On The Mechanics of Fatigue and Fractur in Teeth

Mobin Yahyazadehfar
Department of Mechanical Engineering,

University of Maryland Baltimore County,
Baltimore, MD 21250
Juliana Ivancik
Baltimore, MD 21250;
Protective Equipment Division,
U.S Army Aberdeen Test Center,
Aberdeen, MD 21001
Hessam Majd
On the Mechanics of Fatigue
Baltimore, MD 21250 and Fracture in Teeth
Bingbing An Tooth fracture is a major concern in the field of restorative dentistry. However, knowl-
Department of Mechanics, edge of the causes for tooth fracture has developed from contributions that are largely
Shanghai University, based within the field of mechanics. The present manuscript presents a technical review
Shanghai 200444, China; of advances in understanding the fracture of teeth and the fatigue and fracture behavior
Shanghai Key Laboratory of of their hard tissues (i.e., dentin and enamel). The importance of evaluating the fracture
Mechanics in Energy Engineering, resistance of these materials, and the role of applied mechanics in developing this knowl-
Shanghai 200072, China edge will be reviewed. In addition, the complex microstructures of tooth tissues, their
roles in resisting tooth fracture, and the importance of hydration and aging on the frac-
Dongsheng Zhang ture resistance of tooth tissues will be discussed. Studies in this area are essential for
Department of Mechanics, increasing the success of current treatments in dentistry, as well as in facilitating the
Shanghai University, development of novel bio-inspired restorative materials for the future.
Shanghai 200444, China; [DOI: 10.1115/1.4027431]
Shanghai Key Laboratory of
Mechanics in Energy Engineering, Keywords: crack propagation, dentin, enamel, fatigue crack growth, fracture toughness,
Shanghai 200072, China tooth
Dwayne Arola1
Department of Materials Science
and Engineering,
University of Washington,
Seattle, WA 98195;
Department of Endodontics,
Prosthodontics, and Operative Dentistry,
Dental School,
University of Maryland,
Baltimore, MD 21201
e-mail: darola@umbc.edu
1 Introduction Each tooth is comprised of multiple hard tissues including enamel,

dentin, and cementum as shown in Fig. 1(a). Enamel is the most
From a mechanical perspective, teeth are very resilient struc-
highly calcified tissue in the body (roughly 90% apatite mineral
tures. They have been designed to withstand the loads of mastica-
by volume), and serves as a stiff and wear-resistant outermost
tion, reaching values of 700 N and greater [13], and over
layer occupying the tooth crown. The underlying tissue is dentin,
lifetimes that involve tens of millions of cycles [4]. Although they
one of much lower mineral content (roughly 50% by volume) and
are able to withstand the demands of most oral activities, tooth
is connected to enamel by the dentin-enamel junction (DEJ). That
failure is not uncommon, and thus, is a major concern in the field
interface is highly complex and is perhaps worthy of its own
of restorative dentistry. While dental caries are the primary cause
review [9]. Dentin occupies the major part of tooth by both weight
of failure overall, tooth fracture resulting from mechanical
and volume. It serves as the elastic foundation for enamel and as a
forms of degradation, or potential synergism between participat-
protective enclosure for the dental pulp, the innermost tissue. The
ing chemical and mechanical modes, is among the top three con-
pulp is a living (vital) soft tissue, which contains nerves, blood
tributors [58]. The mechanics behind these failures and the
vessels, and other organic constituents. Located beneath the ana-
relevance of fatigue and fracture to the incidence of these failures
tomic tooth crown, the root also consists primarily of dentin and is
is the primary topic of this review.
covered by a thin layer of cementum, which provides connection
In the discussion of teeth as a mechanical structure, it is impor-
between the tooth and jaw bone via the periodontal ligament [10].
tant to provide details regarding the materials and their roles.
Details regarding the microstructure of dentin and enamel, as well
as the importance to their mechanical behavior will be discussed
1 later in this review.
Corresponding author.
Manuscript received October 7, 2013; final manuscript received March 30, 2014; In discussing the mechanical forms of tooth failure it is impor-
published online April 30, 2014. Assoc. Editor: Francois Barthelat. tant to address whether the tooth is intact (i.e., without evidence
Applied Mechanics Reviews Copyright V

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of prior dental work) or the tooth has been restored (i.e., having
received treatment to repair the tooth and its integrity). Teeth that
have undergone attack by oral bacteria (i.e., dental caries) will
require that the affected dentin and enamel are excavated and that
a dental material is placed within the cavity that restores the
tooths overall form and function. This process is the staple of
restorative dentistry and has served the profession since its incep-
tion in the 18th century [11]. The nature of damage and propensity
for bulk fracture of the tooth are different for unrestored and
restored teeth. For example, unrestored teeth often exhibit cracks
on the surface (Fig. 2(a)). These cracks propagate about the
tooths surface depending on various parameters such as the
amount and condition of contact loading, tooth morphology, the
microstructure of subunits of the teeth, etc. [12,13]. Nevertheless,
cracks located in unrestored teeth generally do not cause bulk
fracture or require extraction. That does not diminish the impor-
tance of this form of structural degradation. Understanding what
causes the initiation of cracks and the mechanisms responsible for
crack arrest is relevant to development of new dental materials
that are inspired by the biological systems they replace.
Restored teeth generally undergo failure due to cracks that can-
not be seen. These cracks develop within the dentin, at the inter-
face between the restoration and surrounding hard tissue as shown
in Fig. 2(b). The failure of restored teeth due to cracks of this type
is a major obstacle to the success of restorative dentistry [1419],
and has been termed the cracked tooth syndrome [20]. Mechani-
cal failures of restored teeth are likely to result from large stresses
and/or fatigue, a cumulative process of damage development and
Fig. 2 Cracks in human teeth. (a) Cracks in unrestored anterior

Fig. 1 Tooth anatomy. (a) Schematic of human tooth. teeth, (b) crack development in tooth restored with amalgam
(reprinted from Ref. [10] with permission from the publisher) (b) restoration. The crack initiated at the interface of the restoration
micrograph of the dentins microstructure. T, IT, and PT repre- and tooth structure in the region where there is a large stress
sent tubule, intertubular, and peritubular dentin, respectively, concentration (the encircled area). Note that the crack exten-
(c) micrograph of enamel microstructure. sion is perpendicular to the tubule orientation in dentin.
030803-2 / Vol. 66, MAY 2014 Transactions of the ASME

