Clin Oral Invest (2011) 15:403–408

DOI 10.1007/s00784-010-0397-7

ORIGINAL ARTICLE

Conservative restoration of severely damaged endodontically

treated premolar teeth: a FEM study
Öznur Eraslan & Oğuz Eraslan & Gürcan Eskitaşcıoğlu &
Sema Belli

Received: 12 August 2009 / Accepted: 17 February 2010 / Published online: 18 March 2010
# Springer-Verlag 2010

Abstract The aim of this finite element method (FEM) loading areas for all models. Root dentine tissue, lingual
study was to test two different restorative techniques used cortical bone, and apical bone structures were other stress
for construction of severely damaged endodontically treated concentration regions. There were stress concentration
premolar teeth using Finite Element Stress Analysis Method. differences among the models at root dentine tissue.
In this study, four types of three-dimensional (3-D) FEM Although the distribution pattern was similar with composite
mathematical models simulating (1) a sound lower single resin restored tooth model, highest stress values were
rooted premolar tooth with supporting structures; (2) a root- observed at root dentine in the model restored with post-
filled lower premolar tooth without lingual cusp, restored and-core. Post structure accumulated more stress on its own
with resin composite; (3) a root-filled lower premolar tooth body. Stress distribution patterns of sound tooth and fiber-
without lingual cusp restored with resin composite in reinforced restoration models were found as similar. The
combination with a polyethylene fiber which is placed present study showed that the use of post material increased
circumferentially to help to create a composite lingual wall; the stress values at root dentine structure while reinforcing
(4) a root-filled lower premolar tooth without lingual cusp the restoration with a fiber decreases stress transmission.
restored with resin composite in combination with a glass Fiber-reinforced restoration provided stress distributions
fiber post, were modeled. A 300-N static vertical occlusal similar to sound tooth.
load was applied on the node at the center of occlusal surface
of the tooth to calculate stress distributions. Solidworks/ Keywords Endodontically treated teeth . Fiber
Cosmosworks structural analysis programs were used for reinforcement . Biomechanics . Finite element analysis .
FEM analysis. The analysis of the von Mises stress values Stress distribution
revealed that maximum stress concentrations were located at

Introduction
Ö. Eraslan : S. Belli
Faculty of Dentistry, Department of Endodontics, Compared to teeth with healthy pulps, root-filled teeth are
University of Selcuk,
considered more susceptible to fracture as they possess
Konya, Turkey
reduced dentinal elasticity, lower water content, deeper
O. Eraslan (*) cavities and substantial loss of dentin [1, 2]. The restoration
Faculty of Dentistry, Department of Prosthodontics, of the pulpless tooth is a critical final step of successful
University of Selcuk,
endodontic therapy. Loss of dentin including anatomic
42079 Kampus,
Konya, Turkey structures such as cusps, ridges, and arched roof of the pulp
e-mail: [email protected] chamber may result in fracture after the final restoration [3].
The prognosis of root-filled teeth depends not only on
G. Eskitaşcıoğlu
the success of the endodontic treatment but also on the
Faculty of Dentistry, Department of Prosthodontics,
University of Yüzüncü Yıl, amount of remaining dentine tissue, and the nature of final
Van, Turkey restoration [4]. The primary responsibility of the teeth in the
404 Clin Oral Invest (2011) 15:403–408

oral cavity is to serve as a mechanical device for the

mastication of food [5]. Thus, post core applications are
often utilized in the restoration of endodontically treated
teeth [6–8].
Also, the development of fiber-reinforced composite
(FRC) technology has provided a significant opportunity to
tailor materials response and to improve the behavior of
existing materials [3]. These new materials and techniques
enable the practitioner to approach old problems from a
different perspective and thereby achieve unique and
innovative solutions [3]. Tooth-colored fiber posts have been
introduced and have several advantages over conventional
metal posts [9]. Later, fiber reinforcement systems have been
introduced in the attempt to increase resin bonded composite
durability and damage tolerance [10]. The reinforcement of
composite restorations with fibrous assemblies can change
the effective fracture strength of the teeth and may be
effective in restoring the fractured cusps in endodontically
treated teeth through the creation of a strong bridge between
the tooth structure and restorative material [3, 10, 11].
Finite element method (FEM) has been shown to be a
useful tool when investigating complex systems [12–14].
Knowledge of stress distribution is important to the
understanding of fatigue development [15]. Overall stress
distribution within the tooth/restoration complex is deter-
mined by not only geometry and material arrangement, but
also material properties, fixation, and loading conditions
determine stress distributions [16]. FE analysis is utilized at
current study to evaluate the effects of different restoration
alternatives on stress distribution characteristics at endodon-
tically treated teeth without lingual cusp. The null hypothesis
tested was that different restoration techniques do not affect
the stress distribution within tooth–restoration complex. Fig. 1 a Three-dimensional finite element model and illustration of
materials involved. b 3-D mesh

