Endodontic Topics 2015, 33, 3–13 © 2015 John Wiley & Sons A/S.

All rights reserved Published by John Wiley & Sons Ltd

ENDODONTIC TOPICS
1601-1538

Biomechanics of fractures in
endodontically treated teeth
ANIL KISHEN

A tooth serves as a mechanical device for masticating food. An intact natural tooth experiences flexing or
bending during the chewing process. Dentin is the major mineralized tissue in a tooth and offers an optimized
mechanical integrity for the tooth. The dentin structure and composition is the key to distributing functional
stresses/strains from the tooth to the surrounding bone. Fractures of endodontically treated teeth are not an
uncommon occurrence in clinical practice. Many iatrogenic and non-iatrogenic factors have been cited to be
responsible for the compromised resistance to fracture in restored endodontically treated teeth. This article
reviews the biomechanical considerations in intact and endodontically treated teeth. The biomechanical
principles underlying the occurrence of cracked tooth and vertical root fracture are also reviewed.

Received 13 October 2015; accepted 16 October 2015.

Introduction apparent fracture predilection of root-filled teeth

Biomechanics is the science that studies the structure
and function of biological systems using the methods
of mechanics. It is a discipline of science borne out of
the undying curiosity of human beings regarding the
functioning of biological systems. A good knowledge
of biomechanics requires an understanding of the
fundamental principles of the mechanics operating in
living systems. It includes scientific areas such as stress
analysis, mechanical property determination, heat
transfer, etc. These studies are mandatory in order to
understand the response of living systems to
functional and parafunctional forces. Some clinicians
are turned off by the mention of these words.
However, they are not aware of the substantial
practical value that can be attained by understanding
orofacial biomechanics (1,2).
Traditionally, biomechanical experiments
conducted to determine the fracture resistance of
intact/endodontically treated teeth have tended to
focus on the strength of the teeth (3). A number of
such studies have suggested that there are no major
differences in the mechanical properties of dentin
from teeth with vital pulp and root-filled teeth (4,5).
The inference from such studies has been that the
would manifest as changes in the strength or
modulus of elasticity (6). From a biomechanical
perspective, strength is merely the ability to resist
deformation (high stiffness) to the applied loads,
measured under a well-controlled situation.
Conversely, toughness is the ability of a material to
absorb energy without fracturing. It is inherently
difficult in artificial materials with very high initial
stiffness (strength) to accommodate a long plastic
yield (toughness) (7,8).
Natural mineralized tissues, such as dentin and
bone, are the result of a long-term optimization
(functional adaptation), controlled by the selection
processes of evolution. Therefore, understanding the
mechanisms of toughness in dental tissues would
provide better insight into the causes of fractures in
teeth. It is key to note that factors which compromise
the biomechanical behavior of a tooth to functional
forces would increase its propensity to fracture.
Biomaterial considerations in
fractures
Dentin is a hydrated, mineralized tissue that forms
the main bulk of a tooth. The mechanical properties

3
Kishen
Fig. 1. The role of different constituents on the mechanical integrity of dentin (2).
of mineralized tissues can be studied as localized
material properties or bulk structural properties
(9,10). From a material perspective, dentin is a
composite material made up of an organic fraction
(30 weight percent), which is mainly collagen, an
interpenetrant inorganic fraction (60 weight
percent), and water (10 weight percent) (11–14). It
also consists of distinct microscopic dentinal tubules
of diameter ranging from 0.5–4.0 lm. The typical
density of dentinal tubules ranges from 10,000 to
96,000 tubules per mm2 (10). The localized
material properties of mineralized tissues are
determined by standard mechanical tests on
uniformly shaped samples. These properties are
relatively independent of the geometry of the tissue
(1).
The inorganic phase in dentin is composed of
poorly crystalline carbonated hydroxyapatite with
needle- and/or plate-like morphology (10 nm 9 50
nm), which exists both within the collagen fibrils
(intrafibrillarly mineralized) and between fibers
(interfibrillarly mineralized) on a nanometric scale.
Ninety percent of the organic phase is collagen,
which is exclusively Type I. Type I collagen is a
strong, three-dimensional fibrous polymer that
usually exists in an aqueous biological environment.
It is often associated with proteoglycan molecules
4
that contain a large amount of bound water (8). The
water content of dentin is believed to vary with
location. The general conjecture is that there are
two types of water in dentin. One type, which is
tightly bound in nature, is associated with the apatite
crystal of the inorganic phase, and collagenous/non-
collagenous matrix proteins of the organic phase.
