Received: 20 September 2021 Revised: 7 December 2021 Accepted: 16 December 2021

DOI: 10.1002/jemt.24040

RESEARCH ARTICLE

The effect of fiber insertion on fracture strength and fracture

modes in endocrown and overlay restorations

Mehmet Ali Fildisi1 | Evrim Eliguzeloglu Dalkilic2

1
Department of Restorative Dentistry, Faculty
of Dentistry, Istanbul Medipol University,
Istanbul, Turkey
2
Department of Restorative Dentistry, Faculty
of Dentistry, Bezmialem Vakif University,
Istanbul, Turkey
Correspondence
Mehmet Ali Fildisi, Department of Restorative
Dentistry, Faculty of Dentistry, Istanbul
Medipol University, 34230, Istanbul, Turkey.
Email: mehmetalifildisi@gmail.com
Funding information
Bezmialem Vakıf Üniversitesi, Grant/Award
Number: 12.2017/35; Bezmialem Vakıf
University, Grant/Award Number: 12.2017/35
Review Editor: Mingying Yang
Abstract
Aim of this study was to determine the fracture strength and modes of endocrown
and overlay restorations with/without fiber reinforcement on endodontically treated
teeth. Sixty-five molar teeth were used: Group IN (intact teeth), Group E (end-
ocrown), Group ER (endocrown + ribbond), Group O (overlay), Group OR (overlay
+ ribbond; n = 13). Ribbond (Seattle, WA) was inserted at the base of pulp chamber
in Group ER and OR. All restorations were designed and produced by using
computer-aided design and computer-aided manufacturing (Sirona Dental Systems,
Bensheim, Germany) and Cerasmart (GC Corp. Kasugai, Aichi, Japan). All teeth were
subjected to thermomechanical aging and fractured in a universal test device. Frac-
tured surfaces were analyzed with a stereomicroscope (SMZ1000, Nikon, Japan).
Data were analyzed with Welch's analysis of variance and Games–Howell test
(p < .001). Group E showed significantly lower fracture strength values than other
groups(p < .05). No statistically significant differences were found among the other
groups(p > .05). Most of the unfavorable fractures were seen in Groups E and O.
Overlay restorations showed higher fracture strength values than endocrown resto-
rations. Although fiber insertion did not improve the fracture strength of the indirect
restorations, it reduced the frequency of irreparable fracture mode. Overlay restora-
tions and fiber application are more advantageous in preserving the durability of the
endodontically treated teeth.

KEYWORDS
CAD-CAM, endocrown, fracture mode, fracture strength, overlay

1 | I N T RO DU CT I O N To date, there is no agreement in the literature concerning which

Endodontically treated teeth are more prone to biomechanical failures
than vital teeth. These failures compromise long-term tooth progno-
ses and can cause tooth loss. The primary reason for the reduction in
stiffness and fracture resistance of endodontically treated teeth is the
loss of structural integrity associated with caries, trauma, and exten-
sive cavity preparation and not dehydration or physical changes in the
dentin. For this reason, it is clinically important to make restorations
in endodontically treated teeth that are resistant to fractures and clini-
cally durable (Chang et al., 2009).
material or technique can optimally restore endodontically treated
teeth. The classic approach is to build up the tooth with a post
and core, and then use adhesive procedures and the placement of
full-coverage crowns with a sufficient ferrule (Sufyan Garoushi
et al., 2009). However, postadaptation is not always ideal, and the
preparation of a postspace increases the risk of accidental root perfo-
ration (Robbins, 2002). Other clinical approaches include monoblock
restorations such as onlay/overlay restorations that do not extend
into the pulp chamber or endocrowns, which do extend into the pulp
chamber walls. In cases where a severe amount of tissue loss of an

