Bio-Emulation Post

CLINICAL RESEARCH pyrig
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Bio-Emulation: te ot
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Biomimetically Emulating Nature

Utilizing a Histo-Anatomic Approach;
Structural Analysis
Panaghiotis Bazos, DDS

Emulation, Athens, Greece
Pascal Magne, DMD, MSc, PhD

Don and Sybil Harrington Professor of Esthetic Dentistry,
Herman Ostrow School of Dentistry,
University of Southern California, Oral Health Center,
Los Angeles, CA, USA
Correspondence to: Panaghiotis Bazos

33 Vasilissis Sophias Avenue 106 75 Athens, Greece
Tel: +30 210 722 2329; e-mail: p_bazos@mac.com
8
THE EUROPEAN JOURNAL OF ESTHETIC DENTISTRY
VOLUME 6 • NUMBER 1 • SPRING 2011
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The main goals for this article are to tiden-
ot
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A thorough understanding of the histo- fo r
anatomic structures and dynamic light tify and reveal previously unreported
en
interaction of the natural dentition pro- histo-anatomic interrelationships and to
vides dental practitioners with the ulti- explain existing ones: the sigmoid curve
mate strategic advantage with regard distribution (convex enamel/concave
to optical integration of the final resto- dentin), the distinction between dentino-
ration. The first part of this article will enamel “junction” (DEJ, visual interface)
attempt to provide insight on the three- and dentinoenamel “complex” (DEC,
dimensional coronal configuration of functional interphase), and the struc-
natural teeth and on the utilization of this tural significance of DEC preservation.
knowledge in the clinical and technical
restorative approach. (Eur J Esthet Dent 2011;6:8–19)
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Introduction the dental professional endeavors to
ss e n c e
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faithfully emulate12-14 the naturally intact
In the modern dental practice, the res- tooth, which serves as the model, men-
toration and tooth should form a struc- tor and measure.
turally adhesive and optically cohesive Despite the aforementioned signifi-
medium, which has the ability to with- cant advancements and improvements,
stand repetitive multi-axial bio-mechan- re-creating the anatomical form and
ical force loads over a prolonged period optical features of the intact tooth re-
of time. mains an arduous, challenging and at
By means of the evolution, advance- times elusive task, both within the clini-
ment, and refinement of adhesive dental cal and technical dental realms. In or-
technology1,2 with regard to the bonding der to optimize the optical integration
materials available on the market in con- of modern composite resins and silica-
junction with the validated clinical pro- based ceramics for restorative dental
tocols at hand,3,4 clinicians and techni- emulation, a thorough understanding of
cians have the ability to biomimetically the coronal elements (enamel/dentino-
reproduce the union between synthetic enamel junction (DEJ)/dentin), their
dental materials and natural anatomic three-dimensional configuration and
tooth structures.5 respective spatial inter-relationships, is
With the perpetual improvement of deemed compulsory.
dental restorative materials, their prop-
erties now include optical light transmis-
sion and color dynamics, adding to the Methodology
plethora of choices. With a multitude of
shades, translucencies, opacities, ef- To ascertain the morphologic relation-
fects and stratification techniques,6-11 ship between the exterior surface of
Fig 1 Bell Stage: Histo-differentiation is the process of transforming a mass of similar-looking epithelial
cells into morphologically and functionally distinct components (enamel/dentinoenamel complex/dentin).
Morpho-differentiation is the process whereby individual tooth buds attain recognizable shapes (incisor
vs molar).
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the enamel layer and the DEJ, the teeth DEJ as the structural epicenter ss e n c e fo r
were submerged in 10% hydrochloric
acid (HCl, Mallinckrodt Baker Inc, Phil- One must examine the significance of
lipsburg, NJ, USA) under ultrasonic vi- the DEJ as an important factor in the un-
bration for 20 minutes, which led to se- derstanding of the developmental adap-
lective enamel demineralization. tation of the surface pattern of enamel
Subsequently, the teeth were soaked expression.
in distilled water for 1 hour in order to During odontogenesis, this junctional
neutralize the acid and facilitate han- interface serves as the histologic blue-
dling. The specimens were photo- print (Fig 1), representing a complex in-
graphed (D200, Nikon Inc, Melville, NY, terdigitation zone between two distinct
USA) on a custom fabricated tripod jig anisotropic calcified tissues with differ-
(XX-Halter, Novoflex, Memmingen, Ger- ent biochemical compositions (Fig 2):
many) maintaining standardized illumi- i) enamel serving as the structural pro-
nation, exposure settings and perspec- tective shell and ii) dentin serving as
tive, prior to and after the acid treatment, the structural dampening core (Fig 3a).
in order to ensure proper alignment of The enamel and dentin demarcation is
the superimposed images. due to the difference of birefringence
Fig 2 Enamel is the densely mineralized brittle yet hard outer shell of the tooth that envelopes/engulfs the
softer dentin core; carbonate-rich hydroxyapatite crystals are arranged in enamel rods. Dentin, conversely,
is a collagen-rich apatite reinforced bio-composite that is resilient yet tougher than enamel and similar
at the nanostructural level to bone. It has a unique structural architecture consisting of dentinal tubules
surrounded by peritubular dentin cylinders of randomly orientated apatite crystallites, embedded in an
intertubular dentin matrix.
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Fig 3 The DEJ, when examined histologically, provides a visual interface, yet when examined on a bio-
mechanical level it is regarded as a functional interphase. Seen above is a 0.5 mm buccal/lingual histologi-
cal section of a maxillary first premolar that was submerged in distilled water and photographed on a black
background (a). The same specimen was photographed by transmissive cross-polarized illumination (b).