The second type is free or unbound water. This water
fills the dentinal tubules and other porosities in
dentin. The free-water is associated with inorganic
ions such as calcium and phosphate and aids in their
transport within the dentin matrix (15). Figure 1
shows the role of different constituents on the
mechanical characteristics of dentin.
The precise distribution and the role of different
types of water on the mechanical characteristics of
dentin have not been extensively studied (16). The
interaction of water and collagen has been found to
occur in a well-defined manner (7). It has been
demonstrated that a monolayer of water molecules
will be adsorbed to the surface of hydroxyapatite by
hydrogen bonds. Additional water would be held by
weak van der Waals forces (16). The strongly
interacting water molecule is integrated as an
integral part of the triple helix of the collagen
structure. Two water molecules are incorporated
into each tripeptide structure. When the water

content exceeds two molecules per tripeptide chain,
the molecules start to swell laterally. Water at this
level of hydration will act as a plasticizer,
maintaining a soft and pliable matrix (7).
Dehydration results in a loss of interfibrillar spaces
and a shrinkage of the overall fibril diameter. As the
polypeptide chains of collagen contact each other,
they form a variety of molecular associations that
cannot be formed in an aqueous environment.
Groups capable of forming interpeptide hydrogen
bonds but previously unable to do so due to the
preferential H-bonding with water could form H-
bonding in the absence of water. These interpeptide
forces stabilize the structure of dried collagen,
increasing its stiffness (7).
Time-dependent properties (viscoelastic behavior)
are very characteristic of dentin material. These
properties include (i) an increase in strain with time
when stress is held constant (creep); (ii) a decrease
in stress with time when strain is held constant
(stress relaxation); (iii) stiffness that is dependent on
the rate at which the load is applied; and (iv)
hysteresis (a lag phase) occurring if cyclic loading is
applied, leading to the dissipation of mechanical
energy (17,18). Loss of free-water will compromise
all of the characteristics of viscoelastic behavior (19).
Pashley suggested that fluid-filled dentinal tubules
function to hydraulically transfer and dissipate
occlusal forces (12). It is noted that bulk dentin and
pulp spaces are filled with water at a particular
hydrostatic pressure. The highly mineralized
peritubular dentin and the less-permeable enamel
and cementum on the outer aspects of teeth
maintain free-water in a confined manner (20).
When chewing forces (compressive forces in the axial
direction) act on fully hydrated dentin in an intact
tooth, the free-water in the dentinal tubules/pulp
spaces, along with the pre-existing hydrostatic
pressure, produces a stress-strain response
characteristic of a tough material, while the loss of
this free-water results in a response characteristic of a
brittle material. Furthermore, the free-water in
dentinal tubules was observed to facilitate the
homogenous strain transfer of the axial chewing
force in a lateral direction in dentin.
On the basis of fracture mechanics, two types of
toughening mechanisms have been suggested in
dentin: (i) intrinsic and (ii) extrinsic (21). The
Biomechanics of tooth fracture
intrinsic toughening mechanism operates ahead of
the crack tip. It acts to enhance the inherent
resistance of the material to microstructural damage
and cracks. The extrinsic toughening mechanism
operates primarily behind the crack tip by promoting
crack-tip shielding, which reduces local stress
intensity at the crack tip. Basically, toughness is
increased by mechanisms that increase the amount of
energy required for fracture. In other words,
methods that prevent strain energy from reaching
the crack tip would improve toughness. The viscous
effects within the material will further slow down the
rate of delivery of energy to the crack tip so that the
crack can only propagate gradually and with
difficulty. The movement of free-water from one site
to another within the dentin matrix may also serve
as a toughening mechanism in dentin (7).
Microcracking, crack blunting, and crack bridging
are examples of extrinsic toughening mechanisms in
dentin (21). Microcracking causes dilation and
increases the compliance of the region surrounding
the crack. The sharpness of the crack tip focuses
strain energy onto the next susceptible bond and is
an important factor governing fracture propagation.
Crack blunting causes the stresses at the crack tip to
be defocused. In crack bridging, as the crack opens,
fibers or filaments extend across it, dissipating
energy by their own deformation or by friction as
they pull out from the bulk of the material (7,21).
In addition, strain energy may not be transmitted to
the crack tip if the shear stiffness of the matrix
material is too low (7) (Fig. 2).
