Basic Research—Technology
Biomechanical Properties of First Maxillary
Molars with Different Endodontic Cavities:
A Finite Element Analysis
Qianzhou Jiang, PhD, DDS, Yuting Huang, DDS, XinRan Tu, DDS, Zhengmao Li, DDS,
Ying He, DDS, and Xuechao Yang, PhD, DDS
Abstract
Introduction: The aim of this study was to compare the
biomechanical properties of first maxillary molars with
different endodontic cavities using the finite element
T he first maxillary molar
method. Methods: Three finite element analysis models
of a maxillary first molar were designed and constructed
with 3 different types of endodontic cavities: a tradi-
tional endodontic cavity, a conservative endodontic cav-
ity, and an extended endodontic cavity. An intact tooth
model was used for comparison. Each model was sub-
jected to 3 different force loads directed at the occlusal
surface. The stress distribution patterns and the
maximum von Mises (VM) stresses were calculated
and compared. Results: The peak VM stress on all
models was at the site of the force load. The occlusal
stresses were spread in an approximate actinomorphic
pattern from the force loading point, and the stress
was much higher when the force load was close to
the access cavity margin. The peak root VM stresses
on the root-filled teeth occurred at the apex and were
significantly higher than that on the intact tooth, which
appeared on the pericervical dentin. The area of pericer-
vical dentin experiencing high VM stress increased as
the cavities extended and the stress became concen-
trated in the area between the filling materials and
the dentin. Conclusions: The stress distribution on
the occlusal surface were similar between the conserva-
tive endodontic cavity, the traditional endodontic cavity,
and the extended endodontic cavity. With enlargement
of the access cavity, the stress on the pericervical dentin
increases dramatically. (J Endod 2018;-:1–6)
Key Words
Endodontic cavity, finite element analysis, minimally
invasive, stress
From the Key Laboratory of Oral Medicine, Guangzhou Institute of Oral Disease, Stomatology Hospital of Guangzhou Medical University, Guangzhou, China.
Address requests for reprints to Dr Qianzhou Jiang, PhD, DDS, Guangzhou Medical University, Endodontics, No 39, Huangsha Road, Guangzhou 510140, China.
E-mail address: jqianzhou@126.com
0099-2399/$ - see front matter
Copyright ª 2018 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2018.04.004
JOE — Volume -, Number -, - 2018
is the largest tooth in
total volume and is gener-
Significance
Minimal invasion endodontic treatment is a novel
concept that recently has been adopted by an
ally considered the most
increasing number of dentists. The aim of this study
anatomically complex
was to compare the biomechanical properties of
tooth (1). The maxillary
first maxillary molars with different endodontic cav-
molar is the second most
ities.
frequently endodontically
treated tooth (2, 3).
Successful root canal treatment depends on the adequate debridement and filling of
the entire root canal system (4). For this purpose, in the clinical context, dentists usually
prepare a much larger endodontic cavity to detect and clear the root canal. However,
removal of much of the tooth structure can undermine its resistance to fracture under
functional loads (5). Traditional endodontic cavities (TECs) involve straight-line path-
ways into the canals to enhance the efficacy of instrumentation and prevent procedural
errors (6). The consequent removal of the tooth structure, coronal to the pulp cham-
ber, along the chamber walls, and around the canal orifices, is the most frequent cause
of fracture in endodontically treated teeth (7, 8) because the removal of a large amount
of dental tissue can threaten the integrity of the dental structure, facilitating fracture. A
previous study reported that the first maxillary molar most frequently fractured after
endodontic treatment (9, 10). Therefore, it is extremely important to determine how
to protect the first maxillary molar and avoid destroying much dental tissue during
endodontic treatment.
Minimally invasive endodontics (MIE) aims to improve traditional endodontic
treatment by designing precise access cavities and pulp chamber finishing. Protecting
the cingulum, the oblique ridge, and the pulp chamber roof, which play very important
roles in the chewing function, can enhance the tooth fracture strength (11). Conserva-
tive endodontic cavities (CECs) have recently been designed to minimize the removal of
the tooth structure. By combining cone-beam computed tomographic (CBCT) imaging
and dental operating microscopy, some dentists have used this contracted access cavity
design during clinical endodontic treatments (12, 13). In previous in vitro studies,
several authors have found that compared with TECs, CECs improved the fracture
strength under a continuous load (14, 15). However, other studies have shown
no obvious difference between CECs and TECs in maintaining fracture strength
(16, 17). The aim of this study was to compare the biomechanical properties of the
first maxillary molar containing different endodontic cavities using the finite element
method (FEM) and to check the hypothesis whether teeth with a minimally invasive
endodontic cavity would relieve the stress distribution.
