BONDED PORCELAIN RESTORATIONS IN THE ANTERIOR DENTITION A Biomimetic Approach Pascal Magne, PD, DR MED DENT a Urs Belser, PROF, DR MED DENT ragelibrary of Congress Catalogin: Magne, Pascal Bended porcelain restorations in the ontrior dentition: a biomimetic cepproach / Poscal Magne, Urs Belser pian Includes bibliographical references and index ISBN 0-86715-422-5 (hardback) 1. Growns (Dentistry). 2. Dental ceramics. 3. Dental bonding. 4. Dentisiry—Aesthetic ospects [DNUM: 1. Dental Bonding—methods. 2. Dental Porcelain. 3 Esthetics, Dental. 4, Tooth Preporation, Prosthodontc. WU 190 M196b 2002] |. Belser, U. I. Tile. RKA66 M24 2002 617.6'9—de2h 2001006636 Gb avintesrence ‘books © 2002, 2003 by Quintessence Publishing Co, Ine Al rights reserved. This book or any port thereof may not be reproduced, stored in a retrieval system, or tronsmitted in any form or by any means, elecronic, mechanical, photocopying, recording, or otherwise without prior written permission of the publisher. Quintessence Publishing Co, Inc 551 Kimberly Drive Corol Stream, IL 60188 wow. quintpub.com Printed in GermanyBonded Porcelain Restorations in the Anterior Dentition: A Biomimetic Approach Pascal Magne, Pp, DR MED DENT Genev tzerland Urs Belser, PROF, DR MED DENT Prosthodontics and Occlusior Quintessence Publishing Co, Inc quinterrence Chicago, Berlin, London, Copenhagen, Tokyo, Paris, Barcelona, Milano, books Sao Paulo, New Delhi, Moscow, Prague, Warsaw, and IstanbulPerec ee ce aoa sk ceric from the University of Geneva in 1992, re- ceived postgraduate training in fixed prostho- dontics and occlusion, and operative dentistry and endodentics, and obtained his PD degree {Privatdocent) in 2001. es pou ad iting Associate’Professor at the Minnesota Dental Research Center for Biomaterials and Biome- chanics from 1997 to 1999, he is currently Senior Lecturer in the Department of Fixed ee Rhee mm CM ir caer meee mums acum Swiss Science Foundation [1997], the Swiss Foundation for Medical-Biological Grants ee nai ec aera ce ci eee ech ea Pan ere ists Cares icc eM Mee cente nid Re gt lecaeni eColit oN Nel ue eR ERM ies Creer Wada RT ao =e Urs Belser received his Dr med dent degree from the University of Zurich in 1974 and ob- Cette Motors cote sl coTATIe uM cto Menke) isere( oA eke Cg ae eee Lorelle eM arom Eo g mel MP Tole ecu og rs Magoo lu CoM re WLU Nol oUt CCRC aera em Ao) MRS OR OMNI WT Mace te LCs Cott ments of Oral Biology and Clinical Dental Sciences at the University of British Columbia from 1980 to 1982, and as Senior Lecturer in the departments of Fixed Prosthodontics and Dental One MOINS Airc ico bs oS eR coche and Head of the Department of Fixed Prosthodontics and Occlusion at the University of CM Const natin cicmemuteic gmt Cmca Core Oe Me me is ee ul els nN eestor o Te oeLeEmerging concepts in biomimetics provide the ability to restore the biomechanical, structural, and esthetic integrity of teeth. New adhesive techniques and novel porcelain veneer designs Ce ie Mee MT Moree] elec Me MCC LMM Te oli eae me colitis) Pee me Seen Meh Ro sree Meee eMule eC RAM eee nee yore ie cera te) incisors and nonvital teeth. As a result, considerable improvements have been made both Be eee aC Roce ece eRe area ee mee naan Peli el t-te Mca eee LUPIN tem iee(s ste eT ure hom ror saters| =i ioc berets coll lela A oe UR UL aC oleh Reo MAL] elie amare esol oli g Sia iteMitro Mo ACM oats Ui fog donee el aM oie) LC Pa Mo Col ol Medi ole Ti Sirecrarelito Mis edu ere oi tol SC Ule Ams a aot MLACol Te AMT e Ls CUO Le CoM ae aM) ML Cerne Meets ROR diol aoe ole Ricoto em ees A a eC Rol eee Rot MN IU aces oR AL lL oC MoM elke eM RC oltord SiMe) etcetera Te MM SLC ao i ceo Ol eM cere oon eS MM oC Watch natures. .Not man-made...a Sat aenot humanly inspired...but divinely designed...and faithfully emulated.DEDICATION sd nd my father, Albin, who supp: ‘ations, To my brother, Mi or dentistry and who was taken fre To my wife, Ge tal technique. In memory us by cancer too early PM In memory of my mother, + To my wife, ChristTABLE OF CONTENTS FOREWORD 19 PREFACE 20 CHAPTER UNDERSTANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE Function, and Esthetics Cracking on CHAPTER 2 NATURAL ORAL ESTHETICS N 99CHAPTER 4 EVOLUTION OF INDICATIONS FOR ANTERIOR BONDED 129 PORCELAIN RESTORATIONS to Bleaching Fg Moditic hologic Modifica CHAPTER 5 INITIAL TREATMENT PLANNING AND DIAGNOSTIC APPROACH 179 Patie boratory Relationships ry Team CHAPTER 6 TOOTH PREPARATION, IMPRESSION, 239 AND PROVISIONALIZATIONCHAPTER 7 LABORATORY PROCEDURES sice of Restorative Moteriol an sier Casts in the Refractory Die yer Finishing fle 1APTER 8 TRYIN AND ADHESIVE LUTING PROCEDURES CHAPTER 9 MAINTENANCE AND REPAIRS GUIDE TO CLINICAL C INDEXFOREWORD tis with considerable pleasure that | write the foreword to Dr Magne and Prof Belser’s book, which takes the science of esthetic dental reconstruction to a new level both ally and academically, Dr Magne spent 2 years as a visiting associate professor in the Minnesota Dental Research Center for Biomaterials and Biomechanics at the University of Minnesota, where many of the ideas pro rmulgated in this book were hotly debated, refined, and tested in a modeling and experimental ert vironment. In this book, clinician will find all that he or she could wish for in terms of indi ‘ond the classic clinical steps for tooth preparation, laboratory procedures, adhesive luling proce dures, and maintenance protocol. Those whe have heard Dr Magne lecture will not be disap- pointed. In fact, they will find much more that is prac Hor lly ond intellectually satisfying The central philosophy of the book is the biomimetic principle, that is, the idea that the intact tooth in its ideal hues and shades, and perhaps more importantly in its