its propagation. The importance of cavity size and design [21,22], and Lee [35]. Research in this area has distinguished that the ini-
the amount of damage introduced to the tissue by excavations tiation of damage begins in enamel and is distributed within a
e.g., Refs. [2326] and the type of restoration e.g., Refs. [27,28] greater part of the volume with increasing load. Most of the cracks
are some of factors which have been studied over the past deca- are limited to the enamel layer and do not influence tooth func-
des. Failures also occur within the restorative materials. Failure of tionality. Only at high load ranges does fracture of the entire tooth
the restoration generally involves sub-critical fracture (i.e., chip- occur (by either tooth chipping or splitting).
ping and indentation fractures) and degradation of the restorative In general, two modes of cracking have been observed to
margins [5,6,29]. These failures are equally important as they develop in teeth under contact loading, including longitudinal
most often result in secondary caries within the adjacent dental cracks and margin cracks. Longitudinal cracks can also be sub-
hard tissues. This topic is beyond the scope of the present review. categorized as radial cracks and median cracks as described in
For those interested in this topic, a review of recent advancements Figs. 3(a) and 3(b). Radial cracks initiate from pre-existing flaws
in restorative materials with a more detailed description of at the base of the enamel and extend upward to the occlusal sur-
mechanical performance and future enhancements was recently face. Median cracks start from shear-nucleated flaws within the
presented by Ferracane [8]. quasi-plastic yield zone directly beneath the contact load at the
More recently a number of investigations have been conducted occlusal surface, and then extend downward through the enamel
to understand the mechanics of tooth failure, as well as to deter- thickness. Margin cracks initiate from intrinsic defects (i.e., the
mine the importance of fatigue and fracture mechanics in the fail- protein-rich tufts) at the DEJ and propagate to the occlusal surface
ure process. Results from these studies are providing a greater of the teeth. Further loading causes other modes of failure such as
understanding of the tooth as a mechanical structure, as well as chipping, cone cracking outside the contact zone, as well as
the fatigue and fracture resistance of dentin and enamel. They are delamination failure at the DEJ or progression into dentin [12,33].
also distinguishing important physiological factors that render the The influence of various dietary-related parameters and tooth
tooth more susceptible to failure. geometry on the failure modes of teeth has been examined. The
The overall objective of this review is to present the work in nature of tooth failures is associated with the dietary habits and
this area, with an emphasis on the importance of applied mechan- food characteristics such as the food particles size and their
ics to the development of knowledge. The manuscript is organized mechanical properties. Mastication involving small, hard objects
in the following manner. Section 2 describes the work that has is likely to induce local deformation at the occlusal surface, which
been performed to assess the fracture resistance of the tooth as a causes generation of radial cracks, whereas large, soft food par-
structure. As studies performed to evaluate the fracture behavior ticles are less likely to cause cracking [35]. Tooth size and mor-
of tooth tissues have largely required nonstandardized approaches, phology are other important factors in the evaluation of critical
Sec. 3 presents the developed methods and their application. Sec- failure load. A comparison of failure loads in a study of different
tion 4 reviews studies performed to determine the fracture behav- primate teeth showed that the general mechanical properties (elas-
ior of dentin and enamel, and that is followed by a description of tic modulus and hardness) of primates enamel are not signifi-
studies evaluating the fatigue crack growth resistance in Sec. 5. cantly different and that the critical failure loads are only a
The influence of important oral conditions and physiological fac- function of teeth morphology and enamel thickness [36].
tors on the fatigue and fracture resistance is discussed in Sec. 6. Differences in the failure modes that develop in teeth of differ-
Lastly, Sec. 7 offers a summary, and addresses challenges and ent mammals and the importance of tooth geometry have also
future work that is needed in this area. been studied. During the generation of biting forces a hoop stress
concentration develops at the cervical base of the tooth and cre-
ates margin cracks [35]. Based on the work of Chai et al. [13],
2 On the Fracture Resistance of Teeth margin cracks are more likely to initiate in smaller teeth sizes
Contact between teeth and food particles, or simply with oppos- with large enamel thickness in contact with soft objects. This
ing teeth, can cause damage at the tooths surface and result in crack type is predominant in teeth, but very stable, as the path
degradation of tooth functionality. Cumulative microscale contact length is very largeit extends from the margins to propagate
with hard small food particles and under low contact forces can about the occlusal surface. A map of radial crack sizes in teeth as
cause wear on the tooths surface. Yet, macroscale contacts a function of bite force is shown in Fig. 3(c). The minimum con-
involving teeth and larger food particles and under higher load tact load required to initiate the growth of dormant margin cracks
ranges (1001000 N) can cause damages in the form of cracks using a flat hard indenter in human molars is about 200 N; the
[30]. By virtue of its high mineral content, tooth enamel is a brittle cracks initiate from the cervical base and traverse roughly 8 mm
material. As such, some of the aforementioned mechanical forms toward the occlusal surface [37]. The critical load required for the
of damage that are observed in teeth may be expected. Neverthe- cracks to grow from the cervical margin to the occlusal surface
less, despite the development of cracks on the surface of teeth as a ranged from 400 to 600 N (Fig. 3(d)) [37]. Similar evaluations for
result of function, these cracks seldom result in bulk fracture of longitudinal cracks, including radial, and median cracks, showed
the tooth. That raises questions such as: What prevents tooth higher loads ranges as shown in Fig. 3(c). Considerable scatter is
fracture from originating from the visible external cracks in enam- generally observed in experimental results involving contact
el? or How does the tooth geometry and enamel thickness con- induced fracture of teeth and is attributed to variations in the tooth
tribute to the tooths ability to maintain its integrity over the range dimensions, contact area (cuspal radius of curvature), and the
of oral functions?. Those and similar questions have stimulated enamel microstructure among the teeth evaluated.
research in this area. In more recent studies, efforts have been focused on validating
The capacity for teeth to withstand the loads of mastication experimental results obtained for cracking of the enamel encase-
without causing tooth fracture is of substantial interest in the field ment using finite element analyses [3739]. Simulations involving
of dentistry and to biological evolution e.g., Refs. [3033]. Hertz- different sizes of teeth and enamel thickness have been performed
ian mechanics has been used to evaluate the nature of contact that to estimate the loads required to develop and propagate cracks in
takes place between teeth and/or restorative materials used for teeth. Assuming that enamel exhibits both homogenous and iso-
tooth replacement for some time [34]. Hertzian mechanics can tropic fracture toughness, simulations showed that margin cracks
offer new insights into the load-bearing capacity of teeth, their grow under lower load ranges when compared to radial cracks
strength and the modes of failure. Robust empirical models under the same starting crack size [37]. The authors also discussed
have been developed to predict the critical loads for the initiation the role of the starter defect for crack initiation and conveyed
of cracks, and for tooth failure, as a function of characteristic that while the initial defect size was not considered in their models
tooth dimensions such as tooth base radius, enamel thickness, and for the tooth failure predictions, a minimum defect size is neces-
material toughness. Details of the models can be found in Lawn sary for stable crack extension. Although the minimum defect size
Applied Mechanics Reviews MAY 2014, Vol. 66 / 030803-3

Fig. 3 Contact loading failures in human molar teeth. (a) Schematic of various cracks types on tooth surface, (b) crack
formation on a human molar due to contact with a flat indenter on the top of the cusp (reprinted from Ref. [38] with permis-
sion from the publisher). M and R in the figure stand for margin and radial cracks, respectively (reprinted from Ref. [95] with
permission from the publisher). (c) Measured radial crack size as a function of indentation load (reprinted from Ref. [37]
with permission from the publisher), (d) measured margin crack size as a function of indentation load (reprinted from Ref.
[37] with permission from the publisher). PR and PM are the estimated critical loads from developed contact models.
required for crack extension requires further assessment, it is limited volume of human dental tissues that enable such evaluations.
believed that enamel microstructure is definitely the source for the Animal teeth (e.g., bovine or ovine) are occasionally adopted as a
starter defect. substitute for human teeth in an attempt to obtain larger sample vol-
Chai et al. [40] described the enamel tufts as intrinsic defects umes, but that raises questions regarding the consistency in micro-
within the microstructure that serve as the starting point for the de- structure between the teeth of humans and other mammals, and the
velopment of radial and margin cracks in teeth. These natural corresponding validity of the results. Even in the adoption of substi-
cracks, which can be found in the enamel, extend from the DEJ to- tutes for human tissue, the maintenance of mineral content and
ward the occlusal surface over tens of micrometers and at the inter- hydration of the tissue are important concerns.
face of the rods [41]. Not all cracks that initiate at the DEJ undergo Miniaturized specimens have often been considered as an alter-
progression to reach the occlusal surface; some are arrested along native to using standardized approaches for measuring the fracture
their path through the enamel thickness. Section 4.1 provides an ex- properties of biomaterials. There are several methods developed
planation of why the progression of some cracks in enamel are to estimate the fracture properties of dental materials and tissues
arrested, and the importance of this observation. of the tooth. Pilliar et al., [4244] adopted a short rod specimen
for determining the fracture toughness of dental materials and
later used this approach to evaluate the fracture toughness of
3 Methods of Evaluating Fatigue and Fracture
bonded interfaces [45]. Wang et al., [46] developed a compact
in Tooth Tissues sandwich specimen for evaluating the fracture toughness of bone
Characterizing the durability of the tooth with regards to the forces and prosthetic materials, which has been adopted for evaluating
of mastication requires an understanding of the mechanical behavior the fracture properties of dental materials as well e.g., Refs.
of the individual tissues. Indeed, evaluations on the fatigue and frac- [4749]. Furthermore, Ruse et al. [50] developed a novel notch-
ture properties of dentin and enamel are an important requisite to the less triangular prism (NTP) specimen for evaluating the fracture
study of tooth fractures. While simple in concept, these investigations toughness of dental materials, adhesive interfaces and hard tissues
involve many complications, much of which is due to the relatively [5153]. Flexural loading of beams has been employed to measure

the fracture toughness of natural materials such as nacre e.g., configurations have been one of the most common formats for
Refs. [54,55] and bone e.g., Refs. [5658] and has also been used estimate the fatigue and fracture properties of dentin and enamel.
for evaluating the fatigue and fracture properties of dentin and However, unlike evaluations performed on ceramics and metals,
enamel e.g., Refs. [5962]. The compact tension configuration has crack propagation in biological materials often follows an oblique
been adopted for evaluating the fracture properties of hard tissues path in flexural configurations and causes a combination of Mode
as well [63]. Nevertheless, constraints in tissue volume have limited I and Mode II driving forces in these specimens. A recent study
this configuration to studies of dentin from the tooth crown e.g., by Bechtle et al. [62] addressed the possible effects from mixed-
Refs. [6466]. A schematic description of the more common speci- mode conditions on the reported fracture toughness of dentin
men configurations that have been adopted is presented in Fig. 4. under the flexure configuration, and presented new geometric
As the specimen size decreases, the specimen geometry can be function solutions for kink cracks in bending specimens.
more difficult to prepare precisely, which can reduce the level of Regarding investigations of dental enamel, most of the early
confidence in the estimated properties. There are other concerns studies on the fracture resistance of this tissue were based on in-
in the evaluation of the fatigue and fracture behavior of teeth. dentation methods rather than a traditional fracture mechanics
Many earlier evaluations suffered from the lack of a precrack in approach involving crack extension e.g., Refs. [6771]. Indenta-
the samples, or alternatively achieved fracture from a notch rather tion techniques have become quite common for evaluating the
than a well-defined crack. Variations in the initial flaw geometry apparent fracture toughness of brittle materials, ceramics in partic-
have been identified to contribute to scatter in the responses and a ular, as it is relatively easy and can be performed on a small vol-
greater potential for over-estimation of the fracture toughness ume of material. In addition, unlike the standard methods it does
[59]. Yet, advances in the methods of specimen preparation and not require a precrack. Yet, there are significant concerns regard-
testing over the last decade have largely overcome these issues ing the use of the indentation approach for estimating fracture
and are resulting in a better understanding of the fracture resist- toughness [7274], especially in evaluations involving biomateri-
ance and fatigue properties of dental tissues. als or hard tissues [75]. One consideration is that there are over 30
One additional concern regarding evaluations on the fracture of different models for estimating the fracture toughness from inden-
these materials is the potential for inadvertent mixed-mode load- tation cracks [74,76], and many of these have been developed
ing rather than pure Mode I. Three-point and four-point flexural from curve fits to data rather than from physical models for
Fig. 4 Schematic of various testing configurations used for dental materials. (a) Compact sandwich specimen (reprinted
from Ref. [46] with permission from the publisher), (b) NTP specimen (reprinted from Ref. [50] with permission from the pub-
lisher), (c) three point bending specimen (reprinted from Ref. [61] with permission from the publisher), (d) four point bending
specimen (reprinted from Ref. [61] with permission from the publisher), (e) miniature CT specimen (reprinted from Ref. [64]
with permission from the publisher), (f) inset CT specimen (reprinted from Ref. [63] with permission from the publisher).

