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Clinical presentations of stress distribution in teeth and the significance in operative dentistry

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C O N T I N U I N G E D U C A T I O N 2 4

CLINICAL PRESENTATIONS OF
STRESS DISTRIBUTION IN TEETH AND
THE SIGNIFICANCE IN OPERATIVE DENTISTRY

MILICICH
Graeme Milicich, BDS*
J. Tim Rainey, DDS†

12
Stress distribution in human tooth structure can be visu- mechanical stress distribution system.4-7 This understand- 7
alized through the use of Moiré fringes, which has ing has resulted in the development of a discipline termed

improved the clinical understanding of recently identified
anatomical structures in molar occlusal surfaces. This arti-
cle discusses the concept of a “peripheral rim of enamel”
and describes the manifestation of compressive and ten-
sile fractures within the peripheral rim of enamel and
dentin. It also emphasizes the benefits of microdentistry
techniques and minimally invasive preparation designs
in the long-term preservation of the natural tooth structure.
Key Words: Moiré fringes, stress, microdentistry, caries,
peripheral, enamel
SEPTEMBER
microdentistry. This philosophy urges the use of modern
methods of caries detection for early accurate minimal
intervention in the caries process to preserve internal
mechanical structures within the tooth that are vital to its
long-term mechanical viability.
Moiré Fringes
To understand the various presentations of tooth fracture
caused by the disruption of the natural stress distribution
mechanism within the tooth, the significance of the Moiré
fringes must be considered. To date, stress studies that
utilize polarized light have generally been conducted

P ublication of one recent article that demonstrates stress

distribution within tooth structure has improved clini-
cians’ understanding of subtle compression and stress
with plastics to show stresses that occur when loads are
applied. This technique is not effective in natural denti-
tion due to their inability to transmit light, so these studies
fracture presentations in teeth.1 Until the publication of
this benchmark article, numerous fracture presentations
observed clinically have been difficult to explain. Strain
distribution within the tooth is related to its structure.
Enamel acts as a stress distributor, transferring the load
vertically to the root, and horizontally via the dentino-
enamel junction (DEJ) to the dentin of the crown. A thick
zone (~200 µm) in the dentin at the DEJ undergoes greater
stress than the central coronal dentin.
Recently discovered structures within the occlusal
surface of molars2,3 indicate that conventional cavity
designs are disharmonious with the tooth’s natural

*Private practice, Hamilton, New Zealand.

†Adjunct Associate Professor, University of Texas Health Science
Center School of Dentistry, San Antonio, Texas.
Graeme Milicich, BDS
P.O. Box 378
Hamilton, New Zealand
Figure 1. The direction of the Moiré fringes indicates
Tel: (011) 64-7-858-0750 the direction of the stress. Thicker zones in the fringes
Fax: (011) 64-7-849-5632 represent increased stress and tighter fringes indicate
E-mail: milicich@wave.co.nz greater stress.

Pract Periodont Aesthet Dent 2000;12(7):695-700 695

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Practical Periodontics & AESTHETIC DENTISTRY

have most often focused on stress distribution associ-

ated with intracoronal pins and posts.
The Moiré fringes study allows the visualization of
stress distribution within natural tooth structure (Figure 1).
Since it has been postulated that the source of abfrac-
tion lesions is stress concentration at the cervical DE J,
the relationship demonstrated in the Moiré fringes study
confirms this hypothesis. The Moiré fringes show the
peripheral rim of enamel transferring occlusal load directly
to the root of the tooth. Compression load in the enamel
Figure 3. Occlusal abfraction guttering occurs
transfers via the DE J into horizontal load in the dentin of between the peripheral rim and the cavity mar-
the crown. In this transfer, a stress concentration occurs gin due to stress concentration. The compressive
at the DE J as it converts the vertical load in the enamel facets are marked in blue.

into the horizontal load in the dentin.

