root canal therapy is an essential phase of such treatments. Elderly patients may exhibit one or more systemic conditions that require special care, in addition to other changes that occur within the dentition and oral mucosa as a result of aging. These make root canal treatment in elderly patients a great challenge. The aim of this review was to characterize pathologic and physiologic changes in elderly patients that can interfere with root canal treatment procedures, as well as attitudes of elderly patients toward such treatment, guidelines and clinical considerations for management of root canal treatment in elderly patients.

Durability of self-healing dental composites: A comparison of performance under monotonic and cyclic loading

Durability is an important quality of dental restorative materials, and the ability to autonomously heal damage incurred during their oral function is highly desirable.

OBJECTIVE

The objective was to evaluate the improvement in durability of self-healing dental composites (SHDCs) in terms of their resistance to fracture and capacity for healing of damage under monotonic and cyclic loading.

METHODS

SHDCs were prepared by incorporating dental resin composites with microcapsules containing healing liquid. Control specimens with the same mass fraction (5% and 25%) of microcapsules filled with water were also evaluated. Two sets of SHDCs were distinguished by the silane coupling agents that functionalized and bonded the microcapsules to resin network. One set used a methacrylate silane (MA-silane) that connected resin network through covalent bonds, and the other used a H-bonding forming hydroxyl silane (OH-silane). The fatigue crack growth resistance was assessed in terms of the threshold stress intensity range and the conventional Paris Law parameters. Cyclic loading was conducted at 5 Hz with maximum cyclic load ranged between approximately 1 N and 5 N. The efficiency of the autonomous healing was determined per the recovering of the fracture toughness and the extension of fatigue life.

RESULTS

The SHDCs with 5 wt% of healing microcapsules exhibited a larger fracture toughness than those with 25 wt% microcapsules. MA-silane SHDCs had approximately five times more responsive microcapsules triggered by fracturing of the composites. Consequently, the MA-silane SHDCs with 5 wt% of microcapsules achieved the best performance in terms of fracture toughness and healing efficiency. In regards to the fatigue crack growth behavior, there was a significant increase in the resistance to fatigue crack growth and 580 ± 15% improvement in the fatigue life.

SIGNIFICANCE

Strong silanization is vital in SHDCs to simultaneously achieve clinically applicable mechanical performance and substantial healing capability. Moreover, the evaluation of self-healing under cyclic loading is a promising tool in quantifying the degree of fracture-induced healing.

Do composite resin restorations protect cracked teeth? An in-vitro study

Aims

To evaluate whether bonded resin composite restorations can effectively immobilise the tooth segments in teeth with a synthesised crack under loading, by exploring the impact of the restoration type (direct versus indirect composite resin) and restoration design (inlay versus onlay) on the fatigue resistance.

Methods

Sound human third molars underwent large mesio-occluso-distal preparations and a groove was cut to simulate a crack. Standardised procedures were adopted and measures were taken during teeth selection so that systematic error and methodology bias were minimised. The teeth were randomly assigned to four groups. The specimens were submitted to cyclic loading and loaded until fracture or to a maximum of 185,000 cycles. The failure mode was recorded.

Results

No failure was observed in 'direct' groups up to the 1000 N force. Survival analysis revealed statistically significant higher survival rates for 'direct' groups compared to 'indirect' groups (χ2 = 11.352, df = 1, p = 0.001) while there was no significant difference between 'inlay' and 'onlay' groups (χ2 = 0.015, df = 1, p = 0.901) (pooled data).

Conclusions

Within the limitations of this in-vitro study, it can be concluded that the direct composite resin restorations sufficiently protected the cracked teeth regardless of the cavity design. As there was no statistically significant difference in survival rates between inlays and onlays it is not possible to favour one design type over the other.

