Aust Endod J 2022; 48: 458–464

ORIGINAL RESEARCH

Stress Distribution and Fracture Resistance of repairing Cracked

Tooth with Fiber-reinforced Composites and Onlay
Rui Shi, MSc1,2; Xingwang Meng, MSc3; Rui Feng, MSc1,2; Shanshan Hong, MSc1; Chen Hu, MSc1,2;
Min Yang, MSc1; and Yuegui Jiang, MSc1,2
1
Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research, Xi’an Jiaotong University, Xi’an, China
2
Department of Endodontics, College of Stomatology, Xi’an Jiaotong University, Xi’an, China
3
Department of Mechatronic Engineering, College of Mechanical Engineering, Xi’an Jiaotong University, Xi’an, China

Keywords
cracked tooth, fiber-reinforced composite,
fracture strength, onlay, 3D finite element.
Correspondence
Mrs Yuegui Jiang, Key Laboratory of Shaanxi
Province for Craniofacial Precision Medicine
Research, Xi’an Jiaotong University, Xi’an,
Shaanxi, China; Department of Endodontics,
College of Stomatology, Xi’an Jiaotong
University, No.98, Xiwu Rd, Xi’an, Shanxi
710004, China. Email: jyg_xjtu@163.com
doi: 10.1111/aej.12578
(Accepted for publication 26 September 2021.)
Abstract
The purpose of this study was to explore the effects of fibre-reinforced compos-
ites and onlay restorations on the fracture resistance of the cracked teeth. The
experiments were grouped as follows: intact teeth, cracked teeth, crown;
onlay; annular ribbond + onlay, laminated ribbond + onlay and fibre
post + onlay; annular ribbond + crown, laminated ribbond + crown and fibre
post + crown. The maximal Von Mises stress of dentin, the maximal Von Mises
stress at the crack, the fracture resistance and fracture pattern under static
loading were analysed by single-factor analysis of variance (ANOVA) and post-
test by LSD. The annular ribbond + crown had a significant difference in frac-
ture resistance than the crown (P < 0.05). The annular ribbond + onlay had
more favourable fractures than crown in fracture pattern, and there were sig-
nificant differences (P < 0.05). Compared with crown restoration, fibre-
reinforced composites and onlay can improve the fracture resistance of the
cracked teeth.

Introduction
As a common non-carious disease of tooth hard tissue,
cracked teeth have the characteristics of complicated clin-
ical manifestations and uncertain prognosis (1,2). Due to
the lack of overt symptoms in the early stage and the hid-
den location of the lesion, it was easy to be misdiagnosed
or missed. The development of multiple factors led to the
occurrence of pulpitis, which made clinical treatment
more difficult. How to choose a reasonable and effective
treatment plan to avoid tooth splitting and tooth loss was
of great significance to ensure the quality of life of
patients. The best way that is currently accepted is to
adjust the occlusion followed by root canal therapy and
crown restoration (3,4). However, some data show that
the one-year survival rate for crown repair after root
canal treatment of cracked teeth with pulp exposure is
95.2% (4) and the three-year survival rate is only
68.91% (5). The hoop effect of crown restoration had a
protective effect on cracked teeth, but when there were
abnormal occlusal forces and deep cracks, the stress con-
centration at the crack might cause the crack to
propagate to the root split (6). The main reason for the
failure of the restoration was the leakage of the crown
and the fracture of the remaining teeth tissue. Therefore,
only using crowns to repair cracked teeth after root canal
treatment cannot fully meet the clinical requirements. In
view of the difficult evaluation of the long-term curative
effect of cracked teeth and the poor prognosis, this paper
adopts the treatment method of combining fibre-
reinforced resin and onlay.
Previous literature shows that the fibre-reinforced
composites (polyethylene fibre (Ribbond), fibre posts)
play a role in stress dispersion because of its structural
characteristics, which can enhance the fracture resis-
tance of the restored teeth and can prevent the further
expansion of cracks to a certain extent (7,8). The onlay
uses the pulp chamber of the endodontically treated
teeth and bonding for retention (9). It is beneficial to
retain the peri-cervical dentin and make the fracture
strength of the restored teeth comparable with that of
the natural teeth (10). Therefore, the combination of
onlay and fibre-reinforced composites (FRC) in the

