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The reinforcement effect of polyethylene fibre and composite impregnated glass

fibre on fracture resistance of endodontically treated teeth: An in vitro study

Article  in  Journal of Conservative Dentistry · October 2012

DOI: 10.4103/0972-0707.101914 · Source: PubMed

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Original Article

The reinforcement effect of polyethylene fibre

and composite impregnated glass fibre on fracture
resistance of endodontically treated teeth:
An in vitro study
Archana Luthria, Srirekha A, Jayshree Hegde, Rupali Karale, Sanjana Tyagi, Sajeev Bhaskaran
Department of Conservative Dentistry and Endodontics, The Oxford Dental College, Hospital and Research Centre, Bommanhalli, Hosur
Road, Bangalore, Karnataka, India

Abstract
Aim: The aim of this study was to evaluate the fracture resistance of endodontically treated maxillary premolars with wide
Aim:
mesio-occluso-distal (MOD) cavities restored with either composite resin, or composite resin reinforced with different types of
fibres.
Materials and Methods
Methods:: Fifty human maxillary premolars were selected. Five intact teeth served as positive controls. Endodontic
therapy was carried out in the remaining forty-five teeth. Standardized MOD cavities were prepared in all the teeth. The teeth
were restored with a nanocomposite using an incremental technique. These forty five teeth were randomly divided into three
experimental groups (Group A, B and C) (n = 15). The teeth in Group A did not undergo any further procedures. The teeth in
Group B and C were reinforced with composite impregnated glass fibre and polyethylene fibre, respectively. Fracture resistance
was measured in Newtons (N).
Results:: The positive controls showed the highest mean fracture resistance (811.90 N), followed by Group B (600.49N),
Results
Group A (516.96N) and Group C (514.64N), respectively. One Way analysis of variance (ANOVA) test revealed a statistically
significant difference between all the groups (P = 0.001). Post-hoc Tukey test revealed a moderately significant difference
(P = 0.034) between Control and Group B, and a strongly significant difference between Control and Group A (P = 0.002),
and Control and Group C (P = 0.001).
Conclusions:: Endodontic therapy and MOD cavity preparation significantly reduced the fracture resistance of endodontically
Conclusions
treated maxillary premolars (P = 0.001). No statistically significant difference was found between the experimental groups
(Group A, B and C) (P > 0.1). However, the fracture resistance of the composite impregnated glass fibre reinforced group was
much higher than the others.
Keywords: Composite impregnated glass fibre; fracture resistance; mesio-occluso-distal cavity; polyethylene fibre

INTRODUCTION wants to wait and evaluate the healing of a periapical lesion

Following endodontic treatment, there is a decrease in the
fracture resistance of the teeth. This is also seen after the
preparation of wide mesio-occluso-distal (MOD) cavities. An
ideal restoration for a tooth is able to maintain the aesthetics
and function, preserve the remaining tooth structure and
prevent the microleakage.[1] Indirect restorative procedures
such as metallic post and core fabrication followed by full
crown are customary.[2] However, there may be cases where
the tooth is still erupting, or where the tooth or root canal
therapy has a questionable prognosis, or where the clinician
before proceeding with full crown restorations. To prevent
the failure of root canal treatment, a simple, quick, high
strength, direct and cost effective restorative procedure
may be desirable. Adhesive technology is advancing by
leaps and bounds every day, making it possible to create
conservative and highly aesthetic restorations with direct
bonding to the teeth. A significant increase in the fracture
resistance of root filled teeth was observed when they were
intracoronally restored with a resin composite material. [3,4]
Reinforcing composites with polyethylene fibres and
glass fibres has successfully provided superior results.[5-7]

Address for correspondence: Access this article online

Dr. Srirekha A., Department of Conservative Dentistry and Quick Response Code:
Endodontics, The Oxford Dental College, Hospital and Research Website:
www.jcd.org.in
Centre, Bommanhalli, Hosur Road, Bangalore - 560 068,
Karnataka, India. E-mail: drsrirekha.a@gmail.com
Date of submission : 15.12.2011 DOI:
Review completed : 19.03.2012 10.4103/0972-0707.101914
Date of acceptance : 23.05.2012

