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Biomimetics Milicich Handout

The document discusses various dental technologies and techniques focused on minimally invasive restorative dentistry, emphasizing the importance of preserving tooth structure and vitality. It highlights the scientific method applied to dental practices, the biomechanics of tooth structure, and the long-term survival rates of different restorative materials like amalgam and composite. Additionally, it explores concepts such as stress distribution in teeth and the significance of the dentino-enamel complex in dental health.

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0% found this document useful (0 votes)

62 views91 pages

Biomimetics Milicich Handout

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Oi Ego

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

1/10/2017

Maximum Intervention,
Technologies that are standing the test of time
Minimal Invasion • Air‐abrasion
Doctor Engineer and Artist
• Hard and soft tissue lasers
Non‐invasive Caries Risk
Assessment Minimally invasive
Restorative techniques to • Magnification – loupes and microscopes
avoid pulp exposures,
Management of a diseased
biofilm. Caries and Perio.
restorative techniques
and preparation
help retain pulp vitality and • Digital X‐rays and imaging
restore long term function
Non‐invasive surface‐
techniques to preserve
biomechanical
using biomechanical • DIAGNOdent and other cavity diagnostic
protection techniques /biomimetic concepts and
using Re‐min and/or GIC
integrity
techniques
systems
• Ozone
• Adhesive ceramic restorations. CADCAM or Lab.

Scientific method
• Observation
• Hypothesis
• Experiment
• Analysis – support or reject hypothesis
• New Hypothesis
• Experiment

Copyright 2017 G W Milicich. Private use only. 1

1/10/2017

Scientific method
• Problem‐ Cavity in a tooth
• Hypothesis‐ Amalgam might work
• Experiment ‐ Fill millions of teeth
• Analysis – sort of works ‐ Lots of teeth
fracture in the long term
• New Hypothesis‐ Amalgam still might
work
• New Experiment‐ Place more amalgams

Tooth Structure Biomechanics The width of the occlusal portion

of the preparation affects the
All occlusal cavity preparations decreased strength of the crown.
the strength of the tooth in proportion to
the width of the preparation The addition of minimal proximal
boxes do not further significantly
reduce the strength of the tooth.
Fracture Strength of Human Teeth Effects of Prepared Cavities on the
With Cavity Preparations Strength of Teeth
Mondelli, Steagall, Ishikiriama, de Lima Navarro & Soares Larson, Douglas & Geistfeld
Journ Pros Dent; 43(4):419‐422, 1980 Op Dent;6:2‐5, 1981

Effects of cavity designs on tooth flexure Effects of cavity designs on tooth flexure
Cuspal Widening
No cavity
2.7µm

CT Scan‐Based Finite Element Analysis of Premolar Cuspal Deflection CT Scan‐Based Finite Element Analysis of Premolar Cuspal Deflection
Following Operative Procedures. Magne P, Oganesyan MS Following Operative Procedures. Magne P, Oganesyan MS
Inter Journ of Periodontic and Restorative Dent:, 2009:29 (4).:361‐369. Inter Journ of Periodontic and Restorative Dent:, 2009:29 (4).:361‐369.

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Effects of cavity designs on tooth flexure Effects of cavity designs on tooth flexure
Cuspal Widening Cuspal Widening
Amalgam Composite Amalgam Composite
5µm 3.5µm

Effects of cavity designs on tooth flexure Effects of cavity designs on tooth flexure
Cuspal Widening Cuspal Widening
Amalgam Composite Amalgam Composite
5µm 3.5µm 5µm 3.5µm
5.4µm 3.8µm

Effects of cavity designs on tooth flexure Effects of cavity designs on tooth flexure
Cuspal Widening Cuspal Widening
Amalgam Composite Amalgam Composite
5µm 3.5µm 5µm 3.5µm
5.4µm 3.8µm 5.4µm 3.8µm
6.9µm

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Long term survival. Composite or Amalgam? Long term survival. Composite or Amalgam?
12yr retrospective study 12yr retrospective study
Amalgam Composite
Clinically Acceptable Clinically Acceptable 75.6% 84.7%
Fractured/cracked tooth Fractured/cracked tooth 10.4% 1.4%
“A large number of amalgam restorations failed in the long term
due to tooth fracture and cracked‐tooth symptoms.”
“The lower fracture rate of composite‐restored teeth in this
study supports the hypothesis that adhesive restorations
strengthen tooth structure.”
12‐year Survival of Composite vs. Amalgam Restorations 12‐year Survival of Composite vs. Amalgam Restorations
N. Opdam, E. Bronkhorst, B. Loomans and M.Huysmans N. Opdam, E. Bronkhorst, B. Loomans and M.Huysmans
J DENT RES 2010 89: 1063 originally online 26 July 2010 J DENT RES 2010 89: 1063 originally online 26 July 2010

Tension Fractures Tension Fractures

Did extension for Even Gold inlays will not protect the tooth
prevention wreck
destruction wreck
these teeth?

Stress concentration Stress concentration

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New Concept New Concept

The Peripheral Rim The Peripheral Rim

Moiré Fringes Increased width

indicates
The direction of
the fringes
increased stress indicates the
A birefringence study of Energy
direction of the
Stress stress
human tooth structure concentration
Sink
occurs where
the fringes are
R Z Wang, S Weiner. Strain Structure in human teeth using Moiré fringes. close together R Z Wang, S Weiner. Strain Structure in human teeth using Moiré fringes.
Journal of Biomechanics 1998 Feb;31(2):135‐141. Journal of Biomechanics 1998 Feb;31(2):135‐141.

New Concept The Peripheral Rim - compression dome

The Peripheral Rim

In engineering terms,
this concept is known as
a tension ring

Clinical Presentations of Stress Distribution in Teeth

and the Significance in Operative Dentistry.
Milicich GW, Rainey JT:
Pract Periodontics Aesthet Dent 2000:12(7),695‐700

The enamel on a tooth acts like a compression dome Nano particulate HA crystals in dentin collagen
Load
The “upside micro‐ and nanofocused X‐ray beams, reveal
down tin can” that the nm‐sized mineral particles aligned
within collagen are pre‐compressed and
compression that the residual strains vanish upon mild
annealing. We show the link between the
dome mineral nanoparticles and known damage
propagation trajectories in dentin,
suggesting a previously overlooked
Designed to compression‐mediated toughening
mechanism.
keep the dentin
in compression Jean‐Baptiste Forien, Claudia Fleck, Peter Cloetens, Georg Duda, Peter
Fratzl, Emil Zolotoyabko, Paul Zaslansky. Compressive Residual Strains in
Mineral Nanoparticles as a Possible Origin of Enhanced Crack Resistance
in Human Tooth Dentin. Nano Lett., 2015, 15 (6), pp 3729–3734

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Nano particulate HA crystals in dentin collagen Nano structure and Macro structure
Similar Functions
“The internal stress works against crack
propagation and increases resistance of the
biostructure. “

Engineers use internal stresses to

strengthen materials for specific technical
purposes. Now it seems that evolution has
long 'known' about this trick, and has put it
to use in our natural teeth.

