J. Dent.

1992;

20:

131-l

39

131

Review

Tooth fracture
F. J. T. Burke
Department of Restorative Dentistry,

in vivo and in vitro

University Dental Hospital of Manchester, UK

ABSTRACT
The incidence, causes and methods of investigating tooth fracture are reviewed. This is a problem ofincreasing clinical significance, with many predisposing factors. Large restorations and extensive carious lesions tend to be associated with most fractures, with fracture incidence being higher in first permanent molars than other tooth types, especially in the lower jaw. Tooth anatomy influences fracture incidence. as does the functional force applied to cusps. Fracture risk in restored teeth may be reduced by cuspal coverage. Traditional tooth fracture investigations using destructive techniques provide valuable information; however, replica and nondestructive techniques are also of value.
KEY WORDS: Tooth fracture, 13 l-l Review 39 (Received 15 January 1991; reviewed 6 March 1991; accepted 19

J. Dent, 1992; 20: September 199 1)

Correspondence should be addressed to: Mr F. J. T. Burke, Department of Restorative Dentistry, University

Dental Hospital of Manchester, Higher Cambridge Street, Manchester M 15 6FH, UK.

TOOTH

FRACTURE

IN WV0

The potentially weakening effect of dental caries and its treatment, alongside the effect of tooth surface loss (attrition, erosion and abrasion) (Eccles, 1982), may predispose to tooth fracture. Tooth fracture may be complete, where part of the tooth becomes detached from the remainder, or incomplete where the fractured portion remains in situ. While the complete fracture may be clinically obvious, an incomplete fracture often may be more subtle, and therefore presents a more difficult diagnostic problem. The symptoms associated with incomplete tooth fracture have been described as the cracked tooth syndrome by Cameron (1964) and Stanley (1968). The incidence of incomplete tooth fracture has not been evaluated clinically, although in a survey of patients referred to endodontists for treatment, it was considered that incomplete tooth fracture may be present in 20 per cent of such patients (Braly and Maxwell, 1981). Fracture of the cusp of a tooth has been considered to be a common clinical problem (Braly and Maxwell, 1981; Cave1 et al., 1985). It would appear that with patients keeping more of their teeth for longer periods of time, the problem of tooth fracture is of increasing importance (Liebow, 1976). Fractures of teeth may vary in severity from the minimal enamel fracture, to fracture of a whole cusp or longitudinal fracture, which may lead to loss of the @ 1992 Butterworth-Heinemann 0300-5713/92/030131-09
Ltd.

tooth. Intermediate cases may be seen, such as cracked cusps associated with large restorations, and these have been reported to have an increasing incidence (Fisher, 1982). Indeed, tooth fracture has been implicated as a major reason for replacement of up to 13 per cent of amalgam restorations and may be responsible for 5 per cent of restorations placed in posterior teeth (Mjiir, 1981; Charbeneau and Klausner, 1984). Such cuspal fractures are considered to frequently present a difficult restorative problem, because the fracture may often extend subgingivally (Lagouvardos et al., 1989).

Causes of tooth fracture

The most common causes of tooth fracture have been identified as high impact forces caused by biting on a hard object or uncontrolled contact of opposing teeth. The cause of tooth fracture was investigated in India by Talim and Gohil(1974), who suggested a classification for tooth fracture (Table I). They found that sudden biting on a hard object was the most common cause of fracture, with stone particles and nuts being particularly implicated. However, other factors may predispose to tooth fracture. These include excessive contact of posterior tooth cusps during eccentric jaw movement, large internally retained restorations, wear, malocclusion, dehydration due to endodontic therapy, and steep cusp inclines and/or deep grooves in

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Table 1. Classification of fractured teeth (from Talim and Gohil, 1974)

Class I

Fracture involving enamel A Horizontal or oblique B Vertical 1. Complete 2. Incomplete Fracture involving enamel and dentine without involving pulp A Horizontal or oblique B Vertical 1. Complete 2. Incomplete Fracture of enamel and dentine involving the A Horizontal B Vertical 1. Complete 2. Incomplete Fracture of the roots A Vertical or oblique 1. Involving the pulp 2. Not involving the pulp B Horizontal 1. Cervical third 2. Middle third 3. Apical third

Class I/

C/ass Ill

Class IV

the occlusal morphology (Helfer et al., 1972; Braly and Maxwell, 1981; Ketterl, 1983; Gheretal., 1987). However, it has been considered that large restorations and carious lesions seem to be associated with most fractures (Eakle et al., 1986).