Intrinsic mechanisms such as crack blunting tend
to affect the crack-initiation toughness, whereas
extrinsic mechanisms such as crack bridging promote
crack-growth toughness. Hydration also increases
the fracture toughness of dentin by extensive crack
blunting, which elevates the crack-initiation
toughness, and additionally from enhanced
uncracked ligament bridging, which promotes the
crack-growth toughness. In comparison, dehydrated
dentin shows little blunting, which results in a lower
crack-initiation toughness. Although significant crack
bridging occurs with crack extension, the rate of
crack bridging is slower in dehydrated dentin when
compared to the hydrated state (21,22). These
observations highlight the fact that the collagen
microstructure and water of hydration are the
5
Kishen
Fig. 2. Different fracture toughening mechanisms operating in dentin (2,21).
foremost factors which contribute to the fracture
toughness in dentin.
Role of dentin in tooth fractures
The major constituents in dentin, especially the
collagen microstructure, minerals, and water of
hydration, contribute to the mechanical integrity of
dentin. In addition, the pulp space in an intact tooth
with vital pulp consists of a connective tissue system
containing cells and fibers, both embedded in the
extracellular matrix. The extracellular matrix proteins
have very high water-holding properties, and the
total water content of the pulp is more than 90%. A
physiological intrapulpal pressure of 10–28 mm Hg
constantly drives pulpal fluid outward along the
dentinal tubules (11). In endodontically treated
teeth, the hydrophilic pulp tissue is lost. In addition,
the canal lumen and dentinal tubules are disinfected
and dried before root filling. The loss of water-rich
pulp tissues and free-water from the inner root
dentin (surface, porosities, and tubules) can
contribute to the reduction in the mechanical
integrity of endodontically treated teeth (23).
In hydrated bulk dentin, the outer and inner
regions demonstrate consistent hydration-induced
pre-existing strains, which did not differ significantly
with an increase in stress within physiological limits.
In dehydrated bulk dentin, the difference in pre-
existing strains between the outer and inner dentin
6
was noticeable (23,24). Earlier experiments have also
demonstrated shrinkage and compressive strains in
unconstrained bulk dentin subjected to dehydration
at room temperature. Moreover, the hydration-
induced residual strain in the dentin increased
considerably with applied stress (24). These authors
linked the observed behavior of dentin to the
response of a fluid-filled cellular solid (20). On that
basis, when compressive loads are applied to bulk
dentin, the water-filled dentinal tubules are
compressed and the water within is squeezed out in
the direction of open dentinal tubules.
The viscosity of water necessitates a certain effort
to force water out through the dentinal tubules.
This will lead to dual effects in hydrated dentin: (i)
an inherent plasticity effect and (ii) a distinct strain
response in the directions parallel and perpendicular
to the dentinal tubules (22). Because of the loss of
free-water from the dentinal tubules and pulp space
(partial drying), the “water-induced effects” are lost,
and subsequently the bulk dentin displays increased
stiffening and low plasticity (24). Furthermore, it
has been shown that fully hydrated dentin material
displays significantly higher crack-initiation
toughness and crack-growth toughness than
dehydrated dentin (21,22). The above variations in
the mechanical characteristics of dentin, together
with the disparity in the biomechanical response of
teeth to chewing forces, predispose endodontically
treated teeth to fracture (25).

Effects of age on the mechanical
characteristics of dentin
Normal dentin alters physiologically to transparent
dentin with age. The physiological transparent (or
sclerotic) dentin appears to be a natural consequence
of aging. The dentinal tubules in transparent dentin
are gradually filled up with a mineral phase over time,
beginning at the apical end of the root and often
extending into the coronal dentin. The large
intratubular mineral crystals deposited within the
tubules in transparent dentin are chemically similar to
intertubular minerals (26). In the past it had been
believed that transparency required a vital pulp (27).
This belief has largely been disregarded. It is currently
apparent that root-filled teeth have the same or a
greater rate of transparent dentin formation when
compared to teeth with vital pulp (28). The elastic
properties of transparent dentin are not significantly
different from normal dentin. But transparent dentin,
unlike normal dentin, exhibits almost no yielding
(plastic strain) before failure. The fracture toughness
in transparent dentin is approximately 20% lower and
the stress-strain response is characteristic of brittle
behavior (29). It has also been reported that the
tensile fatigue strength of aged dentin is lower when
compared to young dentin (30). Hence restorative
procedures in older individuals might require some
modifications to accommodate the reduced fracture
toughness of dentin. The other causes for lower
fracture toughness in transparent root dentin include:
(i) the reduced level of water content in transparent
dentin, (ii) the ability of mineral accretion within the
tubules to lower the tendency for microcrack
nucleation, and (iii) the age-related changes to dentin
collagen; for example, increased collagen cross-linking
in dentin (31,32).