The “pre‐stressed” collagen fibrils Keep the dentin in compression, just

Jean‐Baptiste Forien, Claudia Fleck, Peter Cloetens, Georg Duda, Peter
Fratzl, Emil Zolotoyabko, Paul Zaslansky. Compressive Residual Strains in like pre‐stressed steel tendons in concrete structural beams keep the
Mineral Nanoparticles as a Possible Origin of Enhanced Crack Resistance
in Human Tooth Dentin. Nano Lett., 2015, 15 (6), pp 3729–3734 concrete in compression

Nano particulate HA crystals in dentin collagen Enamel and Dentin tend to behave independently

The presence of these “despite being organically “bonded,” enamel

“intra‐collagenous” nano HA and dentin responded independently. This
crystals also has HUGE unique behaviour with regional variations of
significance to successful these tissues could have serious clinical
long term dentin bonding implications during restorative procedures.”

Jean‐Baptiste Forien, Claudia Fleck, Peter Cloetens, Georg Duda, Peter

Fratzl, Emil Zolotoyabko, Paul Zaslansky. Compressive Residual Strains in Vijay K. Goel, Satish C. Khera, Kanwerdip Singh. Clinical implications
Mineral Nanoparticles as a Possible Origin of Enhanced Crack Resistance of the response of enamel and dentin to masticatory loads. Journal of
in Human Tooth Dentin. Nano Lett., 2015, 15 (6), pp 3729–3734 Pros Dent: Vol 64 (4), Oct 1990, Pg 446–454

The Dentino‐Enamel Complex allow two dissimilar Joining enamel to dentin

materials to function in harmony The dentino‐enamel COMPLEX
“The 200‐300 micron soft zone of dentin, found beneath
enamel in crowns of human teeth, is thought to fulfil MANTLE
DENTIN
important roles in tooth function…. the durability of the
whole tooth relies upon a bucco‐lingual asymmetric
matching of stiffness by means of an interphase: a
cushioning soft layer between enamel and bulk dentin.” “A less simplistic view suggests that the
dentino‐enamel junctional complex should also include the
inner aprismatic enamel and the mantle dentin.”
Zaslansky P, Friesem AA, Weiner S.
Structure and mechanical properties of the soft zone separating bulk
dentin and enamel in crowns of human teeth: insight into tooth M. Goldberg, D. Septier, K. Bourd, R. Hall, J.‐C. Jeanny, L. Jonet,S. Colin, F. Tager, C.
function. J Struct Biol. 2006 Feb;153(2):188‐99. Epub 2005 Dec 9. Chaussain‐Miller, M. Garab´edian, A. George, H. Goldberg, S. Menashi
The Dentino‐Enamel Junction Revisited. Connective Tissue Research, 43: 482–489, 2002

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Joining enamel (or porcelain) to dentin Joining enamel (or porcelain) to dentin
Resin impression of the Resin impression of the
Dentino‐enamel Complex Dentino‐Enamel Complex
• The DEC is a more open • The DEC is a more open ,
structure trabeculated structure
• Lower mineral content • Lower mineral content
than enamel or dentin than enamel or dentin
Isao Urabe, Masatoshi Nakajima, Junji Tagami
Physical Properties of the Dentin‐Enamel Junction Region.
• Acts as a stress breaker • Acts as a stress breaker
AmJDent 2000; 13:129 [intro2] between the enamel between the enamel
compression dome and compression dome and
the dentin the dentin

Effects of cavity designs on tooth flexure Who has seen this?

Cuspal Widening
Amalgam Composite
5µm 3.5µm
5.4µm 3.8µm
6.9µm

CT Scan‐Based Finite Element Analysis of Premolar Cuspal Deflection

Following Operative Procedures. Magne P, Oganesyan MS
Inter Journ of Periodontic and Restorative Dent:, 2009:29 (4).:361‐369.

Peripheral Rim Compression Fracture Peripheral Rim Compression Fracture

Stress
concentration
Compressive Stress cannot
load on be distributed
peripheral rim laterally into
enamel the dentin due
to the presence
of the cavity

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Stress Stress
concentration concentration
Stress Occlusal enamel
concentrates fractures out
between the
Lost energy
cavity wall and Lost energy
dissipation the peripheral dissipation
rim

Peripheral Rim Compression Fracture Peripheral Rim Compression Fracture

Stress Occlusal enamel fractures out
concentration Differentiation between
occlusal enamel and
peripheral rim enamel

Lost energy
dissipation

The most enduring components in ruins are the Domes and arches, inside arches, inside arches.
compression arches and decussation faces Compression arches and
domes work just as well if they
(stones intersecting at angles in buttresses) are upside down!

Keystone

Skewback

Rievaulx Abbey Rievaulx Abbey Talley Abbey

Salisbury Cathedral Wells Cathedral Scissor Arch

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CUT AN OCCLUSAL CUT AN OCCLUSAL

Cusp Tips Cusp Tips
What would
Keystone
happen to the
What would
stability of
happen to the
these
stability of this
Skewback compression
compression
zone arches if this
arch if this area Skewback Skewback Skewback Skewback
Column or area was
Skewback was removed?
circumferential removed?
CUT AN
wall CUT AN
OCCLUSAL!
OCCLUSAL!
Chirk Aqueduct Chirk Aqueduct
Note prism orientation in relation
to a masonry arch!

The Micro event. Cutting a very small occlusal. The Human Enamel Compression Dome

The lateral
occlusal contact The mechanical efficacy of a tooth ‐ a natural
that is distorting
the peripheral
functionally graded material ‐ is a function of
rim now that the hierarchy of scale and material properties
occlusal enamel
buttressing has
been damaged
Peripheral rim Timothy G. Bromage, PhD. Professor, Department of Biomaterials
fracture and Biomimetics Director, Hard Tissue Research Unit.
Email: [email protected].

At the primary hierarchy of scale is enamel thickness Hypothesis

Are Hunter Shreger Bands a version of tension rings in a compression dome?
They are also internal inverted “teacups”, or like a scissor arch
being buttressed by the dentin
What is decussation?
Where enamel prisms lay beside one
another with a completely different
orientation.
Within one or two prisms, orientation
can change by over 30 degrees.
It presents as Hunter Shreger Bands
and gnarled enamel. In horizontal X Section, HS bands
Stress distribution, crack limitation wrap around each cusp and
mechanism. around the tooth

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Hypothesis Hypothesis
Are Hunter Shreger Bands a version of tension rings in a compression dome? Are Hunter Shreger Bands a version of tension rings in a compression dome?
They are also internal inverted “teacups”, or like a scissor arch They are also internal inverted “teacups”, or like a scissor arch
being buttressed by the dentin being buttressed by the dentin

3D representation 3D representation
of a single of a single
Hunter Shreger Band Hunter Shreger Band

Compression domes work Compression domes work

both ways. Upside down both ways. Upside down
or right way up. or right way up.

3D representation
of a single
Hunter Shreger Band
(approx 10 prisms in width)
Compression domes work
both ways. Upside down
or right way up.
J Osborn. Directions and Interrelationship of Prisms
in Cuspal and Cervical Enamel of Human Teeth
J Dent Res May‐June 1968. Vol 47 No. 3. 395‐402

Hunter Schreger Band Florence Basilica

stress breaker crack limitation

HS band decussation
helps limit crack
propagation

Remarkable resilience of teeth. Herzl Chai et al.

