Biomechanical Performance of an Immature Pulpless ...€¦ · Professor Conservative Dentistry &...

Global Dentistry: Case reports

Volume: 1.1Open Access Journal

Volume: 1.11Global Dentistry: Case Reports

*Lt Col Sonali Sharma MDS, PhD ##Lt Gen SM Londhe SM, MDS#Dr. Mithra N Hegde MDS, PhD, MAMS$Dr. Vandana Sadananda MDS

*Professor Conservative Dentistry & Endodontics, Army Dental Centre, Research & Referral, Delhi##Director General Dental Services, Room number 11, L Block, Adjutant General’s branch, IHQ of MOD (Army) New Delhi: 110001#Professor & Head of Department, Conservative Dentistry & Endodontics, A.B. Shetty Memorial Institute of Dental Sciences, [email protected] $Lecturer, Conservative Dentistry & Endodontics, A.B. Shetty Memorial Institute of Dental Sciences, [email protected]

INTRODUCTIONEvidence-based epidemiological studies have corroborated that there is a 4.5 % global incidence of dental trauma annually [1]. It has

been observed that incidence is more in school going children of age 8 to 12 years [2]. These injuries can result in pulp necrosis of immature permanent teeth alongside partial root development with resultant underdeveloped, garbled weak walls [1,2].

A herculean task for an endodontist is to predictably and favourably manage an immature necrotic anterior tooth [3]. The basic tenet of endodontics is to maintain and provide an apical seal in an open divergent apex is a formidable undertaking [3,4]. The challenge takes a gargantuan proportion when along with open apices, the longitudinal growth of the root is stunted too.

Article Type: Original Article

Journal Type: Open Access

Volume: 1 Issue: 1

Manuscript ID: GDCR-1-101

Publisher: Science World Publishing

Received Date: 09 June 2020

Accepted Date: 17 June 2020

Published Date: 05 July 2020

*Corresponding author:

Lt Col Sonali Sharma

Professor Conservative Dentistry & EndodonticsArmy Dental CentreResearch & ReferralDelhiEmail: [email protected]

Citation: Sonali Sharma (2020) Biomechanical Performance of an Immature Pulpless Maxillary Central Incisor Managed with Different Modalities: A Finite Element Analysis. Global Dentistry: Case Reports, 1(1);1-8

Article Information

Biomechanical Performance of an Immature Pulpless Maxillary Central Incisor Managed with Different Modalities: A Finite Element Analysis

Copyright: © 2020, Sonali Sharma, et al., This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 international License, which permits unrestricted use, distribution and reproduction in any medium, provided the original author and source are credited.

ABSTRACTAim: To compare and contrast by three-dimensional FEA the biomechanical performance of an immature endodontically treated central

incisor reinforced by different replacement monoblocks under three different loading conditions.Material and Method: Four models of a pulpless immature central incisor with an underdeveloped root and supporting structures was de-

signed and built. The root length was 2 mm less than a mature central incisor. The radicular space was rehabilitated as follows: Model I: Revas-cularization, Model II: Biomimetic Mineralization, Model III: Biodentine, Model IV: MTA. Three distinct loading scenarios were independently experimented, i.e to simulate the masticatory forces an inclined load of 70 N was applied at 45 degrees; to replicate bruxism, on the incisal edge, a vertical load measuring 100 N was tested; and to simulate a direct impact trauma, a 100 N of the horizontal load was executed on the labial surface of the central incisor.The finite element analysis was carried out with the ANSYS software.

Results: Model II exhibited the lowest concentration of Von Mises stresses as the modulous of elasticity is same as that of dentin, followed by Model I, Model III, Model IV. When the models were loaded to simulate bruxism and horizontal trauma the least amount of stress concentra-tion was found in Model I, Model II, Model III, Model IV in descending order.

Conclusion: The closer the modulus of elasticity of the replacement monoblock was to dentin, the lower the stresses generated. All re-placement materials brought about some amount of reinforcement to a weakened periapex.

