Effect of Two Different Types of Fibers on the Fracture

Resistance of Endodontically Treated Molars Restored

with Composite Resin
Sulthan Ibrahim Raja Khana / Ramachandran Anupamab / Mohanavelu Deepalakshmic /
Kumarappan Senthil Kumard

Purpose: To compare the in vitro fracture resistance of endodontically treated molars with mesio-occluso-distal
(MOD) cavities restored with two different types of fibers.
Materials and Methods: Sixty extracted human mandibular first molars were selected for the study and ran-
domly assigned to six groups (n = 10). Group 1 served as the control. In groups 2 through 6, endodontic access
and standard MOD cavities were prepared. Following root canal treatment, group 2 was left unrestored. In group
3, the teeth were restored with composite resin (Venus, Heraeus Kulzer). In group 4, flowable composite resin
(Venus, Heraeus Kulzer) was used before restoring the teeth with composite resin. In group 5, leno-woven ultra-
high molecular weight polyethylene ribbon fiber (Ribbond) was inserted in the flowable resin in a buccal to lingual
direction, and the teeth were then restored with composite resin. In group 6, translucent glass fiber (Vectris,
Ivoclar) was adapted over the flowable resin in the bucco-lingual direction and restored with composite resin. The
specimens were stored in 100% humidity at 37°C for 1 day. Compressive loading of the teeth was performed
using a universal testing machine at a crosshead speed of 0.5 mm/min. The mean load necessary to fracture
the samples was recorded in Newtons (N). Data were subjected to analysis of variance (ANOVA) and Duncan’s
post-hoc test, where significance was set at p < 0.001.
Results: The highest and the lowest mean fracture strengths were found in sound teeth (1598.8 N) and un-
restored teeth (393.7 N), respectively. The mean load necessary to fracture the samples was 958.6 N in the
polyethylene ribbon group (group 5), 913.2 N in the glass-fiber group (group 6), 699.7 N in teeth restored with
flowable resin and composite (group 4), and 729.3 N in group 3 with composite resin alone. Statistical analy-
sis showed significantly higher fracture resistance of both the fiber groups compared to composite resin alone
(p < 0.001).
Conclusion: Both polyethylene ribbon and glass fiber under MOD composite restorations significantly increased
fracture strength with no statistical difference between the two groups. Therefore, both polyethylene- and glass-
fiber-reinforced composites can be used for access cavity restorations in teeth with weakened cusps.
Keywords: composite resin, endodontic therapy, fracture resistance, polyethylene fiber, glass fiber, molars.

J Adhes Dent 2012; 15: 167–171. Submitted for publication: 12.10.11; accepted for publication: 23.04.12
doi: 10.3290/j.jad.a28731

a Senior Lecturer, Department of Conservative Dentistry and Endodontics,

Chettinad Dental College, Kelambakkkam, Kanchipuram District, India. Idea,
T he restoration of a pulpless tooth is a challenging as-
pect of endodontic therapy, as the tooth is weakened
due to the loss of cusps, ridges, or the arched roof of
hypothesis.
b
the pulp chamber.24,29 The strength of endodontically
Senior Lecturer, Department of Conservative Dentistry and Endodontics,
Chettinad Dental College, Kelambakkkam, Kanchipuram District, India. Ex- treated teeth also depends on the design of the res-
perimental design, wrote manuscript. toration and the type of restorative materials. An ideal
c Senior Lecturer, Department of Conservative Dentistry and Endodontics, restorative material should not only restore and seal but
Chettinad Dental College, Kelambakkkam, Kanchipuram District, India. should also reinforce the defective tooth.
Proofread manuscript.
The advancements in adhesive technology and the
d Professor and Head, Department of Conservative Dentistry and Endodontics,
Chettinad Dental College, Kelambakkkam, Kanchipuram District, India. Con-
strength of newer composites have made it possible to
tributed to discussion. create a conservative and esthetic postendodontic res-
toration. The cusps of teeth that are etched, bonded and
Correspondence: Dr. Sulthan Ibrahim Raja Khan, Chettinad Dental College, De- restored with composite resin are mechanically splinted
part of Conservative Dentistry and Endodontics, Rajiv Gandhi Salai, Kelambak- together and thus reinforce the teeth.12 However, the
kam, Chennai, 603103, India. +91-044-4742-8353, Fax: +91-044-4741-3343.
e-mail: [email protected] contraction of an extensive composite restoration due to

