Stress distribution in molars restored

with inlays or onlays with or without

endodontic treatment: A three-
dimensional finite element analysis
W. Jiang, MS,a H. Bo, MS,b G. YongChun, MS,c and Ni LongXing,
DDS, PhDd
School of Stomatology, Fourth Military Medical University, Xi’an,
Shaanxi, China
Statement of problem. Previous research into the strength of endodontically treated or vital teeth restored with inlays
or onlays has not determined which restoration method and material provide the most favorable stress distribution
upon loading.

Purpose. The purpose of this study was to calculate the von Mises stresses in a mandibular first molar using a 3-di-
mensional (3-D) finite element model. Models compared endodontically treated and vital teeth, a variety of restor-
ative materials, and the use of either inlays or onlays to restore teeth.

Material and methods. Four 3-D models of mandibular first molars were created: (1) the IV group (inlay restored,
vital pulp); (2) the OV group (onlay restored, vital pulp); (3) the IE group (inlay restored, endodontically treated); and
(4) the OE group (onlay restored, endodontically treated). In each group, 3 types of restorative material were tested:
(1) composite resin, (2) ceramic, and (3) gold alloy. The materials had elastic moduli of 19 GPa, 65 GPa, and 96.6
GPa, respectively. Each model was subjected to a force of 45 N directed to the occlusal surface, applied either verti-
cally or laterally (45 degrees obliquely). The stresses occurring in dentin tissue were calculated. The stress distribution
patterns and the maximum von Mises stresses were calculated and compared.

Results. The different restorative materials exhibited similar stress distribution patterns under identical loading condi-
tions. In each group, the gold-restored tooth exhibited the highest von Mises stress, followed by ceramic and compos-
ite resin. The maximum von Mises stress in dentin was found in the IE group (16.73 MPa), which was 5 times higher
than the highest value found in the OV group (2.96 MPa). The highest stresses, which occurred at the floor of the
preparation and the cervical region in dentin, were in the IE group. The stress concentration area in the IE group was
also larger.

Conclusions. The results indicate that endodontic treatment caused higher stress concentration in dentin compared
with vital teeth, but that proper restoration can minimize internal stresses. In the models, the von Mises stress values
increased with the increasing elastic modulus of the restorative material. Composite resin onlays showed the best per-
formance overall in minimizing internal stresses. As internal stresses are indicated as a prime failure mechanism of the
restoration, composite resin onlays are expected to better restore structural integrity. (J Prosthet Dent 2010;103:6-12)

Clinical Implications
Within the limitations of this study, it was determined that a high elas-
tic modulus of the restoration material caused higher stress concentra-
tions. Composite resin onlays were determined to be the best choice to
restore molars, especially those that have been endodontically treated,
for which it is desirable to minimize stress concentrations.

Supported by grant no. 2007BAI18B01 from the National Key Technologies Research and Development Programme of the Eleventh
Five-Year Plan, Ministry of Science and Technology of China.

