Original Research

A comparative evaluation of fracture resistance of

endodontically treated teeth, with variable marginal ridge
thicknesses, restored with composite resin and composite
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resin reinforced with Ribbond: An in vitro study

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Vaishali Kalburge, Shaikh Shoeb Yakub, Jitendra Kalburge1, Hemalatha Hiremath, Anshu Chandurkar

Departments of Conservative
Dentistry and Endodontics,
ABSTRACT
and 1Oral Pathology and Background: The anatomic shape of maxillary premolars show a tendency towards separation
Microbiology, Rural Dental
College, Pravara Institute
of their cusps during mastication after endodontic treatment. Preservation of the marginal ridge
of Medical Sciences, Loni, of endodontically treated and restored premolars can act as a strengthening factor and improve
Maharashtra, India the fracture resistance.
Objectives: To evaluate the effect of varying thickness of marginal ridge on the fracture resistance
of endodontically treated maxillary premolars restored with composite and Ribbond reinforced
composites.
Materials and Methods: One hundred and twenty, freshly extracted, non carious human mature
maxillary premolars were selected for this experimental in vitro study. The teeth were randomly
assigned in to twelve groups (n = 10). Group 1 received no preparation. All the premolars in
other groups were root canal treated. In subgroups of 3 and 4, DO cavities were prepared while
MOD cavities were prepared for all subgroups of group 2, the dimensions of the proximal boxes
were kept uniform. In group 3 and 4 the dimensions of the mesial marginal ridge were measured
using a digital Vernier caliper as 2 mm, 1.5 mm, 1 mm and 0.5 mm in the respective subgroups.
All samples in groups 2.2 and all the subgroups of 3 were restored with a dentin bonding
agent and resin composite. The teeth in group 2.3 and all subgroups of 4 were restored with
composite reinforced with Ribbond fibers. The premolars were submitted to axial compression
up to failure at 45 degree angle to a palatal cusp in universal testing machine. The mean load
necessary to fracture was recorded in Newtons and the data was analysed.
Results: There was a highly significant difference between mean values of force required to
fracture teeth in group 1 and all subgroups of group 2, 3 and 4 (i.e., P < 0.01)
Conclusion: On the basis of static loading, preserving the mesial marginal ridge with thicknesses
of mm, 1.5 mm, 1 mm and 0.5 mm, composite restored and Ribbond reinforced composite
restored maxillary premolars can help preserve the fracture resistance of teeth.
Received : 22‑02‑12
Review completed : 12‑07‑12 Key words: Composite resin, fracture resistance, marginal ridge, Ribbond, universal testing
Accepted : 25‑12‑12 machine

The restoration of endodontically treated teeth is an of treatment options of variable complexity. Root canal
important aspect of dental practice that involves a range treatment should not be considered complete until the final
coronal restoration has been placed. Endodontically treated
Address for correspondence: teeth are weak because of loss of tooth structure caused by
Dr. Vaishali Kalburge
E‑mail: vaishalik19@rediffmail.com caries, access cavity preparation, and instrumentation of the
root canal. The likelihood of survival of a pulpless tooth is
Access this article online directly related to the quantity and quality of the remaining
Quick Response Code: Website:
dental tissue.[1]
www.ijdr.in
The traditional method of restoring non‑vital teeth is
PMID:
*** the post and core restoration, full crown or a cast inlay
that protects the cusps. Teeth weakened by restorative
DOI: procedures should be reinforced by restorative materials to
10.4103/0970-9290.116676
strengthen the remaining tooth structure.
193 Indian Journal of Dental Research, 24(2), 2013
 A comparative evaluation of fracture resistance of endodontically treated teeth Kalburge, et al.

The true breakthrough in the restoration of endodontically Exclusion criteria

treated teeth has been the introduction of adhesive bonding, Teeth affected by caries, developmental anomalies, trauma,
propelled by the development of efficient dentinal adhesives. fracture, and dehydration were excluded.
Resin‑based restorations replace the tooth’s rigidity which
is lost during cavity preparation, and provide splinting of The teeth were randomly assigned in the following groups
cusps. This can increase the fracture resistance of non‑vital of 10 teeth each [Table 1].
teeth.[1,2]
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Except for group 1, standard access cavities were prepared.

