American Society of Biomechanics Journal of Biomechanics Award 2013: cortical bone tissue mechanical quality and biological mechanisms possibly underlying atypical fractures.

The biomechanics literature contains many well-understood mechanisms behind typical fracture types that have important roles in treatment planning. The recent association of "atypical" fractures with long-term use of drugs designed to prevent osteoporosis has renewed interest in the effects of agents on bone tissue-level quality. While this class of fracture was recognized prior to the introduction of the anti-resorptive bisphosphonate drugs and recently likened to stress fractures, the mechanism(s) that lead to atypical fractures have not been definitively identified. Thus, a causal relationship between these drugs and atypical fracture has not been established. Physicians, bioengineers and others interested in the biomechanics of bone are working to improve fracture-prevention diagnostics, and the design of treatments to avoid this serious side-effect in the future. This review examines the mechanisms behind the bone tissue damage that may produce the atypical fracture pattern observed increasingly with long-term bisphosphonate use. Our recent findings and those of others reviewed support that the mechanisms behind normal, healthy excavation and tunnel filling by bone remodeling units within cortical tissue strengthen mechanical integrity. The ability of cortical bone to resist the damage induced during cyclic loading may be altered by the reduced remodeling and increased tissue age resulting from long-term bisphosphonate treatment. Development of assessments for such potential fractures would restore confidence in pharmaceutical treatments that have the potential to spare millions in our aging population from the morbidity and death that often follow bone fracture.

The resistance of cortical bone tissue to failure under cyclic loading is reduced with alendronate.

Bisphosphonates are the most prescribed preventative treatment for osteoporosis. However, their long-term use has recently been associated with atypical fractures of cortical bone in patients who present with low-energy induced breaks of unclear pathophysiology. The effects of bisphosphonates on the mechanical properties of cortical bone have been exclusively studied under simple, monotonic, quasi-static loading. This study examined the cyclic fatigue properties of bisphosphonate-treated cortical bone at a level in which tissue damage initiates and is accumulated prior to frank fracture in low-energy situations. Physiologically relevant, dynamic, 4-point bending applied to beams (1.5 mm × 0.5 mm × 10 mm) machined from dog rib (n=12/group) demonstrated mechanical failure and micro-architectural features that were dependent on drug dose (3 groups: 0, 0.2, 1.0mg/kg/day; alendronate [ALN] for 3 years) with cortical bone tissue elastic modulus (initial cycles of loading) reduced by 21% (p<0.001) and fatigue life (number of cycles to failure) reduced in a stress-life approach by greater than 3-fold with ALN1.0 (p<0.05). While not affecting the number of osteons, ALN treatment reduced other features associated with bone remodeling, such as the size of osteons (-14%; ALN1.0: 10.5±1.8, VEH: 12.2±1.6, ×10(3) µm2; p<0.01) and the density of osteocyte lacunae (-20%; ALN1.0: 11.4±3.3, VEH: 14.3±3.6, ×10(2) #/mm2; p<0.05). Furthermore, the osteocyte lacunar density was directly proportional to initial elastic modulus when the groups were pooled (R=0.54, p<0.01). These findings suggest that the structural components normally contributing to healthy cortical bone tissue are altered by high-dose ALN treatment and contribute to reduced mechanical properties under cyclic loading conditions.

Hidden contributions of the enamel rods on the fracture resistance of human teeth.

The enamel of human teeth is generally regarded as a brittle material with low fracture toughness. Consequently, the contributions of this tissue in resisting tooth fracture and the importance of its complex microstructure have been largely overlooked. In this study an experimental evaluation of the crack growth resistance of human enamel was conducted to characterize the role of rod (i.e. prism) orientation and degree of decussation on the fracture behavior of this tissue. Incremental crack growth was achieved in-plane, with the rods in directions longitudinal or transverse to their axes. Results showed that the fracture resistance of enamel is both inhomogeneous and spatially anisotropic. Cracks extending transverse to the rods in the outer enamel undergo a lower rise in toughness with extension, and achieve significantly lower fracture resistance than in the longitudinal direction. Though cracks initiating at the surface of teeth may begin extension towards the dentin-enamel junction, they are deflected by the decussated rods and continue growth about the tooth's periphery, transverse to the rods in the outer enamel. This process facilitates dissipation of fracture energy and averts cracks from extending towards the dentin and vital pulp.

Contributions of aging to the fatigue crack growth resistance of human dentin.

