Fracture resistance of endodontically

treated molars restored with extensive

composite resin restorations
Gianluca Plotino, DDS,a Laura Buono, DDS,b Nicola M. Grande,
DDS,c Vincenzo Lamorgese, MD, DDS,d and Francesco Somma,
MD, DDSe
Catholic University of Sacred Heart, Rome, Italy
Statement of problem. When cuspal coverage is required, there is no evidence that indirect composite resin restorations are superior to direct restorations in terms of biomechanical behavior.
Purpose. The purpose of this in vitro study was to compare the fracture resistance of cusp-replacing direct and indirect composite resin restorations in endodontically treated molars.
Material and methods. Forty-five human mandibular molars were selected and divided into 3 groups (n=15): DIR
specimens, restored with direct composite resin (Estelite Sigma) restorations; IND specimens, restored with indirect
composite resin (Estelite Sigma) restorations, and control specimens, which remained intact. Endodontic treatment
was performed using NiTi ProTaper rotary instruments, and teeth were filled using lateral condensation of gutta-percha and sealer. Extensive Class II MO cavities were prepared, and the 2 mesial cusps were reduced, allowing a 2-mm
layer of composite resin. All teeth were prepared to the same dimensions, considering reasonable human variation.
Specimens were loaded to failure and the fracture loads were recorded (N). The mode of fracture was determined using a stereomicroscope and classified as favorable or unfavorable failure. The data were subjected to a Kruskal-Wallis
test, multiple-comparison Mann-Whitney test, and a chi-square test (=.05).
Results. Significant differences (P<.001) were observed between the control group and both DIR and IND groups.
However, no significant difference was found between the DIR and IND groups. The chi-square test did not show a
significant difference in the frequencies of favorable/unfavorable failure modes among the 3 groups (P=.981).
Conclusions. No significant difference was observed in the fracture resistance of endodontically treated molars restored to original contours with an extensive cusp-replacing direct or indirect composite resin restoration. (J Prosthet
Dent 2008;99:225-232)

Clinical Implications

Within the limitations of this study, cusp-replacing direct and indirect

composite resin restorations presented similar resistance to fracture
under simulated occlusal loads and may be a viable treatment option
for endodontically treated molars with a guarded prognosis.

Esthetic dentistry continues to

evolve through innovation in bonding systems, restorative materials,
and conservative preparation de-

signs. Increased use of composite

resin materials for the restoration of
the posterior dentition has drawn attention to technological advances in

Assistant Professor, Department of Endodontics.

PhD student, School of Dentistry.
c
Assistant Professor, Department of Endodontics.
d
Private practice, Rome, Italy.
e
Chair and Professor, Department of Endodontics.
a

Plotino et al

this field. A stable and durable bond

between dental materials and tooth
substrates is important from both
a mechanical and esthetic perspec-

226

Volume 99 Issue 3
tive.1 Such materials not only seal the
margin,2 but several studies have also
shown that the use of adhesive materials can reduce the weakening effect
of preparation designs.3,4 In fact, cavity preparation procedures for dental
restorations are a primary factor in
most cuspal fractures,5 especially for
endodontically treated teeth.6,7 Adhesive resin-based restorative techniques for posterior endodontically
treated teeth can be either in the form
of direct composite resin restorations
or composite resin inlays/onlays.
Each of these restorative procedures
has unique advantages and disadvantages. The preferred technique is not
obvious, considering that the clinical
wear of composite resin inlays is expected to equal the wear resistance of
direct posterior composite resin restorations.8 There is also no scientific
evidence to support manufacturers
claims that extraoral postpolymerization improves the wear characteristics
and the mechanical properties of the
material.9,10
Recently developed composite resins are superior to previous versions
with regard to wear resistance and color stability.11,12 However, the primary
shortcoming of composite resins,
polymerization shrinkage, remains a
concern.13 In posterior preparations,
especially when the cervical margin is
located in dentin, the polymerization
shrinkage effects can be significant,
producing marginal defects and gaps
despite careful application.14 This result facilitates microleakage, which
could promote secondary caries,
marginal discoloration, and, in vital
teeth, pulpal irritation and postoperative sensitivity.15 To minimize the
development of stresses, it is important to use incremental placement
techniques, in which the composite
resin is applied in thin or oblique layers and then polymerized throughout
the cusps.16 The composite resin inlay systems were introduced for large
defects, with the aim of overcoming
some of the problems associated with
directly placed posterior composite
resin restorations, such as the polym-