fracture [74]. Even when comparing two highly brittle materials Enamel has been primarily regarded as a brittle material, which
of nearly identical composition, the indentation fracture test has is largely attributed to its high mineral content and the frequent
been shown to give highly misleading results when compared to identification of cracks on the surface of teeth. Furthermore, sev-
other methods [77]. Some consider indentation techniques unsuit- eral studies have credited the DEJ for arresting cracks on the
able for quantifying the fracture toughness of materials [74,75]. occlusal surface of teeth and preventing them from continuing
Thus, while the indentation approach can be used to achieve a rel- into the dentin [51,59,8587]. As such, there has been compara-
ative comparison between the fracture behavior of selected mate- tively little attention on the fracture properties of enamel, espe-
rials, there are strong arguments that it should not be used in cially in comparison to that for bone and dentin. The difficulty in
characterizing the fracture toughness of both engineering materi- conducting such evaluations has served as an additional obstacle.
als and hard tissues. Nevertheless, recent studies have shown that enamel has an inter-
The aforementioned techniques for evaluating the crack growth esting behavior and that it is an important contributor to the
resistance of dental materials utilize a specimen with major tooths overall resistance to fracture [37,39,8890].
dimension of l 4 mm. That value is quite large for application to A description of the fracture resistance of enamel requires a
the dentin and enamel of teeth. Zhang et al. [63] proposed a mini- more detailed description of its microstructure. Enamel is the
ature inset CT specimen (Fig. 4(f)) for evaluating the crack most highly mineralized tissue in the human body. The minerals
growth resistance of dentin and enamel, or for materials where the largely exist as crystallites of carbonated hydroxyapatite and are
available material volume is a strict constraint. This specimen uti- in the form of nanoscale rods. They are systematically assembled
lizes a small piece of tissue, with major dimension of 2 mm. In together with an interfacial thin film of noncollagen proteins to
this configuration, the material of interest is embedded (or form keyhole shaped rods, also referred to as the enamel prisms
molded) within another. For hard tissues, the molding material is (Fig. 1(c)) [91]. The enamel rods extend from the DEJ to the
generally a resin composite that is used in dentistry for placing occlusal surface of the tooth. At the occlusal surface the enamel
direct restorations. The inset CT specimen presently requires the exhibits an amorphous microstructure (i.e., without well-defined
smallest volume of material that has been reported for evaluating rods). There are variations in the microstructure through the thick-
fracture behavior using a conventional crack growth approach. A ness as well. In the outer enamel (close to the tooths surface),
recent investigation reported a generalized equation for the KI in the rods extend inwards in a nearly parallel arrangement from just
the inset CT specimen as function of crack length. The model con- beneath the occlusal surface. In the inner enamel (closest to the
siders a wide range of inset materials, with elastic modulus range DEJ), the rods are assembled in sub-units and bands that deviate
from 10 GPa to 100 GPa [78]. The generalized equation describing from one another. Each band of rods follows a sinusoidal path that
the stress intensity distribution was also validated from an analysis results in a complex decussating structure, which is responsible
of the fracture behavior for a commercial resin composite using for the Hunter-Schreger bands evident from visual inspections
both the inset CT specimen and the standard geometry defined by of the enamel. There are also spatial variations in the geometry of
ASTM E399 [79]. Results obtained for the fracture toughness of the individual rods. Specifically, the effective diameter decreases
the calibration material estimated using both specimen types were from roughly 8 lm at the tooths surface to almost 4 lm at the
within 2%. As such, the inset CT specimen can serve as a viable DEJ [10,91]. Furthermore, at the nanolevel there is a variation in
approach for studying the fracture behavior of small volumes of the orientation of the hydroxyapatite crystals. At the center of the
structural materials. rods (or prism head) the crystals are oriented parallel to the longi-
tudinal axis of the tooth, while in the inter-rod region (about the
prism tail) the crystals are more oblique to the rod axis [10,92]. It
4 Evaluations on the Fracture Resistance is believed that this small variation in crystal orientation has an
of Tooth Tissues important influence on the mechanical properties of enamel at
both the micro and macro levels [93]. There are also spatial varia-
The fracture resistance of hard tissues of the tooth has been tions in the organic content. The protein content in enamel
studied for decades and a relatively wide range in fracture proper- increases from the occlusal surface toward the DEJ where the nat-
ties has been reported for dentin and enamel. Some of this varia- ural defects tufts exist [94]. The tufts are believed to occur
tion can be attributed to relevant factors including differences in because of abrupt changes in the rod orientation that exist at the
the testing methods, variations in the microstructure, structural an- DEJ, and there is larger amount of protein content in this region
isotropy, the potential influence of age, etc. [80]. Variations in the [10]. It has been reasoned that enamel tufts serve to aid in resist-
tensile properties of tooth tissues suggest that inherent flaws con- ing enamel failure by promoting stress shielding and increasing
tribute to the failure of tooth tissues and that a damage mechanics the compliance of the enamel structure e.g., Ref. [95].
approach is potentially warranted for evaluating failure of these The first evaluation on the fracture properties of enamel was
materials [81]. This section focuses on experimental evaluations reported by Rasmussen et al. [96] in terms of the work to fracture
that have been performed to determine the fracture resistance of (Wf: defined as the work required to form a new surface of unit
enamel and dentin, and addresses the importance of relevant con- area) of dental beams loaded in flexure. The estimated Wf for
tributing factors on the fracture properties of these tissues. enamel specimens was 13 J/m2 and 200 J/m2 for crack growth par-
allel and perpendicular to the rod direction, respectively, indicating
4.1 Fracture Properties of Enamel. As cracks are com- a substantial degree of anisotropy [96]. Over the last three decades
monly found within the enamel on the surface of teeth, and clini- the fracture behavior of enamel has been primarily evaluated using
cal evidence of tooth fracture is not uncommon, the fracture the indentation approach. According to the results of these studies,
toughness of this tissue is highly relevant to the field of dentistry. the average indentation fracture resistance (or apparent toughness)
Although classical brittle materials generally have a single-value ranges between roughly 0.5 and 1 MPam0.5 [67,71,9799].
of fracture toughness, some materials exhibit an increase in the Due to limitations of the indentation fracture approach, Bajaj
fracture resistance with crack extension (i.e., rising R-curve and Arola [88,89] evaluated the crack growth resistance of human
behavior). Work with other material systems has shown that this enamel using a conventional fracture mechanics approach
behavior develops as a result of the microstructure, constitutive employing the enamel inset CT specimen (Fig. 4(f)) after Zhang
behavior and the contributing toughening mechanisms e.g., et al., [63]. A representative R-curve obtained for crack extension
Refs. [56,82,83]. While the R-curve is not an intrinsic material from the occlusal surface toward the DEJ is shown in Fig. 5(a).
property due to its dependence on crack size and specimen geom- As evident in this figure, the fracture resistance curves shows that
etry [84], it can provide substantial information on the impor- human enamel exhibits rising R-curve behavior, with increase in
tance/effectiveness of a materials microstructure on resisting crack growth resistance over nearly the entire thickness of the
crack extension. enamel layer. For cracks growing from the occlusal surface

