CLINICAL RESEARCH

Effect of short fiber-reinforced composite combined with

polyethylene fibers on fracture resistance of endodontically
treated premolars
Sabrina L. Soto-Cadena, DDS,a Norma V. Zavala-Alonso, DDS, PhD,b Bernardino I. Cerda-Cristerna, DDS, PhD,c
and Marine Ortiz-Magdaleno, DDS, PhDd

After endodontic treatment, ABSTRACT

the access cavity requires Statement of problem. Whether direct coronal restorations of endodontically treated teeth with
sealing to prevent micro- short fiber-reinforced composite combined with polyethylene fibers provide adequate
leakage and provide mechani- mechanical strength is unclear.
cal resistance to prevent
Purpose. The purpose of this in vitro study was to compare the fracture strength of endodontically
fracture under occlusal forces.1 treated premolars with standardized mesio-occluso-distal (MOD) preparations restored with short
An access cavity has been re- fiber-reinforced composite (SFRC) combined with polyethylene Ribbond fibers (PRFs).
ported to reduce relative stiff-
Material and methods. A total of 40 premolars were selected and distributed into 4 groups (n=10)
ness by 5%, and a mesio- as follows: group restored with SFRC (EverX Posterior), group restored with PRF (Ribbond fibers),
occluso-distal (MOD) cavity and group restored with the combination PRF+SFRC, all followed by a conventional composite
preparation reduced the resin (IPS Empress Direct). MOD preparations and endodontic treatments were prepared except
structural strength by about in the control group (intact teeth). MOD preparations and endodontic treatments were prepared
63%. The strength of except in the control group (intact teeth). Specimens were loaded using a universal testing
endodontically treated teeth machine until fracture occurred at a crosshead speed of 0.5 mm/min, and the failure type and
depends on the selection of fracture patterns was reported descriptively. The mean values of the groups were analyzed by
using the Shapiro-Wilk test and 1-way ANOVA tests (a=.05).
the restorative preparation
technique and type of restor- Results. Restoration with PRF+SFRC provided the highest mean ±standard deviation fracture
ative materials, factors that are resistance (288.2 ±73.5 N). Restoration with just PRF had the lowest values (192.4 ±25.4 N),
which were statistically different from those of SFRC and PRF+SFRC (P<.05). The predominant
subject to the dimensions of
mode of failure was mixed, and all fracture patterns were favorable.
the endodontic access cavity
preparation and remaining Conclusions. Reinforcing endodontically treated premolars with MOD cavities with Ribbond fibers
tooth structure.2,3 followed by a conventional composite resin enhanced fracture resistance and may be suitable for the
direct coronal restoration of large posterior cavities in stress-bearing areas. (J Prosthet Dent
The dentin in an endo-
2023;129:598.e1-e10)
dontically treated tooth has
reduced elasticity because of
the endodontic access and a decrease in water content.4 irrigant solutions used during endodontic treatment such
As a consequence, the tooth is more susceptible to the as sodium hypochlorite and ethylenediaminetetraacetic
formation of cracks and cusp or vertical fractures.5,6 The acid (EDTA) also reduce the mechanical strength of

a
Graduate student, Graduate Prosthodontics, Specialty in Aesthetic, Cosmetic, Restorative, and Implant Dentistry, Faculty of Stomatology, Autonomous University of San Luis
Potosí, San Luis Potosí, SLP, México.
b
Professor, Department of Dental Science Advanced Education, Faculty of Stomatology, Autonomous University of San Luis Potosí, San Luis Potosí, SLP, México.
c
Professor, Faculty of Stomatology, University of Veracruz, Orizaba, Ver, México.
d
Professor, Specialty in Aesthetic, Cosmetic, Restorative, and Implant Dentistry, Faculty of Stomatology, Autonomous University of San Luis Potosí, San Luis Potosí, SLP,
México.

