The compression dome concept:
the restorative implications
Graeme Milicich, BDS
Evidence now supports the concept that the enamel
ona tooth acts like a compression dome, much like
the dome of a cathedral. With an overlying enamel
-ompression dome, the underlying dentin is protected
from damaging tensile forces, Disruption of a compres
sion system leads to significant shifts in load pathways.
The clinical restorative implications are significant and
far-reaching, Cutting the wron of a tooth exposes
cas that exceed
es lead to crack
causing ventual fracture
oth structure. Improved understanding
of the microanatomy of tooth structure and where itis
safe to cut teeth has led to a revolution in dentistry tha
is known by several names, including microdentistry,
ic dentistry
tment concepts
toa coalesce
of principles of tooth
microanatomy, material science, adhesive dentistry, and
hat, when applied together, will
reinforcing
low dentists
ompromised compress!
it more closely replicates the structure of
thy toot
Received: September 4, 2016
Revised
Key words: adhesive cerami
biodome, bioemulation, bion
‘ompression dome, minimally invasive
rnyone who has practiced dentistry for long enough,
recognizes that the conventional model of diagnosis and
restoration proposed by GN. Black does not serve well
in the long term. When GN. Black's restorative model was for-
‘mulated, amalgam and gold were the primary restorative options,
and the associated preparation techniques were based on the
then available technologies and the requirements of the available
restorative materials. The diagnostic model was the naked eye and
a probe. Applying the current understanding of the ultrastruc-
ture of teeth in conjunction with modern diagnostic technolo-
gies, materials, adhesive techniques, and restorative approaches,
dentists can now use minimally invasive biomimetic techniques
to provide restorations that come close to functionally and biome-
chanically mimicking the original, healthy state of a tooth.
‘These advances started more than 25 years ago with a concept
known as microdentistry, and one of the pioneers in this field
was J. Rainey. His articles on dental microanatomy and micro
air abrasion were primary stepping stones and are now core to
the biomimetic and bioemulation concepts currently taught in
advanced restorative programs.”
Concept of the compression dome
An early article describing the compression dome concept in
association with biomechanical function addressed a previously
unreported enamel fracture mechanism now described as occlu-
sal effect caries.* The problem is that teeth have been designed
by nature primarily to withstand compressive loads. Teeth have
not evolved to tolerate the damage that dentistry and high-speed
Fig 1. Stress patterns generated by a vertical load.” The direction
Of the lines indicates the direction of the stresses, obliquely vertical
in the enamel compression dome and horizontal in the dentin core.
Increased wicith of the fringes indicates increased stress. Stress
concentration can be observed at the dentinoenamel complex.
Stress concentration occurs where the fringes are closer together,
a contributory factor to cervical abfraction
wwew.agd org/seneraldentistry 55‘The compression dome concept: the restorative implications
Fig 2. Mesiodistal vertical fracture. A. Symptomless
fracture in a mandibular second molar. B. A plunger cusp
‘on the opposing maxillary second molar is creating a
wedging effect, placing the distal half of the mandibular
tooth into tension and generating the fracture.
cutting equipment can cause. Once the occlusal surface is cut,
the tooth can flex under compressive loads
‘The enamel is designed to act as a compression dome, much
like the dome of a cathedral, transforming and transferring
loads, via the dentinoenamel complex (DEC), into a primarily
compressive load in the dentin.*® The dentinoenamel complex
is a new descriptive term for the dentinoenamel junction.’ The
DEC isa complex interface between the enamel and dentin
where the enamel develops a trabeculated structure and the
underlying dentin does not develop a “normal” dentin structure
for 2-300 jum below the enamel. This interface allows for stress
transfer, thus protecting the dentin from damaging tensile
stresses while maintaining compression in the dentin (Fig 1):
Once the enamel compression dome is violated, the underlying.
dentin is exposed to tensile forces it was not designed to handle.
Disruption of the enamel compression dome leads to energy
concentration in the dentin rather than energy dissipation,
Within the enamel compression dome, there are several
microanatomical structures designed to absorb and distribute
compressive loads, such as the peripheral rim of enamel, the
subocclusal oblique transverse ridge, and the maxillary web
of enamel. It has recently been reported that intracollagenous
hydroxyapatite nanocrystals in the dentin collagen fibrils keep the
fibrils in tension, essentially acting like prestressed reinforcing
steel in concrete, keeping the surrounding hydroxyapatite hard
structure in compression.” The combination of this factor with
the fanctioning of the DEC and the overlying intact enamel com:
pression dome creates a dental structure that can last a lifetime.