growth toughness for the forward direction suggests that the
microstructure of enamel has been designed through the course of
evolution to resist cracks that initiate at the occlusal surface.
Cracks that initiate at the tooths surface may extend toward the
DEJ (i.e., longitudinally along the rods) or about the occlusal sur-
face (i.e., in-plane with the rods but transverse to their axis). Com-
parisons of the crack growth resistance in these two directions
have been performed to understand the orientation dependence.
Bechtle et al. [62,90] prepared flexure specimens from bovine
incisors and subjected them to three-point loading to achieve
Mode I growth. The reported initiation toughness in the longitudi-
nal direction ranged from 0.8 to 1.5 MPam0.5 and increased up to
3.0 MPam0.5. For cracks with transverse orientation, the initiation
toughness was equivalent to that in the longitudinal direction, but
an increase in toughness of up to 4.4 MPam0.5 was documented
over only 0.5 mm crack extension [90]. A similar evaluation was
performed by Yahyazadehfar et al. [100] on sections of occlusal
enamel obtained from human molars. That study concentrated on
the role of the microstructure and rod orientation to the fracture
resistance of enamel. Similar to the finding reported for bovine
enamel, the initiation toughness of enamel was not dependent on
the orientation of crack growth. However, in evaluations on the
human enamel there was relatively little difference observed in
the R-curves obtained for crack growth in the longitudinal and
transverse directions (Fig. 6(a)). Nevertheless, there was evidence
that there was an important contribution of the microstructure to
the fracture behavior. Consequently, a new concept was intro-
duced for describing the enamel microstructure termed the
degree of decussation (D) (Fig. 6(b)), which is simply the ratio of
fracture area composed of decussated enamel to the total fracture
surface area. According to this definition the samples comprised
mostly of uniformly oriented parallel rods (prisms) and low value
of D (comprised mostly outer enamel), exhibited the lowest tough-
ness. The largest extent of toughening was observed in samples of
inner enamel resulting from contributions of the decussation.
Characteristics of the fracture resistance curves for enamel in
Figs. 5 and 6 are reflective of the toughening mechanisms partici-
pating in the fracture process. The most common toughening
Fig. 5 R-curve response of human enamel. (a) Typical R-curve mechanisms observed contributing to crack growth resistance in
response of enamel for cracks growing from occlusal surface enamel include ligament bridging, crack deflection and micro-
toward the DEJ (reprinted from Ref. [88] with permission from cracking (loosening of prisms) [88,90,101]. These mechanisms
the publisher), (b) comparison of R-curve response of enamel occur across length scales, from the nanoscale to the macroscale.
for forward and reverse crack growth directions (reprinted from Observation of the crack path in the transverse direction showed
Ref. [88] with permission from the publisher). that the preferred crack path is along the rod boundary and the
mechanisms associated with crack growth in the inner and outer
enamel are slightly different. In the outer enamel crack branching
and crack bifurcation are evident, which results in the formation
toward the DEJ, the average initiation toughness (Ko) was of unbroken ligaments (Fig. 7(a)). Within the inner enamel the
0.55 6 0.06 MPam0.5, which is in the range of estimated values crack path appears more tortuous, and crack bridging serves a
from indentation technique. However, there is a substantial rise in more dominant role as a result of the cracks interaction with the
the crack growth resistance of enamel with extension (beyond a decussated microstructure (Fig. 7(b)) [100].
factor of 3), with the fracture toughness (at plateau; Kc) reaching The aforementioned investigations adopted linear elastic frac-
an average of over 2 MPam0.5. As evident in Fig. 5(a), the largest ture mechanics for characterizing the fracture properties of
extent of toughening occurs after 1 mm of crack growth, which enamel. However, the size of the process zone and inelastic con-
results from the crack entering the region of decussated enamel. tributions to the fracture process (presence of microcracks and
A comparison of the crack growth resistance has been per- bridging ligaments) substantiates the use of elastic-plastic fracture
formed for cracks extending from the occlusal surface inward to- mechanics or development of a cohesive traction law for a more
ward to the DEJ (regarded as the forward direction) and in the complete characterization. Some efforts have been made in this
opposite direction from the DEJ to the occlusal surface (regarded regard. Bajaj and Arola [88] estimated the contribution of selected
as the reverse direction). Representative crack growth responses mechanisms to the toughening of enamel based on theoretical
in the forward and reverse directions are shown in Fig. 5(b) [89]. models developed to characterize the toughening mechanisms in
The fracture resistance curves revealed that enamel exhibits an ceramics and natural materials (after the work of Evans and Faber
increase in the crack growth resistance in both directions, but [83], Evans and McMeeking [102], Shang and Ritchie [103],
there are unique aspects to the responses. Those cracks growing Sigl [104], Ji and Gao [105]). Unbroken ligament bridges were
from the DEJ toward the occlusal surface (reverse direction) are identified to have the largest contribution to toughening of
clearly less stable with respect to those in the forward direction. In enamel, with bridging stress intensity between 0.2 and
the reverse direction, the average initiation toughness (Ko) was 0.6 MPam0.5, which is up to approximately 25% of the global
0.87 6 0.13 MPam0.5, and there is only a mild rise in the crack toughness. The importance of protein bridging and microcracking
growth resistance with extension; the reported fracture toughness were also assessed, with contributions of up to 0.1 MPam0.5 and
(Kc) for this direction was 1.17 6 0.13 MPam0.5 [89]. The larger 0.5 MPam0.5, respectively.

Fig. 7 Crack path within human enamel resulting from incre-
mental crack growth from the notch in the transverse direction.
(a) Crack path in outer enamel (reprinted from Ref. [100] with
permission from the publisher), (b) crack path in inner enamel
Fig. 6 The influence of prism decussation on the crack growth (reprinted from Ref. [100] with permission from the publisher) .
resistance of human enamel. (a) A comparison of crack growth Note that the crack growth is from left to right.
resistance of enamel in the transverse and longitudinal direc-
tions (reprinted from Ref. [100] with permission from the pub-
lisher. (b) characterization of the degree of decussation of behind the crack tip. In this model, the crack opening displace-
enamel from fracture surface (reprinted from Ref. [100] with per- ment (COD) for very short crack lengths (less than 10 lm) was
mission from the publisher). The arrow is indicative of crack correlated to the size of the cohesive zone and active bridging
growth in the specimen. (c) Crack growth resistance of enamel stresses, which were presumed constant through the cohesive
in the transverse direction as a function of degree of decussa- zone. The estimated bridging stresses ranged from roughly 160 to
tion (D) (reprinted from Ref. [100] with permission from the 800 MPa over a cohesive zone length of 1 to 10 lm [101]. The
publisher). small cohesive zone size and relatively large bridging stresses
suggest that the participating bridging ligaments acting on the
microcracks consisted of proteins, crystallites, and multiple rods.
Ang et al. [101] estimated the crack-tip toughness of bovine Overall, the aforementioned studies accounting for the fracture
enamel from an analysis of cracks induced by Vickers indenta- process zone in enamel provide greater insight, but they do not
tions using a cohesive zone law. Their assessment adopted the co- provide understanding of the isolated contributions of the various
hesive zone solution of the DugdaleMuskhelishvili crack model, toughening mechanisms, or the effects of the spatial variations in
which assumes that toughening is only based on bridging stresses microstructure. Future studies in this direction appear warranted.