Materials and methods lower premolar tooth without lingual cusp, restored with
resin composite without fiber reinforcement (2—composite
This study was conducted using a 3-D FE method and the resin); a root-filled lower premolar tooth without lingual
Solidworks 2007 9.0.3 structural analysis program (Solid- cusp restored with resin composite in combination with a
works Corporation, USA). A three-dimensional FE model polyethylene fiber (Ribbond, Ribbond, Seattle, WA) which
was fabricated to represent an endodontically treated single is placed circumferentially to help to create a composite
rooted mandibular premolar tooth (Fig. 1a). The model lingual wall following a protocol previously described by
contained a simulated periodontal ligament (PDL) and Deliperi et al. [10] (3—fiber reinforcement). In this method,
alveolar bone structure. The geometry used for the tooth the dentin surfaces are treated with an adhesive resin, light-
model was previously described by Wheeler [17]. On the cured, and a matrix band is placed circumferentially. An
basis of the root-form geometry of teeth, a simplified 0.25-mm approximately 1±0.5-mm-thick lingual wall is created
PDL, 0.25-mm lamina dura, and cortical shell (1.5 mm) were using composite resin and light-cured for 40 s. The inner
developed [18]. The remaining bone was modeled as axial cavity surfaces are then lined with a flowable resin
trabecular bone. and kept uncured. A piece of polyethylene fiber (according
Four different models were investigated to evaluate how to the dimensions of the tooth) is cut and wetted using an
the three different restorative options changed the stress unfilled adhesive resin. After removing the excess adhesive
distribution: a sound lower single rooted premolar tooth towards the fibers direction using a hand instrument, the
with supporting structures (1—sound tooth); a root-filled fiber is placed circumferentially inside the cavity walls and
Clin Oral Invest (2011) 15:403–408 405

embedded tightly into the flowable resin. After curing for color graphics to better visualize mechanical stresses in the
20 s, the rest of the cavity is filled using the same models. Bucco-lingual cross-sections of 3-D whole model
composite resin and cured for 40 s. view were presented for each restoration type. All stress
The last model of the study was a root-filled lower values were indicated in megapascals (MPa).
premolar tooth without lingual cusp restored with resin The analysis of the von Mises stress values revealed that
composite in combination with a prefabricated glass fiber maximum stress concentrations were located at loading
post (ParaPost Fiber White, Coltene/Whaledent, Hauptsitz, areas for all models. However, the maximum von Mises
Switzerland; 4—post retained; Fig. 2a–d). stress value was observed at post retained model with
Initially, cross-sections of structures included in mathe- 24.50 MPa (Fig. 3). It was followed by composite resin
matical model were sketched at front and right planes restoration model by 21.20 MPa (Fig. 4), 19.73 MPa by
separately for each unit at computer environment. Coor- sound tooth (Fig. 5), and 18.98 MPa by fiber reinforcement
dinates of the contouring points were then entered as border (Fig. 6). Also, root dentine tissue, lingual cortical bone, and
nodes of mathematical models. These nodes were joined to apical bone structures were other stress concentration
form each structures 3-D volume that together defined the regions. There were stress concentration differences among
final geometry of FE model. The geometric models were the models at root dentine tissue (4.77, 4.95, 4.29,
meshed with tetrahedral quadratic elements (Fig. 1b). Each 5.70 MPa at sound tooth, composite resin, fiber-reinforced
mathematical model included approximately 62,300 nodes composite resin and prefabricated post retained models,
and 47,000 solid elements. The bottom exterior nodes of the respectively). Highest root dentine stress value was ob-
alveolar bone in the FEM models were fixed in all directions served at post-and-core restored model with 5.70 MPa. The
as the boundary condition. A 300-N static vertical occlusal maximum von Mises stress values of structures at different
load was applied on the node at the center of occlusal surface models were summarized at Table 2. Distribution pattern
of the tooth to calculate stress distributions. was similar at sound tooth model, the model with composite
Materials used in study were assumed to be homoge- resin restoration and the model with fiber-reinforced compos-
nous, and isotropic. Elastic properties of materials (Young’s ite resin restoration. Stress was starting at force application
modulus (E) and Poisson’s ratio (μ)) were determined from area, and directing to lingual–apical aspect through lingual
the literature and given in Table 1 [5, 12, 19–22]. root dentine. Stress distribution pattern at prefabricated post
retained model was different from that the other models. It
was starting at same area, but directing more apically through
Results post materials body. Post structure accumulated more stress
on its own body (9.56 MPa). Stress distribution patterns of
Results were presented by considering Von Mises criteria sound tooth and fiber-reinforced restoration models were
[23–27]. Calculated numerical data were transformed into found as similar.