Recent advances in understanding the fatigue and wear behavior of dental composites and ceramics

Dental composite and ceramic restorative materials are designed to closely mimic the aesthetics and function of natural tooth tissue, and their longevity in the oral environment depends to a large degree on their fatigue and wear properties. The purpose of this review is to highlight some recent advances in our understanding of fatigue and wear mechanisms, and how they contribute to restoration failures in the complex oral environment. Overall, fatigue and wear processes are found to be closely related, with wear of dental ceramic occlusal surfaces providing initiation sites for fatigue failures, and subsurface fatigue crack propagation driving key wear mechanisms for composites, ceramics, and enamel. Furthermore, both fatigue and wear of composite restorations may be important in enabling secondary caries formation, which is the leading cause of composite restoration failures. Overall, developing a mechanistic description of fatigue, wear, and secondary caries formation, along with understanding the interconnectivity of all three processes, are together seen as essential keys to successfully using in vitro studies to predict in vivo outcomes and develop improved dental restorative materials.

The Tooth: Its Structure and Properties

This article provides a brief review of recent investigations concerning the structure and properties of the tooth. The last decade has brought a greater emphasis on the durability of the tooth, an improved understanding of the fatigue and fracture behavior of the principal tissues, and their importance to tooth failures. The primary contributions to tooth durability are discussed, including the process of placing a restoration, the impact of aging, and challenges posed by the oral environment. The significance of these findings to the dental community and their importance to the pursuit of lifelong oral health are highlighted.

Enamel Microcracks Induced by Simulated Occlusal Wear in Mature, Immature, and Deciduous Teeth

Enamel wear, which is inevitable due to the process of mastication, is a process in which the microcracking of enamel occurs due to the surface contacting very small hard particles. When these particles slide on enamel, a combined process of microcutting and microcracking in the surface and subsurface of the enamel takes place. The aim of this study was to detect microscopic differences in the microcrack behavior by subjecting enamel specimens derived from different age groups (immature open-apex premolars, mature closed-apex premolars, and deciduous molars) to cycles of simulated impact and sliding wear testing under controlled conditions. Our findings indicated that the characteristics of the microcracks, including the length, depth, count, orientation, and relation to microstructures differed among the study groups. The differences between the surface and subsurface microcrack characteristics were most notable in the enamel of deciduous molars followed by immature premolars and mature premolars whereby deciduous enamel suffered numerous, extensive, and branched microcracks. Within the limitations of this study, it was concluded that enamel surface and subsurface microcracks characteristics are dependent on the posteruptive age with deciduous enamel being the least resistant to wear based on the microcrack behavior as compared to permanent enamel.

Trend-analysis of dental hard-tissue conditions as function of tooth age

OBJECTIVE

This retrospective in-vitro study investigated tooth age effect on dental hard-tissue conditions.

METHODS

Unidentified extracted premolars (n = 1500) were collected and their individual age was estimated (10-100 (±10) years old (yo)) using established dental forensic methods Dental caries, fluorosis and tooth wear (TW) were assessed using the International Caries Detection and Assessment System (ICDAS; 0-5 for crown and 0-2 for root), Thylstrup-Fejerskov (TFI; 0-9) and Basic Erosive Wear Examination (BEWE; 0-3) indices, respectively. Staining and color were assessed using the modified-Lobene (MLI) (0-3) and VITA shade (B1-C4) indices, respectively. Relationships between indices and age were tested using regression models.

RESULTS

Starting at age ∼10yo, presence of caries increased from 35% to 90% at ∼50yo (coronal), and from 0% to 35% at ∼80yo (root). Caries severity increased from ICDAS 0.5 to 2 at ∼40yo and from ICDAS 0 to 0.5 at ∼60yo for coronal and root caries, respectively. Presence of TW increased from 25% (occlusal) and 15% (smooth-surfaces) to 100% at ∼80yo. TW severity increased from BEWE 0.5 to 2 at ∼50yo (occlusal) and ∼0.3 to 1.5 at ∼50yo (smooth-surfaces). Percentage and severity of fluorosis decreased from 70% to 10% at ∼80yo, and from TFI 1 to 0 at ∼90yo, respectively. Percentage of extrinsic staining increased from 0% to 85% at ∼80yo and its severity increased from MLI 0 to 2 at ∼70yo. Color changed from A3 to B3 at ∼50yo (crown), and from C2 to A4 at ∼85yo (root).

