Journal of the Mechanical Behavior of Biomedical Materials 82 (2018) 235–238

Contents lists available at ScienceDirect

Journal of the Mechanical Behavior of

Biomedical Materials
journal homepage: www.elsevier.com/locate/jmbbm

Ex vivo fracture resistance of teeth restored with glass and fiber reinforced T
composite resin
⁎
Sulthan Ibrahim Raja Khana, , Anupama Ramachandranb, Abdulmohsen Alfadleya,
Jagan Kumar Baskaradossc
a
Department of Restorative & Prosthetic dental sciences, College of Dentistry, King Saud Bin Abdulaziz University for health sciences, Kingdom of Saudi Arabia
b
Department of Conservative Dentistry & Endodontics, Chettinad Dental College & Research Institute, Tamil Nadu, India
c
Department of Developmental and Preventive Sciences, Faculty of Dentistry, Kuwait University, Kuwait

A R T I C LE I N FO A B S T R A C T

Keywords: Objectives: This study aims to compare the ex vivo fracture resistance of root canal treated (RCT) teeth restored
Composite resin with four different types of fibers under composite resin.
Fiber reinforced Subjects and methods: One hundred and forty extracted mandibular first molar teeth were assigned to seven
Fracture resistance groups (n = 20/group). Group 1 was the control group. In groups 2−7, endodontic access and standard Mesio-
occluso-distal (MOD) cavities were prepared. Following RCT, group 2 was left unrestored. In group 3, flowable
composite resin (FCR) was used to line the cavities and restored with composite resin. In groups 4,5,6 and 7,
Ribbond, Everstick, Dentapreg and Bioctris fibers were inserted in flowable resin and restored respectively.
Results: All the groups restored with fiber reinforced composite displayed higher fracture resistance than the
group restored with only composite resin (p < 0.001). In addition, Groups restored with Everstick and Bioctris
(Groups 5 and 7) showed higher fracture resistance when compared to Ribbond and Dentapreg (Groups 4 and 6).
Conclusion: E glass fibers demonstrated highest fracture resistance and hence can be preferred over other fiber
types to reinforce RCT teeth with weakened crown structures.

1. Introduction architecture and quality of impregnation of fiber and resin (Soares

The primary objective of a post-endodontic restoration is to provide
adequate fracture resistance to the weakened pulpless teeth. Composite
resins are one of the preferred and more conservative approach to re-
store such teeth. The introduction of fibers in composite resin has
brought about a distinctive class of materials in the armamentarium of
restorative dentistry. These fibers were incorporated into the composite
resin material for their reinforcing effect (AlJehani et al., 2016). The
various attributes of the fiber reinforced composite (FRC) include in-
crease in flexural modulus and fracture resistance (Vallittu, 1998),
stress relievers (Belli et al., 2006) and resistance to crack propagation
(Meiers and Freilich, 2001). The inclusion of a fiber sub-structure under
composite resin have demonstrated superior characteristics when
placed under composite resin in root canal treated teeth as a core build
up material (Khan et al., 2013; Freilich and Meiers, 2004).
Currently, numerous types of fiber with different architecture and
composition are commercially available. The mechanical properties of
FRC are dependent upon fiber type, ratio of fiber to matrix resin, fiber
et al., 2008). A literature review revealed numerous studies which were
conducted to test microfiber embedded in resin matrix in composite
restoration and as fiber post systems. However, there are very few
studies which evaluated the effectiveness of glass fibers substructure
under composite resin.
Bioctris, a novel glass fiber framework system has been developed
which provides a fortifying effect on the restorative material. However,
the fracture resistance of this fiber system under composite resin re-
storation has not been tested. Hence, this study was designed to com-
pare the effect of four different types of fibers on the fracture resistance
of root canal treated teeth under composite resin.
2. Materials & methods
One hundred and forty intact mandibular first molar teeth were
selected for the study. The samples were subjected to thermocycling
(6000 cycles at 5–55 °C, dwell 30 s, transfer time 5 s) and stored in 37 °C
sterile water for 10 days. The teeth were assigned to seven groups of

⁎
Correspondence to: Department of Restorative & Prosthetic dental sciences, College of Dentistry, King Saud Bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City,
Ministry of National Guard Health Affairs, P.O Box: 22490, Riyadh 11426, Kingdom of Saudi Arabia.
E-mail addresses: hidayathullakhans@ksau-hs.edu.sa (S.I.R. Khan), dr.anupama@chettinadhealthcity.com (A. Ramachandran), fadleya@ksau-hs.edu.sa (A. Alfadley),
jagan@hsc.edu.kw (J.K. Baskaradoss).

https://doi.org/10.1016/j.jmbbm.2018.03.030
Received 14 March 2018; Accepted 26 March 2018
Available online 29 March 2018
1751-6161/ © 2018 Elsevier Ltd. All rights reserved.
S.I.R. Khan et al. Journal of the Mechanical Behavior of Biomedical Materials 82 (2018) 235–238

twenty teeth each.

