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JOURNAL OF ENDODONTICS
Copyright © 1995 by The American Association of Endodontists
SCIENTIFIC ARTICLES
Cuspal Deflection in Molars in Relation to Endodontic
and Restorative Procedures
Piyanee Panitvisai, DDS, MDSc and Harold H. Messer, MDSc, PhD
The extent of cuspal flexure following endodontic
and restorative procedures has important conse-
quences for potential fracture. This study was un-
dertaken to determine the extent to which cusps of
molars are weakened by progressively larger re-
storative preparations and endodontic access. Cus-
pal flexure of 13 extracted, intact human mandibular
molars was measured under controlled occlusal
loading. A ramped load of 100 N was applied to the
mesial cusps via a steel sphere, using a closed-loop
servohydraulic testing machine. Lateral cuspal dis-
placement was recorded by linear measuring de-
vices (direct current differential transformers) ac-
curate to 1 ~m. Increasingly extensive MO or MOD
cavity preparations followed by endodontic access
were cut in each tooth. Cuspal deflection increased
with increasing cavity size and was greatest follow-
ing endodontic access. Cuspal deflections of more
than 10/~m were observed. These findings reinforce
the importance of cuspal coverage to minimize the
danger of marginal leakage and cuspal fracture in
endodontically treated teeth.
The relative contribution of restorative and endodontic pro-
cedures to loss of tooth strength is the subject of controversy.
There can be little question that endodontic treatment weak-
ens teeth, resulting in an increased susceptibility to fracture
(1-3). The high fracture rate of these teeth has been attributed
to increased brittleness (4) or to the loss of tooth structure (5,
6). More recent investigations of biomechanical properties of
dentin have effectively rebutted the view that endodontically
treated teeth become brittle (7, 8).
Teeth requiring endodontic treatment have typically lost
substantial tooth structure as a result of caries or trauma, and
often from repeated restorative procedures. The weakening of
teeth following cavity preparations has been shown experi-
mentally in a number of studies (9-11). Both the amount of
57
Printed in U.S.A.
VOL. 21, NO. 2, FEBRUARY1995
tooth tissue lost and the location of the loss were found to
decrease the stiffness of the tooth. The effect of the endodontic
access cavity on the stiffness of a tooth remains equivocal.
Hood (3) and Hansen et at. (12) have argued that the high
fracture rate of endodontically treated teeth may be caused
by cavities being deep159er than in vital teeth; following
endodontic access, the cavity floor effectively extends to the
floor of the pulp chamber. In contrast, Reeh et al. (13) showed,
using strain gauges bonded to cusps of extracted premolars,
that endodontic procedures reduced the relative cuspal stiff-
ness by only approximately 5%. Loss of cuspal stiffness was
caused mainly by restorative procedures, and especially by
the loss of marginal ridge integrity.
The differing results of such studies arise, in part, from the
different methodologies used to assess weakening of teeth. Of
the many testing techniques available, nondestructive testing
offers significant advantages over destructive testing, particu-
larly in efficiency of experimental design and statistical analy-
sis. Both strain gauges and linear displacement devices (e.g.
linear variable differential transformer) provide means by
which the effects of procedures can be measured nondestruc-
tively. Whereas linear variable differential transformers meas-
ure bulk movements of cusps under load (14), strain gauges
provide a sensitive estimation of cuspal flexure (i.e. strains
within cusps) (13, 15). Direct current differential transformers
(DCDTs, a type of linear variable differential transformer)
were used in this study, since actual cusp movement is a more
accurate reflection of the clinical situation, and can be ex-
pressed quantitatively in micrometers of cusp movement.
Because they are nondestructive, both techniques permit se-
quential testing on the same tooth.
This study was designed to measure cuspal deflection of
extracted mandibular molars in response to endodontic and
restorative procedures. In an effort to simulate clinical con-
ditions as closely as possible, extensive cavity preparations
were cut before endodontic access. This allowed us to measure
the effect of endodontic access on an already weakened tooth.
By using DCDTs, the actual extent of cuspal deflection (in
micrometers) could be measured, rather than the less readily
understood relative stiffness reported by Reeh et al. (13).
58 Panitvisai and Messer Journal of EndodonUcs