inttecoranal anotomy and loca: fion in the arch, is the guide to reconstruction and the determinant of success, The approach is ba- sically conservative and biologically sound. This is in sharp contas! lo the porcelain usedtometal technique, in which the metal casting with is high elastic modulus makes the underlying dentin hypo functional, The goa! of the authors’ approach is to retum all of the prepared dental tissues to full function by the creation of hard fissue bond that allows functional stress to pass through the tooth, drawing the entire crown into the final esthetic result I hope that this book will receive o wide readership ond that its principles will be corelully studied and become fully established in teaching and research, as well as de rigueur in the practice of restorative dentistry. Wiliam H, Douglas, BDS, MS, PhD Directo, Minnesota D Chait, Deparment of Oral Science, University of Minnesota Minneapolis, Minnesota Research Center for BiomoteriaPREFACE The most exciting developments in dentisiy have emerged within the post decade. Oro! implant dentisty, guided tissue regeneration, and adhesive restorative dentistry are strategic growth areas both in research and in clinical practice. However, the many advances in dental materials and tech nology have generated « plethora of dental products in the marketplace. Clinicians ond denial tech nicians are faced with difficult choices as the number of treatment modalities continues to grow. Fur ther, changes in technology do not always simplify technique or decrease treatment costs. Prudence and wisdom need to be combined with knowledge and progress when it comes fo improving our patients’ welfare. In this perplexing-context, no one will contest the need for less expensive, satisfaciory, and rational substivies for cutrent reaiments. The answer might come from an emerging interdisciplinary biome terial science called biomimetics.' This concept of medical research involves the investigation of the structure and physical function of biologie “composites” ond the design of new and improved substi jules. Biomimetics in dental medicine has increasing relevance. The primary meaning for denlisiry refers to processing material in a manner similar to that by the oral cavity, such as the calcification of a soit tissue precursor. The secondary meaning refers to the mimicking or recovery of the biome chanics of the original tooth by the restoration. This, of coutse, is the goal of restorative dentistry Several research disciplines in dental medicine have evolved with the purpose to mimic oral struc tutes. However, this nascent principle is applied mostly ct c molecular level, with the cim to enhance wound healing, repait, and regeneration of sof and hard tissues.* When extended to a macro stuctural level, biomimetics can trigger innovative applications in restorative dentisiry. Restoring or mimicking the biomechanical, structural, and esthetic integrity of teeth is the driving force of this process. Therefore, the objective of this book is to propose new crtecia for esthetic restorative den fisty based on biomimetics. Biomimetics in restorative dentisiy starts with an understanding of hard tissue structure and reloted stress distribution within the intact toolh, which is the focus of the opening chapter ofthis book. It is immediately followed by a systematic review of parameters related to natural oral esthetics. Because the driving forces of restorative dentisty cre maintenance of footh vitality and maximum conserva tion of infact hard tissues, a brief chapter describes the ultraconservative treatment options thet con precede a more sophisticated treatment. The core of the book centers on the application of the bio mimetic principle in the form of bonded porcelain restorations (BPR. The broad specttum of indi cations for BPRs is described, followed by detailed instruction on the treatment planning and diog nostic approach, which is the first step in learning this technique. The treatment is then described slep-bystep, including tooth preparation and impression, laboratory procedures relaied fo the fab- tication of the ceramic workpiece, and its Final insertion through adhesive luting procedures. The book ends with discussion of the fol llowup, maintenance, and repair of BPRS.| would have been unable to achieve this work without the valued collaboration of other dentists dental technicians, specialists, ond researchers. We should always remember that o key element for successful and predictable restoration is teamwork and an essential ingredient for teamwork is humility, © consider others better than oneself. We must try to serve each other rather thon expect to be served. om fortunate to have studied under Prof Urs oble fo me. Belser; his teaching and guidance have been invalu Special thanks goes fo Drs William Douglas, Ralph Delong, Maria Pintado, Antheunis Versluis, and Thomas Korioth at the University of Minnesota for their help and friendship during my 2year re search scholarship there. They expanded my vision and knowledge of scientific research in bio- materials and biomechanics J extend appreciation to Michel Magne, CDT, for his significant contributions fo the chapter on lab- oratory procedures and for his skills in fabricating the ceramic restorations for all of the cases in this book, | also acknowledge my patients, who indirectly contributed to the realization of this book nd the privale practitioners who donated exacted teeth for the studies and illustrations. Special thonks in this regard goes to Drs Rosa Serrano of Geneva, Switzetland, and José de Souza Ne gro of Sao Paulo, Brazil Finally, | give honor and glory to my Lord and Savior, Jesus Christ, who has made all of my projects possible through his gracious love