Basic Research—Technology
Fracture Resistance of Endodontically Treated
Teeth Restored with 2 Different Fiber-reinforced
Composite and 2 Conventional Composite Resin
Core Buildup Materials: An In Vitro Study
Ashly Mary Eapen, BDS, MDS, L. Vijay Amirtharaj, BDS, MDS, Kavitha Sanjeev, BDS, MDS,
and Sekar Mahalaxmi, BDS, MDS
Abstract
Introduction: The purpose of this in vitro study
was to comparatively evaluate the fracture resistance
of endodontically treated teeth restored with 2
fiber-reinforced composite resins and 2 conventional
composite resin core buildup materials. Methods: Sixty
noncarious unrestored human maxillary premolars were
collected, endodontically treated (except group 1, nega-
tive control), and randomly divided into 5 groups
(n = 10). Group 2 was the positive control. The remain-
ing 40 prepared teeth were restored with various direct
core buildup materials as follows: group 3 teeth were
restored with dual-cure composite resin, group 4 with
posterior composite resin, group 5 with fiber-
reinforced composite resin, and group 6 with short
fiber-reinforced composite resin. Fracture strength
testing was performed using a universal testing ma-
chine. The results were statistically analyzed by 1-way
analysis of variance and the post hoc Tukey test. Frac-
ture patterns for each sample were also examined under
a light microscope to determine the level of fractures.
Results: The mean fracture resistance values (in new-
tons) were obtained as group 1 > group 6 > group
4 > group 3 > group 5 > group 2. Group 6 showed
the highest mean fracture resistance value, which was
significantly higher than the other experimental groups,
and all the fractures occurred at the level of enamel.
Conclusions: Within the limitations of this study, a
short fiber-reinforced composite can be used as a direct
core buildup material that can effectively resist heavy
occlusal forces against fracture and may reinforce the re-
maining tooth structure in endodontically treated teeth.
(J Endod 2017;-:1–6)
Key Words
Core buildup materials, endodontically treated teeth,
fracture resistance, levels of fracture, mesio-occlusal-
From the Department of Conservative Dentistry and Endodontics, SRM Dental College, Bharathi Salai, Ramapuram, Chennai, Tamil Nadu, India.
Address requests for reprints to Ashly Mary Eapen, Department of Conservative Dentistry and Endodontics, SRM Dental College, Bharathi Salai, Ramapuram, Chennai
600089, TN, India. E-mail address: ash_eapen@yahoo.co.in
0099-2399/$ - see front matter
Copyright ª 2017 American Association of Endodontists.
http://dx.doi.org/10.1016/j.joen.2017.03.031
JOE — Volume -, Number -, - 2017
distal cavity, multidirectional reinforcement, postendodontic restoration, short fiber-
reinforced composite resin
T he integrity and dura-
bility of postendodontic
restorations are consid-
Significance
In contrast to the conventional methods to rein-
force endodontically treated teeth, short fiber-
ered as prerequisite factors
reinforced composite resin, a minimally invasive
in the long-term success of
direct core buildup material seems to be the mate-
endodontically treated teeth.
rial of choice.
These teeth have been proven
to be more brittle and are
prone to fracture under an occlusal load compared with vital teeth because of changes in strength
and modulus of elasticity (1). Although traditional invasive procedures such as posts and cores
followed by conventional crowns are usually used for their reconstruction, these may further
lead to the loss of remaining sound tooth structure. Therefore, intracoronal strengthening of teeth
may be necessary to prevent fracture, particularly in posterior teeth in which stresses generated by
occlusal forces can lead to fracture of unprotected cusps (2).
Advancements in adhesive restorations have significantly contributed to improved
fracture resistance of teeth by creating conservative esthetic restorations bonded to the
teeth (3). Dual-cure composites have been developed as core buildup materials that
help in overcoming the limitations of extended chairside time, reduced interlayer
strength, increased interfacial porosity, and depth of cure (4). Composites reinforced
with fibers such as polyethylene and glass fibers have shown significant improvements
in the marginal integrity and fracture strength of composite resins by the application of a
fiber layer beneath the restoration (5, 6).