MATERIALS AND METHODS LOAD CELL

Selection of Teeth
9.53 mm
DIAMETER
BALL
Intact, noncarious human mandibular molars (mainly
third molars) were collected immediately after extraction and REST SEAT
stored in buffered saline plus 0.05% sodium azide at 4"C.
DCDT I DCDT
Each tooth was cleaned and examined using a fiberoptic light,
and teeth with cracks or other visible defects were excluded.
Teeth were selected for regular occlusal anatomy and similar
crown sizes. Overall, 13 teeth were used in the study, within
3 months of extraction. • ......... iii °
Each tooth was mounted in a nylon ring using dental stone,
so that the stone covered the root to within approximately 2
mm of the cementoenamel junction; this was done to approx-
imate the support of alveolar bone in a healthy tooth. The
tooth was mounted vertically so that a steel loading ball (Figs.
1 and 2) would load equally on the two mesial cusps.

Preparation of Teeth
T T
Seats were cut within the enamel on the cuspal inclines of
the mesial cusps of the tooth with a modified white stone.
The diameter of the stone was identical to that of the loading
[
NYLON MOUN'IING DENTAL STONE
sphere (9.53 mm). The seats were cut far enough up the cuspal RING
incline so that when the tooth was subsequently prepared, the FiG I. Diagrammatic representation of a tooth undergoing testing.
steel sphere did not engage the cavity preparation (Fig. 1). When a vertical load is applied to the cusps via the loading sphere,
Cuspal movement during loading was measured as a linear horizontal cusp displacement is detected by the DCDT attached to
deflection by means of DCDTs. A 0.5-mm diamond round each cusp.
bur was used to cut a shallow indentation in the mesiobuccal
and mesiolingual cusps. This modification located the tip of
the DCDT probe as close as possible to the cusp tip. Deflection
was therefore monitored in a consistent buccolingual axis.

Cavity Preparation

The effects on cuspal movement of increasing sizes of cavity

preparation followed by endodontic access were measured
sequentially. Both two-surface (MO) and three-surface (MOD)
cavity preparations were tested. Finally, the mesial cusps were
separated from the distal cusps by a buccolingual groove. This
step of cuspal isolation was not intended to reproduce a
realistic clinical situation. It is much more extreme than is
likely to be encountered clinically, and was included only to
demonstrate the contribution of adjacent tooth structure to
protecting a cusp against flexure.
The teeth were divided into two groups each of six or seven
teeth. In group l, a sequence of MO cavity preparations of
FIG 2. Photograph showing a mandibular molar mounted in the testing
increasing size, followed by endodontic access, was performed.
apparatus, with a steel sphere occluding with the mesial cusps, and
Each tooth was subjected to a conservative cavity preparation, a DCDT probe contacting each cusp.
followed by an extensive preparation, endodontic access open-
ing, and cuspal isolation. The cavity designs are summarized
in Table 1. In group 2, a similar sequence of MOD cavity prepared under air-water spray with a high-speed handpiece
preparations was followed. In the endodontic access step, all using new carbide pear-shaped burs. Carbide burs (Komet
remaining dentin between the mesial proximal box form and H7L #010) were used for conservative cavities and #012 and
the pulp chamber was removed in both groups. This con- 014 burs were used for extensive cavities. Each bur was used
formed to the findings of an informal survey of mandibular for three cavity preparations.
molars treated in our graduate endodontic clinic. We found
that a large majority had no remaining dentin between the Load Testing
mesial proximal box and the access cavity. However, a layer
of dentin was left between the distal proximal box and the The nylon ring with mounted tooth was attached to the
pulp chamber in the MOD group. Cavity preparations were lower platen of a servohydraulic testing machine (model 810;
 Vol. 21, No. 2, February 1995 Cuspal Flexure 59
TABLE 1. Characteristics of cavity preparations used
Conservative Extensive
Occlusal depth (measured from MLi incline 1.5-2 mm >3 mm
of MBu cusp)
Isthmus width 1/4interouspal width 1/2-2h intercuspal width
Buccolingual box 20 ° angle Up to 90 ° (to line angles)
Depth of gingival floor 3-4 mm from marginal ridge 7-8 mm from marginal
ridge
Axial depth 1.5 mm 2.5 mm
Endoclontic access Standard access, resulting in the loss of all dentin between the
mesial proximal box and the pulp chamber
Cusp isolation A vertical groove was cut buccolingually just distal to the mesial
cusps, extending to the cementoenamel junction and com-
pletely isolating the mesial cusps from the remainder of the
crown

