Context and challenges of numerical simulation in dentistry

Modern dentistry is moving away from a craft-based approach to integrate the precision of bio-engineering. The oral cavity constitutes a complex biomechanical environment, characterized by irregular 3D geometries, anisotropic materials, and multiaxial masticatory forces. Traditional experimental methods, such as photoelasticity or strain gauges, reach their limits as they only capture qualitative or surface data. This narrative review examines how Finite Element Analysis (FEA), a technique derived from aerospace, has established itself to quantify internal stress gradients, which are inaccessible by classical physical measurements.

Study objectives and hypotheses

This synthesis, covering the literature from 1969 to June 2026, aims at four objectives: to trace the historical evolution of FEA in dentistry, to define its specific methodological framework, to list its applications across all specialties (from implantology to endodontics), and to critically evaluate its technical limitations. The authors explore the hypothesis that FEA is a major tool for hypothesis generation and prosthetic design optimization, while highlighting a critical paradox: despite an exponential growth in publications, predictive reliability remains compromised by excessive simplification of biological tissues and a lack of systematic in vivo clinical validation.

Narrative review methodology

This narrative review synthesizes data related to finite element analysis (FEA) in dentistry over a period spanning from 1969 to June 2026. The search was conducted via PubMed/MEDLINE, Scopus, EMBASE, Cochrane Library, and Google Scholar databases.

The selection protocol was based on the following criteria:

• Inclusion of primary research articles on FEA, systematic reviews, and reference textbooks.
• Exclusion of congress abstracts without full text and studies focusing exclusively on non-dental anatomical sites.
• Limitation to English language publications.

Search terms combined keywords such as "finite element analysis", "FEA", "dental biomechanics" and "stress distribution". The authors state that no formal systematic process (PRISMA standards) was applied, as this synthesis was not subject to prospective registration.

The evaluation of the reported methodological quality is based on the compilation of data from specialized journals. Notably, in implantology and prosthodontics, the study by Qiu et al. (2024) reveals that only 2.5% of the models (1 out of 40) underwent experimental validation. In parallel, a historical benchmark analyzing 601 studies published between 1997 and 2016 reports an overall validation rate of 8%.

Current status of validation and methodological quality

This narrative review highlights a significant discrepancy between the ubiquity of Finite Element Analysis (FEA) in dental research and its effective experimental validation. Although the tool is used to model complex structures (bone, teeth, prostheses), the synthesis of data by specialty reveals critical gaps in terms of reliability.

Critical observations by field of application

The analysis of the compiled data highlights systematic errors and persistent technical challenges:

• Periodontology: Erroneous values for the periodontal ligament's modulus of elasticity, introduced in 1980, have spread through hundreds of articles. A sensitivity analysis shows that an inappropriate value can overestimate stresses by up to 1195%.
• Endodontics: No study has yet successfully applied the extended finite element method (XFEM) to test the cyclic fatigue or crack propagation of NiTi rotary instruments, due to the complexity of material properties.
• Oral & Maxillofacial Surgery: The use of CBCT imaging now allows for patient-specific models, but 12 distinct models of heterogeneous bone materials have been identified, illustrating a lack of standardization.

Intrinsic limits and qualitative observations

The review identifies seven fundamental limitation points, notably the oversimplification of biological tissue properties (often considered isotropic and linear when they are anisotropic) and the absence of validated dynamic loading models. The authors emphasize that the anatomical fidelity enabled by CBCT should not be confused with total biological representativeness. The quality of the results strictly depends on the precision of the geometric reconstruction and the realism of the applied loading conditions.

Analysis: Between cutting-edge simulation and clinical reality

This narrative review highlights the transformation of finite element analysis (FEA) from an aerospace engineering tool into a pillar of odontological research. Clinically, FEA offers an unprecedented ability to visualize internal stress gradients, which are inaccessible to traditional strain gauges. It allows for the optimization of implant design and the anticipation of bone response under occlusal loading. However, the authors emphasize a major point: FEA is a hypothesis generator and not direct clinical evidence. The correlation between a simulated stress zone and actual bone loss depends on the accuracy of the input parameters.

Limits of the computational approach

The study identifies persistent technical challenges that qualify the scope of the results. The oversimplification of biological tissues — often modeled as isotropic when they are complex and anisotropic — constitutes a major bias. Furthermore, the majority of the literature suffers from a lack of experimental validation and dynamic loading models. Contrary to the early studies of 1969, while geometric precision has improved thanks to CBCT, biological fidelity remains incomplete, as models do not yet capture the full reactivity of living tissue.

Implications for daily practice

For the practitioner, these results mean that conclusions derived from numerical simulations must be integrated with caution. Although FEA is excellent for comparing two abutment designs or evaluating the impact of an implant position, it cannot guarantee clinical success without prospective human validation. The practitioner should perceive these studies as guides for understanding fundamental mechanical principles rather than as infallible predictions of the treatment outcome.

Summary

This literature review (1969-2026) highlights that while FEA is a major optimization tool, its experimental validation remains the exception: only 2.5% to 8% of studies in implantology compare their models with physical or clinical tests. In pediatric dentistry, 100% of the analyzed studies present a high risk of bias according to the ROBFEAD tool.

In concrete terms, for the practitioner:

• Check the validation: Do not modify your protocol based solely on a numerical simulation; without in vivo or in vitro correlation, these results are only design hypotheses.
• Nuance the precision: A 3D model derived from a CBCT is anatomically faithful but mechanically simplified; the calculated stresses often overlook the actual complexity of biological tissues.
• Priority to clinical evidence: For the choice of prosthetic materials or implant designs, prioritize data from clinical follow-ups rather than the colored stress maps in commercial brochures.

Technical Lexicon of the Study

Experimental validation: An essential process comparing numerical results with real physical measurements (in vitro or in vivo). It is absent in more than 90% of current FEA literature.

XFEM (Extended Finite Element Method): Extension of FEA designed to model discontinuities such as cracks, but whose application to the cyclic fatigue of NiTi instruments is not yet clinically validated.

Anisotropy: Property of dental and bone tissues whose mechanical behavior varies according to the direction of the force. Most models simplify this reality by assuming uniform behavior (isotropy).

Convergence test: Verification step ensuring that simulation precision no longer depends on the digital mesh size. Less than 30% of implantology studies report this essential test.

Heterogeneity: Representation of tissue density variation (e.g., cortical vs. cancellous bone). Modern CBCT models attempt to capture this heterogeneity to improve anatomical fidelity.

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