CONCLUSIONS

Aging is proportionally related to the severity of caries, TW, staining, and inversely to dental fluorosis. Teeth become darker with age.

Diagnosis and Managment of Maxillary Incisor with Vertical Root Fracture: A Clinical Report with Three-Year Follow-Up

According to the American Association of Endodontists, "a 'true' vertical root fracture is defined as a complete or incomplete fracture initiated from the root at any level, usually directed buccolingually." Vertical root fracture (VRF) usually starts from an internal dentinal crack and develops over time, due to masticatory forces and occlusal loads. When they occur in teeth, those types of fractures can present difficulties in diagnosis, and there are however many clinic and radiographical signs which can guide clinicians to the existence of the fracture. Prognosis, most often, is hopeless, and differential diagnosis from other etiologies may be difficult sometimes. In this paper, we present a case of VRF diagnosed after surgical exploration; the enlarged fracture line was filled with a fluid resin. A 36-month clinical and radiological follow-up showed an asymptomatic tooth, reduction of the periodontal probing depth from 7 mm prior to treatment to 4 mm with no signs of ankylosis. In this work, the diagnosis and treatment alternatives of vertical root fracture were discussed through the presented clinical case.

A Preliminary Investigation into the Dietary and Oral Practices Associated with Fractured Teeth and Prostheses in a Trinidadian Population

OBJECTIVES

This preliminary study seeks to determine the relationship between fractured teeth, restorations, prostheses, and specific dietary practices.

METHODOLOGY

Anonymous questionnaires were randomly distributed to a convenience sample of Trinidadian adults at various locations around the country, after gaining consent. Data were analyzed using the software; Statistical Package for the Social Sciences for significant associations between various types of food and broken teeth or prosthesis using odds ratios.

RESULTS

Three hundred questionnaires were completed. Seventy-five percent of the patients preferred crunchy or hard foods and 51% of the respondents liked crushing bones, mostly chicken bones. It was observed that respondents with a dietary preference for fried whole chana, split chana, crab, and sugarcane were significantly associated with broken dentures. Respondents eating whole chana also had a significant association with broken teeth and broken dentures. Associations were found between some dietary preferences, ethnicities, and age groups.

CONCLUSIONS

Significant associations between age, ethnicity, sex, and certain dietary practices and habits were found. There also appears to be a significant relationship between patients with fractured teeth, restorations, and prostheses with certain dietary preferences.

Fractographic Analysis of a Split Tooth Presenting Radiographically as a Horizontal Root Fracture in an Unrestored Mandibular Second Molar

INTRODUCTION

Spontaneously catastrophic fracture of intact unrestored molar teeth is not common. Nevertheless, cracks do occur that progress apically, resulting in the complete splitting of the tooth and root. This report describes a catastrophic fracture that occurred in an unrestored mandibular second molar resulting in a previously unreported combination of a longitudinal and horizontal root fracture, appearing radiographically as a single horizontal root fracture.

METHODS

Tooth fragments were examined clinically, stereoscopically, and by scanning electron microscopy. Fractographic analysis was used to investigate the dynamics involved in fracture initiation, structural resistances encountered during progression of the fracture, and reasons for direction changes culminating in the unusual radiographic appearance.

RESULT

The uniqueness of this report is that it describes fractographic evidence of factors contributing to the initiation and progression of an in vivo crack. It shows fracture markings that are evidence of the energy dissipation mechanisms. The topographic location of these markings confirmed that cracks occur in vivo in stages with different rates of progression.

CONCLUSION

This analysis helps to explain why split teeth are uncommon and highlights some of the multitude of factors that have to coincide for a tooth to catastrophically fracture. The report describes the mechanism of fracture and should stimulate clinicians and researchers to investigate cracking of teeth by undertaking fractographic analysis of extracted cracked teeth.