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1800
endodontically treated tooth occurs, the use of adhesively bonded
restorations such as overlays and endocrowns allows for minimal
preparation and, thus, preservation of tooth structure. Sedrez-Porto
et al. (2016) have reported that endocrown restorations perform bet-
ter compared to traditional restorations.
The computer-aided design and computer-aided manufacturing
(CAD-CAM) technique is based on converting data collected by opti-
cal scanners of intraoral cameras into three-dimensional designs using
computer software. The literature is unclear on which is the best
material for the production of a restoration of devitalized teeth.
Resin-composite and lithium disilicate–reinforced glass ceramic CAD-
CAM blocks are typically preferred in the production of overlay and
endocrown restorations. Recently, however, hybrid materials with
high ceramic fillings are preferred as they are an intermediate product
between classic, particle-filled resin, and ceramics, and they possess
positive properties of both materials (Rocca et al., 2016).
Fiber materials have only recently been introduced to dentistry.
Aside from improving the strength of a restoration, the incorporation
of glass fibers into resin-composite materials usually leads to more
favorable fracture patterns—those above the cementoenamel junction
(CEJ)—due to the fact that the fiber layer acts as a stress breaker and
can deviate the crack propagation (Ganesh & Tandon, 2006).
The polyethylene fiber, ribbond, absorbs and transfers stresses
well in fiber networks due to its low elastic modulus, so its resistance
lu et al., 2002). A number of studies have
to forces is high (Eskitaşcıog
reported that using ribbond in direct restorations has increased the
fracture resistance of the remaining tooth tissue, increased the bond
strength, decreased the effects of C-factor and polymerization shrink-
age, reduced microcracks, preserved dimernsional stability, and
decreased microleakage (Baroudi & Ibraheem, 2015). While there are
TABLE 1 Materials used in this study
Material type Manufacturer
GC Cerasmart GC Corp. Tokyo, Japan
Multilink N Ivoclar Vivadent, Schaan, Liechtenstein
Ribbond Ribbond, Inc., Seattle, Washington, USA
Gradia Direct Posterior GC Corp, Tokyo, Japan
CLEARFIL SE bond Kuraray Medical Inc., Tokyo, Japan
Monobond N, Ivoclar Vivadent, Schaan, Liechtenstein
Primer A, B
Essentia HiFlo GC Corp. Tokyo, Japan
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FILDISI AND ELIGUZELOGLU DALKILIC
studies that have evaluated the fracture strength of direct composite
restorations with different fiber-containing materials, there is no
research on indirect restorations with polyethylene fiber reinforce-
ment (Monaco et al., 2015; Monaco et al., 2016; Rocca et al., 2015).
Therefore, the aim of this study was to determine the fracture
strength and fracture modes of endocrown and overlay restorations
with and without fiber reinforcement on endodontically treated, man-
dibular molar teeth.
Three null hypotheses were tested:
1. Endocrown and overlay restorations do not change the fracture
strength of endodontically treated, mandibular molar teeth.
2. Polyethylene fiber insertion under endocrown and overlay restora-
tions donot change the fracture strength of endodontically treated,
mandibular molar teeth.
3. Polyethylene fiber insertion under endocrown and overlay restora-
tions do not change fracture modes of endodontically treated,
mandibular molar teeth.
2 | M A T E R I A L S A N D M ET H O D S
This study was approved by the Local Ethical Committee (process no:
12.2017/35). The sample size was calculated based on the estimated
effect size between groups, according to the literature. It was deter-
mined that 13 samples were needed for each group to achieve a
medium effect size (d = 0.50), with 80% power and a 5% type
1 error rate.
Materials used in the present study are shown in Table 1. A total
of 65 permanent, mandibular molar teeth with similar dimensions
Composition Lot no
Silica, barium glass filler, Bis-MEPP, UDMA, DMA 008671
DMA, HEMA, Ba-glass filler, ytterbium fluoride, W99238
spheroid mixed oxide, phosphoric acid acrylate
Ultra-high-molecular-weight polyethylene, +D758T0
homopolymer H-(CH2-CH2)n-H
Filler: Silica, prepolymerized fillers, 1,708,182
fluoroaluminosilicate glass resin matrix: UDMA
comonomer matrix
Primer: MDP; HEMA; hydrophilic dimethacrylate; 5A0252
camphorquinone; water.
Adhesive: MDP; HEMA; Bis-GMA; hydrophobic
dimethacrylate; N, N diethanol p-toluidine;
camphorquinone bond; silanated colloidal silica.
Monobond N: Silane ethanol, water, methaycrylate, W95830 Monobond
phosphoric acid methacrylate silane, metallic contact W97811 Primer A
polymethyl W97546 Primer B
Primer A: Adhesive Ivoclar Vivadent aqueous solution
of initiators
Primer B: Adhesive Ivoclar Vivadent HEMA,
phosphonic acid, and methacrylate monomers
Resin (UDMA, bis-MEPP and TEGDMA) 31% filler 1701111
(silicon dioxide [16 nm], 69% glass strontium
[200 nm]) and a small amount of photoinhibitor