Natl Acad Sci U S A. 2009 May 5; 106(18): 7289–7293. Internal tension rings

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Hypothesis Hypothesis
Are Hunter Shreger Bands a version of tension rings in a compression dome? Are Hunter Shreger Bands a version of tension rings in a compression dome?
They are also internal inverted “teacups”, or like a scissor arch Construction diagram of the Florentine Dome
being buttressed by the dentin

J Osborn. Directions and Interrelationship of Prisms The Schiller Institute. The Secrets of the
in Cuspal and Cervical Enamel of Human Teeth Florentine Dome. Karel Vereycken 2013.
J Dent Res May‐June 1968. Vol 47 No. 3. 395‐402

Functional Stress Relief – Vertical Lamellae

“Calculated stress intensities around crack tips

were found to be highly influenced by the elastic
modulus mismatch between enamel and dentin
and hence, the phenomenon of crack arrest at the
DEJ could be explained accordingly via this
elastic modulus mismatch.”

The Bio‐Dome
Normal in un‐restored teeth Crack arrest within teeth at the dentino‐enamel junction
caused by elastic modulus mismatch.
Bechtle S, Fett T, Rizzi G, Habelitz S, Klocke A, Schneider GA.
Biomaterials. 2010 May;31(14):4238‐47. Epub 2010 Feb 18.

Functional Stress Relief – Vertical Lamellae The Peripheral Rim - compression dome

Compression dome –
tension rings of the
Pantheon in Rome
128AD

Note the lamellae are not full length and are

The driving force.
in the “surface” of the enamel at the
maximum convexity of the tooth.
Poisson Effect Distortion.
(much more on this later)

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The is the wall that supports the How valid is this compression dome analogy?
compression dome complex
Don’t send it up the suction!!!!

“despite being organically “bonded,” enamel and

dentin responded independently”
This further supports the concept that the enamel is
acting semi‐independently as a compression dome

Pantheon ‐ Rome
Goel VK, Khera SC, Singh K. Clinical implications of the response of enamel
and dentin to masticatory loads. J Prosthet Dent 1990; 64 (4):446–454.

How valid is this compression dome analogy? How valid is this compression dome analogy?
“electronic speckle pattern correlation interferometry (ESPI)
“The question that arises is, if enamel is so
highlight details of the design strategies of the enamel cap.
brittle, why are teeth so durable? Part of the
(compression dome) The crown not only deforms but also rotates
under load. Much of the load is transferred onto a crucial reason lies in the tooth geometry—the capacity
interphase in dentin just below the dentino‐enamel junction. to support and sustain an essentially
This relatively soft zone compresses asymmetrically when loaded. compressive vertical load, rather like the dome
This shows that the enamel cap has rotated relative to the central of a cathedral (Lawn and Lee,2009).”
bulk of the crown.”
Zaslansky P, Weiner S. Biomechanical Adaptations. In: Epple M, Bäuerlein E Sangwon Myoung, James Lee, Paul Constantino, Peter Lucas,
(eds). Handbook of Biomineralization. Design Strategies of Human Teeth. Herzl Chai, Brian Lawn. Morphology and fracture of enamel.
Weinheim: WILEY‐VCH Verlag GmbH & Co. KGaA, 2007:183‐202. Journal of Biomechanics 42 (2009) 1947–1951

The Peripheral Rim - compression dome This is why your bonded buccal
composites sometimes fall off

Use a low modulus

composite like
Heliomolar that will
flex with the tooth

Tension Ring in Masonry Domes Tension Ring in Masonry Domes

Structural Analysis of Historical Constructions, New Delhi 2006 1 Structural Analysis of Historical Constructions, New Delhi 2006 1
Mahesh N Varma, Prof R. S. Jangid, Dr. V. G. Achwal ISBN 972‐8692‐27‐7 Mahesh N Varma, Prof R. S. Jangid, Dr. V. G. Achwal ISBN 972‐8692‐27‐7

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Does Hoop Stress fracturing happen in teeth? Further evidence of the Compression Dome/Bio‐Dome concept

Finite Element Analysis

Compression “hoop tensile stresses in Fig. 2b
are more uniformly distributed
around the inner enamel wall,
Grey=Compression
and are responsible for the
propagation of radial–median
Dentin Tension cracks downward from the
contact zone or margin cracks
upward from the enamel base”
Radial Stress

Chris Ford, Mark B. Bush, Brian Lawn. Effect of wear on stress distributions and
potential fracture in teeth. Journal of Materials Science: Materials in Medicine Magne P, Belser UC. Rationalization of Shape and Related Stress Distribution in Posterior Teeth: A Finite
November 2009, Volume 20, Issue 11, pp 2243‐2247 Element Study Using Nonlinear Contact Analysis. Int Jour Perio & Rest Dent. V 22, # 5, 2002 pg 2‐ 11.

Further evidence of the Compression Dome/Bio‐Dome concept Further evidence of the Compression Dome/Bio‐Dome concept

Finite Element Analysis Finite Element Analysis

Grey=Compression Grey=Compression

Magne P, Belser UC. Rationalization of Shape and Related Stress Distribution in Posterior Teeth: A Finite Magne P, Belser UC. Rationalization of Shape and Related Stress Distribution in Posterior Teeth: A Finite
Element Study Using Nonlinear Contact Analysis. Int Jour Perio & Rest Dent. V 22, # 5, 2002 pg 2‐ 11. Element Study Using Nonlinear Contact Analysis. Int Jour Perio & Rest Dent. V 22, # 5, 2002 pg 2‐ 11.

Further evidence of the Compression Dome/Bio‐Dome concept Further evidence of the Compression Dome/Bio‐Dome concept

Most of the Most of the

enamel Bio‐Dome enamel Bio‐Dome
complex is still in complex is still in
compression. compression.
Independent of Independent of
the underlying the underlying
dentin tension. dentin tension.

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Compression dome. Bio‐Dome. Bio‐Rim. Sigmoid curve distribution

Sigmoid Curve Distribution

Present in all posterior cusps,
(max/mand). (volume enamel > volume dentin)
More prevalent on functional
cusps as a biomechanical
reinforcement mechanism with
increased enamel volume.
The magnitude of the Sigmoid
curve increases in expression (volume enamel < volume dentin)
moving posteriorly.
Connecting the buccal and
lingual inflection points, one
derives the inflection plane.

The inflection plane is found to bisect the crown roughly in the middle
The reality is teeth are made up of multiple compression domes
allocating Volumetric dominant distribution (V enamel : V Dentin)

Compression dome. Bio‐Dome. Bio‐Rim.

CORONAL

Compression Dome

Bio‐Dome

Bio‐Rim

Adjacent Bio‐domes act as buttresses to one another.

The occlusal surfaces of the adjacent bio‐domes also act like a scissor arch!