598.e1 THE JOURNAL OF PROSTHETIC DENTISTRY

April 2023
Clinical Implications
The reinforcement of large cavities in
endodontically treated posterior teeth with
polyethylene fibers and bondable reinforcement
materials such as short fiber-reinforced composite
resins increases mechanical strength and rigidity by
distributing stress to the tissues under load.
dental tissues, as the dentinal tubules become dehy-
drated, producing porosities in the dentin surface and
promoting fractures.7,8
After endodontic treatment, conventional composite
resin (CCR), bulk fill composite resin, or glass ionomer
have been used for direct restorations.9-11 Bulk-fill
composite resins have been recommended for large
posterior cavities to overcome the limitations of CCR in
depth of polymerization and mechanical properties.12,13
Bulk-fill composite resins placed in increments of up to
5 mm simplify the technique.14 The volumetric shrinkage
of CCRs is a disadvantage of the material.15
The placement of a short fiber-reinforced composite
(SFRC) with a polymethylmethacrylate or bisphenol-a-
glycidylmethacrylate resin matrix has been reported to
reduce restoration failures and eliminate crack propaga-
tion and root fractures.16-18 These materials have been
marketed for dentin replacement in direct restorations.
The SFRC has as reinforcement E-glass type staple fibers,
inorganic particulate filler, a resin matrix with bisphenol
A-glycidyl methacrylate (bis-GMA), triethylene glycol
dimethacrylate (TEGDMA), and linear polymethyl
methacrylate (PMMA) crosslinked to create a semi-
interpenetrating polymer network that provides good
adhesive properties.19 Their short-fiber structure, rein-
forcing restorations in large cavities, possesses better
mechanical properties, avoiding crack formation.20-23 The
SFRC has been proposed for restorations in large cavities,
but, like some bulk fill composite resins, it must be
covered by a layer of CCR to protect the reinforcement
fibers from stress and moisture.24,25
Glass, polyethylene, aramid, and carbon reinforcing
fibers have been used in restorative dentistry.21,22 Poly-
ethylene fibers strengthen by absorbing the forces
occurring within the stressed material in dental cavities.
They have a higher flexural strength than CCR because
the fibers disperse the stress forces in the composite
matrix.26 Polyethylene Ribbond fiber (PRF) is a woven
fabric of cross-linked fibers of fine polyethylene strands.
The material is flexible, exhibiting high tensile strength,
modulus of elasticity, and fracture toughness, and easily
adapts to the morphology and contour of the cavity
walls.27 The use of PRF has been suggested for teeth with
extensive MOD cavities.28,29
Soto-Cadena et al
598.e2
Which of the restorative procedures and types of
restorative materials available provide the best mechan-
ical performance for an extensively damaged tooth is
unclear.30-32 Therefore, the effect of the different pro-
tocols on coronal restorations in extensive MOD cavities
in endodontically treated teeth should be investi-
gated.33,34 The aim of the present study was to compare
the fracture resistance of endodontically treated pre-
molars restored with SFRC, with PRF alone, and with the
combination of both, all then veneered with CCR. The
null hypothesis was that no difference would be found in
the fracture resistance of endodontically treated pre-
molars with MOD cavities with coronal restoration
techniques using SFRC, PRF, and a combination of both.
MATERIAL AND METHODS
Forty sound human maxillary premolar teeth extracted
for periodontal or orthodontic reasons with similar sizes
in all the dimensions were obtained under the approval
of the Ethical Committee of the Faculty of Stomatology
(CEI-FE-013-022), University of San Luis Potosi, Mexico.
The teeth were cleaned of debris and soft tissue remnants
and were stored in physiological saline at 4  C up to 2
months until use. The roots were standardized
embedded vertically up to 3 mm below the cementoe-
namel junction (CEJ) using acrylic resin (Nic tone; MDC
Dental) (Fig. 1A).
Endodontic treatment was performed on 30 teeth,
with 10 teeth being the control group without treatment.
Standardized endodontic access cavities were prepared
by 1 operator (S.L.S.C.) with a high-speed diamond ro-
tary instrument (Kerr Rotary Diamonds; Kerr Corp) un-
der water cooling.
The root canals were instrumented up to a #50 K-file
(Dentsply Sirona), irrigated with 1% sodium hypochlorite
between each file size, and dried with absorbent paper
cones (Dentsply Sirona). Before obturation with the
lateral condensation technique, the root canals had been
irrigated with saline solution to remove the smear layer
and were then conditioned with 5 mL of 17% EDTA
(Sigma Aldrich) for 1 minute, followed by copious irri-
gation with distilled water. After drying with paper
points, a size-40 gutta percha cone was used as the