Pascal Magne References J. Savkoyo M. An 2. Siavkin HC, Biomimetes: Replacing reduction lo biomimetic: A | viewpoint. Microsc Res Tach 1994:27-360-975. » | Am Dent Assoe 1996:127:1254-1 eral syrihess, Ciba Found Symp 1997, body parts is no longer science ftioe 3. Mann S. The biomimetcs of enomel: A paradigm for organised bi aKe ACR TER ] UNDERSTANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE Mimicry in the field of science involves reproducing or copying a model, @ clerence. IF we as dentists wont to replace what has been lost, we need to agree on what is the correct reference. The accepted frame of must be the same for entire profession, and it should be timeless and unchanging. Once this is established, we can then constuct appropriate Jevise valid concepts, and create rational dental treat 1¢ resloralive dentist, the unquestionable reference is the intact natural tooth. Remains of Inca civilization in South America as well as mummies in Egypt! demonstrate age-old principles: the original number, dimensions, and structure of teeth have not changed, While the pattemn of oral disease infections, wear, parafunctions) has been influenced by the everchanging human lifestyle, the original siructure of enamel and dentin appears fo be the same today as it was 3,000 years ago. In this context it seems commendable to study and understand the marvelous design of natural teeth before considering any further concepts in restorative dentistry1. | UNDERSTANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE BIOLOGY, MECHANICS, FUNCTION, AND ESTHETICS Physiologic performance of intact teeth is the result of an intimate and balanced relationship between biologic, mechanical, functional, and esthetic parameters (Fig 1-1a) The most educational situations supporting that fact are found in cases of fraumatic injuries like that illustrated in Fig 1-1. The price of an injury can be paid in the form of either a mechanical thard tissue involvement) or a biologic failure (pulpal involvement), In both cases, the influ ence on the esthetic and functional parameters is obvious. Fortunately for the patient in Fig | 1, simple and economic treatment strategies could be used [fragment reattachment on the left central incisor, root canal therapy and bleaching on the other). Yet a critical question can be raised: What would have been the out come if, instead of being intact, these central incisors had been previously restored by wo FIGURE 1-1; PHYSIOLOGIC PERFORMANCE OF TEETH. Performance of tecih is the result of on ini logic puzzle including biolegy, mechanics, function, and esth rigid and extremely resistant full crowns? We know from impact experiments? that a more profound fracture {root involvement], which would be problematic to restore, is encoun tered when stiff and unyielding crowns ore used. This contrasts with the behavior of the mare fragile jacket crowns, which often shatter, leaving the remaining tooth substance intact. A parlicl crown fracture might be preferable it one considers that the energy dissipated during fracture can prevent further biologic damage or root injury. In consideration of the above-mentioned parameters, it is of primary importance to ask ourselves: Is it better to pursue the development cof strong and stiff restorations of, instead, fo find treatment modalities that reproduce the biomechanical behavior of the intact tooth? Stronger and stiffer might not always be better. te physio ics {1-19}. Illustrative case: The maxillary left central ineiso} fractured following trouma that involved both mexillary central incisors {1-Ib). The tooth fragment was recor ered {I-lc). The situation was potentially compromised by pulpal exposure (1-Id}. After direct capping under rubber dom, the tooth fragment was tebonded to the remaining tooth substance [see Fig 3-10). A |-week postoperative view reveals the favorable sitvation (1-12). One month later, the unfractured right central incisor showed signs of pulpal damage [1-11 The severe organic discoloration wos completely removed by internal bleaching ("walking bleach technique,” see Fig 3-6) aller root canal reaimen! was accomplished. (The roat canal therapy was indicated only by the presence of symptoms and radiographic evidence color relapse |1-1g). The S-year pastoperative view shows stable result from Magne and Magne? with permission. | The tooth was slighily overbleached to anticipate the initial T-1hl. [Figuies 1-1b to I-1g ate reprintedBIOLOGY fmm MECHANICSTHE INTACT TOOTH AND | Unperstar OPTIMAL COMPLIANCE AND 1s section calls for @ strong and na natu sent i lexibility. The latter is an cture to ural protecti led compliance or essential quality’ tha ab f orb the energ 1 words, ¢ compliant. structu a. sudden mpact by bending elas der a gi load. Up fo a certain point, the more resilient a stiucture is, the beter. This ability to store manent dar energy withc s inherent to inlact ante reference. Dentin is the key el pabiliy. Figures 1-2a and 1-26 shape and structure of | sidered o ment in this c show the ssential resilient by Sic an ini nponent. II was d hat during orb the mon and Hood! is able to impael, Tic PRINCIPLE FLEXIBILITY fracture w energy o compare restored with difer Although resilience promote impo elasticity. m nt types of crowns fion aga gy absorption, tender a struc floppy” for ils. pure in core alor Id be functionally inade- without its ter shell of enamel 2b, righ!) In this respect, natural teeth, through the opti entin mal combination of enamel and demonstrate the perfect and unmatched con promise between stiffness, strength, and resilience. Restorative procedures and lions in the structural integrity of teeth can easily violate this subs balance.DENTIN DENTIN+ENA Bk ws aa 5 ‘ BISON1 | UNDERSTANDING THE