Effect of age
With regard to the age at which tooth fracture most frequently occurs, Cameron considered that fractures occurred most frequently in patients over the age of 50 years, and indeed, 80 per cent of the cases which he reviewed were 40 years or older (Cameron, 1964), while Snyder found that most fractures occurred in patients aged between 30 and 59 years (Snyder, 1976). Talim and Gohil considered that most tooth fractures occurred in patients who were middle-aged or older (Talim and Gohil, 1976). However, these figures are at variance with the more recent work of Eakle et al. (1986) who found that 66 per cent of the patients who suffered complete and incomplete tooth fractures were less than 40 years of age. Another recent study of posterior tooth fractures at the University of Athens showed that 82 per cent of the fractures occurred in patients less than 49 years of age (Lagouvardos et al., 1989). This trend may simply indicate that differing age groups of patients attended the clinics where the investigations took place: alternatively, these results may indicate a trend towards tooth fracture in younger age groups.

Effect of tooth type

With regard to tooth type, the incidence of fracture has been shown to be higher in first permanent molars than

other teeth, especially in the lower jaw, possibly because of their high susceptibility to caries and their subsequent restoration (Cave1 et al.. 1985). Indeed, fractures of mandibular first permanent molars accounted for 27 per cent of all posterior tooth fractures in a study of 191 patients (with 206 fractured teeth) by Eakle et al. (1986). The high incidence of fracture of mandibular first molars was explained by Cameron as being due to the increased leverage ( nutcracker effect ) on these teeth, as they were considered to be close to the fulcrum of masticatory movement (Cameron, 1976). The highest frequency of fracture (43 per cent) was also seen in first permanent molars in the study by Lagouvardos et al. (1989) again with fracture incidence being higher in the lower than the upper arch. This is in contrast to fracture incidence in premolar teeth, where the highest incidence has been reported to be in the maxillary arch (Lagouvardos et al., 1989). This finding was also observed in the study by Eakle and Maxwell, where fractures were seen in 49 maxillary premolars and only 12 mandibular premolars (Eakle et al., 1986). It has also been noted that the lingual cusps of lower molars tend to fracture more readily than the buccal cusps (Cave1 et al., 1985; Eakle et al., 1986) while in maxillary molars, buccal and lingual cusps fracture with almost equal frequency. It was also found that in maxillary premolars, the lingual cusps fractured only slightly more frequently than the buccal cusps (Eakle et al., 1986). However, in the study by Cave1 et al., 62 per cent of the maxillary premolar cusp fractures occurred in the nonfunctional buccal cusp (Cave1 et al., 1985). Conversely, in the University of Athens study, the frequency of fractures did not appear to be related to functional or nonfunctional cusps, nor to teeth with vital or non-vital pulps (Lagouvardos et al.. 1989). The frequency of cuspal fracture and its relationship to tooth anatomy has been investigated by Khera et al. (1990). These workers examined serial sections of upper and lower molar and premolar teeth, and analysed the specimens for difference in cuspal width, difference in cuspal angular inclination, difference in enamel thickness and difference in angular inclination. Results showed that the functional cusps of the maxillary molars and of all of the mandibular posterior teeth were significantly wider than the non-functional cusps, although maxillary premolars had smaller functional cusps. It has been suggested that functional cusps of restored teeth fracture less frequently than non-functional cusps, this also being seen in maxillary premolars, where the smaller functional cusps fracture less often (Cave1 et al., 1985; Eakle et al., 1986). This may be correlated with the results of Khera et al. (1990) with regard to cuspal dimension. These workers showed that all of the functional cusps were significantly larger in buccolingual dimensions than the non-functional cusps, with the exception of maxillary premolars. A further comparison of fracture frequency and enamel thickness concluded that thicker enamel made the cusps of molars stronger (Khera et al.. 1990).