458 © 2021 Australian Society of Endodontology Inc


R. Shi et al.
repair of endodontically treated cracked teeth with pulp
exposure is worthy of further exploration.
Materials and methods
This study used 3D finite element analysis (FEA) and
fracture failure test. This experiment was approved by
the ethics committee of our hospital (no.2013-670). After
the patient’s informed consent, the isolated maxillary
first premolar was obtained. Inclusion criteria were as fol-
lows: maxillary first premolars with less abrasion, no
defects, no root canal absorption, no cracks, no filling
materials and root apical development completed.
Three-dimensional FEA
Using Mimics software (V10.01; Materialise, Leuven, Bel-
gium), Geomagic Studio 12.0, Pro/E software and
SolidWorks16.0 for image processing, a normal tooth 3D
finite element (FEA) model was generated. Based on the
normal tooth model (A1), a cracked tooth model was
built, whose crack was wedge-shaped, the direction was
mesial–occlusal–distal, the width of the occlusal surface
was 0.17 mm and the depth was 1.00 mm at the root of
the cemento-enamel junction (CEJ) (11,12). Root canal
Figure 1 Three-dimensional FEA model generation. A1) FEA model of intact teeth, A2) FEA model of cracked teeth, A3) FEA model of crown restora-
tion, B) FEA model of onlay restoration, C1) FEA model of annular ribbond + onlay, C2) FEA model of laminated ribbond + onlay, C3) FEA model of fibre
post + onlay; D1) FEA model of annular ribbond + crown, D2) FEA model of laminated ribbond + crown and D3) FEA model of fibre post + crown.
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Ribbond and Onlay repair Cracked tooth
treatment was performed based on the cracked teeth
model, and the onlay model (B) and the crown restora-
tion model (A3) were established. Onlay and crown
preparations are shown in Fig. 1 (13). The method of lay-
ing an annular ribbond is to lay a ribbond (2.00 mm in
width and 0.60 m in thickness) in the pulp cavity next to
the wall of the pulp chamber. Laminated ribbond was
laid in such a way that the ribbond was stacked to form a
columnar ribbond-reinforced composite with a depth of
2 mm; the fibre post was laid by placing it (1.5 mm in
diameter) in the pulp cavity along the horizontal cheek
tongue and the remaining space in the pulp cavity was
filled with composite resin. The experimental grouping is
shown in Fig. 1.
According to the basic assumption of elastic mechanics,
tissues and materials other than the post, which were
considered orthotropic, were considered as isotropic, lin-
ear and homogeneous (14,15). The simulated mechanical
properties of the tissues and the materials are shown in
Table 1 (16–18).
The mesial, distal and bottom surfaces of the model
were completely fixed. The buccal and lingual alveolar
bones were defined as freedom boundaries. ANSYS was
used to statically load a 270N maximum bite force for
each group of models. The loading location and loading
459

