Dental Traumatology 2016; 32: 110–115; doi: 10.1111/edt.

12223

Efficacy of Ribbond and a fibre post on the

fracture resistance of reattached maxillary
central incisors with two fracture patterns:
a comparative in vitro study

Poornima Ramesh, Sylvia Mathew,
Sreenivasa B.V. Murthy,
John V. George, Swaroop Hegde,
Remya Premkumar
Department of Conservative Dentistry &
Endodontics, Faculty of Dental Sciences,
M.S.Ramaiah University of Applied Sciences,
Bengaluru, India
Key words: fracture resistance; fibre post;
re-attachment; Ribbond
Correspondence to: Poornima Ramesh,
Department of Conservative Dentistry &
Endodontics, Faculty of Dental Sciences,
M.S.Ramaiah University of Applied Sciences,
New BEL Road, MSRIT Post, Bengaluru -
560054, Karnataka, India.
Tel.: +91 80 23602079
Fax: +91 80 23608136
e-mail: drpoornima88@gmail.com
Accepted 13 August, 2015
Abstract – Aim: To compare the fracture resistance of maxillary central
incisor fragments having two different fracture patterns and re-attached
using two different posts – fibre post and Ribbond. Materials and meth-
ods: Sixty extracted human maxillary central incisors were randomly
divided into two groups of thirty samples each. Group A consisted of sam-
ples with ‘labio-palatal’ fracture pattern and Group B with a ‘palato-labial’
fracture pattern. The crowns of all the samples were sectioned using safe-
sided diamond discs. Following cleaning and shaping and sectional obtura-
tion, the samples were randomly subdivided into two subgroups of 15 sam-
ples each. Prefabricated fibre post (Reforpost, Angelus, Londrina, PR,
Brazil) was placed in all samples of Subgroup I, and Ribbond (Ribbond Inc.,
Seattle, WA, USA) was placed in all samples of Subgroup II. The fragments
were re-attached, fracture resistance was tested using Instron Universal Test-
ing Machine, and the failure modes were assessed using a stereomicro-
scope. Results: Group A with a labio-palatal fracture pattern exhibited
higher fracture resistance as compared to Group B (palato-labial) in both
subgroups. The fibre post (Subgroup I) exhibited higher fracture resistance
as compared to Ribbond (Subgroup II). The Ribbond group exhibited signif-
icantly more number of repairable failures as compared to fibre post
group. Conclusion: The labio-palatal pattern of fracture is a favourable
type of fracture on palatal load application. The fragments re-attached using
the fibre post (Reforpost) had a higher resistance to fracture. However, teeth
restored with Ribbond posts exhibited 100% repairable failures upon load
application. The fracture pattern had no influence on the failure modes.

Crown fractures have been documented to account for
up to 92% of all traumatic injuries to the permanent
dentition, and the most affected teeth are the maxillary
incisors due to their anterior position and protrusion
caused by the eruptive process (1,2). Attending to
patients with fractured teeth is a challenge in clinical
dentistry. Advancements in the field of aesthetic den-
tistry and availability of a host of adhesive materials
and techniques have enabled a predictable long-term
reconstruction of fractured teeth. However, re-attach-
ment of these teeth using the tooth’s original fragment
should be the first choice whenever the fragment is
available (3). This technique offers the advantage of
being highly conservative, promoting preservation of
the natural tooth structure, restoring aesthetics and
thereby acceptance by patients who receive a psycholog-
ical benefit through amendment of the mutilation (4).
Numerous factors such as the quality of fit of frag-
ments, extent of fracture lines and the remaining tooth
structure govern the choice of re-attachment or
restoration of fractured teeth (2). The fracture pattern
and the direction of fracture lines are also important
factors to be considered that could influence the long-
evity of the re-attached fragments.
By restoring fractured teeth using a fibre-reinforced
composite post–core that is adhesively luted, a mechan-
ically homogenous structure can be created, which can
resist forces as a single unit, thus creating a monoblock
effect (5).
Fibre-reinforced composites advocated for use as
post-and-core systems can be classified into two cate-
gories: prefabricated posts and customized posts (6).
When the post’s section differs from that of the canal,
the luting technique creates a thick layer of cement
between the root dentin and the post and this interface
becomes the weakest point (7). Customized fibre post–
core systems were produced to overcome this problem
(8).
An example for the customized fibre post–core
system is RibbondÒ (Ribbond Inc., Seattle, WA,

