12/7/11 Restorative Treatment of Cracked Teeth Inside Dentistry dentalaegis.

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Inside Dentistry Sha.e:

November 2011, Volume 7, Issue 10

Published by AEGIS Communications

Treating Cracked Teeth

Treating cracked teeth biomimetically can optimize clinical results.
By Randall G. Cohen, DDS | David Rudo, DDS Figure 1

All-ceramic or ceramo–metal full-coverage crowns are sometimes placed as a preventative

treatment for a tooth that is suspected of having a fracture. Full cut-down crowns, however, will not
necessarily protect teeth from further cracking; they can instead weaken the remaining tooth
structure by compromising the tooth’s elasticity and injuring the dental pulp. Sometimes a cracked
tooth restored with a full crown does not resolve the tooth pain, and endodontics is required. Full-
coverage porcelain-fused-to-metal crowns can develop a .push-pull effect where the higher
Selec. an i e elastic modulus of the casting does not flex along with the underlying dentin, thus rendering it
hypofunctional.1 Figure 2

The gingival margin is the point of maximum flexure and the region with the greatest stress
concentrations. This occurs because of the abrupt geometric discontinuances and changes in
shape at the butt margin.2 The maximum flexure and the great stress concentrations often lead to
the breakdown of the cement seal sometimes resulting in microleakage, recurrent caries at the
crown–tooth interface, pulpal pathology, tooth fracture, and catastrophic failure. Full-crown
restorations have been described as the least desirable treatment option 3 and should be avoided
unless re-treatment of an already-crowned tooth is required.
Select a link below to view Figure 3
additional publications. Traditional G.V. Black amalgam cavity preparation designs involve the removal of a significant
amount of tooth structure and the creation of sharp internal line angles. The sharp line angles act
Compendium
as stress concentrators, leading to the initiation and propagation of cracks, which, ultimately, will
cause restoration failure.2 Because of the mechanical retention and dissimilarity of performance
Inside Dental Assisting
characteristics of the amalgam and the tooth, the components of this tooth–restoration complex
Inside Dental Technology conflict with one another rather than flexing and functioning harmoniously and biomimetically.
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A preferred treatment is one that attempts to replicate the stress distribution, energy absorption,
Special Issues + and other characteristics of the intact natural tooth. These performance characteristics contribute to
Whitepapers the fail safe mode of intact natural teeth.4 Accordingly, this type of treatment option should be Figure 4
considered rather than weakening the remaining tooth with a full-coverage crown. Unlike the full-
crown option, biomimetic preparation principles preserve the dentino-enamel junction (DEJ) in the
gingival region during tooth preparation, thus maintaining the absorbing capacity of the intact tooth
and is, therefore, recommended.5 These biomimetic tooth–restorative complexes help prevent
cracking, fracture, subsequent pulpal degeneration, and catastrophic failure of the restored tooth.6
In this article, the authors will discuss a method for preventing a tooth from cracking, and an
appropriate treatment method should a crack occur.

The Tooth.s Structural Integrity

Figure 5
Understanding the attributes of an intact tooth will help to determine how to replicate its
performance characteristics. Natural tooth structure and its external form have evolved to satisfy
specific functional requirements. By definition, the DEJ is the developmental and structural center
of the tooth, orientated in a specific location within the tooth.7 The DEJ is actually a three-
dimensional region composed of a network of collagen fibrils and dentin in one inter-phase united
with an inter-phase composed of collagen fibrils and enamel. This three-dimensional network
unites the dentin and enamel, which developed from two different embryonic types of cells and
have different performance characteristics. The DEJ collagen fibril network forms the junction
between the harder and stiffer enamel and the softer and more elastic dentin, permitting the tooth
components with different stress/strain responses to function in harmony together. This collagen
fibril network also acts as a fail safe mechanism that inhibits, stops, and redirects a crack or Figure 6
fissure.6 In vitro studies demonstrated that when teeth were overloaded, the cracks in the enamel
did not penetrate into the dentin, rather they actually sheared at the DEJ.4 Other studies have
demonstrated the great energy-absorbing ability of enamel 8 that can sustain deformation without
catastrophic failure.