Disruption of the compression dome
Once the integrity of the enamel compression dome is disrupted,
the tooth can begin to flex and distort. Enamel is a complex
structure in that it can behave like brittle glass and at the same
56 GENERAL DENTISTRY Soptomber/October 2017
Fig 3. Restoration of the vertical fracture shown in
Fig 2. A. Initial adhesive onlay preparation and discrete
dissection of the vertical fracture have been completed.
B, The fracture outline was smoothed and an adhesive
lithium disilicate onlay was bonded. The opposing
plunger cusp has been modified to allow a shallow,
smooth occlusal contour in the onlay, and the occlusion
has been shifted to place a primarily compressive load
cn the existing mesial working cusp.
time like a viscoelastic material.” When intact and loaded,
enamel has been shown to tip and rotate semi-independently of
the underlying dentin due to the flexible nature of the DEC.
The underlying dentin is compressible by nature, yet it is
overlaid by a strong but brittle material. These function in har-
mony to absorb and distribute applied forces. A commonly used
material that incorporates both brittle and flexible materials to
create something stronger than the individual components is,
the laminated glass in automobile windshields. Laminated glass
is so strong that when it is bonded to the frame of the cat, it
becomes a critical component in the designed torsional tigid-
ity of the chassis. Ifa stone strike causes a starburst chip and a
small crack, this crack can be easily spread simply by pushing
outward from the inside of the windscreen, Such pressure puts
the outside layer of glass into tension. Glass is only strong in
compression, just like enamel.
Itis this tensile phenomenon that creates the vertical frac-
tures in the peripheral rim of enamel that leads to occlusal
effect caries.’ Once the occlusal enamel has been disrupted by
removal of essential cross-bracing structures, such as the sub-
occlusal oblique transverse ridge, the underlying dentin distorts
under lateral compressive loads on the enamel compression
dome, causing the enamel at the marginal ridges to be placed
into tension and creating an unstable vertical fracture.
‘Once the enamel compression dome has been violated, the most
common failure observed is the oblique fracture that leads to the
loss of the cusp. When the occlusal incline planes are loaded, the
underlying dentin is placed into tension. The presence of a sharp
internal line angle in a tooth acts asa stress concentrator, and
over a period of time a crack begins to propagate, eventually lead-
ing to loss of the cusp. This failure is most commonly observed
in teeth restored with amalgam but is equally prevalent in teeth
restored with gold when the cusps have not been overlaid.”Fig 4, Example of Incan compression engineering, Five other blocks were in contact with
the upper surface of this stone, and these components were designed to self-center in the
event of movement (arrows).
A less common but more dangerous tooth fracture is the
mesiodistal vertical fracture most often associated with an
opposing plunger cusp. These fractures can occur even in unre-
stored teeth and are further evidence that teeth do not cope well
with tensile forces (Fig 2). Left alone, a fracture will eventually
propagate to the pulp. Simple modification of the occlusion
will not predictably stabilize the fracture and prevent further
propagation. In the author's opinion, the least invasive technique
available to reestablish a stable compression dome is an adhesive
lithium disilicate onlay (Fig 3)
Restorative implications
To prevent the ongoing biomechanical degradation of a tooth,
the primary goal is to avoid the need to mechanically interfere
with the core integrity of the enamel compression dome. The
need to interfere is essentially the result of the modern diet,
which leads to a diseased biofilm that eventually causes caries.
The primary goal in dentistry should be to help patients retain
or regain a healthy biofilm."
For decades dentists have been telling patients to brush, floss,
and use fluoride, but within certain population demographics
the incidence of caries and untreated carious lesions is still
growing. In many areas of biology, itis readily apparent that
changes cannot be forced, but, over time, human intervention
can create a population or evolution shift. This applies to the
health of the dental biofilm, Dentists have to help their patients
‘train’ their oral biofilm back to health through pH management
and dietary modification that will allow healthy commensals to
repopulate the oral biofilm and replace disease-causing aciduric
and acidogenic bacteria in the biofilm
Once the biofilm has been compromised, intervention even-
tually becomes necessary. The primary cavitation sites are the
‘occhisal fissures, This area is also the critical zone required to
maintain stability of the enamel compression dome. An early,
accurate diagnosis made using one of the new diagnostic tech-
nologies allows for early intervention. The goal is to maintain
the occlusal cross-bracing structures. For the past 20 years,
the author has found that the most effective early intervention
technique has been to completely debride the fissures, dissect
out any damaged fissure enamel with fine-tipped micro~air
abrasion (guided with a caries detection dye), and then restore
the microcavities with an autocuring glass ionomer cement.:*
‘To revisit the cathedral dome analogy, this approach would
be similar to placing discrete windows within the dome that
do not interfere with the energy compression pathways. Ifthe
window (cavity preparation) is too large, the associated instabil-
ity could lead to collapse.
