journal of dentistry 40 (2012) 814–820

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Is fracture resistance of endodontically treated mandibular

molars restored with indirect onlay composite restorations
influenced by fibre post insertion?

Nicola Scotti a,*, Francesco Andrea Coero Borga a, Mario Alovisi b, Riccardo Rota a,
Damiano Pasqualini b, Elio Berutti b
a
University of Turin Dental School, Department of Cariology and Operative Dentistry, via Nizza 230, 10126 Turin, Italy
b
University of Turin Dental School, Department of Endodontics, via Nizza 230, 10126 Turin, Italy

article info abstract

Article history: Objectives: The aim of this study was to investigate the influence of post placement on
Received 21 February 2012 fracture resistance of endodontically treated mandibular molars restored with adhesive
Received in revised form overlay restorations.
26 April 2012 Methods: Endodontically treated human molars with two- and one-wall cavities either
Accepted 15 June 2012 underwent or did not undergo fibre post insertion within composite build-up before
cementation of indirect composite onlay restorations. The specimens were thermocycled,
exposed to cyclic loading, and submitted to the static fracture resistance test. Fracture loads
Keywords: and mode of failure were evaluated.
Fibre post Results: Statistical analysis revealed that specimens with fibre posts demonstrated similar
Cuspal coverage failure loads ( p = 0.065) but more favourable fracture patterns compared with specimens
Fracture resistance without fibre posts. No difference was found between two- and one-wall cavities.
Mandibular molars Conclusions: Within the limitations of this study, the insertion of fibre posts did not improve
Residual walls support under indirect composite overlays.
Composite overlay Clinical significance: When restoring heavily broken down endodontically treated mandibu-
lar molars with an indirect overlay composite restoration, the fibre post inserted within the
composite build-up do not provide any increase in fracture resistance.
# 2012 Elsevier Ltd. All rights reserved.

postendodontic tooth fractures have generally been attributed

1. Introduction
Previous studies have emphasised that endodontic treatment
is a major etiological factor for tooth fractures.1 In a recent
analysis, Zadik et al.2 stated that cuspal or vertical root
fractures are the second major reason for the extraction of
endodontically treated teeth. Traditionally, nonvital teeth
were believed to be weak and brittle. However, recent findings
have shown that the biomechanical strength of endodontical-
ly treated teeth is 3.5% less than that of vital teeth.3 Therefore,
to weakened tooth structures caused by dental caries,4,5 tooth
wear, operative dentistry procedures,6,7 and changes in tooth
structure caused by ageing, vital pulp tissue loss, endodontic
procedures,8,9 and root post space preparation.4,10 Indeed, the
preservation of tooth structure has been recognised to be the
most important aspect for the successful management of
structurally compromised, endodontically treated teeth.4,11
On the basis of a recent meta-analysis results, the provision
of an effective coronal restoration should be considered the
final part of the root canal treatment procedure along with

* Corresponding author at: Via Nizza 230, 10100 Turin, Italy. Tel.: +39 340 2861799.
E-mail address: nicola.scotti@unito.it (N. Scotti).
0300-5712/$ – see front matter # 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jdent.2012.06.005
 journal of dentistry 40 (2012) 814–820
obturation to prevent post-operative re-infection.12 The final
restoration following endodontic treatment is currently
dictated by the amount of tooth tissue remaining and the
position of the tooth in the dental arch.13 Aquilino and
Caplan14 showed that endodontically treated posterior teeth
without cuspal coverage were lost at a six-fold higher rate than
teeth with cuspal coverage. A study conducted by Nagasiri and
Chitmongkolsuk15 found that molars lacking full coverage
following endodontic treatment had a survival rate of 36% at 5
years after treatment, showing that posterior teeth without
cuspal coverage have a very poor prognosis after endodontic
therapy.12
Cuspal replacement restorations should consider the
preservation of tooth structure and the type of restorative
material used. Among several available aesthetic treatment
options, resin composites and bonded ceramic restorations
are more conservative than full-coverage porcelain-fused-to-
metal crowns, which require the additional removal of sound
tooth tissue.16 The development of adhesive-based integrated
restorations has enabled the preservation of the maximum
amount of sound tooth structure.17 The use of these restora-
tions is recommended to minimise stress concentrations and
tensile stresses in the remaining tooth structure. In teeth with
limited tissue loss, direct and indirect adhesive restoration
techniques have been indicated to enhance the internal
strength of the tooth structure without occlusal capping.18,19
Thus, the rehabilitation of endodontically treated teeth
with a considerable loss of tissue must involve complete or
partial crown coverage. These kinds of restoration can be
