Australian Dental Journal

The official journal of the Australian Dental Association

Australian Dental Journal 2015; 60: 309–316

doi: 10.1111/adj.12233

Loading and composite restoration assessment of various

non-carious cervical lesions morphologies – 3D finite
element analysis
PV Soares,* AC Machado,* LF Zeola,* PG Souza,* AM Galv~
ao,* TC Montes,*
AG Pereira,* BR Reis,* TA Coleman,† JO Grippo‡
*NCCL Research Group, Operative Dentistry and Dental Materials Department, School of Dentistry, Federal University of Uberl^andia,
Campus Umuarama, Uberl^andia, Minas Gerais, Brazil.
†Shaftsbury Medical Building, Shaftsbury, Vermont, USA.
‡Department of Biomedical Engineering, Western New England University, Springfield, Massachusetts, USA.

ABSTRACT
Background: The present study analysed the effects of different occlusal loading on premolars displaying various
non-carious cervical lesions morphologies, restored (or not) with composites, by 3D finite element analysis.
Methods: A three-dimensional digital model of a maxillary premolar was generated using CAD software. Three non-
carious cervical lesions morphological types were simulated: wedged-shaped, saucer and mixed. All virtual models under-
went three loading types (100 N): vertical, buccal and palatal loading. The simulated non-carious cervical lesions mor-
phologies were analysed with and without restorations to consider specific regions, such as the occlusal and gingival
walls as well as the depth of the lesions. Data summarizing the stress distribution were obtained in MPa using Maximum
Principal Stress.
Results: Palatal loads were responsible for providing the highest values of accumulated tensile stress on the buccal wall;
27.66 MPa and 25.76 MPa for mixed and wedged-shaped morphologies, respectively. The highest tensile values found
on non-carious cervical lesions morphologies restored with composite resin were 5.9 MPa in the mixed morphology, sim-
ilar to those found on sound models despite their morphologies and occlusal loading.
Conclusions: The various non-carious cervical lesions morphologies had little effect on stress distribution patterns,
whereas the loading type and presence of composite restorations influenced the biomechanical behaviour of the maxillary
premolars.
Keywords: Biomechanical behaviour, composite restorations, finite element analysis, non-carious cervical lesions, premolar teeth.
Abbreviations and acronyms: BL = buccal load; DL = depth of lesion; FEA = finite element analysis; GW = gingival wall; MPS = max-
imum principal stress; MS = mixed-shaped; MSR = mixed-shape restored; NCCLs = non-carious cervical lesions; OW = occlusal wall;
PL = palatal load; RM = restored model; SM = sound model; SS = saucer-shaped; SSR = saucer-shaped restored; ST = sound tooth; VL
= vertical load; WS = wedge-shaped; WSR = wedge-shaped restored.
(Accepted for publication 2 October 2014.)

more, the enamel of the cervical region which is thin

INTRODUCTION
Non-carious cervical lesions (NCCLs) are pathological
conditions characterized by the loss of tooth structure
at the cemento-enamel junction (CEJ) that are
unrelated to dental caries.1–3 The occurrence of these
lesions is an increasingly common finding in dental
clinical practice,4–6 and are most prevalent in maxillary
premolars.6,7 The three mechanisms involved in these
lesions are stress (manifested as abfraction), friction
(from wear) and biocorrosion (from chemical, bio-
chemical and electrochemical degradation).8 Further-
© 2015 Australian Dental Association
makes this area susceptible to the formation of lesions.9
The multifactorial aetiology results in various geo-
metric forms and are classified as: wedge-shaped
(WS), saucer-shaped (SS) and mixed-shaped (MS).10 A
wedge-shaped lesion is characterized by a sharp inter-
nal line angle, while a saucer-shaped lesion has a
rounded internal line angle. A mixed-shape lesion has
flat gingival and semi-circular occlusal walls with
smooth lines and is semi-circular in shape.10
In addition, different types of occlusal loads provide
changes to stress distribution patterns in the cervical
309
PV Soares et al.