The introduction of everX Posterior (GC Company, Tokyo, Japan), a short fiber-
reinforced composite (SFC) resin, has gained attention recently as a restorative material
and is recommended to be used in high stress-bearing areas (7, 8). This is composed of
randomly oriented short glass fiber fillers made of a combination of barium glass and
silanated E-glass fibers and is claimed to provide an isotropic reinforcement effect in
multiple directions instead of 1 or 2 directions (9). Previous studies by Garoushi
et al (7, 8) showed that short fiber fillers could stop crack propagation and provide
an increase in fracture resistance of composite resin. Although this material has
been used for onlays and core buildup with posts, there have been no studies so far
on its effect on the fracture resistance of teeth when used solely as a core buildup
material in endodontically treated teeth (10, 11). Moreover, most of the literature
Effect of Core Buildup Materials on Fracture Resistance 1
Basic Research—Technology
compares some of the fiber-reinforced composite (IFC) resins, poste-
rior direct composite (PRC) resins, and dual-cure composite (DCC)
resins as core buildup materials, but there are no comparative studies
of all these materials with the newly developed SFC resins. Hence, the
purpose of this study was to compare the fracture resistance of
endodontically treated teeth restored with the following types of com-
posite resins indicated for core buildup: DCC (MultiCore Flow; Ivoclar
Vivadent, Amherst, NY) and PRC resins (Filtek P60; 3M ESPE, St Paul,
MN), composite resin reinforced with glass fibers (Interlig Glass Fibers;
Angelus, Londrina, PR, Brazil), and SFC resin (everX Posterior). The
null hypothesis of this study was that there is no difference in the fracture
resistance of endodontically treated teeth restored with various core
buildup materials.
Materials and Methods
Sixty intact, noncarious, unrestored human maxillary premolars of
similar dimensions (verified using a digital caliper) devoid of pulpal ab-
errations and that were freshly extracted for orthodontic reasons were
selected for the study. The teeth were cleaned and stored in physiolog-
ical saline at 4
C for 3 days. They were randomly assigned to 6 groups of
10 teeth each. Group 1 was the negative control (NC); the teeth were
intact and were not subjected to cavity preparation or root canal treat-
ment.
Mesio-occluso-distal (MOD) cavities were prepared in the re-
maining 50 teeth using a straight fissure bur and a high-speed airotor
handpiece (NSK Pana Air, Placentia, CA) with water coolant as shown in
Figure 1a and b. The intercuspal distance and buccopalatal dimensions
were recorded using a digital caliper.
Endodontic access cavities were then prepared using a #2 round
diamond bur (Mani, Utsunomiya, Japan). The teeth were selected with a
minimal apical diameter corresponding to a size 15 K-file. The working
length was determined using a size 15 K-file (Mani) and set as the initial
apical file. All the canals were instrumented with K-files (Mani) to an
apical size of 40 using a step-back technique. The coronal portion of
each canal was enlarged with Gates Glidden burs (Mani) with size #3
to #1 in a slow-speed contra-angle handpiece. Irrigation was performed
with 5.25% sodium hypochlorite (Merck Specialties Private Limited,
Mumbai, India) between each file usage during cleaning and shaping
and finally with distilled water. The canals were dried with paper points
(DiaDent, Burnaby, BC, Canada) and obturated by cold lateral conden-
sation with ISO standardized 2% gutta-percha (Densply Maillefer,
Figure 1. (a and b) MOD cavities (B) with one third the intercuspal distance for the buccolingual width of the occlusal isthmus (A). The buccopalatal width of the
approximal preparation (D) was one third of the buccolingual width of the crown (C). The facial and lingual walls of the occlusal segment were kept parallel to each
other. The depth of the preparation (E) was kept up to 1 mm coronal to the level of CEJ.
2 Eapen et al.
Ballaigues, Switzerland) and AH Plus Root Canal Sealer (Dentsply Mail-
lefer, Ballaigues, Switzerland). The gutta-percha was removed below the
level of the CEJ, and the canal orifices were sealed with GC Fuji II. Of the
50 teeth, 10 teeth that served as the positive control (PC) (group 2) did
not undergo further procedures.