372 Journal of Conservative Dentistry | Oct-Dec 2012 | Vol 15 | Issue 4

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Luthria, et al.: Fibre reinforced composite restorations in root filled teeth
However, there are no studies comparing the two in direct
composite restorations.
The aim of this study was to evaluate the fracture resistance
of endodontically treated maxillary premolars with wide
mesio-occluso-distal (MOD) cavities restored with either
composite resin, composite resin reinforced with a
polyethylene fibre, or composite resin reinforced with a
composite impregnated glass fibre.
MATERIALS AND METHODS
50 intact human maxillary premolars, extracted for
orthodontic reasons were collected. All the specimens
were scaled to remove the adhering soft tissue and
calculus, and were stored in physiologic saline. Teeth
with caries, morphological defects or fracture lines were
discarded. Five intact teeth were used as positive controls
and endodontic access cavities were prepared in forty five
teeth using a water cooled diamond bur (Endo Access Bur;
Dentsply) with an airotor hand piece, and the pulp tissue
was removed with barbed broaches. A size 15 K-file (Mani
Prime Dental Pvt. Ltd.) was introduced into each canal
until it could be seen at the apical foramen. The working
length was then determined by subtracting 1 mm from this
length. The canals were prepared with ProTaper (Dentsply
Maillefer) nickel titanium (Ni-Ti) instruments using a 1:64
reduction handpiece (Anthogyr NiTi Control; Dentsply) at
a speed of 300 revolutions per minute. Coronal flaring was
done with the Sx file. Canals were shaped till the working
length using the S1 and S2 files, and the apical third of
the canal was finished using finishing file F1 and later F2.
Copious irrigation using 5 ml of 5.25% sodium hypochlorite
was carried out throughout the procedure. One set of
ProTaper files™ was used for the five teeth.
The tooth root canals were flushed with saline to remove
traces of sodium hypochlorite. The canals were then
dried with absorbent paper points (Dentsply Maillefer).
Obturation was donewith ProTaper gutta percha pointsÔ
and AH Plus root canal sealer (Dentsply De Trey, Konstanz,
Germany ) using a cold lateral condensation technique.
MOD cavities were prepared in the teeth using an airotor
hand piece with a long straight fissure diamond point (SF-
12C; Mani Dia Burs). The diamond abrasive was changed
after every 10 preparations. The dimensions of the cavity
were decided with the help of a periodontal probe to
standardize the remaining tooth structure. The remaining
thickness of the buccal and lingual wall of the teeth was
2.5 mm from the height of contour of the buccal and lingual
surface till the buccal and lingual cavity walls, and the
gingival cavosurface margin was 1.5 mm above the cement-
enamel junction (CEJ) [Figure 1a].[7]
Subsequently, the teeth were randomly divided into three
groups (n = 15):
Journal of Conservative Dentistry | Oct-Dec 2012 | Vol 15 | Issue 4
• Group A – Preparations restored with composite,
without fibre (n = 15)
• Group B - Preparations restored with composite
impregnated with glass fibre (n = 15)
• Group C - Preparations restored with composite
impregnated with polyethylene fibre (n = 15)
• Positive Control - Intact teeth (n = 5)
Preparation of specimens
Group A (No fibre group)
Cavities were cleaned, dried, and etched with 35%
phosphoric acid (Scotch Bond Multi Purpose Etchant;
3M ESPE, St. Paul, MN, USA) for 15 seconds. The tooth
surfaces were then rinsed for 10 seconds and gently dried
for 1-2 seconds. Subsequently, a single bottle total etch
adhesive (Adper Single Bond 2; 3M ESPE, St. Paul, MN,
USA) was applied and photocured using light-emitting
diode (LED) (LEDition; Ivoclar Vivadent) at 600 mW/cm2
for 10 seconds. Light intensity output was verified after
every 10 samples using a digital read out light meter.
Tofflemire retainer and matrix band were applied and
the preparations were restored with a nanocomposite
(Filtek Z350 XT; 3M ESPE, St. Paul, MN, USA) by using an
incremental technique. The layers were placed at a 1.5
mm thickness and cured for 40 seconds according to the
manufacturer’s instruction.[7]
Group B (Composite impregnated glass fibre)
After restoring the preparation as described for group
A, a groove 2 mm wide and 1 mm deep was prepared
buccolingually on the occlusal surface of the restoration
and cusp tips. The ends of the groove were on the
occlusal third of the buccal and lingual surfaces of the