FILDISI AND ELIGUZELOGLU DALKILIC
(mean mesiodistal distance: 11.18 ± 0.27 mm; buccolingual: 10.25
± 0.21 mm) and without caries that had been extracted for periodon-
tal reasons were used in the study. The teeth were cleaned of debris
and soft tissue remnants immediately after extraction and kept in
saline solution. Teeth were divided into five groups (n = 13 per
group). In the control group (Group IN), teeth were not subjected to
any cavity preparation or endodontic treatment.
2.1 | Endodontic treatment
In the tested groups, all teeth first underwent endodontic treat-
ment. Endodontic access cavities were prepared using diamond
burs (G&Z Instrumente Gmbh, Lustenau, Austria) at high speed with
water cooling, and the pulp tissues were extirpated. The working
length of each tooth was determined using #15 K-files (Dentsply,
Maillefer, Switzerland). The shaping of the canals was achieved
with an endodontic motor (X SMART, Dentsply, Maillefer,
Switzerland) and TS1 and TS2 rotary instruments (One shape,
Micro Mega, Besançon, France). EDTA gel (Dia Prep Plus, DiaDent,
Chongju, Korea) was used to lubricate the canal during shaping.
The canals were irrigated with 2 ml of 5.25% NaOCL before chang-
ing each rotary instrument. Paper points were used to dry the
canals. After drying, gutta-percha (Micro Mega, Kent, UK) was cov-
ered with canal paste (AH Plus Sealer, Dentsply De Trey, Konstanz,
Germany) and placed into the canal. The cold lateral condensation
technique was used during the filling of the canal with gutta-
percha.
2.2 | Cavity preparation
Standard cavities were prepared using an aerator (Kavo Super Torque,
KaVo Dental GmbH, Biberach, Germany) with diamond inlay burs
(Intensiv Inlay Set III Extended, Montagnola, Switzerland) under water
cooling. The cavity walls were decreased approximately 2 mm above
the CEJ.
The axial walls of the pulp chamber were prepared using a round-
 
tipped, blue diamond, conical bur to ensure 8 –10 divergent cavity
walls. Cavity margins were finished using butt joints with a 2 mm
thickness. Standardization was achieved by measuring the depth of
the pulp chamber with a periodontal probe and adjusting it to
FIGURE 1 Standard cavity preparation
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1801
approximately 3 mm from the pulp floor to the level of the internal
cavomargin (Figure 1).
Following cavity preparation, canal orifices were sealed with a
resin-modified glass ionomer (Fusion I Seal, PREVEST Denpro, Kash-
mir, India) and polymerized for 20 s with an LED light-curing unit
(VALO, Ultradent Products Inc., South Jordan, UT). The teeth were
then embedded in cold-curing acrylic resins (Paladent RR, Heraeus
Kulzer GmbH & Co., Hanau, Germany) 2 mm below the CEJ using a
cylindrical mold with a diameter of 3 cm and a depth of 2 cm. The
teeth were then divided into four groups according to the different
types of restorations that were applied (Figure 2).
Group E (endocrown): Subsequent to cavity preparation, the
design of the endocrown restorations was done on a CAD-CAM
(Sirona Dental Systems, Bensheim, Germany) device using the CEREC
SW 4.6 program (Figure 3a,b).
Cavities were restored with endocrowns. The production of the
restoration was carried out in a CEREC milling device (CEREC MC,
Sirona Dental Systems, Bensheim, Germany) using CERASMART
(GC Corp. Kasugai, Aichi, Japan) CAD-CAM material.
Group ER (endocrown + ribbond): After standard cavity prepara-
tion, CLEARFIL SE BOND was applied to the cavities according to the
manufacturer's instructions and polymerized with an LED light device
for 10 s. A ribbond fiber that was 8 mm long (Ribbond Inc., Seattle,
WA) was cut and soaked in CLEARFIL SE Bond in an opaque area.
The moistened ribbond was placed against the buccal and lingual walls
of the pulp cavity in a flowing composite (Essentia HiFlo, GC, Tokyo,
Japan) that was placed on the cavity floor and walls and cured with an
LED light-curing unit for 20 s. Another ribbond fiber was cut and
moistened with the same dimensions and placed with a flowing com-
posite toward the mesial and distal walls of the pulp cavity and cured
with light for 20 s. Afterward, the design and production of the end-
ocrown restoration were carried out similar to Group E.
Group O (overlay): Following standard cavity preparation,
CLEARFIL SE Bond was applied to the cavities according to the manu-
facturer's instructions and polymerized with an LED light device for
10 s. Using microfill composite resin (Gradia Direct Posterior, GC
Corp. Tokyo, Japan), the pulp chamber was restored using an incre-
mental technique at a thickness of 2 mm and polymerized with an
LED light-curing unit for 20 s. The height of the composite resin was
generated with a total thickness of 4 mm up to 1 mm above the cav-
omargin level. Afterward, the design and production of the end-
ocrown restoration were carried out similar to Group E.