Biomechanical Properties of First Maxillary Molars 1
Basic Research—Technology
Materials and Methods
FEM Model Generation
An intact, noncarious, mature first human maxillary molar was ob-
tained and scanned with the SkyScan 1072 high-resolution Micro-CT
scanner (SkyScan, Aartselaar, Belgium) with a voxel dimension of
20 mm. An interactive medical image control system (MIMICS 16.0;
Materialise, Leuven, Belgium) was used to identify the different hard tis-
sues visible. Three-dimensional (3D) objects (enamel and dentin) were
automatically created in the form of masks by growing a threshold re-
gion on the entire stack of the scans. These files were refined with
reverse engineering software (Geomagic Studio 10; Geomagic, Inc,
Research Triangle Park, NC). The software SolidWorks (Dassault Sys-
tems SA, Concord, MA) combined the enamel and dentin. The peri-
odontal ligaments (0.25-mm thick) (18) surrounding the roots and
the cortical and cancellous bones were established. The endodontic ac-
cess cavities were then designed on the solid model with SolidWorks.
Cavity Design
The tooth was modeled with its enamel and dentin structures. Four
3D models were generated: the intact (IT) model, the TEC model, the
CEC model, and the extended endodontic cavity (EEC) model. A tradi-
tional access opening in the TEC model was designed so that the entire
roof of the pulp chamber was removed, and a straight-line path was
created from the access opening to the coronal part of the canal
Figure 1. The cavity design and force load. (A1 and A2) The conservative access cavity. (A3) The traditional access cavity. (A4) The extended access cavity. (B1) A
vertical force of 250 N was applied to the central groove area of the model. (B2) A total force of 800 N was applied to 5 points. (B3) A force of 225 N was applied to
the lingual plane of the lingual cusp at 45! to the longitudinal axis of the model.
2 Jiang et al.
(Fig. 1A3). As reported by Eaton (19), the conservative access outline
was determined with a line drawn from the center of the root canal
furcation level landmarks through the central canal orifice at the level
of the floor of the pulp chamber and extrapolated onto the occlusal sur-
face (Fig. 1A1 and A2). The extended access cavity was designed based
on the traditional cavity in which the remaining dentin thickness was
2.0 mm (Fig. 1A4).
Set Material Properties
The models were cross-linked to 3D FEM models with ANSYS14.5
software (ANSYS, Inc, Canonsburg, PA). Consistent with previous
studies, the teeth and materials were considered homogeneous, linear,
elastic, and isotropic (20). In the endodontic treatment models (the
CEC, TEC, and EEC models), the roots were filled with gutta-percha.
The area extending from 2 mm beneath the canal entrance to the level
of the pulp horn was filled with flowable composite resin, and the cavity
was restored with composite resin. The cement layer was 0.04-mm
thick (21). The material properties (elastic modulus and Poisson ratio)
are presented in Table 1.
The contact conditions between the structures of the FEM models
were defined as follows: fixed composite resin–adhesive, adhesive–
enamel, adhesive–dentin, adhesive–flowable composite resin,
enamel–dentin, dentin–pulp (or gutta-percha), dentine–periodontal
ligament, periodontal ligament–cortical bone, periodontal ligament–
cancellous bone, and cortical bone–cancellous bone.
JOE — Volume -, Number -, - 2018

TABLE 1. The Mechanical Properties of the Investigated Materials
Elastic modulus Poisson ratio
Material (E; GPa) (m)
Enamel (22) 84.1 0.002
Dentin (22) 18.6 0.31
Periodontal ligament (22) 0.0689 0.45
Gutta-percha (22) 0.00069 0.45
Cortical bone (23) 13.7 0.3
Cancellous bone (23) 1.37 0.3
Composite resin (24) 12 0.3
Flowable composite resin (24) 5.1 0.27
Cement layer (25) 6 0.3
Pulp (26) 0.002 0.45
Loading Processes
The loading processes were as follows:
1. The models received a vertical occlusal force at a constant intensity
of 250 N (27) to simulate a normal vertical mastication load. The
load was applied to the central groove area of the model (Fig. 1B1).
2. A total force of 800 N (28) was applied to 5 different points as the
pressure load to the occlusal surface to simulate the maximum
mastication force (Fig. 1B2).
3. A total force of 225 N (29) was applied to the lingual plane of the
lingual cusp at 45! to the longitudinal axis of the tooth, which
was allocated 2 points, to simulate the lateral mastication load
(Fig. 1B3).