Biomechanical considerations in
intact teeth
The primary function of a tooth is to serve as a
mechanical device for masticating food. Stress is
produced in a structure due to an external force acting
on it. The direction of the load applied and the shape
of the structure influence the nature of the stress
distribution within the structure. It is recognized that
many damaging effects produced during restorative
Biomechanics of tooth fracture
procedures are due to a lack of understanding of the
biomechanical principles underlying the treatment.
Understanding the nature of stress distribution within
intact tooth structure will aid in understanding how
natural tooth structures resist mechanical forces acting
in the mouth. Similarly, an investigation on the nature
of the stress distribution in prepared teeth and
restored teeth will aid in understanding the
biomechanical responses of such teeth to the
functional forces in the mouth.
When chewing forces act on an intact tooth, it
experiences flexing or bending (Fig. 3A). The
bending-associated stress distribution in a column-
like structure is subjected to an eccentric load (i.e.
load acting away from axis of symmetry). The
column tends to bend, resulting in compressive
stress on one side and tensile stress on the other
side. These stresses are highest at the outer aspect
and diminish to zero toward the center of the cross-
section (Fig. 3B). In a tooth under compressive
force, the maximum stress resulting from bending is
predominantly observed at the cervical aspect of the
root (cervical dentin). The maximum stress/bending
stress reduces notably toward the apical region of
the root (5). This decreased stress distribution in the
middle and apical third of the root was attributed to
the shape/angulation of the tooth and its interaction
with the supporting bone (Fig. 3C) (3). Thus the
cervical root dentin and its relationship with the
supporting alveolar bone is crucial for a stable stress
distribution from the root to the supporting bone.
Biomechanical considerations for
fractures in endodontically treated
teeth
Fracturing is a very complex process that involves
the nucleation and growth of microcracks. The
knowledge of how cracks are formed and how they
propagate within a structure is important in order to
comprehend the causes of failures in structures
during mechanical functions. In a fatigue failure,
microscopic cracks tend to grow with time,
eventually resulting in fracture. Thus, structures with
cracks (even if not superficially visible) could fail
catastrophically. Fractures originate from a stress
concentrator, which can be a crack, or a notch with a
sharp corner, thread, hole, etc. Tensile stresses with
7
Kishen
A B
C D
Fig. 3. Schematic diagrams showing the nature of stress
distributions in a column. (A) The distribution of
bending stress when bending moment is applied.
Bending stress resulted in compressive stress on one side
and tensile stress on the other with a neutral stress plane
intervening. (B) The distribution of bending stress
when a load is applied at a distance from the axis of
symmetry. This resulted in higher compressive stress
when compared to the tensile stress. The neutral axis
shifts in this case and no longer coincides with the axis
of symmetry. (C) Stress distribution pattern in a tooth.
Note: significant bending of tooth at the cervical region
and compressive stress distribution at the middle third,
which reduces to the root apex. (D) Stress distribution
pattern in a post-core restored tooth. CL, CA, TL, TA
are compressive/tensile stress concentration regions in
the remaining root dentin (2,3,25).
magnitudes high enough to provide microscopic
plastic deformation at the crack tip may serve as the
driving force for crack propagation. It is not essential
to apply tensile stress for crack propagation, but it
may be produced within a structure such as dentin
due to residual stresses or tooth structure loss/
removal, or due to the elastic modulus mismatch
8
created by placing restorations/devices with
significant elastic modulus in the tooth. The increase
in magnitude of tensile stresses and concentration of
stresses will render the remaining tooth structure
prone to fracture (Fig. 3D). As well, the tensile
strength of dentin is much lower than its compressive
strength (33). It should be noted that material
properties such as yield strength and tensile strength
have practically no bearing on the vulnerability of a
material to crack extension and fracture. The current
understanding is that the causes of fractures in
endodontically treated teeth are multifactorial in
origin. Broadly, these factors are categorized as
iatrogenic and non-iatrogenic reasons (Fig. 4).
Biomechanics of cracked tooth
A cracked tooth is primarily described as one with
cracks that originate in the mesio-distal plane of the
crown and progress toward the root. The
biomechanical principles underlying cracked tooth are
usually in the crown and hence it is important to study
the stress distribution pattern in the tooth crown in
order to understand the mechanism of cracked tooth.