supported by traditionally luted metal posts, adhesively luted
fibre posts, or no post at all.19 Among these techniques, fibre-
reinforced composite posts, which are adhesively luted into
the canal, guarantee the same retention values even when
they are not as deeply inserted, permitting clinicians to take a
much more conservative approach. Moreover, they have an
elastic modulus that closely matches that of dentine.20 In any
case, the preservation of the intact coronal and radicular tooth
structure, especially the maintenance of the cervical tissue to
create a ferrule effect, is considered to be crucial to achieve
optimal biomechanical behaviour of restored teeth, even
when performing adhesive fibre post placement.21–24 Further-
more, an analysis of the clinical success rate of endodontically
treated teeth with adequate dental tissue revealed that the
build-up technique with fibre post cementation followed by
restoration with direct composite resins was equivalent to a
similar full-coverage treatment with metal-ceramic crowns.25
Therefore, the role of the fibre post in providing reinforcement
has been demonstrated, even in cases of sufficient residual
coronal dentine.21 Indeed, within radicular dentine, fibre posts
have appeared to be useful in distributing stresses and loads
applied to the reconstruction core and prosthetic crown.26
However, post space preparation weakens the radicular
structure because some dentinal tissue should be removed
to place the post.20
Some controversy persists about whether fibre posts are
useful in the indirect composite onlay/overlay restoration of
endodontically treated molars. The purpose of this in vitro
study was to evaluate the effect of post placement on the
fracture resistance of endodontically treated permanent teeth.
The null hypothesis was that there would be significant
815
differences among experimental groups restored with and
without fibre posts in indirect overlay composite restoration.
2. Materials and methods
Fifty noncarious mandibular molars with mature apices,
extracted for periodontal reasons, were selected. The inclu-
sion criteria were similar crown and root sizes and the absence
of cracks under transillumination. Hand instrumentation was
used to debride the tooth surfaces, followed by cleaning with a
rubber cup and pumice slurry. The specimens were stored in
0.5% chloramine-T trihydrate to control infection and prevent
dehydration.
2.1. Specimens preparation
2.1.1. Endodontic treatment
Endodontic treatment was carried out in all samples excluding
the control group (intact teeth, Group 5). Samples were
endodontically instrumented to the working length using
PathFiles (1, 2, 3) and ProTaper files (S1, S2, F1, F2, F3; Dentsply
Maillefer, Ballaigues, Switzerland), with the apex enlarged to a
size 30 (0.09) taper. The working length was established under
10 magnification (Pro Magis; Carl Zeiss, Oberkochen,
Germany) when the tip of the file became visible at the apical
foramen. Irrigation was performed with 5% NaOCl (Niclor 5;
Ogna, Muggiò, Italy) alternated with 10% EDTA (Tubuliclean;
Ogna) using a 2 mL syringe and a 25-gauge needle. Specimens
were obturated with medium gutta-percha points (Inline,
Turin, Italy) using a heat source (DownPak; Hu-Friedy,
Chicago, IL, USA) and an endodontic sealer (EWT pulp canal
sealer; Kerr, Orange, CA, USA). Backfilling was performed with
the Obtura III system (Analytic Technologies, Redmond, WA,
USA).
2.1.2. Luting procedures
After 24 h, the samples were randomly divided into five groups
(n = 10 each). In groups 1 and 2, cavities with two walls
remaining were prepared, with the gingival cavosurface
margin located 1 mm coronal to the cementoenamel junction
(CEJ). In groups 3 and 4, cavities with only the buccal wall
remaining were prepared. Thus, the residual thickness of the
remaining walls at the height of the contour was 2  0.2 mm.
To enable the adjustment of preparation to anatomic
variability, the teeth were prepared free-hand (Fig. 1).
In groups 1 and 3, samples were treated with All-Bond 3
(Bisco, Schaumburg, IL, USA). Enamel margins were etched
with 32% phosphoric acid for 40 s, and dentine was etched for
20 s. Samples were then washed with a water syringe and
gently air dried with an air syringe whilst preventing
dehydration of the dentine. Three drops each of primers A
and B were mixed, and three coats of primer and adhesive
material were applied to the cavity with a small brush. Excess
primer adhesive solution was gently removed with a stream of
air, and the specimens were then light cured for 20 s with an
LED curing lamp (Translux Power Blue; Heraeus Kulzer,
Hanau, Germany) at 1000 mW/cm2. A layer of bonding resin
was then applied, gently air dried, and light cured as
previously described. After fixation of the matrix band with
816 journal of dentistry 40 (2012) 814–820
Fig. 1 – Two-walls remaining specimen: endodontic access
and standardised MOD cavity preparation.
a retainer, a build-up was performed with A2-shaded
nanohybrid resin composite (Venus Diamond; Heraeus Kulzer)
using an oblique layering technique. Each layer, 1.5–2 mm
thick, was light cured for 20 s. After removal of the matrix
band and retainer, additional light curing was carried out on
the buccal and lingual surfaces for 40 s.