Vol 15, No 2, 2013 167

Khan et al

excess sealer wiped off with cotton. Subsequently, mesio-

2 mm occluso-distal (MOD) cavities were prepared up to the
1.5 mm
canal orifices in the teeth using a high-speed bur and
water spray. The thickness of the cavity walls was meas-
ured as 2 mm at the buccal-occlusal surface, 2.5 mm at
the cementoenamel junction, and 1.5 mm at the lingual-
Composite occlusal surface and cementoenamel junction. These
Resin measurements were made using a vernier caliper in all
the samples.
Group 2: MOD cavities were prepared and left unre-
stored.
2.5 mm 1.5 mm
Group 3: The cavities were cleaned and dried. The sur-
face of the cavity wall was etched with 37% phosphoric
polyethylene acid etching gel (Prime Dental Products; Thane, India) for
fiber
15 s and rinsed with water for 15 s. The cavity surfaces
were gently blot dried. Bonding agent (Gluma, Heraeus
Fig 1 Schematic diagram of cross section of the tooth show- Kulzer; Hanau, Germany) was applied to the cavity sur-
ing fiber placement. face using a microbrush and light cured for 20 s using a
QTH light-curing unit (Astralis 7, Ivoclar Vivadent; Schaan,
Liechtenstein). The cavities were then restored with a
polymerization shrinkage affects the outcome of the final hybrid resin composite (Venus, Heraeus Kulzer) using the
restoration.4 To overcome the polymerization shrinkage in- incremental technique; each layer was light cured for 40 s.
duced stresses, flowable composite resin has been used Group 4: The cavities were cleaned and dried. The
to act as a stress breaker.15,32 With the development of cavity surfaces were etched and bonded as described
different types of fibers, such as polyethylene or glass in group 3. The cavity surfaces were then coated with a
fiber, another option is available as stress relievers in layer of low viscosity resin composite (flowable composite
composite resin restorations.6 When reinforced with fib- resin, FCR) (Venus, Heraeus Kulzer) and cured for 20 s.
ers, composite resins show an increase in flexural modu- This low modulus liner was then covered with the same
lus and fracture resistance.30 However, the comparison hybrid resin composite using an incremental technique,
between the fracture resistances of different fibers has and each layer was cured for 40 s.
not been adequately tested. The aim of the present study Group 5: The cavities were cleaned and dried. The
was to compare the fracture resistance of root-filled mo- cavity surfaces were etched and bonded as described in
lars with MOD preparations between teeth restored with group 3. The cavity surfaces were coated with a layer of
polyethylene fiber and glass fiber under composite resin. low viscosity resin composite (FCR) as in group 4. Leno-
woven ultrahigh molecular weight polyethylene fiber (Rib-
bond, Ribbond; Seattle, WA, USA) was removed from the
MATERIALS AND METHODS package using cotton pliers. Care was taken not to handle
the fiber with bare hands or latex gloves. A piece of the
Sixty intact, freshly extracted human mandibular first fiber 10 mm long and 3 mm wide was cut. The fiber was
molars with complete root formation were selected for subsequently coated with adhesive resin. Excess material
the study. The teeth were free of caries, any previous was blotted off with lint-free gauze. Then the fiber was
restorations, and preexisting fractures or cracks when embedded inside the flowable composite on the buccal
observed under transillumination. The teeth were then wall, pulpal floor and lingual wall of the cavities before
stored in chloramine-T at 4°C and rinsed under water curing (Fig 1). After light curing for 20 s, the cavities
prior to use. The teeth were randomly assigned to six were restored with hybrid composite as described above
groups. Each group comprised 10 teeth. using an incremental technique, where each layer was
Group 1: control; no cavity preparation or root canal light cured for 40 s.
treatment. Group 6: The cavities were cleaned and dried. The
Groups 2 to 5: Standard access cavities were pre- cavity surfaces were etched and bonded as described in
pared in the teeth using a high-speed #245 bur (SS White; group 3. The cavity surfaces were coated with a layer of
Lakewood, NJ, USA) and water spray. The canals were low viscosity resin composite (FCR) as in group 4. Sections
instrumented with K-files using a step-back technique and of pre-impregnated translucent glass-fiber mesh (Vectris,
RC EZ lubricant (D-TECH; Pune, India) and 5.25% sodium Ivoclar Vivadent) 3 mm wide and 10 mm long were applied
hypochlorite irrigant. Apical preparation was performed to over the uncured flowable composite to the buccal wall,
size 35 for distal canals and size 30 for mesial canals, floor, and lingual wall of the cavities as in group 5. After
and step-back preparation was done to size 70. Teeth light curing for 20 s, the cavities were restored with hybrid
were obturated with 2% gutta percha (Dentsply DeTrey; composite using an incremental technique, where each
Konstanz, Germany) by cold lateral condensation using layer was light cured for 40 s.
AH plus sealer (Dentply DeTrey). After obturation, radio- Next, all the teeth in the various groups were mounted
graphs were taken. The chamber was then cleaned and in self-curing acrylic resin using 5.1 cm x 5.1 cm custom-