Previous investigations have suggested that the
strength of a tooth is directly related to the amount of
remaining coronal tooth structure. Hence
preservation of the coronal tooth structure has been
recognized to be crucial for the successful
management of endodontically treated teeth.
Nevertheless, endodontic procedures have been
shown to reduce the relative tooth stiffness by only
5%. This was less than that of an occlusal cavity
preparation, which reduced the relative stiffness by
20%. The largest losses in stiffness were related to the
loss of marginal ridge integrity, and mesio-occluso-
distal (MOD) cavity preparation, which resulted in a
63% loss of relative stiffness (34). However, the access
cavity preparation by itself compromises the flexural
integrity provided by the roof of the pulp chamber,
which results in greater cuspal flexure during
function. An increased cuspal flexure of the posterior
teeth would ensue from greater loss of coronal dentin.
Following access cavity preparation, the buccal and
lingual walls of the posterior teeth are suggested to
behave as a cantilever beam, flexing the cusps in a
bucco-lingual direction (Fig. 5A,B). The repeated
flexure of cusps (fatigue) associated with loading and
unloading of the tooth (chewing cycles) results in a

Fig. 4. The risk factors for fracture in endodontically treated teeth (2).
mesio-distal crack that propagates from the crown to
the root aspect of the tooth (cracked tooth) (35)
(Fig. 5C).
Biomechanics of vertical root
fracture
A vertical root fracture is described as a
longitudinally oriented fracture of the tooth that
originates from the apical region of the root and
propagates toward the coronal aspect of the root
(Fig. 5D). It is recognized that, for vertical root
fracture, many factors should interact in influencing
the fracture susceptibility and pattern. However, any
one factor may easily predominate over the rest. A
numerical analysis investigated the extent to which
dentin thickness, radius of root canal curvature, and
external root morphology influence tooth fracture
susceptibility. This study concluded that vertical root
fracture is unpredictable, and removal of dentin does
not always increase fracture susceptibility (36).
Biomechanical studies have demonstrated that
functional (chewing-related) stresses on the tooth
were chiefly distributed at the cervical dentin (crown
and root). Disease processes or clinical procedures
that lead to increased loss of root dentin or eccentric
removal of root canal dentin during instrumentation
alter the radicular stress distribution pattern,
resulting in more stress distribution in the apical
Biomechanics of tooth fracture
direction and in the bucco-lingual plane of the root
dentin. This altered root stress distribution pattern
can be suggested to be due to the reduced resistance
to root flexure. The increased root flexure may
contribute to a fracture that propagates from the
apical portions of the root to the coronal portions in
the bucco-lingual direction (vertical root fracture)
(37,38). The cracks that lead to vertical root fracture
mostly originate in proximity to the root canal wall,
and may be complete or incomplete in nature (38).
Any prominent alteration in the biomechanical
response of a tooth may influence its resistance to
fracture. Different degrees of root canal dentin loss
may occur during root canal instrumentation. This
marked loss of root canal dentin would alter the
biomechanical response of the tooth. Although
previous static and cyclic load-based mechanical tests
have emphasized the importance of preserving root
dentin in order to retain the mechanical integrity of
endodontically treated teeth (39–41), the precise
impact of iatrogenic dentin loss on the biomechanical
behavior of root dentin is not well understood (3–
5,42). Importantly, the degree of dentin loss should
not be considered as a solo factor that influences the
resistance to fracture, but should be corroborated with
other factors such root canal geometry, canal volume,
and residual dentin. The resistance of the root to flex
will also depend upon the distribution of dentin
material around the canal wall. It is also essential to
9
Kishen
A B
C
D
Fig. 5. (A, B) Schematic diagram showing increased
cuspal flexure in bucco-lingual direction with access
cavity preparation. (C) A cracked tooth: mesio-distal
cracks progressing from crown to root. (D) A vertical
root fracture: bucco-lingual crack progressing from
root toward crown.
note that the functional stresses in the root are
predominantly distributed in the bucco-lingual aspect
of the root. Thus, any non-uniform removal of dentin
around the centroid of the root canal would reduce
the resistance to root flexing. When exposed to
chewing cycles, this repeated and increased root
flexing (fatigue) results in bucco-lingual cracks in the
root that progress toward the crown (43).