Results
Under the different force loads, the distributions of von Mises
(VM) stress on the models were related to the locations of the access
cavities. The peak VM stress in all 4 models occurred at the sites of
the force load, and the VM stress on the occlusal surface was spread
in an approximate actinomorphic pattern from the load point. As the
cavity margin approached the load points, the VM stress increased
dramatically (Fig.2A1-A4, B1-B4, and C1-C4). Under the vertical force
of the 1-point load (250 N) (Fig. 2A1–A4), the peak VM stress in all
models occurred at the central groove. When the cavity margin of the
CEC model was very close to the load point, the peak stress was up to
207.72 MPa, which was higher than the stress in the TEC model
(158.21 MPa) and the EEC model (154.94 MPa) (Fig. 3). Under the
vertical force of the multipoint load (800 N) (Fig. 2B1–B4), the peak
VM stress in the CEC model occurred at the central groove, and the
peak stress in the TEC and EEC models occurred at the mesial marginal
ridge and the palatal cusp, respectively. In the EEC model, part of the
access cavity margin was located at the load point of the palatal cusp,
and the peak VM stress was significantly higher in the EEC model
(453.33 MPa) than in the CEC model (342.75 MPa) and the TEC model
(310.14 MPa) (Fig. 3). The VM stress applied at the mesial marginal
ridge in the EEC model (about 324.77 MPa) was also higher than the
stress in the TEC model (about 310.14 MPa) and the CEC model (about
266.28 MPa).
Under the same force load, the range of the VM stress diffused
within the composite resin was smaller than the range within the enamel
(Fig. 2). The VM stress transmitted from the resin to the enamel was
continuous, whereas the transmission of the stress from the enamel
to the resin was hindered to some extent (Fig. 2).
The peak VM stress on the roots in the endodontic treatment
models was much higher than the stress in the IT model. Under a multi-
point vertical force load of 800 N and a lateral force load of 225 N, the
maximum VM stress on the root in the IT model occurred at the peri-
cervical dentin, whereas the maximal VM stress in the root-filled models
JOE — Volume -, Number -, - 2018
Basic Research—Technology
occurred at the apex (Fig. 4). Figure 4C1–C4 shows the VM stress dis-
tribution in cross-sectional images at the level of the cementoenamel
junction. Under an 800-N multipoint vertical force load and a 225-N
lateral force load, the VM stress was significantly concentrated between
the filling materials and the dentin in the EEC model. The stress on the
pericervical dentin showed an increasing trend with the gradual
enlargement of the access cavities.
Discussion
FEM is a useful tool with which to investigate complex systems
(30), and it has been widely applied to endodontic stress analyses.
Knowledge of the stress distribution is important for understanding fa-
tigue development (31). We used FEM to analyze this issue because it is
a suitable method for the performance of clear and objective tests on
biological systems.
The loss of structural tooth integrity that is associated with the
preparation of endodontic access may increase the occurrence of frac-
tures in endodontically treated teeth (32). The ideal access cavity, which
is frequently described in endodontic textbooks, usually shows an easily
identifiable canal entrance at the base of a large pulp floor (33). The
goal of MIE is tissue preservation, preferably by preventing disease or
the interruption of disease progression (34). With the rapid develop-
ment of stomatologic technology, in particular, together with dental
operating microscopy and CBCT imaging, MIE treatment should
become a reality.
In this study, a force of 250 N loaded onto the central groove
confirmed the relationship between the stress distribution and the po-
sition of the force load. Cavity margins closer to the force load experi-
enced the greatest stress, and the stress spread in an approximate
actinomorphic pattern from the force loading point. In the clinical
context, the design of the endodontic access cavity should not only
consider the anatomic location of the root canal system in order to re-
move all potential sources of infection, including remnants of pulp tis-
sue microorganisms, but also should consider the distance between the
biting point and the cavity margin to avoid the concentration of stress.
To simulate the maximum masticatory force, we loaded a force of
800 N at 5 different sites on the models, which approached the real
chewing situation, and the results obtained were close to the true values.
Under a multipoint force of 800 N, the peak VM stress in the TEC model
appeared on the mesial marginal ridge, which could become a vulner-
able area after the endodontic treatment of a maxillary molar (9).