Samples in groups 2 and 4 received the following
treatment. A post space was prepared in the distal canal to
a depth of 5 mm, as measured from the pulpal chamber floor
using a dedicated drill (Dentsply Maillefer). Adhesive proce-
dures were performed with All-Bond 3 (Bisco) as described for
groups 1 and 3. A dual-curing cement (Core X flow; Dentsply
Figs. 2 and 3 – Standardised overlay preparation performed in all samples: mesial (Fig. 2) and occlusal (Fig. 3) views.
Caulk, Milford, DE, USA) was placed into the canal using a tube
with a needle and the appropriate plug (KerrHawe SA, Bioggio,
Switzerland), and by injecting the materials into the post
spaces with a specific composite gun (KerrHawe SA). Number 2
Radix fibre posts (Dentsply Maillefer) were cemented to full
depth in the prepared post spaces. After initial preparation,
photopolymerisation was performed with an LED curing light
(Translux; Heraeus Kulzer) for 40 s at 1000 mW/cm2. A
composite build-up restoration was then performed as
described in groups 1 and 3.
2.1.3. Indirect overlay preparation and cementation
Standardised adhesive overlay preparation was performed for
all samples, reducing the remaining cusps and composite
build-up to 2 mm in all directions. A buccal round shoulder of
1 mm depth, a lingual round shoulder of 2 mm depth, and a
mesiodistal interproximal box up to 1 mm above the CEJ were
prepared (Figs. 2 and 3). Composite overlays of equal thickness
were prepared on a gypsum cast obtained after monophase
bicomponent impression with a light-body putty silicone
material (Flexitime; Heraeus Kulzer). The overlays were post-
cured (Labolight LV-III; GC, Tokyo, Japan) and then cemented
using the adhesive procedure described above. The overlay
internal surface was treated through airborne-particle abra-
sion (50 mm Al2O3 particles at about 2 bar pressure). Prehy-
drolysed one-bottle silane (Monobond-S; Ivoclar Vivadent,
Naturno, Italy) was applied to the conditioned surfaces of the
workpiece and air dried after a 60 s penetration time. A
hydrophobic light-curing bonding resin (OptiBond FL; Kerr)
was applied but was not precured. The overlays were then
placed under a protective cover to avoid premature curing of
the bond by ambient light. The tooth preparations were gently
abraded with 50 mm Al2O3 particles for about 5 s at a tip
distance of about 5 mm, and then conditioned for 30 s with
36% phosphoric acid (Conditioner 36; Dentsply Caulk). Before
 journal of dentistry 40 (2012) 814–820
the application of the bonding agent, the conditioned resin-
composite surfaces were ‘‘primed’’ with silane coupling agent
and air dried after 60 s. Finally, a light-curing bonding resin
(OptiBond FL; Kerr) was applied to the cavity surfaces of all
samples and spread in a thin layer with a gentle air jet without
precuring. At this point, a light-curing resin composite (Venus
Diamond; Heraeus Kulzer) was inserted into all cavities. To
decrease its viscosity, it was preheated at about 50 8C. The
overlays were then inserted into the cavities and fixed in place
manually by applying pressure to the occlusal surface with a
large plugger. Excess luting composite was removed with a
fine spatula along all sample margins. Polymerisation was
achieved using a high-power LED curing unit (Valo; Ultradent,
South Jordan, UT, USA) for at least 60 s/surface. The luting
composite was cured for an additional 10 s/surface using a
thin layer of glycerin gel to eliminate the oxygen-inhibition
layer on the surface of the luting composite. All restored
specimens were finished, polished, and stored in distilled
water at 37 8C for 1 week.
2.2. Mechanical loading
2.2.1. Fatigue loading
All specimens were subjected to 3000 thermal cycles between
5 8C and 55 8C for 60 s each. All specimens were embedded in
light-curing acrylic resin with a thin layer of polyvinyl siloxane
around the root to simulate the periodontal ligament. All
groups were exposed to cyclic loading (Mini Bionix II; MTS
Systems, Eden Prairie, MN, USA) with an inclination angle of
458 to the long axis of the tooth at a frequency of 8 Hz, starting
with a load of 20 N for 5000 cycles, followed by a load of 50 N at
a maximum of 20,000 cycles. A 2-mm-diameter metallic ball
was used. The site of loading was the central fossa contacting
both the buccal and lingual points of the occlusal surface.