master cone with a resin sealer (AH Plus; Dentsply
Sirona). After vertical compaction, the extracoronal
excess of the gutta percha was removed by using a
heated condenser 1 mm from the CEJ. Radiographs of
each tooth were made to evaluate the quality of the
endodontic treatment. All the access cavities were
cleaned and dried.
The pulp chamber floor was layered with resin-
modified glass ionomer cement (Vitremer; 3M ESPE),
etched with 35% phosphoric acid (Scotchbond Etchant;
3M ESPE) for 15 seconds for the dentin and 30 seconds
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598.e3
Figure 1. A, Roots embedded in acrylic resin. B, Standardized MOD cavities in endodontically treated premolars. C, Depth 5 mm. D, Buccolingual with
5 mm. MOD, mesio-occluso-distal.
for the enamel, rinsed with a water spray, and gently air
dried. A primer and bonding agent (Optibond FL; Kerr
Corp) was applied to the cavity surfaces according to the
manufacturer’s instructions and light polymerized for 20
seconds at 1000 mW/cm2 (VALO Curing Light; Ultradent
Products, Inc) by keeping the light tip perpendicular to
the substrate and the tip 5 mm away from the dentin
surface. The power of the light source was checked with a
dental radiometer (Demetron; Kerr Corp) to ensure that
the intensity was not less than 1000 mW/cm2. Materials,
composition and manufacturers are listed in Table 1.
The remainder of the endodontic access cavity was
then initially filled with a light-polymerizing composite
resin (Systemp Inlay; Ivoclar AG). The teeth were stored
at 37  C and 100% humidity for 7 days to allow time for
the resin to fully polymerize. Then, the initial filling
material was removed, and standardized MOD cavities
were prepared by the same operator (S.L.S.C.) at room
temperature with an electric motor (NLX nano; NSK/
Naknishi Inc) at 20 000-rpm using tapered diamond
rotary instruments (Brasseler) and continuous water
cooling (Fig. 1B). The corresponding measurements were
a 5-mm bucco-palatal width, 5-mm depth and 6-mm
mesio-distal width, and the thickness of the buccal wall
was standardized at 2 mm at the buccal occlusal wall, 2.5
mm at the buccal CEJ, 1.5 mm at the palatal occlusal
surface, and 1.5 mm at the palatal CEJ; the measure-
ments made with a periodontal probe (Fig. 1C, D). The
thicknesses of the buccal and palatal or lingual walls were
measured with digital calipers (IP54; iGaging).
The control group had intact teeth without end-
odontic treatment or a restoration. The 30 teeth with
endodontic treatment and cavities were divided into
experimental groups of 10 teeth according to the
restorative procedures. In the group restored with SFRC,
the MOD cavities were restored with SFRC (EverX Pos-
terior; GC) and layered with composite resin (IPS
THE JOURNAL OF PROSTHETIC DENTISTRY
Volume 129 Issue 4
Empress Direct resin composite; Ivoclar AG) using an
incremental technique of 1.5-mm thickness and dental
composite resin filling spatula was used to limit the
placement of the material, each layer was polymerized for
40 seconds at 1000 mW/cm2 (VALO Curing Light;
Ultradent Products, Inc) (Fig. 2A).
In the group with only PRF, the cavities were restored
with a 4-mm-long piece of the PRF (Ribbond) that was
coated with adhesive resin; excess material was blotted off
with lint-free gauze (Protec). The PFR was embedded in a
flowable composite resin (Clearfil APeX Esthetics Flow;
Kuraray) on the buccal wall, pulpal floor, and lingual wall
of the MOD cavities and light polymerized for 20 seconds.
As with group SFRC, the exposed surface of the PRF was
covered and restored with composite resin (IPS Empress
Direct resin composite; Ivoclar AG) (Fig. 2B). In the group
with PRF+SFRC, PRF (Ribbond) was embedded inside the
flowable composite resin (Clearfil APeX Esthetics Flow) on
the buccal wall, pulpal floor, and lingual wall of the MOD
cavities as in group PRF, followed by the SFRC (EverX
Posterior) and covered with the composite resin (IPS
Empress Direct resin composite) as in group SFRC
(Fig. 2C). The occlusal anatomy of the restorations was
shaped to replicate mandibular or maxillary premolar
teeth, and the restoration surface was polished with me-
dium to superfine aluminum oxide polishing disks (Soflex;
3M ESPE). The clinical procedure of the group with SFRC
is described in Figure 3, the group with PRF in Figure 4 and
the group with PRF+SFRC in Figure 5.
A 30-degree oblique compressive load (Fig. 6) was
applied to create a single contact in the buccal cusps at
the junction of the direct CCR filling and enamel with a
universal testing machine (Shimadzu PWS-E100 Corp) at
a crosshead speed of 0.5 mm/min until fracture
occurred.35 The load in the control group was applied at a
similar location to that of the other groups The type of
failure was determined by visual inspection under ×40
Soto-Cadena et al
April 2023 598.e4