Biomechanical considerations in
post-core restored teeth
The biomechanical response of a tooth restored
using a post, core, and crown is distinctly dissimilar
to that of an intact tooth. In a post-core restored
tooth, the “post-core-crown-tooth system” bends or
flexes as a single unit during mastication. The flexing
10
of a post-core restored tooth in comparison to a
normal intact tooth may be suggested to cause
periodontal bone loss in teeth with a metal post
(44). The key differences between an intact tooth
and a tooth restored using a post-core are (i) the
regions of stress concentration in the remaining root
dentin and (ii) an increase in the levels of tensile
stresses in the remaining root dentin for a post-core
restored tooth. Nevertheless, the distribution of
stress concentration zones and magnitude of tensile
stresses has been noted to increase significantly when
the remaining tooth structure is decreased or the
biting loads are angled away from the long axis of
the tooth (3).
The factors responsible for this dissimilar stress
distribution pattern in a post-core restored tooth are
(i) the greater stiffness of the endodontic post and
core restoration, (ii) the angulation of the post with
respect to the line of action of occlusal load, and (iii)
the increased flexure of the remaining reduced tooth
structure. These factors would result in regions of
stress concentration and high tensile stresses in the
remaining tooth structure. Stress concentrations at
the cervical region are mostly due to the increased
flexure of the compromised tooth structure, while
stress concentrations at the apical region are
generally due to the taper of the post (3).
Furthermore, imperfections such as ledges or
microcracks/defects created in the dentin during
preparation or sharp threading from post or pin will
also result in localized stress concentration regions
that can be the locus for a potential fatigue failure
(Fig. 3D) (45). A smooth root canal shape is
therefore recommended to eliminate stress
concentration sites. Post and core restorations do
not reinforce remaining radicular dentin or permit a
uniform distribution of stresses within the remaining
dentin structure (46).
Considerable controversy exists regarding the ideal
choice of material and design of the post and core to
improve fracture resistance in post-core restored
teeth. It is generally believed that carbon and glass
fiber posts have a transverse elastic modulus that is
close to that of dentin and are therefore less
damaging to the remaining dentin structure (47,48).
In the case of posts with mechanical properties
similar to those of dentin, functionally the remaining
dentin, cement interface, and post will all deform
together. Thus the failure mostly appears at the

weakest point, which would be the adhesive joints at
the core-dentin and post-cement-dentin interfaces.
Hence the mode of failure will be loss of marginal
seal, core fracture, post fracture, or loss of retention
(49). The less remaining coronal tooth structure
there is, the greater the stress at the adhesive
interface. Nevertheless, the reinforcement effect after
cementation of a complete crown with a ferrule
effect makes the difference between stiff and elastic
posts less obvious (50). It is also suggested that a
stiff post placed in a tooth with minimal coronal
dentin would withstand greater biting stresses.
Fatigue-induced failure in such post-core systems
would occur at higher stress levels and after a
considerably longer time compared to a low-
modulus post. However, in case of a stiff post, the
risk of an irreparable vertical root fracture would be
high (51–53).
Concluding remarks
Dentin is primarily a collagen-rich organic matrix
reinforced by calcium phosphate mineral particles.
The constituents of dentin material are efficiently
optimized to different mechanical demands in the
mouth. The gradients in the elastic modulus of
dentin have been attributed to the distribution of
the mineral phase, while different toughening
mechanisms have been attributed to the collagen
microstructure and water content in dentin. The
free-water in dentin has a major role to play when
dentin structures respond to forces.
There are different iatrogenic and non-iatrogenic
risk factors that could initiate or propagate cracks
leading to fractures. The biomechanical response of
a tooth structure to chewing forces has a significant
association with its resistance to fracture. These
studies have confirmed that most of the chewing
forces are distributed along the cervical dentin of the
root. In endodontically prepared posterior teeth,
increased cuspal flexure has been the prime feature
that results in cracked teeth while the loss of cervical
root dentin has been the foremost feature that
results in vertical root fracture. Understanding the
biomechanical principles will enable clinicians to
realize the potential risk factors for fractures and
scientists to develop novel treatment strategies to
reinforce endodontically treated teeth.
Biomechanics of tooth fracture
References
1. Kishen A. Investigation on Human Dentin as a
Functionally Adaptive Material. Singapore: Nanyang
Technological University, 2002.
2. Kishen A. Mechanisms and risk factors for fracture
predilection in endodontically treated teeth. Endod
Topics 2006: 13: 57–83.
3. Kishen A, Asundi A. Photomechanical investigations
on post endodontically rehabilitated teeth. J Biomed
Opt 2002: 7: 262–270.
