ORIGINAL ARTICLE „ 305

Archana Srinivasan, Roopa Nadig, Usha Gananeela, Vedavathi Boregowda,

Swapna Devarasanahaali Venataramanaswamy, Karthik Jagdeesh

Fracture resistance of endodontically treated teeth

restored with direct resin restoration reinforced with
fibre post and polyethylene fibre – an in vitro study
Archana Srinivasan,
post graduate student
Key words fibre post, fracture resistance, polyethylene fibre Roopa Nadig, MDS
Professor and Head

Aims and objective: To evaluate the effect of various reinforcement techniques with polyethylene Usha Gananeela,
fibre and fibre post on the fracture resistance of endodontically treated teeth. MDS
Professor
Materials and methods: Forty intact maxillary premolars receiving endodontic treatment and MOD
cavity preparation were divided into four groups: Group I – restored with resin composite; Group II Vedavathi Boregowda,
MDS
– fibre post inserted into the palatal canal followed by resin composite restoration; Group III – poly- Reader

ethylene fibre inserted in the occlusal third of the MOD cavity followed by resin composite restor- Swapna Devarasana-
ation; and Group IV – fibre post transfixed horizontally in a buccolingual direction within the MOD haali Venataramana-
swamy, MDS
cavity, followed by resin composite restoration. Fracture resistance was evaluated using the Universal Reader
testing machine.
Karthik Jagdeesh,
Results: ANOVA statistical analysis showed no significant difference in the fracture resistance be- MDS
tween Group 1 and Group 2, whereas, a significant difference was seen between Group 1 and Reader

Group 3 and also Group 1 and Group 4. The difference in mean fracture resistance was found to be All:
Department of Conservative
statistically significant between Group 2 and Group 3 as well as between Group 2 and Group 4. No Dentistry and Endodontics,
statistically significant difference was observed between Group 3 and Group 4 with respect to the Dayananda Sagar College of
Dental Sciences,
mean fracture resistance (P > 0.05). Bangalore, Karnataka, India
Conclusion: Horizontally transfixed fibre post and polythelene fibre placed within the resin composite
Correspondence to:
restoration showed improved fracture resistance. Dr Archana Srinivasan
The Oxford Dental College,
Hosur Road,
10th Mile Stone,
Bommanahalli, Bangalore -
560068 Karnataka, India
„ Introduction and restorative techniques have been proposed to Tel: +91998679660
Email: archana.srinivasan@
improve the therapeutic success of the teeth with rediffmail.com
Endodontically treated teeth are structurally dif- major structural loss.
ferent from unrestored vital teeth and require Cuspal coverage is thought necessary for the con-
specialised restorative treatment. Restoring non- ventional restoration of the nonvital posterior teeth
vital teeth is a major challenge because it requires to avoid cusp fractures3. Sometimes, in endodonti-
profound knowledge in endodontics, periodontics cally treated teeth, there are residual compromised
and operative dentistry. Among these factors, res- cusps, which are theoretically indicated for reduction
torative treatment for endodontically treated teeth and coverage with restorative materials4. This rec-
might be the most important. A good quality cor- ommendation may be modified for the adhesive res-
onal restoration significantly increases the success torations. With recent advances in adhesive restor-
rate of an endodontic treatment that is carried out ations, a concept of minimal intervention dentistry
well1,2. Against this background, different materials has been introduced to preserve the tooth structure

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306 „ Srinivasan et al Fracture resistance of endodontically treated teeth – an in vitro study