Group 1 was used as a control group and no cavity preparation were
performed. For Groups 2–7, standard access cavities were prepared in
the teeth using a #245 carbide bur (SS White, Lakewood, NJ, USA) with
a high- speed handpiece and air-water coolant spray. The canals were
instrumented using Endoprep- RC® (Anabond Stedman, Pharma
Research (P) Ltd, India) and 5.25% sodium hypochlorite irrigant. Apical
preparation was performed to size 35 for distal canals and size 30 for
mesial canals and step back preparation was done till size 70. Teeth
were obturated with 2% gutta percha (Dentsply De Trey, Johnson City,
TN) using cold lateral condensation technique. After obturation,
radiographs were taken. The chamber was then cleaned and excess
sealer wiped off with cotton. Standard mesiooccluso-distal (MOD)
cavities were prepared. The thickness of the cavity walls was measured
as 2 mm at the buccal-occlusal surface, 2.5 mm at the cemento-enamel
junction, and 1.5 mm at the lingual occusal surface and cemento-en-
amel junction. These measurements were made using a vernier calipers.
The cavities for Group 2 were left unrestored.
For Group 3, the surface of the cavity wall was etched with 37%
phosphoric acid gel (Eco-Etch; Ivoclar Vivadent, Schaan, Liechtenstein,
Swiss) for 15 s and rinsed with water for 15 sThe cavity surface was
gently blot dried. Bonding agent (Te-Econom Bond® Ivoclar Vivadent®/
Schaan, Liechtenstein) was applied to the cavity surface using micro-
brush and light cured for 20 s using a quartz-tungsten-halogen curing
Fig. 1. Diagram of stress apparatus: (a) Compressive force; (b) Stainless steel
unit (QTH) (Astralis 7, Ivoclar Vivadent). The cavity surfaces were then
bar; (c) Sample; (d) Signal conditioning unit (RDP Unit); (e) Computer; (f)
coated with a layer of low viscosity flowable composite resin (FCR) (Te-
LVDT Transducer; (g) Load-cell; (h) Base; (i) Instron Universal Testing Machine.
econom Flow, Ivoclar, Vivadent, Schaan, Liechtenstein) in the buccal
and lingual walls and the pulpal floor. The cavities were then restored
with a hybrid resin composite (Te-Econom Plus, Ivoclar Vivadent, Each sample was loaded at a crosshead speed of 0.5 mm/min (Fig. 1).
Schaan, Liechtenstein) using an incremental technique and each layer The test machine's software recorded the peak-loaded fracture in
was cured for 40 s. newtons (N) for each sample and tabulated.
For Group 4, the cavity surfaces were etched and bonded using the One-way ANOVA was used to compare the failure load data at a
same technique as used for Group 3. The cavity surfaces were then significance level of 5%. Post hoc testing was performed with t-tests and
coated with a layer of flowable resin composite. Leno-woven ultra-high a Bonferroni correction for multiple testing. The analyses were per-
molecular weight polyethylene ribbon fiber (Ribbond; Seattle, WA, formed with SPSS version 11.0 (SPSS Inc., Chicago, IL, USA).
USA) was removed from the package using cotton pliers. A piece of the
fiber 10 mm long and 3 mm wide was cut. The fiber was subsequently
coated with adhesive resin. Excess material was blotted off with lint- 3. Results
free gauze. Then the fiber was embedded inside the flowable composite
on the buccal wall, pulpal floor and lingual wall of the cavities. After Mean fracture resistance (N) and standard deviation for all the
light curing for 20 s, the cavities were restored with hybrid composite groups are presented in Table 1. Fracture resistance of Group 1 was
as described above using an incremental technique, where each layer significantly higher than all the other groups (p < 0.001). Group 2
was light cured for 40 s. showed the least fracture resistance. All the groups restored with fibers
For Group 5, the cavity surfaces were etched and bonded as de- (Groups 4,5,6 and 7) displayed higher fracture resistance than the
scribed for Group 3. The cavity surface was then coated with FCR and group restored with only composite resin (Group 3). In addition, Groups
Everstick (Everstick C&B, GC Corp., Tokyo, Japan). Two fibers of restored with Everstick and Bioctris (Groups 5 and 7) showed increased
10 mm long and 1.5 mm wide dimension was cut and embedded in the fracture resistance when compared to Ribbond and Dentapreg (Groups
FCR adjacent to each other and cured and restored as performed for 4 and 6). No statistical difference was found between Groups 5 and 7 or
Group 4. between Groups 4 and 6. Everstick fibers showed a fracture resistance
For Group 6, the cavity surfaces were etched and bonded as de- of 1433.14 N and Bioctris displayed a fracture resistance of 1480.20 N
scribed for Group 3. The cavity surface was the coated with FCR and (Table 1).
Dentapreg fiber (UFM, ADM AS, Brno, Czech Republic) of 10 mm long
and 3 mm wide dimension was cut and embedded in the FCR and cured Table 1
and restored similar to Group 4. Fracture strength in newton.
For Group 7, the cavity surfaces were etched and bonded as de- Groups Fracture Load (N)
scribed for Group 3. The cavity surface was then coated with FCR and
Bioctris fiber (Bio Composants Medicaux, France) of 10 mm long and Minimum Maximum Mean SD
3 mm wide dimension was cut and embedded in the FCR and cured and e
Group 1 1450.90 1926.70 1677.08 155.19
restored similar to Group 4. Group 2 280.60 402.60 352.54a 32.74
Finally, all the teeth were mounted in self-curing acrylic resin using Group 3 602.30 910.00 775.14b 101.93
5.1 cm * 5.1 cm custom made molds. The teeth were embedded in the Group 4 800.50 1243.80 959.28c 128.67
resin up to the level of cemento-enamel junction. The specimens were Group 5 1280.40 1595.50 1433.14d 98.57
Group 6 856.30 1324.00 979.17c 124.22
stored in an incubator at 37 °c in 100% humidity for 24 h. Group 7 1301.40 1616.70 1480.20d 102.90
Fracture resistance testing done in the Instron Universal Testing
Machine (Instron, Buckinghamshire, England). Compressive force was Different superscript letters between subgroups denote significance at 5% level
applied with a 6 mm diameter stainless steel bar centered on the tooth. (post-hoc test).