MTS Systems, Eden Prairie, MN) via three locating pins

mounted on an X-Y table. The steel sphere used to apply a
Intact
load to the mesial cusps was rigidly attached to the load cell [] MBu cusp]
on the crosshead of the MTS machine (Figs. 1 and 2). • MLi cusp
Throughout the study teeth were subjected to an occlusal
load by means of a steel loading sphere (diameter, 9.53 mm) Conservative MO
contacting the cuspal inclines of the two mesial cusps. Precise
vertical orientation of the tooth was obtained to eliminate
any tilting of the tooth during the loading cycle, by careful Extensive MO
adjustment of the mounting. The MTS machine was set to
provide ramped loading of 20 N/s for 5 s, and ramped
unloading at the same rate. This generated a maximum load Endo access
of 100 N, remaining within the physiological range experi-
enced by human dentition (15). Each tooth was loaded four
times at each stage in the experimental sequence, with loading Cusp isolation
only of the mesial cusps.
0 10 20 30 40 0
Measurement of Bulk Cusp Movement Cuspal deflection (~_~m)

The deflection of each cusp under load was monitored
using a DCDT (model 7DCDT-050; Hewlet-Packard, Rock-
viUe, MD). The devices were calibrated to an accuracy of
_+1.0 um. The HP 7DCDT series of displacement transducers
are linear variable differential transformers with built-in 6V
direct current excited carrier oscillator and phase-sensitive
demodulator systems, which provide unlimited resolution,
high accuracy, and sensitivity. The displacement was con-
verted to a readout in #m.
Two DCDTs were attached to the X-Y table using a
mounting that allowed a horizontal orientation at right angles
to the cusp surface and with the tip of the rod centered in the
indentation near the cusp tip (Fig. 1). The rod was held against
the tooth surface with a load of approximately 0.5 N by means
of a rubber band.
Statistical Analysis
Evaluation of the effect of cavity preparation on cuspal
flexure was undertaken using comparisons between the de-
flections for the various stages of preparation. Three-way
analysis of variance for MO and MOD groups was conducted,
using statistical software for personal computers (Minitab Inc.,
State College, PA). Cusp deflection was the dependent vari-
able; effects of cavity type (MO versus MOD), step in cavity
preparation, and cusp (MBu versus MLi) on cusp deflection
FIG 3. Cuspal deflection (measured in micrometers) associated with
each step in the cavity preparation sequence: MO group (six teeth).
were analyzed. To compare steps individually within and
between groups, a nonparametric analysis (Mann-Whitney U
test) was conducted.
RESULTS
Effect of Type of Cavity Preparation on Cuspal Stiffness
Two types of cavity preparation were investigated: the MO
group with the distal marginal ridge intact (six teeth) and the
MOD group (seven teeth). The MBu cusp and MLi cusp were
analyzed separately. Cusp movement was very low in intact
teeth (up to 1 ~m) (Figs. 3 and 4). In both the MO and MOD
groups, small increases in cuspal movement were recorded
with conservative and extensive cavity preparations (<2 um
and 3 to 5 um, respectively). Endodontic access in both groups
led to a 2- to 3-fold increase in cuspal movement, which was
greater in the MOD group (MBu cusp, 12.3 urn; MLi cusp,
16.5 um) than in the MO group (MBu cusp, 7.5 urn; MLi
cusp, 6.9 ~m). Cuspal isolation resulted in very large values
(25 to 50 urn) (Figs. 3 and 4).
For the analysis of variance, three main factors influencing
cuspal deflection were analyzed: type of cavity preparation
60 Panitvisai and Messer
Intact
[
E] MBu cusp]
• MLi cusp
Conservative MOD
Extensive MOD
Endo access
Cusp isolation
0 T0 20 30 40 50
Cuspal deflection (um)
FIG 4. Cuspal deflection (measured in micrometers) associated with
each step in the cavity preparation sequence: MOD group (seven
teeth).
(MO versus MOD), step of the cavity preparation sequence,
and cusp (MBu versus MLi). Highly significant effects were
observed for all of the independent variables. The MLi cusp
showed greater deflection than the MBu cusp (p < 0.001),
and the MOD preparation resulted in greater cuspal deflection
than the MO preparation (p < 0.001). The progressive loss of
tooth structure with sequential steps in the cavity preparations
also resulted in a highly significant increase in cuspal deflec-
tion (p = 0.000). From Table 2, two interactions showed
statistically significant effects, the interaction between cusp
and step in the cavity preparation sequence (p < 0.000) and
between cavity preparation type and step (p = 0.019). Thus,
the pattern of changes in cuspal deflection in the successive
steps in the cavity preparation sequence was influenced by