The extended dentinoenamel complex is highlighted (c).
between the tissues (Fig 3b). The DEJ Microstructure: enamel vs dentin
is less mineralized than either enamel
or bulk dentin, conversely being richer The microstructure of enamel is domi-
than either in organic matrix. Microscopi- nated by hydroxyapatite crystal-rich
cally, a bi-scalloped surface topography enamel rods, cemented together by an
is present, establishing a complex zone organic matrix protein polymer. Brittle
capable of plastic deformation while be- yet stiff, enamel undergoes only mini-
ing collagen fibril-reinforced.15 mal deformation while transferring loads
Considerable interest has been to the underlying dentin. The key to the
shown in the interconnectivity of the unusual properties of enamel lies in its
inner aprismatic enamel, the DEJ and unique three-dimensional structural
the outer layer of dentin, known as the arrangement, which consists of very long
“mantle dentin” approximately 150 mi- rods of carbonated apatite arranged in
crons in thickness, which is synthe- directional bundles. These bundles are
sized at the onset of dentinogenesis.16 progressively interwoven at higher hier-
This extended dentinoenamel com- archical levels. The rise in crack growth
plex (DEC) has been histologically de- resistance is largely attributed to a com-
scribed17 and observed as a function- bination of mechanisms, which include
ally graded interphase between two crack bridging, crack bifurcation and
vastly bio-mechanically different tissues crack curving, induced by prism decus-
that provides crack tip shielding.18 This sation of the inner enamel.24
is partially accomplished by a localized The microstructure of coronal dentin
reduction in density and mineralization, appears to be that of a mineralized colla-
in both enamel and dentin as they ap- gen fiber bio-composite, the intertubular
proximate their junction19 (Fig 3c). dentin being the matrix and the dentin
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Fig 4 The coronal dentin surface can be considered a three-dimensional configuration of the DEJ.20
When macroscopically observed, a high degree of conformity exists between the gross form of the DEJ
and the overlying enamel surface,21-23 the significant exception being the localized enamel thickness on
the buccal and lingual middle thirds of the crown, forming a transitional sigmoid curve distribution.
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Fig 5 Convex contours of the enamel surface are evident when viewed from the proximal surface, provid-
ing a contrast to the sharp, concave relief of the dentin surface. Congruency of micro-expressions between
enamel and dentin surface characteristics are depicted by the colored arrows. Maxillary first premolar
depicted.
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Fig 6 A pronounced dentin concavity is present on the buccal surface at the junction of the cervical and
middle third of the posterior dentition, forming a sigmoid curve. This localized enamel overexpression may
present a selective bio-mechanical reinforcement mechanism to the compressive loads experienced in the
posterior dentition. Mandibular second molar depicted.
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Fig 7 The above molar was extracted due to periodontal reasons. Upon trans-illumination, multiple crack
extensions are observed, yet they are contained only within the enamel layer. Since the process is gradual,
the cracks will be continuously replenished with protein rich oral fluids, thereby utilizing a self-healing
mechanism.
tubule lumens with their associated cuffs the selective adaptation of teeth, with
of peritubular dentin forming the cylin- the DEC proving to be the most intricate
drical fiber reinforcement. Dentin pos- of mechanisms, imparting the structural
sesses both elastic and plastic material efficiency of an interconnecting network,
properties, which vary significantly from where the various structural elements
region to region. Uncracked-ligament function in unison rather than remain-
bridging presents as the prevalent crack ing independent from each other. The
shielding mechanism observed in the DEC therefore is considered a func-
hydrated dentin core.25 tional shielding mechanism, that should
be preserved whenever possible during
Macrostructure: convex enamel clinical restorative procedures.
Bio-mechanical forces are thus al-
vs concave dentin
lowed to transmit freely through the sur-
Most topographic structures are related faces, dissipating throughout this struc-
to the different functional roles of the turally fluid medium. As a consequence,
enamel and dentin surfaces. The robust, controlled crack extensions are fre-
rounded convex contours of the enamel quently expected to form and progress
surface provide strength to a tissue sub- steadily during a lifetime. This occur-
jected to direct masticatory stresses and rence is validated in the intact teeth of
occlusal loads. In contrast, the sharp, older adults, particularly in trans-illumi-
concave relief of the dentin surface pro- nated views (Fig 7).
vides a stable support for the enamel Lacking awareness of this structur-
shell (Figs 5 and 6). ally advantageous non-uniform distribu-
From a bio-mechanical viewpoint, tion of enamel/dentin gives rise to opti-
harmony between the ectodermal and cal integration nuances. This frequently
mesodermal tissues was necessary for puzzles the restorative team due to the
16
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Table 1 te ot n
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fact that traditional dental morphology Visual observations of the posterior
enamel/dentin surface correlations. ss e n c e
fo r
curriculums focus primarily on external
enamel surface characteristics, over- Morphologic Enamel Dentin
features surface surface
simplifying the subsurface union with
dentin, thus assuming uniform distribu- Marginal ridges Rounded Sharp
tion. Hence the visual correlations be-
Buccal cusp/s Rounded Sharp
tween the enamel/dentin elements are
deemed of significant value (Table 1). Lingual cusp/s Rounded Sharp
Stone replicas (Pearl White, GC Fuji
Rock EP, Alsip, IL, USA) were made in Buccal surface Convex Concave26,27
order to better assess surface topogra-

