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
Restoration of large molar defects
remains a clinical problem. Teeth with
large molar defects often require end-
odontic treatment. It is well estab-
lished that endodontic therapy is im-
portant to preserve teeth that would
otherwise be lost, but endodontically
treated teeth are generally weaker due
to loss of tooth structure and removal
of the pulp.1,2 Consequentially, frac-
tures occurring in vital or pulpless
posterior teeth3-5 are a serious prob-
lem. The risk of tooth fracture also in-
creases with greater width and depth
of caries. Serious fractures involving
dentin tissue (typically classified as
Class III or IV fractures) often cause
large defects that cannot be restored,
resulting in loss of the tooth.6-9 End-
odontically treated teeth can be re-
inforced by restoration; however,
studies have shown that the fracture
resistance of restored teeth is never
the same as that of intact teeth, re-
gardless of the restorative materials
or methods used.7-10 Moreover, stud-
ies have shown that the typical MOD
(mesio-occluso-distal) cavity prepa-
ration significantly decreases the frac-
ture resistance of teeth.6,9,11,12 Great
efforts have been made to evaluate
the various restorative materials avail-
able, and the methods of inlay versus
onlay restoration.13,14
Inlays and onlays are the 2 techni-
cal choices for restoration. In com-
parison with inlays, onlays can cover
one or more cusps of the tooth, re-
sulting in a favorable distribution of
stresses in teeth,15 along with a de-
creased fracture risk.16 Therefore, ex-
tracoronal restorations (onlays) have
been recommended for the protec-
tion of endodontically treated teeth.13
Some studies have shown that after
endodontic treatment, teeth restored
with intracoronal restorations show
more severe fracture patterns.6,9 In
contrast, another report showed that
teeth restored with ceramic restora-
tions (inlays) had fracture strengths
comparable to those of sound teeth.17
Furthermore, it is unclear whether
bonded intracoronal restorations
should be used for large molar de-
Jiang et al
fects, although clinical reports have
been encouraging.18,19
Many materials are available for
dental restorations. The demand for
nonmetal dental restorations has
grown considerably in recent years.
The primary advantages of nonmetal
alternatives (composite resins and
ceramics) are improved esthetics,
the avoidance of mercury, and cost
effectiveness.20 Composite resin and
ceramic restorations retained with an
adhesive resin are the most popular
restorations currently used.21 Com-
posite resins have mechanical prop-
erties similar to dentin,22,23 while ce-
ramic has an elastic modulus similar
to that of enamel.24,25
Various studies investigating the
performance of composite resin and
ceramic restorations have been per-
formed. The primary reason for fail-
ure of indirect composite resin inlays
is fracture in restorations or teeth.20,21
Other failures are related to loss of
marginal adaptation. For ceramic in-
lays, the primary causes of failure are
cohesive bulk fractures and marginal
deficiencies.22,23 Clinically, these fail-
ures manifest through marginal dis-
coloration and secondary caries.24,25
Nevertheless, with respect to wall-to-
wall adaptation, adhesively luted res-
in composite inlays are slightly better
than direct composite restorations,
while ceramic inlays perform as well
as cast-gold inlays.26 When the stress
distribution and the stress transmit-
ted to the remaining tooth structure
are analyzed under different load sim-
ulations, the results seem contradic-
tory. Using the finite element analysis
(FEA) method, some investigators27-31
demonstrated that ceramic inlays re-
duced tension at the dentin-adhesive
interface and may offer better protec-
tion against debonding at the dentin
restoration interface, compared with
the composite resin inlay. However,
Ausiello et al32 reported that ceram-
ic MOD inlays created higher stress
levels at the internal surfaces of the
preparations.
These previously described stud-
ies have yielded conflicting results
7
regarding which material and resto-
ration technique provide the minimal
internal stresses and the best stress
distribution pattern for vital and
pulpless molars. Therefore, the pur-
pose of this study was to compare
the stress distribution and maximum
von Mises stress generated in den-
tin tissue in inlay- or onlay-restored
mandibular first molars using the 3-D
FEA method. Various commonly used
restoration materials were compared.
Inlay- and onlay-restored vital teeth
and endodontically treated teeth were
compared.
MATERIAL AND METHODS
The research protocol was ap-
proved by the Ethical Research Com-
mittee of the School of Dentistry,
Fourth Military Medical University,
Xi’an, China. An intact, caries-free
mandibular first molar of a volunteer
(24-year-old woman) was scanned
with a multilayer spiral computerized
tomography (CT) machine (Light-
Speed64; GE Healthcare Technolo-
gies, Waukesha, Wis) in increments
of 0.625 mm. A total of 45 slices were
made, and 25 were selected for mod-
eling. The scanned slices were import-
ed into an interactive medical image
control system (Mimics 9.0; Materi-
alise, Leuven, Belgium), which identi-
fies different hard tissues of the teeth
based on image density thresholding.
A 3-D object was automatically cre-
ated in the form of masks by growing
a threshold region on the entire stack
of scans, and this was converted into
a stereolithography file. This file was
then refined using reverse engineer-
ing software (Geomagic Studio 10;
Geomagic, Inc, Research Triangle
Park, NC). The quality of the surface
was improved using the sandpaper-
ing tool, while optimal geometry was
maintained. The final solid model for
use with finite element software (Uni-
graphics NX 4; HP Enterprise Servic-
es, Plano, Tex) was generated. After-
ward, the MOD and the endodontic
access cavity preparations were devel-
oped on the solid model using Bool-
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
lateral loading, von Mises stress con-
centrations were found at the cervi-
cal region. These may be compressive
stresses, which may reflect interaction
between the cervical region and alve-
olar bone.