tooth [Figure 1b]. After etching the grooves, single
bottle total etch adhesive was applied and cured for 10
seconds. Flowable composite with 10 mm of composite
impregnated glass fibre (Interlig; Angelus, Londrina PR,
Brazil) was placed on the floor of the groove and light
cured for 20 seconds. A layer of the nanocomposite
was added to cover the exposed fibre surface and cured
from the occlusal direction for 40 seconds according to
manufacturer’s instructions.[7]
Group C (Polyethylene fibre)
Buccolingual grooves were prepared, etched and bonded
in a manner similar to Group B. Flowable composite resin
with 10 mm of polyethylene fibre (Ribbond; Ribbond Inc.,
Seattle, WA, USA) which had been saturated with the
unfilled resin (Scotch Bond Multi Purpose Plus; 3M ESPE,
St. Paul, MN, USA) was added to the groove and cured from
occlusal direction for 20 seconds. The exposed surface of
the fibre was covered with a layer of the nanocomposite
and cured for 40 seconds from the occlusal direction
according to the manufacturer’s instructions.[6] All
restorations were finished and polished (Shofu Dental).
373
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Luthria, et al.: Fibre reinforced composite restorations in root filled teeth
a b
Figure 1: (a) Standardized dimensions of mesio-occluso-distal cavity (b) Preparation of bucco-occluso-lingual groove
Figure 2: Graph depicting mean fracture resistance values
The teeth were then mounted in a block of cold cure acrylic
measuring 2 cm in diameter, at CEJ. A layer of polyvinyl
siloxane was adapted around the root surfaces to simulate
the periodontal ligament. Thermocycling was carried out
for 500 cycles at 5 to 55°C, 30 second dwell time and 5
second transfer time. All the specimens were stored in an
incubator (iBod) at 37°C and 100% humidity for 24 hours.
[5,6]
The fracture resistance of the teeth was measured using
a universal testing machine (LR 50K; LLOYD Instruments),
under a compressive force at a strain rate of 0.5 mm/min.
A 5 mm diameter round stainless steel ball was positioned
parallel to the long axis of the teeth and centered over the
teeth until the bar just contacted the occlusal surface of
the restoration and the buccal and lingual cusps. The force
needed to fracture each tooth was recorded in Newtons.
[5-7]
The study design was a three arm comparative study
where the outcome variable was fracture resistance.
Statistical analysis was performed using descriptive
statistical methods, One Way ANOVA test and the Post-
hoc Tukey test. The Statistical software namely SAS 9.2,
SPSS 15.0, Stata 10.1, MedCalc 9.0.1, Systat 12.0 and R
environment ver.2.11.1 were used for the analysis of the
data and Microsoft word and Excel were used to generate
graphs, tables etc.
374 Journal of Conservative Dentistry | Oct-Dec 2012 | Vol 15 | Issue 4
RESULTS
Highest mean fracture resistance was observed with positive
control followed by Group B and group A respectively. Group
C recorded the lowest mean fracture resistance. One Way
ANOVA test revealed a significant difference (P = 0.001)
between the groups [Table 1] [Figure 2]. On intergroup
comparison, Post-hoc Tukey test revealed a moderately
significant difference between Control and Group B
(P = 0.034) whereas a strongly significant difference was
recorded between Control and Group A (P = 0.002) and
between control and group C (P = 0.001). No significant
difference was recorded between any of the experimental
groups (Group A, B and C) (P > 0.1) [Table 2].
DISCUSSION
Restoration of root filled teeth, despite posing a major
challenge to the clinician, is an essential final step of root
canal treatment. The purpose of the restoration is not only
to repair, reinforce and strengthen the tooth, but also to
provide an effective seal between the canal system and the
mouth. The gold standard of post endodontic restorations
is the full crown; however, there are situations where the
clinician may choose to delay the delivery of the full crown.
In such cases, an efficient, direct, high strength, low cost and
quick intermediary restoration may be desirable. Adhesive
restorations allow a more efficient transfer and distribution
of functional stresses across the bonding interface to
the tooth structure. Nanocomposites display improved
performance due to their dense filler loading. The smaller
size of the fillers allows them to have excellent optical
properties along with good mechanical properties.[8,9]
Despite the advances in material sciences, composite
resins are not commonly used for extensive restorations