DENTAL ENAMEL FORMATION AND IMPLICATIONS FOR ORAL HEALTH AND DISEASE

Dental enamel is the hardest and most mineralized tissue in extinct and extant vertebrate species and provides maximum durability that allows teeth to function as weapons and/or tools as well as for food processing. Enamel development and mineralization is an intricate process tightly regulated by cells of the enamel organ called ameloblasts. These heavily polarized cells form a monolayer around the developing enamel tissue and move as a single forming front in specified directions as they lay down a proteinaceous matrix that serves as a template for crystal growth. Ameloblasts maintain intercellular connections creating a semi-permeable barrier that at one end (basal/proximal) receives nutrients and ions from blood vessels, and at the opposite end (secretory/apical/distal) forms extracellular crystals within specified pH conditions. In this unique environment, ameloblasts orchestrate crystal growth via multiple cellular activities including modulating the transport of minerals and ions, pH regulation, proteolysis, and endocytosis. In many vertebrates, the bulk of the enamel tissue volume is first formed and subsequently mineralized by these same cells as they retransform their morphology and function. Cell death by apoptosis and regression are the fates of many ameloblasts following enamel maturation, and what cells remain of the enamel organ are shed during tooth eruption, or are incorporated into the tooth's epithelial attachment to the oral gingiva. In this review, we examine key aspects of dental enamel formation, from its developmental genesis to the ever-increasing wealth of data on the mechanisms mediating ionic transport, as well as the clinical outcomes resulting from abnormal ameloblast function.

The interrelationship of microstructure and hardness of human coronal dentin using reference point indentation technique and micro-Raman spectroscopy

OBJECTIVES

The aim of this paper is to determine the interrelationship between the microstructure - in terms of chemical composition and crystallinity - to the microhardness of coronal dentin.

METHODS

Dentin microhardness was tested by a novel reference point indenter and compared to the traditional Knoop hardness method. Micro-Raman spectroscopy was used to determine the chemical composition and crystallinity of dentin.

RESULTS

From the occlusal groove to the border of the coronal pulp chamber, dentin hardness decreased from superficial dentin (SD) to deep dentin (DD). Mineral/organic matrix ratios (phosphate/CH and phosphate/amide I) also decreased from SD to DD; however, this change was significant (P<0.05) in the phosphate/amide I ratio only. The phosphate/carbonate ratio decreased significantly by varying position from SD to DD. The degree of the crystallinity, as measured by the full width at half maximum (FWHM) of the peak at 960cm^-1, decreased significantly going from superficial to deep dentin.

SIGNIFICANCE

For the first time, the interrelationship between the microstructure and the mechanical properties of coronal dentin was determined by using the novel reference point indentation technique and micro-Raman spectroscopy. We hypothesize that the decrease in hardness from superficial to deep dentin can potentially be explained by decreased mineral content and increased carbonate content, which is also associated with decreased crystallinity. Collectively, there is a positive association between dentin hardness and mineral content and a negative association between dentin hardness and carbonate content.

The association between electronic-cigarette use and self-reported oral symptoms including cracked or broken teeth and tongue and/or inside-cheek pain among adolescents: A cross-sectional study

Background

Little is known about oral health related to electronic-cigarette (EC) use, even though EC use is increasing rapidly. The aim of this study is to assess the relationship between EC use and oral health, including ‘gingival pain and/or bleeding’, ‘tongue and/or inside-cheek pain’, and ‘cracked or broken teeth’ among adolescents.

Methods

A total of 65,528 students in 2016 were included in this cross-sectional study.