236
S.I.R. Khan et al.
4. Discussion
Mandibular molars are a group of teeth that frequently undergo
endodontic treatment. Furthermore, teeth having MOD cavities are
highly susceptible to fracture as the missing mesial and distal walls puts
severe strain on the remaining tooth structure (Vallittu, 2009). Hence
mandibular molars were selected for the study in which MOD cavities
were prepared.
FRC is essentially a fiber embedded polymer matrix system which
was introduced to overcome the shortcomings of conventional com-
posite resin like brittleness and ease of crack propagation and poly-
merization shrinkage. Many fiber types and architectures are available
for clinical use to reinforce dental composites. Among them, ultrahigh
molecular weight polyethylene fibers (UHMWPE) and glass fibers have
a wide application in dentistry. These fibers can have different or-
ientation - unidirectional fiber laminates- Dentapreg, Everstick and
Bioctris or Continuous bidirectional fibers (woven, mesh type) -
Ribbond.
Ribbond is a plasma treated leno-woven ultrahigh molecular weight
polyethylene ribbon exhibiting open geometry. Ribbond fibers are a
non impregnated fiber exhibiting high tensile strength, modulus of
elasticity and fracture toughness.
Glass fibers are used in different forms to strengthen dental com-
posites; most common being the E glass and S glass. Everstick is based
on the E glass system embedded in PMMA, Bis GMA resin in a semi
interpenetrating polymer network (IPN). It contains 4000 fibers in
unidirectional mode and are coated with epoxy resin. Dentapreg fibers
are based on the S2 glass system embedded in Bis-GMA and TEGDMA in
a cross linked polymer matrix. They contain 8300 unidirectional fibers
coated with plasma enhanced chemical vapor deposition. Bioctris fiber
are also based on the E glass system. However, they are Bis GMA free
and the unidirectional glass fiber coated with silane are embedded in
UDMA and TEGDMA resin in a semi interpenetrating polymer network.
The results of the current study demonstrate that all the restored
teeth were weaker than the control group. All the groups in which fiber
insertion was done prior to the composite restoration showed higher
values than that of the group with composite resin restoration alone.
Similar findings have been reported by numerous authors (Belli et al.,
2006; Oskoee et al., 2011). The fibers terminate the propagation of
cracks as the presence of a different material alters the stress dynamics
at the tooth -resin interface. In addition, placement of these fibers re-
duces the volume of composite resin in the cavity which in turn reduces
the degree of polymerization shrinkage. These fibers resist dimensional
changes or deformation which prevents the failure of the restoration
(Ozel and Soyman, 2009).
The composition of E glass system is calcium–aluminum–bor-
osilicate fiber. There are different types of polymer networks among the
fiber reinforced composites such as semi Interpenetrating Polymer
Network and cross linked polymer systems. The semi-IPN, unlike a cross
linked polymer (CLP), consists of two separate polymer networks which
are not linked by chemical bonds (Sperling, 1994). The structure of
semi IPN consists of a linear resin polymer which is interspersed with
dimethacrylate monomers. These semi-IPN structures can be dissolved
by the solvent present in the adhesive resin which offers a distinct
advantage over the other CLPs (Lastumaki et al., 2002). Semi IPN
structures retain a sticky oxygen-inhibited layer on its external surface
that allows direct chemical bonding with the covering composite, and
thereby eliminate the need for mechanical retention (Freilich et al.,
1998). Wolff et al.Wolff et al. (2012) stated that a homogeneous inter-
diffusion layer was detected in everstick. This phenomenon could be
explained on the premise that the pre-cured FRC and freshly applied
monomers formed a strong bond. This IPN layer occurring between the
matrix and the glass fiber helps in reinforcing the union. The stronger
the fiber- resin interfaces, the greater the static, impact and fatigue
properties. Furthermore, both Everstick and Bioctris fibers have uni-
directional fibers and exhibit semi IPN. The mechanical properties of