4. Sedgley CM, Messer HH. Are endodontically treated
teeth more brittle? J Endod 1992: 18: 332–335.
5. Huang TJ, Schilder H, Nathanson D. Effects of
moisture content and endodontic treatment on some
mechanical properties of human dentin. J Endod
1992: 18: 209–215.
6. Kahler BS, Swain MV, Moule A. Fracture-toughening
mechanisms responsible for differences in work to
fracture of hydrated and dehydrated dentine.
J Biomech 2003: 36: 229–237.
7. Vincent J. Structural Biomaterials. Princeton
University Press, 1990.
8. Currey JD. Effects of difference in mineralization on
the mechanical properties of bone. Philos Trans R Soc
Lond Biol Sci 1984: 13: 509–518.
9. Kinney JH, Pople JA, Marshall GW, Marshall SJ.
Collagen orientation and crystallite size in human
dentin: a small angle x-ray scattering study. Calcif
Tissue Int 2001: 69: 31–37.
10. Mjor IA, Nordahl I. The density and branching of
dentinal tubules in human teeth. Arch Oral Biol 1996:
41: 401–412.
11. Gale MS, Darvell BW. Dentine permeability and tracer
tests. J Dent 1999: 27: 1–11.
12. Pashley DH. Dentin permeability. In: Sp angberg
LSW, ed. Experimental Endodontics. Boca Raton, FL,
USA: CRC Press, 1990.
13. Kinney JH, Balooch M, Marshall GW, Marshall SJ.
Atomic-force microscopic study of dimensional
changes in human dentine during drying. Arch Oral
Biol 1993: 38: 1003–1007.
14. Kinney JH, Balooch M, Marshall GW, Marshall SJ.
A micromechanics model of the elastic properties
of human dentine. Arch Oral Biol 1999: 44: 813–
822.
15. van der Graaf ER, ten Bosch JJ. The uptake of water
by freeze-dried human dentine sections. Arch Oral
Biol 1990: 35: 731–739.
16. Pashley DH, Agee KA, Carvalho RM, Lee KW, Tay
FR, Callison TE. Effects of water and water-free polar
solvents on the tensile properties of demineralized
dentin. Dent Mater 2003: 19: 347–352.
17. Lakes RS. Viscoelastic Solids. Washington, DC: CRC
Press, 1999.
18. Jantarat J, Palamara JE, Lindner C, Messer HH.
Time-dependent properties of human root dentin.
Dent Mater 2002: 18: 486–493.
11
Kishen
19. Wehrli FW, Fernandez-Seara MA. Nuclear magnetic
resonance studies of bone water. Ann Biomed Eng
2005: 33: 79–86.
20. Kishen A. Influence of hydration in dentin: the
missing links. In: First International Conference on
Mechanics of Biomaterials & Tissues. Waikoloa,
Hawaii, USA, 2005.
21. Kruzic JJ, Nalla RK, Kinney JH, Ritchie RO. Crack
blunting, crack bridging and resistance-curve fracture
mechanics in dentin: effect of hydration. Biomaterials
2003: 24: 5209–5221.
22. Nalla RK, Kinney JH, Ritchie RO. On the fracture of
human dentin: is it stress- or strain-controlled? J
Biomed Mater Res A 2003: 67: 484–495.
23. Jameson MW, Hood JA, Tidmarsh BG. The effects of
dehydration and rehydration on some mechanical
properties of human dentine. J Biomech 1993: 26:
1055–1065.
24. Kishen A, Asundi A. Experimental investigation on
the role of water in the mechanical behavior of
structural dentine. J Biomed Mater Res A 2005: 73:
192–200.
25. Asundi A, Kishen A. Advanced digital photoelastic
investigations on the tooth–bone interface. J Biomed
Opt 2001: 6: 224–230.
26. Porter AE, Nalla RK, Minor A, Jinschek JR,
Kisielowski C, Radmilovic V, Kinney JH, Tomsia AP,
Ritchie RO. A transmission electron microscopy study
of mineralization in age-induced transparent dentin.
Biomaterials 2005: 26: 7650–7660.
27. Bang G, Ramm E. Determination of age in humans
from root dentin transparency. Acta Odontol Scand
1970: 28: 3–35.
28. Thomas GJ, Whittaker DK, Embery G. A
comparative study of translucent apical dentine in
vital and non-vital human teeth. Arch Oral Biol
1994: 39: 29–34.