The DE J is a zone approximately 200 µm thick where
collagen density and mineral content are each approxi-
mately 50%, compared to a 30% collagen/70% min-
eral ratio in the body of the dentin. Since the DEJ is more
elastic due to its greater collagen content, it allows micro-
compression to occur between the enamel and the dentin,
which enables the enamel rim — with its high elastic mod-
ulus — to transfer a vertical load directly to the root struc- Subocclusal trans-
verse oblique ridge
ture. Once this initial load transfer occurs, the sheer load
created within the DE J transfers into a horizontal load in Figure 4. A subocclusal transverse oblique ridge
that extends from the distolingual to mesiobuccal
the body of the crown dentin, with the stress decreasing
aspects of mandibular molars. A supporting web
toward the center of the tooth. This increase in load in of enamel is connected to this structure.
the DE J and decrease of stress in the central body of the
dentin is evidenced in the Moiré fringes study.

Peripheral Rim Theory

Once this load distribution system is understood, the func-
tion of the enamel rim assumes greater significance. From
the perspective of stress distribution, the occlusal enamel

Suspensory web
of enamel

Figure 5. A suspensory web of enamel in the

area formerly referred to as the mesial fossae of
maxillary molars. This web is also found
mesially in the adjacent region formerly referred
to as the marginal ridge fossae.

is a separate entity from the peripheral rim enamel.

Figure 2. Delamination of the peripheral rim and occlusal
enamel is apparent as a white line fracture. Note the
occlusal abfraction and recurrent caries associated with
stress concentration.
In simplified terms, the function of the peripheral rim can
be visualized through a comparison to an inverted
teacup. Several years ago, an automobile company suc-
cessfully balanced a 2-ton car on four inverted china
teacups. When loaded correctly, the fragile teacups were
able to support significant loads and successfully trans-
fer the load to the floor. In the same manner, the enamel

696 Vol. 12, No. 7

200007PPA Milicich 8/22/02 10:16 AM Page 697
Figure 6. Caries is established through an enamel
fracture. Minimal decalcification is evident and
inverted. Red line indicates areas of normal inter-
proximal contact point caries decalcification.
Figure 7. Occlusal view of a peripheral rim
enamel fracture and associated occlusal effect
caries in a mandibular molar.
A B
Figure 8A. Peripheral rim fractures are a result
of compressive loads on the buccal cusps.
8B. The development of caries occurs due to the
peripheral rim fracture.
transfers load to the root. The theory that the peripheral
rim of enamel is able to support significant vertical loads
becomes evident in a clinical setting. Clinicians can
observe how the teeth fail in function when their stress
distribution system is disrupted by cavity designs.
A simple tin can is also valuable in this discussion.
Untouched, it can support significant vertical and lateral
compressive loads. Even with the lid removed, it can
Milicich
still support reasonable vertical compressive loads. When
lateral compressive loads are applied to the rim, how-
ever, it distorts easily. Squeezed between two forces on
opposite sides of the rim, an opened can becomes ovate
with the apex of the deformation occurring 90 degrees
around the rim from the compression forces. This is a sim-
plified image, but the effects can be observed clinically
in teeth that are failing due to the presence of restora-
tions. An occlusal cavity in a posterior tooth can cause it
to flex under compressive loads on external cusp planes
to an extent that the distortion in the tooth results in struc-
tural failure of the peripheral rim.8-10
Considering tooth structure in this manner, the mar-
ginal ridge becomes a part of the peripheral rim rather
than a separate morphological identity. Its significance
to the overall stress distribution system increases when
cavity designs are considered for the treatment of pri-
mary interproximal caries. The peripheral rim can be con-
sidered a tension ring. When a minimal MOD-type cavity
is prepared in a sound tooth, the cusps spring apart
approximately 10 µm, which indicates that the tooth struc-
ture is under tension.11 When the marginal ridge is simply
a part of the peripheral rim of enamel, its removal to
treat Class II interproximal caries has long-term signifi-
cance for the structural integrity of the tooth.
Clinical Evidence and Significance
If the peripheral rim of enamel functions almost indepen-
dently of the occlusal enamel and is able to absorb com-
pressive loads without fracturing, a transfer of this load via
the DE J to a horizontal load in the dentin should occur. If
this redistribution of the compressive load cannot be distrib-
uted through the body of the dentin due to the blocking
Figure 9. Radiograph of conventional contact point caries.
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Practical Periodontics & AESTHETIC DENTISTRY