Lingual surface Convex Concave
phy and characteristics (Fig 8).
Occlusal fissures Present Absent
Discussion
The purpose of this quest is to assist With the advent of adhesive den-
dental clinicians, technicians and stu- tal technology, the restorative team is
dents in these disciplines, using proper enabled to provide minimally invasive
visualization and sound understanding treatment, without being obligated to
of spatial ordering among the enamel sacrifice additional tooth structure in
and dentin structural elements. Once an effort to establish traditional funda-
this is mastered, reconstruction of the mental requirements of resistance and
dentition takes on proficient and pre- retention.
dictable qualities. This knowledge may be universally
With the fact that the design of the applied as a foundation for developing
intact tooth is unrivaled on a micro- novel stratification techniques when fab-
structural level, one must be inspired ricating restorations in either composite
to endeavor towards macro-structural resins or etchable ceramics, with either
emulation with the current bio-materials conventional (refractory die or thermo-
available. pressed) or contemporary (CAD/CAM
Armed with this knowledge of the or 3D printing) methodologies.
Bio-Emulation model, commencing di-
rect and indirect adhesive dental resto-
rations takes on a refined and intuitive Conclusion
manner, rather than an over-simplified
automated one. The refinement is not This article presented essential histo-
that of simplification, yet one that thrives anatomic elements, such as the sigmoid
on a thorough understanding of the in- curve distribution (convex enamel/con-
nate structural complexity of the intact cave dentin), the distinction between
tooth; it relies on powerful yet efficient dentinoenamel “junction” and dentino-
spatial ordering principles of the analo- enamel “complex” and the structural
gous dental structures. significance of DEC preservation.
17
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Fig 8 Stone replicas facilitate visual assessment and rumination of the variability between enamel and
dentin surface topography. Thorn-like dentin tips are connected by sharp ridges, defining a constricted
occlusal table when compared to that of the enamel counterpart. This cognitive paradigm shift may enable
pathways towards improving current restorative stratification techniques and inspiring new bio-material
innovations by structural and optical design. Maxillary first molar depicted.
18
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12. Sieber C. Voyage - Visions in Color and Form.
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electron microscopy of Type I collagen at the
dentin enamel junction of human teeth. J Histo-
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19
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CLINICAL RESEARCH pyrig

Biomimetically Emulating Nature

Panaghiotis Bazos, DDS

Pascal Magne, DMD, MSc, PhD

Correspondence to: Panaghiotis Bazos

Tel: +30 210 722 2329; e-mail: p_bazos@mac.com

order to better assess surface topogra-

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