JPOR 394 No.

of Pages 7

journal of prosthodontic research xxx (2017) xxx –xxx

Available online at www.sciencedirect.com

Journal of Prosthodontic Research

journal homepage: www.elsevier.com/locate/jpor

Original article

Fracture resistance of endodontically treated teeth

restored with short fiber composite used as a core
material—An in vitro study

Dr.Tejesh Gupta Garlapati BDS, Dr.Jogikalmat Krithikadatta MDS *,

Dr.Velmurugan Natanasabapathy MDS
Meenakshi Ammal Dental College & Hospital, Department of Conservative Dentistry and Endodontics, Maduravoyal,
Chennai, 600095, India

article info abstract

Article history: Purpose: This in-vitro study tested the fracture resistance of endodontically treated molars
Received 12 October 2016 with Mesial-Occluso-Distal (MOD) cavities restored with fibre reinforced composite material
Received in revised form everX posterior in comparision with hybrid composite and ribbond fiber composite.
26 January 2017 Materials and methods: Fifty intact freshly extracted human mandibular first molars were
Accepted 15 February 2017 collected and were randomly divided into five groups (n=10). Group 1: positive control (PC)
Available online xxx intact teeth without any endodontic preparation. In groups 2 through 6 after endodontic
procedure standard MOD cavities were prepared and restored with their respective core
materials as follows: group 2, negative control (NC) left unrestored or temporary flling was
Keywords:
applied. Group 3, Hybrid composite (HC) as a core material (Te-Econom Plus Ivoclar Vivadent
Fracture resistance
Asia) group 4, Ribbond (Ribbond; Seattle, WA, USA)+conventional composite resin (RCR)
Short fiber composite
group 5, everX posterior (everX Posterior GC EUROPE)+conventional composite resin (EXP)
Core material
after thermocycling fracture resistance for the samples were tested using universal testing
Reinforced composite resin and post
machine. The results were analysed using ANOVA and Tukey’s HSD post hoc tests.
endodontic restoration
Results: Mean fracture resistance (in Newton, N) was group 1: 1568.4221.71N, group 2: 891.0
 50.107N, group 3: 1418.3 168.71N, group 4:1716.7199.51N and group 5: 1994.8
 254.195N.
Conclusion: Among the materials tested, endodontically treated teeth restored with everX
posterior fiber reinforced composite showed superior fracture resistance.
© 2017 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

1. Introduction cusps, ridges and the arched roof of the pulp chamber [1]. This
structural loss is often a result of caries, trauma, access cavity
Endodontically treated teeth are structurally weakened due to preparation and radicular preparation [2]. Certain iatrogenic
loss of physical characteristics like loss of tooth structure, factors like effect of chemicals and intracanal medicaments,