effect of a cavity, then one would expect to find clinical

evidence of stress concentration between the peripheral
rim enamel and the cavity wall. Differences in elastic mod-
ulus between the enamel and the underlying dentin could
cause vertical delamination and fracturing along the
DE J.12,13 The failure of the stresses to be distributed through
the dentin, due to the blocking effect of the cavity, should
cause stress concentration between the peripheral rim and
the cavity margin. This would have the same effect as
stress concentration at the cervical enamel margin has in
Figure 11. Occlusal view of posterior tooth with
causing abfraction lesions. The result would be an occlusal peripheral rim fracture.
abfraction lesion. Once the theory is understood, the clin-
ical evidence becomes clear (Figures 2 and 3).
The preparation of cavities in tooth structure disrupts
the natural load distribution and creates zones of stress
concentration. The clinical presentation of this stress con-
centration depends primarily on two factors: the type of
cavity prepared, and whether the applied load is com-
pressive or tensile.13-15

Conventional Extension-For-Prevention Type

Occlusal Cavity
Dentin has a moderate elastic modulus, and enamel
Figure 12. Caries associated with peripheral rim
has a high elastic modulus. Between them lies the DE J,
fracture and the causative compression facets.
which, due to its high collagen content, has a low elas- Note the inverted enamel decalcification.
tic modulus in comparison to both dentin and enamel.
While dentin can deform elastically under load (due to
its moderate elastic modulus), enamel will fracture rather
than deform.16 Once the occlusal surface of a mandibular
molar has been removed for amalgam placement, the
tooth begins to behave like the tin can with the top
removed. First, the conventional extension-for-prevention

Figure 13. Radiograph demonstrates occlusal

effect caries depicted in figures 11 and 12.

cavity design required by amalgam removes an impor-

Figure 10. Radiograph of occlusal effect caries associated
with the conventional extension of the cavity in figures 8
and 9.
tant occlusal cross-bracing structure — the subocclusal
oblique transverse ridge in mandibular molars (Figure 4),
and the maxillary molar mesial subocclusal enamel web
(Figure 5). Second, amalgam provides little mechanical
support when the tooth is under load.5-7,10,11
One of the most common loads on mandibular molars
is a compressive load on the outer face of the buccal
cusps. As the unsupported dentin deforms under load, a