In contrast to full-coverage crowns, biomimetically restored teeth use adhesive materials and fiber
composites with performance characteristics similar to the hard tissues that were lost to caries or
fracture. The fiber/resin reinforcement used in this restorative concept is Ribbond ®
(www.ribbond.com), a fiber reinforcement composed of ultrahigh molecular weight polyethylene in Figure 7
the form of a three-dimensional leno-weaved ribbon. An integral component of this restorative
concept involves the creation of a three-dimensional bio-liner at the dentin–restorative composite
interface that acts as a uniting component. A gap-free secure bond is formed between the dentin
walls and the composite restorative material. There are documented outcomes of this bio-liner

including increased the microtensile bond strength,9 minimized polymerization shrinkage and
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including increased the microtensile bond strength,9 minimized polymerization shrinkage and
leakage,10 and the ability to bridge cracks in the pulpal floor.6

When placed parallel to and under the occlusal surface of the composite restoration, the three-
dimensional fiber reinforcement ribbon acts as a stress distributor and energy-absorbing
mechanism. These protective mechanisms function as an internal .shock-absorbing system to
prevent the build-up of strain energy and stress concentration that might otherwise lead to the Figure 8
initiation and propagation of cracking and even fracture of the dental–restorative complex.11 This
concept creates a dental–restorative complex that preserves rather than destroys tooth structure,
one in which the performance characteristics of the components of the complex function
harmoniously.

Symptomatology
Cracked tooth syndrome can present varied clinical symptoms including pain on chewing,
percussion sensitivity, and intermittent cold sensitivity. The cold sensitivity usually abates when the
pulpal aspect of the crack remineralizes, and returns when the cracks propagate under occlusal
loading. The longer the crack, the longer the patient experiences the sensitivity cycle.12 This may
be due to the significant increase in stress concentrations immediately in front of the crack tip and Figure 9
the ensuing strain in the region.2 Cracks that develop in the tooth allow for the colonization of
bacteria and caries to develop, putting the health of the pulp at risk, as well as compromising the
structural integrity of the tooth.

Clinical Case
History and Findings
Figure 10
A 62-year-old man presented to the office for routine dentistry with no complaints of sensitivity or
other symptoms. Examination revealed that tooth No. 20 was rotated and had drifted distally,
leaving an open contact. In addition, tooth No. 20 displayed numerous cracks into the dentin,
indicating that the tooth was structurally compromised (Figure 1 and Figure 2). The cracks into
dentin were a result of the flexing under function of the tooth that had been weakened by a wide
occlusal amalgam. It is appropriate to treat cracked dentin even when the patient has no symptoms
because the 50-μm to 100-μm openings allow for bacterial growth and penetration into the dentin.
Untreated cases ultimately result in a fractured tooth, requiring endodontics, periodontics, crown
treatment, or possibly extraction. A similar condition existed for tooth No. 18; tooth No. 19, Figure 11
according to the patient, had been missing for more than 40 years. Restoration of teeth Nos. 18
and 20 was indicated; however, replacement of tooth No. 19 with a conventional fixed bridge was
ruled out because of the thin root on tooth No. 20, the highly weakened tooth structure, and the
narrowed edentulous space. The patient had been functioning satisfactorily for 40 years and did
not want a replacement.

Removal of Structurally Compromised Dentin

After satisfactory local anesthesia had been achieved, the tooth was isolated using a dental dam
Figure 12
and the existing amalgam was removed with a 330-carbide bur. Inspection of the dentin revealed
numerous multidirectional and deep cracks that extended far beyond the original amalgam. Only
the fragile remnants of cusps remained after the removal of the cracks with a flat-ended diamond
(Figure 3), so the cusps were removed as well using a flat-ended diamond with the handpiece
turned to the side. The dental dam was removed to facilitate easier application of the matrix
retainer.

A crack persisted at the floor of the preparation. It was apparent that further penetration into the
floor of the preparation would have resulted in a pulpal exposure, so the remnant of the crack was
allowed to remain (Figure 4). Figure 13

Creating a Predictable Resin-Dentin Bond

The bonding agent selected was Clearfil SE Protect (Kuraray Dental, www.kuraraydental.com) a
sixth-generation, self-etch adhesive system that contains an antibacterial component in Bottle 1
(primer) and a fluoride component in the microfilled resin (Bottle 2.) A single drop of primer was
dispensed into the mixing well, and was applied to the cut tooth surface with a disposable brush.
The primer was allowed to reside on the preparation for 20 seconds by the clock. Then, the
preparation was dried very thoroughly (10 seconds) using an air syringe. Next, one drop from
Bottle 2 (resin) was applied to the preparation, lightly air-dried, then light-cured with a standard Figure 14
curing light for 20 seconds.