Figure 2. Schematic representation of restorations tested. A, Group SFRC: coronally restored with SFRC (EverX Posterior). B, Group PRF: restored with
only PRF. C, Group with PRF+SFRC. All covered with CCR. CCR, conventional composite resin; FC, flowable composite resin; GIC, glass ionomer cement;
GP, gutta percha; MOD, mesio-occluso-distal; PRF, polyethylene Ribbond fibers; SFRC, short fiber-reinforced composite.

with a stereomicroscope (EZ4W; Leica) and was classified RESULTS

according to the type of failure: adhesive failure if there
Table 2 shows the results of the fracture resistance mean
was complete detachment at the interface of the 2
values, which was highest for the control group (435.7
structures; cohesive failure if it occurred inside the ma-
±40.7 N), followed by group PRF+SFRC (288.2 ±73.5
terial structure; and mixed failure (combination of ad-
MPa) and group SFRP (267.2 ±40.7 MPa), which were
hesive and cohesive failure). The evaluation of fracture
statistically similar (P>.05). Group PRF had lower mean
patterns after the fracture strength test was classified as
values than group PRF+SFRC or group SFRC (P<.05). All
favorable: fractures extending up to 1 mm below the CEJ
restored groups showed significantly lower mean fracture
or unfavorable: fractures extending more than 1 mm
resistance than the control group (P<.05).
below the CEJ. The frequency percentages of fracture
The type of posttest failure reported descriptively in
patterns were recorded.
percentages was predominantly mixed: group SFRC 60%,
Statistical analysis was done with a statistical software
group PRF 80%, and group PRF+SRFC 80% (Fig. 7). The
program (IBM SPSS Statistics, v22; IBM Corp). The
remaining failures were all cohesive, with no adhesive
normality of the fracture data distribution was deter-
failures. All fracture patterns were favorable for the
mined with the Shapiro-Wilk test and the test of ho-
restorative procedures evaluated.
mogeneity of variances through the Levene test. Tukey’s
test was used to carry out the analysis of multiple com-
parisons. Because the data followed a normal distribution
DISCUSSION
(P=.097), the 1-way ANOVA parametric test was per-
formed to compare each experimental group with the As the loss of tooth structure integrity with an extensive
control group. The Pearson chi-square test was used for MOD cavity in an endodontically treated tooth in-
the failure mode data (a=.05 for all tests). creases the possibility of fracture, a restoration should