INTACT TOOTH AND 7 JOMIMETIC PRINCIPLE RATIONALIZED ANTERIOR TOOTH SHAPE Moving from the posterior segment in the ante- rior direction within the denial arch, the process of “incisivization’ takes place [Fig 1-3a) whereby the occlusal table is gradually replaced by an incisal edge that has the obvi ous function of cuting Anatomically, incisors show a distinct contrast between facial and palatal surface morphol ogy. The labial aspect of the crown features smooth and mainly convex contours, whereas the palatal surface displays a deep concavity extending axially from the dental cingulum to the incisal edge and laterally between the two pronounced proximal ridges (Fig 1-36). With shape, the incisal edge is designed like a blade, which undoubtedly plays @ major role in e tooth. In some s rising the cuting efficiency of th instances, vertical lo from the cingu lum interrupt the palatal concavity. The portion of the crown featuring the thinnest enamel layer, namely the cervical third, is also the area of » thickness of dentin. Inversely, the thick incisal enamel is supported by a thin dentin wall maximu Cani s display @ different morphology. The cingulum is large and the marginal ridges oped. All of 4 ments are confluent and there is no palotal fossa (Figs 1-3b to 1-3d). The p such architecture will be explained later in view hese convex ele strongly de liarity of of the specific functional requirements of this strategic tooth, FIGURE 1-3: BASIC ANATOMY OF THE ANTERIOR DENTITION. Comparative of extracied teeth | surfox red to the concon of canines (1 28 functional 3, right, 1 ‘igh1 | UNDERSTANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE MECHANICS AND GEOMETRY DURING FUNCTION Thorough understanding of stress and related strain allows restorative techniques to be opti mized, Loadiofailure tests have been popular among the wide range of mechanical testing approaches. However, these “conventional shrength studies, no matter how accurately ducted, are not always sufficient to guarantee s or structural integrity under operational condi Failure under load conditions well below the yield stress often occurs in structures with small cracks or cracklike flaws, such as teeth and some dental materials. Therefore, modern ing approaches must include nondestructive methods. For instance, the effect of functional loading can be quantitatively determined by the crown flexure, which can be measured under simulated conditions by bonded strain FIGURE 1-4: NONDESTRUCTIVE EXPERIMENTAL METHODS IN MECHANICAL TESTING. Experimental sp mparison of strains ot th sf the tooth (1-do}. Numeric modeling of {intact centol incisex) mounted with gauges fo artiented along the long ingual cross sections and hwodimensional fin gauges (Fig I-4a) and numeric methods, such 98 the finite element method (FEM, Figs 1-4b to 17} Such jnvestigation instruments must reproduce the leading configuration of anterior teeth which has been clearly established and can by characterized as follows: Because of the arrangement and position of the anterior dentition, mechanical loads act ccolingual plane of each restrain primarily in the bu oth. Proximal mesiodistal loads (Fig 1-4b) The horizontal component of realistic biting loads induces bending, which is the mojor challenge for the incisor. contact areas fosso and ci sr cinletior eh ca Ab) (Fgue 1-40 lum; strain bbe achiev is teprinied 5 Tint element me FEM1 | UNDERSTANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE It is important to be aware of the yield criteria used for failure prediction in numeric analyses The Von Mises criterion (VM) is commonly used. It works well with materials for which the yield stresses measured in uniaxial tension and com pression are equal. However: Both enamiel and dentin are britle materials that present a higher strength in compression than in tension The ratio between compressive strength and tensile strength has been incorporated in an adapted failure criterion for brittle materiols: the modified Von Mises criterion |mVM).'° Figures 1-50 and 1-56 illustrate the stress distribution (using the m¥M criterion] throughout the central incisor during protrusive movements Initial guidance slarting at the intercuspal position |Fig 1-5a) does not cause significant stresses, as determined by mVM. In this position, most of the tooth crown is sub- jected to compressive forces, and bending is minimal Moving toward an edgetoedge position (Fig 1-5b), significant tensile stress concentrations are detected in the palatal fosse. Even in that challenging position, which in duces maximum bending moments, the facial half of the tooth and the cingulum areo still do not display detrimental siresses. It is oppropr ate to analyze siesses in a direction for which the x and y components of stresses will display their maximum values. The resulting analysis [upper right of Figs 1-5c and 1-5b} outlines the principal siresses in the form of areas of com pression and tension. The original maxillary incisor is separated into two distinct areas when sub ending: the polatal hol namely tensile stresses, whereas the facial half of the tooth displays compressive stresses. Note again the quiescent area of the cingulum regarding tensile stresses. ted to maximum of he toolh exhibits positive values, FIGURE 1-5: STRESS DISTRIBUTION ON A NATURAL MAXILLARY CENTRAL INCISOR DURING FUNCTION. Now: near fir {1-5o] and moving toward an principal stres Jement contact analysis. The mondibular incisor is slic sdgetoedge position [1-5b}. Real 1e bending mode of the crown, In 1-5a, most of the cross-sectional area is subjected tc or negligible tensile stresses. In. 1-5b, sive side (facial half) and a tensile side (palatal hal separated by c 3 intercuspal position xd 5X fo emphasize compression (gray area in e tooth behaves like © cantilever beam with @ compres ‘Maximum tensile forces are found n prolusion starting at hh deformation is m at the level of the fossa, The external force created by the mandibular incisor is about 50 NY, and real horizontal defor ‘mation of the maxillary incisal edge is about 100 pm (1-5b, distance from dotted line}. The tooth is fixed (zero dis slacement) af the cut plane of the ro 32UNDERSTANDING THE INTACT TOOTH AND THE BIOMIM| One may wonder what happens to mandibu: lar incisors (Fig 1-6a) when subjected to simi lor loading conditions, As with maxillary incisors, initial guidance starting ot the inter cuspal position does not produce significant mVM stiesses. In this position, the mandibular crown is subjected only lo compressive forces [Fig 1-6b). Moving toward an edgertoredge position, tensile stresses begin to Tic PRINCIPLE the facial surface [Fig 1-4c}. This stress patiern is exactly the opposite of that of the aniago nistic tooth geo! ploys Because of the favorable facial ry of mandibular incisors, dis lat or ntours (Fig 1-6al, 1 level of facial tensile stresses remains mod ate and compared to tho: found at the antagonistic fossa [see Figs 1-5b ‘and 1-6c}. whicl convex less imental FIGURE 1-6: STRESS DISTRIBUTION ON A NATURAL MANDIBULAR INCISOR DURING FUNCTION. Nonjine iite element confact analysis. The facial of a mandibular incisor exhibits extremely simple morphology with mosily flat o slightly convex surfaces (1-4a). As in Fig 1-5, the mandibular incisor is sliding in profusion starting al he intercuspal position (1-66) and moving toward an edgetoedge position (1-6c]. Real tooth ied 5X. In 1-6b, mos! of the cross-sectional area is subjected to compression (gray ar 6c, the tooth behaves like « cantilever beam with a compressive side (lingual half an arated by @ neutral axis. Maximum tensil found compared to the stresses of the antagonist abou! 50 N, a fed line). The tooth is fixed (zero disp fea! horizontal deformatic 34 the mandibular at the facial middle third fossa. The extemal for sal edge is about at the cut plane of the roo!As previously outlined, form (ie, geometry] and function are essential determinanis of stress dis- tribution. It is important to remember that low stress le els are found in surfaces of maximum convex curvature, ie, the cingulum and the cervical part of the facial surface. Therefore, it is con- cluded that convex surfaces with thick enamel experience fewer stress concentrations than do concave areas, which tend to accumulate them.” This statement is clearly supported by Fig 17a which shows the influence of enamel geometry and thickness after modification of the palatal surface contour of a mandibular incisor. The resulting contour might be assumed as the prox imal aspect of an incisor (Fig 1-7b] or as veri cal lobes extending from the cingulum. The addition of enamel discloses a seemingly better balance and stress distribution. In this regard, it can be presumed that moderate siress concen trations would occur on the totally convex palatal surfaces, such as thal found on canines Canines hove very curvilinear facial surfaces that may better withstand compressive forces. STANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE A canine with its accentuated biconvex con- tour [buccolingual section) displays an almost pertect convex design, which leads to a favor able mechanical configuration. An irregular surface anatomy, ie, the palatal surface anatomy of an incisor [Fig 1-7), log} cally yields to a different sess pattern. Stress concentration in the palatal fossa contrasts with the low siresses observed on smooth and con- vex areas ie, the cervical half of the crown for both palatal and faciol surfaces). Accordingly the following conclusions can be made’ * The palatal concavity provides th with its sharp incisal edge and cutting abil incisor ity but is shown to be an area of stress con cenhration: + Specific areas featuring thick enamel, such as the cingulum and the marginal ridges, can compensate for this shorlcoming and ‘act as stress redistributors. Cingula and marginal crests also represent essential palatal stops that allow for minte nance of the vertical dimension of occlusion in the anterior segment FIGURE 1-7: STRESS DISTRIBUTIONS WITH VARYING ENAMEL THICKNESS AND GEOMETRY. An oxiginal buc copalatal cross section |1-7a, lef) is co right). The modifiad tooth displays surface and correspond fo concav duces the prominent distal cre: the polatal surfoce. ‘areas delimiting th 36 pared fo a modified inc lowes! palatal surface stresses. Two sme ickened enamel.* The m or with @ thickened, com tol enamel (1-76, skess peaks sill subsist in the palatal dified finite element model repro: 7b), This typical incisal feature helps to improve stress distribution along1 | UNDERSTANDING THE INTACT TOOTH AND THE BIOW PHYSIOLOGIC ENAMEL CRAC The assembly of two tissues with distinctly dif ferent elastic moduli requires a complex fusion for long-term functional success. Siress transfer in simple bilaminate structures with divergent pr stresses at the interfa setties usually induces increased focal If enamel and dentin tooth comprised then ce. at the functional surfaces of a such a simply bon enametinitiated cracks would easily cross the bilaminate, dentinoenamel junction {DEJ} and propagate into dentin. In realty, the situation seems to be quite different. Although multiple enam cracks are typically encountered in aged teeth, they seldom alfect the structural integrity of the enameldentin complex cating fecr complex The explanation lies in the mosi fa: ture inherent to the natural tooth—a fusion af the DE] (Figs 1-8q to 1-8c], which can be regarded as a fibrilreinforced bond. tool FIGURE 1-8: SPATIAL DEJ ARCHITECTURE AND FORMATION. Schematic representation © of collagen fibrils {1-Bo), Thick bundles and tulls reinforce the fusion of enamel and dentin /m bundles form “mic {botiom, black s} within the major scallops of the DE dotted airows). These bundles merge with other fibrils before or after entering the enamel n nied from Sieber he middle ure is repr h permiss 38 C PRINCIPLE KING AND THE DE] The DE) is o moderately mineralized interface between two highly mineralized tissues (enamel and dentin). Parallel, coarse collagen bundles [probably the von Korff fibers of the mantle dentin) form massive consolidations that can divert and blunt enamel cracks through considerable plastic deformation Scanning election microscopy hactog} DEJ specimens have demonstrated crack defle fion to another fracture plone when forced through the DEJ.” The structure of the DEJ shows two levels of scalloping [Fig aphs 80), which and increase the effective interfacial are strengthen the bond between enamel ond dentin. The the jt is most prominent wt lloping e subject to the mos functional on om figures are meCollagen mmicroscallops1 | UNDERSTANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE Interestingly, the DE] is preformed in the earliest developmental stage of the tooth crown, at the time of incipient mineralization and much ear lier than on identifiable pulp (Fig 1-8d). This chronology is not coincidental, and another sequence would not allow the creation of such «a complex dentinoenamel fusion. It is probably more correct to regard the crown of the tooth ‘08 growing out bidirectionally from the DE) rather than from the pulp In other words, the DE] is the “center” of the tooth, not the pulp. Dentin FIGURE 1-8 (CONTINUED). Thin tooth section under polarized light showing the collagen tufts in the enomel (1-86: criginal magnification X250; courtesy of NV. Allenspach, University of Geneva). Lovrvoltage field-emission scanning electron microphotograph of the DE) decalcified with neutral ethylenediaminetetraacetic acid: 8O- to 120-nmdiome- ter collagen fibrils merge with dentin matrix fibrils farowheads) and splay out into the enamel matrix (pen arrows) note the cross banding of the collagen fibrils every 600 A (black arrows} |1-8c: original magnification x50, 000} This deep penetration of collagen info the enamel, which is the sine quo non of the DE], could not lake place with fully calcified enamel [99% mineral by weigh!) This points to the fact thatthe DE] forms early in embryonic develop: ment and subsequently cakcifies. The DE] of a primary tooth is being formed at the late bell slage early crown stage] af loath formation; dentin and enomel have begun to form ot the crest ofthe folded internal dental epithelium. At this stage and in the continuing early growih, interpenetration of collagen into the contiguous enamel organ takes place ‘At maturity, this forms the fully functional DE}, which should be considered on interphase rather than on interface 1 8d; courtesy of Dr W. H. Douglas, University of Minnesota. [Figure 1-8c is reprinied from Lin ef al!?with permission.| 401 | UNDERSTANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE Due to the inherent brileness of enomel and the collagenous consolidation of the DE) enamel cracking should be considered on mal aging process. In addition, there are other effects of enamel cracks, which are visible in finile element models. Sttess in the enomel is redistributed around the crack through the DE] which creates @ sites concentiation al the crack tip and leaves the tooth surface in the area of the crack relatively quiescent (Fig 1-8el FIGURE 1-8 (CONTINUED). A photomicrogr Uloted in FEM. Enamel surrounding the flaws o correspond fo mV fom; teeth o graphic view (1-84) of palatal e sile stresses in the numeric model. T D}. (Fi with pe @ loaded horizontally ul thick nission.) a2 siroin gauge study otal surface [|-8e, top). Similar experimental conditions including modeling of single and d 1 MPa). St ove a strain of enamel 1 I-Be is reprinted from Magne el al’ wih permission, Figure 1-8! is reprinted from Thus, enamel cracks can be considered an acceptable enamel attribute, and the DE) plays a significant role in assisting stress trans- Ter (as opposed to stress concentration] and in resisting enamel crack propagation [Fig 1-8) The fascinating properties of the DE} must serve as a reference for the development of new dentin bonding agents, which should allow for the recovery of the biomechanical integrity of the restored crown. viescent with regard to tensile ack tip ore well cbove 200 MPa |1-Be, be }0ug¢ (GI. This appears to be the area of maximum ier s cracked, but the flaws never propagate ir Magne and Douglas1 | UNDERSTANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE NATURAL TOOTH AGING AND ENAMEL THINNING As previously mentioned, enamel and dentin exhibit different physical properties Enamel can resist occlusal wear but is fragile and cracks easily, Dentin, on the other hand, is flexible and compliant but is not wear resis- tnt ond does not age favorably when directly exposed fo the oral environment. Because of their respective shortcomings, nek ther enamel nor dentin independently would be considered effective restorative materials. How- ture, which ever, they form a “composite” sin provides a tooth with unique characteristics the hardness of enamel protects the soft under lying dentin, while the crackarresting effect of dentin and the thick collagen fibers at the DE]" compensate for the inherenily britle nature of enamel. This shuctural and physical interele fionship beNween an extremely hard tissue and a more pliable tissue provides the natural tocth with its original beauty but also its ability to withstand mastication, thermal loads, and