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Table II. Investigations 1956-90

involving tooth fracture reported in the dental literature

Reference Vale, 1956 Vale, 1959 Mondelli et al., 1980 Re and Norling, 1980 Larson et al., 198 1 Re et al., 198 1 Re et al., 1982 Blaser et al., 1983 Simonsen et al., 1983 Landy and Simonsen et al., 1984 Morin et a/., 1984 Reel and Mitchell et al., 1984 Mishell and Share 1984 Eakle and Braly, 1985 Eakle, 1985a Eakle, 1985b Bakke et al., 1985 Joynt et al., 1985 Eakle, 1986a Eakle, 1986b Watts, 1986 Schultz et al., 1986 Stampalia et a/., 1986 Watts et al., 1987 Joynt et al., 1987 Oliveira et a/., 1987 Jensen et al., 1987 Sheth et al., 1988 Weiczkowski et al., 1988 Joynt et al., 1989 Reel and Mitchell, 1989 Reagan et a/., 1989 Purk et al., 1990a Purk et al., 1990b Sorensen and Engelman, 1990 Kane et al., 1990 Dietschi et al., 1990 Burke et al., 1990 N/S, not stated.

Method of application fracture Steel ball 3/l 6 in. diameter 3/l 6 in. steel ball Steel sphere 4 mm diameter 5.56 mm ball bearing Steel sphere 3/l 6 in. (4.76 mm) diameter 7/32 in. ball bearing 7/32 in. ball bearing Metal bar 3/l 6 in. wide N/S N/S Steel sphere 6.3 mm diameter Metal ball 4.7 mm diameter N/S

Crosshead speed per min. N/S N/S 0.5 mm 1 mm N/S 1 mm 1 mm IOmm 0.05 mm N/S N/S 0.05 mm 0.25 mm

20 mm Ball bearing l/8 in. diameter Ball bearing 3/l 6 in. diameter 5mm 5mm N/S N/S N/S 0.5 mm N/S Ball bearing 3/l 6 in. diameter 5mm 4.76 mm ball bearing 5mm 1 mm 8 mm bail bearing 20 lb per second under closed conditions 3.9-5 mm bar 5cm 8 mm ball bearing 1 cm 4 mm ball bearing 2 Metal rods 0.01 cm 1.985 mm in. diameter Specially designed bar 0.5 cm 0.05 cm N/S 5 mm.. . . . sphere 0.5 cm 2 Metal rods 1.985 mm 0.01 cm diameter 0.01 cm 2 Metal rods approx. 2 mm diameter Metal ball 4.7 mm diameter 0.508 mm N/S 0.79 mm2 cast premolar tip 0.79 mm2 cast premolar tip N/S 45 bevel 2 mm sphere 4 mm bar 0.13 mm 0.5 mm 0.5 mm 2.54 mm 2mm 1 mm 1 mm

However, notwithstanding factors such as the above, it was still considered that the extent of the carious lesion and of the intracoronal restoration will exert an effect on the likelihood of fracture (Khera et al., 1990). It has been stated by Hood (1990) that the eventual consequence of the use of cavity designs introduced by Black in 1895 is fracture of one of the cusps. This phenomenon, which is often attributed to ageing, is the result of overextended cavity designs. It is therefore felt surprising that with all the modern restorative techniques

currently available, classic designs still being cut (Hood, 1990).

of Class II cavity are

INVESTIGATIONS OF TOOTH FRACTURE RESISTANCE

One of the earliest investigations of the influence of cavity design on tooth fracture resistance was reported by Vale in 1956. In this study, contralateral pairs of premolars were

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Fig. 7. Diagrammatic representation of the application of a compressive force to a restored tooth, without direct application of the force to the restoration.

Fig. 2. Diagrammatic representation of the application of a compressive force to a restored tooth, with the force being applied directly to the restoration.