The remaining 40 teeth received DCC, PRC, IFC, and SFC resin as
coronal restorations according to the allotted groups, and the restor-
ative procedures are given in Table 1. A thin metal matrix band
(0.00100 ) held by a Tofflemire (GDC, India) retainer was placed around
each tooth before restoration. Table 1 enlists the various materials used
in groups 3 to 6 and their methods of application. All the materials were
restored using an incremental technique and cured with a quartz-
tungsten-halogen light-curing unit at a power intensity of 600 mW/
cm2 (Curing Light 2500, 3M ESPE).
After the procedure, the matrix bands were removed, and the res-
torations were contoured, finished, and polished with a series of abra-
sive disks (Super-Snap; Shofu Inc, Kyoto, Japan). The teeth were stored
in distilled water for 24 hours at 37
C before being subjected to fracture
testing. The roots of the teeth were mounted in self-cure acrylic resin of
3 cm  2.5 cm up to the level of 1 mm apical to the CEJ.
The prepared specimens were placed on a holder slot that was
fixed to the lower arm of the universal testing machine. A metal
indenter with a 6-mm diameter was fixed to the upper arm of a uni-
versal testing machine that was set to deliver increasing loads until
fracture occurred. The load was applied to the occlusal inclines of
the buccal and lingual cusps vertically along the long axis of the
tooth at a crosshead speed of 1 mm/min. The force required to frac-
ture each tooth was recorded in newtons.
Fracture patterns for each sample were examined under a light mi-
croscope. They were classified according to the location of the fracture
as enamel, dentin, at the CEJ, or below the CEJ.
Data and Statistical Analysis
Data were explored for normality by using the Kolmogorov-
Smirnov Z test which showed that data were normally distributed.
The confidence level was 95%. According to the significance level, using
nMaster 2.0 software (Department of Biostatistics, CMC, Vellore, Tamil
Nadu, India), the power was calculated as 80% with a = 0.05 and the
sample size as n = 10. The mean fracture resistance values were statis-
tically analyzed using 1-way analysis of variance, and intergroup com-
parisons were performed using the post hoc Tukey test. These data
JOE — Volume -, Number -, - 2017
 TABLE 1. Materials Used in the Experimental Groups and Their Methods of Application
JOE — Volume -, Number -, - 2017
Type of material
Group 3: DCC
Group 4: PRC
Group 5: IFC
Glass fibers preimpregnated
in light curable composite resin
Nanohybrid flowable
light-cured composite
Nanohybrid light-cured
composite resin
Effect of Core Buildup Materials on Fracture Resistance
Group 6: SFC
3
BisEMA, bisphenol A glycol dimethacrylate; BisGMA, ethoxylated bisphenol A glycol dimethacrylate; DCC, dual-cure composite resin; RC, posterior composite resin; SFC, short fiber-reinforced composite resin; TEGDMA, triethylene glycol dimethacrylate; UDMA, urethane dimethacrylate.
Materials Composition Method of application
MutiCore Flow (Ivoclar Monomer matrix: Cavities conditioned with self-etch adhesive system (ExciTE
Vivadent) Dimethacrylate (base: 28.1wt%, catalyst: 28.4 wt %) F DSC, Ivoclar Vivadent) and light cured for 20 seconds
Inorganic fillers: Y
Barium glass, Ba-Al-fluorosilicate glass, and highly MultiCore Flow was mixed and injected into the
dispersed silicon dioxide (base: 54.9 wt%, catalyst: 54.4 prepared cavities up to the occlusal level through the
wt%). Ytterbium trifluoride (base: 16.4 wt%, catalyst: automix tips provided
16.2 wt%) Y
Additional contents: Light cured for 40seconds
Catalysts, stabilizers, and pigments (base: 0.6 wt%,
catalyst: 1 wt%)
Filtek P60 (3M ESPE) Resin matrix: The prepared cavities were etched (EAZETCH [Anabond
BisGMA, BisEMA, UDMA, and TEGDMA Stedman Pharmaceuticals Research Ltd, Chennai, Tamil
Fillers: Nadu, India]) for 15seconds, rinsed for 10 seconds, and
ZrO2/SiO2, 0.01–3.5 mm; 61 vol% moist dried with damped cotton pellet