‘When intervention is delayed and the critical biomechani
cal tooth components are lost, a downward restorative spiral
begins. Bonded restorations provide significant support to tooth
function in that they help distribute forces, reducing the risk of
fracture propagation.” Amalgam-restored teeth fracture at a rate
7.5 times that of teeth restored with bonded composites
Teeth ate often restored with a monophase technique, when the
tooth in reality is a multiphase system combining enamel, which
is a brittle material, bonded to dentin, which is a more yielding
clastic material. To begin restoring function and stability to the
compression dome, dentists need to consider replicating the natu-
ral, layered, laminated system. Materials and bonding systems
are now evolving that offer options to more closely replicate the
natural structure and energy distribution systems of teeth.
‘With smaller restorations, simple monophase adhesive resto-
rations are probably adequate. However, when there is greater
damage, long-term success is more dependent on restabilizing the
tooth and redirecting the forces as they occur in the natural com
pression dome system. ‘Techniques that utilize fiber-reinforced
composites to create laminated direct restorations and more
complex stress-absorbing designs that use woven high~molecular
‘weight polyethylene fibers have been recently developed and
refined; these offer the potential to help protect the tooth from
further stress-related degradation.”*** Once the significance of
the enamel compression dome and its protective function is
understood and the concept is consistently applied in conjunction
with modern adhesive restorative options, the phrase “you need a
crown” may almost disappear from the professional lexicon.
The stability of compressive structures has been well under
stood over the millennia, and ancient engineers utilized these
principles. Figure 4 shows an example of Incan engineering
wwwagdora/aeneraldentistry 7‘The compression dome concept: the restorative implications
Fig 5. Basic adhesive ceramic onlay design. The arrows lying on the preparation contours
indicate the same self-centering stabilization and compression principles as those shown
inFig 4, The vertical/oblique arrows indicate the strong peripheral compressive forces
generated during occlusal loading of the restoration. This concept only works if @ high-
‘modulus material such as lithium di
‘materials will allow too much flexibility when stat
that demonstrates how these principles were applied. The stone
block was a part of a 2000-year-old wall engineered to with-
stand earthquakes. When disturbed by an earthquake, these
types of blocks are naturally self-centering and can reassemble
themselves as they move. A marble placed on the surface of one
of these blocks will rol to the center.
Figure 5 illustrates how these same principles are used in a
basic adhesive ceramic onlay design. Even when not bonded,
the restoration is self-centering, both mesiodistally and buc-
colingually. The marginal chamfer is kept above the height of
contour and, when placed under load, transmits a compres-
sion force to the underlying tooth, thus helping avoid transfer
of damaging tensile stresses to the underlying dentin. This
concept works only ifa material with a high modulus of elastic-
ity is used, Hybrid materials with a lower modulus will allow
too much flexibility.
‘There are now materials and bonding systems that allow den-
tists to restore biomechanical function to the toath without cut-
ting away the sides of the tooth. This involves another new term,
in biomimetic dentistry, the bio-rim.’® The bio-rim is the area
ofa posterior tooth that lies below the maximum point of con.
vexity Ifthe occlusal enamel of a tooth is considered to be the
cathedral compression dome, then the bio-rim isthe walls sup
porting the dome, When the bio-rim is retained and an adhesive
lithium disilicate onlay is placed on the tooth, the risk of fracture
and the severity of any failure are reduced compared to the tisk
for a full crown that requires the removal of the bio-tim.”
Compression dome adhesive
ceramic onlay
‘There comes a point in the restorative continuum where inter-
nally bonded direct restorations reach their limitations, The
biomechanical integrity of a tooth can now be restored without
destroying the bio-rim, thanks to advances in materials and
adhesives. Anecdotally, many operators using the compression
dome adhesive ceramic onlay technique have noted a reduc
tion in posttreatment endodontic indications when compared
58 GENERAL DENTISTRY Septembor/October 2017
icate is adhesively bonded. Lower modulus hybrid
ing cracked teeth.
to teeth prepared for full ferrule crowns. This is most likely
associated with the retention of the bio-rim, which maintains
a greater distance between the preparation and the underlying
pulp as well as significantly reduces the number of cut odonto-
blastic processes closer to the pulp. The severity of endodontic
reactions depends more on remaining dentin thickness than
con the type of preparation.” The basic adhesive ceramic onlay
design stays above the pulp chamber, greatly reducing the
pulpal preparation trauma compared to full ferrule retention
crown preparations (Fig 6).