Results of the studies by Yahyazadehfar et al. [100] showed that perpendicular to the fibrils. But due to the lack of a well-defined
the growth toughness of human enamel is lowest in the transverse crack, an estimate for the fracture toughness could not obtained. El
direction. The dissimilarity in crack growth resistance between the Mowafy and Watts [113] obtained the first estimate for the plane
longitudinal and transverse directions serves to deflect cracks at the strain fracture toughness (KIc) of human dentin using CT speci-
occlusal surface to propagate transversely about the tooths crown. mens. They reported an average value for KIc of 3.08 MPam0.5 for
That process acts to restrict cracks to the outer enamel, thereby precrack growth parallel to the tubules; there is some concern with
venting progression toward the DEJ. This is an interesting process, these results as the crack was started from a notch and not a pre-
and one that is only apparent from evaluating the fracture behavior crack, which may have caused an overestimation [53,59].
through the crack growth characteristics. A finite element study by One of the most important topics regarding the fracture proper-
Barani et al. [38] simulated crack propagation in enamel on the ties of dentin has been the importance of tubule orientation
tooths surface considering both radial and margin cracks. The sim- [53,59,60,80,96,112,114]. Using the NTP specimen (Fig. 2(b)),
ulations, which included the R-curve response of enamel and Iwamoto and Ruse [53] confirmed that dentin exhibits direction-
through-thickness variation in elastic modulus, confirmed that dependence in the resistance to fracture. For crack extension par-
cracks in enamel prefer to propagate at the surface and about the allel and perpendicular to the tubules, the fracture toughness KIc
periphery of the tooth. Therefore, results of these two studies col- was estimated to be approximately 2.0 MPam0.5 and
lectively establish that the tooths resistance to fracture and penetra- 1.1 MPam0.5, respectively. Nalla et al. [60] also evaluated anisot-
tion of cracks initiating at the occlusal surface comes from a ropy in the fracture behavior of dentin from elephant tusks, which
combination of the microstructure of the enamel and the tooth ge- enabled the use of larger specimen sizes. Results were in agree-
ometry. The DEJ may still play an important role. When the driving ment with those obtained for human dentin, with estimated frac-
force is large enough to exceed the mechanisms of toughening and ture toughness being lowest for cracks growing perpendicular to
the crack proceeds in the longitudinal direction from the occlusal the tubules (Kc 1.6 MPam0.5) and with regards to the condition
surface, the DEJ will serve as the second defense in preventing where cracks extension occurs parallel to the tubules (Kc
bulk fracture [9,51,85,87,106]. It appears that the microstructure of 2.5 MPam0.5) [60].
enamel may possess many valuable secrets that are applicable to Due to the spatial variations in the microstructure of dentin in
increasing the fracture resistance of engineering structures. human teeth, the fracture resistance is potentially location depend-
ent. Indeed, Wang [115] reported that the fracture toughness of
4.2 Fracture Properties of Dentin. As cracks located at the root dentin (4.8 MPam0.5) was substantially greater than that for
tooths surface are deflected by the microstructure of enamel and tissue of the crown (2.1 MPam0.5). They postulated that the dif-
then arrested within the decussated zone or at the DEJ, they are ferences in fracture resistance are related to properties of the col-
not likely to cause tooth failure. Tooth fracture is more likely to lagen fibrils in coronal and radial dentin and the anisotropy in the
originate from cracks that initiate and grow within the dentin. tissue cause by the fibril orientation in the root [116].
Flaws in the form of cracks can be introduced within the dentin In the previous studies a single value of crack growth resistance
during the restorative process as a result of material removal was reported. Yet, more recent studies on dentin have evaluated
[25,26]. As an alternative, cracks may develop in dentin from the fracture behavior in terms of the R-curves. Typical fracture
incipient flaws as a result of fatigue, particularly in regions of resistance curves for human dentin obtained using the CT speci-
stress concentration posed by the restoration geometry [21]. In men configuration are shown in Fig. 8(a); representative responses
recognition of the significance of fracture to the field of dentistry, are shown for crack growth in-plane and perpendicular to the
many investigations have been conducted to characterize the frac- tubules. As evident in this figure, human dentin exhibits rising
ture properties of dentin. Reviews on this topic have been pre- R-curve behavior regardless of the tubule orientation. In both ori-
sented earlier [107,108]. entations the growth response develops a well-defined plateau
Similar to the discussion of fracture in enamel, a more detailed after approximately 0.5 mm of crack extension, indicating that the
description of dentins microstructure is warranted. Dentin pos- fracture process has reached a steady-state.
sesses a much higher organic content than enamel with a composi- R-curves have been obtained from experiments on dentin using
tion of approximately 45% mineral, 33% organic material the single crack in flexural and CT specimen geometry
(collagen type I), and 22% water by volume [10]. The microstruc- [62,117120]. A direct quantitative comparison of the responses
ture of dentin is illustrated in Fig. 1(b). The most distinct feature across these studies is not possible due to the influence of specimen
of the microstructure is the dentin tubules, which are a network of geometry on the toughening behavior [73,84]. For the CT specimen
microscopic channels extending radially outward from the pulp configuration, the average initiation (Ko), growth (Kg), and fracture
toward the DEJ and cementum. The number, diameter, and orien- toughness (KC) for cracks extending perpendicular to the plane of
tation of the tubules vary with distance from the pulp. The tubule tubules were 1.34 6 0.06 MPam0.5, 0.93 6 0.39 MPam0.5/mm, and
density and size of tubules are lowest at the DEJ and there is an 1.65 6 0.10 MPam0.5, respectively (Fig. 8(b)) [120]. Toughening
increase in both of these parameters with increasing proximity to was attributed to the development of crack bridging behind the
the pulp region [109]. Each tubule is surrounded by a highly min- crack in addition to inelastic deformation promoted by the miner-
eralized cuff of apatite crystals known as the peritubular dentin. alized collagen and generation of microcracks within the peritubu-
The intertubular dentin occupies the region between the tubules lar cuffs (Fig. 9) [118,120]. For cracks in-plane with the tubules,
and comprised of mineralized collagen fibers, which are oriented the average initiation 2.2 MPam0.5, growth 1.2 MPam0.5/mm)
in planes that are roughly perpendicularly to the tubules [80,110]. and plateau toughness 2.7 MPam0.5 are greater than those values
The mineralized collagen fibers are comprised of collagen fibrils for the transverse direction (Fig. 8(c)) [66]. The mechanisms con-
with diameter of 50100 nm. The fibrils are reinforced by apatite tributing to the toughening behavior in this orientation are similar,
crystals, existing in plate form with roughly 5 nm thickness [111], except perhaps for a larger contribution of the mineralized colla-
and located in both interfibrillar and intrafibrillar sites. gen caused by its orientation.
The first reported evaluation on the fracture properties of dentin Spatial variations in the fracture resistance of human dentin
consisted of estimates of the work to fracture (Wf) for dentin beams have been evaluated [66], and results obtained for cracks extend-
under flexure loading [96]. The average Wf for fracture perpendicu- ing in-plane with the tubules are shown in Fig. 8(d). The fracture
lar and parallel to the tubules was 270 J/m2 and 550 J/m2 estimated, resistance curves shown here are for 3 regions, namely from tissue
respectively [96,112]. The orientation dependence of Wf was attrib- that is closest to the DEJ (outer dentin), closest to the pulp cavity
uted to the organization of the collagen fibrils surrounding the of the tooth (i.e., inner dentin) and midway between those two
tubules. For crack growth perpendicular to the tubules the fracture locations (middle dentin). As evident in this figure, the fracture
surface was in the plane with the collagen fibril network, whereas resistance behavior is similar across the crown of the tooth, but
in the parallel orientation the fracture plane was oriented there is a distinct decrease in toughness with increasing proximity

Fig. 8 Crack growth response of human coronal dentin obtained from miniaturized CT
specimen. (a) Typical R-curve response in dentin (reprinted from Ref. [66] with permission
from the publisher), (b) R-curve response for the crack growing perpendicular to the tubules
(90 deg orientation) (reprinted from Ref. [120] with permission from the publisher), (c) R-
curve response for the crack growing parallel to the tubule plane (0 deg orientation)
(reprinted from Ref. [66] with permission from the publisher). (d) A comparison of the crack
growth resistance of dentin in 0 deg orientation as a function of spatial distance with respect
to occlusal surface (reprinted from Ref. [66] with permission from the publisher). Note that
the results presented in both Figs. 8(b) and 8(c) achieved from middle dentin.
to the pulp. This finding is of substantial importance to the field of 30%. Toughening mechanisms have been identified operating in
dentistry as it establishes the larger potential for tooth fracture with front and behind the crack tip, which function to resist fracture
increasing depth of restorative work (cutting, etching, etc.,) that differently. While a cohesive zone could be adopted to evaluate
may introduce flaws. One interesting finding that was noted in com- their combined affect (e.g., as performed by Yang et al., [122] for
paring the fracture resistance across the regions is that the toughen- bone), a hybrid approach could also be used. This process
ing mechanisms were actually dependent on location. Within the involves experiments and numerical modeling and enables greater
inner dentin, which exhibits the largest tubule density, toughening isolation of the contributions from the extrinsic and intrinsic
was achieved by meandering of the crack to nearby lumens (Figs. toughening mechanisms to the fracture resistance. In this case the
10(a) and 10(b)). This process results in a reduction of the stress in- COD achieved from experimental measurements serve as the
tensity at the crack tip via blunting as the crack tip is located within benchmark solution for the numerical simulations. In the study by
the lumen and via the microcracking process in the K-dominant Ivancik and Arola [66], the hybrid process was used with the
zone, as well as by crack curving [66,119]. Within the specimens of numerical model incorporating elastic-plastic constitutive behav-
middle dentin microcracking of peritubular cuffs were also domi- ior, and a cohesive zone behind the crack tip developed to account
nant (Fig. 10(c)). However, in the outer dentin the toughening for the unbroken ligaments of tissue operating in the crack wake.
behavior appeared to be largely attributed to the development of According to this approach, it was found that extrinsic toughening
unbroken ligaments behind the crack tip (Fig. 10(d)). Thus, in addi- contributed an average of 26% of the total energy for fracture,
tion to exhibiting anisotropy in the fracture resistance, human den- intrinsic toughening was roughly 3%. In comparing the spatial
tin also exhibits spatial variations. It is quite interesting to note that variations in toughening (i.e., within the inner, middle, and outer
the microstructure of dentin appears to have been graded in such a regions), the contributions of extrinsic toughening were 2.5 times
manner that, in case of failure of the enamel and the DEJ to achieve greater in the outer dentin than close to the pulp. The differences
crack arrest, can serve as the third defense. are expected to be due to the greater collagen content near the
One obvious limitation of the aforementioned studies is that DEJ, which increases the crack closure stresses caused by the
they have treated the fracture resistance assuming linear elastic unbroken ligaments and fibrils.
behavior. Due to the presence of a fracture process zone and the
capacity of these material to undergo inelastic deformation, a rig- 5 Evaluations on the Fatigue Properties
orous evaluation of the fracture resistance must account for these
factors. Indeed, Yan et al., [121] applied elastic-plastic fracture of Tooth Tissues
mechanics to human dentin and found that inelastic processes con- In this section, the fatigue response of enamel and dentin are
tributed significantly to the fracture toughness of this tissue, discussed. Overall, fatigue failures can involve the initiation of
resulting in an increases of the estimated toughness by more than damage or well-defined flaw, propagation of that damage or flaw