Ribbond and Onlay repair Cracked tooth
Table 1 Material properties assigned to dental tissues and restorative
material (MPa)
Elastic modulus
Tissue or Material (MPa)
Enamel 84100.00
Dentin 18600.00
Pulp 2.00
Periodontal ligament 68.90
Cortical bone 13700.00
Cancellous bone 1370.00
Gutta-percha 0.69
Glass ion 17200
Composite resin 10000
Fibre tape-flowing resin composite 23600.00
Fibre post 45000.00
Ceramic restoration (elastic porcelain) 38110.00
Cast cobalt-chromium metal 211000.00
direction were as follows: vertical load: on the mid of the
buccal triangle ridge and palate triangle ridge, parallel to
the longitudinal tooth axis, buccal to 45 acting on the
mid of the buccal triangle ridge, palate to 45 acting on
the palate triangle ridge. The maximal Von Mises stress of
dentin and the maximal Von Mises stress at the crack
were recorded under different loads, and the dentin stress
nephogram was plotted. The effects of the restoration
methods of each group on the stress distribution and
stress magnitude of the cracked teeth were compared.
Fracture failure test
Dental plaque, calculus and periodontal tissues of the
teeth were removed using a hand scaler and stored in a
0.1% thymol solution for 3 months at room temperature.
The 80 teeth were randomly divided into 10 groups
(n = 8) in the same way as in the three-dimensional
finite element experiment, as shown in Table 1. The
crack shape was the same as the three-dimensional finite
element model, and the width of the occlusal surface was
1.00 mm. RCT was performed on the isolated teeth of A3
and the experimental group.
The method of laying the ribbond and the fibre post
was the same as the three-dimensional finite element
experiment. Standard metal onlay teeth were as follows:
2.00 mm thickness of the occlusal fascia, 2-mm long
onlay-cores and 2–6° degree of abduction. Standard full
metal crown tooth was prepared as follows: 1.50 mm
thick of the occlusal surface, 0.80 mm shoulder and 2–6°
degree of polymerisation. For the onlay and crown
group, silicon rubber was used to make impressions. The
repair material was cobalt-chromium metal, and glass
ionomer cement was used to bond the restorations.
460
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R. Shi et al.
All specimens were subjected to cold and heat cycles at
5 ℃  2 ℃ to 55 ℃  2 ℃ with 30 s dwell-time and 5 s for
transfer and for 2000 times to simulate temperature fati-
Poisson’s ratio gue. All specimens were embedded vertically in cold-
0.30
cured acrylic resin (2.5 mm in diameter and 4.0 mm in
0.31 height) to a level of 1.0 mm apical to the CEJ, to which
0.45 0.3-mm-thick silicone paste was applied between the
0.45 roots and acrylic resin to simulate the periodontal liga-
0.30 ment. A universal testing machine (Instron, Canton, MA,
0.30 USA) was used to perform the fracture test. A 4-mm-
0.45
diameter round tip load cell (Spherical stainless steel
0.30
0.24
loading head) was used to apply pressure to the long axis
0.26 of the central fossa centre at a strain rate of
0.32 1.0 mm
min 1 until fracture occurred. After fracture, the
0.24 fracture strength and fracture mode were recorded.
0.42 Favourable failure was defined as fracture above the CEJ,
or 1 mm or less apical to the CEJ, and unfavourable fail-
ures were defined as fractures and fractures more than
1 mm apical to the CEJ (19).
The fracture strength was analysed by single-factor
analysis of variance (ANOVA) and post-test by LSD,
a = 0.05. The fracture mode was compared by Fisher’s
exact test, a = 0.05. All statistical analyses were per-
formed in SPSS22.0 (IBM, Inc., Armonk, NY, USA).
Results
Three-dimensional FEA
Under the same magnitude of loading force, the maximal
Von Mises stress of dentin and the maximal Von Mises
stress at the crack in the direction of palatal 45° were
greater than the buccal 45° and also greater than the ver-
tical one. The cracked tooth group had the highest peak
stress in the three loading directions. The stress distribu-
tion is shown in Fig 2, 3 and 4.
In comparison with the maximal Von Mises stress of
dentin, the value of annular ribbond + onlay (vertical:
29.5 Mpa, buccal: 58.3 Mpa and palate:76.9 Mpa) and
laminated ribbond + crown (vertical:28.8 Mpa, buccal:
60.6 Mpa and palate: 99.7 Mpa) were lower than that in
the crown group (vertical: 33.5 Mpa, buccal: 62.5 Mpa
and palate: 102.5 Mpa). The stress distribution was the
same as that of the intact teeth group (vertical: 31.5 Mpa,
buccal: 66.4 Mpa and palate: 98.2 pa), and the stress
peak was lower than that in the intact teeth group. In the
comparison with the maximal Von Mises stress at the
crack, the value of FRC repair (C, D) was lower than
those in the crown group (vertical: 15.6 Mpa, buc-
cal:42.8 Mpa and palate: 46.5 Mpa), and the value of the
annular ribbond + onlay group (vertical:12.9 Mpa, buc-
cal:32.1 Mpa and palatal:32.2 Mpa) in the three loading
directions was the smallest.
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R. Shi et al. Ribbond and Onlay repair Cracked tooth

Figure 2 Photographs of the Von Mises stress distribution (MPa) of 270N maximum occlusal force in three different loading directions.

180 140
160 120
140
100
Peak stress/MPa
Peak stress/MPa

120
100 80

80 60
60
40
40
20
20
0 0
A1 A2 A3 B C1 C2 C3 D1 D2 D3 A2 A3 B C1 C2 C3 D1 D2 D3
Grouping Grouping

Vercal Buccal to 45° Palate to 45° Vercal Buccal to 45° Palate to 45°

Figure 3 Histogram of the maximal Von Mises stress of dentin. Figure 4 Histogram of the maximal Von Mises stress at the crack.