The development of fiber‑reinforced composite (FRC)
technology has led to substantial improvement in the In groups 2 through 4, root canal treatment was performed
flexural strength, toughness, and rigidity of dental resin and obturation was done.
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 08/17/2024

composites. FRC technology has increased the use of

composite resin materials in extensive preparations. In groups 2.1, 2.2, and 2.3, class II MOD cavities were
prepared with gingival cavosurface margin located 1.5 mm
In this study, it was hypothesized that creating an elastic above the cemento‑enamel junction (CEJ) using 245 carbide
layer under a composite restoration using a leno‑woven bur (MANI, Tokyo, Japan). The dimensions of the mesial and
ultra high molecular weight (LWUHMW) polyethylene the distal box were approximately the same; a buccolingual
fiber ribbon and/or flowable composite would increase width of 3 mm at gingival floor and convergence of the
the fracture strength of endodontically treated teeth buccal and lingual walls toward occlusal were insured. The
with mesio‑occluso‑distal (MOD) cavity preparations cavosurface angle in all walls was approximately 90°.
and in class II cavities with variable marginal ridge
thicknesses. In the remaining groups, class II disto‑occlusal (DO)
preparations were prepared in the same manner as that of the
In this study, it was also hypothesized that composite resin MOD group and the mesial ridge was preserved for 2 mm,
restorations also strengthen the endodontically treated 1.5 mm, 1 mm, and 0.5 mm in the respective groups. The
teeth. thickness of the mesial marginal ridge was measured with
a digital Vernier caliper within 0.01 mm tolerance.
AIMS AND OBJECTIVES
After completion of the cavity preparation, all the
• To evaluate the effect of different thicknesses of marginal prepared teeth were etched with 35% phosphoric
ridge on the fracture resistance of endodontically treated acid (Prime Dental Products, Mumbai, India) for 15 s,
maxillary premolar restored with composite resin and rinsed for 10 s, and dried with air, leaving a shiny hydrated
Ribbond reinforced composite resin. surface of moist dentin.
• To evaluate the strengthening effect of composite
resin and composite reinforced with Ribbond on Table 1: Study groups
endodontically treated maxillary premolars. Group No. of
samples
1 Intact teeth, no treatment 10
Purpose of the study 2.1 MOD cavities non‑restored 10
The purpose of this study was to analyze the fracture 2.2 MOD cavities restored with resin 10
resistance of endodontically treated maxillary premolars 2.3 MOD cavities with Ribbond‑reinforced composite 10
with different thicknesses of mesial marginal ridge, which 3 Teeth restored with composite resin
3.1 Class II DO cavities with 2‑mm‑thick mesial 10
are restored with composite resin and Ribbond‑reinforced marginal ridge
composite resin. 3.2 Class II DO cavities with 1.5‑mm‑thick mesial 10
marginal ridge
3.3 Class II DO cavities with 1‑mm‑thick mesial 10
MATERIALS AND METHODS marginal ridge
3.4 Class II DO cavities with 0.5‑mm‑thick mesial 10
One hundred and twenty freshly extracted human mature marginal ridge
maxillary premolar teeth with approximately similar 4 Teeth restored with composite resin reinforced
with Ribbond
dimensions and without any defects were selected. The
4.1 Class II DO cavities with 2‑mm‑thick mesial 10
teeth were cleaned of debris and soft tissue remnants and marginal ridge
were stored in physiological saline at room temperature 4.2 Class II DO cavities with 1.5‑mm‑thick mesial 10
until required. marginal ridge
4.3 Class II DO cavities with 1‑mm‑thick mesial 10
marginal ridge
Inclusion criteria 4.4 Class II DO cavities with 0.5‑mm‑thick mesial 10
Maxillary premolars without any defects, extracted for marginal ridge
orthodontic reasons (within a 6‑month period). DO=Disto-occlusal, MOD=Mesio-occluso-distal

Indian Journal of Dental Research, 24(2), 2013 194

 A comparative evaluation of fracture resistance of endodontically treated teeth Kalburge, et al.

In groups 2.2, and 3.1, 3.2, 3.3, and 3.4, Adper single Bond calculated [Graph 1, Tables 2 and 3] and statistically
(3M ESPE) was applied. Then using a Tofflemire Retainer analyzed [Table 4].
and an ultrathin matrix band, the teeth were restored with
A2 shade resin, Filtek Z‑100 (3M ESPE), using an oblique RESULTS
layering technique.
By applying Student’s unpaired “t” test to the above table, it
In groups 2.3, and 4.1, 4.2, 4.3, and 4.4, after the bonding is seen that there is a highly significant difference between
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procedures as in group 3, the cavity surfaces were mean values of force required to fracture in group 1 and all
coated with flowable composites. A piece of LWUHMW subgroups of groups 2, 3, and 4 (i.e., P < 0.01).
polyethylene fiber 2 mm in width was cut and coated
with adhesive resin. Excess material was removed and the
DISCUSSION
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fiber was embedded inside the flowable composite (Filtek