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598.e5 Volume 129 Issue 4

Figure 3. Endodontically treated teeth restored with SFCR. A, Layer of resin-modified glass ionomer cement. B, Etched with 35% phosphoric acid.
C, Priming and bonding procedures. D, EverX Posterior applied. E, SFRC applied as base material in 4-mm layer F, Definitive coronal restoration
completed with CCR. CCR, conventional composite resin; SFRC, short fiber-reinforced composite.

provide strength and rigidity, replacing lost enamel and
dentin to prevent and stop the propagation of cracks
and fractures.1 The present in vitro study compared 3
procedures with 2 materials for the restoration of
endodontically treated premolars with MOD cavities
and found that restorations combining SFRC with PRF
resulted in increased fracture resistance. The highest
number of failure types were mixed, and all fracture
patterns were favorable. Therefore, the null hypothesis
was rejected.
The restorative procedure and filling material should
provide sufficient mechanical strength for a tooth with a
large MOD cavity.9 In teeth with missing walls and high
C-factor cavities, the restorative technique is the key to
the adhesion of restorative materials.7
Premolars were tested in the present study because
they are more frequently exposed to destructive lateral
forces than molar teeth and are more prone to cuspal
fracture.10 The MOD cavities were designed to decrease
tooth strength, as an endodontic access cavity without
proximal marginal ridges has been associated with higher
stress-bearing areas.35
The high fracture strength values with the PRF+SFRC
restorative procedure may be because stress was

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April 2023 598.e6

Figure 4. Endodontically treated teeth restored with PRF. A, Layer of resin-modified glass ionomer cement. B, Etched with 35% phosphoric acid. C,
Priming and bonding procedures. D, FC applied to floor. E, Embedding PRF into bed of FC and insertion of fibers at occlusal position. F, Definitive
coronal restoration completed using CCR. CCR, conventional composite resin; FC, flowable composite resin; PRF, polyethylene Ribbond fibers.

transferred from the matrix of the SFRC combined with
the action of the PRF embedded into the bed of flowable
composite resin; these 2 restorative materials acted as a
filler block.6 Dentin contains collagen fibers embedded in
a hydroxyapatite matrix and is microstructurally more
similar to SFRC than to CRC or bulk-fill composite
resin.13
Group SFRC had higher fracture resistance than
group PRF, consistent with a previous study of the frac-
ture resistance of molars comparing CRC with particulate
filler.17 In the present study, SFRC was used as a bulk
dentin replacement and has been reported to have better
resistance to fracture, flexural strength, and microhard-
ness values than bulk-fill composite resin.11 The multi-
directional short fibers in the composite resin are key to
promoting the reinforcement effect compared with CCR,
and the short fibers present in the resin matrix can arrest
fracture propagation toward the CEJ and root, which
could greatly improve the prognosis of a tooth with se-
vere structural loss.18

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Figure 5. Endodontically treated teeth restored with SFCR and PRF. A, Layer of resin-modified glass ionomer cement. B, Etched with 35% phosphoric
acid. C, Priming and bonding procedures, D, FC applied in floor. E, Piece of PFR. F, PRF insertion at occlusal position from buccal to lingual direction
embedded inside FC. G, SFRC applied. H, Definitive coronal restoration completed with CCR. CCR, conventional composite resin; FC, flowable composite
resin; PRF, polyethylene Ribbond fibers; SFRC, short fiber-reinforced composite.