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Figure 14. A tension facet and peripheral rim
fracture are evident at the distal contact point.
Figure 15. Radiograph of caries development in
the peripheral rim fracture. Note the minimal
depth of the extension-for-prevention amalgam
compared to areas where decay was removed.
Figure 16. Occlusal effect fracture caries and
the dentin fracture associated with the tension
cusp. The most common fracture presentation
observed clinically is tension cusp fractures.
compressive distortion in the cusps is created.8,13 The tooth
becomes ovate, which places the peripheral rim enamel
in the contact point areas under tension. Eventually, ver-
tical fracturing of the enamel may occur in the marginal
ridge zone of the peripheral rim. These enamel frac-
tures are not to be confused with naturally occurring stress
relief lamellae in virgin teeth. Continual flexure in this
fracture can eventually result in caries propagation through
Milicich
the enamel crack (Figure 6). This caries presentation can
best be described as “occlusal effect caries.” The inter-
proximal caries is developing only because an occlusal
cavity has been prepared in the tooth.
The proposition that preparation of an occlusal cav-
ity in a tooth creates the potential for interproximal caries
has serious significance for the development of minimal
intervention microdentistry. Radiographically, this type of
caries presentation is difficult to diagnose.17 Apart from
a faint and diffuse graying of the contact point enamel,
little enamel decalcification can be detected. Due to
the lack of a conventional interproximal enamel caries
marker, the dentin caries is often overlooked unless frac-
ture has been noted at clinical examination, and the radi-
ographs are viewed with that in mind (Figures 7 through
13). While these examples are exemplified in mandibu-
lar molars, this effect can occur in any tooth that has a
compressive force applied to the cusp where a moder-
ate-sized restoration has been placed.
Tension Fracturing of Cusps
Vertical fracturing in the contact point area of the periph-
eral rim and associated caries can occur when cusps
are placed under tension loads. Although the interprox-
imal caries presentation remains the same as with com-
pression fractures, there is generally an associated dentin
fracture under the tension facet cusp. This is due to the
inability of dentin to absorb tensile forces once it has
been separated from the surrounding tooth structure by
a cavity preparation that removed the occlusal enamel
cross-bracing structures.9 -11 Tooth structure is designed
to absorb compressive and tension loads as a total
A B
Figure 17A. Dentin fractures occur beneath the tension
facet cusp. 17B. Cavity preparations that remove the
occlusal enamel cross-bracing structures often result in
tension cusp fractures.
PPAD 699
200007PPA Milicich 8/22/02 10:17 AM Page 700
Practical Periodontics & AESTHETIC DENTISTRY
biomechanical entity and does not adapt well when
this force distribution system is disrupted to any extent
by conventional cavity designs (Figures 14 through 17).
Conclusions
If the preparation of an extension-for-prevention occlusal
cavity can cause long-term failure of the tooth, then cavity
designs must be addressed to accommodate the natural
stress distribution mechanisms within the tooth. It could
be necessary to conserve the occlusal cross-bracing struc-
tures of the subocclusal oblique transverse ridge and
maxillary molar mesial subocclusal enamel web, and —
if at all possible — to avoid the cutting of the peripheral
rim of enamel. To conserve these structures, contempo-
rary caries diagnostic techniques must be understood
and utilized so that caries can be treated in its prelimi-
nary stages without unnecessary destruction of these vital
anatomical entities. The utilization of magnification, caries
detection dye,18 laser caries diagnosis,19 and minimally
invasive cavity designs utilizing air abrasion to avoid the
microfracturing that occurs in enamel when cavities are
prepared with high-speed rotary instrumentation are all
promising new techniques.20-23 Due to the way it selec-
tively cuts compromised tooth structure, air abrasion allows
conservation of sound tooth structure. It was this tech-
nology that allowed anatomical structures such as the
subocclusal oblique transverse ridge and maxillary molar
mesial subocclusal enamel web to be observed clini-
cally. In contrast, high-speed rotary burs indiscriminately
cut both sound and unsound tooth with equal ease.
In addition to the need for minimally invasive den-
tistry, the techniques and materials utilized in restoring
minimal cavities should be considered. To conserve the
integrity of the peripheral rim and occlusal cross-bracing
structures, tunnel preparations become an appropriate
treatment option when treating primary interproximal
caries in posterior teeth. This approach will prevent com-
pressive fracturing of the peripheral rim and tension frac-