enamel.6,12 Occlusal interferences can lead to a weak- MATERIALS AND METHODS

ening of the continuity between the hard tooth struc-
Three-dimensional linear elastic analysis was per-
tures and cause increased stress in the cervical
formed using anatomically based geometric represen-
region,13 resulting in fatigue and possible rupture of
tations for dentine, pulp, enamel, periodontal
rigid structures such as enamel.6,12
ligament, cortical bone and trabecular bone. Seven
The multifactorial characteristics of NCCLs must
models were generated, simulating a sound tooth
be considered while developing a restorative proto-
model (SM), three NCCL morphologies (wedge shape,
col for these lesions; however, their treatment
saucer shape and mixed shape)10 and the restored
remains controversial. The placement of retention
models of all lesions types (RM) (Fig. 1).
points at the lesion internal angles14 and the resto-
An extracted sound maxillary premolar (CEP/UFU:
ration of NCCLs without retention points are proce-
#065/11) was selected to base the 3D models of FEA.
dures shown by some clinical studies.15,16 On the
The tooth was placed in a contact scanner (MDX-40,
other hand, some authors believe that rounding the
Roland Co, Osaka, Japan) for the external morphol-
depth of the angular lesion17,18 is justified by
ogy acquisition and generation of a digital file (STL –
improving the biomechanical behaviour of the
stereolithography). The enamel and dentine contours
restorative material, thus promoting their clinical
were then scanned and performed.24
longevity.18–20
STL files were exported to CAD software (Computer
Methods that use simulated dental structures and
Assisted Desing; Rhino3D 4.0, Rhinoceros, USA), for
their properties are useful to analyse the dental
the generation of external and internal contours of
behaviour associated with structural loss, occlusal
enamel, dentine, pulp, periodontal ligament, cortical
conditions and the effects of restorative materials,
and trabecular bone (Fig. 2a). These contours were
taking into account their properties.18,21 The finite
made by point and line association using polyline mod-
element analysis (FEA) method provides the analysis
ule of CAD software. The volumes corresponding to
of stress observed in various clinical situations. This
each structure were created (Fig. 2b) and the NCCLs
analysis allows the evaluation of different factors in
morphologies with their respective restorations were
the same model by avoiding change to the original
obtained through Booleans operations (Fig. 1). The
digital image.18,22,23 The aim of this study was to
models were exported to the biomechanical analysis
evaluate the effect of stress in NCCL morphology in
software ANSYS 12.0 (Ansys Workbench 12.0.1, PA,
a premolar, submitted to three different occlusal
EUA), using the STEP format (Fig. 2c). In this soft-
loadings, as well as their restored status in the bio-
ware, the following steps were performed: pre-process
mechanical behaviour of premolars using 3D finite
(volumes definition, mechanical properties insertion,
element analysis.
connections type, mesh creation of each structure and

(b) (c) (d)

(a)

(e) (f) (g)

Fig. 1 NCCLs morphologies in simulated models. (a) sound tooth (ST); (b) wedge-shaped (WS); (c) saucer-shaped (SS); (d) mixed-shaped (MS); (e) WS
restored (WSR); (f) SS restored (SSR); (g) MS restored (MSR).

310 © 2015 Australian Dental Association

 Biomechanical behaviour of various NCCLs geometry

(a) (b) (c) (d)

(e) (f) (g) (h)

Fig. 2 Finite element models generation. (a) CAD software model outlines; (b) volumes created on CAD software; (c) volumes exported to ANSYS work
bench 12.0; (d) mesh; (e) vertical loading (VL); (f) buccal loading (BL); (g) palatal loading (PL); (h) displacement restriction (on the blue area – the
displacing was null).

boundary conditions), process (data calculation) and Table 1. Mechanical properties used to perform
post-process (results analysis by stress distribution cri- orthotropic and isotropic structures.
teria). Volumes corresponding to each structure were
meshed with controlled and connected elements, after Structures Orthotropic structures30
a conversion mesh test. This process involved division Elastic modulus (MPa)
of the system to be studied into a set of small discrete
Longitudinal Transversal Z
elements defined by nodes. The number of elements
generated varied depending on the different volumes so Enamel 73720 63270 63270
Dentine 17070 5610 5610
that the final model accurately represented the original Shear coefficient (MPa)
geometry. Solid quadratic tetrahedral elements with 10 Enamel 20890 24070 20890
nodes were used (Fig. 2d). The values for mechanical Dentine 1700 6000 1700
Poisson ratio (v)
properties were obtained by literature review. Enamel 0.23 0.45 0.23
For the initial analysis, all the dental structures and Dentine 0.30 0.33 0.30
restorative material in the models were considered
homogeneous and displaying linear elastic properties. Structures Isotropic structures
Enamel and dentine were considered orthotropic and Elastic Poisson
the other structures isotropic (Table 1). The hybrid modulus (MPa) ratio (v)
composite resin restorations were bonded by mesh Pulp38 2.07 0.45
connection with dentine and enamel. Periodontal ligament39 68.9 0.45
Establishing boundary conditions consisted of devel- Cortical bone40 13700 0.30
Medular bone40 1370 0.30
oping a displacement/restriction model with load appli- Hybrid composite resin41 22000 0.27
cation. The models were submitted to three types of
loads (100 N) applied on specific surfaces previously
defined in software CAD. A vertical load (VL) was dis- (Fig. 2h). Stress distribution analyses were recorded
tributed equally on both cusps, thus simulating homo- using the Maximum Principal Stress criteria, measured
geneous contact distribution (Fig. 2e). Both a buccal in MPa. For analysis of specific regions, three sites
load (BL) (Fig. 2f) and palatal load (PL) (Fig. 2g) simu- were selected in the lesion: occlusal wall (OW); depth
lated occlusal interference on the buccal and palatal of lesion (DL) and gingival wall (GW) (Fig. 3).
slopes of the premolars.12 The BL was applied in the
buccal cusp at 45 degrees to the long axis and the PL
RESULTS
was equally applied in the palatal cusp. Models were
constrained on the lateral and base of cortical and tra- The stress distribution between all the models under
becular bone to avoid the model displacement different loading conditions is shown in Figs. 4–7.
© 2015 Australian Dental Association 311
PV Soares et al.