2.2.2. Fracture resistance
The specimens were then submitted to the static fracture
resistance test using a universal testing machine (Instron,
Canton, MA, USA) with a 2-mm-diameter steel sphere
crosshead welded to a tapered shaft and applied to the
specimens at a constant speed of 2 mm/min and an angle of
458 to the long axis of the tooth. The forces necessary to
fracture each tooth were measured in Newtons (N). Fractured
specimens were observed under optical microscopy (Wild,
Heerbrugg, Gaiss, Switzerland) at 40 magnification to
establish failure modes, which were classified as: restorable
failures (including adhesive failures) when the fracture line
was above the CEJ or 1 mm or less apical to the CEJ; or
Table 1 – Fracture resistances of the groups expressed in Newton and failure modes of samples. Different superscript
letters indicate statistical differences ( p < 0.05).
Group n Characteristics
resistance  standard
1 10 Two-wall cavity, no fibre post inserted
2 10 Two-wall cavity, fibre post inserted
3 10 One-wall cavity, no fibre post inserted
4 10 One-wall cavity, fibre post inserted
Control 10 Intact teeth
817
non-restorable failures, including vertical root fractures, when
the fracture line was more than 1 mm apical to the CEJ.
2.3. Statistical analysis
Data are expressed as means  standard deviations and
frequencies (%). The Kolmogorov–Smirnov statistical test for
normality revealed a normal data distribution. The Kruskal–
Wallis test was used for comparison among groups, and the x2
test was used to compare the failure modes of the specimens.
Differences were considered statistically significant when
p < 0.05. All statistical analyses were performed using the
SPSS software (ver. 19.0 for Windows; SPSS Inc., Chicago, IL,
USA).
3. Results
The mean values of fracture resistance in all groups are listed
in Table 1. The Kruskal–Wallis test showed no significant
difference among groups (H = 7.814, p = 0.065). The evaluation
of failure mode among all groups is reported in Table 1. The x2
test showed no significant difference in the fracture patterns
among groups (x2 = 1.6368, p = 0.200). The highest proportion
of restorable fractures (70%) was observed in samples where
the fibre post was inserted regardless of the residual walls
number (Groups 2 and 4). The highest proportion of non-
restorable fractures (60%) was observed in Group 1.
4. Discussion
In the current study, we examined the fracture resistance of
endodontically treated mandibular molars restored with
composite overlays supported by build-up with or without
fibre post insertion. The data led to the conclusion that the
initial null hypothesis must be rejected because the fracture
values of different restorations tested were did not differ
significantly.
The present study used mandibular molars because they
reportedly comprise the most common extracted tooth profile
within endodontically treated posterior teeth; the most
common reasons for extraction were secondary caries and
cuspal or radicular fracture.2
To evaluate the distribution of occlusal and masticatory
loads on molar crowns, forces are usually applied to
the central pit and parallel27 or oblique28 to the dental
axis. Nevertheless, recent studies demonstrated that during
Mean fracture Non-restorable Restorable
fractures (n) fractures (n)
deviation
1021.0913  199.26 a 6 4
1221.2074  95.08 a 3 7
1063.3139  163.17 a 7 3
1136.0456  155.71 a 3 7
2992.63  179.72 b 2 8
818 journal of dentistry 40 (2012) 814–820
maximum intercuspidation within the second phase of
chewing, higher stresses are more concentrated along the
cervical dental portion and mesiolingual radicular area of
the mandibular molars.29 Jiang et al.28 employed a finite
element model to analyse stress concentration in vital or
endodontically treated mandibular molars restored with
indirect adhesive restorations. Samples received a vertical or
458 oblique occlusal load at a constant intensity of 45 N to
simulate masticatory loads. In all specimens receiving
lateral load application, the stress was mainly concentrated
along the cervical radicular portion of the tooth and at the
floor of the preparation, as well as at the loading site.
Therefore, in the present study, samples were submitted to a
lateral load with a 458 angle to distribute the stresses in areas
of higher fracture risk.
Several studies have shown that the use of fibre posts
should increase the fracture resistance of endodontically
treated premolars.30–33 Fracture resistance seemed to be
affected by the number of residual walls and by the presence
of a post.34 The use of a fibre-reinforced post was clearly
advantageous in terms of stress distribution in lower
premolars with two or more walls.35,36 Moreover, some studies
have emphasised the important effect of glass fibre post
placement on the fracture resistance of endodontically treated
premolars with fewer than two remaining cavity walls.37
Therefore, the role of a fibre post restorative technique in
endodontically treated molars remains under discussion.