KEYWORDSBiodentine, Biomimetic mineralization, Finite element analysis, MTA, Modulous of elasticity, Revascularization, Von Mises stresses

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Calcium hydroxide apexification has resulted in varying degrees of success in inducing a calcific barrier [5]. However studies by, Andreasen et al conversely advocated that placement of long term calcium hydroxide in the root canal will lead to the weakening of the apical third [6]. In the event of additional trauma, even of a minute magnitude can lead to fracture of the fragile weakened root apices. Hence, should a second injury occur, teeth would be more susceptible to root fractures and preserving those teeth will be difficult [4,7]. For this reason, the use of reinforcement in these weak roots is necessary [8].

In the past, a great many materials have been experimented for augmenting the fracture resistance of immature endodontically treated teeth. El-Khodery et al had investigated the effect of composites on the internal strength of the root canal [7,8]. MTA has been reviewed exhaustively for apical closure [9,11]. Manifold case series have found MTA and composite restorations an alternative combination for reinforcing the root canal [12]. Various studies have compared MTA, calcium hydroxide, biodentine and bioaggregate and found all these were effective in varying degrees [13-16]. Diverse passive materials have also been used as obturating materials but with limited success as a reinforcement option [12]. Regenerative strategies have also been exhaustively researched as an alternative approach is to develop and restore a functional pulp-dentin complex [17-20]. Biomimetic mineralisation approach is an innovative method to regenerate dental hard tissue which will hermetically seal the internal root canal space [21,22].

Various materials have been attempted to reinforce the immature apex with variable results [21-25]. The greatest challenge is if the apical third has not attained its full dentin thickness. To further compound and challenge the fragility of the immature apical third is the onslaught of normal masticatory or aberrant forces acting on the tooth.

This study has been designed to simulate various forces generated during mastication, bruxism and trauma and aimed at studying the effect of these forces on various reinforcement materials in an immature central incisor with an open divergent open apex with thin, fragile dentinal walls. For simulating real-life conditions and analyzing the stresses generated, finite element analysis is an excellent non-invasive tool [26-27]. Hence it has been used to model an immature central incisor with incomplete root formation in this study.

MATERIAL AND METHODSThe initiation of any finite element analysis is to dissect the

specific geometry of the structure employing a collection of definite sections termed finite elements. These elements are meet at a pointcalled nodes. The assemblage of finite elements and nodes is known as the mesh. The model of the maxillary central incisor and supporting structures were designed, based on material properties and features obtained from previous studies (Table 1, Figure 1) [24,25,28-30]. All constituents were isotropic however composite materials are considered orthotropic, as they exhibit contrasting mechanical properties along the fibre direction (x-direction) and with the other two normal directions (y and z-direction).

Four different models were developed and each model had 315807 number of elements and 53900 number of Nodes. The simulation of models was to replicate the clinical conditiona post 3 months of placement of the reinforcement material (Figure 1-4).

MODEL 1: Immature central incisor with an underdeveloped apical third (2 mm less) with thin apical dentinal walls managed with revascularization protocol and restored with composite.

MODEL 2: Immature central incisor with an underdeveloped apical third (2 mm less)with thin apical dentinal walls, root canal reinforced with the homogeneous unit with dentine coagulum through a biomimetic mineralisation strategy and restored with composite.

MODEL 3: Immature central incisor with an underdeveloped apical third (2 mm less) with thin apical dentinal walls, root canal reinforced with biodentine and restored with composite.

MODEL 4: Immature central incisor with an underdeveloped

apical third (2 mm less) with thin apical dentinal walls, root canal reinforced with MTA and restored with composite.

Each Model was meshed to prevent displacement and set boundary conditions and then subjected to three different loading conditions:i. An inclined load of 70 N was applied to central incisor crown at

45 degrees, to replicate masticatory forces.ii. A vertical load of 100 N was applied on the incisal edge of central

incisor crown to replicate bruxism.iii. A horizontal load of 100 N was applied labially on the central

incisor crown to replicate external traumatic forces.As a confining boundary stipulation, no deracination was

conceded for the nodes along the lower borderline of the models. The finite element biomechanical stress analysis was performed with the finite elementapplication software program (ANSYS).

The results of finite element analysis are communicated as stresses allocated in the structure or framework under scrutiny. These stresses are an aggregation of tensile, compressive shear stress known as Von Mises stresses. It’s a failure criterion tested on ductile substances. Von Mises stresses relies on the consolidated stress field and is extensively used to gauge the prospect of damage occurrence.