turing of cusps that occur with conventional MOD-type
cavity preparations. As a consequence, the use of
autopolymerizing glass-ionomer cement has to be con-
sidered when restoring this form of cavity design.24-27
Current cavity designs and treatment concepts have
evolved from a tradition based on the mechanical require-
ments of amalgam, often to the exclusion of the biome-
chanical requirements of the tooth. Only by reassessing
their restorative criteria and modalities can clinicians
avoid the perpetuation of the treatment cycle to which
patients are currently subjected.28-30
700 Vol. 12, No. 7
References
1. Wang RZ, Weiner S. Strain structure in human teeth using Moiré
fringes. J Biomech 1998;31(2):135-141.
2. Rainey JT. A subocclusal transverse ridge: Identification of a pre-
viously unreported tooth structure: The Rainey ridge. J Clin Pediatr
Dent 1996;21(1):9-13.
3. Rainey JT. The maxillary molar mesial subocclusal enamel web:
Identification of a previously unreported tooth structure: The maxil-
lary Rainey web. J Clin Pediatr Dent 1998;22(3):195-198.
4. Gale EN, Osborne JW. The effects of alloy, cavity width and tooth
position on marginal failure of Class II amalgams. J Dent Res
1980;59(special issue A):293:Abstract 101.
5. Gelb MN, Barouch E, Simonsen RJ. Resistance to cusp fracture
in Class II prepared and restored premolars. J Prosthet Dent
1986;55:184-185.
6. Larson TD, Douglas WH, Geistfield RE. Effect of prepared cavi-
ties on the strength of teeth. Oper Dent 1981;6:2.
7. Mondelli J, Steagall L, Ishikiriama A, et al. Fracture strength of
human teeth with cavity preparations. J Prosthet Dent 1981;43(4):
419-422.
8. Grimaldi J. Measurement of the Lateral Deformation of the Tooth
Crown Under Compressive Cuspal Loading. [thesis]. University of
Otago, Dunedin, New Zealand, 1971.
9. Panitvisai P, Messer HH. Cuspal deflection in molars in relation
to endodontic and restorative procedures. J Endod 1995;21(2):
57-61.
10. Re GJ, Norling BK. Forces required to crack unfilled and filled molar
teeth. J Dent Res 1980;59(special issue A):351:Abstract 334.
11. Larson TD, Douglas WH, Geistfield RE. Effect of prepared cav-
ities on the strength of teeth. Oper Dent 1981;6(1):2-5.
12. Khers SC, Carpenter CW, Vetter JD, Staley RN. Anatomy of
cusps of posterior teeth and their fracture potential. J Prosthet Dent
1990;64(2):139-47.
13. Rasmussen ST. Fracture properties of human teeth in proximity to
the dentinoenamel junction. J Dent Res 1984;63(11):1279-1283.
14. Cavel VT, Kelsey WP, Blankenau RJ. An in vivo study of cuspal
fracture. J Prosthet Dent 1985;53:38-42.
15. Sano H, Ciucchi B, Mathews WG, Pashley DH. Tensile proper-
ties of mineralized and demineralized human and bovine dentin.
J Dent Res 1994;73(6):1205-1211.
16. Renson CE, Braden M. Experimental determination of the rigid-
ity modulus, Poisson’s ratio and elastic limit in shear of human
dentin. Arch Oral Biol 1975;20(1):43-47.
17. Christensen GJ. Dental radiographs and dental caries: A chal-
lenge. J Am Dent Assoc 1996;127(6):792-793.
18. Al-Sehaaibny F, White G, Rainey T. The use of caries detector dye
in diagnosis of occlusal carious lesions. Pediatr Dent 1996;20(4):
293-298.
19. Ross G. Caries diagnosis with the DIAGNOdent Laser: A user’s
product evaluation. Ont Dent 1999;76(2):21-24.
20. Xu HH, Kelly JR, Jahanmir S, et al. Enamel subsurface damage due
to tooth preparation with diamonds. J Dent Res 1997;76(10):
1698-1706.
21. Summitt JB, Osborne JW. Initial preparations for amalgam restora-
tions: Extending the longevity of the tooth-restoration unit. J Am
Dent Assoc 1992;123(11):67-73.
22. Ferianakis K, White GE. Newer Class I cavity preparation for
permanent teeth using air abrasion and composite restoration.
J Clin Pediatr Dent 1999;23(3):210-216.
23. Walls AW, Murray J J , McCabe J F. The management of occlusal
caries in permanent molars. A clinical trial comparing a mini-
mal composite restoration with an occlusal amalgam restoration.
Br Dent J 1988;164(9):288-292.
24. Hunt PR. A modified Class II cavity preparation for glass-ionomer
restorative materials. Quint Int 1984;15 (1011):101-108.
25. Knight GM. The tunnel restoration — Nine years of clinical experi-
ence using capsulated glass ionomer cements. Case report. Aust
Dent J 1992;37(4):245-251.
26. Ten Cate JM, Van Duinen RN. Hypermineralization of dentinal
lesions adjacent to glass-ionomer cement restorations. J Dent Res
1995;74(6):1266 -1271.
27. Brantley CF, Bader JD, Shugars DA, Nesbit SP. Does the cycle of
re-restoration lead to larger restorations? J Am Dent Assoc 1995;
126(10):1407-1413.
28. Siurjons, H. Extension for prevention: Historical development and
current status of GV Black’s concept. Oper Dent 1983;8(2):57-63.
29. Hodges DJ, Mangum FI, Ward MT. Relationship between gap
width and recurrent dental caries beneath occlusal margins of
amalgam restorations. Commun Dent Oral Epidemiol 1995;23:
200-204.
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Carol Stream, I L: Quintessence Publishing; 1989:61-68.
 200007PPA Milicich 8/22/02 10:17 AM Page 702