the type of cavity preparation (MO versus MOD) and the
cusp (MBu versus MLi).
Effect of Step of Cavity Preparation on Cuspal Stiffness
The analysis given above showed a highly significant effect
overall of the sequence of cavity preparations on cuspal
deflection. Nonparametric sign tests were conducted to deter-
mine which steps in the sequence were significantly different
from each other. In the MO group, extensive cavity (p =
0.0391), access (p = 0.0063), and cusp isolation (p = 0.0005)
were statistically significantly different from the preceding
step. In the MOD group, only access (p = 0.0001) and cusp
isolation (p = 0.0001) were statistically significantly different
from the preceding step.
The analysis of variance also showed a highly significant
effect of type of cavity preparation (MO versus MOD, p <
0.001) on cuspal deflection. Individual comparisons of MO
versus MOD preparation were conducted for each step of the
sequence, using the Mann-Whitney U test. Only the access
step showed a statistically significantly difference (p = 0.0003)
between MO and MOD preparations.
douma! of Endodontics
DISCUSSION
The effects of endodontic versus restorative procedures
were determined by measuring cuspal deflection with a DCDT
device attached to each cusp. The technique proved to be
extremely sensitive, since it was able to detect cuspal move-
ments of the order of 1 ~m. The magnitude of the cuspal
deflection under physiologically realistic loads was quite strik-
ing. Following endodontic access, individual cusps were dis-
placed by more than 10 ~zm in teeth with MOD cavity
preparations. After complete cuspal isolation from the rest of
the tooth (in an admittedly unrealistic clinical situation),
individual cusps flexed by up to 50 ~m without fracture of
any cusp in any of the teeth tested. Overall, the MLi cusp
showed greater deflection than the MBu cusp (p < 0.001).
This can be explained by the significantly larger buccolingual
dimensions of the MBu cusp (functional cusp) than the MLi
cusp (nonfunctional cusp), as well as the greater thickness of
enamel of the MBu cusp of lower molars (16).
The magnitude of the observed deflections has clinical
relevance beyond that of loss of cuspal strength. Restorations
that do not protect cusps (particularly MO or MOD amalgam
without cusp overlay) will not prevent cuspal flexure under
occlusal load. The potential production of large marginal gaps
between tooth substance and restorative material with every
chewing cycle has significant implications for marginal leak-
age.
In both the MO and MOD groups, endodontic access
resulted in a highly significant increase (p = 0.0063 and
0.0001, respectively) in cusp deflection over the preceding
step. In both groups, the extensive cavity preparation led to
cuspal movement of 3 to 5 urn, while endodontic access
produced a further 2- to 3-fold increase (Figs. 3 and 4). This
result is in contrast to observations of Reeh et at. (13), where
endodontic access led to only a small (5%) change in cuspal
stiffness. This apparent contradiction may be partly due to
the difference in tooth type (premolars versus molars) and in
methods of measuring changes in cuspal stiffness (strain
gauges versus DCDTs). We believe, however, that it is largely
due to the different criteria of cavity preparation. The results
of Reeh et al. (13) were based on a series of conservative or
"ideal" preparations for both restorative and endodontic pro-
cedures, with minimal loss of tooth bulk. Specifically, the
endodontic access in that study was cut within the confines
of the occlusal cavity floor, with remaining dentin between
the access opening and both proximal boxes. Thus, the effec-
tive "floor" of the cavity was not changed as a result of
endodontic access. In the present study, endodontic access
included removal of all dentin between the pulp chamber and
the mesial proximal box. This more realistically reflects the
normal clinical situation, as we found in examining cases in
our clinic.
Endodontic access in the MOD group weakened the tooth
significantly more than in the MO group (p = 0.0003). The
remaining marginal ridge supports the cuspal stiffness of the
tooth, leading to lesser cusp deflection (MBu cusp, 7.5 um;
MLi cusp, 6.9 ~m in the MO group versus the MBu cusp,
12.3 ~m; MLi cusp, 16.5 ~m in the MOD group). This
occurred even though the remaining marginal ridge was not
adjacent to the cusps under load. This is in agreement with
previous investigators (12, 13, 17). This study has shown that
remaining tooth structure (even the opposite remaining mar-
ginal ridge) is still a major contributor to cuspal stiffness.
 Vol. 21, No. 2, February 1"995 Cuspal Flexure 61