168 The Journal of Adhesive Dentistry

 Khan et al

made molds. Self-curing polymethyl-methacrylate resin Table 1 Fracture strength by group

(DPI) was mixed in a glass dappen dish and poured into
the mold. The teeth were embedded in the resin up to the Groups Fracture load (N)
level of the cementoenamel junction. After the resin had
set, the embedded teeth were removed from the mold. Minimum Maximum Mean SD
The specimens were subsequently stored in an incubator 1 1365.90 1866.50 1598.84d 168.36
at 37°C in 100% humidity for 24 h. Fracture resistance
testing was done in a Instron universal testing machine 2 355.50 421.00 393.79a 24.48
(Lloyds; Fareham, UK). The specimens were clamped onto 3 502.60 857.60 699.71b 114.57
the machine. Compressive force was applied with a 6-mm
diameter stainless steel bar centered on the tooth. Each 4 473.20 926.30 729.34b 168.00
sample was loaded at a crosshead speed of 0.5 mm/min.
5 767.60 1340.50 958.64c 162.79
In all cases the force was applied to the restoration touch-
ing the buccal and lingual cusps of the teeth. The test 6 744.40 1290.50 913.20c 151.35
machine’s software recorded the peak-loaded fracture.
Group definitions: 1: control. 2: endodontic access, standard MOD cavi-
The force necessary to fracture each tooth was recorded ties were prepared, left unrestored. 3: endodontic access, standard
in Newtons (N) for each sample and tabulated. This data MOD cavities were prepared, teeth restored with composite resin.
was then subjected to a one-way ANOVA and a post-hoc 4: endodontic access, standard MOD cavities were prepared, flowable
composite resin (Venus, Heraeus Kulzer) liner placed before restoring
Duncan’s multiple range test with p < 0.001. with composite resin. 5: endodontic access, standard MOD cavities were
prepared, leno-woven ultrahigh molecular weight polyethylene ribbon
fiber inserted in flowable resin and adapted to cavity, then restored with
composite resin. 6: endodontic access, standard MOD cavities were pre-
RESULTS pared, translucent glass fiber adapted over flowable resin, restored with
composite resin. Different superscript letters between subgroups denote
Mean fracture resistance (N) and the standard de- significance at the 5% level (post-hoc test).
viation for each of the six experimental conditions are
presented in Table 1. The statistical analysis indicated
that the fracture resistance of group 1 was significantly
higher than other groups (p < 0.001). Group 2 showed dergo cuspal fracture if restored with amalgam.7 How-
the least fracture resistance. In addition, there was no ever, improved fracture resistance of teeth after using
statistically significant difference in the fracture strength resin composites for MOD restorations has been demon-
between groups 3 (dentin bonding system + composite strated.10,18
resin) and 4 (flowable composite). Teeth restored with When restoring with composite, many factors may af-