Y
Bonding agent (Adper Single Bond, 3M ESPE) applied, air
dried, and light cured for 30 seconds
Y
Cavities filled incrementally with 2 mm composite resin
and light cured for 20 seconds
Y
Finally light cured for 40 seconds
Interlig Fiber (Angelus) Glass fibers: Etching and bonding procedures were done as per group 4
60  5wt% Y
Impregnated resin: The cavity surfaces were lined with flowable composite
Tetric N-Flow (Ivoclar 40  5wt%: Bis-GMA, diurethane, barium glass, silicon resin (Tetric N-Flow)
Vivadent) dioxide, catalysts. Y
Tetric N-Ceram Resin matrix: The Interlig Fibers embedded into the flowable resin
Bis-GMA, UDMA (27.8%), TEGDMA (7.3wt %) composite from the buccal surface toward the pulpal
Fillers: floor and from there to the lingual surface
(a) barium glass, ytterbium trifluoride, mixed oxide, Y
silicon dioxide (63.8 wt%) Light cured for 20 seconds
(b) Additives, stabilizers, catalysts, pigments (1.1 wt%) Y
Matrix: The cavities were incrementally (2 mm) restored with
Bis-GMA, UDMA (15 wt%), and ethoxylated Bis-EMA nanohybrid composite resin (Tetric N-Ceram) up to the
Basic Research—Technology
(3.8 wt%) occlusal level
Fillers: Y
(a) Barium glass, ytterbium trifluoride, mixed oxide, Light cured for 40 seconds
silicon dioxide (63.5 wt%)
(b) Prepolymers (17 wt%)
(c) Additives, stabilizers, catalysts, pigments (0.7 wt%)
EverX Posterior Resin matrix: Etching and bonding procedures were done as per groups 4
(GC Company) Semi-interpenetrating polymer network (semi-IPN): net- and 5
poly(methyl meth’acrylate)-inter-net-poly(bis-glycidyl- Y
A-dimethacrylate): Bis-GMA, TEGDMA, and PMMA everX Posterior added incrementally until it reached 1.5–
Fillers: 2 mm below the occlusal level
E-glass fiber, barium borosilicate Y
Light cured for 20 seconds
Y
Nanohybrid composite resin of 1–2 mm was covered on
the occlusal aspects of the cavities
Y
Light cured for 40 seconds
Basic Research—Technology
FRACTURE RESISTANCE(in Newtons)
1200
1000 842.51±294.41
800
MEAN ± SD
434.56±174.31
600
400 233.88±26.42
200
0
GROUP I GROUP II GROUP III
Figure 2. A graph showing the mean fracture resistance values of the groups.
provide a statistically significant difference that can be clinically
correlated.
Results
The mean fracture resistance values and standard deviation of the
groups are given in Figure 2. Group 1 (NC) showed a mean fracture
resistance value of 842.519 N, which was significantly higher than the
other groups (P < .05) except group 6 (SFC: 712.8 N) (P = .484).
Group 2 (PC) had a significantly lower mean fracture resistance of
233.880 N compared with groups 1, 4 (PRC: 465.13 N), and 6 (SFC)
(P < .05). The levels of fractures are shown in Table 2. In SFC, all
the fractures occurred at the level of enamel, similar to the PC. All
the specimens in PRC and IFC showed fractures in the enamel or dentin,
whereas all the PC specimens fractured at or below the CEJ.
Discussion
The selection of an ideal restorative modality to compensate for the
loss of coronal tooth structure is considered as the key for success of
postendodontic restorations (3). The traditional attempts for reinforc-
ing such teeth vary from the usage of pins, cast restorations, and full-
crown coverage procedures to post placement (12). Unfortunately,
most of these weaken the minimal remaining tooth structure, leading
to fracture disposition of the root and/or crown structure.
Despite advancements in material sciences and with the concept of
minimally invasive procedures, composite resins are still not commonly
used for extensive restorations or in high stress-bearing areas because
of their relatively high brittleness, low fracture toughness, and formation
of microcracks in the tooth structure caused by polymerization
shrinkage (6). Hence, composite resins are reinforced with microglass
fibers, a fiber-reinforced substructure, whiskers, and particulate
ceramic fillers to improve their mechanical properties (13–15).