1802
FIGURE 2 Representation of the groups. E, Endocrown; ER, endocrown + ribbond; O, overlay; OR, overlay + ribbond
FIGURE 3 Design of the endocrown restoration (a and b)
Group OR (overlay + ribbond): After standard cavity preparation,
CLEARFIL SE Bond was applied to the cavities according to the manu-
facturer's instructions and polymerized using an LED light device for
10 s. Ribbond was placed in the pulp chamber, as in Group
ER. Following the ribbond application, pulp chambers were restored
with a 2-mm-thick incremental technique up to 1 mm above the
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FILDISI AND ELIGUZELOGLU DALKILIC
cavomargin level (as in Group O) and polymerized with an LED light-
curing unit for 20 s. Afterward, the design and production of the end-
ocrown restoration were carried out similar to Group E.
Indirect restorations produced in all groups were cemented using
dual-cure resin cement (Multilink Speed, Ivoclar Vivadent, Schaan,
Liechtenstein) according to the manufacturer's instructions (Figure 4a).
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FILDISI AND ELIGUZELOGLU DALKILIC 1803

FIGURE 4 (a) Cementation of the restorations. (b) Fracture strength test

2.3 | Thermomechanical aging and fracture T A B L E 2 Mean fracture strength values of the groups, standard
strength test deviations, and significant differences

N Fracture strength (mean ± SD; Newton)

All teeth, including those in the control group, were subjected to
Group S 13 2880 ± 608.7 A
thermomechanical aging. Chewing simulation was applied to the teeth
Group E 13 2303.1 ± 197.0 B
after placement in a chewing simulator (CS-4 SD Mechatronic
Group ER 13 2920.7 ± 779.9 AB
Feldkirchen Westerham, Germany) for 480,000 cycles, with 100 N
Group O 13 2814.9 ± 280.5 A
force in the vertical direction at 1.7 Hz speed. Vertical force was
Group OR 13 2985.4 ± 449.5 A
applied to the central fossa of the restorations with a 3.2-mm-
diameter steel ball in distilled water. The teeth were then subjected to Note: Different letters show the difference between groups (p < .05).
thermal aging in a thermal cycler device (Thermocycler, SD Abbreviations: E, Endocrown; ER, endocrown + ribbond; O, overlay; OR,
overlay + ribbond.
Mechatronik Thermocycler THE-1100, Feldkirchen-Westerham,
Germany) at 10,000 cycles between 5 C and 55 C with a 30-s dwell
time and a 10-s transfer time. the Shapiro–Wilk test. As the data were normally distributed, Welch's
After the aging process was completed, the teeth were fractured analysis of variance was used to compare the groups. Pairwise com-
by applying a 5 mm diameter steel ball to the central fossa at a speed parisons were made using the Games–Howell test. Significance was
of 0.5 m/s in a universal test device. The fracture strength values of set at p < .001.
the samples were recorded in Newtons (Figure 4b).
An analysis of the fracture surfaces was examined using a stereo-
microscope (SMZ1000, Nikon, Japan) at 8 magnification and then 3 | RE SU LT S
categorized into five fracture modes: Type I (reparable): cohesive fail-
ure, fracture in the restoration; Type II (reparable): adhesive failure, The results of the fracture strength test, standard deviations, and dif-
adhesive failure between the restoration and teeth; Type III (repara- ferences between groups are shown in Table 2. The lowest fracture
ble): cohesive–adhesive failure, fracture in the restoration with adhe- strength value occurred in Group E, and this value was significantly
sive failure between the restoration and teeth; Type IV (reparable): different from Groups O, OR, and IN (p < .05). There was no signifi-
tooth fracture that occurred above the CEJ with a restoration frac- cant difference between the other groups tested (p > .05).
ture; and Type V (irreparable): tooth fracture that occurred below the The results from the fracture mode analyses are listed in
CEJ with a restoration fracture. Table 3. According to these results, irreparable fracture modes (Type
V) were seen more frequently in Groups E and O, which were
treated without ribbond (Figure 5a,b). An adhesive failure type was
2.4 | Statistical analyses not observed in the endocrown restorations but was, instead, pri-
marily observed in Group OR (Figure 5c). The cohesive–adhesive
The homogeneity of the fracture strength test data was examined fracture mode (Type III) was primarily found in Groups E and ER
using the Levene test. The normality of the data was examined using (Figure 5d,e).
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1804 FILDISI AND ELIGUZELOGLU DALKILIC