No statistically significant differences were found

Fracture resistance
Using SPSS22 statistical software, the difference between
groups was statistically significant using one-way analysis
of variance (F = 42.645, a = 0.05 and P < 0.05). The
mean values of fracture strength of each group are shown
in Table 2 and Fig. 6. The fracture resistance of onlay (B)
and FRC repair (C, D) was found to be better than the
cracked teeth (A2) and intact teeth (A1), and there were
significant differences (P < 0.05). Among them, annular
ribbond + crown (D1) was significantly different
(P < 0.05) in fracture strength than the crown (A3).
between crown (A3) and onlay (B) (P > 0.05); there
were no statistically significant differences between rib-
bond repair (C1,C2,D1,D2) and fibre post repair (C3,D3)
(P > 0.05). In the annular ribbond (C1,D1), crown was
found to be better than onlay having a statistically signifi-
cant difference (P < 0.05). In the laminated ribbond (C2,
D2), crown was found to be better than onlay having no
statistically significant difference (P > 0.05). In the fibre
post repair (C3, D3), onlay was found to be better than
crown having no statistically significant difference
(P = 0.05).

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Ribbond and Onlay repair Cracked tooth R. Shi et al.

Figure 5 Photographs of representative specimens displaying different
fracture modes. ‘+’ indicates favourable fracture,’-‘ indicates unfavour-
able fracture.
Fracture pattern
The photographs of representative specimens displaying
different fracture modes are shown in Fig. 5. The mean
values of fracture modes in each group are shown in
Fig. 6. The results showed that intact teeth (A1) were all
favourable fractures, and cracked teeth(A2) were all
unfavourable fractures. There were more favourable frac-
ture modes for annular ribbond + onlay(C1). The favour-
able fracture patterns of annular ribbond + onlay(C1)
were better than cracked teeth(A2), and there was a sta-
tistically significant difference (P < 0.05). The favourable
fracture patterns of annular ribbond + onlay(C1) were
better than the crown(A3), and there was a statistically
significant difference (P < 0.05). The favourable fracture
patterns of the experimental group (B, C and D) and the
control group (A2 and A3) were all lower than intact
teeth (A1) ( P < 0.05); there were no statistics between
the other groups.
Discussion
In this experiment, the fracture resistance of the cracked
teeth was the lowest, and the crack tip was an area of
obvious stress concentration. Pure crown restoration
could enhance the fracture resistance of cracked teeth to
a certain extent. It is suggested that crown restoration
should be carried out as soon as possible after root canal
treatment of cracked teeth. This is consistent with Ytc A
et al (20) that crown restoration should be regarded as an
important part of the root canal treatment plan for
cracked teeth.
The ultimate tensile strength of dentin was 40 MPa.
According to the results obtained, the maximum Von
Mises stress at the crack in the experimental group was
lower than the crown group and ultimate tensile
strength, indicating that there were still some problems
in the restoration of cracked teeth with crown alone. The
study by Gu Daming et al (5) also found this problem.
Even if crown restoration was performed on cracked
teeth after treatment, the 3-year survival rate was still
low. For cracked teeth, the fracture of endodontically
treated teeth results from their biomechanical compro-
mise and stress concentration at the crack tip (21,22). For
cracked maxillary first premolars with significant neck
narrowing, the higher incidence of fracture is related to
the loss of tooth structure due to crown preparation.
According to the results, fibre-reinforced resin could
not significantly improve the fracture strength of cracked
teeth after treatment, but it could increase the ratio of
favourable fracture of cracked teeth to a certain extent.
Studies by Costa S et al. (23) and Karzoun W et al. (24)
showed that, due to the characteristics of polyethylene
fibre and fibre post, fibre-reinforced resin could increase
the fracture strength of teeth after root canal treatment,
suggesting that it is feasible to use fibre-reinforced resin
to repair cracked teeth. These studies corroborate, to

Table 2 Comparison of fracture strengths

Subgroups
Group Mean (SD) (a = 0.05)

A1 1206.57(179.02) d
A2 471.15 (220.80) e
A3 3013.30 (716.73) b c
B 3013.83 (783.35) b c
C1 3054.85 (505.99) b c
C2 3304.47 (719.84) a b c
C3 3644.64 (916.17) a b
D1 3714.46 (718.23) a
D2 3644.09 (601.21) a b
D3 3010.05 (595.57) c

ANOVA test and LSD post hoc test.