a
PhD candidate, Department of Operative Dentistry and Endodontics.
b
Attending Doctor, Department of Operative Dentistry and Endodontics.
c
PhD candidate, Department of Operative Dentistry and Endodontics.
d
Professor and Director, Department of Operative Dentistry and Endodontics.
The Journal of Prosthetic Dentistry Jiang et al
January 2010 7
Restoration of large molar defects fects, although clinical reports have regarding which material and resto-
remains a clinical problem. Teeth with been encouraging.18,19 ration technique provide the minimal
large molar defects often require end- Many materials are available for internal stresses and the best stress
odontic treatment. It is well estab- dental restorations. The demand for distribution pattern for vital and
lished that endodontic therapy is im- nonmetal dental restorations has pulpless molars. Therefore, the pur-
portant to preserve teeth that would grown considerably in recent years. pose of this study was to compare
otherwise be lost, but endodontically The primary advantages of nonmetal the stress distribution and maximum
treated teeth are generally weaker due alternatives (composite resins and von Mises stress generated in den-
to loss of tooth structure and removal ceramics) are improved esthetics, tin tissue in inlay- or onlay-restored
of the pulp.1,2 Consequentially, frac- the avoidance of mercury, and cost mandibular first molars using the 3-D
tures occurring in vital or pulpless effectiveness.20 Composite resin and FEA method. Various commonly used
posterior teeth3-5 are a serious prob- ceramic restorations retained with an restoration materials were compared.
lem. The risk of tooth fracture also in- adhesive resin are the most popular Inlay- and onlay-restored vital teeth
creases with greater width and depth restorations currently used.21 Com- and endodontically treated teeth were
of caries. Serious fractures involving posite resins have mechanical prop- compared.
dentin tissue (typically classified as erties similar to dentin,22,23 while ce-
Class III or IV fractures) often cause ramic has an elastic modulus similar MATERIAL AND METHODS
large defects that cannot be restored, to that of enamel.24,25
resulting in loss of the tooth.6-9 End- Various studies investigating the The research protocol was ap-
odontically treated teeth can be re- performance of composite resin and proved by the Ethical Research Com-
inforced by restoration; however, ceramic restorations have been per- mittee of the School of Dentistry,
studies have shown that the fracture formed. The primary reason for fail- Fourth Military Medical University,
resistance of restored teeth is never ure of indirect composite resin inlays Xi’an, China. An intact, caries-free
the same as that of intact teeth, re- is fracture in restorations or teeth.20,21 mandibular first molar of a volunteer
gardless of the restorative materials Other failures are related to loss of (24-year-old woman) was scanned
or methods used.7-10 Moreover, stud- marginal adaptation. For ceramic in- with a multilayer spiral computerized
ies have shown that the typical MOD lays, the primary causes of failure are tomography (CT) machine (Light-
(mesio-occluso-distal) cavity prepa- cohesive bulk fractures and marginal Speed64; GE Healthcare Technolo-
ration significantly decreases the frac- deficiencies.22,23 Clinically, these fail- gies, Waukesha, Wis) in increments
ture resistance of teeth.6,9,11,12 Great ures manifest through marginal dis- of 0.625 mm. A total of 45 slices were
efforts have been made to evaluate coloration and secondary caries.24,25 made, and 25 were selected for mod-
the various restorative materials avail- Nevertheless, with respect to wall-to- eling. The scanned slices were import-
able, and the methods of inlay versus wall adaptation, adhesively luted res- ed into an interactive medical image
onlay restoration.13,14 in composite inlays are slightly better control system (Mimics 9.0; Materi-
Inlays and onlays are the 2 techni- than direct composite restorations, alise, Leuven, Belgium), which identi-
cal choices for restoration. In com- while ceramic inlays perform as well fies different hard tissues of the teeth
parison with inlays, onlays can cover as cast-gold inlays.26 When the stress based on image density thresholding.
one or more cusps of the tooth, re- distribution and the stress transmit- A 3-D object was automatically cre-
sulting in a favorable distribution of ted to the remaining tooth structure ated in the form of masks by growing
stresses in teeth,15 along with a de- are analyzed under different load sim- a threshold region on the entire stack
creased fracture risk.16 Therefore, ex- ulations, the results seem contradic- of scans, and this was converted into
tracoronal restorations (onlays) have tory. Using the finite element analysis a stereolithography file. This file was
been recommended for the protec- (FEA) method, some investigators27-31 then refined using reverse engineer-