T A B L E 3 Fracture modes and

Type I Type II Type III Type IV Type V (irreparable)
percentages of the groups
Group E — — 10 (76.9%) 1 (7.7%) 2 (15.4%)
Group ER — 2 (15.4%) 10 (76.9%) — 1 (7.7%)
Group O — 3 (23.1%) 5 (38.4%) 2 (15.4%) 3 (23.1%)
Group OR — 7 (53.8%) 4 (30.8%) 1 (7.7%) 1 (7.7%)

Abbreviations: E, Endocrown; ER, endocrown + ribbond; O, overlay; OR, overlay + ribbond.

F I G U R E 5 (a) Type V fracture type in Group E. (b) Type V fracture mode in Group O. (c) Type II adhesive failure type in Group OR. (d) Type III
cohesive–adhesive failure mode in Group E. (e) Type III cohesive–adhesive failure in Group ER. E, Endocrown; ER, endocrown + ribbond;
O, overlay; OR, overlay + ribbond

4 | DISCUSSION
Due to advances in adhesive dentistry, clinicians have preferred
restorative options such as endocrowns and overlays over classic
treatments (Roscoe et al., 2013). In the literature, there have been
few in vitro studies comparing endocrown and overlay restorations
(Monaco et al., 2016; Rocca et al., 2015). Therefore, there is no spe-
cific information concerning which restoration is more reliable. In
addition, the effectiveness of using polyethylene fibers under these
indirect restorations is unknown. For these reasons, the fracture
strength of root canal–treated, lower molar teeth with endocrown
and overlay restorations was evaluated with and without added poly-
ethylene fibers under these restoration types. Our results show that
the fracture strength of endocrown restorations was significantly
lower than overlay restorations. Furthermore, the application of poly-
ethylene fibers under indirect restorations had no effect on the
fracture strength but did change the fracture mode. Therefore, we
rejected our first two hypotheses, but our third hypothesis was
accepted.
Fracture strength tests are the most common method used to
measure the strength of posterior restorations. These tests are per-
formed by applying static forces to determine the most appropriate
restoration type and material (Soares et al., 2006). In our study, force
was applied to the surface of the tooth using a stainless steel sphere
with a diameter of 5 mm in a vertical direction parallel to the long axis
of the tooth to simulate the forces in centric occlusion.
Before performing mechanical tests, the teeth were embedded in
chemically cured acrylic approximately 2 mm above the CEJ, without
mimicking the periodontal ligament. It has been reported that a peri-
odontal ligament simulation can act as a shock absorber and positively
alter fracture strength and failure modes (Soares et al., 2005). How-
ever, de Kuijper et al. (2019) have reported that cold and heat