used, one of each pair acting as control, and the other being prepared with a Class II cavity. The teeth were then fractured by a compressive load applied to a steel ball centred in the occlusal fossa. The results showed that: 1. When the isthmus width was one-quarter of the intercuspal width, the fracture force was the same for control teeth and prepared teeth. 2. When the isthmus width was one-third of the intercuspal width, the fracture force was two-thirds that of the intact controls. 3. There was no difference between the fracture force for restored and prepared/unrestored teeth. 4. Teeth restored with gold overlays were twice as strong as unrestored teeth with the same cavity preparation. A similar technique has been utilized to examine the effect of restorative techniques on the fracture resistance of teeth in many subsequent investigations (Table II). In the investigations quoted in this table, a universal testing machine was used to deliver a compressive force to the occlusal surfaces ofthe teeth to be tested, with various steel spheres or bars being used to apply the compressive force at varying crosshead speeds. In some investigations the ball bearing was allowed to find its most stable position at or near the central fossa of the tooth (Re et al., 1982). while in other experiments the bearing is held in a specially designed testing head (Eakle and Braly, 1985). In other investigations, two bearings are used to apply the compressive force (Weiczkowski et al., 1988; Joynt et al., 1989) while other workers prepare the points of contact of the tooth to prevent slipping of the ball bearing (Morin et al.. 1984; Eakle, 1986a. b). These measures were taken to stabilize the position of the sphere on the tooth (a problem which may, in part, be overcome by the use of a steel bar) and to ensure that the sphere or bar is positioned so that it contacts only the buccal and lingual cusp inclines, rather

than the restoration. Under these conditions, when a force is applied to the tooth, the buccal and lingual cusps are placed under compressive stress and deform outward with a resultant tensile stress at the tooth/restoration interface. However, if the force is applied to the restoration alone, a compressive force is applied to the restoration and thereby transmitted to tooth substance. Accordingly there would still be tensile stress at the restoration/tooth interface (Figs 1. 2). Alternative non-destructive techniques have been developed to investigate the stresses occurring in teeth following cavity preparation and restoration. An early study, which examined such stresses using a nondestructive technique, was conducted by Noonan (1949). In this investigation, varying designs of cavity were cut in sheets of Bakelite and packed with dental amalgam. When the amalgam had set, loads were applied and the models were then examined in a polariscope. Hood et al. in 1975 used a photoelastic technique to observe the stresses in three different pontic designs. utilizing two-dimensional photoelastic sheets. These workers employed a technique similar to the one used to examine stress distribution in Class V restorations in 1972 (Hood, 1972). Two-dimensional photoelastic models were also used in a study of stresses in inlay and onlay preparations (Fisher et al., 1975). The setting up of a mathematical model is an alternative method of analysis of stress in fractured teeth (Bell et al., 1982), a method also put forward by Peters (1981) and used in subsequent investigations (deVree et al., 1984). Finite element analysis was also used in a study by Khera et al. (1988). However, the development and use of strain gauges (Malcolm, 1973; Malcolm and Hood, 1977) appears to give sensitive estimation of stresses in teeth. In these studies, subfracture loads were applied through a steel ball in the occlusal fossa, while the strain gauges applied to the

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buccal and lingual cusps measured cusp movement. These results were expressed in a relative stiffness ratio (RS), where the stiffness of the intact tooth is 1. Values of greater than 1 indicate a rigidity greater than that of the intact tooth, while lesser values indicate a reduced stiffness. A similar bonded strain gauge technique has also been utilized by Douglas (1985).

Effect of cavity dimension

The importance of conservative cavity preparation, while not extensively practised until recent times, has been advocated in the past as a method of preserving tooth strength (Bronner, 1930; Markley, 1951). However, it was the pioneering work of Vale (1956) which confirmed the wisdom of conservative cavity preparation by showing a decrease in the strength of a prepared tooth when the width of the isthmus was extended from one-quarter to one-third of the distance between the buccal and lingual cusp-tips. Nevertheless. while Vale did not demonstrate a decreased strength in the most minimal cavity preparations, Mondelli et al. (1980) did demonstrate a decrease in strength when teeth were prepared, even with a narrow Class I preparation. Their investigation of upper premolars also showed that, in all preparations, the narrower the isthmus, the greater the load required to cause fracture. This was found to be statistically true for Class I preparations of various dimensions. However, for Class II preparations, only in those with an isthmus of one-quarter the intercuspal distance was the strength statistically superior to the other dimensions. On analysis of their results, Mondelli et al. (1980) suggested that cast restorations with cuspal protection were indicated when the occlusal isthmus measured one-half or more of the intercuspal distance. A study by Larson et al. (1981) partly confirmed the work of Mondelli et al. (1980) and indicated that the extension of a preparation to involve proximal boxes does not significantly reduce the strength of the tooth, provided that only a minimal amount of dentine is removed. Indeed, it is suggested that breaking the continuity of the enamel weakens the tooth and that this step should be avoided if possible (Hood, 1990). Upper premolar teeth were used in a study by Blaser et al. (1983). These workers found that the loss of strength in teeth with wide occlusal isthmus preparations was not as severe as previously reported. They considered that narrow isthmus/deep pulpal floor preparation had a greater weakening effect than the wide isthmus and shallow floor preparation. Furthermore, they noted that larger teeth may resist fracture better than small teeth. The effect of cavity width and depth on fracture resistance was also investigated by Re et al. (1982). With regard to facie-occlusolingual (FOL) restorations, they found that there appeared to be a relationship between the extent of a restoration and the ability to restore the strength of a fractured tooth. The greatest strength and lowest susceptibility to unrestorable fracture was seen in