Z‑250 3M ESPE) in a buccal to lingual direction. After
This study examined the fracture resistance of endodontically
curing for 20 s, the cavities were restored with composite
treated maxillary premolars, the anatomic shape of which
as described above for group 3.
creates a tendency toward separation of their cusps during
Forty‑eight hours after restoration, finishing was done with mastication. In addition, loss of tooth structure during
Super snap polishing kit (Shofu, Higashiyama‑ku, Kyoto, endodontic access and cavity preparation procedures makes
Japan) under air–water spray, followed by polishing a green these teeth even more prone to fracture.
abrasive impregnated rubber point. Then the teeth were
stored in an incubator. Endodontic access to the pulp chamber destroys the
structural integrity provided by the coronal dentin of the
Finally, teeth from all the groups were submitted to a pulpal ceiling, allowing greater flexion of the tooth under
thermocycling regimen of 500 cycles between 5°C and 55°C function. Root canal procedures alone reduce tooth stiffness
water baths. The dwell time was 30 s, with a 10‑s transfer by only 5%, whereas tooth structure removal in an MOD
time between baths. preparation reduces tooth stiffness by 50%.[3]

Each tooth was vertically positioned with its root The general effect of MOD intracoronal cavity preparations
embedded into a plastic cylinder of self‑curing acrylic resin is the creation of long cusps. Thus, the restorative material
up to 1 mm below CEJ. Subsequently, universal testing
machine was used to conduct a fracture test at a crosshead Table 2: Force required (N) to fracture teeth
speed of 2 mm/min. The lingual cusp of each specimen was Group T01 T02 T03 T04 T05 T06 T07 T08 T09 T10
submitted to axial compression up to failure at an angle 1 6600 6200 5800 7200 7800 8000 8400 7600 6600 5800
2.1 3000 3200 1800 2400 1600 1200 1800 2000 2800 3000
of 45° to the palatal cusp and 150° to its longitudinal axis 2.2 3600 4200 4200 1800 3000 2400 3000 3800 4000 3400
in universal testing machine (Mechatronic, Ichalkaranji, 2.3 3600 2400 3000 6600 3600 6000 5800 4800 4400 4800
India) [Figure 1]. The forces required to produce fracture 3.1 4000 6000 6400 5400 5400 6000 4800 4200 4600 5200
were recorded in Newton, mean values of force were 3.2 3800 4200 5200 4800 5600 5400 5000 4600 4400 4000
3.3 4800 4800 3200 4600 4200 3800 3800 4000 4400 4600
3.4 5400 3600 4800 3800 3800 2400 3600 3800 3200 3000
4.1 4800 4800 4800 5400 6600 4400 3800 4400 4200 5000
4.2 3600 3600 4800 4200 3400 5400 4000 3600 3600 4800
4.3 4200 3400 3800 4200 4600 4800 5400 3600 4800 4000
4.4 4800 4800 4200 3000 4200 3600 3000 3400 3000 3200
T=Tooth no

Table 3: Mean and SD values of force required to fracture

the teeth
Group Mean±SD
1 7000.00±885.44
2.1 2280.00±658.48
2.2 3340.00±754.00
2.3 4500.00±1296.91
3.1 4820.00±729.10
3.2 4280.00±587.87
3.3 4100.00±646.53
3.4 3720.00±688.18
Figure 1: Premolar mounted on the universal testing machine; the 4.1 5200.00±785.95
lingual cusp of each specimen is submitted to axial compression 4.2 4700.00±574.46
up to failure at an angle of 45° to the palatal cusp and 150° to its 4.3 4220.00±493.56
longitudinal axis 4.4 3740.00±810.18

195 Indian Journal of Dental Research, 24(2), 2013

 A comparative evaluation of fracture resistance of endodontically treated teeth Kalburge, et al.