29. Kinney JH, Nalla RK, Pople JA, Breunig TM, Ritchie
RO. Age-related transparent root dentin: mineral
concentration, crystallite size, and mechanical
properties. Biomaterials 2005: 26: 3363–3376.
30. Tonami K, Takahashi H. Effects of aging on tensile
fatigue strength of bovine dentin. Dent Mater J 1997:
16: 156–169.
31. Bajaj D, Sundaram N, Nazari A, Arola D. Age,
dehydration and fatigue crack growth in dentin.
Biomaterials 2006: 27: 2507–2517.
32. Viguet-Carrin S, Garnero P, Delmas PD. The role of
collagen in bone strength. Osteoporos Int 2006: 17:
319–336.
33. Lehman ML. Tensile strength of human dentin.
J Dent Res 1967: 46: 197–201.
34. Reeh ES, Douglas WH, Messer HH. Stiffness of
endodontically-treated teeth related to restoration
technique. J Dent Res 1989: 68: 1540–1544.
35. Panitvisai P, Messer HH. Cuspal deflection in molars
in relation to endodontic and restorative procedures.
J Endod 1995: 21: 57–61.
12
36. Zhi-Yue L, Yu-Xing Z. Effects of post-core design and
ferrule on fracture resistance of endodontically treated
maxillary central incisors. J Prosthet Dent 2003: 89:
368–373.
37. Kinney JH, Habelitz S, Marshall SJ, Marshall GW.
The importance of intrafibrillar mineralization of
collagen on the mechanical properties of dentin.
J Dent Res 2003: 82: 957–961.
38. Currey JD. The design of mineralised hard tissues for
their mechanical functions. J Exp Biol 1999: 202:
3285–3294.
39. Patel DK, Burke FJ. Fractures of posterior teeth: a
review and analysis of associated factors. Prim Dent
Care 1995: 2: 6–10.
40. Meister F Jr, Lommel TJ, Gerstein H. Diagnosis and
possible causes of vertical root fractures. Oral Surg
Oral Med Oral Pathol 1980: 49: 243–253.
41. Lagouvardos P, Sourai P, Douvitsas G. Coronal
fractures in posterior teeth. Oper Dent 1989: 14: 28–32.
42. Papa J, Cain C, Messer HH. Moisture content of vital
vs. endodontically treated teeth. Endod Dent
Traumatol 1994: 10: 91–93.
43. Ossareh A, Kishen A. Effect of endodontic chemicals
on the ultrastructure, chemical and mechanical
characteristics of dentin hard tissue. J Endod 2014:
40: e6.
44. Eliasson S, Bergstrom J, Sanda A. Periodontal bone
loss of teeth with metal posts. A radiographic study.
J Clin Periodontol 1995: 22: 850–853.
45. Kishen A, Kumar GV, Chen NN. Stress-strain
response in human dentine: rethinking fracture
predilection in post-core restored teeth. Dent
Traumatol 2004: 20: 90–100.
46. Sornkul E, Stannard JG. Strength of roots before and
after endodontic treatment and restoration. J Endod
1992: 18: 440–443.
47. Isidor F, Brondum K. Intermittent loading of teeth
with tapered, individually cast or prefabricated,
parallel-sided posts. Int J Prosthodont 1992: 5: 257–
261.
48. Isidor F, Odman P, Brondum K. Intermittent loading
of teeth restored using prefabricated carbon fiber
posts. Int J Prosthodont 1996: 9: 131–136.
49. Ukon S, Moroi H, Okimoto K, Fujita M, Ishikawa M,
Terada Y, Satoh H. Influence of different elastic
moduli of dowel and core on stress distribution in
root. Dent Mater J 2000: 19: 50–64.
50. Hu YH, Pang LC, Hsu CC, Lau YH. Fracture
resistance of endodontically treated anterior teeth
restored with four post-and-core systems. Quintessence
Int 2003: 34: 349–353.
51. Freeman MA, Nicholls JI, Kydd WL, Harrington GW.
Leakage associated with load fatigue-induced
preliminary failure of full crowns placed over three
different post and core systems. J Endod 1998: 24:
26–32.
52. Martinez-Insua A, da Silva L, Rilo B, Santana U.
Comparison of the fracture resistances of pulpless
 Biomechanics of tooth fracture

teeth restored with a cast post and core or carbon- 53. Sidoli GE, King PA, Setchell DJ. An in vitro
fiber post with a composite core. J Prosthet Dent evaluation of a carbon fiber-based post and core
1998: 80: 527–532. system. J Prosthet Dent 1997: 78: 5–9.

13