weor during a lifetime. FIGURE 1.9: THE SEASONS OF TOOTH LIFE. Anter Original morphology and thickness of the enamel shell (Fig 19a) seem to have been designed fo anticipate wear and function requirements"* specifically those with greater bulks of enamel ie, the incisal edge of anterior teeth. This “pre: ventive” architecture still allows physiologic wear fo create dentin exposure in the incisal area (Figs 1-9b to 1-9d). By the same token, teeth in the posterior region, where masticatory forces are sttonger, have thicker enamel than maximum wear areas do anterior teeth The dynamic wear pattem of the incisal edge must stand as a reference for the development of new materials, which should be able to cage similarly to enamel and dentin Natural tooth aging also impacts the optical interaction between enamel and dentin |Figs | 9e and 1-91}. Here again, the incisal edge is the most affected (see Fig 28) th initially present typical mamelons and surface texture (19a). These elements are progressively eliminated by wear Ongoing enamel cracking ond dentin exposure (1-9 to 1-94} are linked to obvious color changes. enamel and dentin, especially the crucial role of dentin Oplimized ceramic or composite sralification techniques are needed to rep enamel and dentin 44 treme wear allows for undersia limiting light transmission in the incisal oreo (1-9e, 1-99. nding the optical interaction beween oduce the sel ve light transmission of1 | UNDERSTANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE Agerelated changes of the dentition are the main challenge of modern dentistry, which is foced with a population that is getting older and keeping more of its natural teeth. Smiles can show physical and esthetic signs of aging. Among these, excessive wear in the incisal area contibutes to the loss of anterior tooth prominence and insufficient anterior guid once, thus generating new responsibilities for the restorative dents. This degenerative phe- nomenon is overshadowed by color changes following dentin exposure, enamel cracking, and related extrinsic infiltration [Figs 1-100 and 1-10}, The widespread interest in vital bleach- ing has become the driving force of esthetic dentistry to rejuvenate toolh appearance at a limited cost. However, this ultraconservative chemical ireaiment addiesses only the cosmetic component of a complex problem FIGURE 1-10: ENAMEL IN THE AGING PROCESS. Teeth of o 70yearald potien! with obvious age-related enamel In the physiologic aging process, the original enamel thickness is progressively reduced (Figs 1-10c fo 1-10e} The color and cosmetic problems related to tooth aging should not be the only concem of the restorative dentist. As mentioned. previ ously, dentin plays crucial role in providing the tooth with compliance and_ flexibility, whereas the enamel shell will assure its rigidity and strength. The increased crown flexibility of worn teeth can be associated with functional nd mechanical problems. A sufficient and uniform thickness of facial enamel is essential to the balance of func- tional stresses in the anterior dentition.” wear, cracking, and extrinsic inflration of both central incisors (1-102, 1-10b). Bleaching will not address the biome chanical issues, which require crown sifness recovery through adequate restora! in Figs 5-4 and 6-22). Detail views of extracted contral incisors (1-10c to 1-1 1d palatoincisal wear the loss of tooth form, surface architecture, 46 ive approaches {see treament sleps Tangential light is used to reveal1 | UNDERSTANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE Combined results of different studies yield sig- nificant information about the effect of various fissue reductions on anterior crown flexure’ Substantial loss of facial enamel or presence of endodontic access cavities is more likely to affect crown rigidity than is the interdental reduction of enamel or large Class 3 cavities {Fig 1-110). As a matter of fact, thin, aged facial enamel can lead to high stress concentrations during function, Surface cracks typically found on aged teeth account for this problem. The signif icant effect of the enamel shell on stress distri bution was demonstrated using both strain gauge experiments and finite element models facial enamel negatively affects the behavior of remaining palatal enamel. Similarly, loss of palatal enamel will significanily affect remain- ing facial enamel Recovery of the original enamel thickness and architecture is necessary for the biomechanical balance of the tooth crown. The choice of restorative material is critical in this matier (Fig 111d and 1-11e) Resfitution of enomel thickness is therefore o combined esthetic and biomechanical en- deavor. Bonding and adhesive ceramic restorative procedures have the potential to reverse the esthetic manifestations of aging in teeth (Figs 1-1 1b to 1-1 Ie). (Figs 1-11b and 1-1 1¢).’* The total loss of 5 22 3 20; 218 ————— ete BAZ, = 1.0 Intact Proximal Facial Class 3 Endo Facial Facial enamel’ enamel, covites* access’ enomel, y} # Hord tissue removal from incisors wt FIGURE 1-11: IMPACT OF ENAMEL LOSS AND ENAMEL RESTITUTION. Grophic representation of relative flexi bility (changes in flexibility relative to the baseline) for natural incisors alter removal of coronal fissues (=| Tal; total removal of proximal enamel (second column) does not affect crown sigiity, but total removal af facial enamel (last column] is most adverse; %, % and % indicate the omount of facial enamel thickness removed. Tooth preparation by total facial enamel removal was simulated in FEM (1-1 1b to 1-1 Je}; the plot of tangential stresses (red line) proceeds for each tooth along the palatal surface from cervical to incisal; @ dramatic increase in tensile sitesses is found in the femaining enamel of he palatal fossa [tooth loaded polataly with 50 N onto incisal edge, deformation factor 10x oon mM stress mapping) {1-1 1b, 1-1 Te}. The original profle of tangential stress is comp cofier bond ing o feldspathic porcelain veneer (1-1 1d}; the use of composite as the veneering material allows only partial recov ery of sifiness [1-1 le]. The original stress distibution of the natural tooth (gray line] is reported as a reference. 