110 © 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

USA), which is commercially available and was first
introduced as a splint material. The material has a
three-dimensional structure due to the leno weave or
triaxial braid, and this provides mechanical interlocking
with composite resin at different planes. In addition,
microcracking is minimized during polymerization of
the resin (9).
ReforpostÒ (Angelus, Londrina, PR, Brazil) is a
commercially available prefabricated glass fibre-rein-
forced composite post embedded in an epoxy resin
matrix having serrations on the surface. It is said to
exhibit favourable biomimetic properties (10).
Long-term retention rate and success of the re-at-
tachment procedure could be influenced by a variety of
factors acting in tandem, knowledge of which would
enable one to provide the best treatment possible
towards rehabilitation of mutilated anterior teeth.
There is limited literature evaluating the effect of dif-
ferent planes of fracture as well as the influence of dif-
ferent post systems used to re-attach the fracture
segments. Hence, this study was undertaken to com-
pare the influence of two different fracture patterns
and two fibre-reinforced post systems on the fracture
resistance of re-attached maxillary central incisors.
Materials and methods
Sixty freshly extracted intact human maxillary central
incisors with closed apices extracted for periodontal
reasons were included for the study. The teeth were
cleaned of tissue fragments and any visible debris,
scaled with ultrasonic scaler tips and stored in distilled
water until use.
The teeth were divided into two groups of 30 sam-
ples each depending on the direction of fracture line
(Fig. 1). Samples belonging to Group A (‘labio-pala-
tal’) was sectioned such that the amount of remaining
crown structure was 6 mm on the labial surface and
2 mm on the palatal surface and vice versa for Group
B (palato-labial). These measurements were made using
digital vernier calipers, considering the mid-point of the
cemento-enamel junction (CEJ) as the reference. This
was done for the purpose of standardization and to
obtain fragments of uniform size. Based on these
measurements, all the samples were sectioned using a
safe-sided diamond disc in an oblique direction. The
Fig. 1. Schematic Representation of the fracture patterns.
Group A: Labio-palatal fracture pattern; Group B: Palato-
labial fracture pattern.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Ribbond and fibre post for reattachment of teeth 111
sectioned fragments were stored in distilled water for
24 h until re-attachment.
The roots of all teeth were cleaned and shaped up to
60 K of file size. The apical third of the roots were
obturated by the sectional method, up to 5 mm using
gutta percha and AH plus sealer (AH Plus Dentsply
DeTrey GmbH, Konstanz, Germany) (11). The canal
entrances were sealed with a non-eugenol temporary
filling material (Cavit-G, 3M ESPE, St. Paul, MN,
USA) (12). The roots were then coated with a thin
layer of polyvinyl siloxane impression material to simu-
late the periodontal ligament. All the teeth were then
mounted in acrylic resin using a preformed stainless
steel mould up to 2 mm beneath the cemento-enamel
junction (6). The specimens were then stored in 100%
humidity at 37°C for 24 h until re-attachment proce-
dures were undertaken (13).
All samples in groups A and B were further subdi-
vided into subgroups I and II depending on the type of
post used for re-attachment.
Post placement and fragment re-attachment
Post space was prepared using Peeso Reamers with
sizes 1, 2 and 3, and the canal walls were smoothened
for all samples. Fifteen specimens each from groups A
and B were restored with fibre posts (Reforpost; An-
gelus, Londrina, PR, Brazil – size 01, 1.1 mm). The
post was cemented into the root canal as per the manu-
facturer’s recommendation using the ParaCore system
(Coltene Whaledent, USA). Following cementation of
the post, the fit of the fractured fragment was verified.
A trough was created within the fragment in the area
of the pulp chamber, for the post to fit in. The frag-
ment was etched, primed and re-attached using a flow-
able composite (3MTM ESPETM FiltekTM Supreme XTE,
USA) and light-cured. A chamfer margin was created
on the attached fracture line and restored with flowable
composite to merge the fragments (14).
Samples of Subgroup II were restored using
Ribbond (Ribbond Inc., Seattle, WA, USA). The post
length was measured using a graduated probe. A 2-
mm-width Ribbond fibre was selected for the study.
The required length of Ribbond was selected, that is
double the length of the post space. The Ribbond fibre
was wetted by soaking it in the adhesive resin, and
excess was removed using a gauze piece. The steps of
conditioning and adhesive resin application onto the
canal walls of the post space were similar to what were
described for the fibre post subgroup. The ParaCore
dual-cured core and resin cement was then injected
directly into the root canal using the root canal tip. To
insert the Ribbond into the canal, the mid-point of the
wetted Ribbond was draped over the end of a plugger
and this was inserted and pushed into the canal until
the apical end of the post space. The instrument was
then rotated one-quarter turn while withdrawing it