as much as possible, and it has been advocated that access cavities were prepared, with the buccolingual
with direct and indirect adhesive techniques, the in- width of the occlusal isthmus – of the width of the
ternal strength of teeth can be reinforced without intercuspal distance, and the buccolingual width of
occlusal capping5,6. proximal preparation – of the buccolingual width
Generally, placement of a post is indicated when- of the crown. The gingival extent of the prepar-
ever the coronal tooth structure is insufficient in qual- ation was 1 mm above the cementoenamel junction
ity and quantity to support a core build-up7. Because (CEJ); (3 mm occlusally, proximally – 3.3 mm), using
more tooth structure is removed during post place- a high-speed handpiece and a straight fissure dia-
ment, the resistance to occlusal forces is diminished mond point. Working length was determined and
and the possibility of fracture increases8. On the the canals were enlarged up to F1 size Protaper files
other hand, adhesive restorations, with the poten- (Dentsply, Surrey, UK). Both the canals (buccal and
tial to reinforce weakened tooth structure, transmit palatal) were dried with paperpoints and obturated
and distribute stresses across the bonding interface with Protaper F1 cone using AH Plus sealer (Dent-
to the tooth9-11. Therefore, even without fibre post sply). Gutta-percha (GP) cones were seared off at
placement, it is possible to dissipate occlusal forces in the level of the coronal orifice. Teeth were then di-
a wide surface area as a result of micromechanical ad- vided into four groups of 10 teeth each.
hesion, rendering the tooth more resistant to fracture.
Although fibre post placement within the canal
has shown contradictory results with the fracture re-
„ Restoration
sistance of endodontically treated teeth, a variation
Group I
in its position of placement, that is, placing it across
the mesio-occluso-distal (MOD) cavity preparation A Universal matrix band and retainer was applied to
of the endodontically treated teeth has shown an the tooth to confine the core build-up material. A non-
improvement in the fracture resistance12. rinse conditioner (ParaBond, Coltène/Whaledent, Alt-
Polyethylene fibres under composite restorations stätten, Switzerland) was applied to the entire cavity
in endodontically treated molars with MOD cavities and the excess was blot dried with a paper point.
increases fracture strength. Polyethylene fibres (Rib- One drop from each of two adhesives (ParaBond
bond; Seattle, WA, USA) are a reinforced ribbon with Adhesive A and ParaBond Adhesive B, Coltène/
high modulus of elasticity. It is treated with cold gas Whaledent) was mixed and applied for 30 s, and gen-
plasma to enhance its adhesion to synthetic restora- tly blow-dried to remove excess material. Then the
tive materials, including chemically cured or light entire cavity was filled with resin composite (ParaCore,
cured composite. The special fibre network of this Coltène/Whaledent) in increments and light cured.
material allows the efficient transfer of forces act-
ing on it. Presence of glass or polyethylene network
Group II
creates a change in stress dynamics at the enamel/
composite/adhesive interface. A standardised post space of 8 mm from the CEJ was
Therefore, this study has been designed to find prepared in the palatal canal using a Parapost drill,
a more conservative approach to restore endodonti- fibre post (no. 11, Tenax fibre post; both Coltène/
cally treated teeth, as compared to the conventional Whaledent) was selected. The fibre post was treated
and more invasive cusp capping procedure. with 3% hydrofluoric acid for 30 s and a silane cou-
pling agent was applied for 60 s and gently air dried.
The post space was irrigated with 2.5% NaOCl
„ Materials and methods and dried with paper points. Non-rinse conditioner
(ParaBond, Coltène/Whaledent) and bonding
Forty intact non carious maxillary premolars extracted agent (ParaBond Adhesive A and ParaBond Adhe-
for periodontal and orthodontic reasons were col- sive B, Coltène/Whaledent) were applied and the
lected, cleaned of debris and calculus, then stored in canal filled with dual cure resin cement (ParaCore,
distilled water at room temperature. Standard MOD Coltène/Whaledent). The treated post was placed

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 Srinivasan et al Fracture resistance of endodontically treated teeth – an in vitro study „ 307

inside the canal and cured for 40 s. The rest of the Fig 1 A diagram
CR depicting a Group III
cavity was filled as in Group 1. sample.
Fibre
FCR
DBS CR
Group III (Fig 1) 1 mm

In this group, the restoration of the MOD cavity

was done as in Group I. A groove was made with
a diamond bur in a buccolingual direction, which
was 2 mm in width and 1 mm in depth extending
from the buccal cusp to the palatal cusp. The buc- DBS
cal and the palatal ends were placed at the occlusal
third of the two surfaces. A groove was etched with Fig 2 (a and b) Group
37% phosphoric acid (Ultradent, South Jordan, UT, IV samples.
USA), rinsed for 10 s and air dried gently. Bonding
agent was applied in two coats (Swiss Tech SL bond,
Tulsa, OK, USA) with the applicator tips and light
cured for 20 s. Flowable composite (Synergyflow,
Coltène/Whaledent) was placed in the groove. This
was followed by the placement of a polyethylene
fibre (Ribbond; Ribbond, Seattle, WA, USA) within
the groove and light curing for 40 s. The rest of the
groove was then restored with dual cure resin ce-
ment (Paracore, Coltène/Whaledent). Finishing and
a
polishing was performed after the polymerisation of
the composites.