polyethylene and glass fibers (groups 5 and 6, resp) fect the resistance of a tooth to vertical and/or cuspal
showed increased fracture resistance when compared fracture, such as cavity dimensions20 or the restorative
with teeth restored with composite resin only (group 3) systems utilized.21 Polymerization shrinkage is a prob-
(p < 0.001). No statistically significant differences were lem with extensive direct composite restorations. One
found between groups 5 and 6. of the methods suggested for reducing debonding during
polymerization shrinkage is to apply a low viscosity flow-
able resin to act as a “stress breaker”.33 Hence, in this
DISCUSSION study, the effect of flowable composite as an “elastic
buffer” under a composite resin was evaluated; it was
Endodontically treated teeth often lose substantial tooth found that the use of flowable composite liner did not
structure from previous caries, pre-existing restorations, increase fracture strength. Similar results were shown in
and/or endodontic procedures. 1 This compromise of previous studies by Belli et al.4,6 This phenomenon can be
architectural integrity results in reduced fracture resis- explained due to the presence of a weak interaction and
tance of endodontically treated teeth, especially molars, gap formation between the flowable resin and restorative
which are subjected to higher occlusal forces. resin.5 The presence of a void between the flowable and
Root canal treatment should not be considered com- hybrid composite would permit some flexure of the restor-
plete until the coronal restoration has been placed. The ation and subsequent flaw formation and fracture.5
various techniques and materials used for the final res- The development of fiber-reinforced composite (FRC)
toration include complete cast coverage,13 indirect cast technology has brought a new material into the realm of
restoration covering the cusps,24 complex amalgam res- metal-free, adhesive esthetic dentistry. Many investiga-
torations,27 and composite restorations.12 Adhesive res- tors have confirmed the reinforcing effect of fibers on dif-
torations transmit and distribute functional stresses bet- ferent polymer types.2,16 The explanation for this increase
ter across the bonding interface to the tooth, potentially was the transfer of stress from the weak polymer matrix
reinforcing weakened tooth structure.14 to fibers that have a high tensile strength.22
Mandibular molars were selected for the study because Many fiber types and architectures are available for
these teeth have a high incidence of caries and are sub- clinical use to reinforce dental composites. Currently, ul-
jected to high occlusal forces. An endodontically-treated trahigh molecular weight polyethylene fibers (UHMWPE)
tooth with an extensive MOD cavity preparation may un- and glass fibers are being used extensively. Continuous