from the canal to release the Ribbond from the instru-
ment. An additional piece of Ribbond was inserted if
space permitted, between the protruding ends of the
first piece. The free ends of the Ribbond protruding
from the canal were used to aid in the fragment re-at-
112 Ramesh et al.
tachment. The fragments were re-attached in a similar
manner as described previously for the fibre post
group. All the samples were stored at 37°C at 100%
humidity for 24 h.
Fracture resistance testing
An Instron Universal Testing Machine was used to
apply a constant load at a crosshead speed of 1 mm
min-1 until fracture occurred. The jig was positioned
in the universal testing machine such that the loading
tip contacted the palatal surface of the samples 2 mm
beneath the incisal edge, providing a 45° angle
between the palatal surface and the loading tip
(Fig. 2). Load necessary to fracture the sample was
recorded in newtons.
Evaluation of mode of failure
The mode of failure was determined by examining all
the samples under a stereomicroscope (3.5X). The
mode of failure was designated as ‘repairable’ and
‘non-repairable’. The repairable group comprised of all
fractures above cemento-enamel junction, cervical frac-
tures and core-tooth fractures, and the non-repairable
group consisted of fractures below CEJ, oblique frac-
ture and fracture in the middle or apical third of the
root (15).
Statistical analysis
The Excel and SPSS (SPSS Inc, Chicago, IL, USA)
software packages were used for data entry and anal-
ysis. The results were averaged (mean  standard
deviation) for continuous variable parameter and
number and percentage for discrete variables. Stu-
dent’s t-test was used to determine whether there was
a statistical difference between the groups in the
parameters measured. Chi-square test was performed
to analyse the mode of failure. In all the above tests,
a ‘P’ value of less than 0.05 was accepted as indicat-
ing statistical significance.
Fig. 2. Schematic Representation of the fracture resistance
testing apparatus. a: Plunger; b: Loading Tip; c: Sample
holding Jig; d: Tooth sample. Detail A depicts point of loading.
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Results
Following analysis, fracture resistance of teeth restored
with fibre post was significantly higher in comparison
with those teeth restored with Ribbond in both groups
A and B (P < 0.05) as shown in Table 1. The fracture
resistance of teeth with a labio-palatal fracture pattern
was significantly higher as compared to the teeth with
a palato-labial fracture pattern across all specimens
(P < 0.05) as shown in Table 2. There was no signifi-
cant difference between the modes of failure comparing
groups A (labio-palatal) and B (palato-labial), P > 0.05
among the teeth in the fibre post subgroup (Table 3).
All the teeth in the Ribbond subgroup exhibited repair-
able failures in both the groups. However, when com-
paring the mode of failure between fibre post and
Ribbond, it was found that there was a significant dif-
ference between the failure modes of Ribbond and fibre
post, with Ribbond exhibiting significantly higher num-
ber of repairable failures as compared to fibre post,
(P < 0.05), which is depicted in Table 4.
Discussion
Crown fractures could manifest as different fracture
patterns with the fracture line running in various
directions, extending apically to varying depths. A
review of published case reports indicates that 80% of
traumatized incisors fracture in an oblique fashion
from the labial to lingual aspect with the fracture line
proceeding in an apical direction (16). According to a
study conducted by Dean et al. (17), this fracture pat-
tern is an unfavourable one as it exhibited low resis-
tance to labially applied forces attributed by the
authors to the lack of lingual support in such situa-
tions. They also put forth that the most favourable
fracture is when the plane of the fracture angles cervi-
cally in a lingual-to-labial direction (17). This was
probably due to the amount of lingual support that
the tooth provided the fragment, when the fracturing
force was placed on the facial aspect of the fragment
(17).
Reconstruction of crown fractures has developed
through the years. Re-attachment of crown was popu-
larized by means of various case reports and in vitro
studies published in the literature (13, 18–21). How-
ever, the literature lacks studies focusing on the re-at-
tachment technique as well as the two fracture
patterns, and hence, the present study was undertaken.
In the present study, it was found that on applica-
tion of a palatal load, the samples with the labio-pala-
tal fracture pattern (Group A) exhibited significantly
higher resistance to fracture as compared to the palato-
labial group (Group B), P < 0.05. The reason for the
labio-palatal group (Group B) to be exhibiting higher
values of fracture resistance could be attributed to the
amount of labial support provided to the fragment by
the remaining labial tooth structure on application of
the testing load on the palatal aspect (17). In a study
conducted by Dean et al. (17), fracture patterns simu-
lating the palato-labial group were considered favour-
able as the study tested the influence of a labial impact
 Ribbond and fibre post for reattachment of teeth 113