Composite resin reinforced with polyethylene fibers and glass fi-
bers (Interlig Fibers) have been shown to have a better effect on the
resistance and durability of endodontically treated teeth (5, 17), but
these reinforced fibers create a discontinuous phase with the
continuous polymer resin matrix leading to delamination and thus
failure at the interface (17). It can be stated that the effectiveness of fiber
reinforcement depends on many factors including the resins used; the
quantity, length, form, and orientation of the fibers; and the adhesion
and impregnation of the fibers to the resin matrix (18–20). Our
study compared the recently introduced everX Posterior, which is
4 Eapen et al.
712.8±79.84
465.13±159.36
404.31±94.25
GROUP IV GROUP V GROUP VI
intended to be used as a bulk substructure covered with a layer of
particulate composite resin (18, 19, 21), with the other available
core buildup materials.
Maxillary premolar teeth were used in this study because during
mastication the anatomic shape of premolars creates a tendency for
the separation of cusps. Post placement in these teeth is also not usually
recommended because of their delicate root morphology (20). Siso
et al (12) reported that unrestored teeth with MOD preparation leads
to a significant reduction (50%) in tooth strength because of the loss
of marginal ridges compared with unaltered premolar teeth. Hence,
in this study, the MOD cavity was prepared, and each preparation
was proportional to the tooth dimension in order to simulate the worst
clinical situation.
Burke and Watts (22) proved that when the cylindric indenter
makes contact with the tooth, it acts as a wedge between the buccal
and lingual cusps and decreases the mean fracture resistance values
while promoting more catastrophic types of fracture. Similarly, in our
study, the application of force was on the cuspal inclines vertically
because it was found to be appropriate to simulate the clinical intraoral
conditions.
In this study, group 1 (NC) showed the highest resistance to frac-
ture (842.519  294.416), whereas group 2 (PC) showed the least
fracture resistance (233.880  26.428), proving the deleterious effects
of the loss of vital tooth structure because of MOD and access cavity
preparations. This is in accordance with many previous studies (3, 23).
All the experimental groups showed improved fracture resistance
when compared with the PC. However, significant differences were
found only in the PRC and SFC groups. Filtek P60, a highly filled pack-
able posterior composite resin of 60%–70% filler volume with a
compressive strength of 360–380 MPa with reduced polymerization
shrinkage, could have indirectly contributed to the better results in
the PRC group (24).
Among the experimental groups, there was no significant differ-
ence between DCC, PRC, and IFC resins. MultiCore Flow (DCC group)
has an elastic modulus of 6 GPa, which is much less than the elastic
modulus of dentin. Because flowable resins have lower filler volume
(42%–53%), they have reduced hardness (25). This could have attrib-
uted to its poor performance when compared with the NC and SFC
groups.
The least fracture resistance value of 404.314 N was observed in
IFC resin among the experimental groups. This is in concurrence
with the results of previous studies (16, 17, 26, 27). Although both
JOE — Volume -, Number -, - 2017

TABLE 2. Levels of Fractures in Various Groups
Level of Group 1: NC Group 2: PC
fractures (n = 10) (n = 10)
Enamel 10 — —
Dentin — —
At CEJ or below CEJ — 10
CEJ, cementoenamel junction; DCC, dual-cure composite resin; NC, negative control; PC, positive control; PRC, posterior composite resin; SFC, short fiber-reinforced composite resin.
IFC and SFC resins are fiber-based composite resins, IFC resin showed
less fracture resistance compared with SFC resin, which was statistically
significant. The reasons may be manyfold including SFC fibers are pre-
incorporated with resin compared with IFC, which is reinforced with
resin during placement in the cavity; the formation of voids during
this placement creates huge oxygen-inhibited areas within the FRC com-
plex (28); and there is a lower flexural resistance (282 MPa [Norma
ISO 10477]) of the Interlig fibers. Furthermore, glass fibers are
more rigid and cannot easily adapt closely to the teeth, which may result
in uneven thickness of the composite material, thus resulting in
decreased functionality of the reinforced composite in clinical condi-
tions (29).