TASLE 2. Three-way analysis of variance of the effects of cavity type, step in the cavity preparation sequence, and cusp type on
cuspal deflection
df Seq SS Adj SS Adj MS F p
Source
Cusp 1 361.3 361.9 361.9 11.55 0.001
Step 4 25877.0 25324.2 6331.0 202.04 0.000
Type 1 362.9 362.9 362.9 11 3 8 0.001
Interactions
Cusp x step 4 963.7 977.4 244.4 730 0.000
Cusp x type 1 0.9 0.9 0,9 0.03 0.867
Step x type 4 386.4 386,4 96,6 3.08 0.019
Cusp x step x type 4 63.8 63.8 15.9 0,51 0.729
Error 110 3446.9 3446.9 31,3
Total 129 31462,8

Even the adjacent (distal) cusps provided support for the
mesial cusps under load. When a cusp was completely isolated
from the remainder of the crown of the tooth, cuspal deflec-
tion became much more extensive, ranging from 25 to 50
/,i,m.
The results also clarify the role that the dimensions of
cavity preparations play in cuspal flexure. Although several
laboratory studies have shown that cavity preparations cause
a significant decrease in the stiffness of teeth (10, 11, 13), the
majority have concentrated on the occlusal width of the
cavity. In one of the few studies concerned with the depth of
the cavity preparation, Blaser et al. (18) showed that a narrow
isthmus and deep pulpal floor preparation had a greater
weakening effect than a wide isthmus and shallow floor prep-
aration. Thus, in endodontically treated posterior teeth, the
main problem may well be the depth of the cavity, as the
floor of the pulp chamber effectively constitutes the cavity
floor. This appears to be the case when the layer of dentin
between the pulp chamber and the proximal box is lost.
Hood's (19) cantilever beam hypothesis is founded on such
reasoning: that cusps behave like simple cantilever beams
where the deflection of the beam (unsupported cusp) is pro-
portional to the cube of its length (L3). The results of this
study are consistent with such a hypothesis, and provide
support for the importance of restorations that protect cusps,
such as cusp overlays.
This study was supported by the National Health and Medical Research
Council of Australia.
The authors thank David Cheadle and Christopher Cain for their technical
support.
Drs. Panitvisaiand Messer are affiliated with the School of Dental Science,
University of Melbourne, Melbourne, Australia. Dr. Panitvisars permanent ad-
dress is School of Dentistry, Chulalongkorn University, Bangkok, Thailand.
Address requests for reprints to Dr. Harold Messer, School of Dental Science,
University of Melbourne, 711 Elizabeth Street, Melbourne 3000, Australia.
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