tion of endodontically treated teeth.13 demonstrated that ceramic inlays re- ing software (Geomagic Studio 10;
Some studies have shown that after duced tension at the dentin-adhesive Geomagic, Inc, Research Triangle
endodontic treatment, teeth restored interface and may offer better protec- Park, NC). The quality of the surface
with intracoronal restorations show tion against debonding at the dentin was improved using the sandpaper-
more severe fracture patterns.6,9 In restoration interface, compared with ing tool, while optimal geometry was
contrast, another report showed that the composite resin inlay. However, maintained. The final solid model for
teeth restored with ceramic restora- Ausiello et al32 reported that ceram- use with finite element software (Uni-
tions (inlays) had fracture strengths ic MOD inlays created higher stress graphics NX 4; HP Enterprise Servic-
comparable to those of sound teeth.17 levels at the internal surfaces of the es, Plano, Tex) was generated. After-
Furthermore, it is unclear whether preparations. ward, the MOD and the endodontic
bonded intracoronal restorations These previously described stud- access cavity preparations were devel-
should be used for large molar de- ies have yielded conflicting results oped on the solid model using Bool-
Jiang et al
8 Volume 103 Issue 1
ean operations and the parameters
described below.
For the IV group (inlay restored,
vital pulp), the preparation was 4 mm
deep, and it was one third of the width
of the tooth’s occlusal surface, where-
as at the isthmus, the width was one
fourth of the intercuspal distance. The
cavity margin curved smoothly and
continuously. The proximal box was
1 (width) x 2 (length) x 5.5 (depth)
mm on both sides of the tooth. For
the OV group (onlay restored, vital
pulp), the cavity preparation was the
same as for the IV group; however, all
of the cusps were shortened by 2 mm.
A 1-mm-wide butt joint margin was
prepared.
For the IE (inlay restored, end- 1 Solid models generated with software, loading direction, and loading
odontically treated) and OE (onlay point. IV group (inlay restored, vital pulp); IE group (inlay restored, end-
restored, endodontically treated) odontically treated); OE group (onlay restored, endodontically treated); OV
groups, the cavity preparation was group (onlay restored, vital pulp).
the same as for the IV and OV groups,
except that the roof of the pulp cham- Table I. Material properties
ber was removed and canals were
E (GPa) Poisson’s Ratio
prepared to a #35 ISO K-file size, and
then filled with gutta-percha. Zinc
Enamel 84.105,31 0.3012,14,28,31
phosphate was used as the base to
fill the pulp chamber. Both the lingual Dentin 18.605,13,31,32,33 0.315,12,13,14,31,33
and buccal walls had a 6-degree axial
Pulp 0.0025,14,30 0.455,12,14,30
inclination in all models. The cavity
was characterized by sharp internal Alveolar bone 11.5013 0.305,13,33
line angles. The models developed for
Zinc phosphate cement 22.4033 0.2533
this study and the loading point are
presented in Figure 1. Composite resin 1914 0.2412,14,28,31
Models were then imported into
Ceramic 6512,13,30 0.1913,30
finite element analysis software
(Abaqus 6.6; SIMULIA, Providence, Gold alloy 96.633 0.3533
RI) to generate a volumetric mesh.
Material properties were attributed Gutta-percha 0.1434 0.4534
to the model after importation into
the finite element analysis software.
To maintain the geometric profile of of the literature. All materials were supporting bone. Adjacent surfaces
irregular surfaces, the triangulated el- modeled as linearly elastic and isotro- belonging to the different domains of
ements were idealized for automatic pic materials. the tooth were considered to be bond-
mesh generation using a tetrahedral In this study, the cement layer was ed together. A static finite element
mesher. Finally, material properties not considered because the Young’s analysis was adopted for predicting
were assigned for each domain of the modulus of zinc phosphate cement the stress distribution generated in
tooth, and volumes were meshed us- is close to that of dentin, regardless the restored tooth by each loading
ing 10-node tetrahedral elements. of the material used. Consequently, condition. The model received a ver-
Two mechanical material proper- the mechanical impact of the cement tical or 45-degree oblique occlusal
ties were specified for each isotropic layer was considered not to be signifi- load at a constant intensity of 45 N to
material: the Poisson’s ratio and the cant. Fixed zero-displacements in the simulate a mastication load. The load
elastic modulus (Table I),13,14,30,31,33,34 mesial-distal directions were defined was applied on the tooth at the cen-
which were determined from a review at the horizontal-cut planes of the tral groove area of the tooth.
The Journal of Prosthetic Dentistry Jiang et al
January 2010 9
RESULTS 18
16
The primary focus of simulation D Composite