erization shrinkage that occurs when

using conventional incremental techniques.17 The primary advantages of
indirectly placed composite resin inlays and onlays are the minimization
of polymerization stress due to the
extraoral method of polymerization,
better control of anatomic form and
proximal contacts, and improved surface finish.12,18
However, the unresolved problem
with indirectly placed inlays/onlays
is the bond between the composite
resin cement and the restoration.19
Adhesive systems with direct composite resin restorations provide superior bond strengths when compared
to indirect restorations.20-22 Furthermore, it has been stated that direct
composite resin restorations are preferred over indirect composite resins
because they preserve more sound
tooth structure.23 The marginal seal
and fracture resistance of the restorative materials are important factors
for the long-term performance of posterior composite resin restorations.24
It has been shown that the resulting weakening of the tooth due to
restorative procedures increases with
the reduction of tooth structure.2527
The literature is contradictory regarding the strengthening effect of
bonded restorations on weakened
teeth. Several in vitro studies demonstrated that directly bonded restorations increased the fracture resistance
of teeth.2,3 However, others evaluated
teeth restored with bonded restorations and showed fracture strengths
similar to those of teeth with the same
unrestored cavity preparation.28-30
Conversely, recent reports indicate
that tooth-color adhesive restorative
materials may be promising alternatives for cusp-replacement restorations even in endodontically treated
teeth with extensive loss of tooth
structure.31,32
The need for cuspal coverage has
always been considered an indication
for the placement of an onlay/overlay
because, in this instance, extensive
direct restorations are technically difficult to perform.33-35 However, when

The Journal of Prosthetic Dentistry

cuspal coverage is required, there is

no evidence that indirect restorations
are superior to direct restorations in
terms of biomechanical behavior. 36-39
In fact, the few studies that demonstrated the effectiveness of these techniques only compared them on the
basis of microleakage.40,41
The purpose of this in vitro study
was to compare the fracture resistance of extensive direct and indirect
composite resin restorations in endodontically treated molars. The null
hypothesis tested was that there is no
difference in the resistance to fracture
and the mode of failure between direct and indirect composite resin restorations in endodontically treated
molars prepared with an extensive
loss of tooth structure.

MATERIAL AND METHODS

Forty-five recently extracted human mandibular molars with completely formed apices, without caries
or visible fracture lines, were selected
from a tooth bank. The selection of
specimens was based on the teeth
having similar bucco-lingual (BL)
and mesio-distal (MD) dimensions,
as determined with a digital caliper
(Mitutoyo, Tokyo, Japan). All external debris was removed with a hand
scaler, and the teeth were stored individually in buffered saline plus 0.5%
thymol (Carlo Erba, Milan, Italy) at
37C. Cleaned specimens were carefully inspected under a stereomicroscope (Stemi SV6; Carl Zeiss SpA,
Arese, Italy) at x30 magnification to
detect cracks in the teeth. Specimens
that did not meet the criteria were replaced.
The product (mm2) of the BL and
MD dimensions was determined. On
the basis of this value, the 45 specimens were sequenced according to decreasing values, and alternating specimens were subsequently allocated to
3 groups of 15 teeth each, so that the
average tooth size in each group was
as equal as possible to minimize the
influence of size and shape variations
on the results. Tooth dimensions were

Plotino et al

227

March 2008
assessed with 1-way analysis of variance (ANOVA) to determine significant differences between groups. The
control group contained teeth that remained intact; the teeth of the other
2 groups were subjected to the endodontic and restorative procedures.
Two preliminary radiographs were
made in bucco-lingual and mesio-distal directions to determine root canal
anatomy. Endodontic treatment was
performed using NiTi rotary instruments (ProTaper; Dentsply Maillefer,
Ballaigues, Switzerland). Five percent
sodium hypochlorite was used for irrigation during the endodontic treatment. A 17% EDTA solution (EDTA
17%; OGNA Laboratori Farmaceutici,
Milan, Italy) was used after the last
instrument, followed by a final flush
with saline solution. The canals were
dried with paper points (Dentsply
Maillefer) and all roots were obturated with laterally condensed guttapercha (Dentsply Maillefer) and resinbased endodontic sealer (Topseal;
Dentsply Maillefer). The access opening was sealed with an elastic lightpolymerizing provisional restorative
material (Fermit; Ivoclar Vivadent,
Schaan, Liechtenstein) to protect the
endodontic filling material from leakage of the saline storage media. The
teeth were then stored in buffered saline plus 0.5% thymol at 37C for 1
week to ensure complete polymerization of the sealer.
One operator made all of the
preparations and restorations. The
enamel and dentin of the access cavity were etched with 37% phosphoric
acid (3M ESPE, St. Paul, Minn) for 40
seconds and 20 seconds, respectively,
rinsed for 20 seconds with an air/water spray, and gently air-dried to avoid
dessication. The primer (Scotchbond
Multi-Purpose Primer; 3M ESPE) was
applied with a microbrush to the
tooth surface for 20 seconds and then
air-dried for 5 seconds. Light-polymerizing adhesive (Scotchbond MultiPurpose Adhesive; 3M ESPE) was
applied with another microbrush, the
excess was gently air-thinned, and the
surface was exposed to an LED-po-