(b) (c) (d)

(a)

(e) (f) (g)

Fig. 3 Specific regions analysed for stress values calculation (MPa) of NCCL morphologies. OW (occlusal wall); DL (depth of lesion); and GW (gingival
wall), for: (a) sound model (SM); (b) wedge-shaped (WS); (c) saucer-shaped (SS); (d) mixed-shaped (MS); (e) wedge-shaped restored (WSR);
(f) saucer-shaped restored (SSR); (g) mixed-shaped restored (MSR).

15

12,917

10,833 (b) (c)

8,75

6,6667

4,5833

2,5

0,41667 (e)
(d)
–1,6667

–3,75

–5,8333

–7,9167

–10 (a) (f) (g)

Fig. 4 Maximum Principal Stress (MPS), distribution for models that received vertical loading (VL): (a) sound model (SM); (b) wedge-shaped (WS);
(c) wedge-shaped restored (WSR); (d) saucer-shaped (SS); (e) saucer-shaped restored (SSR); (f) mixed-shape (MS); (g) mixed-shape restored (MSR). In
perspective view, models with restored lesions; observe that the composite resin was placed on transparency to enable NCCLs walls visualization.

Positive and negative values indicate that the corre-
sponding regions are subjected to tensile or compres-
sive stresses, respectively.
The sound model (SM) presented better stress distri-
bution for all loading types compared with the non-
restored models. For vertical loading, tensile stress
accumulated in the buccal cervical region demon-
strated the highest values on the OW, approximating
1.5 MPa (Fig. 7). On the SM/BL model, stress con-
centration in the buccal cervical region was greater
compared with VL (Fig. 4). In addition, BL promotes
stress concentration on the palatal surface. Finally,
the PL produced the highest tensile stress concentra-
tion in the buccal cervical region when compared with
312
the others. For SM/BL and SM/PL, DL (depth of
lesion) all demonstrated the greatest values of tension,
3.95 and 16.95 MPa, respectively (Fig. 7).
The vertical loading produced lower levels of stress
concentration than the other types, independently of
lesion morphology (Fig. 4). Higher values of tensile
stress were found on the OW, with the highest for
MS lesions, 1.65 MPa (Fig. 7). For compressive stress,
the greatest concentration was shown at DL, with the
highest value for MS, –3.39 MPa.
Models loaded in the buccal direction presented
higher tensile stress concentration on the superior wall
of the lesion and affected the dentine on the opposite
face (palatal) in the cervical region (Fig. 5). The BL
© 2015 Australian Dental Association
 Biomechanical behaviour of various NCCLs geometry

15

12,917
(b) (c)
10,833
8,75

6,6667

4,5833

2,5

0,41667 (d) (e)

–1,6667

–3,75

–5,8333

–7,9167

–10 (a) (f) (g)

Fig. 5 Maximum Principal Stress (MPa) distribution for models that received buccal loading (BL): (a) sound model (SM); (b) wedge-shaped (WS);
(c) WS restored (WSR); (d) saucer-shaped (SS); (e) SS restored (SSR); (f) mixed-shape (MS); (g) MS restored (MSR). In perspective view, models with
restored lesions; observe that the composite resin was placed on transparency to enable NCCLs walls visualization.