* Corresponding author.
E-mail addresses: tejjo89@gmail.com (T.G. Garlapati), drkrithikadatta@hotmail.com (J. Krithikadatta), vel9911@yahoo.com
(V. Natanasabapathy).
http://dx.doi.org/10.1016/j.jpor.2017.02.001
1883-1958/© 2017 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: T.G. Garlapati, et al., Fracture resistance of endodontically treated teeth restored with short fiber
composite used as a core material—An in vitro study, J Prosthodont Res (2017), http://dx.doi.org/10.1016/j.jpor.2017.02.001
JPOR 394 No. of Pages 7
2 journal of prosthodontic research xxx (2017) xxx –xxx
Table 1 – Composition of the materials testes in the study.
S. no Materials tested
1. Hybrid composite
(Te-Econom Plus ivoclar Vivadent Asia) LOT: U33179
2. everX posterior (everX posterior GC EUROPE) LOT:1407081
3. Ribbond (Ribbond; Seattle, WA, USA) LOT: 9560
bis-GMA: bisphenol-A-glycidyldimethacrylate; TEGDMA: triethylene glycol dimethacrylate; PMMA:polymethylmethacrylate; bis-EMA:
Ethoxylatedbisphenol-A-dimethacrylate; wt%: weight percentage.
non-iatrogenic factors like history of recurrent pathology,
anatomical position of the teeth and effect of ageing on the
dentinal tissues can also result in fracture of endodontically
treated teeth [2]. Studies have shown that endodontically
treated teeth have reduced level of proprioception [3,4] and
hence impaired normal protective reflex. Long term survivabil-
ity of root canal treated teeth not only depends on the success of
the endodontic treatment but also on the amount of remaining
dentine thickness and post endodontic restoration [5].
Restoring endodontically treated teeth with appropriate
material, capable to resist fracture is an important factor to be
considered during post endodontic restoration. With the
development and advancements of dentin bonding systems
and increased strength of the newer fibre reinforced compos-
ite materials, these structurally and chemically weakened
teeth could be reinforced. Eskitascioglu et al., reported that
endodontically treated teeth are susceptible to fracture and
this can be prevented by using fiber reinforced composite
materials [6]. Belli et al., placed polyethylene fiber ribbon in the
bed of flowable resin to reinforce tooth structure and
concluded that placement of fiber under composite restora-
tion significantly increased the fracture strength of enodo-
dontically treated teeth [7].
When fibres like polyethylene and glass are used, they act
not only as a stress reliever in composite resins [8] but also show
increased resistance to fracture and flexural modulus [9,10].
Recently e-glass fibre with barium glass filler fiber reinforced
composite material everX posterior has been introduced.
Manufacturers claims that this short-fiber composite reinforces
the restoration by preventing crack formation which is the main
cause for failure of the post endo restoration.
Mechanical properties of polyethylene fiber [10,7,11] and
everX posterior [12–16] have been reported in literature, but the
evidence on fracture resistance of everX posterior, when used
as a core material in an appropriate tooth model has not yet
been studied. Hence the aim of this study is to compare
fracture resistance of an endodontically treated molars with
MOD cavities restored with fibre reinforced composite
material everX posterior in comparision with Hybrid compos-
ite and polyethylene ribbond Fiber composite in a tooth model
replicating the clinical scenario.
2. Materials and methods
Fifty intact freshly extracted human mandibular first molars of
similar dimensions with complete root formation were
collected from the department of Oral and Maxillo-facial
Please cite this article in press as: T.G. Garlapati, et al., Fracture resistance of endodontically treated teeth restored with short fiber
composite used as a core material—An in vitro study, J Prosthodont Res (2017), http://dx.doi.org/10.1016/j.jpor.2017.02.001
Specification of the material
bis-GMA, bis-EMA, UDMA, silica 78.5 wt%
Short E-glass fiber with barium galss fillers, bi-GMA, TEGDMA and PMMA
Leno Weave Ultra High Modulus polyethylene fiber ribbon.
surgery of our institution. All the teeth were extracted due to
periodontal reasons and were caries free and without any
previous restorations, pre-existing fractures or cracks when
observed under maginification & transillumination. Any
calculus and soft tissues deposits were removed from the
teeth using a hand scaler, rinsed in water and stored in
physiological saline. To avoid size discrepency of the tooth,
small and large teeth were excluded and then randomly
divided. All the teeth were used within one month from the
time of extraction.
2.1. Preparation of base
To mimic or reproduce the alveolar bone and periodontal
ligament, root surfaces of all the teeth were dipped in molten
wax to 1mm apical to the cement-enamel junction (CEJ) which
resulted in formation of about 0.2–0.3mm thick wax layer.
Custom made molds of standard size of 5.15.1cm were
prepared for mounting the samples. Self-curing polymethyl-
methacrylate resin mixed in porcelain jar and poured in to the
mold. All the samples were embedded vertically into the mold
to a level 1mm apical to the CEJ. The teeth samples were
removed from the resin block after the resin had set and wax
was eliminated from the samples and the base. Elastomeric
impression material was loaded in the mold cavity and the
sample was re-seated in position. The extruded flash paste
was trimmed with a no.15 scalpel blade.
The samples were randomly divided into 5 groups (n=10)
(Table 1):
Group 1: positive control (PC) intact teeth without any
endodontic preparation.
Groups 2–5 after Endodontic procedure MOD cavities were
prepared and divided accordingly.
Group 2: negative control (NC) left unrestored or temporary
filling was applied.
Group 3: Hybrid composite (HC) as a core material (Te-
Econom Plus ivoclar Vivadent Asia).
Group 4: Ribbond (Ribbond; Seattle, WA, USA) + conven-
tional composite resin (RCR).
Group 5: everX posterior (everX Posterior GC EUROPE) +
conventional composite resin (EXP).
2.2. Endodontic procedure (Groups 2–5)
Standard endodontic access cavities were prepared in 40 teeth
using high speed airotor hand piece (NSK Nakanishi Inc Japan)
with coolant, No: 2 Endodontic aceess bur (Dentsply DeTrey;
Konstanz, Germany) later access cavity was refined using