RESULTSTo simulate mastication there application of an inclined load of

70 N, for Model I in which revascularization was attempted, it was observed that the stresses generated were transmitted through the tooth and periodontal ligament to the surrounding bone. The section of the restored tooth showed that the stresses increased at the fragile periapex (Figure 2a). The maximum stress was at the labial middle third of the radicular surface. There is also increased stress at the junction of the crown root cervical labial surface. The analysis of reinforcement material core also showed maximum stress at the junction of coronal and middle third radicular portion and then mildly increasing stress at apical third. The analysis of for the Model 1 of the dentin showed maximum stress on the coronal third, more towards the junction of the middle third but confined to coronal third. The periodontium showed stresses transferred to the alveolar crestal region (Figure 2b).

Model II was subjected to an inclined load of 70 N to replicate mastication and the replacement material was a product of biomimetic mineralization strategy which resulted in dentin like the material of 18.6 GPa modulus of elasticity mimicking that of dentin. The location of stress was similar to that of Model 1 but the magnitude

Description Material Properties

Modulus of Elasticity [GPA] Poissons Ratio

Enamel 41 0.3

Dentine 18.6 0.31

Pulp 2.3E-08 0.3

Periodontal ligament 68.93-3 0.45

Cortical bone 13.7 0.3

Cancellous bone 1.37 0.3

Gingiva 0.0196 0.3

MTA 30 1.84

Revascularization 15 0.92Biomimetic mineralization 18.6 18.6

Biodentine 22 0.3Bonding system [clearfil se bond] 0.56 0.25

Composite core 12 9.3

Table 1 : Overview of Material Properties



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challenge especially when the open apices are divergent with thin delicate dentinal walls which are prone to fracture [28]. Thus in this study, we evaluated a pulpless divergent blunderbuss open apex in which the root had not developed to its full longitudinal growth by 2 mm (Figure 1).

Mente et al have conducted a cohort comparing the outcome of MTA plug in the management of immature root apex and at the end of 4 years follow up, they found the result very promising [29]. MTA has been evaluated as a single visit apexification and as well as a reinforcing material. MTA and variant combinations have been attempted to reinforce and rehabilitate the thin dentinal walls of root canals of immature teeth [12,30-32]. Other materials which have been assessed as a reinforcement material include Ribbond, biodentine, bioaggregate, resin and other bioceramics [23-25,28,30-33]. Hence this study was conceptualized to compare different materials for reinforcing and rehabilitating a pulpless, immature central incisor with incomplete root formation. MTA and biodentine were thus selected as one of the reinforcing materials IN Model III and Model IV respectively.

Revascularization studies have shown that over a period of a year the disinfected root canal shows an increase in root canal length, there is an increase in dentinal wall thickness of weakened apical canal walls, closure of open apices, and healing of periapical lesions [17-20,34]. The tissue which is generated in the root canals is mainly of 3 types: an intracanal bone-like tissue with trabecular formation, intracanal cementum –cementum like material leading to increase in the thickness of root and connective tissue similar to periodontal ligament, has been observed in some studies [35-37]. Hence in this study, revascularization protocol has been included in Model I.

Biomimetic mineralisation is an avant-garde approach for dental hard tissue regeneration with the view to imperviously seal off or plug the root apex [21,22]. Le Zhang attempted to imperviously obturated the root canal with the replacement material coalescing with the radicular dentin. This was brought about by the growth of fluoridated hydroxyapatite crystal extending into the c axis and thus sealing off the root canal canaliculi from the external environment [21]. Hence, in this study, a biomimetic approach of canal mineralization by use of dentin chip coagulum was included in Model II. The modulus of elasticity of this replacement material is thus similar to that of dentin.

Tay and Pashley have discussed the concepts of replacement

was marginally lesser on the whole tooth and transference of forces to periodontium was lesser. There was a marginal increase in stress in the replacement cone and on dentin as compared to Model I (Figure 2a & 2b).

Model III was similarly subjected to 70 N of an inclined load to simulate mastication. It had replacement material of biodentine. It was observed that the location of maximum stresses was in similar areas of the radicular coronal region and middle third as in Model I and II and magnitude was marginally lesser on the whole tooth. The replacement material had a greater magnitude of stresses as compared to the replacement Model I & II (Figure 2a & 2b).