The number of cycles that any one tooth experiences, and the
magnitude of cyclic stress are dependent on many factors, which
may include the presence of prior restorations, tooth recruitment
in mastication, patient age, dental health, etc. Nevertheless, finite
element evaluations of the stress distribution within restored and
unrestored teeth suggest that the cyclic stresses are within the
elastic range [27,125].
According to the stresses borne by mastication, teeth are sub-
jected to high-cycle fatigue and both the stress-life and fatigue
crack growth approaches are applicable for analyzing fatigue fail-
ures in tooth tissues. The stress-life fatigue behavior is commonly
described in terms of the stress amplitude (r) of the fatigue cycle
and number of cycles to failure (Nf), and modeled using a power
law description after Basquin [126] according to
B
r A Nf (1)
where A and B are empirical constants that are developed from a

best-fit to the experimental data. In conditions in which the life of
the material/component is governed by the growth of a crack, the
fatigue crack growth rate is generally interpreted in terms of the
stress intensity range (DK). Assuming that the driving force pro-
motes a DK that is greater than the stress intensity threshold
(DKth) of the material, then the steady state fatigue crack growth
response can be described using a power law form after Paris
et al., [127] according to
da
CDK m (2)
dN
where C and m are scaling constants termed as Paris Law coefficient

and exponent, respectively. The incremental fatigue crack growth
rate da/dN is quantified by the ratio of incremental fatigue crack
extension (Da) to the number of cycles associated with the period of
growth (DN) and the stress intensity range (DK) is simply
(DK Kmax Kmin). Both the stress-life behavior and fatigue crack
growth resistance of enamel and dentin have been studied. Detailed
reviews of the fatigue behavior of hard tissues of the human body
have been reported [108,128]. Thus, this portion of the review is
focused on new results and only highlights previous findings.
5.1 Fatigue Properties of Enamel. Although cracks are of-

ten observed in the enamel of vital teeth and have been noted to
develop under cyclic temperature changes [129], studies on the
fatigue behavior of enamel are scant. Undoubtedly, the largest ob-
stacle to these studies is the limited volume of enamel that is
available, and the corresponding restrictions to specimen size and
geometry. However, in a recent investigation aimed at evaluating
the durability of adhesive bonds to enamel [130], the stress-life
fatigue response of enamel was evaluated for the first time. In this
study small sections of cuspal enamel were bonded to a resin com-
posite in a beam configuration (Fig. 11(a)). The specimens were
evaluated under cyclic flexure loading and a finite element analy-
sis was performed to estimate the stress state with the enamel,
Fig. 9 Toughening mechanisms in human coronal dentin for resin adhesive and composite, as required due to the presence of
cracks oriented perpendicular to the tubules. (a) The develop- the interface. Results showed that there was a large variability in
ment of unbroken ligaments in the intertubular dentin (reprinted the fatigue performance of the enamel-bonded interface beams
from Ref. [120] with permission from the publisher). Note that (Fig. 11(b)), and that fatigue failure occurred within the enamel,
the crack is growing from right to left. (b) Bridging ligaments not within the adhesive joint. In fact, all fatigue failures occurred
formed by dentin collagen (reprinted from Ref. [120] with per- in the enamel and adjacent to the adhesive interface. A fracto-
mission from the publisher) (c) microcracks and separation in graphic analysis showed that both the initiation of failure and
the peritubular cuffs as shown with the white arrows (reprinted
from Ref. [120] with permission from the publisher).
propagation occurred at the interface of adjacent enamel rods.
Accounting for the stress concentration that develops at the inter-
face due to the elastic mismatch between the three materials, the
to a critical state, and then followed by rupture. The process of estimated endurance limit of enamel was approximately 12 MPa.
mastication results in cyclic loading of teeth and generally occurs That value is much smaller (far less than half) than the apparent
at a frequency of just below 2 Hz [123,124]. Estimates for the endurance limit of the resin composite and dentin.
number of cycles resulting from daily routines indicate that the Studies on the fatigue crack growth response of enamel are
average tooth may experience up to 750 k cycles annually [4]. equally scant. Bajaj et al. [131] evaluated the fatigue crack growth

Fig. 10 Toughening mechanisms during crack growth in human coronal dentin in the
direction parallel to the tubules. (a) Crack extension in inner dentin. The crack primarily
extends from lumen to lumen as shown with the white arrows. Some degree of peritubular
microcracking is also observed at the crack tip as outlined (white encircled area) (reprinted
from Ref. [141] with permission from the publisher). (b) Micrograph showing the presence of
ligaments bridging the crack in inner dentin (arrows) (reprinted from Ref. [141] with permis-
sion from the publisher), (c) microcracking of the peritubular cuffs is predominant in central
dentin (reprinted from Ref. [141] with permission from the publisher), (d) example of liga-
ments bridging the crack and microcracks observed during crack growth in outer dentin
(reprinted from Ref. [141] with permission from the publisher).
behavior of human enamel and compared the responses to that of Similar to the evaluation of directional dependence in the R-
sintered hydroxyapatite. Results of that investigation showed that curve behavior, the fatigue crack growth resistance of enamel has
the threshold stress intensity of outer enamel is approximately been examined in the forward (from the occlusal surface to the
0.35 MPam0.5, about three times the value for hydroxyapatite DEJ) and reverse (from the DEJ outwards) directions [89]. Inter-
(0.13 MPam0.5). The findings revealed that the microstructure of estingly, steady state long crack fatigue crack growth behavior
enamel and the organic proteins act to increase the resistance to was only achieved in the Forward direction (Fig. 12(b)). Results
crack propagation [131]. Electron microscopy evaluations of the from that investigation also showed the importance of decussation
fracture surfaces showed that the enamel exhibited similar extrin- on the crack growth process. For example, crack initiation within
sic toughening mechanisms in resisting fatigue cracks as those outer enamel occurred at a significantly lower stress intensity
operating during quasi-static crack growth. The cracks generated range (DK 0.39 6 0.09 MPa.m0.5) than that for inner enamel
in the enamel were close to the occlusal surface of the tooth (i.e., (DK 0.53 6 0.12 MPa.m0.5). Stable crack extension in the for-
outer enamel) and propagated toward the region of decussation. ward direction occurred over more than a millimeter of crack
Upon reaching the decussated rods the crack underwent several extension with the stress intensity range of 0.390.65 MPa.m0.5.
toughening mechanisms including crack curving, the development In contrast, cracks in the reverse directions reached instability
of unbroken ligament bridges and crack bifurcation. over only hundreds of micrometers of growth. These findings rein-
One interesting aspect of the fatigue crack growth response of force those obtained from monotonic loading, and suggest that the
enamel is that it exhibits both short and long crack behavior. microstructure of enamel appears to have been designed to be
A representative fatigue crack growth response for enamel is most effective in resisting cracks that initiate at the occlusal sur-
shown in Fig. 12(a). Two regions of distinct behavior are evident. face and undergo extension toward the DEJ.
The short crack response refers to crack lengths that are small
when compared to the dimensional scale of the microstructure or 5.2 Fatigue Properties of Dentin. Fatigue of dentin has
primary elements contributing to toughening [132]. For short received the attention of investigators for more than a decade.
cracks, the resistance to cyclic crack extension increases with Indeed, the failure of teeth with restorations has been identified to
crack length as signified by the reduction in incremental growth occur through a process involving fatigue and fatigue crack
rate. This behavior is indicative of the increase in the degree of growth [21]. Several studies have evaluated the fatigue behavior
extrinsic toughening that develops behind the crack tip until the of dentin and reviews on this topic have been reported previously
process zone reaches a steady-state length behind the crack tip. [108,134]. Therefore, only a brief review of earlier work is pre-
Thereafter, the crack undergoes an increase in the incremental sented here along with highlights, and with more emphasis placed
growth rate with stress intensity range, which is characteristic of on recent findings and their importance.
long crack behavior. Enamel is not the only hard tissue that exhib- Investigations on the stress-life fatigue response have distin-
its short crack behavior [133]. guished that dentin exhibits metal-like fatigue behavior

Fig. 11 Fatigue life response of human enamel. (a) Schematic
of enamel specimen preparation and testing (b) fatigue life
response of enamel (reprinted from Ref. [130] with permission
from the publisher). Note that the enamel cubes were oriented
in specimens in such a manner that the occlusal surface was
always subjected to tension (reprinted from Ref. [130] with
permission from the publisher). Arrows represent those sam-
ples that did not fail within 1.2 3 106 cycles.
Fig. 12 Fatigue crack growth response of human enamel. (a)