teeth with narrow/shallow restorations. Width alone appeared to have little effect on restorability, since six teeth with narrow/deep preparations and five with wide/ deep preparations were unrestorable. More severe fractures were seen to occur with deeper restorations. The effect of the use of sharp line angles on stress concentration has also been examined (Eakle and Braly, 1985). This study indicated that, while concentrations of stress occurred around sharp line angles, there was not a significant weakening of the tooth by using sharp rather than rounded line angles. However, no hand instruments were used to sharpen the angles. and the preparations were fairly conservative in that the occlusal isthmus was less than one-quarter of the intercuspal width. Nevertheless, when the effect of sharp internal angles was examined in Class I cavities in molars, it was considered that there was no reduction in strength when compared with cavities with rounded internal angles (Re and Norling, 1980). Other studies have investigated the effect of restorative materials on tooth fracture resistance (Stampalia et al., 1986; Watts. 1986; Joynt et al., 1987; Sheth et al.. 1988; Reel and Mitchell, 1989). From these studies it may be concluded that preparation of teeth for restoration reduces resistance to fracture and that in this respect there is no difference between amalgam and composite materials (Joynt et al., 1987). Furthermore, cusp reinforceresistance to ment (Morin et al., 1984) and improved fracture (Eakle, 1985a, 1986b) may be demonstrated using a bonded composite restorative technique. Indeed, a hybrid composite material has been shown to restore the strength of teeth with Class I cavities to a similar strength level as sound teeth (Watts et al.. 1987). Another study compared the fracture strength of teeth with weakened marginal ridges restored with Class I composite restorations and those restored with Class II composites and amalgams (Purket al., 1990a). These workers showed that in the Class II amalgam restorations only the material fractured, while in the Class II composite specimens, six of the 25 teeth also showed a fracture. It was therefore considered that. in cases where the risk of restoration fracture was high, the use of amalgam rather than composite may be desirable (Purk er al.. 1990a, b). It has been found that alternative restorative techniques may also restore the fracture resistance of teeth. For example, MOD amalgam overlays have been shown to produce fracture resistance similar to that of unprepared controls, while MOD gold overlays enhanced fracture resistance to a level much greater than that of the unprepared control teeth (Salis et al., 1987). The toothstrengthening effect of overlay placement has also been demonstrated with indirect composite restorations, when the incorporation of 2 mm cuspal overlays in a composite inlay preparation increased the fracture strength to a value equivalent to that of sound teeth (Burke, 1991). The effect of fissure sealant application on fracture resistance has been investigated by Schultz et al. (1986). These workers concluded that pit and fissure sealants

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do not affect the fracture resistance of maxillary first premolars, but that preparation of one or more proximal boxes significantly reduces strength of teeth which have had sealant applied to the occlusal fissure; however, there was no difference in fracture resistance when one or more than one box was prepared.