The present results were consistent with those of

other studies that reported improved fracture resistance
of endodontically treated teeth restored with a short
fiber-reinforced dentin base compared with a hybrid
composite resin and PRF, obtaining similar or even
improved fracture resistance of the restorative material
and tooth tissue.23 Ozcevik et al21 evaluated the frac-
ture resistance of SFRC (EverX Posterior) under CCR
and showed similar resistance to intact teeth, SFRC
under CRC provided better strength than CRC alone or
only with PRF. Sáry et al22 concluded that the SFRC
(EverX Posterior) and microhybrid resin restorations
were characterized by the highest percentages of
favorable fractures, while the microhybrid resin had
the lowest values. Insufficient scientific evidence is
available on the mechanical properties of different
commercial brands of SFRC, including EverX Posterior,
a popular brand. In 2017, Garoushi et al23 compared Figure 6. Restored tooth at 30-degree angulation in universal testing
the mechanical properties of 5 commercial brands of machine.

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April 2023 598.e8

Table 1. Materials used in this study

Product Name Type Manufacturer Composition Batch Number
Vitremer Resin-modified glass ionomer 3M ESPE Powder: fluoraluminosilicate glass, redox catalyst system, pigments. NC86518
cement Liquid: aqueous solution of a polycarboxylic acid modified with pedant
methacrylate groups, Vitrebond copolymer, water, HEMA, photoinitiators.
Primer: Vitrebond copolymer, HEMA, ethanol, photoinitiators.
OptiBond FL Light-polymerized total-etch Kerr Corp Primer: HEMA, GPDM, MMEP, ethanol, water, initiators. 7 766 889
adhesive bonding system Bonding agent: Bis-GMA, HEMA, GPDM, barium-aluminum borosilicate
glass, disodium hexafluorosilicate, fumed silica (48% filler).
EverX Posterior Millimeter-scale short GC Filler: Silicon dioxide (max. 5 wt%), Barium glass (max. 70 wt%) E-glass 2 108 043
fiber- reinforced composite fiber (max. 15 wt%). Resin: Bis-GMA, TEGDMA, PMMA.
Ribbond fibers Polyethylene fibers Ribbond Preimpregnated, silanized, plasma-treated, leno-woven, ultrahigh 55 334
emodulus polyethylene fibers.
Clearfil Universal flowable Kuraray Resin matrix: TEGDMA, Bis-GMA.Inorganic filler: silanated barium glass, 960 345
AP e X Esthetics composite resin silanated colloidal silica, silanated silica (85.0 wt%, 71.0 vol%).
Flow
IPS Empress Direct Nanohybrid composite resin Ivoclar AG Dimethacrylate, Ba-Al- SiO4 glass silicate, oxide silicates, YbF3. Z002P2

Bis-GMA, bisphenol A-glycidyl methacrylate; PMMA, polymethyl methacrylate; TEGDMA, triethylene glycol dimethacrylate.

Table 2. Mean ±standard deviation (SD) fracture resistance of restorative

procedures
Fracture Resistance (N)
Group Mean ±SD DF F P Value
Control 435.7 ±40.7a 39 29.08 -
SFRC+PRF 288.2 ±73.5*b 19 30.71 .001
SFRC 267.2 ±40.7*b 19 255.64 .001
PRF 192.4 ±25.4*c 19 34.58 .003

DF, degrees of freedom; F, F test; PRF, Polyethylene Ribbond fibers; SD, standard
deviation; SFRC, Short fiber-reinforced composite. *Indicates significant difference
versus control group (P<.05). Mean followed by the same lower-caste letter within the
column are not statistically different.