Plotino et al

lymerization unit with an intensity of

800 mW/cm2 (Starlight pro; Mectron
SpA, Carasco, Italy) for 40 seconds. A
second layer of adhesive was applied
with the same protocol. Subsequently, the access cavity was filled with a
dual-polymerizing composite resin
(Virage Dual; Sweden & Martina,
Padua, Italy).
Class II MO cavities were prepared
with a water-cooled high-speed handpiece and a bur kit (Universal Set; Intensiv, Grancia, Switzerland) that was
replaced after 5 preparations. All teeth
were prepared as closely as possible
to the same size using a periodontal
probe and standard burs (Universal
Set; Intensiv) to measure the depth

and width (Figs. 1 and 2). The pulpal

floor was prepared at a depth of 4
mm from the occlusal cavosurface
margin, and the 2 mesial cusps were
reduced to allow for a 2-mm layer of
composite resin to ensure adequate
bulk. The proximal box was located 1
mm coronal to the cemento-enamel
junction. Its width corresponded to
one third of the distance between
the buccal and lingual surfaces of the
teeth at the point of the height of the
contour, and its axial depth was 1.5
mm. The buccal-lingual width of the
occlusal portion of the cavity preparation corresponded to two thirds
of the distance between the 2 sound
cusps, while the occlusal portion of

1 Schematic illustration of mesial view of preparation design. A is distance

between buccal and lingual surfaces of teeth at point of maximum circumference; 1/3 A is one third of distance between buccal and lingual surfaces of
teeth at point of maximum circumference.

2 Schematic illustration of occlusal view of preparation design. A is distance

between buccal and lingual surfaces of teeth at point of maximum circumference; 1/3 A is one third of distance between buccal and lingual surfaces
of teeth at point of maximum circumference; B is distance between 2 sound
distal cusps; 2/3 B is two thirds of distance between 2 sound distal cusps.

228

Volume 99 Issue 3
the cavity preparation extended mesio-distally to include the distal occlusal fossa, thus preserving the distal
marginal ridge. The axial wall length
was 1.5 mm. The angles of divergence
of the preparation walls were approximately 5-15 degrees, and the internal
line angles were rounded. Occlusal
finish lines were not bevelled.
Clinical and laboratory procedures were standardized as follows.
Fifteen teeth were restored with direct
composite resin restorations (DIR).
Immediately following that, the foundation was placed and the cavity was
prepared. Fifteen teeth were restored
with indirect composite resin restorations (IND); a week later, the foundation was placed and the cavity was
prepared.
For teeth restored with direct composite resin restorations (DIR), adhesive procedures of the preparation
(enamel, dentin, and foundation)
were repeated as described above.
A matrix retainer system (Tofflemire
matrix; Miltex Inc, York, Pa) was used
and changed for each restoration.
The matrix was tightened and held
by finger pressure against the gingival
margin of the cavity, so that the preparations could not be overfilled at the
gingival margin. The composite resin
(Estelite Sigma; Tokuyama Dental
Corp, Tokyo, Japan) was placed using
the oblique incremental technique,42,43
and each increment was no more than
1.5 mm to ensure adequate polymerization. Each increment was polymerized for 40 seconds (20 seconds of
slow-rise function repeated 2 times)
with an LED-polymerizing unit with
a power light intensity of 800 mW/
cm2 (Starlight pro; Mectron SpA) in
contact with the occlusal surface of
the tooth. The external layer was polymerized after placement of a glycerine gel (DeOx; Ultradent Products
Inc, South Jordan, Utah) to maintain
an anaerobic environment to permit
complete polymerization of the resin
surface. The composite resin restorations were formed with A3 shade in
order to simulate dentin, and a final
thin layer of 0.5-1 mm of A1 shade to