Von Mises Stress (MPa)

results was on the von Mises stress 14 D Ceramic
D Gold
at the cavity floor and at the cervical 12 BP Composite
region in dentin. The different restor- 10 BP Ceramic
ative materials exhibited similar stress BP Gold
8
distribution patterns for all treatment
groups. In each group, the maximum 6
von Mises stress generated in dentin 4
was lower with vertical, rather than 2
lateral, stress loading. The maximum
0
von Mises stresses generated in den- OV IV IE OE
tin and at the cavity floor with lateral
2 Maximum von Mises stress generated in dentin (D) and bottom of
loading are presented in Figure 2. In
preparation (BP) with lateral loading. Note stress values in IE group
the IV group, when the occlusal load are higher than other groups under analogous loading conditions.
was applied on the model vertically or
with a 45-degree inclination, the gold-
restored tooth exhibited the highest
von Mises stress, followed by ceramic
inlay and composite resin inlay. The
same ranking was observed with re-
spect to the elastic moduli of these
materials. With vertical application of
the load, the stress was concentrated
at the floor of the preparation, and at
the cervical region of the tooth, in ad-
dition to at the loading site. The distal
stress concentration was higher than
the mesial stress concentration at the
cavity floor. At the cervical region, the
highest stress concentration occurred
at the mesiolingual area, near the
floor of the preparation. When the
load was applied at a 45-degree incli- 3 Von Mises stress distribution in cavity floor with lateral loading. Shown
nation, the gold-restored tooth again are: CR (composite resin), C (ceramic), G (gold). Note in OE group, stress
exhibited the highest values, followed distribution was more uniform, and stress values were lower (red color indi-
by the ceramic inlay and composite cates highest values of von Mises stress).
resin, similar to the outcome of the
vertical load test. For the 45-degree- tion, and in the cervical region of the The OV group exhibited the small-
inclination loading, the area of stress tooth. When loaded vertically, the est von Mises stress of all groups. In
concentration changed such that highest stress concentration occurred the OV group, a more uniform stress
stress concentrations near the lingual- in the middle of the buccopulpal and distribution was observed, and the
pulpal line angle were higher than linguopulpal line angle. There was no maximum stresses were lower than
those at the buccal surface. significant difference among the dif- those of the IV and IE groups under
The IE group again showed gold ferent materials in terms of the high- both loading conditions. In the OE
to demonstrate the highest stresses, est stress values recorded in the cer- group, the highest von Mises stress
followed by the ceramic inlay, with vical region. The highest values were for all materials was also lower than
composite resin showing the lowest generated in the middle of the buccal that of the IV and IE groups, but was
stresses. In the IE group, the maxi- and lingual surfaces. When the load- still higher than that of the OV group.
mum stress generated in the dentin ing was inclined lingually, the highest In addition, stress was concentrated
was higher than in the IV group. In stress values generated in the dentin less severely at the floor of the prepa-
addition to being concentrated at the increased. The maximum value of ration and at the cervical region. The
loading site, the stress was also con- stress in the buccal wall was higher stress concentration in these 2 areas
centrated at the floor of the prepara- than that occurring in the lingual wall. (floor of the preparation, cervical re-
Jiang et al
10 Volume 103 Issue 1
for restoration failure.10,11 Therefore,
a primary objective of this study was
to evaluate the maximum von Mises
values and stress distribution in den-
tin after stress loading to identify fail-
ure mechanisms of restorations under
various restoration conditions and
with various restorative materials.
The highest von Mises stress at
the preparation floor, 6.38 MPa,
was found for a gold-inlay-restored,
endodontically treated tooth loaded
obliquely. This value is 8 times higher
than the highest stress (0.76 MPa)
recorded in the vital tooth restored
with a composite resin onlay. The
stress values found for the endodon-
tically treated tooth restored with a
4 Von Mises stress distribution in cervical plane of tooth with lateral load- composite resin onlay are lower than