FILDISI AND ELIGUZELOGLU DALKILIC
applications during thermal cycles in the aging process may cause
deformations in the material that mimic the periodontal ligament,
which could affect the results. Therefore, periodontal ligament simula-
tion is not recommended. In our study, long-term thermal cycle appli-
cations were planned. Therefore, to prevent the negative effects of
this application on periodontal ligament simulation, the teeth were
directly embedded in chemically cured acrylic.
The thermal cycle is a common method used for aging teeth when
evaluating the strength of restorations bonded to dental tissues by
adhesive systems (Dos Santos et al., 2005; Yang et al., 2005). Thermal
aging mimics the changes in the oral environment that occur during
eating, drinking, and breathing (Singh & Goel, 2005). Ernst et al. (2004)
determined that most of the temperature values occurring in the oral
cavity are generally limited to between 5 C and 55 C. Therefore, the
samples in all of the groups in this study were subjected to thermal
cycles that mimicked this clinical situation, and the technique was
applied for 10,000 cycles, corresponding to 1 year of clinical use, at
temperatures between 5 C and 55 C. Chewing test devices are used
to better understand the in vivo behavior of adhesive restorations and
to imitate the effect of mechanical forces that may occur in the oral
cavity. In this study, a long-term chewing force of 480,000 cycles was
applied to the specimens to achieve clinical aging at the interface of
the restorations.
When the fracture strength of the indirect restorations was com-
pared with intact teeth, significantly lower fracture strengths were
found in the group restored with endocrowns. No differences were
found between other indirect restoration groups and intact teeth.
Gresnigt et al. (2016) evaluated the fracture strength of endocrowns
produced with lithium disilicate and multiphase composite under axial
forces on lower molar teeth. They did not detect any differences
between endocrown restorations produced from either material and
intact teeth under axial forces. Guo et al. (2016) also examined the
fracture strength between intact teeth, endocrowns, and post and
core crown restorations in premolar teeth and found that the intact
teeth had higher fracture strength values than the endocrown and
post and core crown groups.
It is known that pulp chambers and cavity margins restored with
composite resins are able to protect and strengthen tooth structure
by eliminating undercuts in the tooth (Bindl et al., 2005). In addition,
this composite layer ensures optimal cavity sealing and maintains the
endodontic treatment (Magne et al., 2005). In this study, when the
fracture strengths of endocrown and overlay restorations were com-
pared, we found that the fracture strength of the overlay restorations
was higher than in endocrown restorations. The higher fracture
strength in the overlay restorations may have been caused by a
strengthening of the pulp chamber walls by the addition of composite.
In contrast, Monaco et al. (2016) and Rocca et al. (2015) did not find
any difference in the fracture strength of endocrowns and overlays.
This may be due to differences in the indirect restorative materials
used and the aging procedures between the studies. Hybrid CAD-
CAM material that contained 29% resin dispersed in a matrix com-
posed of 71% nanoceramics was used in this study, while Monaco
et al. (2016) used microfilled resin composite as an indirect restorative
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1805
material (Edelhoff & Brix, 2011). Rocca et al. (2015) applied 1,500
thermal cycles for the aging of teeth and applied mechanical aging to
the surface of their samples with a force of 49 N in a chewing simula-
tor. In contrast, we used 100 N force in a chewing simulator for the
mechanical aging of the tooth surfaces in all of the groups, and ther-
mal aging was applied for 10,000 cycles, corresponding to 1 year of
clinical use. Thus, different thermal and mechanical aging methods
may have caused different fracture strength results. However, despite
these differences, the fracture strength results of indirect restorations
under axial forces were well above the average chewing force values
(approximately 600–900 N in humans) in all groups (Ahlberg
et al., 2003).
In studies where fiber is used with composite restorations, the
fiber has been shown to increase the strength of the restoration. Fur-
thermore, it ensures reparable fracture modes above the enamel–
cementum level (Dere et al., 2010; Sufyan Garoushi et al., 2009)
because the fiber layer acts as a stress breaker and stops the progres-
sion of a crack (Dere et al., 2010). When the fiber layer is positioned
in the area between the tooth and the restoration, it is capable of
slowing or stopping crack progression in the underlying tissues, thus
preventing the formation of irreparable fractures (Dere et al., 2010;
Göhring & Roos, 2005). There are numerous studies that have investi-
gated fracture strength and fracture modes with the addition of poly-
ethylene fibers to root canal–treated teeth restored with composite.
Belli et al. (2006) and Hshad et al. (2018) reported, in their studies
evaluating the effect of polyethylene fibers on fracture strength and
fracture modes in mesio-occlusal-distal cavities, the use of ribbond
was found to significantly increase fracture strength. Similarly, Sáry
et al. (2019) reported that reparable fractures were predominant in
groups that used fibers. Monaco et al. (2015) evaluated fracture
strength by placing fibers of different thicknesses (Vectris, Ivoclar
Vivadent, Schaan, Liechtenstein) under overlay restorations on premo-
lar teeth that had undergone root-canal treatments. They reported
that increasing the thickness of the fiber had a positive effect on the
fracture strength. In our study, two layers of crosswise polyethylene
fibers were placed under the endocrown and overlay restorations and
found that this application did not change the fracture strength but
did reduce the irreparable fracture mode. The contrasting results
between our study and Monaco et al. (2015) may be due to the thick-
ness and type of fibers used. In addition, we placed the fibers on the
pulp chamber floor and not in the indirect restoration. Similar to our
study, Rocca et al. (2015) compared endocrown and overlay restora-
tions with different fiber additions and concluded that they did not
change the fracture strength of the overlay restorations.
El Ghoul et al. (2019) studied the fracture strength and failure
types of endocrowns produced from different materials under axial
and lateral forces and determined that the rates of reparable fractures
were higher than those of irreparable fractures, except in a lithium dis-
ilicate endocrown group. In our study, the ratio of reparable fractures
was higher than irreparable fractures in all groups. The differences in
these results may be due to the extension of the endocrown restora-
tions to the pulp chamber and the difference in the materials used. It
is thought that preparations made deeper into the pulp chamber may