Model IV was rehabilitated with MTA and on the application of 70N inclined load resulted in a greater increase in magnitude on the replacement material on the surrounding dentin at the middle third. The stresses transmitted to periodontium is lesser as compared to Model III (Figure 2a & 2b).

To simulate bruxism a vertical load of 100N was applied to the central incisors incisal edge. All the models showed a similar level of stresses, but the replacement materials had an increasing magnitude from Model I to Model IV in the radicular middle third of the material and with increased stress in the fragile apex. The surrounding dentin had a fall in magnitude from Model I to Model IV. The transmission of forces to the periodontal apparatus is of the extreme high magnitude from crestal cervical region to the mid root level and this increased as one moved from Model I to Model IV (Figure 3a &3b).

To simulate the frontal trauma a force of a horizontal load of 100 N was applied labially. The stresses were mainly concentrated in the middle third of buccal and palatal surfaces and also at the neck of the crown. The replacement materials have the maximum stress concentrated on the cervical or coronal third and lesser magnitude on the fragile apical third. The magnitude of the stresses increases from Model I to Model IV. The forces transmitted on to dentin are also more in intensity at the coronal third and junction of the middle third and apical third. The transmission on the periodontium is also more on the crestal level (Figure 4a & 4b).

DISCUSSIONThe eventual measure of endodontic success is to achieve a three-

dimensional hermetic apical seal. However, achieving an impervious seal in an immature non-vital seems like an insurmountable

Figure 1: Model Build Up



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monoblocks. Monoblock per se means a single homogenous unit. The monoblocks could be primary, secondary, tertiary monoblocks [38]. In theory the notion of achieving a biologically sound homogenous entity coalescing with radicular dentin is an ideal situation. But the reality is far removed from the lab-based concepts. The hard truth is that as we move from primary to secondary and to tertiary monoblocks, there is an introduction of more interfaces with a different modulus of elasticity, due to which the reinforcement of these replacement monoblocks are compromised. The other challenges are removal of the smear layer, etching of the radicular dentin, impregnation of the adhesive into the etched dentin. Further, the problem is compounded when the tooth is traumatized and the root development is stunted leading to incomplete root length formation. To fortify an open divergent open apex with incompletely formed delicate periapex one needs a replacement material which has a modulus of elasticity similar to that of dentin. Hence, the tooth which was modelled and included in the study was a dentin coagulum grew into and obturated the dentinal tubules. In the root canal, the regenerated fluoridated hydroxyapatite densely packed and bundled together with a c-axis extension incisor which had root growth stunted from the standard

by 2 mm. Conditions of primary monoblocks were replicated and the materials which are commonly used for apical closure were used as reinforcement for obturation of the root canal.

The moot question is to devise a method to analyze the stresses induced during mastication, during bruxism or frontal trauma. In the pursuit of understanding the stresses which a tooth undergoes, an array of methods have been utilized to forecast the specific tissues response to the corresponding load. These encompass theoretical mathematical theorems, laser-based holographic interferometry and photoelastictechniques. The limiting factor was that the aforementioned methods were all confined to surface analysis, but could not give a three-dimensional dynamic analysis. Thus we need a system which can also be validated. Finite element analysis, which was first introduced in the 1960s, for analysing aeronautical designs, is a non-invasive software (ANSYS) based numerical iteration analysis which aids in determining the stresses generated and resultant displacements through a predetermined model. It is an ever-evolving stress iteration analysis tool for biomechanical evaluation in biological research. It is a non-invasive, conclusive for modelling

Figure 2: Stress Pattern Under inclined loading of 70N



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framework and configurations and analyzing their mechanical behaviour and properties. It also assists in the visualization of superimposed craniofacial structures and provides the latitude in establishing and stipulating the locus and simulating the quantum and direction of applied force. Since it is non-invasive and does not affect the viscoelastic properties of the subject, it can be repeated. To design a structure we initially need the modulus of that material of elasticity and Poisson ration, this we have primarily appropriated from the classical study by Pegoretti [39], studies by Sharma et al., [40-42] and multiple studies [16, 23-27] [Table 1].