Typical fatigue crack growth response in enamel from inset CT
[61,134], i.e., it exhibits a reduction in life with increasing stress
specimen (reprinted from Ref. [88] with permission from the
amplitude. Dentin exhibits an apparent endurance limit that publisher), (b) comparison of the fatigue crack growth
ranges between 20 and 50 MPa and is generally interpreted resistance of enamel for crack extension in the forward and
between 1 106 and 1 107 cycles; the presence of an endurance reverse directions (reprinted from Ref. [88] with permission
response depends on the nature of loading, including the stress from the publisher).
ratio and testing frequency. Nalla et al. [134] reported that the
fatigue life of human dentin decreases with a reduction in loading
frequency and that an increase in the mean stress causes a reduc- repair damage through remineralization processes are important
tion in the endurance limit [135]. Furthermore, the stress-life considerations.
behavior is a function of tubule orientation (Fig. 13(a)) [136], The fatigue response of dentin has also been evaluated in terms
with lowest resistance to fatigue occurring when the cyclic normal of its fatigue crack growth resistance. Similar to the findings
stresses are directed along the axis of the tubules. More recent obtained from evaluations on the S-N behavior, independent stud-
work has shown that the processes used for cutting of dentin dur- ies on the fatigue crack growth resistance of dentin have shown
ing the introduction of restorations can cause a substantial reduc- that it is a function of testing frequency [137], and stress ratio (R)
tion in fatigue strength. Specifically, Majd et al. [26] discovered [138]. Higher fatigue crack growth rates occur with lower loading
that cutting of coronal dentin with either carbide cutting burs or frequency and increasingly positive stress ratios. Moreover, the
an abrasive air jet (both clinically relevant) substantially degraded threshold stress intensity (DKth) of dentin decreases with increas-
the stress-life fatigue resistance. Cutting with carbide burs ing stress ratio for R > 0, a characteristics that is exhibited by
reduced the apparent endurance limit by nearly 40% (Fig. 13(b)). many engineering materials. That behavior is believed to result
Furthermore, development of a Kitagawa-Takahashi diagram for from dissipation of the tissues ability to resist damage by viscous
the fatigue responses suggested that the average intrinsic flaw processes under the sustained mean stress.
length resulting from bur cutting was approximately 70 lm. Dentin exhibits anisotropy in the fatigue crack growth resist-
Results from that study distinguished that dentin is sensitive to ance with respect to the tubule orientation [139141]. A compari-
flaws and that the methods presently used for cutting and remov- son of the fatigue crack growth behavior of dentin with cracks
ing demineralized tissues introduce detrimental defects. Of related extending parallel, oblique and perpendicular to the tubules
importance, a recent preliminary study of dentin obtained from (0 deg, 45 deg, and 90 deg orientations, respectively) showed that
restored teeth, i.e., that underwent a period of oral function after cracks preferred to grow perpendicular to the tubule axis under
placement of the restoration, showed substantially lower fatigue cyclic loading. Hence, cracks that develop within this tissue have
strength than unrestored tissue [107]. As dentin is not capable of a preferred growth direction, and anisotropy in the growth resist-
repairing damage through a process of remodeling, the develop- ance contributes to the clinical observations that cracks extend
ment of tools for minimizing the introduction of damage or the from the line angle of restorations (region of maximum stress

Fig. 14 Comparison of fatigue crack growth resistance of
human coronal dentin at room and human body temperatures
A comparison of the critical stress intensity required for the initia-

tion of cyclic crack growth (i.e., Kmax estimated from DKth) and
the initiation toughness for quasi-static loading (Ko) shows that
the resistance to crack extension under cyclic loading is more than
50% lower. In addition, the average fracture toughness of dentin
(Kc) is over twice the maximum (i.e., critical) value of stress
intensity (Kmax) at instability during cyclic loading. Observations
of the fracture surfaces from dentin samples suggest that the ex-
trinsic mechanisms of toughening (mainly crack bridging) are
substantially less effective during cyclic loading when compared
to their contributions in the quasi-static condition [66]. In short,
fatigue of the unbroken ligaments reduces their potency. Conse-
quently, the fatigue crack growth properties of tooth tissues, as
Fig. 13 Fatigue life response of human coronal dentin. (a) The well as the contribution of clinically relevant factors to changes in
role of tubule orientation on the fatigue life response of young the fatigue crack growth resistance, are of substantial importance
coronal dentin (reprinted from Ref. [140] with permission from to incidence of restored tooth fractures.
the publisher), (b) comparison of fatigue life diagram for bur
treated dentin beams and control beams (reprinted from
Ref. [26] with permission from the publisher) . Arrows indicate
those beams that did not fail.
6 Influence of Aging, Dehydration and Other Factors
Based on the large range in oral conditions and parafunctional
habits, there are a number of potential contributors to the fatigue
concentration) and largely extend perpendicular to the tubules and fracture behavior of teeth. For example, the influence of tem-
(Fig. 2(b)). The larger fatigue crack growth resistance in the 0 deg perature variations, dehydration and polar solvents are relevant
and 45 deg orientations has been attributed to the arrangement of concerns to the fracture resistance of tooth tissues. With regards
collagen fibers in relation to the crack orientation. By virtue of the to thermal variations, increases in temperature up to 60 C are
collagen fibril arrangement in the intertubular dentin, the collagen reportedly not important to the fracture resistance of dentin
fibrils are believed to play a greater role in resisting crack growth [112,113]. However, Rasmussen and Patchin [112] reported that a
via extrinsic toughening in the 0 deg and 45 deg orientations. A decrease in temperature below 0 C caused an increase in the
recent study by Ivancik et al. [141] distinguished that the fatigue work to fracture of dentin. Clearly it is far more convenient to
crack growth resistance of dentin is not only dependent on the tubule conduct experimental evaluations at room temperature rather than
orientation but there are also spatial variations. Specifically, there is a 37 C, and the majority of reported evaluations are conducted in
significant decrease in the stress intensity threshold, and increase in ambient conditions. But that raises concern as to whether the tis-
the incremental rate of cyclic crack extension with an increase in sues response at room temperature is representative of that at
proximity to the pulp cavity [141]. Thus, due to the potential for body temperature. A comparison of the fatigue crack growth
introducing defects during the cutting of dentin [26], the probability behavior of human dentin at both 22 C and 37 C has shown that
of tooth fracture after the placement of a dental restoration increases there is no significant difference (Fig. 14). While no equivalent
with depth of the preparation from the occlusal surface. evaluation has been reported for enamel, the lower relative
A survey of the mechanisms identified in resisting fatigue crack organic content would be expected to result in less temperature
growth shows that they are consistent with those active in quasi- dependence than dentin.
static crack extension, and that extrinsic toughening via crack Changes in the level of hydration is a relevant concern as there
bridging is believed to be the most potent. Nevertheless, dentin is can be a reduction in the level of salivary flow rate with aging, as
far less resistant to the initiation of crack extension and fracture a result of some medications or other conditions e.g., Refs.
under cyclic loading in comparison to under quasi-static loading. [142,143]. As expected, dehydration causes a reduction in the

crack growth resistance of dentin [118,144]. In evaluating the
influence of hydration on the R-curve behavior of dentin, Kruzic
et al. [118] showed that removal of water under vacuum resulted
in less prominent rise in the R-curve with crack growth. All three
components of the response, i.e., the initiation, growth and plateau
toughness were reduced by more than 40% of those values for the
fully hydrated tissue. One of the most interesting findings is that
the degradation in toughness caused by loss of water was tempo-
rary. Shortly after rehydration, the R-curve recovered to that of
the originally hydrated tissue [118]. A distinct difference between
the two conditions was that larger CODs were observed in the
hydrated state. Hydrated dentin undergoes more extensive inelas-
tic deformation around the crack tip as a result of the intrafibrillar
spaces being occupied by water molecules, which results in
plasticization of this highly organic system. The viscoplastic
nature of the near-tip deformation promotes crack blunting, and
results in higher crack growth resistance in the hydrated condition.
Apart from the inelastic deformation, which serves as an intrinsic
toughening mechanism ahead of the crack tip, crack bridging by
unbroken ligaments of tissue was identified to be the major tough-
ening mechanism contributing to the rising R-curve responses in
conditions of hydration.
In contrast to the influence of dehydrating dentin by vacuum,
chemical dehydration of dentin using polar solvents (e.g., ethanol)
causes a marked rise in crack growth resistance. Nalla et al., [145]
showed that while the initiation toughness of samples precondi-
tioned in water and ethanol solution were not significantly differ-
ent, the ethanol treatment caused an increase in the crack growth
resistance; the growth toughness and fracture toughness increased
by approximately 150% and 70%, respectively. The change in
fracture behavior within polar solvent was rationalized to result
from the formation of cross-links between the collagen peptides
that developed with the removal of water [146]. These covalent
cross-links enhance the strength of the briding ligaments behind
the crack tip, thereby increasing the potency of bridging stresses
that act to shield the crack tip of the opening mode stress intensity
[145].
As a result of improvements in oral health, there is an increase
in the number of senior dentate patients. This rise in number of
elderly patients has become another important concern in den-
tistry. Interestingly, although bone undergoes a decrease in the
degree of mineralization with age, human dentin undergoes an Fig. 15 Influence of aging on the microstructure and fatigue
increase [147149]. The process begins in the third decade of life response of human dentin. (a) Micrographs of fatigue fracture
surfaces of young (left) and old (right) dentin (reprinted from
and is associated with a progressive filling of the dentin tubules Ref. [141] with permission from the publisher). Note that the
with mineral until they become completely filled [10,140]. A tubules in young dentin are open. However, they become
comparison of the microstructure of dentin from young and old occluded with aging. (b) Comparison of the fatigue life
patients is shown in Fig. 15(a). Dentin undergoes a reduction in responses of old and young dentin (reprinted from Ref. [61]
the resistance to fatigue with patient age [61,150]. Kinney et al. with permission from the publisher) (c) comparison of fatigue
[61] focused on the properties of dentin from the tooth roots and crack growth responses of old and young dentin (reprinted
found that fatigue strength of old dentin (patient age > 65) was from Ref. [141] with permission from the publisher).
significantly lower than that of young dentin (patient age <25) in
the low-cycle range (Fig. 15(b)), whereas for high-cycle fatigue
(Nf 100 k cycles) there was no apparent different between the on the degree of anisotropy in the fatigue crack growth resistance
two age groups. In the study of Arola and Reprogel [150] involv- of dentin. It was found that the direction of lowest fatigue crack
ing tissue from the tooth crown, there was a significant decrease growth resistance is perpendicular to the lumens, regardless of
in the fatigue strength of dentin from senior patients (age > 50), age, and the degree of anisotropy remained nearly constant. Inter-
and over the entire stress-life regime. The difference in fatigue estingly, the age-related degradation appears to be most severe in
behavior between the two studies could suggest that there are spa- the tissue that is located farthest from the pulp [141]. Overall, the
tial variations in the rate of physiological aging and/or the degree fatigue crack growth properties of dentin show the lowest degree
of degradation in fatigue resistance between tissue of the tooth of spatial variation in old teeth.
root and crown. The influence of aging on the fracture toughness of dentin has
Changes in the fatigue crack growth behavior of dentin with also been investigated. Koester et al. [119] was among the first to
aging have also been studied [64]. A comparison of fatigue crack report on the R-curves for human dentin, and showed that the frac-
growth in dentin obtained from young and old patient age ture toughness decreases significantly with aging. This evaluation
groups is shown in Fig. 15(c) for cyclic extension occurring per- identified that occlusion of the tubules adversely affects the extent
pendicular to the tubules. Aging of dentin causes a significant of extrinsic toughening. The unfilled lumens in young dentin pro-
reduction in the resistance to the initiation of fatigue crack vide a source for crack initiation and the development of second-
growth, and significant increase in the rate of incremental exten- ary daughter cracks. These satellite cracks provide potential for
sion. Owing to the influence of tubule orientation on the fracture crack deflection, branching, and at larger crack lengths results in
behavior, Ivancik et al. [141] characterized the influence of aging occurrence of bridging.