481 | UNDERSTANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE BIOMIMETICS APPLIED TO MECHANICS A notural tocth’s unique ability to withstand masticatory and thermal loads during a lifetime is the result of the stuctural and physical inter relationship between on extremely hord tissue (enamel) and 6 more pliable tissue (dentin), The recognition of this relationship hes led to growing concern about the biomechanical response of intact hard issue To restorative pro: cedures. The situction has been porficularly informative about posterior teeth. A significant step was made when researchers focused their tention on the biomechanical side effects of amalgam restorations (ie, cuspal fractures and cracked tooth syndromes) number of studies’'* analyzing biophysical siress and strain have shown the following * In response, a * Restorative procedures can make the tooth crown more deformable. «The tooth can be strengthened by increasing its resistance to crown deformation Based on these principles, tooth reinforcement was ablained by some form of full or partial coverage lextracoronal strengthening) at the expense of the intact tooth substance Today, adhesive technology has proved is eff ciency in simullaneously reestablishing crown siifness and allowing maximum preservation of the remaining hard fissue (intracoronal strength ening). These studies demonstrated. that bonded composite restorations permit the 60 recovery of tooth stifess, which was not pos sible with amalgam filings However, it should be remembered that the physical properties of composite resins are somewhat limited. One limitation is the elastic modulus, which for an average microfilled hybrid can be up to 80% lower (approximately 10 to 20 GPa) than the elastic modulus of enamel {approximately 80 GPa]. As mentioned before, the enamel shell proves to be insinu- mental in the wy slresses are distributed within the crown When a more flexible material replaces the enamel shell, only partial recovery of crown rigidity can be expected. Studies conducted by Reeh et al and Reeh and Ross* showed a recovery of 76% to 88% in crown siiffness offer the placement of composite restorations and composite veneers. On the other hand, it was demonstrated that crown rigidity can be recovered 100% when feld- spathic porcelain {elastic modulus approx mately 70 GPa] is u as with porcelain veneer restorations (see 11d).’ Teet lain veneers also proved their cbsoluie biomimetic behavior when subjected io cumule five restorative procedures* and. catastrophic testing (Fig 1-12) J as an enamel subs! Fig | restored with dentinbonded porceFIGURE 1-12: CATASTROPHIC FAILURE OF INTACT INCISORS VERSUS INCISORS RESTORED WITH DENTIN- BONDED PORCELAIN VENEERS, *1 | UNDERSTANDING THE INTACT TOOTH AND THE BIOMIMETIC PRINCIPLE From Figs I-11 and 1-12, it is easy to under- stand the impact of the biomimetic principle, which logically leads to analysis of which mate- rials can best simulate the behavior of enamel and dentin, Part of this approach is represented in Table 1-1. Simple feldspathic porcelain can be compared fo enamel. It is important to men- tion that: Most denial ceramics have a higher ultimate tensile strength than natural enamel. High: strength materials such as reinforced ceramics do not seem to be required to comply with the biomimetic principle. Wear properties (abrasiveness) of feldspathic materials, however, remain a concem,*! espe ial for full coverage of lateral segments of the denition, as well os inlays and onlays, In this regard, bioactive glass ceramics might bring significant improvements in the neor future, On the other hand: Porcelain veneers might not subject opposing teeth to significant wear problems because of the conservative nature of the treciment: the polatal and functional side of the tooth often remains intact. FIGURE 1-12 (CONTINUED). The in vitro simulation in 1-12a to The closest substitute for dentin is represented by hybrid composites, due to their similar elas fic modulus, Most composites, however, de- velop shrinkage stresses and exhibit high ther mal expansion (up to 4% the thermal expansion of the natural tooth or porcelain). This will raise significant problems when combining thin layers of porcelain and luting composites, especially when thick die spacers [> 200 pm) are used during the fabrication of the restorations (see Fig S134 The most challenging parameter is the simule tion of the DEJ, the complexity of which seems 10 be out of reach.’?* Nevertheless, progress in adhesion has cllowed improvement in the integrity of the tooth-restoration interface (Figs 1 12 and 1-12d; see also Fig 8-11] Applying thé biomimetic principle, it seems reasonable to conclude that new restorative approaches should cim to create not the strongest restoration but rather a restoration that is compatible with the mechanical, bio: logic, and optical properties of underlying denial tissues. 12d appears to be clinically celevont, os illustra Pi ly by this case of fracture; a crack storied in the palatal concavity and propagated obliquely toward the facial aspect of the root {1-12e, 1-12F; courtesy of Dr L. N. Baratieri et al, Federal University of Sonta Cotarino}. The similarity between 1-12a and 1-12 is stiking, Such ¢ clinieal situation is no 982 necdoial, as demonshated by Baratieri et al