Effect of endodontic

treatment

The fracture of teeth at some time subsequent to root canal treatment is a common clinical observation (Lewinstein and Grajower, 1981) with Gher et al. (1986) in a study of the clinical features associated with tooth fracture, finding that 71 per cent of the fractured teeth which they examined had been root tilled. This increased risk of fracture has been attributed to several factors: 1. The loss of tooth substance due to carious destruction necessitating root canal therapy (Cortade and Timmermans, 1971). 2. The effect of the endodontic access cavity preparation. This has been investigated by Howe and McKendry (1990) who compared the effect of MOD cavity preparations with endodontic access preparations and found no significant difference in fracture resistance between teeth with only an endodontic access cavity and those prepared for conservative MOD amalgam restorations. However, teeth prepared with both MOD and endodontic access cavities had their fracture resistance reduced to 5.5per cent of the value of those with only one of these cavity preparations. 3. The effect on the physical properties of dentine. The effect of root canal treatment on dentine hardness has been investigated by Lewinstein and Grajower (1981) in a study of 16 vital and 32 root-filled teeth which had been extracted. Their results indicated that root canal therapy did not affect the hardness of dentine, even after periods of 5-10 years. Healey, in 1960, wrote that the coronal portion of treated pulpless teeth was more brittle and fragile than when the pulp was vital, and considered that this was often attributed to decreased moisture content. This view was confirmed, in part, by Helfer et al. (1972) who showed that there was 9 per cent less moisture in the calcified tissues of pulpless dog s teeth than in those of vital teeth. These workers also found that there was greater loss of moisture in anterior teeth than posterior teeth, and that it was only after the twelfth week following pulp extirpation that the difference in percentage loss of moisture became more consistent. The strength and toughness of dentine from root-treated teeth has been investigated by Carter et al. (1983) who, using a punch shear test, reported a 14 per cent reduction in strength and toughness and concluded that dentine from root-treated molars was weaker and more brittle, compared with samples from teeth with vital pulps. The fracture resistance of endodontically treated premolar teeth was investigated by Hansen (1988) in a retrospective survey. It was found that of the 181 teeth

which were filled with MOD amalgams, 13 per cent fractured within the first year after treatment and onethird fractured within 3 years. By comparison, none of the 40 root-tilled premolars filled with MOD resin restorations fractured during a similar period. When observed over a 3-lo-year interval, the resin-restored premolars also had a better survival rate, although this difference was not statistically significant. In the amalgam group, the buccal cusp failed in the upper premolar in 52 per cent of cases while in the lower first premolar, only fractures of the lingual cusp were seen. Only three of the 107 fractures were vertical, leading to loss of the tooth. However, these results differ from those obtained in the in vitro study by Stampalia et al. (1986) whose work showed vertical fracture in 21 of 22 teeth tested on a universal testing machine. This difference in results may be explained not only by the difference in forces applied in the laboratory and in the clinical situation, but also by the differing cavity dimensions in the two investigations, It may also be explained by the fact that in vitro testing of a rigidly supported tooth ignores the resiliency of the periodontal ligament (Craig, 1985). The restoration and prevention of cusp fracture of rootfilled teeth has been the subject of some debate, with preservation of all remaining sound dentine being considered to be a primary objective and with full occlusal coverage being the minimal acceptable restoration (Johnson et al., 1976) or a restoration such as an inlay which provides cuspal protection (Hood, 1985). However, dentists may not find it acceptable to place a final restoration upon a root-tilled tooth until there is radiographic evidence of periapical healing, perhaps 6-12 months after root canal treatment. As Hansen (1988) has demonstrated, during that period there is a considerable possibility of cuspal fracture in premolar teeth restored with amalgam. Accordingly, consideration should be given to the provision of bonded composite resin restorations as an interim measure, while apical healing is being ascertained.

INVESTIGATION OF FORCES GENERATED DURING MASTICATION

The studies which were noted in Table ZZemployed tooth fracture resistance as a means of observing the effect of tooth cavity preparation/restoration on the strength of a tooth. However, while these studies are of relevance in comparing the effect of varying restorative techniques, if they are to have clinical relevance, the forces utilized should be within the limits which may be obtained with the natural dentition. It is therefore of interest to observe the results of investigations where the bite force was measured. Studies indicate that different persons chew at different speeds, and that this is related to the type of food being chewed, with one cycle of mastication normally taking between half and three-quarters of a second. Furthermore, the rate of loading of specimens has been considered to

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have an effect on results obtained in transverse testing (Jones et al., 1970). The measurement of forces within the oral cavity has evolved from the use of crude methods where devices were placed between the teeth, to more sophisticated apparatus with leads to recording equipment more recently being replaced by radiotelemetry methods. The investigation of masticatory forces has been carried out by three methods (Bates et al.. 1975): 1. With measuring 2. With transducers 3. With transducers interface. devices between the teeth. within restorations. in dentures at the denture/mucosa