 
 
  
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Graph 1: Mean values of force required to fracture the teeth

Table 4: Comparison of mean values of force required to fracture in group 1 and groups 2.1, 2.2, 2.3, 3.1, 3.2, 3.3, 3.4, 4.1, 4.2,
4.3, and 4.4
Mean±SD Mean±SD Student’s unpaired “t” test value “P” value Result/significance
Group 1 Group 2.1 <0.01 Highly significant
7000.00±885.44 2280.00±658.48 13.53
Group 2.2 <0.01 Highly significant
3340.00±754.00 9.95
Group 2.3 <0.01 Highly significant
4500.00±1296.91 5.03
Group 3.1 <0.01 Highly significant
4820.00±729.10 8.98
Group 3.2 <0.01 Highly significant
4280.00±587.87 8.36
Group 3.3 <0.01 Highly significant
4100.00±646.53 8.09
Group 3.4 <0.01 Highly significant
3720.00±688.18 9.25
Group 4.1 <0.01 Highly significant
5200.00±758.95 4.88
Group 4.2 <0.01 Highly significant
4700.00±574.46 6.89
Group 4.3 <0.01 Highly significant
4220.00±493.56 8.67
Group 4.4 <0.01 Highly significant
3740.00±810.18 8.59
By applying Student’s unpaired “t” test to the above table, it is seen that there is a highly significant difference between mean values of force required to fracture
in group 1 and all subgroups of groups 2, 3, and 4 (i.e., P<0.01)

used must not only replace the lost tooth structure but also amalgam and composite resins are the most commonly used.
increase the fracture resistance of the tooth and promote Amalgam does not adhere to dental structure, thus does not
effective marginal sealing.[4] compensate for the loss of fracture resistance.[4] It has been
found that amalgam restoration regained only 2% stiffness
Restorations that enhance structural integrity would of the tooth structure.[3]
be expected to increase the prognosis of endodontically
treated teeth which are exposed to heavy masticatory For these reasons, adhesive materials have been considered
loading forces. However, there is no consensus regarding useful for tooth reinforcement. Denehy and Torney (1976)
the preferred type of final restoration for endodontically were the first authors to propose the use of adhesive
treated posterior teeth.[5] In the past decade, improved materials to reinforce the dental structure and to offer
restorative adhesive bonding technique and materials have support for enamel altered by cavity preparation.[1] The
led some authors to suggest that endodontically treated teeth use of resin composites in restoring extensive cavities
can be restored in a more conservative manner than was reinforces dental stiffness. It has been suggested that
previously considered appropriate.[6] Numerous materials the adhesive nature of composites binds the cusps and
have been used as substitutes for natural dental tissues; decreases their flexion, which is the main cause of
Indian Journal of Dental Research, 24(2), 2013 196
 A comparative evaluation of fracture resistance of endodontically treated teeth Kalburge, et al.

fractures in amalgam.[4] Adhesive restorations efficiently interfacial stresses developed along the etched enamel/
transmit and distribute functional stresses across the resin boundary. Embedding an LWUHM polyethylene fiber
bonding interface to the tooth and reinforce weakened into a bed of flowable resin under an extensive composite
tooth structure.[7] restoration increases both the fracture strength in root‑filled
premolars with class II DO and class II MOD cavities and
Reel et al. showed that maxillary premolars when restored the micro tensile bond strength to dentin. The development
with bonded composite resins were approximately100% of FRC technology has increased the use of composite resin
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stronger than unrestored premolars, but Joynt et al. reported materials in extensive preparations.[11]
a 23% increase in strength.[8]
Comparing of the mean values of force required to fracture
However, separate studies have proposed that significant teeth in group 1 and the teeth in the remaining experimental
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 08/17/2024

differences exist in fracture resistance between intact and groups, it can be concluded that there is a highly significant
restored premolars with resin composite and dentin‑bonding difference between mean values of force required to fracture
agent, with intact teeth being superior. These differences in teeth in group 1 and all subgroups of groups 2, 3, and
results could reflect the variation in type and size of teeth, 4 (i.e., P < 0.01).
preparation design, experimental material, loading speed,
direction of load, and thermocycling. The mean values of force required to fracture the teeth
in groups 3 and 4 showed that as the thickness of mesial
In this study, the results showed that the difference in mean marginal ridge decreased, the force required to fracture
force required to fracture the teeth in group 1 (intact teeth) the teeth also decreased, but the difference was statistically
with group 2 (MOD cavities, unrestored), group 2.1 (MOD insignificant.
cavities restored with composite), and group 2.3 (MOD
restored with Ribbond reinforced composite) were On comparing the mean values of force required to fracture
statistically significant. in group 2.1 and 2.2, 2.3 and other subgroups of groups 3
and 4, it is seen that there is a highly significant difference
The least fracture resistance was seen in group 2.1, which between the mean values of force required to fracture
is in accordance with Linn and Master, who demonstrated teeth in group 2.1 and other subgroups of group 2, and all
that endodontically treated teeth with MOD cavities were subgroups of groups 3 and 4 (i.e., P < 0.01).
severely weakened due to the loss of reinforcing structure,
such as marginal ridges and pulp chamber roof, causing the From the results, it is seen that the mean forces required to
tooth to become more susceptible to fracture. These findings fracture teeth in all the subgroups of Ribbond‑reinforced
are also supported by Belly and others, who reported that composites were greater than the respective subgroups of
MOD cavity preparations reduced the fracture resistance composite‑restored teeth, confirming the reinforcing effect
of root‑filled teeth. of LWUFMW polyethylene fiber.[11]