ing. Note that in IE group, stresses concentrated in this area, and stress val- those of the vital tooth restored with
ues were much higher than other 2 groups (red color indicates highest values a composite resin inlay. In each group,
of von Mises stress). regardless of whether loading was
vertical or oblique, the gold restora-
tion resulted in the highest von Mises
stress in the tooth tissues. The next
highest stresses were found in ceram-
ic and composite resin restorations,
again, regardless of loading point.
This trend corresponds to the ranking
of the elastic modulus for each mate-
rial, and, therefore, indicates that ma-
terials with a smaller elastic modulus
reduce the stress generated in the re-
sidual tissue. This result is consistent
with those of Lin and Ausiello et al,5,32
who observed that, due to their rigid-
ity, materials with high elastic moduli
cannot effectively redistribute stresses
into the cavity, resulting in an increase
in the amount of stress on the tooth.
For all models, the stress was pri-
5 Von Mises stress distribution in dentin with lateral loading. Vertical cross-
marily concentrated at the floor of
section (buccolingual direction) through loading point showed stresses
mainly concentrated at cavity floor and cervical region; stress values in IE the preparation and at the cervical
group were higher than other groups (red color indicates highest values of region of the tooth. These regions
von Mises stress). of concentrated stress are shown in
Figure 5. The preparation floor was
not only the primary target of stress
gion) are presented in Figures 3 and DISCUSSION transmission, but was also the inter-
4. Because the von Mises stresses in face where different materials con-
these 2 planes were too small to be Studies have shown that the frac- tacted each other; therefore, different
identified in the OV group using the ture resistance of teeth restored by material properties appear to have
same scale as for the other 3 groups, inlays/onlays is higher than the maxi- caused the materials to react differ-
only the stress concentrations in IE, mum occlusal force of the average hu- ently under loading. This may explain
OE, and IV groups are exhibited. man being, and, thus, occlusal force is why the stress concentration occurred
not expected to be a sufficient cause at the floor of the preparation. During
The Journal of Prosthetic Dentistry Jiang et al
January 2010 11
lateral loading, von Mises stress con- the present study was not designed to large preparations require cuspal cov-
centrations were found at the cervi- evaluate the fracture strength or the erage to prevent possible fractures,
cal region. These may be compressive failure mode of the teeth. Higher or even with adhesive restorations.13
stresses, which may reflect interaction lower loads would change the stress Couegnat et al14 observed that when
between the cervical region and alve- values, but not the general stress dis- both nonundercut and undercut
olar bone. tribution pattern. preparations were restored with in-
The results of this study show that, Among the materials evaluated in lays, the greatest amount of stress
as expected, the structural integrity this study, composite resin seems to was located within the tooth. In con-
of the tooth is diminished with end- be the best choice for indirect resto- trast, for onlays, the greatest amount
odontic treatment, resulting in higher rations. However, as the integrity of of stress was within the restorations.
von Mises stress concentration. Stress the cement layer was not considered These results are in agreement with
concentrations with loading indicate in this study, this conclusion cannot those of the current study. An onlay-
the location and likelihood for fail- be definitively made. Although the restored tooth exhibited the most fa-
ure initiation, and are thus related to focus of this study was directed to vorable stress distribution pattern in
the fracture resistance of the tooth. stresses generated in dentin tissue, dentin tissue.
In this study, in an alternative model, cement failure is another primary As a 3-dimensional (3-D) finite
the MOD cavity of an endodontically reason for the failure of indirect res- element computer analysis of various
treated molar was restored using pri- torations. Some clinical and in vitro situations, this study has limitations.
mary enamel and dentin, but even this studies have indicated that ceramic Notably, the physical properties of
“restored” tooth experienced greater inlays show better marginal integrity the actual materials will be different