Compression dome. Bio‐Dome. Bio‐Rim. New Concept

Occlusal Effect Caries

Cut an occlusal and you can

cause interproximal cavitation

Clinical Presentations of Stress Distribution in Teeth

and the Significance in Operative Dentistry.
This demarcation stress line in the Bio‐Dome highlights the interface between Milicich GW, Rainey JT:
the peripheral rim and the “ inverted scissor arch” of the occlusal enamel Pract Periodontics Aesthet Dent 2000:12(7),695‐700

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Functional Stress Relief – Vertical Lamellae Adult caries often begins under
“The enamel lamellae are shown to be a
enamel cracks
permeable pathway, allowing caries‐ Caries developing in
Only in producing bacteria access to the dentin‐ fractures is extremely
specific enamel junction. Caries can thus be difficult to detect
circumstances established within the tooth, without with conventional
visible evidence at the surface” radiography

Enamel cracks. The role of enamel lamellae in caries initiation Walker et al Enamel cracks. The role of enamel lamellae in caries initiation
Walker BN, Makinson OF, Peters MC Walker BN, Makinson OF, Peters MC
Normal in unrestored teeth Aust Dent J 1998 Apr;43(2):110‐6 Aust Dent J 1998 Apr;43(2):110‐6

Adult caries often begins under Occlusal Effect

enamel cracks
Decay developing and
spreading in dentino‐enamel
complex at the base of an
enamel fissure.
No enamel demineralization.

Enamel cracks. The role of enamel lamellae in caries initiation

Walker BN, Makinson OF, Peters MC Compression distortion
Aust Dent J 1998 Apr;43(2):110‐6

Occlusal Effect Caries Occlusal Effect Caries

Compression Because the

underlying dentin is
distortion leads to a
not in tension, it does
tension fracture in
not fracture, only the
the mesial and/or the
enamel fractures
distal peripheral rim
enamel

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Occlusal Effect Caries What is the

It is the wall that supports the compression dome complex
no dentin fracture

Walker et al

Pantheon ‐ Rome

What is the
It is the wall that supports the compression dome complex
If occlusal enamel is so important,
what should we do?
• Diagnose early and accurately
Laser or light fluorescence, light transmission,
caries detection dye, good lighting and
magnification
• Treat with minimally invasive techniques
Requires an understanding off occlusal
microanatomy.
Micro‐air abrasion guided with CDD, microburs,
Pantheon ‐ Rome
good lighting and magnification.

Teach the importance of occlusal Occlusal Effect Caries

Why doesn’t it show on an X‐ray?
micro‐anatomy in the schools
• Diagnose early and accurately
“… decay is difficult to detect in
Laser or light fluorescence, light transmission,
radiographs unless larger than
caries detection dye, good lighting and 2mm to 3mm deep into
magnification dentin, or 1/3 the bucco‐
• Treat with minimally invasive techniques lingual distance.”
Requires an understanding off occlusal
microanatomy.
2mm deep “cavity”
Micro‐air abrasion guided with CDD, microburs,
good lighting and magnification.
ROCK WP, KIDD EAM.
Br Dent J. 164(8): 243‐47, 1988.

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Occlusal Effect Caries Occlusal Effect Caries

Why doesn’t it show on an X‐ray? Why doesn’t it show on an X‐ray?

1/3
occlusal
width Less than 1/3
width of tooth

3mm deep “cavity” 4mm deep “cavity”

ROCK WP, KIDD EAM. ROCK WP, KIDD EAM.

Br Dent J. 164(8): 243‐47, 1988. Br Dent J. 164(8): 243‐47, 1988.

Occlusal Effect Caries The evidence is before us, but at the same time,
Why doesn’t it show on an X‐ray?
invisible to us, because it is fragmented and
dispersed in the research literature.
However, when the pieces of the puzzle are
Greater than 1/3
assembled in a certain way, a new picture is
width of tooth beginning to emerge.
Biomimetic Dentistry
Mimicking Mother Nature as closely as we can with
ROCK WP, KIDD EAM. current materials, techniques and technologies.
Br Dent J. 164(8): 243‐47, 1988.

Dentin tension fracture Sub-occlusal oblique transverse ridge

Load is placing the

underlying dentin
into tension

No enamel
demineralization

Large M/D dentin

fracture
Note the use of CDD to guide
focused micro‐preparation
No pink, NO CUT. Rainey T. A sub‐occlusal transverse ridge: identification of a
previously unreported tooth structure: the Rainey Ridge.
Journal of Clinical Pediatr Dent. 21(1); 9‐13, 1996.

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Sub-occlusal oblique transverse ridge Sub-occlusal oblique transverse ridge

There are many subtle, There are many subtle,

but critical anatomical but critical anatomical
structures that we are structures that we are
indiscriminately removing indiscriminately removing

Rainey T. A sub‐occlusal transverse ridge: Rainey T. A sub‐occlusal transverse ridge:

35yr old lower molar identification of a previously unreported tooth 35yr old lower molar identification of a previously unreported tooth
structure: the Rainey Ridge. Journal of Clinical structure: the Rainey Ridge. Journal of Clinical
Pediatr Dent. 21(1); 9‐13, 1996. Pediatr Dent. 21(1); 9‐13, 1996.

Sub-occlusal oblique transverse ridge Sub-occlusal oblique transverse ridge

There are many subtle,

but critical anatomical
structures that we are
indiscriminately removing

Rainey T. A sub‐occlusal transverse ridge: Rainey T. A sub‐occlusal transverse ridge:

Sub-occlusal oblique transverse ridge Sub-occlusal oblique transverse ridge

Some 65yr old Greek. Owns a Citrus Grove!
instability
developing

Sub‐occlusal Oblique transverse Ridge

Rainey T. A sub‐occlusal transverse ridge: Rainey T. A sub‐occlusal transverse ridge:
Suspensory Web of Enamel identification of a previously unreported tooth identification of a previously unreported tooth
structure: the Rainey Ridge. Journal of Clinical structure: the Rainey Ridge. Journal of Clinical
Peripheral Rim of Enamel Pediatr Dent. 21(1); 9‐13, 1996. Pediatr Dent. 21(1); 9‐13, 1996.

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Maxillary Web Maxillary Web

Retained intercuspal
X‐Brace
Fractured occlusal
– peripheral rim
interface

Rainey JT: The maxillary molar mesial‐sub occlusal enamel web:

Restorations over 30yrs old Rainey JT: The maxillary molar mesial‐sub occlusal enamel web:
Identification of a previously unreported tooth structure: the Identification of a previously unreported tooth structure: the
maxillary Rainey web. Pediatr Dent. 22(3); 195‐198, 1998 maxillary Rainey web. Pediatr Dent. 22(3); 195‐198, 1998

One more upper molar sub-structure One more upper molar sub-structure

Anatomy textbooks describe Anatomy textbooks describe

these grooves as fissures these grooves as fissures
They are not all fissures! They are not all fissures!

One more upper molar sub-structure One more upper molar sub-structure

Keeping the
occlusal and
These areas are fissures peripheral
rim of
enamel
The rest are simple intact keeps
the tooth
developmental folds in stable
the enamel
Maxillary web removed and peripheral rim transected
Every cusp fractured plus a M/D fracture!
NOT A BRUXER!

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Do adhesive ceramics work?