simulate enamel.
The matrix was removed, and to
ensure that the deepest parts of the
interproximal box had been polymerized adequately, each restoration was
further polymerized for 60 seconds
from the buccal aspect and 60 seconds from the lingual aspect of the
box. After polymerization, specimens
were finished and polished with rubber cups and points (Identoflex; KerrHawe SA, Bioggio, Switzerland).
For prepared teeth to be restored
with indirect composite resin restorations (IND), impressions with a
vinyl polysiloxane (Aquasil; Dentsply
Caulk, Milford, Del) were made using
a custom-made impression tray. The
impressions were poured with a vacuum-mixed type IV stone (FujiRock EP;
GC Italia Srl, San Giuliano Milanese,
Italy) and separated from the dies after 1 hour. After separation, the cast
was carefully evaluated to ensure that
the finish line was entirely visible, and
that there were no distortions, air
bubbles, or undercuts, prior to sending the cast to the dental laboratory.
The dies were coated with separating medium (Tenatex wax; Kemdent,
Swindon, UK) and onlays were fabricated with the same composite resin
and technique used for the direct restorations. Onlays were further polymerized in a light-heat polymerization
oven (LaborluxL 300W; Micerium
SpA, Avegno, Italy) for 10 minutes.
Each restoration was verified for
fit accuracy and adjusted accordingly,
then finished with a fine diamond rotary cutting instrument (Intensiv FG;
Intensiv). Both the internal surfaces
of the onlays and the teeth were airborne-particle abraded with 50-m
silica-coated aluminium-oxide particles (Special sand, Kumapan; Consorzio Onda, Grugliasco, Italy). Then
the teeth were treated, as previously
described for the DIR specimens, with
etching, primer, and bonding agents.
The onlays, after the airborne-particle
abrasion, were cleaned with ethyl alcohol (95% vol), and silane and bonding
agents were applied. The same dualpolymerizing composite resin (Virage

The Journal of Prosthetic Dentistry

Dual; Sweden & Martina) used for the

foundation procedure was used as a
luting agent. The composite resin was
then placed on the tooth, the onlay
was seated in place, and the excess cement was removed with a brush. Cavosurface margins were coated with a
glycerine gel (DeOx; Ultradent Products Inc) to permit complete polymerization of the luting agent. Each restoration, for the first 10 seconds held
under load, was polymerized with an
LED-polymerizing unit (Starlight pro;
Mectron SpA) from the occlusal, facial, and lingual directions for 20 seconds in each direction, 3 times each
(for a total of 1 minute in each direction). After complete polymerization,
specimens were finished with carbide
finishing burs (Dentsply Maillefer) to
remove excess cement, then repolished with rubber cups and points
(Identoflex; KerrHawe SA).
Root surfaces were marked 3 mm
below the crown margin to simulate
the biologic width and covered with
0.3-mm-thick wax (Tenatex wax; Kemdent). Specimens were then embedded in autopolymerizing acrylic
resin (Ortho-Jet; Lang Dental Mfg
Co, Wheeling, Ill) surrounded by a cylindrical-shaped plastic mold (IKEA;
Rome, Italy), with the long axis of the
tooth parallel to that of the cylinder.
After the first signs of polymerization,
teeth were removed from the resin
blocks, and the wax on the root surfaces was removed using a hand instrument. Light-body silicone-based
impression material (Aquasil Ultra
LV; Dentsply Caulk) was injected into
the resin base, and the teeth were
reinserted into the resin base. Thus,
the standardized silicone layer that
simulated the periodontal ligament
were created.44,45 All specimens were
stored in buffered saline plus 0.5%
thymol (Carlo Erba) at 37C for 1
week before undergoing the testing
procedure.
Specimens were mounted in a jig
that allowed loading at the central
fossa with a lingual orientation in the
axio-occlusal line at a 15-degree angle to the long axis of the tooth. The

Plotino et al

229

March 2008
choice of this angulation was based
on anatomic observation.46 Continuous compressive force at a crosshead speed of 1.6 mm/s was applied
in a universal load testing machine
(LR30K; Lloyd Instruments Ltd, Fareham, UK) using a 6-mm-diameter steel
ball (Fig. 3). The fracture loads were
determined in Newtons (N), and the
modes of fracture were recorded and
classified by 2 independent observers
using a stereomicroscope (Stemi SV6;
Carl Zeiss SpA). Favorable failures
were defined as repairable failures,
including adhesive failures, above the
level of bone simulation. Unfavorable
failures were defined as nonrepairable
failures, including (vertical) root fractures, below the level of bone simulation.47 Disagreements were resolved
by discussion between the 2 observers.
The data were analyzed using statistical software (SPSS 11.0; SPSS Inc,
Chicago, Ill). Data were subjected to
a Kruskal-Wallis test to determine
significant differences in failure loads
among groups. When the KruskalWallis test indicated a significant difference, multiple comparisons were
performed using the Mann-Whitney
test to determine which group differed
from the others. Percentages were determined for the mode of failure, and
statistical evaluation was completed
using a chi-square test to determine
significant differences in the mode of
failure among groups. A preset alpha
level of .05 was used for all statistical
analyses.