15

12,917

10,833 (b) (c)

8,75

6,6667

4,5833

2,5

0,41667 (d) (e)

–1,6667

–3,75

–5,8333

–7,9167

–10 (g)
(a) (f)

Fig. 6 Maximum Principal Stress (MPa) distribution for models that received palatal loading (PL): (a) sound model (SM); (b) wedge-shaped (WS);
(c) WS restored (WSR); (d) saucer-shaped (SS); (e) SS restored (SSR); (f) mixed-shape (MS); (g) MS restored (MSR). In perspective view, models with
restored lesions; observe that the composite resin was placed on transparency to enable NCCLs walls visualization.

promoted higher values of tensile stress on the OW of
SS and MS models, with values of 5.99 and
6.87 MPa, respectively (Fig. 7). Compressive stress
was shown in the DL, –15.03 MPa, for WS lesion.
Palatal loads presented the highest tensile stress val-
ues when compared to other types of loads, despite
the lesion geometry. Palatal loads were associated
with the tensile stress concentration in the cervical
© 2015 Australian Dental Association
region of the buccal surface. The dentine of the oppo-
site palatal surface was also affected (Fig. 6). Highest
values of tensile stress were found on the DL for both
the MS and WS models, with values of 27.66 and
25.76, respectively (Fig. 7).
Despite the lesion morphology or loading type,
when the NCCLs were restored with composite resins,
improved stress distribution was identified in the mod-
313
PV Soares et al.
MPa
29
GW
24 DL
OW
19
14
9 WS
4
–1
–6
–11
–16
OW DL GW
VERTICAL LOAD
Fig. 7 Maximum Principal Stress values (MPa) on NCCLs at specific regions on models: OW (occlusal wall); DL (depth of lesion); and GW (gingival
els. Restored NCCLs demonstrated stress distribution
patterns similar to those found on a healthy tooth.
The restored models present lower stress levels in the
cervical regions, with the highest stress values of
1.2 MPa, 4.9 MPa and 5.4 MPa for VL, BL and PL,
respectively (Figs. 4–7).
DISCUSSION
Regarding the aspects analysed in this present study
of NCCLs, loading types and their restoration with
composite resins were considered factors that influ-
enced the stress distribution patterns in premolars.
The presence of NCCLs promoted changes on stress
distribution patterns due to loss of dental structure.25
The morphology of the NCCLs on maxillary premo-
lars had minimal effect on their biomechanical behav-
iour. However, due to the complex interaction of
aetiologic factors,8 the knowledge of different charac-
teristics associated with each morphology can contrib-
ute to the prevention and treatment of the NCCL.9
The results of this study demonstrated that loading
type and presence of composite resin restorations are
major factors in modifying stress distribution patterns
when compared to unrestored NCCLs morphologies.
The PL and BL produced higher concentrations of
stress in the cervical region on the buccal and palatal
surfaces compared to the VL. This finding indicates
that different positions of occlusal contacts promote
changes in tensile stress magnitude in the cervical
region which could initiate failure.12 The presence of a
traumatic dental occlusion (misdirected or premature
contact forces) are considered important factors in the
occurrence of NCCLs.26 For this reason, the removal
of interferences and occlusal equilibration must be per-
formed in order to allow homogeneous occlusion con-
tact,27 which was simulated to the VL.
314
SW
SS
MS
WSR
SSR
MSR
OW DL GW OW DL GW
BUCCAL LOAD PALATINE LOAD
wall).
The SS, WS and MS NCCLs morphologies, subjected
to PL, demonstrated tensile stress concentration at the
depth of the NCCLs. The authors agree that the load
type directly influences the compressive and tensile
stress patterns in the cervical region. The association of
tensile stress on deep NCCLs with a composition of
perpendicular dentine tubules could result in transver-
sal progression of the lesion. On the other hand, these
same morphologies subjected to BL tend to present
compressive stress in the centre of the lesion, and tensile
stress in the enamel on the occlusal wall, which could
result in longitudinal progression. Therefore, both types
of loading can result in the progression of NCCLs and
premature failure of their restorative treatment will
occur unless occlusal adjustments were performed.
The progression of NCCLs is correlated with the
tensile stress concentration on OW or DL. In the cer-
vical region, the enamel prisms and dentine tubules
are located transversely to the tooth long axis of the
tooth when compared with the occlusal third.28 This
orientation results in less rigid regions and are more
susceptible to fracture.29,30 Besides the unfavourable
direction, the dentinal tubules in the cervical region
are presented in higher density and volume,31 which
also contributes to decreased resistance in this area.32
In this study, the enamel and dentine were considered
orthotropic, with the same properties for transversal
and Z-axis but different for the longitudinal axis.30
The orthotropic properties of tooth substance produce
higher fragility to the cervical third due to the lower
elastic modulus of enamel and dentine in this area.
Thus, this suggests a greater possibility of the progres-
sion of NCCLs when submitted to higher tensile stress.
In non-restored models, despite the load applied
and morphologies, higher stress accumulation was
produced on the NCCLs walls. These increased stres-
ses would be a factor that influence the growth of
© 2015 Australian Dental Association