Table 1. Comparison of fracture resistance (newtons) of teeth restored with fibre post (Reforpost) and Ribbond with two
different fracture patterns
Group Subgroup N Mean SD Median ‘t’ value ‘P’ value
Labio-palatal (Group A) Fibre post (Subgroup I) 15 568.4 18.651 569.0 25.118 <0.001
Ribbond (Subgroup II) 15 533.4 19.628 537.6
Palato-labial (Group B) Fibre post (Subgroup I) 15 519.7 22.360 529.4 8.884 0.006
Ribbond (Subgroup II) 15 488.1 34.416 472.9

Table 2. Comparison of fracture resistance (newtons) of teeth having the two fracture patterns restored with fibre post
(Reforpost) and Ribbond
Subgroup Group N Mean SD Median ‘t’ value ‘P’ value
Fibre post (Subgroup I) Labio-palatal (Group A) 15 568.4 18.651 569.0 47.995 <0.001
Palato-labial (Group B) 15 519.7 22.360 529.4
Ribbond (Subgroup II) Labio-palatal (Group A) 15 533.4 19.628 537.6 19.578 <0.001
Palato-labial (Group B) 15 488.1 34.416 472.9

Table 3. Comparison of mode of failure between the two fracture patterns restored with Fibre post (Reforpost) and Ribbond
Failure
Subgroup Group Repairable Non-repairable Total v2 value ‘P’ value
Fibre Post Group A 12 3 15 0.240 0.624
80.0% 20.0% 100.0%
Group B 13 2 15
86.7% 13.3% 100.0%
Total 25 5 30
83.3% 16.7% 100.0%
Ribbond Group A 15 – 15 – –
100.0% 100.0%
Group B 15 15
100.0% 100.0%
Total 30 30
100.0% 100.0%

Table 4. Comparison of mode of failure between fibre post three composite posts, namely FibreKor, Luscent
(Reforpost) and Ribbond anchors and Ribbond in narrow and flared canals. It
Failure was found that the fracture strengths of Luscent
v2 ‘P’ anchors and FibreKor were significantly higher than
Repairable Non-repairable Total value value Ribbond in narrow canals, while Ribbond fared better
in the flared canal group. The authors attribute it to
Fibre 25 5 30 5.455 0.020
post 83.3% 16.7% 100.0% the fact that the flared canals allow the placement of
Ribbond 30 0 30 more fibre and more composite compared to the nar-
100.0% 0% 100.0% row canals (6). In the present study, the post spaces
Total 55 5 60 were prepared up to a diameter of 1.1 mm correspond-
91.7% 8.3% 100.0% ing to Peeso Reamer 3 for standardizing both groups,
which was in fact narrower than the narrow canal
group in the study conducted by Newman et al. (6).
Thus, the lower amount of Ribbond fibre and compos-
and not a palatal load application, as was carried out ite placed could have contributed to the reduced frac-
in this study. ture resistance obtained by Ribbond as compared to
Of the two fibre-reinforced post systems used for this Reforpost in the present study (6).
study, it was observed that the fracture resistance of Another study conducted by Aggarwal et al. (12)
teeth re-attached using fibre post (Reforpost, Angelus, compared the fracture resistance and fracture mode of
Subgroup I) was significantly higher than teeth re-at- endodontically treated teeth with wide root canals
tached using Ribbond (Subgroup II). Irrespective of restored with various dowel methods which included
the fracture patterns (groups A & B), Reforpost (Sub- Reforpost and Ribbond. It was found that specimens
group I) performed better than Ribbond (Subgroup II). restored with Ribbond showed the least resistance to
This is in accordance with a study conducted by New- fracture, significantly lower than all the other groups
man et al. (6) who compared the fracture strength of (12). Conversely, a study conducted by Kivanc et al.