RESULTS
Mean (SD) bucco-lingual and mesio-distal dimensions of the teeth were
9.94 (0.46) mm and 11.25 (0.50) mm
for DIR specimens, 9.86 (0.42) and
11.12 (0.54) mm for IND specimens,
and 9.97 (0.50) and 11.30 (0.53) mm
for control specimens, respectively.
The mean sizes of the teeth in the 3
groups were not significantly different
for bucco-lingual (P=.797) or mesiodistal (P=.627) dimensions.
The Kruskal-Wallis test showed

Plotino et al

3 Simulated occlusal loading using 6-mm-diameter steel sphere

placed on central fossa with lingual orientation in axio-occlusal
line at 15-degree angle to long axis of mandibular molar tooth.

Table I. Percentage (frequency) of mode of failure for all groups (n=15)

Group

Favorable

Unfavorable

DIR (direct)

33% (n = 5)

67% (n = 10)

IND (indirect)

33% (n = 5)

67% (n = 10)

Intact teeth

40% (n = 6)

60% (n = 9)

that there were significant differences

among the groups in their resistance
to fracture under load (P=.001). The
Mann-Whitney test showed significant differences (P<.001) between
the control group and both DIR and
IND groups. No significant difference was found between DIR and
IND groups (P=.512). The specimens
fractured, respectively, at a mean
(SD) failure load of 1421.4 (319.5)
N and 1367.8 (266.3) N. The mean
fracture strength of the control group
was 2451.3 (569.9) N. Teeth restored
with direct and indirect restorations
had a decreased fracture resistance of
42% and 44%, respectively, compared
to intact teeth.
Almost 65% of failures for all
groups were unfavorable (DIR, 67%;
IND, 67%; control group, 60%). Disagreements between the 2 independent
observers were resolved by discussion
for 2 specimens, because the location of the fracture line was difficult
to define with respect to the level of
bone simulation. The chi-square test

did not show a significant difference

in frequencies of favorable/unfavorable failure modes between the 3
groups (P=.984) (Table I). All failures
of the restored teeth were fractures
of the composite resin restorations
in combination with tooth material
(cohesive failures); no purely adhesive
failures were observed.

DISCUSSION
The results of the present study
support the null hypothesis that there
is no difference in the resistance to
fracture and the mode of failure between direct and indirect composite
resin restorations in endodontically
treated molars prepared with an extensive loss of tooth structure.
Numerous studies have been conducted to determine the ideal method to restore endodontically treated
teeth. Endodontic treatment is considered to weaken teeth, resulting in
increased susceptibility to fracture.
Consequently, authors suggest that

230

Volume 99 Issue 3
cuspal coverage with cast restorations
is necessary for predictable restorative success of endodontically treated
posterior teeth.7
It has been shown that the resulting weakening of teeth due to restorative procedures increases with
the reduction of tooth structure.25-27
According to Reeh et al,6 endodontic
procedures have only a small effect on
the tooth, reducing the relative rigidity by 5%, which is contributed entirely by the access opening. Restorative
procedures and, particularly, the loss
of marginal ridge integrity, were the
greatest contributors to loss of tooth
rigidity. The loss of 1 marginal ridge
resulted in a 46% loss in tooth rigidity, and an MOD preparation resulted
in an average loss of 63% in relative
cuspal rigidity.
Metal onlays and crowns have
traditionally been recommended for
large restorations, including cusp
coverage. More recently, the use of
indirect composite resin techniques
has been indicated as well.34,35 However, biomechanically, there is no evidence that indirect composite resin
restorations are superior to direct
restorations, and there are few longitudinal studies on the clinical behavior of extensive composite resin
restorations.33,36-39 Complex direct
composite resin restorations exhibit
durability and have been shown to
have sufficient strength to withstand
occlusal forces and protect the remaining tooth structure.8,33 Clinical
evidence suggests that the longevity
of direct composite resin posterior
restorations is equal to that of indirect composite resin posterior restorations.11 Nevertheless, there is sparse
long-term information concerning the
longevity of cusp-replacing composite
resin restorations.33
The results of the present study
demonstrated that there are no differences in the in vitro fracture resistance of extensive direct and indirect
composite resin restorations. These
results are in agreement with those
of Kuijs et al,51 who reported no differences in fracture strength between