Bridging the Crack with a Fiber-Reinforced Liner

Further reduction in polymerization contraction stress was accomplished by lining the dentin with
Ribbond® , a high molecular weight, leno-weaved fiber, although this was less necessary in this
very flat, low-stress preparation. However, the Ribbond ® /Majesty Flow lining also serves to re-
create the intact dentin’s energy-absorbing capability by redirecting forces laterally. By adapting
the Ribbond® closely to the dentin substrate, the clinician can increase the fracture toughness of
Figure 15
the tooth and prevent the existing dentin crack from propagating and causing failure. The
multidirectional Ribbond fibers bridging the crack act like stitches and transfer the stresses to
regions of greater structural integrity.6

A tiny amount of Ribbond ® Securing Composite was applied to the floor of the preparation, and a
small amount was also applied to the end of an endodontic plugger. The end of the plugger was
used to pick up a piece of Ribbond (Figure 5) to enable its transfer to the preparation and the
plugger was then used to press the fiber into place. The field was then light-cured for 20 seconds to
secure the Ribbond ® to the dentin floor (Figure 6).
Figure 16
Building the . Biobase

A thin layer of a heavily filled, flowable composite (Clearfil Majesty Flow, Kuraray Dental) was then
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A thin layer of a heavily filled, flowable composite (Clearfil Majesty Flow, Kuraray Dental) was then
applied and cured for 20 seconds to completely cover the dentin surface. The “biobase” was built
up further by adding a 2-mm layer of Clearfil AP-X (Kuraray Dental). This greatly simplified final
preparation technique was completed by creating an enamel bevel and a smooth, gradually
sloping “bathtub” design with a finish line several millimeters above the tissue margin. Perfectly flat
preparations should be avoided because they create difficulties in lining up the casting for easy
seating. Accordingly, the preparation required no retraction cord to make an accurate impression
Figure 17
using a vinyl polysiloxane material. The patient was dismissed with no provisionalization required
(Figure 7).

Bonding .he Indi ec Re o a ion

The dental laboratory fabricated a custom-shaded onlay made from Estenia. (Kuraray Dental), a
ceramic-filled, heat-cured composite that has the same hardness and flexural modulus as tooth
enamel. On the insertion visit, the preparation was cleaned with a slurry of coarse pumice, rinsed,
and isolated with cotton rolls.

The intaglio of the restoration was etched (K-Etchant Gel, Kuraray Dental) and rinsed. Next, a Figure 18
single drop of Clearfil Ceramic Primer (Kuraray Dental) was applied to the internal aspect of the
casting and dried thoroughly. The case was placed onto the die model, and an applicator stick was
created with Delar blue wax melted onto a cotton-tipped applicator. The blue wax was softened in
a flame and attached to the case so that the stick was oriented over the canine on the same side of
the arch.

The adhesive was a dual-cured, universal bonding agent (Clearfil DC Bond, Kuraray Dental). One
drop from Bottle A and one drop from Bottle B were combined in a mixing well and stirred for 5
seconds with the applicator brush. The mixture was applied generously to the dentin substrate
(Figure 8) and allowed to stay for 20 seconds. The surface was lightly dried and light-cured. The
Figure 19
restoration was loaded with adhesive cement (Clearfil Esthetic Cement, Kuraray Dental) through its
automix syringe, and brought to the tooth using the applicator stick (Figure 9).

The gross excess of cement was first removed with the end of a cotton roll with digital pressure
from the restoration down to the tooth. Then, while maintaining constant apical pressure on the
restorations, a 5-second “wave-cure” with the standard curing light was performed to bring the
unset cement to the gel point. At this point, with the assistant maintaining apical pressure on the
casting, the excess interproximal cement was removed with floss. After using a scaler on the
accessible surfaces, the final cure of the cement was accomplished with two circuits of a 10-second
light burst on each of the facial, occlusal, and lingual aspects of the restoration. Lastly, a brief Figure 20
polish with coarse pumice on a prophy cup imparted a smooth finish to the tooth/restoration (Figure
10). Proximal and occlusal adjustments in biomimetic restorations are rare because complete
seating is easily attainable and verifiable.