Group IV (Figs 2a and 2b)

Perforations in the teeth were made with a no. 2
round bur at the prominent point on the palatal and
buccal suface, so that it corresponded to the diam-
eter of the fibre post. A fibre post (no. 11, Tenax fibre
post, Coltène/Whaledent) was treated with hydro-
fluoric acid and silane coupling agent as in Group
II and was transfixed horizontally, through the per- b
foration, at the level of the dentinoenamel junction.
This location results in the least dental tissue weak-
ening. Luting was performed with flowable compos- mens were embedded in cold-cured acrylic resin
ite (Synergyflow, Coltène/Whaledent). Extremities up to 1.5 mm apical to the CEJ (to simulate bone)
of the post were cut with a diamond bur near the and subjected to a compressive force at a crosshead
buccal and palatal surfaces. This was followed by speed of 0.5 mm/min in a test machine. The force
restoration of the cavity as in Group I. was applied with a steel ball with a tip diameter of
5 mm. In all the specimens, the force was applied
to the occlusal surface of the restoration at 30 de-
„ Fracture testing
grees with the force-applying apparatus parallel to
The samples were subjected to thermocycling (6000 the long axis of the tooth, touching the buccal and
cycles at 5–55°C, dwell 30 s, transfer time 5 s) and lingual cusps. The force applied was measured in
stored in 37°C sterile water for 10 days. The speci- Newtons at fracture.

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308 „ Srinivasan et al Fracture resistance of endodontically treated teeth – an in vitro study

(P < 0.05) as well as between Group 1 and Group 4

Mean Fracture Resistance (Newtons) in the groups
(P < 0.01) was observed (Table 1).
Fracture Resistance (Newtons)

500
The difference in mean fracture resistance was
400 found to be statistically significant between Group 2
300 and Group 3 (P < 0.05), as well as between Group 2
and Group 4 (P < 0.01).
200
No statistically significant difference is observed
100 between Group 3 and Group 4 with respect to the
mean fracture resistance (P > 0.05).
0
Group 1 Group 2 Group 3 Group 4

Fig 3 Mean fracture resistance (Newtons) in the groups.

„ Discussion
„ Results Endodontically treated teeth demonstrate a lower
fracture resistance in the face of a myriad of intraoral
The statistical technique used in this study was forces because of coronal destruction from dental car-
Analysis of Variance (ANOVA). Higher mean frac- ies, fractures and previous restorations or endodontic
ture resistance was recorded in Group 4 followed techniques. Maxillary first premolars have a unique
by Group 3 and Group 1 respectively. The lowest position in the arch and contribute to aesthetics. On
fracture resistance was recorded in Group 2. The the other hand, they are exposed to a combination
difference in mean fracture resistance between the of shear and compressive forces in terms of function.
three groups is found to be statistically significant As a result, maxillary premolars need aesthetic restor-
(P < 0.01) (Fig 3). ations with high strength13. Also, this group of teeth
In order to find out among which pair of groups present a restorative challenge because of insufficient
there existed a significant difference, multiple com- remaining coronal structure. Maxillary first premolars
parisons using the Bonferroni method were carried were therefore chosen for the study. Mesio-occlusal-
out. It was observed that there was no significant dif- distal (MOD) cavities were prepared in the study to
ference between Group 1 and Group 2 with respect simulate a situation that is often found clinically, as the
to the mean fracture resistance (P > 0.05). But a MOD cavities have also shown to reduce the struc-
significant difference between Group 1 and Group 3 tural stability by about 63%14.

Table 1 Multiple comparisons.

Dependent Variable: Fracture Resistance (Newtons) Bonferroni

(I) Group (J) Group Mean Differ- Std. Error Sig. 95% Confidence Interval
ence (I–J) Lower Bound Upper Bound
Group 1 Group 2 2.95000 24.56463 1.000 65.6338 71.5338
Group 3 –72.89000* 24.56463 .032 –141.4738 –4.3062
Group 4 –785.51600* 24.56463 .008 –154.0998 –16.9322
Group 2 Group 1 72.89000 24.56463 1.000 71.5338 65.6338
Group 3 –75.84000* 24.56463 .023 –144.4238 –7.2562
Group 4 –88.46600* 24.56463 .006 –157.0498 –19.8822
Group 3 Group 1 72.89000* 24.56463 .032 4.3062 141.4738
Group 1 75.84000* 24.56463 .023 7.2562 144.4238
Group 1 –12.62600 24.56463 1.000 –81.2098 55.9578
Group 4 Group 1 85.51600* 24.56463 .008 16.9322 154.0998
Group 1 88.46600* 24.56463 .006 19.8822 157.0498
Group 1 12.62600 24.56463 1.000 –55.9578 81.2098

* The mean difference is significant at the .05 level.