An evaluation of the fatigue crack resistance of human dentin was conducted to identify the degree of degradation that arises with aging and the dependency on tubule orientation. Fatigue crack growth was achieved in specimens of coronal dentin through application of Mode I cyclic loading and over clinically relevant lengths (0 ≤ a ≤ 2 mm). The study considered two directions of cyclic crack growth in which the crack was either in-plane (0°) or perpendicular (90°) to the dentin tubules. Results showed that regardless of tubule orientation, aging of dentin is accompanied by a significant reduction in the resistance to the initiation of fatigue crack growth, as well as a significant increase in the rate of incremental extension. Perpendicular to the tubules, the fatigue crack exponent increased significantly (from m=14.2 ± 1.5 to 24.1 ± 5.0), suggesting an increase in brittleness of the tissue with age. For cracks extending in-plane with the tubules, the fatigue crack growth exponent does not change significantly with patient age (from m=25.4 ± 3.03 to 22.9 ± 5.3), but there is a significant increase in the incremental crack growth rate. Regardless of age, coronal dentin exhibits the lowest resistance to fatigue crack growth perpendicular to the tubules. While there are changes in the cyclic crack growth rate and mechanisms of cyclic extension with aging, this tissue maintains its anisotropy.

On the R-curve behavior of human tooth enamel.

In this study the crack growth resistance behavior and fracture toughness of human tooth enamel were quantified using incremental crack growth measures and conventional fracture mechanics. Results showed that enamel undergoes an increase in crack growth resistance (i.e. rising R-curve) with crack extension from the outer to the inner enamel, and that the rise in toughness is a function of distance from the dentin enamel junction (DEJ). The outer enamel exhibited the lowest apparent toughness (0.67+/-0.12 MPam(0.5)), and the inner enamel exhibited a rise in the growth toughness from 1.13 MPam(0.5)/mm to 3.93 MPam(0.5)/mm. The maximum crack growth resistance at fracture (i.e. fracture toughness (K(c))) ranged from 1.79 to 2.37 MPam(0.5). Crack growth in the inner enamel was accompanied by a host of mechanisms operating from the micro- to the nano-scale. Decussation in the inner enamel promoted crack deflection and twist, resulting in a reduction of the local stress intensity at the crack tip. In addition, extrinsic mechanisms such as bridging by unbroken ligaments of the tissue and the organic matrix promoted crack closure. Microcracking due to loosening of prisms was also identified as an active source of energy dissipation. In summary, the unique microstructure of enamel in the decussated region promotes crack growth toughness that is approximately three times that of dentin and over ten times that of bone.

Role of prism decussation on fatigue crack growth and fracture of human enamel.

The role of prism decussation on the crack growth resistance of human enamel is evaluated. Miniature inset compact tension (CT) specimens embodying a section of cuspal enamel were subjected to Mode I cyclic or monotonic loads. Cracks were grown in either the forward (from outer enamel inwards) or reverse (from inner enamel outwards) direction and the responses were compared quantitatively. Results showed that the outer enamel exhibits lower resistance to the inception and growth of cracks. Regardless of the growth direction, the near-threshold region of cyclic extension was typical of "short crack" behavior (i.e. deceleration of growth with an increase in crack length). Cyclic crack growth was more stable in the forward direction and occurred over twice the spatial distance achieved in the reverse direction. In response to the monotonic loads, a rising R-curve response was exhibited by growth in the forward direction only. The total energy absorbed in fracture for the forward direction was more than three times that in the reverse. The rise in crack growth resistance was largely attributed to a combination of mechanisms that included crack bridging, crack bifurcation and crack curving, which were induced by decussation in the inner enamel. An analysis of the responses distinguished that the microstructure of enamel appears optimized for resisting crack growth initiating from damage at the tooth's surface.

A comparison of fatigue crack growth in human enamel and hydroxyapatite.

Cracks and craze lines are often observed in the enamel of human teeth, but they rarely cause tooth fracture. The present study evaluates fatigue crack growth in human enamel, and compares that to the fatigue response of sintered hydroxyapatite (HAp) with similar crystallinity, chemistry and density. Miniature inset compact tension (CT) specimens were prepared that embodied a small piece of enamel (N=8) or HAp (N=6). The specimens were subjected to mode I cyclic loads and the steady state crack growth responses were modeled using the Paris Law. Results showed that the fatigue crack growth exponent (m) for enamel (m=7.7+/-1.0) was similar to that for HAp (m=7.9+/-1.4), whereas the crack growth coefficient (C) for enamel (C=8.7 E-04 (mm/cycle)x(MPa m(0.5))(-m)) was significantly lower (p<0.0001) than that for HAp (C=2.0 E+00 (mm/cycle)x(MPa m(0.5))(-m)). Micrographs of the fracture surfaces showed that crack growth in the enamel occurred primarily along the prism boundaries. In regions of decussation, the microstructure promoted microcracking, crack bridging, crack deflection and crack bifurcation. Working in concert, these mechanisms increased the crack growth resistance and resulted in a sensitivity to crack growth (m) similar to bone and lower than that of human dentin. These mechanisms of toughening were not observed in the crack growth response of the sintered HAp. While enamel is the most highly mineralized tissue of the human body, the microstructural arrangement of the prisms promotes exceptional resistance to crack growth.

Age, dehydration and fatigue crack growth in dentin.

A preliminary study of the effects from age and dehydration on fatigue crack growth in human dentin was conducted. Compact tension (CT) fatigue specimens of coronal dentin were prepared from extracted molars and subjected to high cycle fatigue (10(5)