12 year old
22 years old fracture

19 years old

Do adhesive ceramics work? Do adhesive ceramics work?

12 year old
28 years old fracture

25 years old

19 year old feldspathic onlay

19 years old

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Joining enamel (or porcelain) to dentin

Resin impression of the
Dentino‐enamel Complex
• The DEC is a more open
structure
• Lower mineral content
than enamel or dentin
Isao Urabe, Masatoshi Nakajima, Junji Tagami
Physical Properties of the Dentin‐Enamel Junction Region.
• Acts as a stress breaker
AmJDent 2000; 13:129 [intro2] between the enamel
compression dome and and sensitivity and on chewing
7 the dentin (any or all of the above)

There are six types of tooth fracture There are six types of tooth fracture
1. Occlusal effect fractures – vertical in the enamel peripheral rim
• Teeth are designed to work in compression
2. Occlusal effect fractures – occlusal abfraction – loss of tooth
• Disturb the compression dome system” and areas between peripheral rim enamel and the restoration
become exposed to tension 3. Vertical mesio‐distal fractures
• Fractures are driven by a compressive load creating a force 4. Oblique cusp fractures – most common form
that places either enamel or dentin into 5. Randomly oriented Poisson Effect vertical fractures in the
dentin core
6. Catastrophic point overload fractures (trauma and foreign
objects in food)

The three basic forces driving fractures Cyclical stresses and strains well below the
single load failure load cause crack
propagation over time.
This high cycle fatigue load can be as low
as only 25% of the failure load for dentin.

Tensile Force Shear Force Torsional Force

The time part of the equation in teeth is
REVIEW OF THE FRACTURE TOUGHNESS APPROACH
Karl‐Johan Soderholm
Department of perative Dentistr
Co ege of Dentistr niversit of orida pg
20‐40yrs

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Then there are the catastrophic fractures Or the subtle diagnostic challenges
• Patient presented with intermittent pressure sensitivity on
lower right.
• Pointed to the 46.
• Removal of the old amalgam exposed a dentin fracture.
• Restoration did not resolve the symptoms!
• Similar treatment to 47, another fracture.
• Still no resolution after treatment.
• Patient still pointing to the 46!
• The 46 and 47 had “symptomless” dentin fractures
Virgin tooth. A foreign object in the food You need an Erbium Laser!
created an unexpected point overload. Closed flap bony crown lengthening

Or the subtle, diagnostic challenges Mesio‐distal Vertical Cracked Tooth

Differential Diagnosis
The BIG question ‐ Reversible or Irreversible Pulpitis?
The unrestored 48 had a
vertical mesio‐distal fracture • Reversible
halfway down the mesio‐buccal Transient hot or cold sensitivity
cusp incline! Pressure sensitivity
Restoration instantly resolved
No percussion sensitivity
the symptoms.
Recovers from stimulus very quickly
Some teeth have no symptoms at all, but you can see the crack
Remove the restoration and have a look
• Tx. Adhesive Onlay – warn patient of possible need for future
endo

Mesio‐distal Vertical Cracked Tooth

Differential Diagnosis
Cracks with Reversible Pulpitis
The BIG question ‐ Reversible or Irreversible Pulpitis
• Irreversible • Don’t kill the pulp!
Spontaneous pain • Deal to the fractures without exposing the pulp
Prolonged response to hot or cold
Percussion sensitivity • Don’t leave unstable dentin above oblique cracks
• If there is associated periodontal bone loss ‐ extract
• Recreate the compression dome without
• Start Endo ‐ If crack extends to involve pulpal floor – extract
• If pulpal floor is intact ‐ Adhesive restoration as per endo
preparing full crown coverage
protocol and advise re the potential for the crack to continue
extending

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Two basic dentin fracture types Two basic dentin fracture types
Oblique under the cusps Oblique under the cusps

Two basic dentin fracture types Longitudinal fractures

Vertically oriented mesiodistal cracks
72.0% of longitudinal tooth fractures occurred in restored teeth
28.0% were found in intact teeth.

RESTORATION METHOD
BONDED: Resin (4.7%) or Porcelain (0.9%)
NON‐BONDED: Gold (20.5%) or Amalgam (18.7%)
As a group, BONDED RESTORATIONS worked better
Seo DJ,Yi YA, Shin SJ, Park JW.
Analysis of factors associated with cracked teeth.
J Endod. 2012 Mar;38(3):288‐92. doi:
10.1016/j.joen.2011.11.017. Epub 2012 Jan 5.

We contribute to dentin failure! Then there are disasters!

Dentin has a fatigue limit. For stresses smaller than the
normal stresses of mastication, 30 MPa, a flaw‐free
dentin specimen apparently will not fail. However, a more
conservative approach based on fatigue crack growth
rates indicates that if there is a pre‐existing flaw of
sufficient size 0.3‐1.0 mm , it can grow to catastrophic
proportion with cyclic loading at stresses below 30 MPa.

The Mechanical Properties Of Human Dentin: Critical Review And Re‐evaluation Of

The Dental Literature. J.H. Kinney, S.J. Marshall, G.W. Marshall.
Critical Reviews in Oral Biology & Medicine. 14(1):13‐29 (2003)

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Mesio‐distal fracture in a virgin tooth

hat causes this

Mesio‐distal fracture in a virgin tooth Mesio‐distal fracture in a virgin tooth

TENSION

hat causes this Oblique occlusal forces hat causes this

Oblique cusp fractures once the Oblique cusp fractures once the
occlusal integrity has been destroyed occlusal integrity has been destroyed

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Oblique cusp fractures once the Oblique cusp fractures once the
occlusal integrity has been destroyed occlusal integrity has been destroyed
The bricks above the
crack in the wall are
NOT CONNECTED to
the base.
A big shove and they
will tip off.

The dentin above the

oblique fractures is
NOT CONNECTED to the
underlying dentin

Oblique cusp fractures once the How do we account for mesio‐distal and bucco‐lingual
occlusal integrity has been destroyed fractures in teeth with existing oblique fractures?
The bricks above the
crack in the wall are
NOT CONNECTED to
the base.
A big shove and they
will tip off.

Flicked off with a The dentin above the

probe! oblique fractures is
NOT CONNECTED to the
underlying dentin

Same tooth with oblique

fractures removed

How do we account for mesio‐distal and bucco‐lingual Poisson’s ratio

fractures in teeth with existing oblique fractures?

For a linear isotropic material subjected only to compressive (i.e. normal) forces, the
deformation of a material in the direction of one axis will produce a deformation of the material
along the other axis in three dimensions.

Where:

Same tooth with oblique

fractures removed Poisson Effect

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How do we account for mesio‐distal and bucco‐lingual How do we account for mesio‐distal and bucco‐lingual
fractures in teeth with existing oblique fractures? fractures in teeth with existing oblique fractures?

Compression
FE analysis: Clenching
Grey = Compression.
Stress greatest in the
layer of dentin
directly over the pulp
Tension

This effect is three dimensional

Same tooth with oblique Same tooth with oblique
fractures removed Poisson Effect fractures removed Magne P, Belser UC. Rationalization of Shape and Related Stress Distribution in Posterior Teeth: A Finite
Element Study Using Nonlinear Contact Analysis. Int Jour Perio & Rest Dent. V 22, # 5, 2002 pg 2‐ 11.