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 Srinivasan et al Fracture resistance of endodontically treated teeth – an in vitro study „ 309

Several materials and techniques have been pro- in the stress dynamics at the enamel/composite/ad-
posed to increase the rate of success in restoring hesive interface18. Also, the possible reason could
teeth with extensive loss of tooth. In the present be that the extension of the fibre ends through the
study, the effect of fibre insert and fibre post on occlusal one-third of the buccal or lingual walls al-
the fracture resistance of endodontically treated pre- lowed the fibre to keep the cusps together. Also, the
molars restored with direct resin composite has been additional bonding ability of the material provides a
evaluated. greater fracture resistance in root-filled teeth with
Based on the results of this study, the highest MOD cavities. The fracture resistance also increases
fracture resistance was observed in Group IV (hori- when fibres are placed close to the point where force
zontally transfixed fibre post), followed by Group is exerted because it leads to a shorter working arm
III (polyethylene fibre). The least fracture resistance according to Lever’s Principle. Previous studies have
was seen in Group II, though there was no statistic- proved that the placement of fibres at the tensile
ally significant difference between Group I and II. side of resin composite specimens improves flexural
In Group I (the control group), post endodon- properties, whereas placement of fibres at the com-
tic restoration of the sample was done with dual pressive side leads to early crack formation19.
cure resin composite. Restoration of an endodonti- The tightly woven leno weave unique to Ribbond
cally treated tooth, especially premolars, with resin (Seattle, MS, USA) provides a fixed position between
composite is more conservative than the full cover- the warp (lengthwise) and weft (crosswise) fibres.
age crowns. Studies have shown that restoration The special fibre network of this material allows the
of MOD preparations in endodontically treated efficient transfer of the forces acting on it and the
maxillary premolars with direct resin composite presence of a glass or polyethylene network creates a
rendered the tooth a cusp fracture resistance which change in stress dynamics at the enamel/composite/
did not differ significantly from that of sound nat- adhesive interface. Polyethylene fibres under com-
ural teeth15,16. Hence, this group was chosen as a posite restorations in endodontically treated molars
positive control. with MOD cavities increases fracture strength.
Group II was restored with glass fibre post and The results also showed that there was signifi-
dual cure resin composite as a final restoration. Nam cant improvement in the fracture resistance when
et al found that the fracture resistance of endodon- a post was transfixed horizontally (Group IV). This
tically treated premolars with one to four remaining was in accordance with the study done by Baltrao
coronal walls significantly increased when they were et al12. It can be speculated that there was a po-
restored with fibre posts. Teeth showed better stress tential reinforcement of dental structure, preventing
distribution and fracture patterns when restored with cusp deflection. Since the modulus of elasticity of a
fibre posts17. Hence, in the present study, posts were fibre post is similar to that of dentine and the resin
used in the palatal canal of the teeth with two re- composite, compressive stress absorption may have
maining walls. Results of this study showed lower occurred, thereby increasing the collapse threshold
values for fracture resistance in Group II as compared of the adhesive interface and keeping the restoration
to Group I, although there was no statistically signifi- protected against fracture. In deep cavity prepar-
cant difference between the two groups. A possible ation, the compressive force acting on the occlusal
reason for this was that the removal of additional surface generates a tensile force in the dentine lo-
tooth structure during post space preparation to fit cated in the centre of the pulp chamber floor and
the prefabricated fibre post could have made the a strong compressive stress in the surrounding area
tooth weak8. – hence fracture occurs. Due to the cusp locking
The results showed that the use of polythelene produced by anchoring with a horizontally transfixed
fibres within the composite restoration (Group III) fibre post, the forces generated were prevented from
improved the fracture resistance of the endodonti- discharging on the pulp floor, avoiding fracture of
cally treated teeth. This is in accordance with the cusp and floor.
study done by Belli et al, wherein the improvement in In this study, a loading angle of 30 degrees with
the fracture resistance was attributed to the change the long axis in a buccal direction was used. Some

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