Results

For EC use, 0.5% (n = 297) students were daily users, 1.9% (n = 1259) were ‘1 to 29 days past month users’, and 5.9% (n = 3848) were former users. Overall, 18.5% students reported they had experienced ‘gingival pain and/or bleeding’, 11.0% reported ‘tongue and/or inside-cheek pain’, and 11.4% reported a ‘cracked or broken tooth’ within the past 12 months. When comparing ‘daily EC users’, ‘1 to 29 days past month EC users’, and ‘former EC users’ with ‘never EC users’, the adjusted ORs for ‘cracked or broken tooth’ were 1.65 (95% CI: 1.19–2.27), 1.26 (95% CI: 1.06–1.51), and 1.16 (95% CI: 1.04–1.30), respectively. Comparing ‘daily EC users’ with ‘never EC users’, the adjusted OR for ‘tongue and/or inside-cheek pain’ was 1.54 (1.05–2.26). However, EC use among adolescents was not associated with ‘gingival pain and/or bleeding’ when adjusted for the potential confounders.

Conclusions

Based on the results, the odds of cracked or broken teeth among daily, ‘1 to 29 days past month’, and former EC users were significantly higher than those among never EC users. The odds of tongue and/or inside-cheek pain among daily EC users were significantly higher than those among never EC users. In conclusion, the results suggest that daily EC use among adolescents may be a risk factor for cracked or broken teeth and tongue and/or inside-cheek pain.

Diagnosis of Vertical Root Fractures in Restored Endodontically Treated Teeth: A Time-dependent Retrospective Cohort Study

INTRODUCTION

The purpose of this study was to examine different patient- and treatment-related factors associated with the time of presentation of vertical root fractures (VRFs) in endodontically treated teeth restored with crowns.

METHODS

One hundred ninety-seven root-filled, crowned teeth with no post and suspected of VRFs were included in the study. Patient details with relevance to endodontic treatment and clinical signs/symptoms were documented, and radiographs were taken. A diagnosis of a VRF was confirmed after surgical flap elevation. Frequency distributions were determined, and statistical analyses were performed using Pearson chi-square analysis, Fisher exact test, cross tabulation, Pearson correlation, and multiple logistic regression.

RESULTS

Mandibular molars (34%) and maxillary premolars (22.8%) were the most frequently affected teeth. The postoperative time to the diagnosis of a VRF was 4.35 (±1.96) years. Female patients, posterior teeth, overfilled canals, and patients older than 40 years were associated with the presentation of VRFs within 5 years of the postoperative period. Clinical findings most frequently observed were pain on percussion (60%), pain on palpation (62%), presence of a deep narrow pocket (81%), and sinus tract/swelling (67%). "Halo"-type radiolucency (48.7%) was the most common radiographic feature related to VRFs.

CONCLUSIONS

Pain on palpation/percussion, deep narrow pocket, sinus tract, and halo-type radiolucency are characteristic features of VRFs. Posterior teeth, overfilled canals, female patients, and older patients (>40 years) presenting with the previously described clinical features in endodontically treated teeth restored with crowns are more likely to present with VRFs within 5 years postoperatively.

Mechanical properties of human enamel under compression: On the feature of calculations

The paper is aimed at determination of the causes of shape effect in human tooth enamel under compression and correction of the relevant mechanical characteristics. For this purpose, six groups of samples with different ratios of the compression surface diagonal to the sample height, which consisted of 10 cuboid samples in each, were prepared from the backside of human enamel. The lateral deformation of a sample was calculated at the maximum compressive stress for correction of the mechanical characteristics. It is shown that the ratio between the lateral and axial deformations decreases with an increase in the ratio of the compression surface diagonal to the sample height. This is caused by the friction between the compression plates and the working surfaces of the enamel sample when the lateral deformation is suppressed. In addition, the slope of enamel sample by about 15° occurred during compression due to the inclination of rigid and low deformable enamel rods. The corrections of the elastic modulus and the compression strength taking into account the lateral deformation and the sample slope are carried out. The mechanical properties of enamel samples with the 2.1 aspect ratio are closer to the intrinsic properties of human enamel samples. The elastic modulus and the compression strength of human enamel under compression are 5.64 GPa and 363 MPa, respectively. The lateral deformation (~10%) may be considered as the critical parameter that indicates the strength of human enamel.