The results of this study show that,
as expected, the structural integrity
of the tooth is diminished with end-
odontic treatment, resulting in higher
von Mises stress concentration. Stress
concentrations with loading indicate
the location and likelihood for fail-
ure initiation, and are thus related to
the fracture resistance of the tooth.
In this study, in an alternative model,
the MOD cavity of an endodontically
treated molar was restored using pri-
mary enamel and dentin, but even this
“restored” tooth experienced greater
stress than the intact tooth under
the same loading (data not shown).
Thus, it is indicated that if the tooth
structure is modified by endodontic
treatment, the tooth’s structural in-
tegrity cannot be fully restored, no
matter what type of restoration ma-
terial is used. It is notable that when
stress was applied laterally, it was
found to concentrate in the cervical
portion of the root, especially in the
inlay-restored, endodontically treated
group (IE group), which demonstrat-
ed a von Mises stress value in this part
of the tooth that was much higher
than in the other 3 groups. In in vitro
studies, Hannig et al6 and Soares et
al9 reported that the endodontically
treated tooth restored with an inlay
demonstrated severe fracture pat-
terns, typically categorized as Class
III or IV fractures. Since tooth fracture
involving the roots is the worst sce-
nario for tooth restoration, it is par-
ticularly important to avoid such frac-
tures when restoring a pulpless molar.
Although von Mises stress concen-
tration cannot predict failure paths/
fracture patterns in a static computer
simulation, higher stress concentra-
tions with loading are a definitive
mechanism of failure and, thus, are
related to the fracture strength or fail-
ure mode of teeth. However, it should
be noted that the FE model used in
Jiang et al
the present study was not designed to
evaluate the fracture strength or the
failure mode of the teeth. Higher or
lower loads would change the stress
values, but not the general stress dis-
tribution pattern.
Among the materials evaluated in
this study, composite resin seems to
be the best choice for indirect resto-
rations. However, as the integrity of
the cement layer was not considered
in this study, this conclusion cannot
be definitively made. Although the
focus of this study was directed to
stresses generated in dentin tissue,
cement failure is another primary
reason for the failure of indirect res-
torations. Some clinical and in vitro
studies have indicated that ceramic
inlays show better marginal integrity
than composite resin inlays. However,
Lin5 and Ausiello et al32 demonstrated
that large ceramic restorations result
in higher stress levels in the internal
surfaces of the preparation. The au-
thors concluded that the use of re-
storative materials with low moduli
limits the stress intensity transmitted
to the remaining tooth structures.5,32
In contrast to ceramic, the compos-
ite resin inlays redistribute stress and
show elastic biomechanical proper-
ties similar to those of sound teeth.
More studies are required to investi-
gate this finding further.
On the basis of esthetic and eco-
nomic concerns, gold restorations
are less popular. Nevertheless, the
biocompatibility and marginal adap-
tation of gold are reasons that this
material is still used clinically. It is im-
possible to assess all of the properties
of a restorative material in a comput-
er simulation, and gold was included
in this study as a control material. In
comparing the results, it is interest-
ing that, in contrast to restoration
methods, only small differences were
observed between stresses generated
by the different restorative materi-
als (Fig. 2). Thus, using the proper
restoration method may be more im-
portant than using a particular restor-
ative material.
Some investigators believe that
11
large preparations require cuspal cov-
erage to prevent possible fractures,
even with adhesive restorations.13
Couegnat et al14 observed that when
both nonundercut and undercut
preparations were restored with in-
lays, the greatest amount of stress
was located within the tooth. In con-
trast, for onlays, the greatest amount
of stress was within the restorations.
These results are in agreement with
those of the current study. An onlay-
restored tooth exhibited the most fa-
vorable stress distribution pattern in
dentin tissue.
As a 3-dimensional (3-D) finite
element computer analysis of various
situations, this study has limitations.
Notably, the physical properties of
the actual materials will be different
from the linear isotropic properties
used in this computer analysis; thus,
the results of a computer simulation
must be regarded only as indicative
of clinical situations. Further experi-
mental and clinical tests should be
performed before firm conclusions
are drawn.
CONCLUSIONS
Within the limitations of this
study, the following conclusions were
drawn:
1. Cavity preparation and end-
odontic treatment cause higher von
Mises stress and significant stress
concentrations, which are expected
to have a negative influence on the
fracture resistance of teeth.
2. An increase in the elastic modu-
lus of the restorative materials was as-
sociated with an increase in the von
Mises stress values generated in the
tooth. Composite resin restorations
showed the most favorable stress dis-
tribution pattern in MOD cavity res-
torations in both vital and endodon-
tically treated teeth. Gold, which had
the highest elastic modulus of the
materials tested, caused the greatest
stress concentration in the tooth.
3. After endodontic treatment, a
tooth restored with an onlay showed
a more favorable stress distribution
12
than that restored with an inlay, re-
gardless of the material or loading
condition, especially in the cervical
portion of the root.
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Corresponding author:
Dr Ni LongXing
Department of Operative Dentistry and
Endodontics
School of Stomatology, Fourth Military
Medical University
No.145, Changle Rd
Xi’an, Shaanxi
CHINA
Fax: 86-29-83224432
E-mail: nilongx@fmmu.edu.cn
Copyright © 2010 by the Editorial Council for
The Journal of Prosthetic Dentistry.
Jiang et al