Clinical Ca e 2
A 91-year-old man in good general health elected to have tooth No. 31 restored once he had
experienced a fracture on tooth No. 32 that required surgical removal (Figure 11). The patient was
a vibrant person, physically active and mentally sharp, who liked to take vacations with his wife to
Disney World and really enjoyed dining out. The cracks into the dentin allowed tooth decay to
Figure 21
develop (1-μm of bacteria can easily penetrate 50-μm to 100-μm cracks). When his functioning
third molar split the week prior to this appointment and required removal, he wanted to make sure
he could still chew on his right side. The preoperative view showed occlusal-effect caries and
cracks into dentin in tooth No. 31, which substantially undermined the coronal tooth structure.
Dentin cracks were removed with the exception of the deepest part of the buccal crack that was
encroaching on the pulp. Once debridement of the carious dentin had been completed, a coarse
flat-ended diamond was used to flatten the remaining tooth structure (Figure 12). Isolation was
accomplished with retraction cord soaked in astringent (Hemodent , Premier Dental,
www.premusa.com.)

The “soft zone” of the tooth, corresponding to the DEJ, was created by applying a thickened Figure 22
flowable composite (Ribbond ® Securing Composite) to the dentin walls and floor and adapting
multiple overlapping Ribbond ® squares (Figure 13). The bioliner was completed by adding a
heavily filled, low-shrinking flowable composite (Clearfil Majesty Flow) and light-cured 20 seconds
(Figure 14). The bulk of the biobase was then built up with a light-cured composite (Clearfil AP-X.)
The biobase was contoured axially using a flat-ended diamond to create a smooth transition
between tooth structure and composite in the furcation area. Once the biomimetic onlay
preparation was completed, an impression of the case was made and the patient was dismissed
(Figure 15).

When the casting was returned from the laboratory, the preparation was isolated by applying the
rubber dam, then cleaned of salivary proteins and debris using coarse pumice (Figure 16). One
drop from each of the two bottles of bonding resin (Figure 17) were combined in a single mixing
well, then brushed onto the preparation (Figure 18). Simultaneously, the assistant applied an etch
(K-Etchant Gel, Kuraray Dental) to the interior of the casting, then rinsed and dried it. One drop of
silanating agent (Clearfil Ceramic Primer) was applied to the interior of the case and dried. A wax
stick applicator was attached to the onlay, and the casting was loaded (Figure 19) with resin
cement (Clearfil Esthetic Cement, Universal shade) and seated onto the preparation (Figure 20). A
one-third piece of cotton roll on a mosquito hemostat was used to remove excess cement while
continual downward pressure was exerted on the case to avoid dislodgment. The cement was
brought to its gel state after a wave cure (5 seconds) then the remaining excess was removed with
scalers and curettes. After checking the occlusion, the white rubber point and the coarse pumice
were used to bring the finished case to a smooth finish (Figure 21 and Figure 22).

Di c ion
Cracks that develop in dentin in the months and years after amalgam or composite restorations fail
can propagate under occlusal function and lead to caries, pulpal inflammation, pain, and tooth
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can propagate under occlusal function and lead to caries, pulpal inflammation, pain, and tooth
loss.

The biomimetic clinical protocol to treat and prevent dentin cracks by replacing lost tooth structure
with materials that will flex along with the tooth has proven to be clinically successful. In addition,
biomimetic techniques maximize bond strength and minimize stresses, ultimately resulting in
highly esthetic, durable, and maintainable restorations.

Proper restorative material selection is vital to achieving the desired result. In the clinical example
presented, an antibacterial self-etch adhesive (Clearfil SE Protect) was chosen because it
disinfects the dentin and provides a predictably strong bond to the dentin. Further, this product has
low technique sensitivity, which is characteristic of self-etch adhesives. The fluoride contained
within the microfilled resin (Bottle 2) has been shown to stabilize the resin–dentin bond over time,
avoiding the slow degradation that is associated with some self-etch adhesives.13 Further work has
suggested that the fluoride within Clearfil SE Protect will inhibit secondary caries formation. The
use of a heavily filled, low-shrinking flowable composite (Clearfil Majesty Flow) as a liner provides
excellent dentin surface coverage, strength, and an elastic modulus that approximates human
dentin.14

The bulk of the lost tooth structure should also be replaced using a composite material that
approximates dentin’s flexibility to lessen the stress at the restoration–tooth interface. The material
also should have the same hardness as dentin to facilitate effective cutting during the preparation
phase, and must be compatible with the adhesive used. In this clinical example, Clearfil AP-X was
selected because of its compatibility with the dentin bonding agent, its simplified light-curing
protocol, its physical properties of elasticity and hardness, and its ease of handling.