these lesions. However, misdirected applied forces in
models with restored NCCLs promote dissipation of
the stress. In these cases, the stress concentration
increased in the buccal cervical region, especially in
the dentine and part of the composite resin restora-
tion. In all of the morphologies and loadings, lesions
restored with composite resin resulted in lower stress
concentration, resembling a sound tooth due to the
mechanical properties of composite resin.
The treatment of NCCLs does not consist of simply
restoring the loss of dental structure but to identify
and manage all of their aetiologic factors. The com-
posite adhesive restoration of NCCLs is considered an
effective replacement for the lost tissue in that it can
promote improvement in aesthetics and aid in the
reduction of hypersensitivity.33–35 In addition, com-
posite resins have an elastic modulus similar to den-
tine, which may be considered sufficient to offset the
stress generated by occlusal forces.36 Kim et al. con-
sidered rounding the internal angles of NCCLs,
removing sclerotic dentine, and even creating reten-
tion with diamond burs to improve the longevity of
composite restorations.16
The wear of sound tooth structure may result in
increased pulpal irritation and mechanical pulp expo-
sure, outweighing the benefits associated with this
type of management. In addition, several studies
showed that the depth of the NCCLs might promote
higher stress concentration, thus inducing the progres-
sion of the lesions.18 This approach is against the phi-
losophy of minimal invasive dentistry.
In addition to eliminating stresses from occlusal
loading, restorative treatment of the NCCLs must be
taken into account. Furthermore, the properties and
quantity of saliva on the surfaces affected by biocorro-
sion, frictional toothbrush/dentifrice abrasion and the
presence of sclerotic dentine, usually at the base of the
lesions must also be considered.8,37 Other factors that
can affect restoration longevity include marginal stain-
ing (possibly due to polymerization shrinkage of the
composite), the insertion of large volumes of uncured
resin or difficulty in preparing and finishing interproxi-
mal areas.20 Based on these clinical findings, the use of
adhesive restorative materials are very effective and the
non-invasive treatment of choice.18
Although the 3D models and orthotropic character-
istics were utilized, characteristics of the composite
resin properties, heterogeneous structures and non-
linear analyses were also made in order to elucidate
the results shown. For validation of the 3D-FEA data,
in vivo and in vitro studies are still needed. How-
ever, the biomechanical behaviour presented by the
3D models tested demonstrated the importance of
restoring tooth structure loss and the need to remove
occlusal interferences in the prevention and treatment
of NCCLs.
© 2015 Australian Dental Association
Biomechanical behaviour of various NCCLs geometry
Within the limits of this study, the results indicate
that the main factors affecting biomechanical behav-
iour of premolars were loading types and the impor-
tance of restoring NCCLs with composite resins.
Various NCCLs morphologies demonstrated minimal
effects on stress distribution patterns. The load
applied on the palatal cusps showed more damage to
the dental structure when compared to loads on the
buccal or both cusps. The composite restoration of
NCCLs despite their morphology resulted in similar
stress distribution patterns as did sound teeth. Based
on these findings, rounding the internal angles of the
NCCL is not recommended.
ACKNOWLEDGEMENTS
This study was supported by the National Council for
the Improvement of Higher Education (CAPES) and
the Foundation of Ampere to Research of Minas Ge-
rais State – Brazil (FAPEMIG) (Grant no. APQ-
02504-12). The authors thank the Integrated Research
Laboratory (CPbio-FOUFU) and Nucleus of Exten-
sion, Research and Teaching of NCCL and Dentin
Hypersensitivity.
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Address for correspondence:
Professor Paulo Vinicius Soares, DDS, MS, PhD
Coordinator of NCCL Research Group
Operative Dentistry and Dental Materials Department
School of Dentistry
Federal University of Uberlandia
Av. Para, 1720 – Campus Umuarama
Bloco 4L, Sala 4L42
Uberl^andia – Minas Gerais 38400-902
Brazil
Email: paulovsoares@yahoo.com.br
© 2015 Australian Dental Association