CONTINUING EDUCATION CE 24
CONTINUING EDUCATION

(CE) EXERCISE NO. 24

To submit your CE Exercise answers, please use the answer sheet found within the CE Editorial Section of this issue and complete as follows:
1) Identify the article; 2) Place an X in the appropriate box for each question of each exercise; 3) Clip answer sheet from the page and mail
it to the CE Department at Montage Media Corporation. For further instructions, please refer to the CE Editorial Section.
The 10 multiple-choice questions for this Continuing Education (CE) exercise are based on the article “Clinical presentations of stress distrib-
ution in teeth and the significance in operative dentistry” by Graeme Milicich, BDS, and J. Tim Rainey, DDS. This article is on Pages 695-700.

Learning Objectives:
This article discusses the concept of a “peripheral rim of enamel” and describes the compressive and tensile fractures within this structure
and dentin. Upon reading this article and completing this exercise the reader should:
• Understand the benefits of microdentistry techniques and minimally invasive preparation designs for the preservation of
natural tooth structure.
• Identify various tooth structures involved with stress distribution during cavity preparation.

1. What is the significant conclusion from the Moiré Fringes
study?
a. Enamel has no significance in stress transfer.
b. Dentin fails under occlusal load.
c. Stress is evenly distributed throughout tooth structure.
d. A tooth is a complex structure designed to effectively
distribute and absorb stress.
2. What recently reported anatomical structure is significant
in occlusal stress distribution?
a. The marginal ridge.
b. The oblique transverse ridge.
c. The subocclusal oblique transverse ridge and maxillary
molar mesial subocclusal enamel web.
d. The dentinoenamel junction.
3. What is the biomechanical significance of the DEJ?
a. It allows caries to spread laterally.
b. It acts to transfer vertical load in the enamel into a
horizontal load in the dentin.
c. It causes fracturing between enamel and dentin.
d. It has no functional significance.
4. What is the significance of the peripheral rim of enamel?
a. It is very stable in vertical compressive load.
b. The marginal ridge is a part of the peripheral rim.
c. Cutting an occlusal cavity disrupts the ability of the
peripheral rim to distribute occlusal loads.
d. All of the above.
10. What is required to prevent occlusal effect caries and
5. What is the potential effect of cutting a conventional
G.V. Black extension for prevention of occlusal cavity?
a. It has no effect.
b. It unnecessarily cuts sound tooth structure.
c. It has the potential to cause recurrent caries.
d. It allows compressive flexing of the tooth resulting in
peripheral rim enamel fracture and the potential for
interproximal caries.
6. What is occlusal effect caries?
a. Recurrent caries that occurs due to underextension of
the cavity.
b. Compressive distortion of the peripheral rim due to the
presence of an occlusal cavity causing vertical fracture
of the enamel allowing caries to establish.
c. Failure of the occlusal restoration due to compressive
loads leading to recurrent caries.
d. Fracturing of the occlusal enamel under compressive load
leading to recurrent caries.
7. What causes occlusal abfraction and peripheral rim guttering?
a. The presence of an existing large cavity.
b. Stress concentration between the peripheral rim and
the restoration.
c. Fracturing between the peripheral rim and underlying
dentin along the DEJ.
d. All of the above.
8. What is the difference in fracture presentation between
compressive loads and tensile loads on cusps?
a. There is no difference.
b. Tensile loads cause horizontal fractures through dentin.
c. Compressive loads cause cusps to fall off.
d. Tensile loads cause occlusal abfractions.
9. Why is occlusal effect caries difficult to diagnose radio-
graphically?
a. There is most often minimal enamel decalcification in
the fracture so it will not appear on the radiograph.
b. X-rays will not penetrate the area.
c. Occlusal effect caries does not exist.
d. Fractures can easily be seen on radiographs.
peripheral rim fracturing?
a. Accurate caries diagnosis.
b. Conservation of the important anatomical structures of
the peripheral rim, subocclusal oblique transverse ridge,
and maxillary molar mesial subocclusal enamel web.
c. Minimally invasive tunnel preparations to treat inter-
proximal caries to conserve the peripheral rim.
d. All of the above.

702 Vol. 12, No. 7

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