The final casting of the tooth should be made from a stiffer material than the underlying composite
but still flexible so that a .flexibility gradient is established, similar to what exists in the intact tooth.
Suitable materials are cast-ceramic and cast-gold, and a ceramic-filled, heat-cured laboratory
composite (Estenia® ) as shown in the example.

In both clinical cases, teeth with structural compromises were restored biomimetically rather than
using the aggressive crown preparation that has long been part of the routine practice of
restorative dentistry. Furthermore, the long-term success in both cases will be extended by not
cutting down the two abutment teeth for a fixed bridge.

Concl. sion
The biomimetic protocol for preventing and treating cracked teeth is advanced, yet simplified. By
keeping cast restorations well above the tissue margin, impression making and cementation in a
less-than-ideal field is eliminated. By preserving the DEJ at the tooth’s gingival margin, the
clinician maintains the tooth’s flexibility and avoids failure at the tooth’s weakest point. If recurrent
caries occurs in a biomimetically restored tooth, it frequently takes place in an accessible, easily
repaired part of the restoration, well away from the gingival margin. This is in sharp contrast to a
failed full cut-down crown where cement washout leads to submarginal caries and sometimes a
non-restorable fracture. Frequently, a replacement crown is needed along with periodontal surgery
and endodontics. Indirect biomimetic restorations, therefore, represent an upgrade of the quality of
care over the destructive 360º crown preparations that are frequently performed in clinical practice.
With reliable bonding technology, no longer are geometric retention forms required for restorative
dentistry, and so the clinician can take full advantage of today’s bonding agents, composites, and
resin cements to prevent and treat teeth with stress fractures.

Disclos re
Dr. Cohen has received an honorarium from Kuraray Dental for this article.

References
1. Douglas W. In: Magne P, Belser U, eds. Bonded Porcelain Restorations in the Anterior Dentition:
A Biomimetic Approach. Chicago, IL: Quintessence Publishing. 2002;19.

2. Gordon JE. The New Science of Strong Materials. Princeton University Press. 1984.

3. Schmitt J, Robbins W, Schwarz R. The Fundamentals of Operative Dentistr. . 2nd ed. Chicago,
IL: Quintessence. 2001;vii.

4. Lee JJ, Kwon JY, Chai H, et al. Fracture modes in human teeth. J Dent Res. 2009;88(3):224-228.

5. White SN, Miklus G, Chang PP, et al. Controlled failure mechanisms toughen the dentino-
enamel junction zone. J Pros Dent. 2005;94(4):330-335.

6. Belli S, Cobankara FK, Eraslan O, et al. The effect of fiber insertion on fracture resistance of
endodontically treated molars with MOD cavity and reattached fractured lingual cusps. J Biomed
Mater Res B Appl Biomater. 2006;79(1):35-41.

7. Magne P, Belser U. Bonded Porcelain Restorations in the Anterior Dentition: A Biomimetic

Approach. Chicago, IL: Quintessence Publishing. 2002;38-40.

8. Xie Z, Swain MV, Hoffman MJ. Structural integrity of enamel: experimental and modeling. J Dent
Res. 2009;88(6):529-533.

9. Belli S, Donmez N, Eskitascioglu G. The effect of c-factor and flowable resin or fiber use at the
interface on microtensile bond strength to dentin. J Adhes Dent. 2006;8(4):247-253.

10. Erkut S, Gulsahi K, Caglar A, et al. Microleakage in overflared root canals restored with different
fiber reinforced dowels. J Oper Dent. 2008;33(1):96-105.

11. Rudo DN, Karbhari VM. Physical behaviors of fiber reinforcement as applied to tooth
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11. Rudo DN, Karbhari VM. Ph. sical behaviors of fiber reinforcement as applied to tooth
stabili ation. Dent Clin North Am. 1999;43(1):7-35.

12. Brannstrom M. The h drod namic theor of dentinal pain: sensation in preparations, caries,
and the dentinal crack s ndrome. J Endod. 1986;12(10):453-457.

13. Donme N, Belli S, Pashle DH, Ta FR. Ultrastructural correlates of in vivo/in vitro bond
degradation in self-etch adhesives. J Dent Res. 2005;84(4):355-359.

14. Data on file. Kurara Dental.

Abo. he A ho
Randall G. Cohen, DDS
Private Practice
Yardle. , Penns lvania

David Rudo, DDS

Developer and President
Ribbond, Inc.
Seattle, Washington

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