JPOR 394 No. of Pages 7
journal of prosthodontic research xxx (2017) xxx –xxx
start-X tips (Dentsply DeTrey; Konstanz, Germany). The
coronal pulp tissue was removed with spoon excavator and
canal patency was confirmed with 10 size k-file (Mani Inc.,
Tochigi, Japan). The canals were negotiated with 15 k-file till
the apical foramen and working length is determined by
subtracting 1mm from this length. The coronal portion of all
the canals were enlarged using Gates Glidden drills (Mani Inc.,
Tochigi, Japan) till size 3 with slow speed contra angle hand
piece. Remainder of the root canals were prepared employing
the step back-technique using ISO k-files, 17% EDTA gel (RC
HELP Prime Dental Products; Thane, India) lubricant and 3%
sodium hypochlorite irrigant (Prime Dental Products; Thane,
India). Apical enlargement was done to file size 35 for the distal
canals and size 30 for the mesial canals and step-back done till
file size 70. Canals were dried with paper points and obturated
with 2% gutta percha (Dentsply DeTrey; Konstanz, Germany)
and AH plus (Dentsply DeTrey; Konstanz, Germany) as an
endodontic sealer using cold lateral compaction technique.
Root canal obturation material at the canal orifice, on the
access cavity walls were removed with hot excavators and the
chamber was cleaned with cotton. Obturation was evaluated
radiographically. Pulp chamber floor was layered with resin-
modified glass-ionomer cement (GC Fuji II LC Capsule, GC
Corporation).
MOD cavities were prepared down to the level of canal
orifice using high speed airotor hand piece with coolant, Endo
acess bur maintaining the following thickness of the walls: (1)
Buccal wall at buccal occlusal surface—2mm. (2) CEJ—2.5mm.
(3) Lingual occlusal surface—1.5mm. (4) Lingual cemento
enamel junction—1.5mm as show in (Fig. 1a). The widths of
the remaining wall thickness were measured using digital
calliper (Aydal, Istanbul, Turkey) to ensure the thickness.
2.3. Post-endodontic restoration (Groups 3–5)
The access cavities were restored with respective restorative
materials as described below. The restorative procedures were
carried out using Tofflemire matrix system (Hu-friedy,
Chicago, IL, USA) for creating the proximal contours.
2.3.1. Group 3
The surface of the cavity was etched with 37% phosphoric acid
etching gel (Prime Dental Products; Thane, India) for 15s and
rinsed with water for 15s. Floor and walls of the cavity were
gently blow-dried. Using micro applicator tips, the bonding
agent was applied to all the cavity surfaces and light cured for
20s using Elipar Freelight 2 (3M ESPE, Saint Paul, USA). The
cavity was restored with Hybrid composite (Te-Econom Plus,
Ivoclar Vivadent, Asia) using incremental technique of 1.5mm
thickness (Fig. 1b) and each layer cured for 40s. The intensity of
the light cure unit was checked using dental radiometer
(Demetron, Kerr, Orange, CA, USA) to avoid declining in
intensity of the light.
2.3.2. Group 4
The surface of the cavity was etched and bonded as described
in group 3. Surface of the cavity was coated with low viscosity
resin composite (3M-ESPE, St Paul, MN, USA). Leno Woven
Ultrahigh Molecular weight (LWUHM) polyethylene fibre
(Ribbond; Seattle, WA, USA) was cut to measure 10mm long
Please cite this article in press as: T.G. Garlapati, et al., Fracture resistance of endodontically treated teeth restored with short fiber
composite used as a core material—An in vitro study, J Prosthodont Res (2017), http://dx.doi.org/10.1016/j.jpor.2017.02.001
3
and 3mm wide. The fibre was coated with the adhesive resin
(3M-ESPE, St Paul, MN, USA) and excess adhesive was removed
from the fiber surface using a dry hand instruments towards
the direction of the fibers. The fibre was inserted inside the
cavity and adapted over the pulpal floor, buccal and lingual
wall as shown in (Fig. 1c). The low viscosity resin composite
and the polyethylene fibre were cured together for 20s. The
reminder of the cavity was restored with hybrid composite as
mentioned in group 3 by using incremental technique and
curing each layer individually.
2.3.3. Group 5
The cavity surface was etched and bonded as mentioned in
group 3. The entire cavity was restored with everX posterior
(everX Posterior GC EUROPE) using incremental technique
leaving 2mm for placement of top layer using Hybrid
composite (Fig. 1d) (Te-Econom Plus ivoclar Vivadent Asia)
and curing each layer for 20s.
The occlusal surface was finished with 30 mm finishing bur
(Dentsply DeTrey; Konstanz, Germany) and polished with
medium to super-fine aluminium oxide polishing disks (Sof-
lexTM, 3M ESPE, St Paul, MN, USA). All the samples were
subjected to thermocycling as recommended by Gale and
Darvell [17]: 35  C (28s), 15  C (2s), 35  C (28s), 45  C (2s) which
completes one full cycle. This cycle was repeated for
3 consecutive days.
2.4. Fracture resistance testing
All the samples were fixed with help of a clamp and positioned
in universal testing machine (Instron 3382 USA universal
testing machine). Compressive force was applied on the centre
of the samples using 6mm stainless steel sphere in contact
with three points including buccal, lingual walls and the
restoration surface, with a cross head speed of 0.5mm/min.
The peak-load fracture was recorded in Newtons (N) for each
sample and tabulated. Fracture specimens were observed
under stereomicroscope to ascertain the fracture modes.
2.5. Statistical analysis
The mean values between groups were compared with one
way ANOVA followed by Tukey’s HSD post hoc tests for
multiple pairwise comparisons with (p value <0.05) was
considered statistically significant (Fig. 2).
3. Results
The highest fracture resistance values were found in EXP
(group 5) 1994.8254.2N and the lowest fracture resistance in
NC (group 2) 89150.1N respectively. The mean load required
for fracture of the samples was 1568.4221.7N for PC (group 1),
1418.3168.7N for HC (group 3), 1716.7199.5N for RCR (group
4) and 1994.8254.2N for EXP (group 5) (Table.2). Among the
materials tested EXP (group 5) showed higher values when
compared with other groups (p<0.001) (Table.3). The failure
modes observed in the samples are illustrated in Fig. 3 and
results shown in Table 4. All the samples of HC group showed
cohesive failure within the composite core while similar
JPOR 394 No. of Pages 7