stress than the intact tooth under than composite resin inlays. However, from the linear isotropic properties
the same loading (data not shown). Lin5 and Ausiello et al32 demonstrated used in this computer analysis; thus,
Thus, it is indicated that if the tooth that large ceramic restorations result the results of a computer simulation
structure is modified by endodontic in higher stress levels in the internal must be regarded only as indicative
treatment, the tooth’s structural in- surfaces of the preparation. The au- of clinical situations. Further experi-
tegrity cannot be fully restored, no thors concluded that the use of re- mental and clinical tests should be
matter what type of restoration ma- storative materials with low moduli performed before firm conclusions
terial is used. It is notable that when limits the stress intensity transmitted are drawn.
stress was applied laterally, it was to the remaining tooth structures.5,32
found to concentrate in the cervical In contrast to ceramic, the compos- CONCLUSIONS
portion of the root, especially in the ite resin inlays redistribute stress and
inlay-restored, endodontically treated show elastic biomechanical proper- Within the limitations of this
group (IE group), which demonstrat- ties similar to those of sound teeth. study, the following conclusions were
ed a von Mises stress value in this part More studies are required to investi- drawn:
of the tooth that was much higher gate this finding further. 1. Cavity preparation and end-
than in the other 3 groups. In in vitro On the basis of esthetic and eco- odontic treatment cause higher von
studies, Hannig et al6 and Soares et nomic concerns, gold restorations Mises stress and significant stress
al9 reported that the endodontically are less popular. Nevertheless, the concentrations, which are expected
treated tooth restored with an inlay biocompatibility and marginal adap- to have a negative influence on the
demonstrated severe fracture pat- tation of gold are reasons that this fracture resistance of teeth.
terns, typically categorized as Class material is still used clinically. It is im- 2. An increase in the elastic modu-
III or IV fractures. Since tooth fracture possible to assess all of the properties lus of the restorative materials was as-
involving the roots is the worst sce- of a restorative material in a comput- sociated with an increase in the von
nario for tooth restoration, it is par- er simulation, and gold was included Mises stress values generated in the
ticularly important to avoid such frac- in this study as a control material. In tooth. Composite resin restorations
tures when restoring a pulpless molar. comparing the results, it is interest- showed the most favorable stress dis-
Although von Mises stress concen- ing that, in contrast to restoration tribution pattern in MOD cavity res-
tration cannot predict failure paths/ methods, only small differences were torations in both vital and endodon-
fracture patterns in a static computer observed between stresses generated tically treated teeth. Gold, which had
simulation, higher stress concentra- by the different restorative materi- the highest elastic modulus of the
tions with loading are a definitive als (Fig. 2). Thus, using the proper materials tested, caused the greatest
mechanism of failure and, thus, are restoration method may be more im- stress concentration in the tooth.
related to the fracture strength or fail- portant than using a particular restor- 3. After endodontic treatment, a
ure mode of teeth. However, it should ative material. tooth restored with an onlay showed
be noted that the FE model used in Some investigators believe that a more favorable stress distribution
Jiang et al
12 Volume 103 Issue 1
than that restored with an inlay, re- 12.Soares PV, Santos-Filho PC, Gomide 25.Albakry M, Guazzato M, Swain MV. Biaxial
HA, Araujo CA, Martins LR, Soares CJ. flexural strength, elastic moduli, and x-ray
gardless of the material or loading Influence of restorative technique on the diffraction characterization of three press-
condition, especially in the cervical biomechanical behavior of endodontically able all-ceramic materials. J Prosthet Dent
portion of the root. treated maxillary premolars. Part II: strain 2003;89:374-80.
measurement and stress distribution. J 26.Hickel R, Manhart J. Longevity of restora-
Prosthet Dent 2008;99:114-22. tions in posterior teeth and reasons for
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