237
Journal of the Mechanical Behavior of Biomedical Materials 82 (2018) 235–238
FRC structure with continuous unidirectional fiber can express better
results compared to reinforcement with other fiber such as short and
random (Khan et al., 2015).
Ribbond being a non-impregnated fiber, manual impregnation of
resin could have resulted in poor impregnation of the adhesive to the
fiber which creates voids between the matrix. This could have led to the
premature failure of the restoration. Similar outcomes were reported by
other authors. Foek et al.Foek et al. (2009) found that resin adhesion to
polyethylene reinforced composites was less favorable because of the
difficulty in plasma coating, silanization and impregnation of the
polyethylene fibers. Vallittu et al.Vallittu (1997) using scanning elec-
tron microscopy demonstrated good adhesion between glass fiber and
matrix but relatively poor adhesion between UHMWPE and matrix re-
sins. Additionally, linear polymers can be fully dissolved by the ad-
hesive resin whereas cross-linked polymers present in Ribbond do not
dissolve (Sperling, 1994), this can also explain decreased fracture re-
sistance of Ribbond fiber. Goldberg et al.Goldberg and Burstone (1992)
stated that unidirectional fiber has greater flexural strength and rigidity
than woven fibers. Multi directional fibers,as present in Ribbond fiber,
is therefore accompanied by a decrease in strength in comparison with
unidirectional fiber (Dyer et al., 2004).
Dentapreg also demonstrated lesser fracture resistance when com-
pared to E glass fibers in the present study. These results are in ac-
cordance with a previous study which states that although Dentapreg
displays a plasma-enhanced chemical vapor deposition (PECV) coating
and as claimed by the manufacturer due to which direct bond is formed
between monomers and glass fibers, however these claims are not
supported by controlled pre-clinical or clinical studies (Freilich et al.,
1998).
Dentapreg with its high modulus presents a mismatch with dentin's
elastic modulus. According to Lertchirakarn et al.Lertchirakarn et al.
(2002), an elastic modulus similar to dentin will improve the fracture
resistance of an endodontically treated tooth. Materials with high
elastic modulus tend to accumulate stresses, while low elastic modulus
materials dissipate them. Stress accumulation leads to crack develop-
ment and propagation, while restorative materials that absorb and
dissipate stress will protect the underlying structure (Dejak et al.,
2003). Also, Dentapreg contains significantly higher number of fibers
than Everstick. This dense glass fibers content with minimal matrix
layer could lead to the failure as numerous fibers may undergo plucking
or fraying as hypothesized by Callaghan et al.Callaghan et al. (2006).
Additionally, Dentapreg fibers also lack the semi - IPN structures which
could also explain its poor performance.
Test designs of laboratory studies can never simulate the clinical
situation. Clinical loading of teeth is a dynamic process as compared
with the more static nature of laboratory studies. Also due to a large
number of other variables involved (i.e. tooth condition, tooth type,
procedures and restorative materials) it is almost impossible to compare
fracture resistance data between laboratory studies (Fokkinga et al.,
2004).
5. Conclusion
Within the limits of this laboratory investigation, the results have
shown that insertion of all the above fibers significantly increased the
fracture resistance of the restored teeth. Among the different fibers
tested, Everstick and Bioctris demonstrated the highest fracture re-
sistance. Thus, it can be inferred that E-glass system is able to reinforce
teeth better than S2 glass or Polyethylene fibers.
Number of Reprints
Not Needed.
S.I.R. Khan et al.
Conflict of interest
None.
Significance
The inclusion of a fiber sub-structure under composite resin helps in
improving the physical properties of the restorative material. This is the
first study that compares the characteristics of Bioctris Bioctris fiber
(Bio Composants Medicaux, France) with other glass and fiber re-
inforced composite resin.
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