4 journal of prosthodontic research xxx (2017) xxx –xxx

Fig. 1 – Schematic illustration of the tooth model. (a) No coronal restoration, (b) after etching and bonding coronally restored with
Hybrid compostite, (c) after etching, bonding placement of polyethylene fiber and restored with composite, (d) after etching,
bonding application of everx posterior followed by composite restoration as a top layer. B, buccal; L, lingual; CR, composite resin;
DBS, dentin bonding system; FCR, flowable composite resin; EXP, evereX posterior; PEFR, polyethylene fiber ribbond; PDL,
periodontal ligament; GP, gutta-percha; RMGIC, resin modified glass-ionomer cement.

Please cite this article in press as: T.G. Garlapati, et al., Fracture resistance of endodontically treated teeth restored with short fiber
composite used as a core material—An in vitro study, J Prosthodont Res (2017), http://dx.doi.org/10.1016/j.jpor.2017.02.001
JPOR 394 No. of Pages 7

journal of prosthodontic research xxx (2017) xxx –xxx 5

2500

2000

1500

1000

500

0
HC RCR EXP NC PC

Fig. 2 – Mean and SD load values at the point of fracture of

different experimental groups (HC: Hybrid composite; RCR:
Ribbond+conventional composite resin; EXP: everX posteri-
or+conventional composite resin; NC: negative control; PC:
positive control).

finding was noted in 5 samples in RCR group and 2 samples of

EXP group respectively. Samples in EXP group showed more of
adhesive failure. All the samples with different core materials
experienced favorable fracture (coronal to the CEJ).