TENSION

This effect is independent of the forces creating

Same tooth with oblique Same tooth with oblique
the oblique fractures under the cusps
fractures removed fractures removed

Deeper cavities Deeper cavities

= less dentin over = less dentin over
the pulp the pulp
= increased = increased
stresses in the stresses in the
remaining dentin remaining dentin

Primary fracture is a vertical M/D fracture Primary fracture is a vertical M/D fracture

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How do we account for random mesio‐distal and bucco‐ How do we account for random mesio‐distal and bucco‐
lingual fractures in teeth with existing oblique fractures? lingual fractures in teeth with existing oblique fractures?
Note: buccal and
palatal enamel
have not been
reduced down to
the dentin Deeper cavities Deeper cavities
= less dentin over = less dentin over
the pulp the pulp
= increased = increased
stresses in the stresses in the
remaining dentin remaining dentin

Independent of the M/D fracture is an area of Independent of the M/D fracture is an area of
Poisson Effect fracturing under the old amalgam Poisson Effect fracturing under the old amalgam

Deep dentin exhibited the lowest resistance to the initiation

Note: the Poisson Effect of fatigue crack growth, and the highest incremental fatigue
radial fractures are centred crack growth rate (over 1000 times that in peripheral dentin).
Cracks in deep dentin underwent incremental extension
under the site of the under cyclic stresses that were 0 lower than those
amalgam, independent of required in peripheral dentin.
the mesio‐distal fracture Molars with deep restorations are more likely to suffer from
the cracked‐tooth syndrome, because of the lower fatigue
crack growth resistance of deep dentin.

The three dimensional nature of the Poisson effect J. Ivancik, N.K. Neerchal, E. Romberg, and D. Arola.
accounts for the multi‐directional nature of the fractures The Reduction in Fatigue Crack Growth Resistance of Dentin with Depth. J
Dent Res 2011 90(8):1031‐1036.

Deep dentin exhibited the lowest resistance to the initiation

of fatigue crack growth, and the highest incremental fatigue Note: the Poisson Effect
crack growth rate (over 1000 times that in peripheral dentin). radial fractures are centred
Cracks in deep dentin underwent incremental extension
under cyclic stresses that were 0 lower than those under the site of the
required in peripheral dentin. amalgam, independent of
Molars with deep restorations are more likely to suffer from the mesio‐distal fracture
the cracked‐tooth syndrome, because of the lower fatigue
crack growth resistance of deep dentin.

J. Ivancik, N.K. Neerchal, E. Romberg, and D. Arola. The three dimensional nature of the Poisson effect
The Reduction in Fatigue Crack Growth Resistance of Dentin with Depth. J
Dent Res 2011 90(8):1031‐1036.
accounts for the multi‐directional nature of the fractures

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Poisson Effect Fractures Poisson Effect Fractures

Not

Not
Not

A bonded restoration prevents the horizontal slip A bonded restoration prevents the horizontal slip
between the restoration and the underlying dentin between the restoration and the underlying dentin

Ribbond bonded directly Bonding allows

to dentin • distribution of stress and strain
• prevents the load limit of dentin
from being reached
Reduces lateral distortion
from Poisson Effect

A bonded restoration prevents the horizontal slip

between the restoration and the underlying dentin What to do?
• If any of these cracks types are treated
Poisson Fracture Treatment incorrectly, the pulpal symptoms will not
• Fractures under old amalgams – resolve….
Bonded Ribbond and a bonded
restoration • Then unnecessary/avoidable endo is
performed to stop the patient complaining
Preventing Poisson Fracture
• Don’t place amalgams • Diagnose correctly and treat accurately and
• Place bonded restorations the pulp will survive

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Clinical example of differential treatment of a fracture Clinical example of differential treatment of a fracture

The driving loads are

These both look like completely different and the
Occlusal Effect Caries treatment is totally different

Clinical example of differential treatment of a fracture Clinical example of differential treatment of a fracture

Occlusal Effect Caries

Compressive distortion of
peripheral rim of enamel >
Tension in enamel only
NO DENTIN RACTURE

Treatment:
Simply remove the caries and
fracture and restore with a
Load vectors create tension on bonded restoration
Compression > tension in enamel the underlying dentin

Clinical example of differential treatment of a fracture Occlusal Effect or Vertical Tension Fracture?

Simply restoring the distal crack with

a bonded restoration will doom this
tooth to failure.
Treatment:
• Dissect out oblique cusp fractures
and distal enamel fracture.
• Splint M/D fracture with Ribbond.
• Fill core with everX Posterior.
• Recreate disrupted enamel
compression dome with bonded
e.max onlay. DANGER! Tension in dentin as well
?
• Puts dentin back into Mesio‐distal dentin fracture.
compression. Tooth at extreme risk!

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Occlusal Effect or Vertical Tension Fracture? Occlusal Effect or Vertical Tension Fracture?
Check the occlusion. Check the occlusion.

Looks like occlusal The CULPRIT!

overload splitting
the distal half of the
tooth.
Patient is only 24
and can’t afford any
dentistry.

Occlusal Effect or Vertical Tension Fracture? Occlusal Effect or Vertical Tension Fracture?
Still looks like Fine, vertical mesio‐
Occlusal Effect distal fracture.
Caries NOT Occlusal Effect
Caries.
Needs complex
reconstruction.

Occlusal Effect or Vertical Tension Fracture? Occlusal Effect or Vertical Tension Fracture?
STABILIZE! Dentin replaced
Distal wall built up with fibre reinforced
incrementally. EverX Posterior
Ribbond across
floor.

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Occlusal Effect or Vertical Tension Fracture? Occlusal Effect or Vertical Tension Fracture?
Completed Or, create a fibre
restoration reinforced BioBase
and finish with a
DEAL WITH THE One Visit CEREC
CULPRIT! inlay/onlay
restoration
Occlusion shifted
away from a
centralized splitting
force

Where is the strength in a tooth?

Take a solid plastic rod

Remove the core

Where is the strength in a tooth? Where is the strength in a tooth?

3mm Beam theory states that the load‐
32 = 9
carrying capacity of a beam is
proportional to the square of the
distance from the neutral axis centre, to
4.52 = 20.25
the tensile side. The part of the tooth
. mm that remains after crown prep has the
We are left with a pipe of least load resisting capacity of the
original clinical crown. That is assuming
the original diameter and a that there is much remaining
1.5mm
smaller diameter rod walls central “tooth structure”.
This is why full crowns on laterals and
premolars fracture so often!

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Where is the strength in a tooth? Where is the strength in a tooth?

3mm 3mm
Subtract the core from the Subtract the core from the
original rod The other half is in the original rod
20.25 – 9 = 11.25 core. The strength is 20.25 – 9 = 11.25
proportional to the
. mm square of the radius. . mm

Approximately half the

1.5mm “strength” of the original rod 1.5mm
walls walls
still resides in the walls of
the pipe

Where is the strength in a tooth? Where is the strength in a tooth?