direct and indirect composite resin

restorations in premolars. Furthermore, previous studies reported no
significant differences in resistance to
cuspal fracture between direct posterior composite resin restorations and
composite resin inlays,3,49 confirming
that biomechanically, no difference
exists between direct and indirect
placement of composite resin.
In the present study, no differences
were found in the mode of failure of
restored teeth. These results are in accordance with Kuijs et al,51 who reported no differences in the failure mode
between direct and indirect composite resin restorations. In the present
study, all failures of the restored teeth
were cohesive fractures regardless of
the type of restoration; no pure adhesive failures were observed. These
results are somewhat in contrast with
those of Kuijs et al,51 who reported
more combined cohesive and adhesive fractures for indirect restorations
than the direct composite resin restorations, which demonstrated more
adhesive fractures. These findings
corroborate the clinical findings that
fracture tendency of direct composite
resin restorations is similar to that of
inlay/onlay restorations.8
Both direct and indirect restorations had a decrease in fracture resistance, respectively, of 42% and
44%, compared to intact teeth. These
results are in agreement with other
studies reporting that restored teeth
had a significantly lower resistance to
fracture.3,28-30 This confirms that cavity preparation reduces the rigidity of
teeth and that the restorative process, even when adhesive techniques
are associated with cuspal coverage,
is not able to restore the resistance to
load to the level of nonrestored, noncarious molars.3,6,29,50
The results of the present study
suggest that the rationale for the use
of direct composite resin restorations
could be extended to teeth with a
large amount of lost tooth structure.
Although extensive restorations are
technically difficult to perform using
direct techniques, more expensive re-

The Journal of Prosthetic Dentistry

storative procedures may not be the

first choice for treating severely damaged posterior teeth with a poor prognosis for endodontic or periodontal
reasons. In these situations, extensive
composite resin restorations may be
placed as an intermediary restoration.
The restorations may later be used as
a foundation for a subsequent definitive restoration, providing increased
longevity at low cost and preserving
tooth structure.8,18 Considering the
increased treatment time and cost to
produce crowns and indirect onlays,
the advantage of the direct placement
of composite resin restorations may
be considered as a viable treatment
option for posterior endodontically
treated molars with uncertain prognosis requiring coverage of 1 or 2
cusps and having the cervical margin
situated in enamel. Other advantages
of a direct composite resin restoration as definitive treatment for posterior endodontically treated molars include that dental laboratory support
is eliminated and that the restoration
is placed in a single visit.
The limitations of this study must
be recognized. The experimental
methods used for in vitro analyses do
not accurately reflect intraoral conditions. There are a number of factors
that may interfere with resistance to
fracture, such as the differences between specimens, tooth embedment
method, type and direction of load
application, crosshead speed, and
simulation of thermal or mechanical
fatiguing. The continually increasing
load applied to the teeth in this study
is not typical of the type of loading
that occurs in clinical conditions, in
which failures occur primarily due to
fatigue. Future research in this area
should use cyclic loading and other fatiguing simulation to more accurately
reproduce the clinical environment.
Additional clinical studies are necessary to determine the long-term prognosis for extensive direct composite
resin restorations of endodontically
treated molars.

Plotino et al

231

March 2008
CONCLUSIONS
Within the limitations of this in
vitro study, endodontically treated
molars prepared with an extensive
loss of tooth structure and restored
to their original contours with direct
composite resin restorations presented a resistance to fracture under simulated occlusal load not significantly
different than that of indirect composite resin restorations. Restored
teeth had a decrease in fracture resistance compared to intact teeth. Furthermore, no differences were found
in the mode of failure of the restored
and intact teeth.

REFERENCES
1. De Munck J, Van Landuyt K, Peumans M,
Poitevin A, Lambrechts P, Braem M, et al. A
critical review of the durability of adhesion
to tooth tissue: methods and results. J Dent
Res 2005;84:118-32.
2. Dietschi D, Herzfeld D. In vitro evaluation
of marginal and internal adaptation of
class II resin composite restorations after
thermal and occlusal stressing. Eur J Oral
Sci 1998;106:1033-42.
3. Cotert HS, Sen BH, Balkan M. In vitro
comparison of cuspal fracture resistances
of posterior teeth restored with various
adhesive restorations. Int J Prosthodont
2001;14:374-8.
4. Rasheed AA. Effect of bonding amalgam on
the reinforcement of teeth. J Prosthet Dent
2005;93:51-5.
5. Goel VK, Khera SC, Gurusami S, Chen RC.
Effect of cavity depth on stresses in a restored tooth. J Prosthet Dent 1992;67:17483.
6. Reeh ES, Messer HH, Douglas WH. Reduction in tooth stiffness as a result of endodontic and restorative procedures. J Endod
1989;15:512-6.
7. Sorensen JA, Martinoff JT. Intracoronal reinforcement and coronal coverage: a study
of endodontically treated teeth. J Prosthet
Dent 1984;51:780-4.
8. van Dijken JW. Direct resin composite
inlays/onlays: an 11 year follow-up. J Dent
2000;28:299-306.
9. Kildal KK, Ruyter IE. How different curing
methods affect mechanical properties
of composites for inlays when tested in
dry and wet conditions. Eur J Oral Sci
1997;105:353-61.
10.Reinhardt JW, Boyer DB, Stephens NH.
Effects of secondary curing on indirect
posterior composite resins. Oper Dent
1994;19:217-20.
11.Manhart J, Chen H, Hamm G, Hickel R.
Buonocore Memorial Lecture. Review of
the clinical survival of direct and indirect
restorations in posterior teeth of the permanent dentition. Oper Dent 2004;29:481-