Furthermore, as the cavity size increased from the CEC to the EEC,
the stress on the mesial marginal ridge gradually increased compared
with the stress on the mesial marginal ridge in the other models. There-
fore, protecting the mesial marginal ridge is very important in
increasing the fracture strength after root canal therapy. In addition,
the oblique ridge is an important anatomic structure for the maxillary
first molar in the chewing process, especially when it resists diagonal
forces. The minimally invasive access cavities should keep the oblique
ridge integrated.
Through the occlusal stress nephogram, we found that the range of
the VM stress that diffused from the composite resin was smaller than
the stress that diffused from the enamel. Enamel that was more rigid
was more stress resistant (35). This may be attributable to the fact
that enamel with a higher elastic modulus can resist elastic deformation
and accommodate greater stress internally (36). In the present study,
cross sections of the cementoenamel junction showed that the VM stress
increased with the gradual enlargement of the access cavity. Composite
resin, which has a lower elastic modulus than dentin, will increase the
stress on the dentin to support the resin under greater distortion (36).
Therefore, the stress on the dentin is higher when the access cavity filled
with composite resin is larger.
Biomechanical Properties of First Maxillary Molars 3
Basic Research—Technology

Figure 2. The distribution of VM stress on the occlusal surfaces in the 4 models (IT, CEC, TEC, and EEC). (A1–A4) The distribution of VM stress on the occlusal
surfaces of the models (IT, CEC, TEC, and EEC) under a 1-point vertical force of 250 N. (B1–B4) The distribution of VM stress on the occlusal surfaces of the models
(IT, CEC, TEC, and EEC) under a total multipoint vertical force of 800 N. (C1–C4) The distribution of VM stress on the occlusal surfaces of the models (IT, CEC, TEC,
and EEC) under a total multipoint lateral force of 225 N.

The VM stress on the roots in the root-filled models was much difference in the efficiency of root canal preparation between the mini-
higher than the stress on the roots in the IT model. This may be because mally invasive design and the traditional design (15). Nevertheless,
after endodontic treatment, the interior of the tooth is filled with a minimally invasive access would compromise the instrumentation effi-
particular material, such as a composite resin and adhesive, whose cacy in distal canals of mandibular molars. In this study, the minimally
physical properties differ from those of dentin. When the occlusal sur- invasive cavity was designed according to the line from the center of the
face of a tooth is loaded with a force of constant intensity, the stress is
not transmitted continuously and is concentrated on the pericervical
and apical dentin. In this study, root canal treatment also produced
an area of concentrated stress at the apex, even when the root canal
had not been treated. These data indicate that changes in the tooth struc-
ture can affect the distribution of stress.
Under general condition, endodontic access cavities should be de-
signed according to the situation of tooth, and the treatment should be
minimally invasive in order to preserve as much tooth. Some minimally
invasive access cavities were suggested by the clinician located on the
carious cavities. The anatomy of root canal system should be evaluated
before conducting minimally invasive cavity preparation. Understanding
the root canal system of the tooth with the help of CBCT imaging is an
important step, and the use of a root canal microscope is indispensable
in the whole treatment process. In addition, the cleaning effect of the
root canal system can be increased by means of ultrasound and laser.
It is also worth thinking about the cleaning effect after minimally invasive Figure 3. The maximum von Mises stress values (MPa) on the occlusal sur-
cavity preparation. A previous study found that there was no significant face.

4 Jiang et al. JOE — Volume -, Number -, - 2018


Figure 4. The distribution of VM stress on the apex and pericervical dentin under a total multipoint force load of 800 N in 4 models (IT, CEC, TEC, and EEC). (A1–
A4) The distribution of VM stress on the apex of the models (IT, CEC, TEC, and EEC). (B1–B4) The distribution of VM stress on the pericervical dentin of the models
(IT, CEC, TEC, and EEC). (C1–C4) The distribution of VM stress on the cross-sectional images at the level of the cementoenamel junction.
root canal furcation level landmarks through the central canal orifice at
the level of the floor of the pulp chamber. It decreased the difficulty of
instrument entrance. The root canal instrumentation effect should be
studied further.
Conclusion
Within the limitations of this study, it can be concluded that the
peak stress values on the occlusal surface were similar among the
CEC, TEC, and EEC. However, the CEC model, which preserved a higher
amount of coronal hard tissue, may preserve better fracture resistance.
In all models, as the volume of the cavity increased, the stresses in the
cervical region were more concentrated. Therefore, the CEC could
reduce stress distribution on the cervical structure.
Acknowledgments
This work was supported by Liwan District Minsheng science
and technology project, China (no. 2016080054) and the Scientific
Research Project of Guangzhou University, China (no.
1201210402). The authors deny any conflicts of interest related
to this study.
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