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Khan et al

bidirectional fibers (woven, mesh type) reinforce the poly- The glass fiber group also demonstrated a high fracture
mer equally in two directions. The use of woven fibers pro- resistance in the present study. This is in accordance with
vides the orthotropic properties in a plane.31 Thus, mesh a study done by Oskoee et al.23 The glass fiber mesh
fibers of polyethylene and glass fibers were selected for could be easily cut and embedded into dental composite
the study. without any major structural alteration; the fiber bundles
Ribbond (Ribbond; Seattle, WA, USA) is a leno-woven maintain their orientation and do not separate from each
ultrahigh molecular weight polyethylene ribbon. Ribbond other when closely adapted to the contours of the teeth.
fibers exhibit high tensile strength, modulus of elastic- Thus, the favorable elastic modulus and the interwoven
ity, and fracture toughness, and also conform well to the nature of a fabric distribute the load over a wider area,
contours of the teeth. It is also biocompatible and has thereby decreasing the stress levels. These fibers con-
excellent optical properties.25 taining PMMA resin additionally form chemical bonds with
Glass fibers are used in different forms to strengthen the initial increment of the composite, and therefore resist
dental composites; woven glass-ribbon fabrics are most the composite pulling away from the margins. Thus, they
commonly used. Vectris is a continuous bidirectional fiber have a strengthening effect on the composite margins.
(woven type) based on the E-glass fiber system. The E- In the present study, both fiber groups showed sig-
glass fiber system is based on the SiO2-Al2O3-CaO-MgO nificantly high fracture resistance. Both polyethylene and
component, which has good glass-forming ability. The glass fibers have an inherent crack-stopping property.
glass fibers used in this study consisted of both linear This was theorized on the concept that the presence of
and cross-linked polymer phases. The linear phase in this the fiber network would create a change in the stress
material, which is polymethylmethacrylate (PMMA), is dis- dynamics at the restorative/adhesive interface. They
solved using bis-GMA, as shown by Lassila et al.17 Thus, also increase the resistance to dimensional changes
in this study, flowable composite resin (FCR) was used in or deformation.11 In addition, these fibers replace part
conjunction with glass fibers. of the composite increment, resulting in a decrease in
Although the literature contains many studies with the overall volumetric polymerization shrinkage of the
fiber-reinforced composite (FRC), the comparison between composite.
glass and polyethylene fibers as an “elastic buffer” to In the present study, a static loading method was used
reduce the polymerization shrinkage has not been suf- to test the samples for fracture resistance. A further study
ficiently evaluated. using a dynamic method to test the fatigue strength is
In the present study, the fracture test was performed by planned to strengthen the results. Moreover, a larger
applying axial forces to the center of the occlusal surface. sample size may have been able to demonstrate a differ-
The teeth were subjected to vertical compressive loading ence among the two fiber groups.
with a stainless steel sphere 6 mm in diameter. Numerous
studies have shown that the use of a 6-mm steel sphere
for resistance to fracture testing was ideal for molars, be- CONCLUSION
cause it contacts the functional and nonfunctional cusps
in positions close to those found clinically.9,28 The force Under the conditions of this in vitro study, it can be in-
needed to fracture the samples was recorded in Newtons. ferred that composite resin restoration of the prepared
Although microcrack formation leads to the eventual fail- cavities increases the fracture resistance of root-filled
ure of the restoration, the present study recorded the molars because of its reinforcing effect on the tooth
peak-load fracture in order to test the fracture resistance. structure. Use of flowable composite as a liner under
The results of the current study demonstrate that the composite restoration did not significantly increase
the fracture resistance of teeth restored with Ribbond the fracture resistance of root-filled molars because of
and glass fiber was much higher than the other restored the weak interaction and gap formation between the
groups. However, the difference between the two fiber flowable composite and restorative resin. Finally, inser-
groups was statistically not significant. tion of a polyethylene ribbon fiber or a glass fiber be-
Polyethylene fibers show a mean fracture resistance neath composite resin in root-filled molars with a MOD
of 958.6 N, significantly higher than teeth restored with preparation significantly increased fracture strength with
only composite resin (group 3). Other authors have re- no statistical difference between the two groups. Thus,
cently reported similar outcomes.6,26,28 The open geom- both the polyethylene and glass fibers prove their role
etry of the tightly woven leno-weave allows for complete as a “stress breaker” in counteracting the polymeriza-
infusion and “wet-out” of the fibers by the resin. To tion shrinkage stresses of composite core buildup res-
reduce the fiber’s superficial tension, gas plasma treat- torations.
ment has been used, ensuring a good bond to composite
materials.34 The leno-weave fiber possesses the proper-
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