462 © 2021 Australian Society of Endodontology Inc


R. Shi et al.
100%
90%
80%
Fracture mode(%)
70%
60%
50%
40%
30%
20%
10%
0%
A1 A2 A3 B C1 C2
Groups
favorable unfavorable
Figure 6 Fracture mode of each group.
some extent, by Otero C et al (25), in which the authors
report fibre-reinforced composite bases did not improve
the fatigue resistance of cracked endodontically treated
molars, but favourably influenced the failure mode.
Although the internal fixation effect of fibre-reinforced
resin was not as strong as the external fixation effect of
crown restoration, the different laying methods of fibre-
reinforced resin could improve the stress concentration at
the crack tip of the cracked tooth to a certain extent.
Regarding the influence of crown restoration methods
on fracture strength, regardless of the type of restoration
method was used, there was a significant increase in frac-
ture strength in restored teeth when compared to nega-
tive control groups (no restoration). The study by Lin CL
et al (26) showed that, compared with the affected teeth
after root canal treatment with different crack depths,
crowns had a lower risk of failure than inlay and endo-
crown. It was suggested that the hoop effect of the full
crown was better than onlay in protecting cracked teeth.
However, when the fibre-reinforced resin was combined
with the different restorations, the two interact, the frac-
ture strength was increased to a certain extent and the
favourable fracture mode also increased accordingly. For
the maxillary first premolars, due to their own anatomi-
cal factors, it was very important to retain intact peri-
cervical dentin on the fracture mode of cracked teeth
(27).
This experiment used the static load method to study
the crack development of the cracked teeth under the
extreme force value. Although Liu Weicai et al. found
that the cyclic loading method had a greater impact on
the strength of the material than the static loading
method for ceramic materials for teeth crowns (28), static
loading may be more advantageous for cobalt-chromium
metal materials.
In this three-dimensional study, the crack morphology
was set to simulate the clinical crack morphology as
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Ribbond and Onlay repair Cracked tooth
much as possible, and the width of the crack surface was
set to 0.17 mm, which was in line with Chen Min et al
(13) through microcomputer tomography technology to
observe and study in vitro isolated teeth The width of the
cracks on the crown of the piercing cracked tooth was
the same. The three-dimensional FEA and the fracture
failure test method in this experiment simulated the clin-
ical reality as much as possible, but it still has certain limi-
tations.
C3 D1 D2 D3
Conclusion
Compared with the traditional resin + crown restoration,
fibre-reinforced composites (C,D) can significantly
improve the fracture resistance of the affected teeth in
the crown restoration after the root canal treatment of
maxillary first premolars with pulp exposure. The annu-
lar ribbond + onlay repair is the best.
Authorship declaration
All authors have contributed significantly, and all
authors are in agreement with the manuscript.
Acknowledgement
This work was supported by Shaanxi Science and Tech-
nology Public Relations Project, China (no. 2018SF-115).
Author contribution
Rui Shi: Designed the experiment, did the experiment in
both fracture failure test and three-dimensional finite
element analysis. Analyzed the data and wrote the writ-
ing. Xingwang Meng: Built the three dimensional finite
models in Three-dimensional finite element analysis and
helped in some fracture failure test. Rui Feng:: Worked as
an assistant and helped in Crack preparation and root
canal treatment in fracture failure test. Shanshan Hong:
Worked as an assistant and helped in crown restoration
in fracture failure test. Chen Hu: Worked as an assistant
and helped in specimens preparation in fracture failure
test. Min Yang: Worked as an assistant and helped in col-
lation of data in fracture failure test. Yuegui Jiang:
Designed the experiment and revised the article. All
authors have contributed significantly, and all authors
are in agreement with the manuscript.
Conflict of interest
The authors deny any conflict of interest. The authors do
not have any financial interest in the companies whose
materials are included in this article.
463

Ribbond and Onlay repair Cracked tooth
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