Imagine this an endo premolar

with a large internal cavity and
In the cervical half of the tooth, access hole.
this “pipe” is the Now do a full crown prep!
This is where the tooth’s
strength resides. Conserve it.

Where is the strength in a tooth? Where is the strength in a tooth?

From another perspective. The remaining rod is still the
Take the same diameter rod. same diameter.
Without reducing its diameter, It is still just as “strong” and
cut 2mm off the top. retains all of its load carrying
capacity.

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Cementation requires the destruction Cementation requires the destruction

of all the of all the

Cementation requires the destruction Adhesive designs, ceramic or direct composite,

of all the retain the

Zero pulpal stress.

The tooth was symptomless If you cemented a
ceramic
Minor margin restoration on
modification with a SE cement,
following fracture it will fall off!

Cementation demands a ferrule. Cementation demands a ferrule.

Without a ferrule, even with pins, a Without a ferrule, even with pins, a
cemented crown will overload a core cemented crown will overload a core

0 reduction on 0 reduction on
bonded core bonded core
surface surface

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Cementation requires the destruction Cementation requires the destruction

of all the of all the
Ferrule Cementation >17% endo in 5 years (CRA) U of South Carolina ‐1 endo rate
4 million dentin tubules/cm2 under full crown preps per year!!
are exposed in a crown prep

Ferrule cementation Placing an aesthetic

designs remove most, if margin removes all of the
Pulp not all of the Pulp very
unhappy unhappy
Plus it puts the pulp
at high risk

Adhesive designs, ceramic or direct composite, You would expect a bonded composite crown to
retain the survive, why not a bonded ceramic?

This was the

final prep
Retained Biorim
Happy Pulp

Adhesive designs, ceramic or direct composite,

retain the

If there is no room for a conventional

cementation ferrule, and you are not
using adhesive techniques, you are
then forced to do an
endo, core and crown

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Primary = 1 interface
Secondary = 2 interfaces
Tertiary = 3 interfaces
David Rudo
Increasing numbers of
interfaces increases stress
concentrations into the
dentin (less stress is
absorbed by the core)

S.Belli, O.Eraslan, G.Eskitascioglu, V.Karbhari.

Monoblocks in root canals: a finite elemental stress
analysis study.
International Endodontic Journal,44,817–826,2011

Which technique matches dentin the best? Reinforcing tooth structure

45 root filled teeth deliberately fractured
vertically through the root
1. Restored with dual cure bonded Z100
2. Restored with dual cure resin cement and
Ribbond polyethylene woven fibre
3. Restored with dual cure resin cement and
Stick‐Net unidirectional e‐glass fibre

Restored teeth then re‐fractured using the same technique

S.Belli, O.Eraslan, G.Eskitascioglu, V.Karbhari. Evaluation of Fracture Resistance of Reattached Vertical

Monoblocks in root canals: a finite elemental stress Fragments with Fibre Reinforced Composites: An in‐vitro
analysis study. study. B Shiva Kumar et al.
International Endodontic Journal,44,817–826,2011 J Contemp Dent Prac Ju ug ( )

Reinforcing tooth structure Reinforcing tooth structure

None of the Ribbond reinforced teeth re‐fractured

along the same plane as the original fracture
Evaluation of Fracture Resistance of Reattached Vertical Evaluation of Fracture Resistance of Reattached Vertical
Fragments with Fibre Reinforced Composites: An in‐vitro Fragments with Fibre Reinforced Composites: An in‐vitro
study. B Shiva Kumar et al. study. B Shiva Kumar et al.
J Contemp Dent Prac Ju ug ( ) J Contemp Dent Prac Ju ug ( )

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Bonded Ribbond/Composite Core 4 Primary Ribbond Effects

Distributes and helps absorbs loads Depending on where and how it is used and
and stresses without transferring all how it is applied:
the stresses into already weakened 1. Reinforces tooth structure
tooth structure
2. Reinforces composite
Polyethylene Fibre Leno weave
Tensile strength 435,000psi – 3.0GPa 3. Help control C‐Factor shrinkage stresses
Modulus of Elasticity 24,800,000psi – 171GPa (decoupling)
(high strength fishing lines, bullet proof vests)
4. Distributes stress and reduces stress
S.Belli, O.Eraslan, G.Eskitascioglu, V.Karbhari.
concentration
Monoblocks in root canals: a finite elemental stress
analysis study.
International Endodontic Journal,44,817–826,2011

Fibre Reinforced Composite Engineering Tough fiber composite architectures

Triaxial braid and Leno weave

THM Ultra

Tough fiber composite architectures Finite Element Analysis : Triaxial Stress Reduction
Triaxial braid and Leno weave

Unidirectional glass i ond eno wea e

Stress distribution via Multi‐directional linear orientation

multiple load paths
Eskitascioglu et al. J Dent. Research 2006; Vol. 85
Special issue A

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Cook‐Gordon Mechanism for stopping cracks at a Cook‐Gordon Mechanism for stopping cracks at a
weak interface weak interface
EDJ/Ribbond Fracture planes occur
along the decussation
Enamel interfaces) of the
Hunter Shreger
bands(prism groups in
opposite planes

a rac approaches a wea inter ace Dentin Arrest at the DEC

Inter ace rea s ahead o main crac
c T shaped crac stopper
David Rudo ‐ Ribbond

Cook‐Gordon Mechanism for stopping cracks at a Cook‐Gordon Mechanism for stopping cracks at a
weak interface weak interface

Multiple Multiple
crack crack
stopping stopping
events events
No fibre No fibre
THM Ultra THM Ultra

Segments polymerization shrinkage Area under the graph = amount of energy absorbed
Nodes inhibit micro‐cracks from coalescing into real cracks
Stops crack propagation, encapsulates crack growthDrs. Selim Erkut and zlem Acar Drs. Selim Erkut and zlem Acar

Redirecting Cracks Micro events determine global response

The Ribbond should
have been at the
bottom of the beam!

Note: the composite

fractures above the
Ribbond look just like
the enamel tufts in the
SEM

BIOMECHANICAL PROPERTIES AND CLINICAL USE OF A POLYETHYLENE FIBRE POST‐CORE MATERIAL

SEMA BELLI & G RCAN ESKITASCIOGLU INTERNATIONAL DENTISTRY SOUTH AFRICA VOL 8., NO 3
Liberty Ship

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Energy absorption mechanism In cross section, tension will cause separation

i.e., toughness of enamel and fiber composites between individual fibres within a strand
(does not effect longitudinal strength)
Enamel has been regarded as a hard ceramic like material with
very limited toughness. In the past two years, reports have
emerged showing that enamel behaves in a somewhat more
metal‐like manner in terms of elastic and plastic properties
(including creep) (He and Swain, 2007b). Using SEM analysis,
we provided direct evidence for the first time showing that
Decoupling ‐ C‐Factor shrinkage stress control
the ability of enamel to absorb energy and
sustain deformation without catastrophic
failure is attributed to its viscoelastic protein
layers.

hearin o protein la ers etween apatite cr stals The Effect of C‐Factor and Flowable Resin or
Fiber Use at the Interface on Microtensile Bond
ailure mechanism is the tou henin Structural Integrity of Enamel: Experimental and Modelling
Z. Xie, M.V Swain and M.J. Hoffman
Strength to Dentin. Belli S, Donemz N,
Eskitasciogiu G.
ener a sor in mechanism J DENT RES 2009; 88; 529 J Adhes Dent;8:247‐253.