4. Discussion
Access cavity preparation during endodntic therapy has an
impact on the structural integrity of the tooth structure and
renders the tooth prone for fracture. According to Randow and
Glatz, when pulp is removed during routine endodontic
therapy there is loss of positive feed back mechanism, which
contributes for fracture of teeth [4].
Endodontic therapy alone reduces tooth stiffness by only
5% where as compromised tooth structure especially in an
MOD preparation reduces tooth stiffness by 69% [18]. An ideal
post endodontic restoration should be capable of transmitting
and distributing functional stresses while maintaining ade-
quate coronal seal. Major contributing factors that affect the
resistance of a tooth to fracture are cavity dimensions and
properties of the restorative materials. In complex direct
composite restorations polymerization shrinkage is major
factor for debonding of the restorative material. However this
can be overcome by the use of a low viscosity flowable resin
that act as a stress beaker [10]. Nevertheless, direct composite
restoration may not function optimum in large access
preparations.
In our study we have used mandibular molars because
these teeth have a high incident rate for developing dental
caries that necessiate restorative intervention [19]. Also, these
teeth are subjected to heavy occlusal forces and more prone to
fracture [20,21].
Endodontically treated teeth with an extensive MOD
preparation were selected in the study because this cavity
design with long cusp exhibit high cuspal deflections, thus
representing the worst case secenario [22]. To evaluate a
Fig. 3 – Categories of failure modes observed in samples: Red
arrow: Adhesive failure; Blue arrow: Cohesive failure and
Green arrow: Mixed failure.
restorative material for high fracture resistance, periodontal
ligament and bone has to be incorporated in the in-vitro testing
models, which has a significant effect on stress distribution
and fracture resistance [23]. However many studies in the
literature have excluded this step [24–26]. A finite element
analysis by Rees, concluded that inclusion of periodontal
ligament and bone is mandatory in these type of tests [27]. A
thin layer of elastomeric impression material was used to
mimick the periodontal ligament as recommended in previous
studies [28–30]. This aids in dampening of the occlusal forces
incident on the samples. Thermocycling of samples repro-
duced the ageing of the restoration as seen in clinical situation.
The effect of reinforcment using bonded fibers have been
demonstrated eariler [22]. With the use of reinforced compo-
sites, the bondable reinforcement fibers like polyethylene fiber
and glass fibers, when used in endodontically treated tooth
help in improving the fracture resistance of the tooth structure
[10]. Polyethylene longitudinal fiber is made of with a spectrum
of 215 fibers. When high amount of load is applied to the tooth
structure these fibers undergo stress-modifying effect by
absorbing and distributing the forces to the tooth. This is made
possible due to the monoblok created between dentin and
restorative material [31]. This polyethyelene fiber is with
special pattern of cross linked locked stitched threads which

Please cite this article in press as: T.G. Garlapati, et al., Fracture resistance of endodontically treated teeth restored with short fiber
composite used as a core material—An in vitro study, J Prosthodont Res (2017), http://dx.doi.org/10.1016/j.jpor.2017.02.001
JPOR 394 No. of Pages 7

6 journal of prosthodontic research xxx (2017) xxx –xxx

Table 2 – Mean load of experimental groups recorded at the point of fracture.

Groups N Mean Std. deviation Minimum Maximum p-Value
HC 10 1418.3 168.7 1058 1731 <0.001
RCR 10 1716.7 199.5 1445 2174
EXP 10 1994.8 254.2 1666 2431
NC 10 891.0 50.1 837 1000
PC 10 1568.4 221.7 1258 1900
Total 50 1517.8 413.7 837 2431

HC: Hybrid composite; RCR: Ribbond+ conventional composite resin; EXP: everX posterior +conventional composite resin; NC: negative control;
PC: positive control.