Ta recreate the enamel compression dome, simple cementa-
tion techniques have to be abandoned, and a commitment
must be made to adhesively bond a ceramic, such as lithium
disilicate, to the tooth.” Over the past 9 years, the author
has placed more than 3000 adhesive ceramic lithium disilicate
onlays (Multilink Automix, Ivoclar Vivadent) based on the
design concepts presented in this article and can report 2 frac-
tured restorations and zero incidents of dentin debonding, The
high-end bonding systems now available are coming close to
replicating the strength of the natural enamel-dentin bond at
the dentinoenamel complex.” As a restorative material, lithium
disilicate performs clinically as an equal to both metal-ceramic
and veneered zirconia crowns.” The primary advantage of
lithium disilicate is that it can be adhesively bonded. Ina recent
clinically based study, the authors reported that:
The presence of a liner or base of glass-ionomer cement
resulted in a risk for failure twice as large as that of restora-
tions without liner or base material. Restorations performed
with simplified adhesive systents (2-step etch-and-rinse and
L-step self-etch) presented a risk of failure 142% higher than
restorations performed with adhesives with bonding resin as a
separate step (3-step etch-and-rinse and 2-step self-etch).”
Simple cementation or the use of a self-etching resin cement
does not provide this laminated integrity, so the overlying,
restoration cannot behave as a compression dome. If adhesiveFig 6. Compression dome adhesive ceramic onlay. A. In cross-section, the dentinoenamel complex describes a sigmoid
curve. The blue line is the inflection plane that joins the buccal and lingual points where the concave becomes convex.
Below this plane is the bio-rim, and above this plane is the enamel compression dome. 8. The basic onlay design aims at
retaining circumferential enamel above the inflection plane (arrow), creating a stable peripheral bond in conjunction with
a compressive design.
technology is combined with a high-strength ceramic onlay,
such as lithium disilcate, to create a fully integrated, multiphase,
laminated structure, the tooth can be restored to a biomechani-
cal state close to its original state before it began to fail
To successfully embrace the restorative concepts associated
with the compression dome, there has to be a commitment to
adhesive dentistry. Amalgam is not a good restorative material
choice for trying to retain, restore, or recreate the integrity
of the enamel compression dome.” Equally, the cementation
of restorations, whether inlays or crowns, does not provide
the adhesive support between the restoration and the tooth
that is required for the reestablished restorative compression
dome to function correctly. The natural enamel compression
dome is "bonded" to the dentin and peripheral enamel. To
replicate the natural design, ceramic onlay restorations should
create the same type of bonded interface. By retaining the
bio-rim and staying above the maximum point of convexity
as much as possible, the preparation design for a compression
dome adhesive ceramic onlay allows most, if not all, of the
restorative margin to be placed on enamel, greatly increasing
clinical performance."*
Success with adhesive ceramic onlay restorations is well
documented in the literature." Arnetzl & Arnetz| reported
.93-month survival rate of 99.3% in 286 occlusal onlays made
of Vita Mark II ceramic (VITA North America): Considering
Vita Mark II has a compressive strength approximately
third that of lithium disilicate, equal or better performances
Schulte et al reported 95%
could reasonably be expected.”
survival rates over a range of 9.5 years with IPS Empress ceram-
ics (Ivoclar Vivadent), a material that is similar in strength to
Vita Mark 112!" The success of these weaker materials, even in
challenging adhesive onlay designs, can probably be attributed
to the previously described adhesive lamination effect, whereby
a brittle material such as ceramic or enamel can work in strain
harmony with the underlying dentin and enamel when they
are adhesively bonded together. A recent article eloquently
describes the concepts of lithium disilicate adhesive onlays.”
Conclusion
The engineering world is focusing more and more on working,
‘out how nature has solved enginecring problems. As a con
sequence, materials and design solutions are being developed
to integrate what are often simple but elegant solutions.
Clinicians can look at restorative dentistry from a similar
perspective duc to the new, more biomimetic materials and
effective adhesives, creating the opportunity to revolutionize
restorative approaches. The simple concept of visualizing a
tooth as a complex compression dome system has created a
different perspective, and new materials and improved adhe-
sive technologies provide the opportunity to apply the concept
in less invasive restorative options with the potential for
increased performance and longevity.
Author information
Dr Milicich isa recently retired private practitioner in Hamilton,
New Zealand.
Disclaimer
The author has no financial, economic, commercial, or profes:
sional interests related to topics presented in this article.
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