Variations in masticatory forces produced by the oral musculature have been shown by most workers, given that the limiting factors are the muscular power that the subject can produce, alongside their pain threshold, and in the case of dentures, the stability and retention of the appliance. The bite force for denture wearers has been shown to be less than that for dentate subjects, even for satisfactory as well as unsatisfactory dentures (Haraldson eta]., 1979). Age, per se, has been shown to have little effect on masticatory function/bite force (Carlsson, 1984). While results may tend to show an age-linked effect, it is considered to be the age-related impairment of the dentition which results in most of the decline in masticatory efficiency (Carlsson, 1984). In general. it has been found that the magnitude of occlusal forces is greater in posterior regions of the mouth than anterior regions, and that biting forces are greater than chewing and swallowing forces (Lundgren and Laurell, 1986). It may therefore follow that the larger bite forces may be more likely to cause tooth fracture. Few methods of measurement of bite force have been developed for routine clinical use, despite the recognized importance of maintaining or restoring acceptable masticatory function. Indeed, bite force measurements may be used as an indicator of masticator-y function. Earliest bite force recordings were carried out by Howell and Manley (1948) and Anderson (1953, 1956) who, using a strain gauge in an inlay, found a whole tooth maximum load of 14.9 kg. The greatest recorded masticator-y load in a full denture was found to be 12 kg, in a study using a strain gauge inserted in a denture premolar (Yurkstas and Curby, 1953). Another early study examined the effect of modifying the occlusion on masticatory stress, and found that when the tooth surface was artificially raised above the general occlusal level by 0.5 mm, the loads were twice the normal level (Anderson and Picton, 1958). Removable dentures are usually associated with a reduction in bite force which is most pronounced in full dentures (Haraldson et al., 1979) but also present in partial dentures, as demonstrated by Watt et al., (1958). These workers reported average bite loads of 21.7 kg for natural teeth, 11.2 kg for tooth-borne dentures, and 7.4 kg for tissue-borne dentures. Conversely, fixed prostheses are not usually associated with such a reduction. In healthy

subjects with a good dentition, the maximal bite force has been calculated to average 300-500 N, but with great individual variation (Carlsson, 1974: Bates et al.. 1975). When bite force was measured in two matched groups, one dentate and the other treated by osseointegrated implants, there were no statistically significant differences. The maximal bite force in the implant group, measured with a bite fork between opposing teeth, was between 42 and 412 N. with a median value of 143 N, while the range in the dentate group varied from 103 to 368 N (Carlsson and Haraldson, 1985). Another study of 19 oral implant patients showed maximal bite force measurements of between 410 and 90 N in men and 230 and 40 N in women, although the mean values were not statistically different (Haraldson and Carlsson. 1977). The bite force of patients being treated for dysfunction of masticatory system was measured by Helkimo et al. (1975). They recorded a maximum bite force value of 48 kg for control patients in their investigation. In another study of 100 male dental students, bite force measurements were recorded and related to mandibular dysfunction symptoms and tooth wear (Helkimo and Ingervall, 1978). The mean bite force measured was found to be 471 N, with a range of 191802 N, no difference having been noted in bite force in subjects with different dysfunction indices, although bite force measurements increased with increasing tooth wear. Occlusal forces were measured by a sound transmission technique in studies by Gibbs et al. (198la, b). In these studies. it was found that the maximum biting force during clenching averaged 162 lb (73 kg) for 20 subjects, and ranged from 55 to 280 pounds (25-127 kg), but no correlation was found between either sex or age.

CONCLUSION
Tooth fracture is an increasingly common occurrence, with permanent molar teeth showing the highest incidence of fracture clinically. Among premolars, maxillary teeth fracture more often than mandibular teeth. Tooth fracture resistance has been an established method ofinvestigation of the effect of cavity/restoration design on tooth strength for over three decades. While alternative non-destructive experimental methods may give valuable information on the stresses and strains generated by restorative techniques, tooth fracture resistance remains an important method of investigation of any new restorative technique. Since values of biting force of up to 800 N have been measured clinically, experimental forces of this value may be seen to be of clinical relevance.

References
Anderson D. J. (1953) A method of recording masticatory loads. J. Dent. Res. 32, 785-789. Anderson D. J. (1956) Measurement of stress in mastication I. J. Dent. Res. 35, 664-670. Anderson D. J. and Picton D. C. A (1958) Masticatory stresses in normal and modified occlusion. J. Dent. Res. 37, 312-317.

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