due to their brittle nature. Reinforcement with fibres
has been shown to impart strength and toughness to
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Luthria, et al.: Fibre reinforced composite restorations in root filled teeth
Table 1: Mean fracture resistance in Newton (n) in all four groups as seen in the study
Min-Max Mean ± SD
Control 672.50-1233.0 811.90 ± 238.58
Group A 323.30-782.00 516.96 ± 151.87
Group B 421.80-789.00 600.49 ± 131.69
Group C 305.10-649.20 514.64 ± 111.33
Table 2: Pair wise comparison: Difference and P value
in the study
Difference P value
Control-Group A 294.94 0.002**
Control-Group B 211.41 0.034*
Control-Group C 297.26 0.001**
Group A-Group B 83.53 0.401
Group A-Group C 2.32 1.000
Group B-Group C 85.85 0.377
+Suggestive significance (P value 0.05 < P < 0.10), *Moderately significant
(P value: 0.01 < P ≤ 0.05), **Strongly significant (P value: P ≤ 0.01)
composite resins.[10,11] The fibres used in this study had
different arrangements and surface treatments. Original
Ribbond™ (Group C) consists of cold plasma treated,
Leno Weave Ultra High Modulus (LWUHMW) polyethylene
fibres, which are arranged in a lock-stitch design. Interlig™
(Group B) consists of glass fibres pre-impregnated with
light curable composite resin arranged in a braided design.
Fibres were placed occlusal to the restoration following a
technique given by Oskoee et al.,[7] and Belli et al..[6] Placing
fibres on the occlusal surface keeps buccal and lingual
cusps together and protects the natural cusps resulting in
higher fracture resistance. In addition, fracture resistance
increases when fibres are placed close to the point where
the force is exerted because it leads to a shorter working
arm according to levers principle.[6,7] The results of the
present study revealed that the positive control group
had highest mean fracture resistance (811.90 N). This
is in accordance with the study by Beli et al.,[5] and also
denotes that endodontic and restorative treatment have a
detrimental effect on fracture resistance of teeth.[12]
Among the experimental groups, Group B had the highest
mean fracture resistance (600.49 N) followed by Group A
(516.96 N), and Group C (514.64 N) [Table 1] [Figure 2]. The
One Way ANOVA test done in the present study revealed a
statistically significant difference (P = 0.001) between all the
groups [Table 1]. Post-hoc Tukey test revealed a moderately
significant difference between Control and Group B
(P = 0.034) and a strongly significant difference between
Control and Group A (P = 0.002), and between Control and
Group C (P = 0.001). No significant difference was found
between any of the experimental groups (Group A, B and C)
(P > 0.1) [Table 2]. Group A showed an acceptable fracture
resistance due to the use of nanocomposites in the present
study. The high filler loading enables nanocomposites to
demonstrate good physical and mechanical properties and
reinforce the tooth structure well. Single bottle total etch
system gave evidence of better bond strength than the
Journal of Conservative Dentistry | Oct-Dec 2012 | Vol 15 | Issue 4
95%CI Significance
515.6-1108.1 F = 6.258 P = 0.001**
432.85-601.07
527.56-673.42
452.99-576.29
newer self- etch systems.[13] The presence of the adhesive
layer under the restoration acts as a stress buffer. A Study
by Ausiello et al.,[14] has shown that an optimal adhesive
layer thickness leads to maximum stress release while
preserving interface integrity. The fracture resistance of
Group A can be attributed to the increase in strain capacity
of the adhesive resin and the improved physical and
mechanical properties of nanocomposites.[15]
This study recorded that Group B had the highest fracture
resistance amongst the experimental groups. The
superior performance of Group B may be because of the
pre-fabricated resin impregnation of these fibres by the
manufacturers. Also, glass fibres have very high tensile
strength, density and percentage of elongation allowing
them to withstand high stresses without fracturing.[16]
Results of this study were in agreement with the study by
Kolbeck et al.,[17] who reported the glass fibres performed
better than polyethylene fibres due to pre-impregnation
with light cured composite which ensures a good bond
with the composite resin. Group C also showed reasonably
good fracture resistance. Polyethylene fibres have shown
high fracture resistance in previous studies.[5,6] According
to the manufacturer Original RibbondÔ fibres are woven