Studies have shown higher fracture strength values and
better stress distribution for fibre-reinforced post restorations
in combination with zirconia-ceramic crowns on endodonti-
cally treated maxillary molars.38 Moreover, more favourable
restorable fracture patterns were described.37,38 Nevertheless,
the absence of the post seemed to decrease the fracture
resistance and increase the cusp strain, regardless of the
remaining tooth tissue.39
The results of this in vitro study show that the insertion of a
glass fibre-reinforced post during the buildup of mandibular
molars with one or two residual cavity walls and overlay
preparation margins coronal to the CEJ appeared not to
significantly increase the fracture resistance of the restora-
tion. These results are in accordance with those of Salameh
et al.,40 who found that the presence of a glass fibre post did
not improve the fracture resistance of ceramic or resin
composite onlay restorations, but did improve the resistance
of gold onlay restorations. Previous studies demonstrated that
indirect restorative techniques should significantly improve
fracture resistance in endodontically treated posterior teeth
compared with direct restorative techniques.41–43 Salameh
et al.44 tested the fracture resistance of different types of full-
coverage crown with or without a fibre post, and found that
the post was able to transmit part of the loading stress to the
prepared root canals, thereby distributing the load over a
larger surface area of the tooth structure and resulting in
higher fracture loads. Thus, the adhesive bonding of a post to
the tooth structure may enable the active transmission of the
applied load.45 These inconsistencies with the results of the
present study may be attributed to the type of tooth tested
and, above all, to the kind of indirect restoration tested. We
tested onlay composite restorations, which enabled the
preservation of a large amount of sound tooth structure and
the superior distribution of functional stresses. Indeed, Dejak
et al.46 demonstrated that adhesive onlay restorations with
rounded shoulder margins had the lowest values of the
inverse of the Tsai-Wu strength ratio, and thus showed
favourable distribution of contact stresses between the
cement and the enamel. Composite resin onlays showed
superior performance overall in minimizing internal stresses
and reducing the stresses generated along cavity preparation
margins and adhesive interfaces.
In the present study, only cavities with one or two
remaining walls were tested because these clinical conditions
can be restored with indirect adhesive restorations whilst
preserving a satisfactory amount of enamel. The final fracture
resistance values obtained in this study seemed not to be
influenced by the number of residual cavity walls. This finding
is probably due to the use of the indirect overlay restoration
technique,47 which can distribute the occlusal stresses along
the enamel margins that were similar in both preparations
tested. Previous studies have confirmed that the placement of
a glass fibre post had a significant influence on fracture
resistance when fewer than two cavity walls remained, but no
significant influence when two or three walls were present.36
However, these studies usually tested direct intracuspal
restorations, which are completely different from extracor-
onal restorations.
One of the main issues regarding restoration of endodonti-
cally treated teeth has been the risk of non-restorable
fractures. The introduction of fibre post, whose elastic
modulus is in the same range of that of dentine, reduced
the onset of catastrophic vertical root fractures because it
allows teeth to flex under loading yielding improved stress
distribution at the post-cement–dentine interface and into the
root itself.48,49 A previous study by Goel et al.50 stated that
unfavourable stress gradients are concentrated on the base of
scraped cusps, where most of the forces meet. Probably the
fibre post is able to dissipate, transmit and distribute
functional stresses across the bonding area, which is larger
than in build-up samples (Group 1 and 3). The fracture pattern
results of the present study are in agreement with those
obtained by other authors.44,51,52 Salameh et al.40 confirmed
that fibre post appeared to have a positive effect on fracture
patterns, resulting in higher percentage of restorable frac-
tures. Cagidiaco et al.53 suggested that fibre post placement
could be considered a protective factor against irreparable
failure in posterior teeth, which undergo a great loss of dental
tissue. Fibre-reinforced posts could certainly protect against
fracture risk due to vertically applied loads. Samples were
loaded at a 458 angle in this study, and the results confirmed
the protective role of fibre posts against irreparable fracture
patterns in this loading condition. Thus, the insertion of a fibre
post results in a higher percentage of restorable fractures,
which might be of even more clinical importance regarding
the fate of the restored tooth after a coronal fracture.
5. Conclusions
Within the limits of this in vitro study, we can assert that fibre
post placement does not fundamentally increase fracture
resistance of endodontically treated mandibular molars with
 journal of dentistry 40 (2012) 814–820
indirect composite overlay restorations. However, fibre post
insertion could be more helpful in distributing cervical or
radicular stresses due to extra axial loads. Long-term clinical
studies are required to confirm the present findings.
Conflict of interest
Authors declare no competing conflicts of interest with the
materials discussed in this manuscript.
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