Nazari et al. [120] also investigated the effects of aging on the have been discussed in previous reviews [80]. The maintenance of
fracture toughness of human dentin for cracks oriented perpendic- their elastic properties and strength over time will be critically im-
ular to the tubules. In that orientation there was a significant portant to understand.
reduction in the initiation (Ko) and plateau (Kc) toughness with In regards to enamel, there are some additional factors that may
increasing age. In old dentin the crack growth resistance increased be valuable to explore. In contrast to the efforts regarding aging of
with extension from initiation to fracture (Kc 1.17 MPam0.5) by dentin, the effects of aging on the fatigue and fracture resistance
less than 10%, whereas in young dentin there was a 25% increase of dental enamel have not been fully addressed. Enamel under-
from initiation to fracture (Kc 1.65 MPam0.5). Consistent with goes an increase in the elastic modulus and hardness, as well as an
the mechanisms noted previously, extrinsic toughening via unbro- increase in the indentation brittleness with age [97,159]; that is
ken ligaments were predominant in young dentin. However, they believed to occur due to a loss of proteins. Past studies concerning
were only seldom noted in the fracture process zone in the old fracture of enamel have also emphasized the contributions of pro-
samples. Collectively, the results of these studies suggest that den- teins in the potency of the toughening mechanisms and in crack
tin undergoes a decrease in the resistance to fracture with aging, arrest. However, an investigation on the changes in fracture resist-
and that it is largely due to the reduction in extrinsic toughening ance with removal of proteins, or via a modification of their con-
arising from the development of unbroken ligaments. formation, has not been reported. As such, while the role of
proteins is undoubtedly important, their specific contribution to
the fracture resistance of enamel remains a little vague.
7 Challenges and Future Work As evident from a description of the methods employed for evalu-
A review of research on the mechanics of tooth fractures was ating the fracture behavior of tooth tissues, there are no methods that
presented, including investigations on the fatigue and fracture have been standardized within the size scale of the materials avail-
properties of the dentin and enamel. Results from evaluations on able. That may raise some criticism in the validity of the results,
the resistance to fracture of these hard tissues has shown that both which is an issue that has been raised with respect to the methods
are primarily extrinsically toughened, and that it arises from the used in characterizing synthetic dental materials as well e.g., Ref.
development of unbroken ligaments that act to shield the crack [160]. The use of different methods of investigation, involving speci-
through the development of bridging stresses. Extrinsic toughen- men sizes and configurations, also makes it more difficult to compare
ing plays a critical role in the fatigue crack growth resistance of the findings across investigations. Thus, development of standardized
dentin and enamel, as is also found in many engineering materials methods for evaluating the fatigue and fracture properties of materi-
[151]. However, cyclic loading causes extensive degradation in als at the size scale necessary for their application to hard tissues of
the potency of the bridging elements in hard tissues. And as the tooth would make a substantial contribution to the field, and facil-
a result, the crack growth resistance of these materials is consider- itate further progress. The development of standardized methods for
ably lower under cyclic conditions in comparison to that in quasi- this purpose would undoubtedly support their application to biomedi-
static loading. Therefore, fatigue should be recognized as a crit- cal materials in other areas as well.
ically important factor in fragility failures involving hard tissues Growing knowledge on the fracture properties of natural mate-
of the tooth. Recognition of that behavior raises the importance of rials has fueled engineers and scientists to develop new bioins-
adopting fatigue as a platform for evaluating tooth tissues in pired microstructures with impressive performance e.g., Refs.
future evaluations. [161164]. Dental hard tissues have considerably higher tough-
Despite the contributions from past studies in understanding the ness than their fundamental constituent (HAp), which is very brit-
fatigue and fracture properties of hard tissues, this field is far from tle and has low resistance to fracture. As previously mentioned,
mature. There are a number of challenges and unanswered ques- the proteins play a critical role in the toughing mechanisms that
tions that remain to be addressed. One of the primary concerns is contribute to the crack growth resistance of these materials. But
the development of biofilm on the tooths surface. While tooth the proteins also appear to act in repairing damage within mineral-
fracture is one of the primary causes for restored tooth failures, ized tissues [12,165]. That topic has not been pursued in detail
secondary caries is by far the most common cause of failure and has remained controversial. Recent investigations have shown
[6,152]. Secondary caries result from the acid production of bio- significant advances in the synthesis of enamel, and with nanome-
films e.g., Refs. [29,153], which here refers to a colony of bacteria chanical properties that are similar to that of dental enamel
from the oral cavity. Although previous studies have evaluated the [166,167]. One limitation of the mechanical evaluations that are
degradation of restorative materials under the challenge of bio- adopted for characterizing these synthesized materials is that their
films [154157], the influence of biofilms on the fatigue and frac- fracture behavior is not considered. Resistance to fracture is a vital
ture resistance of dental hard tissues has not been addressed. requirement for most structural materials [168], including those in
Mechanical forms of damage at the tooths surface and micro- nature. Perhaps that topic will spark the interests of future scien-
cracks at bonded interfaces in restored teeth can facilitate the pen- tists in the area of applied mechanics.
etration of bacteria. Acid production of biofilms reduces the local
pH to a level that promotes demineralization of the dentin and
enamel. Do et al. [158] evaluated the stress-life fatigue behavior Acknowledgment
and fatigue crack growth resistance of dentin within a lactic acid
The authors acknowledge that some of the investigations
environment having pH 5, and reported that a pH < 7 causes
described in this manuscript were supported by the National Insti-
significant degradation in the fatigue resistance. Nevertheless, a
tute of Dental and Craniofacial Research through grant (R01
lactic acid solution having constant pH cannot represent the com-
DE016904; PI - Arola) and the National Science Foundation (BES
plexity of conditions promoted by the acid production of biofilms.
023823). The authors would also like to thank Kuraray America,
Thus, further work regarding the synergism between cyclic
Ultradent Products, and 3 M ESPE for their donations of bonding
stresses and demineralizing environments on the fatigue behavior
materials and supplies, which were essential for conducting many
of hard tissues may be warranted. In addition, as new dental mate-
of the experimental evaluations described in this manuscript.
rials are developed with anticaries resistance and remineralizing
capacity, careful and clinically relevant evaluations concerning
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Mobin Yahyazadehfar

Department of Mechanical Engineering,

1 Introduction Each tooth is comprised of multiple hard tissues including enamel,

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Fig. 2 Cracks in human teeth. (a) Cracks in unrestored anterior

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where A and B are empirical constants that are developed from a

where C and m are scaling constants termed as Paris Law coefficient

5.1 Fatigue Properties of Enamel. Although cracks are of-

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Fig. 12 Fatigue crack growth response of human enamel. (a)

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A comparison of the critical stress intensity required for the initia-

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