Oskee et al (30) showed that there was increased fracture resis-
tance when glass fibers were placed on the occlusal third instead of
the gingival third of the cavities. The proximity of the fiber location to
the force exertion point (shortening of the working arm according
to the lever principle) and maintaining the buccal and lingual cusps
close to each other by occlusal surface fibers protect the natural cusps,
resulting in higher fracture resistance. In our study, the fibers were
placed on the floor of the cavity rather than on the occlusal third for
standardization, and this could have influenced the results of the study.
Among the experimental groups, SFC resin showed a significant in-
crease in fracture resistance (712.800  79.8496) comparable with
the NC. The reason may be attributed to the support of the bulk SFC sub-
structure to the overlying conventional composite resin by transferring
the stresses from the polymer matrix to the fibers, the individual fibers
acting as crack stoppers.
The mechanical properties are enhanced and achieved by having a
fiber length equal to or greater than the critical fiber length (21). The
critical fiber length is the minimum length at which the center of the fi-
ber reaches its ultimate tensile strength when the matrix reaches its
maximum shear strength (13) (ie, a minimum of 0.5–1.6 mm should
exist to exhibit enhanced properties) (31). Because the length of the E-
glass fibers in the bisphenol A glycol dimethacrylate polymer matrix is
3 mm, this could have also influenced the results obtained in this study,
showing higher fracture resistance of the tooth.
Previous studies showed that when short random FRC was used as
the substructure for particulate filler composite, the load-bearing ca-
pacity of this combination increased linearly as the thickness layer of
FRC increased (32). From this point of view, in this study, the short fiber
composite base was covered with only a 1-mm-thick layer of PFC resin.
According to the Krenchel factor, short randomly arranged fibers
(E-glass fibers) when incorporated in the resin matrix provide an
isotropic reinforcement effect in multiple directions instead of just 1
or 2 directions. With continuous bidirectional fibers, the reinforcing ef-
fect is provided in 2 directions with a reinforcement efficiency of 50%,
whereas multidirectional random fibers will render a reinforcement ef-
ficiency of 38% in 1 plane and 20% in 3 dimensions (33).
Although there is a direct correlation between the level of fractures
and the reinforcement effect of the material to the tooth, in this study,
in addition to the fracture resistance values, the levels of fractures
were also evaluated. Fractures at the enamel and dentin levels can be
JOE — Volume -, Number -, - 2017
Basic Research—Technology
Group 3: DCC Group 4: PRC Group 5: IFC Group 6: SFC
(n = 10) (n = 10) (n = 10) (n = 10)
2 6 10
6 8 4 —
4 — — —
considered favorable because they can be easily repaired without any
additional reinforcement (3), but when it is extended up to the level
of or below the CEJ, it requires more complex restorative procedures
or it may even lead to loss of the tooth. In both the NC and SFC groups,
the fracture modes were all at the level of enamel, suggesting adequate
reinforcement in endodontically treated teeth. In applications such as
cuspal restorations, multidirectional reinforcement can arrest cracks
and prevent their propagation in the cervical direction, in addition to
being able to redistribute the 3-dimensional stress without causing un-
intended debonding or fracture in the cavity or substrate (34).
Although most of the fractures in the IFC group were in the enamel
and a few were in the dentin, correlating its least fracture resistance with
fracture levels, it can be said that this group may not be able to resist
heavy stresses. In the PRC group, the fracture modes were mostly at
the dentin levels, but this group showed better fracture resistance
values. On the contrary, all the fractures in the DCC group were at
the level of the dentin or CEJ and, along with the lower fracture resis-
tance values, indicate its less reinforcing effect.
Based on the results of this in vitro study, this study emphasizes
the use of an SFC substructure under a PFC in endodontically treated
teeth using the advantage of bilayered restoration to mimic the natural
behavior of enamel and dentin. This combination could provide a better
reinforcing effect in endodontically treated teeth and may also result in a
better compound without delamination under high stresses. This com-
bination can be recommended to be used as an ideal direct core
buildup material in high stress-bearing areas, replacing the current
invasive methods. Further investigations are required to gain valuable
information on the influence of simulating the periodontal ligament
in such in vitro studies before the extrapolation of these results to
the clinical scenario.
Conclusion
Within the limitations of this in vitro study, SFC resin in a MOD
cavity increased the fracture resistance of endodontically treated pre-
molars significantly.
Acknowledgments
The authors deny any conflicts of interest related to this study.
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