Table 3 – Statistical results of Tukey HSD Post HOC tests for Table 4 – Proportion of teeth with different failure modes.
multiple comparisions of means.
Groups Cohesive Adhesive Mixed
Groups Mean difference p-Value failure failure failure
HC RCR 298.4 0.010 HC 10 0 0
EXP 576.5 <0.001 RCR 5 3 2
NC 527.3 <0.001 EXP 2 8 0
PC 150.1 0.417
RCR EXP 278.1 0.018 HC: Hybrid composite; RCR: Ribbond+conventional composite
NC 825.7 <0.001 resin; EXP: everX posterior +conventional composite resin.
PC 148.3 0.429
EXP NC 1103.8 <0.001
PC 426.4 <0.001 fibers can control polymerization shrinkage and marginal
NC PC 677.4 <0.001 microlekage because of their fiber orientation [33]. The
otherimportant function of this short fiber composite
substructure is to support the surface particulate filler
composite layer and thereby prevent crack propagation
increase the durability, stability, and shear strength of the apart from distrubuting the stresses [33–35]. Random fiber
fiber. These fibers are preimpregnated, silanized and plasma organization has a significant role in mechanical properties.
treated [22]. Embedding Ribbond polyethylene fiber into the The transfer of stresses from the polymer matrix to the fibers
bed of flowable composite under a composite restoration is vital for the optimal reinforcement of the polymers. This in
helps in reinforcing the tooth by increasing the elastic turn is a function of the critical fiber length. According to
modulus and prevents from fracture. Vallittu et al., the E-glass with bis-GMA have a critical fiber
In the present study the fracture resistance was tested length between 0.5 and 1.6mm and the short fibers present in
using universal testing machine by applying axial static everX posterior is equal to or greater than this length. This
compressive load with a help of a 6mm stainless steel sphere feature enables uniform stress distribution [36]. The failure
to the center of the occlusal surface. Various studies have of these samples were adhesive in nature which points to the
reported that the use of stainless steel 6mm stainless steel tooth restoration interface as the weakest phase unlike
sphere is ideal for fracture resistance testing in molars, samples of the other groups.
because of uniform contact with the both functional and Samples restored with composite resin showed lower
non functional cusps by the stainless steel sphere. According resistance to fracture because of more shrinkage stresses
to Haebkost Lde et al., the diameter of the ball has known leading to marginal break down and gaps, which is very
to influence outcome in fracture resistance of the tooth. A minimal in fiber reinforced composites.
large diameter ball is known to cause increased fracture In a laboratory mechanical test showed significant im-
rates compared to a smaller ball [32]. Apart from the above provements in the fracture resistance, load bearing capacity
mentioned factors, stress applied to teeth and dental restora- and flexural strength of this short E-glass fiber filler com-
tions is usually low and repetitive rather than being isolated posite resin when used as an direct onlay restorations [37].
and impactive in nature. On the other hand, because of Based on above results it is shown to be superior in
the linear relationship between fatigue and static loading, fracture resistance when used as a post endodontic core
the compressive static test also gives valuable information restoration.
concerning load bearing capacity.
Among the fiber reinforced composites tested in our study,
both reinforced composite resins performed better and the 5. Conclusion
results were statistically significant. EXP group showed
superior results. Between EXP and RCR groups the former Within the limitation of this study it can be concluded that
showed significantly higher fracture resistance with a peak everX posterior showed superior fracture resistance com-
load of 1994.80N254.19 which is higher than the postive pared to other core composite materials tested. However, the
control group. everX posterior is a fiber reinforced composite influence of dynamic loading, other teeth like premolars and
which is mainly composed of short E-glass fiber fillers. These their clinical performance needs to be further studied.

Please cite this article in press as: T.G. Garlapati, et al., Fracture resistance of endodontically treated teeth restored with short fiber
composite used as a core material—An in vitro study, J Prosthodont Res (2017), http://dx.doi.org/10.1016/j.jpor.2017.02.001
JPOR 394 No. of Pages 7

journal of prosthodontic research xxx (2017) xxx –xxx 7

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Please cite this article in press as: T.G. Garlapati, et al., Fracture resistance of endodontically treated teeth restored with short fiber
composite used as a core material—An in vitro study, J Prosthodont Res (2017), http://dx.doi.org/10.1016/j.jpor.2017.02.001