Fig. 2 Illustration of different

restorative techniques, a sound
tooth, b composite resin, c fiber
reinforcement, and d post
retained models
406 Clin Oral Invest (2011) 15:403–408

Table 1 Mechanical properties of investigated materials

Material Elastic modulus Poisson’s

(E; GPa) ratio (μ)

Enamel [19] 41 0.31

Dentin [20] 18.6 0.31
Periodontal Lig. [22] 0.0000689 0.45
Gutta-Percha [5] 0.14 0.45
Cortical bone [21] 13.7 0.30
Cancellous bone [21] 1.37 0.30
Composite [12] 12 0.30
Glass fiber post [12] 40 0.26
Fiber reinforcement [20] 23.6 0.32

Discussion

Fig. 4 Distribution of von Mises stresses (MPa) in bucco-lingual

This FEM utilized study showed that the von Mises stress
section of composite resin restored tooth model. Blue to red colors
distribution characteristics at restoration-tooth complex of represent stress values from lower to higher, respectively
sound tooth, direct composite resin restored, and fiber-
reinforced composite resin restored tooth models were similar. restoration may increase the bond strength by increasing
Thus the null hypothesis is accepted in part. On the other the force required to create and propagate a crack through the
hand, the distribution of stress in prefabricated glass fiber post interfacial composite/adhesive bonding resin complex [28].
restored tooth model was different. Therefore, we have to Fiber reinforcement materials are often used for this purpose
reject the hypothesis for post restored tooth model. These and they provided conservative and aesthetic restoration of
results were similar to a study of Eskitascioglu et al. [20] that endodontically treated teeth with extensive tooth structure
compared two different restorative techniques and stated that loss [11, 28, 29]. The higher modulus of elasticity and lower
stresses have been accumulated along the post core system flexural modulus of the polyethylene fiber are believed to
by use of a post of high elastic modulus. Current study adds have a modifying effect on the interfacial stresses developed
the comparison of sound tooth and fiber-reinforced restora- along the etched enamel/resin boundary [30]. Embedding a
tion of an endodontically treated tooth without usage of post Leno Wave Ultra High Modulus polyethylene fiber into the
to this findings. Modifications that would reduce or eliminate bed of flowable resin under an extensive composite
the interfacial stress concentration within the composite restoration increases both the fracture strength in root-filled

Fig. 3 Distribution of von Mises stresses (MPa) in bucco-lingual Fig. 5 Distribution of von Mises stresses (MPa) in bucco-lingual
section of post retained tooth model. Blue to red colors represent section of sound tooth model. Blue to red colors represent stress
stress values from lower to higher, respectively values from lower to higher, respectively
Clin Oral Invest (2011) 15:403–408 407