1806
cause stress in the root dentin, which could increase the tendency to
form irreparable fractures.
When the fracture modes were analyzed, adhesive failure was pri-
marily observed in the overlay groups, while none were found in the
endocrown group. The high rate of adhesive failure in the overlay
groups may have been due to incompatibility in the bonding between
the resin composite and the indirect restoration. Monaco et al. (2016)
determined that the addition of fibers reduced the irreparable fracture
mode of endocrown restorations. Similarly, in our study, the application
of polyethylene fibers reduced the amount of irreparable fractures in
both types of indirect restorations. Placing polyethylene fibers on the
pulp chamber floor toward the pulpal cavity walls may have stopped
the progress of cracks due to its high elasticity and woven structure.
There are a number of limitations in this study. First, human teeth
were used, which were similar sizes and extracted for periodontal rea-
sons. Thus, standardization was difficult as the mineralization of the
teeth was varied because they belonged to different people. Second,
a static test method was preferred to determine the strength of the
teeth. The fracture strength test method is a simple and frequently
preferred method to determine the strength of materials in vitro.
However, dynamic test methods such as the fatigue test may better
imitate clinical conditions. Third, a periodontal ligament imitation was
not applied around the roots of the teeth. Finally, only two layers of
crosswise ribbond were placed under the endocrown and overlay res-
torations using one type of CAD-CAM material. Further studies
should focus on the use of more layers of ribbond, different types of
fibers, and CAD-CAM materials.
5 | C O N CL U S I O N
1. Overlay restorations showed higher fracture strength values than
endocrown restorations.
2. Ribbond did not significantly change the fracture strength values
of the endocrown and overlay restorations but reduced the fre-
quency of irreparable fracture modes in both of the indirect
restorations.
ACKNOWLEDGMENTS
This study was supported by the Scientific Research Projects Coordi-
nation Unit of Bezmialem Vakıf University by the support project
numbered 12.2017/35. The funders had no role in the design, conduc-
tion, evaluation or interpretation of the study, or in writing the manu-
script. Many thanks to Assistant Professor Sevilay Karahan for her
help with statistical analyses. The authors do not have any financial
interest in the companies whose materials are included in this article.
CONF LICT OF IN TE RE ST
This manuscript has not been published elsewhere in part or in
entirety and is not under consideration by another journal. I have read
and understood your journal's policies, and I believe that neither the
manuscript nor the study violates any of these. There are no conflicts
of interest to declare.
10970029, 2022, 5, Downloaded from https://analyticalsciencejournals.onlinelibrary.wiley.com/doi/10.1002/jemt.24040 by Egyptian National Sti. Network (Enstinet), Wiley Online Library on [21/12/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
FILDISI AND ELIGUZELOGLU DALKILIC
AUTHOR CONTRIBU TIONS
Mehmet Ali Fildisi performed all restoration and polymerization pro-
cedures, participated in the study design, prepared and submitted the
manuscript. Evrim Eliguzeloglu Dalkilic participated in the study
design, conducted broad research regarding the content of this study,
reviewed current literature, and helped to prepare the manuscript.
DATA AVAILABILITY STAT EMEN T
The data that support the findings of this study are openly available.
OR CID
Mehmet Ali Fildisi https://orcid.org/0000-0001-7114-072X
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(2022). The effect of fiber insertion on fracture strength and
fracture modes in endocrown and overlay restorations.
Microscopy Research and Technique, 85(5), 1799–1807.
https://doi.org/10.1002/jemt.24040