Plotino et al

508.
12.Ferracane JL. Is the wear of dental composites still a clinical concern? Is there still
a need for in vitro wear simulating devices?
Dent Mater 2006;22:689-92.
13.Ferracane JL. Developing a more complete
understanding of stresses produced in dental composites during polymerization. Dent
Mater 2005;21:36-42.
14.Dietschi D, Scampa U, Campanile G, Holz
J. Marginal adaptation and seal of direct
and indirect Class II composite resin restorations: an in vitro evaluation. Quintessence Int 1995;26:127-38.
15.Brannstrom M. Communication between
the oral cavity and the dental pulp associated with restorative treatment. Oper Dent
1984;9:57-68.
16.Nikolaenko SA, Lohbauer U, Roggendorf
M, Petschelt A, Dasch W, Frankenberger R.
Influence of c-factor and layering technique
on microtensile bond strength to dentin.
Dent Mater 2004;20:579-85.
17.Burke FJ, Watts DC, Wilson NH, Wilson
MA. Current status and rationale for
composite inlays and onlays. Br Dent J
1991;170:269-73.
18.Donly KJ, Jensen ME, Triolo P, Chan D. A
clinical comparison of resin composite inlay
and onlay posterior restorations and castgold restorations at 7 years. Quintessence
Int 1999;30:163-68.
19.Hisamatsu N, Tanoue N, Yanagida H,
Atsuta M, Matsumura H. Twenty-four hour
bond strength between layers of a highly
loaded indirect composite. Dent Mater J
2005;24:440-6.
20.Jayasooriya PR, Pereira PN, Nikaido T,
Tagami J. Efficacy of a resin coating on
bond strengths of resin cement to dentin. J
Esthet Restor Dent 2003;15:105-13.
21.Kitasako Y, Burrow MF, Nikaido T, Harada
N, Inokoshi S, Yamada T, et al. Shear and
tensile bond testing for resin cement evaluation. Dent Mater 1995;11:298-304.
22.Burrow MF, Nikaido T, Satoh M, Tagami J.
Early bonding of resin cements to dentin-effect of bonding environment. Oper Dent
1996;21:196-202.
23.Tyas MJ, Anusavice KJ, Frencken JE, Mount
GJ. Minimal intervention dentistry--a
review. FDI Commission Project 1-97. Int
Dent J 2000;50:1-12.
24.Hickel R, Manhart J. Longevity of restorations in posterior teeth and reasons for
failure. J Adhes Dent 2001;3:45-64.
25.Fokkinga WA, Kreulen CM, Vallittu PK,
Creugers NH. A structured analysis of in vitro failure loads and failure modes of fiber,
metal, and ceramic post-and-core systems.
Int J Prosthodont 2004;17:47682.
26.Panitvisai P, Messer HH. Cuspal deflection
in molars in relation to endodontic and restorative procedures. J Endod 1995;21:5761.
27.Mondelli J, Steagall L, Ishikiriama A, de
Lima Navarro MF, Soares FB. Fracture
strength of human teeth with cavity preparations. J Prosthet Dent 1980;43:419-22.
28.Stampalia LL, Nicholls JI, Brudvik JS, Jones
DW. Fracture resistance of teeth with
resin-bonded restorations. J Prosthet Dent
1986;55:694-8.
29.St-Georges AJ, Sturdevant JR, Swift EJ Jr,