Studies by Bayram et al., have compared the fracture resistance of immature teeth rehabilitated with MTA, biodentine, bioaggregate [16]. They have concluded that all three materials were effective in reinforcing the tooth but there was no difference between the stresses generated amongst the three. In this study, it was observed during mastication, that the MTA induced more stresses as compared to biodentine Figure 2a) Even the stresses transmitted to dentin was more with MTA as compared to biodentine group. The transmission of forces to the periodontium was more with the biodentine than

with MTA (Figure 2b). During bruxism, the MTA group exhibited lesser Von Mises stresses as compared to Biodentine group (Figure 3a) During horizontal trauma, the MTA group exhibited larger magnitude of Von Mises stresses and there was more transmission to the surrounding dentine and less transmission of forces to periodontium than Biodentine (Figure 4a) As in the other reviewed studies, the concentration of stresses in the apical area is lesser with all replacement materials.

Eram et al conducted a study comparing the fracture resistance of MTA, Biodentine, Bioaggregate [15]. It was found that the 4 mm apical plug of MTA exhibited increased fracture resistance in comparison to 8.5 mm of MTA obturation. On replacing MTA with Biodentineor Bioaggregate, the Von Mises stress heightened by 64% and 94% respectively. Further, they observed that complete obturation with any of the three materials as compared to apical plug leads to an increase in stress concentration at the cervical area. This effect of cervical concentration of stress was also seen in this study with all the replacement approaches (Figure 2a, 3a, 4a). During mastication, the cervical stress concentration was more on the labial surface but during trauma, an extremely high concentration was seen at both

Figure 3: Stress Pattern Under vertical loading of 100N



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labial and palatal cervical region (Figure 4a).Bucchi et al conducted a finite element analysis on an immature

central incisor managed revascularization protocol. Stress value peaks were of lower magnitude in the dentine reinforced samples in comparison to the cementum-reinforced samples in all loading conditions. In this study, the finite element analysis was done on an immature pulpless tooth with incomplete root formation with a thin fragile apex and root length was 2mm shorter. Since the tissue inside is either dentin, cementum or periodontium the modulus of elasticity was lesser than that of dentin. The loading was done at three months postoperatively thus there was no increase in the thickness of the radicular apical dentin. The stresses during mastication were lesser compared to other replacement modalities and concentrated more on the labial surface at the junction of incisal and middle third of the root. The transmission of forces to dentin was lesser than the other groups. But transmission of forces to periodontium was more than the biomimetic group. In both bruxism and trauma conditions, the stresses induced were of lower magnitude than other but the stresses transferred to periodontium was more than Biomimetic remineralization group (Figure 2b, 3b, 4b).

Le Zhang et al conducted a study in which the freshly extracted prepared teeth were kept immersed in a supersaturated solution of phosphate and calcium which also contained fluoride and gallium. The precipitate which grew in and obliterated the canals ere of hydroxyapatite. Hence in this study, we have filled the immature undeveloped tooth with dentin coagulum and then after three months loaded it in three conditions to simulate mastication, bruxism and trauma. Since the modulus of elasticity, this biomimetic dentin coagulum derived mineralized material was the same as that of dentin, the magnitude of stresses was much lesser than that of MTA and Biodentine and marginally more than that of Revascularization Model under loading conditions. But the stress concentration pattern was more or less similar for all models for that particular loading condition.

CONCLUSIONWithin the limitation of the study, it can be surmised the current

status regarding the selection of appropriate restorative materials for reinforcing weak immature anterior teeth following root canal treatment:

Figure 4: Stress Pattern Under horizontal loading of 100N



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1. Since there is no extreme magnitude of Von mises stresses at the rehabilitated it can be inferred that all replacement material bring about intraradicular reinforcement.

2. The closer the elasticity of modulus of the replacement monoblock was to dentin, the lower the stresses generated. Model II had a minimal magnitude of von mises stress followed by Model I, then Model II and then Model IV. Thus the ideal replacement reinforcing material is the Biomimetic mineralization protocol using dentin coagulum. Thereafter, the revascularization group showed promising results. The next best was Biodentine followed by MTA reinforcement.

3. The viability and feasibility of selecting the appropriate restorative materials for reinforcing weak immature anterior teeth following root canal treatment are highlighted and the search for an ideal primary monoblock is the ultimate goal.Conflict of Interest Statement: The authors declare there has

been no conflict of interestAcknowledgement: Mr Nagabhushana Musalammagari for the

Finite Element Analysis

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