The FEM results are presented as stresses distributed in the

investigated structures. The stress conditions contain combi-
nations of tensile, compressive, and shear stress components,
which are often expressed in von Mises equivalent stresses
[24, 33]. This study also chose von Mises stresses for
presentation of the results. However, it should be emphasized
that the von Mises stress does not distinguish between
compressive or tensile stresses. Since compressive strength of
dentin is considerably higher than its tensile strength, stress
concentrations with predominant tensile stress components
will have a higher risk of failure. As with many in vitro studies,
it is difficult to extrapolate the results of this study directly to a
clinical situation. The model used in this study implied several
assumptions regarding the simulated structures. Materials used
in this study were assumed to be homogeneous and isotropic,
including the fiber-reinforced materials. The properties of the
materials modeled in this study, particularly the living tissues,
Fig. 6 Distribution of von Mises stresses (MPa) in bucco-lingual however, are different. This is one of the limitations of FEM
section of fiber-reinforced restoration model. Blue to red colors
represent stress values from lower to higher, respectively
studies. Clinical experiences indicate that most fractures in
restorations occur after several years. Generally, such failures
are unrelated to episodes of acute overload, but result from
molars with MOD cavities [28] and the microtensile bond fatigue failure. Consideration of only one-point load location
strength to dentin [29] but decreases microleakage in cavities and the absence of dynamic loading is another limitation of the
with a high c-factor [31]. study. Also, it is important to point out that the stress
Ko et al. [32] indicated that posts changed dentin stress distribution patterns may have been different depending on
substantially under compression in vertical loading. Confirm- the materials and properties assigned to each layer of the
ing their results, the posts affected the dentin stress distribution model and the model used in the experiments. Thus, the
in this study. It was reported that the stress concentrations at inherent limitations in this study should be considered. On
the cervical region are mostly because of the increased flexure the other hand, FEM studies give the clinician a prediction of
of the compromised tooth structure, while stress concentra- the success of a restoration in oral conditions in a biomechan-
tions at the apical region are generally due to the taper of the ical perspective. And, as stated before, FEM has been shown
root canal and characteristics of the post [4]. The regions of to be a useful tool when investigating complex systems [12–
high stress concentration are also associated with the apical 14]. Further studies that better simulate the oral environment
termination of the post [4]. Confirming these findings, stress which include fracture strength are recommended.
concentration areas were located at post system or cervical
dentin region via different restorative material (with different
elastic modulus) within root canal at current study. Conclusion
The size of occlusal force is selected as 300 N. However,
it is not necessary for this force to match the reality exactly Within the static one-point loading condition of this study,
because standardization between conditions has been the following conclusions were drawn:
ensured in the current study and the conditions have been
compared qualitatively with each other. Chen and Xu [13] 1. The use of a post material increases the von Mises
have emphasized that the value of FEM modeling is in stress values at root dentine structure while reinforcing
relative values calculated at distribution pattern. the composite restoration with a fiber without a post

Table 2 The maximum von Mises stress values of structures involved in different models (MPa)

Enamel Composite Fiber Post Dentin Pulp T. Gutta P. P. lig. Cortical B. Spongy B.

Sound tooth 19.73 – – – 4.77 0.45 – 0.42 1.63 0.14

Composite R. 5.66 21.20 – – 4.95 – 0.21 0.29 2.13 0.17
Fiber reinf. 6.34 18.98 8.49 – 4.29 – 0.24 0.33 2.39 0.14
Post retained 10.60 24.50 – 9.56 5.70 – 0.26 0.42 2.21 0.14
408 Clin Oral Invest (2011) 15:403–408

providing lower von Mises stress values at tooth 14. Eskitascioglu G, Usumez A, Sevimay M, Soykan E, Unsal E (2004)
The influence of occlusal loading location on stresses transferred to
structures
implant-supported prostheses and supporting bone: a three-
2. Restoration of a severely damaged endodontically dimensional finite element study. J Prosthet Dent 91:144–150
treated tooth by a fiber reinforcement restoration 15. Magne P, Perakis N (2002) Stress distribution of inlay-anchored
technique may be recommended instead of restoration adhesive fixed partial dentures: a finite element analysis of the
influence of restorative materials and abutment preparation
with a post system in order to acquire more similar
design. J Prosthet Dent 87:516–527
stress distribution to the sound tooth. 16. Magne P, Versluis A, Douglas WH (1999) Rationalization of incisor
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17. Wheeler RC (2003) Wheeler’s dental anatomy, physiology, and
Conflict of interest statement This study is funded by Research
occlusion, 8th edn. Saunders, St. Louis, p 154
Projects Council of University of Selcuk. The authors declare that they
18. Tada S, Stegaroiu R, Kitamurs E, Miyakawa O, Kusakari H
have no financial, professional or other personal interest that could
(2003) Influence of implant design and bone quality on stress/
influence the position presented in the paper.
strain distribution in bone around implants: a 3-dimensional finite
element analysis. Int J Oral Maxillofac Implants 18:357–368
19. Belli S, Eskitaşcioglu G, Eraslan O, Senawongse P, Tagami J
(2005) Effect of hybrid layer on stress distribution in a premolar
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