In cross section, tension will cause separation In cross section, tension will cause separation
between individual fibres within a strand between individual fibres within a strand
(does not effect longitudinal strength) (does not effect longitudinal strength)

This phenomenon is used in David Alleman’s

Decoupling ‐ C‐Factor shrinkage stress control
technique to control C‐Factor shrinkage
Shrinkage Stress
stresses when bonding to very deep,
compromised dentin (schlerotic or affected
Decoupling disconnecting dentin) where bond strengths may only be
Bond is protected 10‐15MPa

Ribbond C‐Factor stress breaker Effect of Bondline Thickness Vistap.M.Karbhari Ph.D.

Polymerization shrinkage occurred

within the Ribbond luting composite region.
There was no gap formation between
the canal walls and the Ribbond‐luting
composite region.

Figure 10: Scanning e ectron micrographs from the apica section Erkut. Microleakage in Over flared
of the interfacia a ers bet een dentin resin based uting agent Root Canals Restored with Different
and RD in the R group.D dentin L uting agent h brid Fiber Reinforced Dowels
The closer the fibre is to the substrate; the greater is the fibre effect.
one RT resin tag R Ribbond (origina magnification ). perative Dentistr 33‐1 The further away the fibre is from the substrate, the greater is the resin effect.

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The three most common sources of

Fiber effects
post treatment pain
Positive Fiber effects
• Segments and minimizes polymerization shrinkage • Failure of a dentin bond under
• Encapsulates, inhibits, stops, redirects crack propagation composite
• Stops micro‐cracks from coalescing into real cracks • Undiagnosed or inaccurately treated
• Toughening mechanism dentin fractures
• Load carrying and stress distribution mechanism • Consequences of deep decay

BONDED WALLS
C=
UNBONDED WALLS

Bouschlicher,Vargas,Boyer. Effect of composite type, light intensity, configuration

factor and laser polymerisation on polymerisation contraction forces
Am J Dent 1997 Apr,10(2)88‐96

Smooth surface Two walled cavity

1 BONDED 2 BONDED
C= C=
5 UNBONDED 4 UNBONDED

C‐Factor 0.2 C‐Factor

C‐ actor 0.5
0.
Facial Veneer Cl IV cavity
Very shallow buccal

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Three walled cavity Four walled cavity

3 BONDED 4 BONDED
C= C=
3 UNBONDED 2 UNBONDED

C‐Factor 1 C‐Factor 2
Cl III cavity Cl II cavity

Five walled cavity Polymerization stress reduction by flow

was shown to depend on C‐Factor
• C = 0.5 71% of polymerization stress was
5 BONDED
C= relieved by flow
1 UNBONDED
• C = 2 35% of stress was relieved by flow
• C = 5 negligible stress reduction
C‐Factor 5
Cl I cavity The MOST DIFFICULT restoration in dentistry is a
Cl V deep cavity bonded composite “core” in an endo pulp chamber!
Feilzer AJ, De Gee AJ, Davidson CL; uantitative determination of
stress reduction by flow in composite restorations.
Dent Mater 6:167‐171 July 1990

The Clinical Implications The Clinical Implications

Incremental build up Incremental build up

Horizontal increment Horizontal increment

Keep at 1mm

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The Clinical Implications The Clinical Implications

Incremental build up Incremental build up

Horizontal increment Sectional increment

Keep at 1mm
This reduces C‐Factor
C‐ actor 0. ‐ 1.0
Large free surface

The Clinical Implications The Clinical Implications

Incremental build up Incremental build up

Sectional increment Sectional increment

Touching 2 walls Touching 2 walls
C‐ actor 0. C‐ actor 0.
Large exposed free Large exposed free
surface surface

The ultimate in polymerization stress control.

A sectioned, 1mm thick layer

The Clinical Implications Effects of Layering Techniques on Bond Strengths

Incremental build up

C‐Factor 0.5
increments over
a Bio‐base
4mm 4 Increment 4 Increment 4 Increment
Bulk Fill Vertical Fill Oblique Fill Horizontal Fill
Influence of C‐Factor and Layering Technique on Microtensile Bond
Strengths to Dentin. S Nikolaenko, R.Fankenberger et al
Dental Materials 2004, Voll 20: 579‐585

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Effects of Layering Techniques on Bond Strengths Compression dome. Bio‐Dome. Bio‐Rim.

35
31
30 1 layer (4mm)

25 2 layers (2mm)
19.8 19
20 17.6
16 4 layers (1mm)
15.7
15
11
10
5
MPa
Bulk Fill Oblique Vertical Horizontal
Influence of C‐Factor and Layering Technique on Microtensile Bond
Strengths to Dentin. S Nikolaenko, R.Fankenberger et al Occlusal dentin shade is concave
Dental Materials 2004, Voll 20: 579‐585

Putting all the concepts together Putting all the concepts together
• 2 separate cavities prepared
• Triodent wedge guard used to
protect adjacent tooth
• Enamel margins bevelled
• Affected dentin left to avoid a
pulp exposure

Where is the decay?

Symptomless tooth!

Putting all the concepts together Putting all the concepts together
• 2 separate cavities prepared • Selective acid etch enamel
• Triodent wedge guard used to margins
protect adjacent tooth • 2 step SE Bond ‐ Clearfil SE Bond 2
• Enamel margins bevelled • Scrub in primer 20 sec, air dry
• Affected dentin left to avoid a • Apply resin, blot excess out with a
pulp exposure micro‐brush, cure
• 2mm wide sound dentin and
enamel margin

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Putting all the concepts together AdDent Composite Warmer

• 0.5mm layer of radio‐opaque
flowable
• Cure
• Consider this to be a part of your
dentin hybridization step
Attachments for either compules or syringes Pre‐dispensed increments

Placement instruments. Micro‐brush and Ash 6 Probe.

Putting all the concepts together Putting all the concepts together
• A square of Ribbond THM Ultra is • Place a thin layer of warm enamel
placed into a thin layer of warm shade to the height of the
composite and pressed right marginal ridge
through to the underlying set • Split the increment vertically –
flowable. don’t join two opposing walls
• Use the microbrush that was usd
to apply the bonding resin B
• This wets the fibres at the same
time as placing
• Keep away from the margin

Putting all the concepts together Putting all the concepts together
• Fill in the rest of the interproximal • 1mm layer of dentin shade
enamel

Copyright G W Milicich 2017. Private use only 24

1/10/2017

Putting all the concepts together Putting all the concepts together
• 2nd 1mm layer of dentin shade • Enamel shade contoured with
• Contoured with probe into a probe
concave fissure pattern, 1mm • The depth of the fissures is
below the final surface almost down to the underlying
dentin shade.
• This gives colour depth without
having to stain

Putting all the concepts together Putting all the concepts together
• White enamel shade applied to
match the initial tooth