SFRC in relation to their microstructural characteristics:

Alert (light cured packable; Jeneric/Pentron), Easy Core
(dual core flowable; SpofaDental), Build-It (dual core
flowable; Jeneric/Pentron), TI-Core (auto cure pack-
able; Essential Dental Systems), and EverX Posterior,
which showed the highest fracture toughness (2.4 MPa
m1/2) among the materials tested (P<.05). Therefore,
EverX Posterior properties make this an SFRC a
promising candidate as a base material for application
in high-stress areas and large cavities in posterior
teeth.25
Restoration only with PFR had the lowest fracture
resistance values. However, the effect of the test for
fracture resistance in all 3 restorative procedures resulted
in favorable fracture patterns, allowing the coronal res-
torations to be repaired.17 Studies have reported that the
placement of PRFs is an effective and practical treatment
option for the reinforcement of CRC core material in
endodontically treated teeth, without the need for post
placement, as they distribute stress along the restorative-
tooth interface.29 The PRF transfer the stress from the
matrix to the fibers, stopping crack propagation through
the dental filling materials.30 Oskoee et al31 reported that
PRF exhibited a greater reinforcing effect than glass fi-
bers, as did Belli et al,32 who evaluated the use of PRF
embedded in a thin layer of FC, concluding that this
Figure 7. Representative fracture pattern. Fractures favorable with
fracture occurring in cervical third of root above cementoenamel
junction. Mixed fracture pattern predominant type.
restorative procedure increased the resistance of
endodontically treated teeth with large cavities. In
contrast, Ramesh et al33 reported that PRF as a rein-
forcement in endodontic teeth without posts failed, but at
the level of being repairable and favorable above the CEJ.
The use of PRF in endodontically treated molar teeth
with MOD cavities significantly increased the mean
values of fracture strength compared with FC under CCR
or with CRC alone, which no had effect on fracture
resistance values.32
Contemporary restorative dentistry is based on ad-
hesive techniques and consists of preserving as much
tooth tissue as possible. The choice of which type of
restoration (direct versus indirect and composite versus
ceramic) should be taken into account for the extent of
the cavity diagnosed.36
An indirect restoration is indicated for patients with
extensive cavities and/or teeth that require cuspal
coverage with extensive proximal reduction that reduces
the thickness of the remaining walls and may lead to

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598.e9
fracture. Indirect restorations are also indicated for pa-
tients with multiple medium or large restorations in the
same quadrant, cavities that are difficult to access, such
as the distal walls of the second molars, and when the
proximal box extends subgingivally. A direct restoration is
indicated when all cusps are preserved and the proximal
box is supragingival and easily accessible.37-39
Key local factors should be considered when restoring
endodontically treated posterior teeth with extensive
cavities to ensure they can resist fracture and will have
long-term clinical performance. Factors that the clinician
must consider to determine the type of restoration to use
include cavity morphology, quantity and quality of
remaining tissue, thickness of remaining walls, occlusion,
location of gingival margins, presence of cracks, tooth
position in the arch, periodontal pathology, masticatory
force, and presence of parafunctional habits.40
The tooth preparation design must ensure structural
integrity to avoid fracture. Therefore, extensive cavities
should be restored with inlays whose interproximal
extent is apical to the CEJ and the wall thickness of non-
functional cusps should be at least 2.0 mm to prevent
crack formation.41,42 Thompson et al43 in their review
stated that the cavity depth, cavity isthmus width,
preparation taper, and morphology of internal line angles
were the main factors influencing inlay longevity in
preparation design.
Limitations of the present study included the in vitro
design that may not have accurately reproduced the
clinical failure mode. In addition, no dynamic loading
was applied to evaluate the fatigue of the filling materials.
As the testing of fracture resistance represents a static
loading method, furthers studies should use a dynamics
method.
CONCLUSIONS
Based on the findings of this in vitro study, the following
conclusions were drawn:
1. The use of PRF and SFRC individually in deep MOD
cavities was beneficial to the fracture patterns.
2. The effect of placing SFRC over PRF in MOD cav-
ities in endodontically treated premolars increased
fracture resistance values.
3. This restorative procedure is a suitable and conser-
vative treatment option.
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inlays and partial ceramic crowns: influence of remaining cusp wall thickness https://doi.org/10.1016/j.prosdent.2023.01.034

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