Thompson JY. Fracture resistance of prepared teeth restored with bonded inlay restorations. J Prosthet Dent 2003;89:551-7.
30.Allara FW Jr, Diefenderfer KE, Molinaro JD.
Effect of three direct restorative materials
on molar cuspal fracture resistance. Am J
Dent 2004;17:228-32.
31.Krejci I, Duc O, Dietschi D, de Campos
E. Marginal adaptation, retention and
fracture resistance of adhesive composite
restorations on devital teeth with and without posts. Oper Dent 2003;28:127-35.
32.Van Meerbeek B, Vargas M, Inoue S,
Yoshida Y, Peumans M, Lambrechts P. Adhesives and cements to promote preservation dentistry. Oper Dent 2001;26(Suppl
6):119-44.
33.Van Nieuwenhuysen JP, DHoore W, Carvalho J, Qvist V. Long-term evaluation of
extensive restorations in permanent teeth. J
Dent 2003;31:395-405.
34.Magne P, Dietschi D, Holz J. Esthetic restorations for posterior teeth: practical and
clinical considerations. Int J Periodontics
Restorative Dent 1996;16:104-19.
35.Blank JT. Scientifically based rationale
and protocol for use of modern indirect
resin inlays and onlays. J Esthet Dent
2000;12:195-208.
36.Plasmans PJ, Creugers NH, Mulder J. Longterm survival of extensive amalgam restorations. J Dent Res 1998;77:453-60.
37.Robbins JW, Summit JB. Longevity of
complex amalgam restorations. Oper Dent
1988;13:54-7.
38.Smales RJ. Longevity of cusp-covered amalgams: survivals after 15 years. Oper Dent
1991;16:17-20.
39.Smales RJ, Hawthorne WS. Long-term survival of extensive amalgams and posterior
crowns. J Dent 1997;25:225-7.
40.Pioch T, Staehle HJ, Duschner H, GarciaGodoy F. Nanoleakage at the composite-dentin interface: a review. Am J Dent
2001;14:252-8.
41.Alani AH, Toh CG. Detection of microleakage around dental restorations: a review.
Oper Dent 1997;22:173-85.
42.Liebenberg WH. Successive cusp build-up:
an improved placement technique for posterior direct resin restorations. J Can Dent
Assoc 1996;62:501-7.
43.Liebenberg WH. The axial bevel technique:
a new technique for extensive posterior
resin composite restorations. Quintessence
Int 2000;31:231-9.
44.Ottl P, Hahn L, Lauer HCh, Fay M. Fracture
characteristics of carbon fibre, ceramic and
non-palladium endodontic post systems
at monotonously increasing loads. J Oral
Rehab 2002;29:17583.
45.Heydecke G, Butz F, Hussein A, Strub JR.
Fracture strength after dynamic loading of
endodontically treated teeth restored with
different post-and-core systems. J Prosthet
Dent 2002;87:43845.
46.Okeson JP. Management of temporomandibular disorders and occlusion. 3rd ed.
St Louis: Elsevier Health Sciences; 1993.
p.69-71.
47.Larson TD, Douglas WH, Geistfeld RE. Effect of prepared cavities on the strength of
teeth. Oper Dent 1981;6:2-5.
48.Kuijs RH, Fennis WM, Kreulen CM, Roeters

232

Volume 99 Issue 3
FJ, Verdonschot N, Creugers NH. A comparison of fatigue resistance of three materials
for cusp-replacing adhesive restorations. J
Dent 2006;34:19-25. Epub 2005 Jun 2.
49.Dalpino PH, Francischone CE, Ishikiriama
A, Franco EB. Fracture resistance of teeth
directly and indirectly restored with com-

posite resin and indirectly restored with

ceramic materials. Am J Dent 2002;15:38994.
50.Reeh ES, Douglas WH, Messer HH.
Stiffness of endodontically-treated teeth
related to restoration technique. J Dent Res
1989;68:1540-4.

Corresponding author:
Dr Gianluca Plotino
Via Eleonora Duse, 22
00197 Rome
ITALY
Fax: +39068072289
E-mail: gplotino@fastwebnet.it
Copyright 2008 by the Editorial Council for
The Journal of Prosthetic Dentistry.

Receive Tables of Contents by E-mail

To receive tables of contents by e-mail, sign up through our Web site at http://www.journals.elsevierhealth.com/periodicals/ympr.
Instructions
Log on and click Register in the upper right-hand corner. After completing the registration process, click on My
Alerts, then Add Table of Contents Alert. Select the category Mosby or type The Journal of Prosthetic Dentistry in
the search field and click on the Journal title. The title will then appear, and having already completed the Registration process, you may add tables of contents alerts by accessing an issue of the Journal and clicking on the Add TOC
Alert link.
You will receive an e-mail message confirming that you have been added to the mailing list.
Note that tables of contents e-mails will be sent when a new issue is posted to the Web site.

The Journal of Prosthetic Dentistry

Plotino et al