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
114 Ramesh et al.
(22) found no difference between different types of
fibre-reinforced composite (FRC) post groups including
Luminex, Dentatus, Ribbond and EverStick posts.
However, the study was conducted on thin-walled roots
(22).
In the study conducted by Newman et al. (6), the
authors mention that they were uncertain about the
possibility of achieving complete light polymerization
of the Ribbond posts at the most apical portion,
although the manufacturer’s protocol was strictly fol-
lowed. However, the authors used a light-polymerizable
composite luting agent for Ribbond (6). In the present
study, a dual-cured resin luting agent (ParaCore, Col-
tene Whaledent) was used for both the post systems.
The literature provides very minimal information on
the light-transmitting ability of Ribbond post and lut-
ing composite used. Further studies are also required
to compare the light-transmitting ability of Ribbond
and Reforpost and to analyse whether this factor could
influence the fracture resistance of teeth.
The sectioned fragments were stored in distilled
water for 24 h until re-attachment, and this was done
as per the study conducted by Shirani et al. (13) where
they observed that a 24-h rehydration of the dehy-
drated tooth fragments resulted in higher bond
strengths. Following post placement and re-attachment
of fragment, a circumferential chamfer was given to
increase the retention of the fragments. The chamfer
was created on the fracture line after the bonding
procedure, and this area was restored using flowable
composite. The creation of the chamfer margin after
the re-attachment procedure ensures the precise fit of
the fragments and at the same time aids in masking the
fracture line (14).
On assessing the mode of failure following load
application, it was observed that the Ribbond post sys-
tem exhibited 100% of repairable failures in all the
specimens. On the other hand, the fibre post group
(Reforpost, Subgroup I) had 83.3% of repairable fail-
ures which was significantly lower than the Ribbond
group (P < 0.05). The fracture patterns (groups A &
B) did not have any influence on the mode of failure in
both the post systems. Both the post systems compared
in this study were fibre-reinforced composite posts hav-
ing similar modulus of elasticity to that of dentin. The
lower flexural modulus of fibre-reinforced posts can
decrease the incidence of root fracture (23). It was
observed that unlike Ribbond group, the Reforpost
group exhibited a few modes of ‘non-repairable fail-
ures’.
The fact that Ribbond produced a majority of
repairable failures is in accordance with other studies
conducted. Ozcopur et al. (20) showed that individual
posts such as EverStick and Ribbond showed more
repairable fracture modes when compared to a prefab-
ricated fibre post, UniCore, and a metal post, Para-
Post. Another in vitro study on the fracture resistance
and the incidence of vertical root fracture of pulpless
teeth restored with various post-and-core systems
found that the polyethylene woven fibre (Ribbond) and
composite resin without a prefabricated post resulted
in significantly fewer vertical root fractures, but mean
© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
failure load was the lowest (24). Aggarwal et al. (12)
also reported that Ribbond exhibited 100% repairable
failure modes, similar to what was noted in the present
study, thus proving Ribbond to be a favourable
restorative modality.
Based on the present and the above studies, for the
rehabilitation of fractured teeth, it is reasonable to con-
clude that we need to be judicious in selecting the
restorative material that possesses optimal strength and
fracture toughness. At the same time, the technique
chosen must ensure that upon failure, the tooth is
repairable without causing any more catastrophic dam-
age to the remaining tooth structure.
The present study had a few inherent limitations.
This study is an in vitro investigation, and hence, the
fracture patterns could be standardized across all sam-
ples. However, in a clinical scenario, a traumatic
impact will not provide such uniform fracture patterns.
Also, in a clinical situation, the tooth is subjected to a
variety of functional and parafunctional forces as well
as impact from other directions. Further studies may
be undertaken to evaluate the effects of these parame-
ters. A combined use of both Ribbond and fibre post
has also been proposed for optimal results, and further
studies are required in this direction (25).
Conclusion
Under the conditions of this study and within its limi-
tations, the following conclusions can be drawn: Teeth
with a labio-palatal fracture pattern is a favourable
type of fracture when the load application is from the
palatal side. Teeth restored with Reforpost has a higher
resistance to fracture as compared to Ribbond post
system. However, teeth restored with Ribbond posts
exhibited 100% repairable failures upon load applica-
tion. The pattern of fracture has no influence on the
reparability of the specimens following load applica-
tion, across both post systems. Further long-term clini-
cal studies are required to confirm and correlate the
present findings.
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