Ultra high strength polyethylene (UHSPE) fibers with Considering the mean values of force required to fracture
higher ribbon reinforcement material, Ribbond (Ribbond teeth in all experimental groups, it can be concluded
Inc., Seattle, WA, USA), have been available commercially that 0.5 mm thickness of marginal ridge is also of prime
since 1992. This material is composed of pre‑impregnated, importance in restoring the endodontically treated
silanized, plasma‑treated, leno‑woven, ultra high molecular maxillary premolars. For this reason, it can be recommended
weight (UHMW) polyethylene fibers. Leno‑weave is a that if during cavity preparation in endodontically treated
special pattern of cross‑linked, locked‑stitched threads maxillary premolars, the remaining marginal ridge
which increase the durability, stability, and shear strength thickness is judged to be 0.5 mm, it should be retained. It
of the fabric.[9] improves the strength as well as esthetic appearance, since
restoration of MOD cavities is more difficult than of DO
Application of a fiber layer in a restorative material increases cavities due to construction of the proximal contact and
the load‑bearing capacity of the restoration and prevents contour. In addition, the probability of overhang at the
crack propagation from the restoration to the tooth. proximal margin has been shown to occur from 25% to
76% of time, and providing the proper anatomic form of
The elastic modulus of UHMWPE fiber was previously MOD restorations in comparison with DO restorations is
shown to be 1397 MPa. However, in clinical conditions, more time consuming.
UHMWPE fiber Ribbond is used in combination with
flowable resin and an adhesive resin, resulting in the elastic Occlusion on a premolar is located on the cuspal tips and
modulus increasing to 23.6 GPa.[10] The higher modulus of at the marginal ridge. Because occlusion takes place on the
elasticity and lower flexural modulus of the polyethylene marginal ridge of a premolar, it is important to know the
fiber are believed to have a modifying effect on the strength of the restored tooth with variable marginal ridge
197 Indian Journal of Dental Research, 24(2), 2013
 A comparative evaluation of fracture resistance of endodontically treated teeth Kalburge, et al.

thickness.[1] Marginal ridge enamel is composed of gnarled SUMMARY AND CONCLUSION

enamel and is stronger.[12]
Within the limitation of this in vitro study, the following
The results of this study support the idea that in can be concluded:
endodontically treated maxillary premolars, when minimal • MOD cavity preparations reduced fracture resistance of
dentin structure connects the buccal and the lingual walls root‑filled teeth.
of preparation, a method that could reinforce the tooth • On the basis of static loading, preserving the mesial
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should be used. The ability to predictably restore an marginal ridge with thicknesses of 2 mm, 1.5 mm, 1 mm,
endodontically treated tooth to its original strength and and 0.5 mm, composite‑restored and Ribbond‑reinforced
fracture resistance without placement of a full coverage composite‑restored maxillary premolars can help
restoration could provide potential periodontal health and preserve the fracture resistance of teeth.
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 08/17/2024

is economic to patients.[6] • Inserting an LWUHMW polyethylene ribbon fiber in

root‑filled premolar teeth with class II DO and class II
In this study, each specimen block was fixed in a jig that MOD preparations significantly increased fracture
ensured a loading angle of 150° to the long axis of tooth. This strength.
angle was chosen because it simulates the average angle of
contact between maxillary and mandibular premolars in REFERENCES
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There are many differences between fractures that occur
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3. Reeh ES, Douglas WH, Messer HH. Stiffness of endodontically treated
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How to cite this article: Kalburge V, Yakub SS, Kalburge J, Hiremath H,
Chandurkar A. A comparative evaluation of fracture resistance of endodontically
Further long‑term clinical trials are needed to measure the treated teeth, with variable marginal ridge thicknesses, restored with composite
performance of resin composite restorations in vivo and to resin and composite resin reinforced with Ribbond: An in vitro study. Indian J
evaluate bonding stability for longer periods due to the fact Dent Res 2013;24:193-8.
Source of Support: Nil, Conflict of Interest: None declared.
that the adhesive bond might fail under clinical situations.

Indian Journal of Dental Research, 24(2), 2013 198