using the lock-stitch leno weave which prevents slipping
of fibres within resin matrix, prevents micro-cracks from
propagating to form larger cracks and reinforces the
restoration in multiple directions. Beli et al.,[6] found that
insertion of polyethylene fibre in the occlusal third of a
composite restoration increased the fracture resistance
of root filled teeth compared to teeth restored with
composite resin alone. However, the present study showed
that insertion of polyethylene fibre did not significantly
increase the fracture resistance of a root filled tooth as
compared to teeth restored with composite resin alone
(Group A) (P > 0.1).
The causes for lower fracture resistance of Group C may
include the following:
• Non uniform wetting of fibre with unfilled resin – Manual
wetting of Original RibbondÔ (Group C) with unfilled
adhesive was done as suggested by the manufacturer.
This may lead to areas of non-uniform wetting in the
fibre which will affect the adhesion of fibre to resin
matrix. This in turn, may cause several problems in
the future of the restoration. The poorly impregnated
regions may become areas of increased water sorption,
hence causing deterioration of mechanical properties
of the composite. Discolouration due to penetration
375
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Luthria, et al.: Fibre reinforced composite restorations in root filled teeth
of oral microbes into these voids may also occur. Such
voids may also act as oxygen reserves hence preventing
complete polymerisation of composite resin.[18]
• The LWUHMW polyethylene fibre is treated with cold
gas plasma to convert the material from hydrophobic
to hydrophilic. This treatment is meant to make the
fibre surface more receptive to bonding with the resin
however; it makes the fibre very technique sensitive.
Any contamination to the fibre surface may affect its
adhesive properties. Handling of the polyethylene
fibres was found to be tougher in the present study.
The fibres frayed on cutting, and became very stiff
after the wetting procedure.
• An additional reason for its poor performance may
be lower tensile strength, density and elongation
compared to glass fibres.
Though it was not among the objectives of the study it
was observed that the majority of failures in the fibre
reinforced groups were favourable in nature. The fracture
in 80% cases occurred superior to the CEJ. This can prove
immensely beneficial to clinicians as despite fracturing,
the tooth remains repairable with techniques such as post
and core followed by full crown. Additionally, the study
done by Reeh et al.,[12] showed a relative loss of stiffness
of 5% due to endodontic procedures and 63% in MOD
cavity preparation whereas the present study found a
relatively smaller decrease of 25-35% in fracture resistance
of root filled teeth with MOD cavity preparation restored
with nanocomposites or nanocomposites restored with
different fibres. Despite this decrease in fracture resistance
all the experimental groups demonstrated results much
higher than the average normal biting force of human
maxillary premolars (100-300N).[19] Many differences exist
between fractures occurring clinically and those induced
by a machine. Forces generated intraorally during function
vary in magnitude, speed of application and direction,
whereas the forces applied to the teeth in this study were
at a constant direction and speed and they increased
continuously until fracture occurred. Further in vivo studies
should be done to test the reinforcement effect of fibres in
clinical situations.
CONCLUSIONS
1. Root canal treatment and MOD cavity preparation
significantly reduced fracture resistance of root filled
maxillary premolars (P = 0.001).
2. Even though there was no statistically significant
difference between the test groups, the fracture
resistance of the composite impregnated glass fibre
reinforced group was much higher.
376 Journal of Conservative Dentistry | Oct-Dec 2012 | Vol 15 | Issue 4
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ACKNOWLEDGMENT
Dr. R. Gopalan, Composite technology park, Kingeri
Dr. KP Suresh (statistician)
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How to cite this article: Luthria A, Srirekha A, Hegde J, Karale
R, Tyagi S, Bhaskaran S. The reinforcement effect of polyethylene
fibre and composite impregnated glass fibre on fracture resistance
of endodontically treated teeth: An in vitro study. J Conserv Dent
2012;15:372-6.
Source of Support: Nil, Conflict of Interest: None declared.